Evaluation of venous reflux by color duplex scanning in patients with varicose veins of the lower limbs: correlation with clinical severity by CEAP classification

Abstracts

Contexto: As alterações de pele manifestadas na insuficiência venosa crônica têm como etiologia mais comum o refluxo venoso. Alguns autores relatam que o refluxo venoso superficial é responsável por 40-60% das úlceras de perna nos portadores de varizes primárias. Objetivo: Correlação do refluxo venoso superficial ao mapeamento dúplex com o quadro clínico (classificação CEAP - clínica, epidemiológica, anatômica e fisiopatológica) nos portadores de varizes primárias de membros inferiores. Método: Estudo transversal e descritivo, desenvolvido em portadores de varizes primárias. As variáveis primárias foram: refluxo venoso e quadro clínico. O quadro clínico foi caracterizado por grupos: A, B e C, representados pelas categorias clínicas da CEAP. Dados complementares foram: tipos de refluxo em veias safenas magnas e parvas, conforme classificação de Engelhorn (2004). Testaram-se as hipóteses de inter-relações entre presença de refluxo e quadro clínico, utilizando-se os testes exato de Fisher e qui-quadrado no nível de 5% de probabilidade. Resultados: Das 242 extremidades inferiores examinadas, 15 foram excluídas, totalizando 227 na amostra final. Noventa e nove (83,9%) pacientes eram do sexo feminino. A média de idade foi de 50 anos, com mediana igual a 49 anos. Noventa e três extremidades (41%) não apresentavam refluxo, e 134 (59%) o apresentavam isolado e/ou associado. O refluxo isolado em veias perfurantes (p = 0,0008) e destas em associação com o refluxo em veias safenas magnas (p < 0,0001) estão significativamente relacionados à gravidade do quadro clínico. Conclusão: Há correlação entre a presença do refluxo venoso superficial ao mapeamento dúplex e a gravidade do quadro clínico nos portadores de varizes primárias de membros inferiores.

Refluxo venoso; varizes primárias; mapeamento dúplex

ORIGINAL ARTICLE

Evaluation of venous reflux by color duplex scanning in patients with varicose veins of the lower limbs: correlation with clinical severity by CEAP classification

Áurea Regina Teixeira de Andrade^I; Guilherme Benjamin Brandão Pitta^II; Aldemar Araújo Castro^III; Fausto Miranda Júnior^IV

^IAngiologist and vascular surgeon, Hospital das Clínicas Dr. José Augusto Leite, Aracaju, SE, Brazil. Specialist, Angiology and Vascular Surgery, SBACV and Associação Médica Brasileira (AMB)

^IIProfessor, Vascular Surgery, Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil

^IIIPhD. Associate professor, Department of Surgery, Universidade Estadual de Ciências da Saúde de Alagoas Governador Lamenha Filho - Escola de Ciências Médicas de Alagoas (UNCISAL), Maceió, AL, Brazil

^IVMSc. Associate professor, Methodology of Scientific Research, Department of Social Medicine, UNCISAL, Maceió, AL, Brazil

Correspondence

ABSTRACT

Background: Skin changes observed in chronic venous insufficiency have venous reflux as the most common etiology. Some authors have reported that reflux in the superficial venous system accounts for 40-60% of leg ulcers in patients with primary varicose veins.

Objective: To evaluate the correlation between superficial venous reflux and clinical status (CEAP classification - clinical, etiology, anatomy and pathophysiology) in patients with primary varicose veins of the lower limbs using duplex scanning.

Method: A cross-sectional and descriptive study was performed in patients with primary varicose veins. Primary variables were venous reflux and clinical status. Clinical status was characterized by groups A, B, and C, represented by CEAP clinical categories. Types of venous reflux in the great and small saphenous veins were used as complementary data, according to Engelhorn’s classification (2004). Hypotheses of interrelationship between incidence and types of reflux were statistically analyzed using Fisher’s exact and chi-square tests. Significance was set at 0.05%.

