European Journal of Cardiovascular Medicine

Varicose veins are enlarged, palpable subcutaneous veins with abnormal blood flow, typically located in the legs and the primary sign of chronic venous insufficiency. Their development involves a complex interplay between an individual's genetic background and risk factors, including age, gender, family history, pregnancy, obesity, and prolonged standing^1,2.

A significant proportion of patients with varicose veins are at risk of developing severe and potentially debilitating complications, including superficial or deep thrombosis, which can lead to pulmonary embolism or post-thrombotic syndrome. Additionally, long-standing varicose veins can cause skin thickening and pigmentation, known as lipodermatosclerosis, which can lead to chronic inflammation, scarring, and limited mobility. Furthermore, patients may experience haemorrhage from a superficial varicosity, which can be painful and require urgent medical attention. In some cases, varicose veins can progress to ulceration, which can be challenging to manage and may require prolonged wound care and rehabilitation. These complications highlight the importance of early detection and management of varicose veins to prevent progression to more severe and debilitating outcomes³.

Various methods employed for diagnosis of venous insufficiency are phlebography, Magnetic Resonance Venous Imaging (MRVI) and CT Venous Imaging (CTVI) and Duplex imaging⁴. Phlebography is useful in case of imaging secondary venous insufficiency. Ascending phlebography was a method of choice in past to demonstrate patency of the veins, define the anatomy and to detect incompetent perforating veins. It is performed by injecting contrast medium into a vein on the dorsum of foot and directing it into the deep veins with an ankle torniquet. However, it cannot provide a quantitative functional assessment of its severity or the adequacy of collateral veins and has been superseded by development of other non-invasive tests especially Duplex scanning⁵.

Magnetic Resonance Venous Imaging is useful in evaluation of the abdominal and pelvic vasculature. It can be employed for evaluation of pelvic venous outflow obstruction by providing information from the IVC through the iliac venous system. CT Venography can be used in the preoperative evaluation of varicose veins. CT Venography with 3D reconstruction can provide a thorough understanding of the of the varicose vein anatomy but has certain limitations such as it cannot provide real- time images and thus the movement of valve cannot be evaluated. Other associated limitations are radiation exposure, additional cost and contraindication in patients with renal dysfunction and allergy ^{6, 7, 8}.

The imaging of varicose veins has largely been superseded by Duplex imaging as it provides anatomic and functional assessment of venous reflux. The acceptability and non-invasive nature of the technique makes it suitable for routine pre-operative assessment.⁹ Good knowledge of the anatomy and pathophysiology of the varicose veins in patients is important in planning the appropriate treatment. The duplex ultrasound examination in patients with chronic venous insufficiency (CVI) should demonstrate both the anatomical patterns of veins and abnormalities of venous blood flow in the limbs¹⁰.

This study aims to evaluate and demonstrate both anatomical patterns of veins and abnormalities of venous blood flow in the lower limbs of patients presenting with varicose veins.

A descriptive cross-sectional study of 100 subjects with symptomatic and asymptomatic visible varicose veins referred from other clinical departments to the department of Radiodiagnosis were imaged using Duplex color Doppler ultrasonography at a tertiary care hospital from April 2019 to October 2019. The exclusion criteria were all the patients with deep vein thrombosis, lower limb varicose veins with pregnancy or intraabdominal masses and suspected arterial and lymphatic diseases of the lower limbs. After the informed consent was obtained, the study subjects underwent clinical manoeuvres for complete assessment of causes of chronic venous insufficiency. Patency of the sapheno-femoral junction (SFJ) and sapheno-popliteal junction along with duration of venous reflux at SFJ was assessed. Level of incompetent perforating veins and varicosities of the superficial venous system was evaluated using GE Voluson S10 Expert and GE Voluson P8 ultrasound machines.

Examination technique of lower limb venous doppler study: The venous system is examined in supine position with all venous segments were examined for venous flow characteristics and the effects of compression. The popliteal veins were examined in patient in prone with knees slightly flexed. All the veins were viewed in transverse and longitudinal plane imaging for compressibility and flow pattern respectively. The patients were instructed to breathe normally during USG examination. Venous reflux is assessed by imaging the targeted vein while applying limb compression using one of the described methods, then abruptly releasing it to observe the presence and duration of reflux. The Valsalva manoeuvre is performed to evaluate valvular competence at the saphenofemoral junction. A reflux duration of more than 500 msec was considered as significant incompetence. The perforators were examined in standing position with weight bearing on the non-examined limb. The incompetent perforators were identified and documented for their diameter at the muscle fascia location in relation to the knee, leg and ankle joints along the medial, lateral and posterior aspect.

