Endovenous Glue-Induced Thrombosis: Incidence, Risk Factors and Prevention

Ultrasonographic measurement of saphenous vein diameter compared to CEAP classification in patients with varicose veins

Annotation. The article presents the results of a study aimed at assessing changes in the diameter of the great saphenous vein of the lower extremities in patients with varicose veins treated with thermal methods. Two thermal techniques were considered in the study, namely endovenous laser ablation and radiofrequency ablation. The changes in the diameter of the great saphenous vein at different stages of treatment were compared: before surgery, 2 weeks, 1 month, 3 months, 6 months and 12 months after the intervention. The ultrasound method was used to determine the change in the diameter of the great saphenous vein. The results were processed using Microsoft Office for Windows software. The statistical analysis showed that both methods demonstrate high efficiency in the treatment of patients with varicose veins of the lower extremities. In both groups, a significant reduction in vein diameter was observed at each of the control stages. The conclusions of the study are of practical importance for choosing the optimal treatment tactics for patients with varicose veins of the lower extremities. They can serve as a basis for further clinical trials aimed at improving thermal techniques and evaluating their effectiveness in different groups of patients.

Annotation. The article presents the results of a prospective analysis of the data obtained by determining the change in the diameter of the great saphenous vein on the lower extremities in patients with varicose veins of the lower extremities who were operated on using non-thermal techniques. The present study highlights two non-thermal techniques that were used, namely: “Flebogrif” and “VenaSeal”. Also, the difference in the diameter of the great saphenous vein at different treatment periods was analyzed: before surgery, 2 weeks, 1 month, 3 months, 6 months and 12 months after surgery. To determin`e the diameter of the great saphenous vein, an ultrasound method was used. The data we obtained were processed using the Microsoft Office for Windows office suite for working with various types of data. The data obtained as a result of statistical processing indicate that both techniques are effective in the surgical treatment of patients suffering from varicose veins of the lower extremities. Both techniques, in both groups, demonstrated a positive effect of reducing the diameter of the great saphenous vein in the postoperative period, at each of the control stages. The data obtained allow us to better understand the effectiveness of the use of non-thermal treatment methods in patients suffering from varicose veins of the lower extremities.

Minimaly invasive and pathogenetically based methods are currently prevalent in phlebology, as they are in other fields of surgery. CHIVA (Сure conservatrice et hemodynamiу que de l’insuffisance veineuse en ambulatoire) hemodynamic surgery is one of these popular minimally invasive surgical procedures. The execution technique relies on the findings of a duplex ultrasound scan that is used to analyse the hemodynamics of the superficial venous network. The CHIVA strategy aims to preserve the venous material while also restoring normal distal venous pressure and venous function. However, this technique has a number of disadvantages, including the possibility of vein recanalisation and relapses, as well as the fact that the immediate cosmetic outcome is not always satisfactory. Objective — to compare the outcomes of lower extremity varicose vein treatment based on the employed method: the CHIVA method executed via open surgery versus the CHIVA method combined with other minimally invasive methods (sclerotherapy, endovenous laser coagulation (EVLC)). Materials and methods. A randomised prospective study was conducted on 52 patients with varicose veins of the lower extremities categorised as C1‑C3 according to the CEAR classification. The patients were divided into 2 groups of 26 patients each, with one group undergoing the CHIVA procedure using the classic open technique, and the other group receiving a combination of CHIVA with EVLC and sclerotherapy. To evaluate the results, we used Hobb’s criteria, measured the diameter of the great saphenous vein via ultrasound, analysed alterations in the Venous Clinical Severity Scoring (VCSS) , studied data from the Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ 20), and determined the incidence of relapses. Results. After CHIVA and CHIVA + EVLC + sclerotherapy, the normalisation of hemodynamics and interruption of the venous shunt led to a substantial reduction in the diameter of the great saphenous vein within 6 months after the operation (p<0.01). Both groups had an improvement in VCSS 6 months after surgery. No statistical difference was observed between the treatment groups. All methods had a positive impact on the quality of life of patients, as shown by the CIVIQ 20 questionnaire. Of the 52 operated patients, there were 4 relapses (7.7%). No relapses were noted in the group receiving CHIVA with EVLC and sclerotherapy (p=0.039). As evaluated by Hobb’s criteria, patients exhibited greater satisfaction with the outcomes of hemodynamic surgery combined with EVLC and sclerotherapy due to its better and faster aesthetic outcomes (р=0.012 and 0.05). Conclusions. All 52 patients exhibited favourable treatment outcomes, demonstrating a reduction in CVI symptoms during a comprehensive clinical assessment using ultrasound within 6 months and 1 year. The combination of CHIVA with EVLC and sclerotherapy showed distinct advantages in the treatment of varicose veins, yielding the most favourable cosmetic outcomes according to Hobb’s criteria and achieving a reccurence rate of 0%.

