PREVALENCE OF DEEP VENOUS REFLUX AS PRIMARY AETIOLOGY

IN CASE OF LOWER LIMB VARICOSE VEINS

ABSTRACT ID NO 99

INTRODUCTION

• Varicose veins

• Chronic venous insufficiency

• Venous reflux

AIM

• To study the prevalence of deep venous reflux as primary aetiology in cases with lower limb varicose veins.

• Isolated deep venous reflux.

OBJECTIVES

• The objectives will be to see the various patterns and durations of below mentioned refluxes in patients with lower limb varicose veins.– The Deep Venous Reflux – The Sapheno-femoral & Sapheno-popliteal reflux – The Perforator Reflux

MATERIALS & METHODS

• Sample size– 110 cases of lower limb varicose veins that were

managed at this tertiary care centre during June 2012- June 2014.

• Type of study– A descriptive cross sectional study.

INCLUSION CRITERIA

• Clinically confirmed cases of varicose veins which will be further classified on the basis of CEAP classification.

• Cases of chronic venous insufficiency in the form of skin changes, ulceration and lipodermatosclerosis.

• Patients who have not been treated earlier by medical or surgical modality of treatment for varicose veins.

EXCLUSION CRITERIA

• Patients with history of superficial and deep vein thrombosis.

• Patients in the age group less than 15 yrs to exclude the congenital causes of varicose veins.

• Patients who have been treated earlier by medical or surgical modality for varicose veins.

DOPPLER EXAMINATION

• Patients were examined in standing position.

• Axial scan and continuous scan was performed for superficial and deep venous system.

• The Valsalva maneuver was used to elicit the presence of reflux.

DEFINITION OF SIGNIFICANT REFLUX

• More than 500 msec – Superficial veins.– Deep femoral veins.– Femoro-popliteal veins.– Deep calf veins.

• More than 350 msec– Perforators.

CASE 1

33 Y / Male

Varicose veins, Ulcers, Skin changes

3 years durationLLL

C2, 4, 6 Ep An Pr

CASE 1

CASE 2

46 Y / Female

Varicose veins, Skin changes

2 years duration LLL

C2, 4 Ep An Pr

CASE 2

CASE 3

50 Y / Female

Varicose veins, Skin changes, Ulcer

7 years durationRLL

C2, 4, 6 Ep An Pr

CASE 3

RESULTS• The mean age of study population was 48.34 ± SD 12.9 years.

• CEAP distribution C4 - 67 (60.9 %) C5 - 05 ( 4.5 %) C6 - 11 (10.0 %)

• Superficial Incompetence SFJ - 65 (59.1 %) SPJ - 11 (10.0 %) Perforator - 68 (61.8 %)

• DVR Combined - 42 (38.2 %) Isolated - 08 ( 7.3 %)

DEEP VENOUS REFLUX

PROX FV DISTAL FV POP V GPJ PTV

Number of patients 42 14 4 0 0

3

8

13

18

23

28

33

38

43

Distribution of Segmental DVR

Num

ber o

f pati

ents

7%

93%

ISOLATED DVR

PresentAbsent

MEAN GSV DIAMETER

Present Absent

Mean GSV diameter

4.47 3.75

0.5

1.5

2.5

3.5

4.5

GSV

dia

met

er

 SFJ reflux Number of patients (n)

GSV diameter (mm)

p-value

Mean SD

Present 65 4.47 0.77

< 0.001

Absent 45 3.75 0.43

GSV

0 20 40 60 80 100

100-Specificity

100

80

60

40

20

0

Sensi

tivi

ty

DISTRIBUTION OF SFJ REFLUX & DVR IN C4 - C6 GRADE

C4 - C6 GradeSFJ Reflux

Present (n) Percentage (%)

Present 44 67.69

Absent 21 32.31

Total 65 100.00

C4 - C6 GradeDeep Venous Reflux

Present (n) Percentage (%)

Present 31 73.81

Absent 11 26.19

Total 42 100.00

DISCUSSION

• Irodi et al. – 12 % patients in C3 grade.– 43% patients in C4 grade.– 11 % patients in C5 grade.– 34% patients in C6 grade.

• Mercer – Study on 89 cases of lower limbs. – Detected reflux at the SFJ in 59 legs (66 per cent) and

at the SPJ in 26 (29 per cent) by duplex imaging.

DISCUSSION

• Myers et al. – Demonstrated combined prevalence of DVR and

reflux in superficial system to be 48 % in cases of varicose veins.

• Hanrahan and associates– Total incidence of deep system reflux to be 49.5%.– Did not quantify the reflux to primary or

secondary.

DISCUSSION

• Irodi et al. – Found 50 (50%) cases of deep venous reflux but none of

the cases had reflux in isolation.

• Myers et al. (1995)– Found that out of 96 cases; 8% cases had isolated DVR.

• Hanrahan et al. (1991) – Conducted a doppler study on 95 patients– Found the prevalence of deep venous reflux to be 2%

DISCUSSION

• Joh & Park – used recumbent patient position. – The mean diameter of a GSV with reflux was 6.4 ± 2.0

mm.– Normal GSV mean diameter measured 5.0 ± 2.4 mm.– GSV diameter threshold of 5.05 mm and greater had

the best value for predicting reflux.– The sensitivity and specificity at 5.05 mm were 76% and

60%, respectively.

LIMITATIONS OF STUDY

• No control groups of normal cases were taken

• Although quantitative assessment of deep venous reflux has been done, insignificant reflux in GPJ and PTV could have been due to inadequate valsalva technique.

• Non - availability of pneumatic cuff inflation technique in our study would have contributed to the results.

• Study of GSV and SSV has been primarily done at the junctional sites. Assessment of segmental reflux in these territories away from the junctional site would have given better correlation between various factors.

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