Based on the data included in our study, the descriptive statistical analysis was applicable. The data collected were analysed in terms of mean, standard deviation, percentage calculations and expressed in the form of tables.

Demographic features of the study group:

Table-1: Age distribution:

Table 2: Gender distribution

The youngest patient was aged 21 years and the eldest one was 79 years with male preponderance of 79%. The mean age observed in the present study was 46.87 ± 6.4 years (tables 1 & 2).

Distribution of the affected limb:   

The bilateral limb involvement with varicosities was 40% followed by 31% in left limb and 29% in right limb as in the table 3.

Table-3:

Competency of the vessels affected - Saphenofemoral junction:

Amongst the 40 patients with bilateral lower limb involvement, 34 of them had incompetent saphenofemoral junction with majority of the patients had grade 1 & 2 saphenofemoral incompetency in both bilateral and unilateral limbs. (table 4; figures 1-4).

Table 4:

Figure 1: Transverse Pulsed wave (PW) Doppler image showing grade I reflux seen in right SFJ on Valsalva manoeuvre on standing.

Figure 2: Transverse PW Doppler image showing grade II reflux seen in right SFJ on Valsalva manoeuvre on standing and supine position.

Figure 3: Transverse PW Doppler image showing high velocity grade III reflux at left SFJ in standing position.

Figure 4: Transverse PW Doppler image showing high velocity grade IV reflux at left SFJ in supine position.

Competency of the vessels affected - Saphenopopliteal junction:

Incompetent Saphenopopliteal junction was observed among 13 patients and most of them (7 patients) had bilateral incompetence, whereas right and left saphenopopliteal junctions were affected among 4 and 2 patients respectively (table 5).  

Table 5:

Distribution of patients based on the presence of varicosities:

On analysing the varicosities based on their territories, majority of the varicosities were observed along the SSV territories in the both bilateral and unilateral affected limbs.  However, on considering the affected bilateral limbs, both SSV and GSV territories (10 cases each) were equally affected. Moreover, it was observed that out of 40 cases with bilateral affected limbs, 20 cases had both SSV and GSV territory varicosities (table-6).

Table 6:

Presence of incompetent perforators along the level of the lower limb affected:

It was observed that many patients had incompetent perforators at multiple sites with anterior thigh perforators were more common amongst the unilateral lower limb varicosities. Posterior mid-calf level perforators were predominantly observed amongst the bilateral lower limb varicosities with medial mid-leg region being the next common site of incompetent perforators (table 7, figures 5 & 6).

Figure 5: Transverse gray-scale US image showing a dilated incompetent perforator (arrow) noted at medial mid-leg level.

Figure 6: Transverse PW Doppler image showing dilated incompetent perforator (arrow) noted above ankle.

Table 7:

Duration of reflux at SFJ:

Above table illustrates majority of the cases with incompetent SFJ had reflux duration of more than 1000 msec with nearly equal number of patients had reflux duration of 1001 to 2000 msec (38.6%) and >2000 msec (36.1%) (table 8).

Table 8:

Out of 100 cases in the present study, most of the patients were in the age group of 41 to 50 years (39%) followed by 19% between 51 to 60 years, implying that the most common affected age group was 41 to 60 years. Similar to this study, a randomised trial study conducted in 2002 by Cesarone MR et al¹¹ on the epidemiology of varicose veins, reported that the venous abnormalities increase with age and another study by Narra RK et al¹² showed the highest rate of occurrence in the age group of 40 to 50 years and least in the age group of 20 to 29 years.

In the present study male predominance was observed with 79% being males and 21% females and similar gender demographic pattern was observed in the study conducted by Ummer SB et al¹³, where 21 (62%) were male and 13 (38%) were females. A study conducted in India by lrodi et al¹⁴ also opined that the male predominance due to the lesser number of affected Indian women seeking for medical help.

Bilateral lower limb varicosities, with the incidence of 40% followed by 31% with left lower limb and the rest 29% of right lower limb was observed in the present study. Whereas in the study by lrodi et al¹⁴ 59 patients had left side involvement and 41 with right sided involvement and no cases with bilateral limb involvement was observed. In the study conducted by Ummer SB et al¹³, out of the 38 limbs studied, 21 (55.2%) were right lower limb and 17 (44.7%) were left lower limb which was similar to the results seen in the present study population. However, few studies by Bechsgaard T et al¹⁵ and Robertson L et al¹⁶ have shown no difference between the sides and sites of involvement.

