European Journal of Cardiovascular Medicine

Varicose veins, characterized by dilated, tortuous superficial veins, are a manifestation of chronic venous insufficiency (CVI). Varicose veins are a prevalent and long-standing condition primarily affecting the superficial venous system of the lower limbs, characterized by visibly dilated and tortuous subcutaneous veins.1 the great saphenous vein (GSV) is most commonly involved. Venous reflux, defined as retrograde blood flow lasting more than 0.5 seconds on Doppler, is a key pathophysiological mechanism.

A study suggests that approximately one-third of individuals aged 18 to 64 may experience varicose vein pathology during their lifetime2. Varicose veins is also a common condition in India, with studies showing varying prevalence rates among different populations. Research conducted in northern India revealed that 46.7% of females and 27.8% of males were affected by varicose veins3. The prevalence of the disease has high predilection among women than men and varies with occupation and environmental factors.” Numerous epidemiological investigations have demonstrated associations between varicose vein development and factors such as advancing age, hereditary tendencies, occupational immobility, pregnancy, metabolic syndromes, and hormonal imbalances. Additionally, Varicose Veins have been observed in adults without any apparent risk factors, suggesting role of genetics in development of this medical condition 4. Numerous symptoms, like throbbing, aching, swelling, fatigue and cramping of legs, can be caused by varicose veins. Emotional, physical, and financial quality of a patient’s life could all significantly affected by this illness. It may raise the risk of depression by causing social disengagement and low self-esteem. Additionally, leg fatigue can also interfere with regular activities and lower productivity at work5. If it is left without treatment, may lead to major complications like edema, thrombophlebitis, hemorrhage and skin alterations like dermatitis, lipodermatosclerosis, skin pigmentation or dis coloration, ulceration and induration of the skin6.

Varicose veins are diagnosed through a comprehensive general medical history and thorough physical examination, followed by precise diagnostic tests for assessing the type and severity of venous insufficiency. These tests may include duplex Doppler evaluation, duplex ultrasound imaging, angioscopy, thermography, phlebodynamometry or capillaroscopy.”

“Color Doppler ultrasound serves as a cornerstone in non-invasive vascular imaging, enabling visualization of venous blood flow and structural assessment to identify reflux and anatomical anomalies associated with venous insufficiency. Most hemodynamic parameters relevant to venous reflux diagnosis can be reliably obtained through color Doppler imaging. It serves as a valuable and efficient tool for ongoing vascular assessment7 Ultrasound-based colour Doppler imaging provides a non-invasive, reliable means to assess both the anatomy and function of superficial and deep venous systems. While venous reflux is a dynamic functional assessment, GSV diameter is an anatomical parameter that can also provide diagnostic and prognostic information.

This study explores the association between GSV diameter and the presence of reflux to assess if vein size can be used as a surrogate marker for reflux in clinical practice.

The present observational cross-sectional was conducted among patients with 144 extremities at tertiary care centre. The period of study was from February 2023 to February 2025. All the patients who had been diagnosed clinically as varicose veins and were referred for ultrasonography to Radio diagnosis department. Patients were selected by convenient sampling. All patients with clinically suspected varicose veins undergoing colour Doppler for evaluation of lower limbs were included. Patients with varicose veins confined to short saphenous vein territory and Patients with reflux in deep venous system or deep vein thrombosis were excluded.

The research protocol underwent review by the Institutional Review Board (IRB) and received approval by the ethics committee of Kalinga Institute of Medical Sciences and Pradyumna Bal Memorial Hospital, Patia, Bhubaneshwar, Odisha.

Study procedure: All ultrasonographic evaluations were performed using a GE Voluson S10 ultrasound machine equipped with a high-frequency (8-12 MHz) linear array transducer. To minimize inter-observer variability, all scans were performed by a single radiologist with expertise in vascular imaging. The examination was performed with the patient in the supine position. The diameter of the great saphenous vein (GSV) was measured at rest and during the Valsalva maneuver using grey-scale and colour Doppler sonography. The Valsalva maneuver was standardized by instructing patients to perform a forceful exhalation against a closed glottis to increase intra-abdominal pressure and enhance reflux detection.