INTRODUCTION: Chronic venous insufficiency (CVI) is a pathological condition characterized by impaired outflow of venous blood from the lower extremities to the heart. CVI is one of the most common chronic diseases worldwide and is associated with high prevalence, age-related factors, geographical variations, and significant socioeconomic burden. In our study, we focused on differences in anthropometric parameters (internal lumen diameter) of the main subcutaneous veins of the lower extremities between healthy volunteers and patients with different classes of chronic venous insufficiency according to the CEAP (2020) classification. OBJECTIVE: To determine the relationship between the diameters of the great saphenous vein (GSV) and the small saphenous vein (SSV) in both lower limbs and the stages of chronic venous insufficiency (CVI) C3–C6 according to the CEAP (2020) classification, as well as the number of affected main trunks. MATERIALS AND METHODS: Ultrasound angioscanning was performed on a Mindray DC-70 (China) (5–12 MHz sensor) of the subcutaneous veins of the lower extremities of 165 patients: 20 volunteers without US-signs of damage to the venous system, 100 patients with varicose veins of class C3–C4а and 45 patients with active trophic ulcers of venous etiology that corresponded to class C6 according to the CEAP classification. The internal lumen of LSV and SSV was measured on both lower limbs at different levels. Statistics: The analysis was performed in SPSS 26.0. The normality of the distribution was tested using the Kolmogorov-Smirnov test. Group comparisons were made using Student’s t-test. The significance level was set at p<0.05. RESULTS: LSV diameter significantly increases from normal (3.3±0,5 mm) to classes C3–C4а (6.8±1.6 mm, p<0.001) and C6 (8.1±1.7 mm, p<0,01) according to CEAP (2020); SSV is significantly wider in patients with CVI (up to 6.3 mm) compared with healthy volunteers (1.9±0.3 mm, p<0.001), but without significant differences between C3–C4а and C6. DISCUSSION: According to the US study, the diameter of the LSV trunk significantly increases as CVI progresses to classes C3–C4а and C6 and can serve as a marker of disease severity. The absence of a significant increase in the diameter of the SSV trunk during the transition from class C3–C4а to class C6 emphasizes the leading role of LSV in the pathogenesis of trophic disorders in the soft tissues of the lower extremities in CVI. It was also observed that impaired venous outflow with a large number of affected mains significantly impairs tissue trophism in the zone of trophic ulcer formation. CONCLUSION: Thus, as a result of our study using ultrasound duplex scanning of the lower extremity veins, we found that the trunk diameter of the great saphenous veins significantly increased with the progression of chronic venous insufficiency to CEAP (2020) classes C3–C4а and C6. This can also serve as an additional marker of disease severity, which is consistent with the clinical guidelines for this pathology. At the same time, the absence of a significant increase in the trunk diameter of the small saphenous vein during the transition from class C3–C4а to class C6 underscores the leading role of the GSV in the pathogenesis of trophic disorders in the soft tissues of the lower extremities in CVI. With the progression of the pathology involving a large number of affected main trunks, the impairment of venous outflow significantly worsens tissue trophism in the area of trophic ulcer formation.