Results: Of 242 lower limbs, 15 were excluded, so that the final sample was comprised of 227 lower limbs. Ninety-nine (83.9%) patients were female. Mean age was 50 years and median was 49 years. Reflux was absent in 93 limbs (41%), and 134 (59%) showed isolated and/or associated reflux. Isolated reflux in perforating veins (p = 0.0008) or in association with great saphenous vein reflux (p < 0.0001) was significantly related to clinical status severity.

Conclusion: Duplex scan showed correlation between presence of superficial venous reflux and clinical status severity in patients with primary varicose veins of the lower limbs.

Keywords: Venous reflux, primary varicose veins, duplex scan.

Introduction

Venous reflux plays a major role in the magnitude of signs and symptoms of chronic venous insufficiency of the lower limbs, which can be manifested from a mere feeling of weight and tiredness to chronic and extensive ulcers.¹

Skin changes manifested by venous insufficiency, resulting from venous hypertension, have venous reflux as its most common etiology,² in the superficial system,³ deep system⁴ and perforating and communicating system,⁵ either alone or in association.

Venous reflux is predictive of venous ulcer genesis, especially when higher than 10 mL/s, regardless of being located in superficial or deep veins.⁶

Some authors, using duplex scanning, claim that superficial venous reflux contributes to 40-60% of venous ulcers in patients with primary varicose veins of the lower limbs.^7-10

This study aimed at comparing superficial venous reflux, evaluated by duplex scanning, and clinical status in patients with primary varicose veins of the lower limbs to verify whether presence and extension of reflux are related to clinical severity of the CEAP classification (clinical, etiologic, anatomical and physiopathological).

Methods

A cross-sectional descriptive study was performed, in which patients were given care at private clinics. Consecutive patients with primary varicose veins and reflux in the saphenofemoral and/or short popliteal and/or perforating-communicating junctions and integrity of the deep venous system through vascular ultrasound were included in this study. Exclusion criteria were patients with arterial and/or lymphatic insufficiency, pregnant women, diabetics, psychiatric patients, and those with past history of lower limb surgery.

Two primary variables were studied: venous reflux and clinical status. Complementary data also evaluated were types of reflux in great and short saphenous veins, according to Engelhorn's ultrasound classification.¹¹ Valvular functioning was evaluated with the aid of color Doppler ultrasound, Valsalva's maneuvers and manual muscle compression distal to transducer placement to produce and detect reflux in the superficial venous system.¹¹ Venous reflux was defined as flow in the inverted direction for a period longer than 0.5 seconds.¹² SONOLINE Versa Pro Ultrasound Imaging System (Siemens Medical System) was the ultrasound device used, adapted with 5, 7.5, 8 and 10 MHz probes. A Doppler spectral analysis ultrasound was used, comprised of a basic unit with 7.5 and 10-MHz linear transducer (Diasonic Gateway) and high-frequency linear probes (7.5 or 10 MHz). Venous anatomy was studied using B mode (two-dimensional image), and venous flow was evaluated by pulsed Doppler, complemented by color Doppler ultrasound. CEAP clinical classification^2,12 was used to evaluate clinical status, defined as follows:

- C₀ absence of visible or palpable signs of venous disease;

- C₁presence of telangiectatic or reticular veins;

- C₂presence of varicose veins;

- C₃ presence of edema;

- C₄skin ulcers;

- C₅skin ulcers and healed scar;

- C₆skin ulcers and active ulcer.

Three groups were predetermined:

- A, represented by patients in category C₁ and C₂ of CEAP classification;

- B, represented by patients in category C₃ and C₄ of CEAP classification;

- C, represented by patients in category C₅ and C₆ of CEAP classification;

Calculation of sample size was estimated in 110 patients, based on studies in the international literature.^1,7,9,13 For the statistical analysis, general data were submitted to a descriptive analysis and later hypotheses on interrelation between the following variables were tested: incidence and type of reflux with clinical status, using the chi-square test (alpha = 0.05%), and Fisher's exact test when there were cells with values lower than 5.