Sites of Measurement: GSV diameter was measured at four predefined anatomical locations along its course from the Sapheno-femoral junction to the below-knee region:

·         2 cm distal to the Sapheno-femoral junction (SFJ).

·         Mid-thigh (midpoint between the SFJ and the lower thigh landmark).

·         Lower thigh (5 cm proximal to the superior margin of the patella).

·         Below the knee (5 cm distal to the inferior margin of the patella).

The maximal anteroposterior diameter was measured in millimeters at each site in transverse plane both at rest and during Valsalva maneuver. Measurements were recorded bilaterally when applicable. Assessment of Venous Reflux: Venous reflux was evaluated using colour Doppler and spectral Doppler imaging. Reflux was defined as retrograde venous flow lasting longer than 0.5 seconds after releasing manual distal limb compression or during Valsalva maneuver, consistent with Society for Vascular Surgery guidelines.”

Outcome Measure: The primary outcome was to determine the relationship between the GSV diameter at various anatomical sites and the presence of venous reflux. Additionally, the study aimed to establish cutoff values for GSV diameter at different levels, which may help identify venous reflux in patients unable to perform the Valsalva maneuver (e.g., due to obesity, poor effort, or restrictive lung disease).

Data Analysis

The collected data were tabulated in Microsoft Excel and analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Frequencies, means and standard deviations were drawn and summarised. Chi Square test, student t test & ROC Curve analysis for sensitivity & specificity were employed to compare and analyse the data. P value was set as equal or less than 0.05 was regarded to be significant.

A total of 144 extremities were included in the study, with patients in an age range of 29 to 84 years. The mean age was 53.88 years (SD = 10.96) Figure 1 reveals the distribution of age among participants. The 51-60 years’ age group has the highest frequency (50), making up 34.7% of the total, followed by 41-50 years’ group (29.9%). The 61–70 years’ age group comprised 19.4% of the study population, while those above 70 years accounted for 5.6%. Only 2.1% of the participants were younger than 30 years. (Figure 1) Most of the subjects were male gender comprised of 64% and rest were females (36%) (Figure2)

Table 1 reveals the presence of different symptoms related to varicose veins among the subjects. Pain was reported by 130 (90.3%) extremities, visible varicosities were found in 81 (56.3%) extremities, telangiectasia was present in 10 (6. 9%). Edema of the leg was observed in 72(50%), pigmentation was present in 93 (64.6%) and ulcer was noted in 28 (19.4%) extremities. Overall pain and pigmentation were the common symptoms. Edema and visible varicosities were observed in around half of the cases. (Table1)

More than half of the participants were present with venous reflux (76%) and 24% (34 subjects) of them were not having venous reflux. There was a significant difference (p less than 0.05) between the presence and absence of venous reflux among the participants. (Table 2)

Table 3 reveals the data on the Great Saphenous Vein (GSV) diameter at different anatomical locations, comparing cases with and without venous reflux. In both groups, the GSV diameter decreased from SFJ to below the knee. The largest difference was observed at the 2 cm distal to the SFJ in both the groups (6.33 mm vs. 3.97 mm).). The smallest difference is observed below the knee (4.80 mm vs. 3.30 mm). At all measurement sites, the mean GSV diameter was significantly larger in individuals with venous reflux than in those without and the difference was statistically significant (P = 0.001) at every site.(Table 3)

Table 4 explained the summary of all ROC curves of GSV diameter at 4 anatomical locations and interpretation of the cutoff values, sensitivity, specificity, and AUC for the GSV diameter at different measurement points. Highest Accuracy (AUC = 0.979) was observed at 2 cm distal to SFJ with Cutoff value of 5.25 mm, Sensitivity of 80%, and specificity of 98%. GSV Diameter at the middle thigh (AUC = 0.912), Cutoff value of 4.90 mm with 84% sensitivity and 80% specificity. GSV Diameter at the lower thigh (AUC = 0.920), Cutoff value of 4.75 mm with 74% sensitivity and 94% specificity and high specificity suggests this threshold is useful in ruling out false positives.GSV Diameter below the knee (AUC = 0.855), Cutoff value of 3.95 mm with 90% sensitivity but only 59% specificity. (Table4)

Table-1: Distribution of symptoms among subjects

Table-2: Distribution of venous reflux among participants

Table-3: Distribution of venous reflux at different sites of leg.

