Saphenopopliteal Incompetence Research Articles

Varicose veins: a clinical profile

Background: The CEAP classification includes classifying varicose veins on the basis of their clinical, etiological, anatomical and pathophysiological classification.Methods: It was a prospective study of 50 patients presenting to a tertiary care hospital, MGM Medical College and Hospital, Kamothe, Maharashtra with varicose veins over a period of 2 years (November 2019 to November 2021). Institute Ethics Committee approval was obtained before start of study. All patients clinically diagnosed of symptomatic or complicated primary lower limb varicose veins with saphenofemoral and/or sapheno-popliteal incompetence with or without perforator incompetence were included. All cases with recurrent varicose veins were excluded. Result was tabulated and analysed at the end of the study using IBM SPSS software.Results: The age group with maximum varicose vein was between 21-30 years and incidence being more common in male population. The majority of the patients had massive varicose veins (C2). Pain was the most frequent presenting symptom. The majority of the study group had both saphenofemoral junction and perforator incompetence. Primary varicose veins are far more common (76%) than secondary and congenital varicose veins.Conclusions: Varicose veins are highly common in the Indian population. The CEAP classification has been a major contributor to advances in the field of varicose veins since its inception, and it has now become universally accepted due to its simplicity and reliability.

A prospective study of etio-pathogenesis, management and complications of lower limb varicose veins among the patients admitted in a rural Tertiary Healthcare Centre

Background: In a developing country like India, study encompassing the clinical evaluation and management of lower limb varicose veins on the conventional lines seem a necessity to improve the quality care with the available resources. Aims and Objectives 1. To analyse the age and sex incidence of lower limb varicose veins. 2. To study the correlation between occupation and lower limb varicose veins, the clinical manifestations of lower limb varicose veins, the different treatment modalities like sapheno-femoral flush ligation, multiple subfascial perforator ligations, stripping and sclerotherapy and the respective clinical outcomes at the end of three months of follow up.Methods: A total 60 number of patients with primary lower limb varicose veins were admitted, investigated, operated and followed up from June 2019 to January 2020. Final outcome was evaluated. Results: It was noted that the varicose veins affected the younger adult and middle age population. A greater portion (48.3) of the patients had combined valvular incompetence (sapheno-femoral and sapheno-popliteal incompetence) Sapheno-femoral flush ligation withstripping appeared to be the best method of surgical management for incompetence in the long saphenous vein territory. Subfascial perforator ligation in patients with no junctional incompetence showed no recurrence Sclerotherapy was found to be an effective procedure especially for early varicosities. Conclusions: Majority 0f the patients presented with complications of varicose vein with combined valvular incompetence and Sapheno-femoral flush ligation with stripping appeared to be the best method of surgical management for incompetence in the great saphenous vein territory. When no junctional incompetence is present, performing sub facial perforator ligation alone for isolated perforator incompetence showed no recurrence in this study.

A study on complications, surgical management and its outcome with varicose veins in lower limbs

Background: Varicose veins are a common clinical condition affecting the lower limbs. Usually patient comes for a cosmetic problem; it can cause complications giving rise to significant morbidity if not treated in time. Different options are available for surgical management. Aim & Objective: The present study mainly investigates the complications, surgical management and its outcome with varicose veins in lower limbs. Methodology: We include 80 patients over a two year period all admitted patients to a Princess Esra Hospital, Shahali Banda, Hyderabad and Owasi Hospital and Research Centre, Kanchan Bagh, Hyderabad from period June 2017-June 2019. Results: In the present study showed long saphenous system involvement in 72.5% of cases. Majority of patients in the present series were patients of CEAP class 2 and 3 class. Almost 73.75 % had combined saphenofemoral and perforator incompetence. In the present study, underwent duplex USG evaluation for confirmation of diagnosis. This investigation was required to accurately diagnose 18 cases of saphenofemoral incompetence, 10 cases of saphenopopliteal incompetence and 12 cases of perforator incompetence. Most of the patients had wound infections followed by hematoma and residual varicosity. Conclusion: From this study we conclude that commonest age group affected is 21-40 years. The involvement of long saphenous and communicating system is commonest followed by long saphenous involvement alone. Pain is the commonest symptom. Patients with involvement of longsaphenous and communicating system or long saphenous and short saphenous involvement were more symptomatic than the others. Commonest complication in post-operative treatment is wound infection. Complications of varicose veins responded well to operative treatment.