Three-dimensional computed tomography venography is a useful tool to identify increased saphenous vein diameter and provides a complementary road map for surgery in patients with varicose veins. In this study, we investigated the correlation between saphenous vein diameter on computed tomography venography and venous reflux detected on duplex ultraonography. We enrolled 152 patients (213 extremities) who underwent endovenous laser ablation therapy, following high ligation of the saphenofemoral junction between January 2014 and December 2019. All patients underwent preoperative computed tomography venography evaluation. The saphenous vein diameter was measured on computed tomography venography, and venous reflux was evaluated in the operating room using Doppler ultrasonography. Among the 152 patients included in the study, 61 showed varicose veins affecting the bilateral extremities. Among the 213 extremities investigated, 165 (77.5%) and 48 (22.5%) extremities showed varicosities involving the greater and lesser saphenous veins, respectively. Among all extremities, venous reflux was detected in 172 (80.8%). The mean diameter of the greater saphenous vein measured 5 cm distal to the saphenofemoral junction was 8.07±1.82 mm in patients with reflux and 5.11±1.20 mm in patients without reflux (p < .05). The small saphenous vein diameter measured 5 cm distal to the saphenopopliteal junction was 7.65±1.74 mm in patients with reflux and 5.04±1.80 mm in patients without reflux (p < .05). Based on the receiver operating characteristic curve, the greater saphenous vein threshold diameter of 5.880 mm measured 5 cm distal to the saphenofemoral junction was the optimal cut-off value to predict reflux (sensitivity 91.4%, specificity 81.8%). The lesser saphenous vein diameter of 5.285 mm measured 5 cm distal to the saphenopopliteal junction was the optimal cut-off value to predict reflux (sensitivity 94.9%, specificity 75.0%). Vein diameter cannot be used as an absolute reference for venous reflux; however, it may have predictive value in patients with varicose veins. Computed tomography venography based measurements of vein diameter may serve as a useful diagnostic tool to predict venous reflux and recommend treatment.

Three-dimensional computed tomography venography is a useful tool to identify increased saphenous vein diameter and provides a complementary road map for surgery in patients with varicose veins. In this study, we investigated the correlation between saphenous vein diameter on computed tomography venography and venous reflux detected on duplex ultraonography. We enrolled 152 patients (213 extremities) who underwent endovenous laser ablation therapy, following high ligation of the saphenofemoral junction between January 2014 and December 2019. All patients underwent preoperative computed tomography venography evaluation. The saphenous vein diameter was measured on computed tomography venography, and venous reflux was evaluated in the operating room using Doppler ultrasonography. Among the 152 patients included in the study, 61 showed varicose veins affecting the bilateral extremities. Among the 213 extremities investigated, 165 (77.5%) and 48 (22.5%) extremities showed varicosities involving the greater and lesser saphenous veins, respectively. Among all extremities, venous reflux was detected in 172 (80.8%). The mean diameter of the greater saphenous vein measured 5 cm distal to the saphenofemoral junction was 8.07±1.82 mm in patients with reflux and 5.11±1.20 mm in patients without reflux (p < .05). The small saphenous vein diameter measured 5 cm distal to the saphenopopliteal junction was 7.65±1.74 mm in patients with reflux and 5.04±1.80 mm in patients without reflux (p < .05). Based on the receiver operating characteristic curve, the greater saphenous vein threshold diameter of 5.880 mm measured 5 cm distal to the saphenofemoral junction was the optimal cut-off value to predict reflux (sensitivity 91.4%, specificity 81.8%). The lesser saphenous vein diameter of 5.285 mm measured 5 cm distal to the saphenopopliteal junction was the optimal cut-off value to predict reflux (sensitivity 94.9%, specificity 75.0%). Vein diameter cannot be used as an absolute reference for venous reflux; however, it may have predictive value in patients with varicose veins. Computed tomography venography based measurements of vein diameter may serve as a useful diagnostic tool to predict venous reflux and recommend treatment.

