Implications of the Expanded Venous Reflux Study

Abstract

Background —Duplex ultrasonography remains the diagnostic modality of choice used to assess for venous reflux. Historically, our institution's practice assessed for deep venous reflux at the level of the common femoral and femoral veins, and the saphenous vein was only imaged at the saphenofemoral junction (SFJ). The American Venous Forum's Varicose Vein Venous Registry attempts to standardize the collection and analysis of clinical information on venous disease. As such, patients are subjected to a more complete study that expands on the superficial venous system. This investigation aims to identify those patients with superficial venous reflux whose diagnosis may have been missed with our previous protocol. Methods —This study reflects a retrospective review of all venous reflux studies performed with the expanded imaging protocol between October 1, 2010 and July 29, 2011, imaging the distal external iliac, common femoral, femoral, popliteal, posterior tibial, peroneal and anterior tibial veins. The great saphenous vein (GSV), small saphenous vein (SSV), anterior and posterior accessory saphenous veins (AASV and PASV), and perforator veins were evaluated for patency and reflux at multiple stations. The incidence and trends of various reflux patterns were examined. Results —A total of 1091 limbs of 593 patients were examined during this 10-month time period. Seventy-five limbs were excluded on the grounds of previous GSV harvest, stripping or ablation, limiting our analysis to 1016 limbs. Sixty-eight limbs (7%) revealed deep venous reflux without associated superficial reflux, 292 limbs (29%) revealed isolated superficial venous reflux, and 461 limbs (45%) revealed combined deep and superficial venous reflux. Of the 753 total limbs with superficial venous reflux, 528 limbs (70%) revealed “classic” reflux at the SFJ and 225 limbs (30%) revealed “accessory” superficial reflux without reflux at the SFJ. Of this “accessory” venous reflux cohort 76 limbs (34%) revealed GSV reflux caudal to the junction, 10 limbs (4%) revealed isolated AASV reflux, 20 limbs (9%) revealed isolated SSV reflux, 2 limbs (1%) revealed isolated PASV reflux, 10 limbs (4%) revealed perforator reflux exclusive of any other identified superficial venous reflux, and 106 limbs (47%) revealed a combination of accessory reflux patterns. Fifty-three of the 225 limbs with “accessory” venous reflux (24%) received surgical intervention in the form of “accessory” venous ablation or ligation, or 5% of the total patient population in this series. Conclusion —In summary, while the expanded venous reflux study requires more time and skill to perform, it reveals a cohort of patients with superficial venous insufficiency that may have previously been missed. Specifically, 225 limbs in our series (22% of the total series and 30% of limbs with superficial venous reflux) demonstrated “accessory” superficial venous reflux patterns without reflux at the SFJ which may have previously gone undiagnosed and thus untreated.