Endovenous Laser Ablation (EVLA) of Great Saphenous Vein to Abolish “Paradoxical Reflux” in the Giacomini Vein: A Short Report

Reflux in the GSV due to sapheno-popliteal incompetence associated with ascending (paradoxical) reflux in the Giacomini vein is a rare but well described pattern of reflux. Treatment of this type of reflux is controversial and only surgical treatment has been described. We describe 2 patients in whom this type of reflux was successfully abolished following endovenous laser ablation (EVLA) of the GSV with the SPJ and Giacomini vein regaining competency. Paradoxical reflux in the Giacomini vein and SPJ is secondary to GSV incompetence which exerts a syphon effect. EVLA of the refluxing segment of GSV interrupts this effect and prevents the paradoxical reflux at the SPJ.

Primary Lower Limb Varicosities Arising Directly from Normal Deep Venous Systems: A Series Report

Primary lower limb varicosities classically arise from incompetence of the junction of the superficial and the deep venous systems with retrograde flow into the saphenous veins. However, some patients with superficial varicosities have no demonstrable incompetence of the saphenofemoral or saphenopopliteal junctions. In this study, we examined 52 limbs with primary varicose disease in whom saphenofemoral and saphenopopliteal incompetence had been excluded (clinically and with the hand-held Doppler) using a duplex ultrasound scan. Seventeen (33%) of the limbs had superficial varicosities despite normal long and short saphenous veins. The varicosities in 12 of these legs originated from groin veins, while those in the remaining 5 limbs communicated directly with normal deep veins. In this latter group of limbs, the superficial varicosities were found on the lateral aspect of the thighs only. Primary varicosities arising from normal deep venous systems have not been previously described, and are relatively rare (1.0% of patients referred to our clinic). As this complex venular anatomy was only detected on duplex scanning, we conclude that this study provides further evidence of the need for this imaging modality in patients with varicose disease of uncertain origin and/or those with an unusual distribution of superficial varicosities.

Treatment of primary varicose veins: An assessment of the combination of high saphenous ligation and sclerotherapy

This study was conducted to determine the optimal treatment for minimizing the recurrence of varicose veins, and to assess the value of the combined treatment of high saphenous ligation and sclerotherapy. A combined total of 967 limbs in 660 patients with primary varicose veins were treated. The treatments comprised: sclerotherapy alone in 81 limbs, high saphenous ligation alone in 3 limbs, a combination of sclerotherapy and high saphenous ligation in 843 limbs, and a combination of sclerotherapy and ligation of incompetent perforating veins in 10 limbs. Recurrent varicose veins appeared from 3 months after the initial treatment in 61 (6.3%) limbs. Saphenous-type recurrence, being the presence of saphenofemoral incompetence (SFI) and/or saphenopopliteal incompetence (SPI), was found in 20 limbs, and further treatment was given. Segmental-type recurrence, being superficial varices without SFI or SPI, was found in 41 limbs, all of which were treated with further sclerotherapy alone. To minimize the recurrence rate of varicose veins, the presence or absence of SFI, SPI, and incompetent perforating veins must be confirmed prior to the initial treatment. It was concluded that the combination of high saphenous ligation and sclerotherapy is effective for patients with SFI and/or SPI, whereas sclerotherapy alone is better for patients without SFI or SPI.