Results

The initial sample was comprised of 121 patients, in a total of 242 limbs; however, three patients (six limbs) represent the study deviation because duplex scanning did not have the information required to fill in the data collection form. Nine limbs were excluded due to deep venous system reflux (n = 2), previous deep venous thrombosis (n = 3) and previous surgical intervention in the lower limbs (n = 4).

Descriptive analysis of data showed that there were 99 female patients (83.90%) and 19 male patients (16.19%). Mean age was 50 years, and 50% of patients were in the age group 40-59 years; median was 49 years. The final sample was composed of 227 lower limbs, whose superficial venous reflux was absent in 93 (41%) and present in 134 (59%), either alone or in association, and distributed as follows: 17 (7.5%), 8 (3.5%) and 40 (17.6%) had isolated great saphenous vein reflux, short saphenous vein reflux and perforating vein reflux, respectively.

Eight lower limbs (3.5%) had reflux in both great and short saphenous veins; 40 (17.6%) in great and perforating saphenous veins; four (1.7%) had associations of reflux in short and perforating saphenous veins; and in 17 (7.5%) there was diagnosis of associations of all three types of reflux, according to Table 1.

Table 1

The chi-square test table was used for new tests to verify which reflux associations were more related to clinical status severity. Occurrence of reflux association between the great saphenous veins and the perforating veins (chi-square= 43.5; p = 0.001) and occurrence of perforating vein reflux alone (chi-square = 14.3; p = 0.0008) are significantly related to clinical status severity, as shown in Tables 2 and 3, respectively.

As to occurrence of reflux in perforating veins in clinical categories and their location in assessed limbs, there was prevalence of categories C₂, C₃ and C₄, with location in the medial aspect in all clinical classes, as shown in Figure 1.

Complementary data were used to evaluate types of reflux in great and short saphenous veins, according to Engelhorn. All 82 cases of great saphenous vein reflux were classified and distributed, as shown in Figure 2. There was higher frequency (31.7%) of type II reflux (proximal), followed by type IV (segmental) in 28.1%, and type VI (diffuse) in 25.6% of cases.

Short saphenous vein reflux was also classified as type (Figure 3), and type II (proximal) was predominant (37.8%). Occurrence of type I (Giacomini vein) and type IV reflux were 18.9 and 16.2%, respectively. There was no register of type V reflux (multisegmental). Type III (distal) and type VI (diffuse) refluxes occurred in 13.3% of the sample.

Discussion

Vascular clinical examination was performed within classical semiological patterns, and clinical status was stratified using the CEAP classification, clinical category, because it is internationally known, more comprehensive and enables interinstitutional studies.^2,14,15

Duplex scanning was the method of choice to screen venous disease because it is sensitive, specific and provides anatomical and functional data of venous systems.² Patients were examined in the supine position and standing erect, according to Sarquis.¹⁶

Superficial venous reflux is currently considered the most frequent cause of morphological and functional changes, accounting for about 40-60% of perimalleolar ulcers in patients with primary varicose veins of the lower limbs.^7-10 There was significant relationship between clinical status severity and presence of superficial venous reflux in the sample (chi square = 58.8; p < 0.0001). Labropoulos et al.,¹⁷ considering the superficial venous system as responsible for skin changes, evaluated patients with venous reflux and previous venous thrombosis, relating them with venous ulcer. They observed low incidence of ulcer in patients with absence of superficial venous reflux in spite of obstruction in the deep venous system.

In this study, occurrence of reflux in great saphenous veins alone or in association with short saphenous vein insufficiency was not statistically significant; however, Labropoulos et al.¹⁸ observed that, in a sample of 255 lower limbs with superficial venous insufficiency, venous ulcer was present when the great saphenous vein had reflux in its entire extension (8%), and such frequency increased to 14% when both refluxes in the short and great saphenous veins were associated. Association of reflux in great saphenous and perforating veins was statistically significant (chi-square = 43.5; p < 0.0001) and determined severity of venous disease. Our data corroborated the observations performed by Hanrahan et al.,¹⁰ who analyzed 95 lower limbs with venous ulcer and found 19% of reflux association in great saphenous and perforating veins.

