Proximal Reflux Adversely Affects Distal Venous Function

Abstract

In limbs with chronic venous insufficiency (CVI), the presence of popliteal vein reflux has correlated with severity of venous insufficiency. Correction of proximal deep venous reflux has improved clinical manifestations of CVI, but the hemodynamic results of doing so have been disappointing. The present study was done to ascertain the effects of proximal reflux upon distal vein function. A total of 226 patients (175 women, 51 men) entered this study. Venous insufficiency in each of 450 limbs was classified according to Joint Councils' recommendations, and reflux was assessed by a modification of a method of Nicolaides and of van Bemmelen. Reflux in the femoral vein (FV), greater saphenous vein (GSV), popliteal vein (PV), and lesser saphenous vein (LSV) of the nonweight-bearing limb was quantitated by using the ATL 9 duplex scanner with a 5 MHz probe during rapid distal pneumatic cuff deflation. Data obtained included vein diameter, reflux volume, and reflux peak velocity. Limbs with PV reflux with and without FV reflux were then compared with those without PV reflux with and without FV reflux according to sex. The men in this study group were older than the women (P < 0.05) and had a more advanced stage of venous insufficiency (P < 0.001). Therefore, analyses were performed separately in men and women. In men, when FV reflux was absent, only 14 of 69 limbs had popliteal reflux (20.3%), but when FV reflux was present, 19 of 33 limbs (57.5%) also had PV reflux. In women, when FV reflux was absent, only 33 of 304 limbs had PV reflux (10.9%). However, when FV reflux was present, 12 of 48 limbs (25%) also had PV reflux. The diameter of the FV was not influenced by the presence or absence of PV reflux alone but if both FV and PV reflux was present, a greater FV diameter was observed in women. In men, the popliteal venous diameter was influenced by presence of FV reflux, and in women, PV diameter was increased in diameter if FV reflux was present and PV reflux absent. A trend toward increased volume and velocity of PV reflux flow was seen in women, but in men, PV volume and velocity of reflux flow were significantly greater if FV reflux was present. Limbs with multiple levels of reflux exhibited a higher clinical class of venous stasis than those with lesser numbers of levels of reflux. Accurate segmental evaluation of venous reflux by duplex scanning allows dissection of the influence of reflux within one venous segment upon another. Further, proximal reflux exhibits a deleterious effect on distal venous function. Correction of femoral venous reflux should be an objective in treating chronic venous insufficiency.