Autor:innen:
Dr. med. Christoph Wilmanns | VenenClinic, Hochstraße 23, 53474 Bad Neunahr, Germany | Germany
Dr. Alicia Poplawski | University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany | Germany
Prof. Dr. med. Paul Karl Walter | Hospital St.Irminen, Krahnenufer 19, 54290 Trier, Germany | Germany
Background
Clinical consequences of reflux and recirculation in primary varicose veins are not completely understood. In particular the perforator type origin may not be sufficiently addressed by modern interventional therapy.
Purpose
Purpose was to define the reflux origin, recirculation pathways and associated clinical presentations in primary varicose veins.
Methods
In an explorative investigation the origin of superficial venous incompetence was assessed in 107 consecutive varicose limbs of primary or recurrent nature and of 79 patients as junctional (JP, great saphenous vein, reflux extends above or below the knee) or perforator reflux phenotype (PP, from suspect perforator veins (SPV, >3,9 mm or association with varicose tributaries in case of missing truncal reflux) or, for methodologic reasons, the small saphenous vein) and correlated with the clinical (CEAP C-) stage. Exclusion criteria was prior thrombotic disease. In order to determine recirculation pathways, reflux or reentry were recorded by duplex under Valsalva, or as spontaneous/under distal compression/de-compression, in 64 SPV as inside-out (i-o, reflux) or outside-in (o-i, reentry) and labeled with one or two points each, one point in case of a weak and/or short flow, two points in case of full color intensity or > 0.1 m/sec at PW-Doppler examination and >0.5 seconds duration. Phenotype, SPV parameter, and clinical stage were compared by multivariate analysis.
Results
68 limbs were with JP, 49/19 with/without presence of SPV, and 39 with PP. Peripheral complication CEAP C3-6 was associated with the presence of SPV in primaries (recurrences) of JP in 24/35 (63%) (6/14, 43%) limbs compared to 3/15 (20%) (0/4, 0%) without (odds 11.94, p < 0.01 / 12.30, p < 0.01). Advanced stage disease CEAP C4-6, however, at first manifestation was more frequent in case of JP below knee in 14/39 limbs (36%, 0.21, p=0.01) or JP above in 3/11 (27%, 0.25, p=0.12) compared with PP 5/31 (16%). SPV flow at first manifestation was more directed o-i in JP below knee (estimate 1.62, p=0.02) or i-o in JP above knee (0.29, p=0.81) compared with PP, but diameter of the most dilated perforator vein was higher in JP above knee (0.21, p < 0.01) or below knee (0.05, p=0.28) compared with PP. During peripheral compression SPV flow was more directed o-i compared with decompression (p=0.009). Subgroup analysis indicates a particular flow i-o of SPV during decompression in case of primary PP C3.
Conclusions
Multivariate analysis yields a comprehensive description of superficial hemodynamics and associated clinical presentation in primary varicose veins. High stage (C4-6) disease was predominantly associated with truncal origin of reflux combined with SPV while intermediate stage (C3-) disease rather with perforator type origin. SPV flow in case of JP was more reentry, in case of PP however more reflux. Clinical stage thus was associated with reflux origin and flow pattern of SPV impacting appropriate treatment decisions.