With regard to perforating vein reflux, Stuart et al.,¹⁹ evaluating a group of patients belonging to categories C₀ to C₆ of CEAP classification, observed that disease severity was related to number of insufficient perforating veins in each limb and to association of superficial veins, especially with short saphenous vein insufficiency. Our observations are in agreement with the studies conducted by Lees & Lambert⁹ and Hanrahan et al.¹⁰ relative to occurrence of reflux in perforating veins located in the medial aspect of lower limbs in patients with primary varicose veins.

As to location of insufficient perforating veins, Delis et al.,^20,21, Sandri et al.²² and Stuart et al.¹⁹ observed that the medial aspect of lower limbs was the most frequent. However, in this study, such location did not account for disease severity. There was reflux in perforating veins, either alone or in association with all clinical categories, from C₁ to C₆ of the CEAP classification; however, absence of reflux in such veins alone was predominant in CEAP C₁. Labropoulos et al.²³ reported that presence of insufficient perforating veins is rare in individuals with no signs and/or symptoms of venous disease. Stuart et al.¹⁹ showed that patients with telangiectasias had only 5% of insufficient perforating veins, while those with healed or open ulcer contributed to 77% of perforating vein insufficiency of the sample. However, the role of insufficient perforating veins in severity of chronic venous disease of the lower limbs is still controversial. It is worth stressing that identification of reflux in perforating veins before lower limb varicose vein surgery contributes to its recurrence, therefore their evaluation in the venous bed is crucial, according to Hanrahan et al.²⁴

Short saphenous vein reflux was not significant to determine clinical status severity, either alone or in association with great saphenous and perforating veins. However, Bass et al.,²⁵ evaluating 20 lower limbs with venous ulcer in lateral malleolus, observed that all limbs had isolated reflux in the short saphenous vein. In this study, presence of reflux in the short saphenous vein alone was 3.5 and 12.8% in association with other refluxes. Chi-square and Fisher's exact statistical tests do not confirm relation between presence of reflux in short saphenous vein and clinical status severity.

When studying models of reflux in saphenous veins, type II (proximal) was the most frequent for both saphenous veins, corroborating the findings obtained by Engelhorn. It is known that superficial venous reflux has significant clinical and hemodynamic accountability in the genesis of skin lesions and that some types of reflux are predictors of venous ulcer formation. Therefore, intervention can be performed using preventive or therapeutic measures to improve the high morbidity rate caused by chronic venous insufficiency.

Correlation patterns between clinical examination and duplex scanning are still far from being established, especially due to the polymorphism of chronic venous insufficiency. For that reason, incentive to new studies in this issue are justified to establish the relative risk a given observation group has of developing venous ulcer of the lower limbs. Thus, a preventive medicine could be developed for a near future.

Conclusions

There is a correlation between presence of superficial venous reflux using duplex scanning and clinical status severity in patients with primary varicose veins of the lower limbs.

Perforating vein reflux alone and in association with saphenous vein reflux is predominant, both directly related to severity of chronic venous disease of the lower limbs.