Background. The article presents the data of sonographic study of patients with varicose veins of the lower extremities in order to determine the typical ultrasound manifestations of connective tissue dysplasia. Revealed changes in these patients indicate a widespread and combined lesion of the lower extremity venous system almost on all the levels, which explains the pathogenic role of connective tissue weakness of veins framework and has a great diagnostic value in the planning stages of surgical treatment and selecting the volume of full and adequate surgical intervention. The purpose was to identify typical preoperative sonographic changes of the venous system in patients with varicose veins of the lower extremities with connective tissue dysplasia. Materials and methods. One-hundred and four patients with varicose veins of the lower extremities were preoperatively examined for typical clinical, phenotypic and biochemical markers of undifferentiated connective tissue dysplasia and divided into two groups according to the presence or absence of connective tissue dysplasia manifestations. Then, during preoperative preparation sonographic features were identified by ultrasound scanning using standard protocol for examination. Results. The form of varicose veins was determined in all patients. In patients with dysplasia symptoms mixed form dominated (23 (67.65 %) patients). During measuring main venous trunks the patients of this group had mainly thinning of vein walls, with significantly expanded diameters, reduced contractility, increased rigidity. In some places the walls of veins were significantly thinned. Valve unit worked poorly with signs of failure, which manifested by hemodynamic significant vertical and horizontal reflux. Reflux was mainly decompensated with retrograde blood flow over 1.5–3 seconds. Valve failure was observed in the superficial and deep veins. The patients often had abnormalities of sapheno-femoral junction: aneurysm extensions (7 (20.59 %)); tortuous great saphenous vein looking like a cluster of grape (4 (11.76 %)); real doubling the main trunk of the thigh (7 (20.59 %)) and shin (3 (8.82 %)). Also in this group of patients (23 (67.65 %)) widespread and combined varicose process of the main trunk in thighs and shins predominated. In addition, multiple perforating veins failure was observed, mainly in shins with hemodynamic significant reflux at these levels. Conclusions. Restructuring of the connective tissue in patients with symptoms of connective tissue dysplasia significantly affect the state of the venous system of the lower extremities, namely its functionality, which can be efficiently evaluate today with ultrasound scanning. In these patients sapheno-femoral junction valve failure with pronounced vertical reflux along a significant segment of the limb prevails. Perforating veins of shin and foot manifested with horizontal refluxes at their levels. In 2/3 patients mixed form of varicose vein of the low extremities was diagnosed that confirms the prevalence of venous system lesions with more severe varicose of the main venous structures. More often different configurations of vein aneurysm are determined, both in the area of junctions and along the venous trunk.

Aim. Improve the results of treatment of patients with decompensated forms of chronic venous insufficiency by determining the main forms of venous hypertension inherent in varicose veins and postthrombotic syndrome.&#x0D; Materials and methods. From 2018 to 2022, 147 patients with chronic venous insufficiency (CVI) C6 according to CEAP, aged from 38 to 69 years (on average, 55±5.3 years), were treated in the surgical clinic of the Communal non-commercial enterprise «Transcarpathian Regional Hospital» of the Transcarpathian Regional Council from 2018 to 2022. According to the etiopathogenesis of decompensated CVI, 76 (51.7%) patients were diagnosed with varicose veins of the lower extremities, and 71 (48.3%) patients with postthrombotic syndrome (PTS). Research of venous hemodynamics began with the determination of vertical reflux in the system of the large saphenous vein, then in the system of the small saphenous vein, then the presence of vertical reflux in the system of deep veins of the lower extremities and horizontal reflux in the thigh and lower leg. At the same time, isolated and combined forms of horizontal and vertical refluxes were distinguished.&#x0D; Research results. Based on the complex ultrasonographic examination (USG) and the etiopathogenesis of chronic venous insufficiency, 76 (51.7%) patients with varicose veins (VC) had superficial venous hypertension. In decompensated forms of PTPS, 71 (48.3%) in 68 (95.8%) patients had deep venous hypertension, and in 3 (4.2%) a mixed form of venous hypertension. According to USG studies, the diameter of the large saphenous vein (LSV) in patients of the 1st group was on average 10.3±0.2 mm, the small saphenous vein (SSV) was 5.3±0.1 mm. In patients of the second group, the diameter of the LSV was 11.1±0.5 mm, the SSV was 6.5±0.2 mm. Failure of penetrating veins in the first group was found in 14 (18.4%), and only in 12 (15.8%) cases horizontal reflux was single. The average diameter of penetrating veins was 5.1±0.5 mm&#x0D; In the second group of patients, horizontal reflux in penetrating veins was found in all patients, and in 56 (78.9%) of them, it was multiple. At the same time, the average diameter of penetrating veins was 5.8±0.9 mm.&#x0D; The size of trophic ulcers was larger in the second group of patients. With a diameter of a trophic ulcer up to 10 cm in patients with superficial hypertension, 42.1% had the IIst depth of the lesion, and with deep venous hypertension, the IIIst depth of the lesion was observed in 51.4% of cases. 34.2% of patients with superficial hypertension had trophic ulcers with a diameter of up to 5 cm and a depth of lesions of the IIst, then patients with deep venous hypertension had trophic ulcers of up to 5 cm in diameter with a depth of lesions of the IIst in only 5.8% of cases. IV st. of lesion depth was observed only in three patients with a mixed form of venous hypertension.&#x0D; Conclusions. In decompensated forms of varicose veins, superficial venous hypertension is observed in almost all patients. With PTS in the stage of decompensation, 95.8% of patients have a deep form of venous hypertension, and 4.2% of patients have a mixed form of hypertension. In 68 (95.8%) patients of the second group, blood refluxes in deep, penetrating and superficial veins were interconnected with each other, where their pathological effect was mutually reinforcing. In 61 (81.5%) patients with a superficial form of venous hypertension, each of the refluxes had an independent character and was hemodynamically unrelated to each other.