Preliminary Results of PTFE Patch Saphenoplasty to Prevent Neovascularization Leading to Recurrent Varicose Veins

Objective: Recurrence is common after varicose vein surgery. Neovascularization may be one cause of recurrent veins. This was a study of PTFE patch saphenoplasty to try and prevent recurrent veins. Design and setting: Prospective cohort study of patients treated in a vascular surgical unit. Patients and interventions: Fifty patients having surgery for symptomatic long saphenous varicose veins (66 legs, 51 primary and 15 recurrent veins) had a PTFE patch sutured over the saphenous opening after flush saphenofemoral ligation. Main outcome measures: The rate of varicose vein recurrence and neovascularization 1 year after surgery were determined using clinical examination and venous duplex imaging. Results: Forty patients (80%) remained pleased with the results of their surgery. Recurrent veins were visible in 14 (21%) legs: 10 were principally due to neovascularization, two to sapheno-popliteal incompetence and two to an incompetent mid-thigh perforating vein. Three other legs had neovascularization but no recurrent veins. Both recurrent veins (47% versus 14%) and neovascularization (40% versus 14%) were significantly more common in patients having surgery for recurrent veins. Conclusions: PTFE patching was safe but did not abolish neovascularization. Neovascularization was the principal cause of recurrent veins in this study and perseverance with investigations into other barrier methods is worthwhile.

Prospective audit of surgery for varicose veins.

Recent reports have demonstrated a high recurrence rate following varicose vein surgery. It has been suggested that this is due to inadequate surgery. This has been assessed by a prospective surgical audit. Fifty limbs in 33 patients awaiting varicose vein surgery were examined before operation and 6 weeks after operation. A duplex scanner was used to detect sites of venous incompetence. Eighteen operations were performed for recurrent disease, 38 limbs had an incompetent connection between the long saphenous vein or another superficial vein and the common femoral vein in the groin, and 11 limbs had saphenopopliteal incompetence. Following surgery, persisting incompetence existed in seven limbs in the groin and eight limbs in the popliteal fossa; this was due to inadequate surgery in 13 of 15 cases. Thirty-four operations were performed by trainees who were responsible for 14 of the 15 cases of persisting incompetence in the groin or popliteal fossa. Improved surgical technique and training is required to reduce recurrence following varicose vein surgery.

A comparison of colour duplex ultrasound with venography and varicography in the assessment of varicose veins

Ninety-three legs in 68 consecutive patients presenting for preoperative assessment of varicose veins were examined by a combination of ascending venography with varicography and also by colour duplex ultrasound. Ninety-one to ninety-two per cent of incompetent sapheno-femoral and sapheno-popliteal communications were demonstrated by ascending venography/varicography and 92-95% by ultrasound. Ascending venography/varicography demonstrated 83-90% of incompetent perforators whilst ultrasound demonstrated only 40-63%. We conclude that ultrasound is an accurate method of assessing primary and recurrent sapheno-femoral and sapheno-popliteal incompetence but is of limited value in assessing perforator incompetence. This is a significant limitation of ultrasound in view of the importance of perforator disease, and it is likely that this technique can only be used in combination with other venographic methods.

Duplex ultrasonography of recurrent varicose veins.

Varicose veins are a common clinical finding with a high recurrence rate following treatment with either surgery or sclerotherapy. Patterns of incompetence in 100 limbs with recurrent varicose veins were determined using duplex ultrasonography. Saphenofemoral or recurrent groin tributary incompetence was present in 44 limbs, an incompetent long saphenous remnant in 20, saphenopopliteal incompetence in 28, perforator incompetence in 35 and deep venous incompetence in 22. No significant incompetence was detected in 15 limbs. The findings suggest an important role for deep venous incompetence in recurrent veins and show that a re-exploration of the groin is unnecessary in over half of limbs with recurrent veins.