References

• 1. Labropoulos N, Giannoukas AD, Delis K, et al. Where does venous reflux start? J Vasc Surg. 1997;26:736-42.
• 2. Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg. 1995;21:635-45.
• 3. Sethia K, Darke SG. Long saphenous incompetence as a cause of venous ulceration. Br J Surg. 1984;71:754-5.
• 4. Negus D, Friedgood A. The effective management of venous ulceration. Br J Surg. 1983;70:623-7.
• 5. Cockett FB. The pathology and treatment of venous ulcers of the leg. Br J Surg. 1955;43:260-78.
• 6. Vasdekis SN, Clarke GH, Nicolaides AN. Quantification of venous reflux by means of duplex scanning. J Vasc Surg. 1989;10:670-7.
• 7. Shami SK, Sarin S, Cheatle TR, Scurr JH, Smith PD. Venous ulcers and the superficial venous system. J Vasc Surg. 1993;17:487-90.
• 8. Wong JK, Duncan JL, Nichols DM. Whole-leg duplex mapping for varicose veins: observations on patterns of reflux in recurrent and primary legs, with clinical correlation. Eur J Vasc Endovasc Surg. 2003;25:267-75.
• 9. Lees TA, Lambert D. Patterns of reflux in limbs with skin changes associated with chronic venous insufficiency. Br J Surg. 1993;80:725-8.
• 10. Hanrahan LM, Araki CT, Rodriguez AA, Kechejian GJ, LaMorte WW, Menzoian JO. Distribution of valvular incompetence in patients with venous stasis ulceration. J Vasc Surg. 1991;13:805-11; discussion 811-2.
• 11. Engelhorn CA, Engelhorn AL, Cassou MF, Zanoni CC, Gosalan CJ, Ribas E. Classificação anatomofuncional da insuficiência das veias safenas baseada no eco-Doppler colorido, dirigida para o planejamento da cirurgia de varizes. J Vasc Bras. 2004;3:13-9.
• 12. Labropoulos N, Tiongson J, Pryor L, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg. 2003;38:793-8.
• 13. Labropoulos N, Kang SS, Mansour MA, Giannoukas AD, Buckman J, Baker WH. Primary superficial vein reflux with competent saphenous trunk. Eur J Vasc Endovasc Surg. 1999;18:201-6.
• 14. Rutherford RB, Padberg FT Jr, Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring: An adjunct to venous outcomes assessment. J Vasc Surg. 2000;31:1307-12.
• 15. Eklöf B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40:1248-52.
• 16. Sarquis AL. Avaliação pré e pós-operatória no tratamento cirúrgico conservador de varizes tronculares com o duplex scan a cores. Cir Vasc Angiol. 1996;12:9-11.
• 17. Labropoulos N, Leon M, Nicolaides AN, et al. Venous reflux in patients with previous deep venous thrombosis: correlation with ulceration and other symptoms. J Vas Surg. 1994;20:20-6.
• 18. Labropoulos N, Leon M, Nicolaides AN, Giannoukas AD, Volteas N, Chan P. Superficial venous insufficiency: correlation of anatomic extent of reflux with clinical symptoms and signs. J Vasc Surg. 1994;20:953-8.
• 19. Stuart WP, Adam DJ, Allan PL, Ruckley CV, Bradbury AW. The relationship between the number, competence, and diameter of medial calf perforating veins and the clinical status in healthy subjects and patients with lower-limb venous disease. J Vas Surg. 2000;32:138-43.
• 20. Delis KT, Ibegbuna V, Nicolaides AN, Lauro A, Hafez H. Prevalence and distribution of incompetent perforating veins in chronic venous insufficiency. J Vasc Surg. 1998;28:815-25.
• 21. Delis KT. Perforator vein incompetence in chronic venous disease: A multivariate regression analysis model. J Vasc Surg. 2004;40:626-33.
• 22. Sandri JL, Barros FS, Pontes S, Jacques C, Salles-Cunha SX. Diameter-reflux relationship in perforating veins of patients with varicose veins. J Vasc Surg. 1999;30:867-74.
• 23. Labropoulos N, Delis KT, Nicolaides AN. Venous reflux in symptom-free vascular surgeons. J Vasc Surg. 1995;22:150-4.
• 24. Hanrahan LM, Araki CT, Fisher JB, et al. Evaluation of the perforating veins of the extremity using high resolution duplex imaging. J Cardiovasc Surg (Torino). 1991;32:87-97.
• 25. Bass A, Chayen D, Weinmann EE, Ziss M. Lateral venous ulcer and short saphenous vein insufficiency. J Vasc Surg. 1997;25:654-7.

Publication Dates

• Publication in this collection
  26 May 2009
• Date of issue
  Mar 2009

History

• Accepted
  05 Dec 2008
• Received
  04 Jan 2008