In this study, out of 40 varicose veins in both legs, 34 (85%) cases had incompetent SFJ bilaterally. Out of 34 patients with incompetent saphenofemoral junction (SFJ) in bilateral leg, 13 (32.5%), 11 (27.5%), 08 (23.5%) and 2 (5%) of them had Grade 1, 2, 3 and 4 incompetence. Meanwhile in right leg, 11 (47.8%) had grade 2, 10 (34.8%) had grade 1 and 1 each had grade 3 and 4 incompetence respectively. Whereas in the left limb, 12 (46.15%) had grade 1 incompetence, followed by grade 2 incompetence in 34.6% of patients and 12.9% and 3.22% presented with grade 3 and 4 incompetence. On analysing the saphenopopliteal junction, out of 40 patients with varicosities in both lower limbs 7 (17.5%) had incompetent saphenopopliteal junctions bilaterally. Whereas in 29 patients with varicose veins in only right limb 4 (13.8%) had incompetent SPJ and amongst 31 patients with left lower limb involvement 2 patients (6.4 %) had incompetency at saphenopopliteal junction. Similarly, in the study conducted by Bashir et al¹⁷ out of total 36 patients, 41.7% patients had incompetent SFJ and 11.12% patients had incompetent SPJ. In the study by lrodi et al¹⁴, the superficial venous reflux in some form was seen in all the limbs evaluated at the junctional sites and in the perforators with the SFJ being incompetent in 92 % of the limbs. The SPJ incompetence was found in 14 % of the limbs.

On analysing the varicosities based on their territories, majority of the varicosities were observed along the SSV territories in the both bilateral and unilateral affected limbs (43%).  However, on considering the affected bilateral limbs, both SSV and GSV territories (10 cases each) were equally affected. Moreover, it was observed that out of 40 cases with bilateral affected limbs, 20 cases had both SSV and GSV territory varicosities. Contrary to this, in a study conducted by Azhar et al¹⁰, 58.5% patients had GSV varicosities, 39% varicosities involvement of both GSV and SSV and 2.1% had varicosities involving only SSV territory.

It was observed that many patients had incompetent perforators at multiple sites with anterior thigh perforators were more common amongst the unilateral lower limb varicosities. Posterior mid-calf level perforators were predominantly observed amongst the bilateral lower limb varicosities with medial mid-leg region being the next common site of incompetent perforators. Earlier studies by Delis KT et al¹⁸ showed predominant involvement of medial leg perforators. In a study by Maragadha M et al¹⁹, of the 37 participants (62%) with perforator incompetence, majority of the incompetent perforators were medial to the ankle (28 of 37 – 75%). In the study by Azhar et al¹⁰ 69.5 % cases had an incompetent perforator at below knee, medial mid leg followed 67.4% patients with incompetent perforators below knee medial lower 1/3rd of leg.

In the present study the patients with increased reflux duration were more among those with femoral vein incompetency. The reflux duration was >2000msec at in 30 out of 83 patients at SFJ. In the study conducted by Irodi A et al¹⁴, duration of reflux was continuous in 39/92 patients at SFJ, between 1001 to 2000 among 20 of them, 10 each had the reflux duration of <1000mesc and between 2001 to 3000 msec. They have even described the distribution of this duration at femoral vein, popliteal vein and even at SPJ, which were comparatively lesser. Labropoulos N et al²⁰ analysed the upper limit of reflux duration, explains that the duration of reflux in superficial veins was between 0 to 2400 ms among their patients. The incidence of lesser than 500 ms was observed among 96.7% of these veins. In the perforator veins, deep femoral veins and calf veins it was mean of 190 ms. Hence, they interpreted that cut-off value for reflux in the superficial and deep calf veins would be >500 ms and for femoropopliteal veins >1000 ms. In a study by Bechsgaard T et al¹⁵, although the velocities at each incompetent level was not reported, the peak reflux velocities they observed at varicose veins by VFI method was 47.4 cm/s and by SDUS it was 62.0 cm/s, which are advanced doppler techniques. In the study conducted by Yamaki T et al²¹, 146 patients were documented to have peak reflux varicosity over 30 cm/s was associated with venous incompetence. Similarly, in Konoeda H et al²², RT at SFJ was 465 ms, and peak reflux velocity of 26.2 cm/s been reported among their cases with varicose veins.

Colour doppler ultrasound is a quick, cost-effective and non-invasive modality for assessing venous insufficiency of lower limbs having varying degrees of deep, superficial and perforator valvular incompetence with combined multiple sites being the commonest pattern. Thus, duplex color doppler ultrasonography is the investigation of choice in the evaluation of lower limb venous disease as a preoperative tool to identify the distribution and extent of reflux as well as mapping the incompetent sites, so that these are precisely targeted to achieve increased postoperative success rate.

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