The morphology of recurrent varicose veins

Over an 18-month period, of 444 patients referred for treatment for varicose veins, 95 (21%) had had previous surgery. By means of clinical hand-held Doppler and in selected venographic evaluation these were subdivided into three groups as follows. Type 1:29 of the 95 patients had recurrence through thigh perforators. Type 2:10 patients had developed incompetence through a second saphenous system, in nine of the 10 in the short saphenous having had previous long saphenous surgery. Type 3:46 patients had recurrent sapheno-femoral incompetence and 10 sapheno-popliteal incompetence. A persistent long saphenous trunk in the thigh was present in approximately two-thirds of cases of types 1 and 3. In over half of the type 3 patients saphenofemoral recurrence was by reconstitution of the junction by neovascularisation. These morphological studies demonstrate why there may be an increased risk of recurrence if the long saphenous trunk is not excised at the time of primary surgery.

Functional Meaning of Different Injection Levels in the Course of Sclerotherapy

The successive changes of vein function in the course of sclerotherapy were studied by non-invasive photoplethysmography. The effect of injection at different levels was analysed in 30 patients, 22 with long saphenous varicosis, four with short saphenous varicosis and four with long saphenous varicosis and leg ulcers. The first two groups were treated by injections descending from the *crosse (saphenofemoral or saphenopo-pliteal junction) according to the method of Tournay. The third group (with leg ulcers) were treated by ascending injections, beginning adjacent to the ulcer and ending with crosse injection. Three case-reports are given, of one in each group, to show the typical changes of vein function in the different sclerosing methods. Crosse obliteration proved to be the most important step in improving vein function. It was followed by sclerosing of perforators of the lower leg, which influenced vein function in varying ways. Sclerosing remaining varicose dilations only optimized the cosmetic results without any measurable effect on vein function. According to our observations, failure to correct sapheno-femoral respectively sapheno-popliteal incompetence is inadequate treatment.

The assessment of primary varicose veins by doppler ultrasound—The role of sapheno-popliteal incompetence and the short saphenous systems in calf varicosities

One hundred consecutive limbs presenting with primary varicose veins to a surgical outpatient clinic were assessed clinically and by Doppler ultrasound. By this means the incidence of sapheno-femoral and sapheno-popliteal incompetence was established and the relative role of these two systems in the development of varicosities determined.

The Incidence, Diagnosis and Management of Sapheno-Popliteal Incompetence

The great variation in the reported incidence of S-P incompetence suggests that it is often overlooked in patients with varicose veins. In a small series of 200 patients the incidence of S-P incompetence was 24%. Recurrent varicose veins were due to primary S-P incompetence in 36% of legs (following S-F ligation) and recurrent S-P incompetence in 14%. The diagnosis is made on clinical and Doppler examination. Surgical management requires a sound knowledge of the anatomical and pathological variations in the popliteal fossa, and a wide exposure to ensure flush S-P ligation. Recurrent S-P incompetence is usually due to inefficient surgery, but may be due to ‘regrowth’ following flush S-P ligation.

Doppler ultrasound detection of saphenofemoral and saphenopopliteal incompetence and operative venography to ensure precise saphenopopliteal ligation.

Recurrent varicose veins may result from inadequate assessment or inadequate surgery. In this study, 110 consecutive patients (165 limbs) were assessed pre-operatively for the presence or absence of reflux at the saphenofemoral (SF) and saphenopopliteal (SP) junctions by clinical assessment and by Doppler ultrasound. The pre-operative results where then compared with findings at the time of surgery. Doppler ultrasound as a means of predicting SF and SP incompetence was superior to clinical assessment. Doppler Doppler ultrasound detected 100% (two false positives) of incompetent SF junctions, and 100% (six false positives) of incompetent SP junctions, compared to the clinical detection of 72% (no false positives) and 64% (five false positives), respectively. Short saphenous venography was performed in 36 limbs in which SP reflux was suspected on clinical assessment and/or by Doppler ultrasound. It proved valuable in demonstrating the level and mode of termination of the short saphenous vein. This guided the placement of the skin incision.