Summary. Introduction. Varicose veins of the lower extremities are an urgent medical and social problem, which leads to the continuous modernisation of diagnostic and treatment technologies. Surgical treatment of varicose veins has been and will remain the main method of treating varicose veins for a long time [1]. At the turn of the 20th and 21st centuries, a tremendous breakthrough occurred in the treatment of varicose veins. The classical varicose vein removal surgery (phlebectomy, safenectomy) with its disfiguring skin incisions, pain after surgery, long hospital stays and prolonged rehabilitation was replaced by laser surgery, the so-called endovenous laser vein coagulation (EVLC). According to international studies, the laser method (EVLK, EVLT, EVLO) surpasses all known methods of treating varicose veins in terms of therapeutic and cosmetic results and can be used in most cases. The best wavelength for venous laser is 1470 nm, and the effectiveness of the procedure depends on the method of laser coagulation. Aim. To analyse the effectiveness of combined surgical treatment of varicose veins of the lower extremities using ultrasound intraoperative navigation during the procedure. Materials and methods. The study included 246 patients with varicose veins of the lower extremities of class C2-C5. In 172 patients, varicose veins were detected in the basin of the IVC, in 49 patients - in the basin of the MPS, 25 patients had varicose lesions in the basin of the MPS and IVC, in 66% of patients, saphenous varicose veins (IVC and/or MPS) were combined with varicose veins in the basin of non-saphenous veins and reticular varicose veins. In 31% of patients, varicose veins had complications in the form of varicothrombophlebitis and/or saphenous vein phlebitis. Patients with signs of acute thrombosis (up to 1 month old) were not included in the study. The observation period lasted 1.5 years for each patient. All patients underwent a combined surgical intervention - EVLK and miniphlebectomy under ultrasound Doppler monitoring, in combination with sclerotherapy. Research results and discussion. The assessment of treatment results was based on the presence of patient complaints, analysis of clinical symptoms by a vascular surgeon, presence or absence of complications during the observation period, recurrence of the disease during the observation period, and analysis of ultrasound assessment of the veins by an ultrasound diagnostician. Ultrasound Doppler was performed on a mandatory basis in patients of all groups before surgical treatment, ultrasound intraoperative navigation during surgical correction and as a control within 1 to 3 days after surgery. Dynamic follow-up (including ultrasound Doppler) was performed in all patients at 1, 3, 6 and 12-18 months after surgical treatment. Conclusions. Most patients have a complete recovery after surgical treatment. Careful history taking in patients of this group and performing ultrasound Doppler ultrasound of the veins of the lower extremities allowed for effective surgical treatment. Specialists’ understanding of the capabilities of ultrasound Doppler ultrasound of the veins of the lower extremities, as well as compliance with the full examination protocol for ultrasound Doppler veins, allows us to provide detailed information to determine the most effective treatment tactics and prevent complications of the disease.

Purpose:Radiofrequency ablation (RFA) has gained popularity for treatment of varicose veins. The diameter of the saphenous vein should be considered before RFA because occlusion of the vein may differ depending on its diameter. Until now, however, there have been few data about the correlation between the diameter of the saphenous vein and the stump length after RFA. The purpose of our study was to investigate its correlation.Materials and Methods:A retrospective review was performed from prospectively collected data of RFA patients between March 2009 and December 2011. Preoperatively, the saphenous vein diameter was measured. Ablation was initiated 2 cm distal from the junction. Postoperatively, stump length was measured at 1 week and 6 months. After 2 years, we measured the length from the saphenofemoral junction to the leading point of occlusion for great saphenous vein, and length from the saphenopopliteal junction to the leading point of occlusion for small saphenous vein. The paired t-test, independent t-test, and correlation analysis were used for statistical analysis. P-value <0.05 was considered statistically significant.Results:During the study period, RFA was performed in 201 patients. Endovenous heat-induced thrombosis developed in 3 patients (1.5%). After 2 years, the stump length was obtained in 74 limbs. The mean diameter and stump length of the saphenous vein were 6.7±1.8 mm and 12.5±8.5 mm, respectively. Correlation analysis showed that the Pearson correlation coefficient of these factors was −0.017.Conclusion:There was no correlation between the diameter of saphenous vein and stump length.

