Leg Perforator Vein Incompetence: Functional Anatomy

Abstract

To retrospectively determine the anatomic patterns of reflux of incompetent perforator veins (IPVs) at the sites of their highest prevalence in relation to the anatomic distribution of valvular incompetence in the veins of the calf and thigh, with emphasis on the deep system, across the clinical spectrum of chronic venous disease (CVD). This study was granted institutional ethics committee approval; the need for patient consent was waived. Five hundred five limbs in 359 consecutive subjects who were suspected of having CVD but did not have arterial disease, prior venous thrombosis (<1 year), venous or orthopedic surgery, or vascular malformations were clinically stratified for CVD according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) system and underwent venous hemodynamic investigation with duplex ultrasonography. One hundred thirty limbs were CEAP clinical classes C(0-1), 262 limbs were classes C(2-3), and 113 limbs were classes C(4-6). IPV reflux patterns and anatomic distribution of deep venous reflux in the lower limb were determined across the clinical classes of CVD. Statistical analysis was performed with Spearman rank correlation, chi(2), and Mann-Whitney testing. Valvular incompetence in limbs with IPVs increased with CEAP clinical class (P < .01) in femoral, popliteal, posterior tibial, peroneal, gastrocnemial, and soleal veins; reflux was distributed evenly across these veins. Of 554 IPVs found, 377 (68.0%) occurred at four sites: middle third of medial calf (n = 165 [29.8%]), lower third of medial calf (n = 85 [15.3%]), middle third of medial thigh (n = 73 [13.2%]), and middle third of posterior calf (n = 54 [9.7%]). IPVs with superficial and deep reflux in adjoining veins, as compared with IPVs with superficial reflux alone, increased as clinical class increased from C(2) to C(6) (P < .02) at all four sites of highest IPV prevalence; determined in detail, reflux patterns of IPVs were linked to CEAP clinical class (P < .05) but not anatomic site (P > .2). Most IPVs in C(1-3) limbs had superficial reflux alone. IPVs with superficial reflux outnumbered IPVs with superficial and deep reflux even in C(4-6) limbs, where deep venous incompetence was most prevalent. Axial venous reflux (proximal-to-distal) changes (P > .4) were small in superficial and deep veins across the spectrum of CEAP clinical classes C(2-6). Patterns of perforator reflux were linked to clinical severity of CVD in the CEAP classification and displayed an even distribution anatomically. IPVs with deep and superficial reflux in adjoining veins increased with CEAP clinical class, in line with valvular incompetence in the deep veins of the calf and thigh.