Table 4: Comparison of all ROC Curves at 4 anatomical sites.

The present study aimed to measure the association between venous reflux and the diameter of the great saphenous vein in patients with varicose veins using color Doppler ultrasound, by examining 144 extremities of patients who attended our hospital with a chief complaint of leg discomfort suspected to be due to varicose veins.

In this study varying association between the venous reflux and diameter of great saphenous vein at different anatomical locations was observed. This study confirms a strong positive association between GSV diameter and the presence of venous reflux, especially at the saphenofemoral junction. Increased vein diameter likely reflects chronic venous hypertension and valvular incompetence.

Prevalence of varicose veins was similar to previous research conducted in USA by Michael H. Criqui8. The Edinburgh Vein Study done by Muzaffar A et al. found that the prevalence of varicose veins increased from 11.5% in individuals aged 18-24 to 55.7% in those aged 55-649.  Similarly, a study published by Piazza G et al. noted that varicose veins affect approximately 22 million women and 11 million men between the ages of 40 to 80 years in the United States. These findings pointed the higher prevalence of varicose veins among older populations, consistent with the age distribution observed in this study10.” In the present study, more than half of the participants (64%) were male and 36 % of the individuals were female gender. Our observation of male predominance of varicose veins did not match with the observation of female predominance described in some of the literature. Research indicated a higher prevalence in women; for example, a study reported rates ranging from 2% to 56% in men and from less than 1% to 73% in women11. Similarly, the study by Tisi PV et al found that varicose veins are more common in women, with prevalence rates ranging from 25% to 33% in women and 10% to 20% in men12.

“

In this study, most of the study subjects presented with pain and edema of the legs as major symptoms. This observation was similar with findings from other recent studies by Yun S et al in 2021 highlighted that common symptoms of chronic venous disease were pain, heaviness, and discomfort in the lower limbs13. A comprehensive review by Raetz et al in 2019 noted that individuals with varicose veins often report aching, pain, tightness, and muscle cramps in the legs. These studies corroborate the present study findings, emphasizing that pain and edema are prevalent symptoms among individuals suffering from varicose veins14.”

Present study reported that approximately 50% of participants with varicose veins have a family history of the condition. This finding was similar with existing research highlighting the significant role of heredity in varicose vein development. A study reported by Ahti TM et al found that individuals with varicose veins were 21.5 times more likely to report a positive family history compared to control group15.  Present study reported that 76% of participants with varicose veins exhibited venous reflux, while 24% did not. This finding similar with other research conducted in Korea by Ji Yoon Choi16, in which 213 extremities were investigated, of which 172 exhibited venous reflux, constituting approximately 80.8%. Similarly, another study assessing valvular incompetencies in lower limb veins using Doppler ultrasound reported that saphenous venous reflux at the groin was noted in 63% of limbs17.

“Current study findings indicated that the Great Saphenous Vein (GSV) diameter is significantly larger in individuals with venous reflux compared to those without, with the most pronounced difference observed 2 cm distal to the saphenofemoral junction (SFJ) (6.33 mm vs. 3.97 mm) and the smallest difference below the knee (4.80 mm vs. 3.30 mm). These observations are similar to several studies conducted in India and globally, which have explored the relationship between GSV diameter and venous reflux.”

A study by Aiyappan et al. in Tamil Nadu assessed the association between SFJ reflux and GSV diameter in patients with chronic venous disease. The researchers measured the GSV diameter at the SFJ, proximal thigh (15 cm distal to the SFJ), and calf. They found that the mean GSV diameter at the SFJ was significantly larger in patients with SFJ incompetence (8.09 mm) compared to those without (5.31 mm). The study determined a cutoff GSV diameter of 5.95 mm at the SFJ to predict SFJ incompetence, with a sensitivity and specificity of 76.3% each18.