Colour Doppler ultrasonography plays an important role in determining the morphological and hemodynamic information of the venous system. This study aimed to find out the prevalence of increased great saphenous vein diameter at the level of the knee among patients with varicose veins in a tertiary care centre. A descriptive cross-sectional study was carried out in the Department of Radiology at a tertiary care centre from 30 October 2021 to 31 March 2022 after taking ethical approval from the Institutional Review Committee (Reference number: 028-077/078). A convenience sampling technique was used for the study. The study group consisted of patients over 18 years, coming for ultrasonography examination of the lower limb with the clinical symptoms and signs of varicose veins. The great saphenous vein diameter was measured at the level of the medial femoral condyle of the knee using the software in the ultrasonography unit. B mode, colour Doppler and spectral analysis were done. A cut-off value of 5 mm for the diameter of the great saphenous vein was taken to indicate the presence or absence of varicosity and saphenofemoral reflux. Point estimate and 90% Confidence Interval were calculated. Among 72 patients with varicose veins, the diameter of the great saphenous vein was increased in 59 (81.94%) (74.50-89.38, 90% Confidence Interval) patients. The mean diameter of the great saphenous vein in our study was similar when compared to other studies conducted in similar settings. saphenous vein; ultrasonography; varicose veins.

A pilot study of venous duplex ultrasound parameters in healthy children.

Recommended reporting standards for endovenous ablation for the treatment of venous insufficiency: Joint Statement of the American Venous Forum and the Society of Interventional Radiology

Introduction: Chronic venous disease is a commonly occurring disease that includes a variety of pathological conditions like varicose veins, oedema, skin abnormalities, and ulceration, among which the most prevalent are the varicose veins. Doppler imaging is presently the first investigation for evaluating chronic venous disease. Aim: To investigate the relationship between Saphenofemoral Junction (SFJ) reflux and Great Saphenous Vein (GSV) diameter in patients with chronic venous disease and to determine the best cut-off value of GSV diameter in predicting reflux. Materials and Methods: The present cross-sectional study was conducted in the Department of Radiology, SRM Medical College and Hospital, Tamil Nadu, India, from December 2019 to June 2021 on 76 patients with chronic venous disease. The study was conducted on a GE Logic P9 ultrasound machine, the diameter of GSV was measured close to the SFJ, at the Proximal Thigh (PT); 15cm distal to the SFJ, and at the calf. The diameter of the GSV was compared with the presence of SFJ reflux. Similarly, Short Saphenous Vein (SSV) diameter was also measured posterior to the knee and was correlated with Saphenopopliteal Junction (SPJ) reflux. Chi-square and student t-tests were used for analysis with a cut-off value determined through Receiver Operating Characteristic (ROC) curve analysis. Results: The mean age of study participants was 51±15.85 years with age range of 19 years to 78 years. Of total, 42 (55.26%) had chronic venous insufficiency on the left side and 34 (44.74%) had on the right side. The mean GSV diameter at SFJ and at PT was higher in patients with SFJ incompetence and was statistically significant with a p-value of 0.001 and 0.002, respectively by t-test. Although the mean GSV diameter at calf was higher in patients with SFJ incompetence, it was statistically insignificant. The GSV diameter at the SFJ had the best cut-off value for predicting incompetence, with a mean diameter of 5.95 mm with 76.3% sensitivity and 76.3% specificity. The cut-off of SSV at the posterior knee for predicting SPJ incompetence was 4.6 mm which had a sensitivity of 72.7% and specificity of 88.7% and diagnostic accuracy of 86.84%. Conclusion: The GSV diameter at SFJ and PT help in predicting SFJ incompetence. The SSV diameter at SPJ aids in predicting SPJ incompetence.