Study by Joh and Park in Korea reported that the mean diameter of refluxing GSVs was 6.4 mm, compared to 5.0 mm in normal GSVs. They identified a GSV diameter threshold of 5.05 mm as having the best positive predictive value for pathological reflux. This study highlighted the association between increased GSV diameter and presence of venous reflux19. Another research by Choi et al. found that the mean GSV diameter measured 5 cm distal to the saphenofemoral junction was significantly larger in patients with reflux (8.07 mm) than in those without reflux (5.11 mm).16

These studies, along with present study findings, focused on clinical significance of measuring GSV diameter at various anatomical locations, especially near the SFJ, to predict and assess venous reflux. The consistent observation that GSV diameter is larger in individuals with reflux highlights its potential as a diagnostic marker. 

These studies together supported that a GSV diameter in the range of approximately 5 to 6 mm near the SFJ is indicative of venous reflux, with high sensitivity and specificity. The slight differences in cutoff values and diagnostic accuracy metrics across studies may stem from variations in measurement protocols, patient populations, and the exact anatomical points of measurement.

Current study found that great saphenous vein (GSV) diameter at various anatomical locations and their corresponding diagnostic metrics are consistent with, yet slightly more sensitive and specific than, those reported in other studies.  Present study observed that the cutoff value as equal or greater than 5.25 mm with Sensitivity as 80% and Specificity as 98% at 2cm Distal to the Saphenofemoral Junction (SFJ). Area under the Curve was found as 0.979 which was highly acceptable. Higher specificity at this site suggested a more precise identification of patients without reflux, potentially reducing false-positive diagnoses. This finding was in accordance with other studies by John and park19in 2013, Choi et al16in 2022.  Present study observed that the Cutoff value as equal as or greater than 4.90 mm with Sensitivity as 84% and Specificity as 80%; Area under the Curve was found as 0.912 at Middle Thigh which is acceptable. Engelhorn et al., 20 concluded that GSV diameter thresholds ≥7 mm, 4 mm, and 4 mm at the SFJ, thigh, and calf, respectively, predict the reflux. Mendoza's study21reported that the GSV diameter at the PT (Proximal Thigh) typically ranges from 2 to 6 mm. Additionally, when the PT diameter was 3.7 mm or less, reflux was observed in only 3% of patients. Where as in the present study reflux was found in more than 70% of the subjects that may be suggesting that all subjects suffering severely with varicose veins.”

Present study observed that the Cutoff value as equal or greater than 4.75 mm with Sensitivity as 74 % and Specificity as 94%. Area under the Curve was found as 0.920 at lower thigh which was highly acceptable. Kim et al. in 2020 identified a cutoff diameter of 5.0 mm at the lower thigh, with an AUC of 0.642, indicating moderate diagnostic accuracy22.  Present study cut off value is slightly lower than previous research might be due to difference in techniques but the higher specificity in the present study at this location suggests a robust ability to correctly identify patients without reflux, minimizing false positives.

 Present study observed that the Cutoff value as equal or greater than 3.95 mm with Sensitivity as 90 % and Specificity as 59% at Below the Knee. Area under the Curve was found as 0.855 which was moderately acceptable. Engelhorn et al.23 in 1997 proposed a cutoff value of 4.0 mm at the calf, accurately predicting reflux 74% of the time which was similar to the current study. Present study found higher sensitivity at this site indicating a strong ability to detect reflux when present, though the lower specificity suggests a higher rate of false positives. Similarly, by interpreting ROC curves and interquartile range analysis of the study conducted by M. Young Jin Kim et al22 estimated cut off diameter below knee, could be close to the cut off diameter obtained in the study. However, the study did not calculate the cut off diameter below knee.

The study confirms a strong correlation between venous reflux and increased GSV diameter, having the most significant difference and highest diagnostic accuracy observed at 2 cm distal to the SFJ, with cut off diameter of 5.25 mm making it most reliable site for reflux detection. Measurement of the GSV diameter may be used to predict venous reflux in patients who cannot perform the Valsalva manoeuvre. It can also be used as standards for developing therapies and tracking results. GSV diameter can serve as a useful predictor of reflux and aid in clinical decision-making for intervention

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