References

Classification of varices over 607 echo mappings: natural history of varicose veins

in : Negus D., Jantet G., Colleridge-Smith PD, eds, Plebology 95, Suppl.1, London, Springer-Verlag,1995 ; 160-163
D. CRETON
E C Ambroise Paré, rue Ambroise Paré 54100 F. NANCY

INTRODUCTION

Preoperative mapping shows us that there is an enormous variety of types of limb varix. The more accurate the preoperative hemodynamic examination, the greater the variety of varix. We felt that it would be useful to classify this different types, and to compare them with the age of the patients, in order to try to understand how varicose illness evolves.

METHOD AND MATERIAL

In 1994 we studied 607 consecutive preoperative mappings carried out by Doppler ultrasonic scan (ESAOTE AU 530, 7.5 Mz 10 Mz) on patients with essential varices. During this period, a total of 740 varix operations were performed, of which 133 were for varicose recurrences ; the latter were excluded from this study.

RESULTS

We defined several anatomical types of varicose vein corresponding to several hemodynamic types of dysfunction :

  • 272 refluxes involving the entire long great saphenous vein from the saphenofemoral junction to the malleolar region. These 45% were labelled LSR (long saphenous reflux).
  • 87 refluxes involving the proximal great saphenous vein from the saphenofemoral junction to the upper bifurcation of the leg, the Boyd perforator region, respecting saphenous vein of the leg. These 14% were labelled SSR (short saphenous reflux).
  • 47 refluxes involving the short saphenous vein; 7.7% labelled SSV.
  • 20 associated refluxes involving all or part of the great saphenous vein and the short saphenous vein; 3.3%
  • 5 refluxes on an isolated popliteal fossa perforator vein; 0.8% labelled PFV (popliteal fossa vein).
  • 23 isolated refluxes on a saphenous tributary, essentially great saphenous vein with normal long saphenous trunk function; 3.7% labelled ST (saphenous tributary ).
  • 64 isolated varices fed by perforators, by crural genital veins or sub-cutaneous abdominal veins not involving the saphenous trunk; 10% labelled IV (isolated varices).
  • 21 refluxes isolated on the first tributary of the sapheno-femoral junction; 3.4% labelled ST1( first saphenous tributary ) (20 on an antero-lateral tributary, and one on a postero-medial tributary); reflux always respecting the continence of the saphenous preostial valve and sometimes the saphenous ostial valve.
  • 29 short refluxes involving a proximal high semi-saphenous vein from the sapheno-femoral junction to mid-thigh and running into a saphenous tributary (often antero-lateral ); 4.7% labelled HSR/2 (high semi saphenous reflux).
  • 21 short refluxes involving a distal low semi-saphenous vein fed by a thigh perforator or by a pudental vein respecting the arch and the saphenous termination; 3.4% labelled LSR/2 (low semi-saphenous reflux ).
  • 13 short refluxes involving a middle semi-saphenous vein respecting saphenous termination and the distal section of the leg; 2.1% labelled MSR/2 ( middle saphenous reflux ).

Although the age of the patients at the date of the operation does not correspond to the dates the varices appeared, it is nevertheless an efficient method of comparison with which to study the age at which the different sorts of varix appear. The cumulative patient percentage curve, based on the age of the patients when they underwent the operation, and for each category of varix, shows that varices which do not totally concern the great saphenous vein are operated in younger patients, whilst complete great saphenous refluxes concern patients who underwent operations at an older age. In the 30-40 age group we find :

  • 25% entire great saphenous vein refluxes (LSR)
  • 30% short reflux of the great saphenous vein (SSR)
  • 33% partial saphenous refluxes- high semi, low semi, middle -(SR/2)
  • 37% partial reflux on the sapheno-femoral junction, first saphenous tributary (ST1)
  • 48% refluxes on an isolated vein (IV)
  • 58% refluxes on a saphenous tributary (ST)

Approximately half of the non-saphenous pathology has already been operated on between the ages of 30 and 40, as against only 1/3 for complete saphenous pathology.

  • 50% of saphenous tributary refluxes (ST) are operated on at the age of 33
  • 50% of isolated vein refluxes (IV) are operated on at the age of 36
  • 50% of partial reflux of the sapheno-femoral junction (ST1) are operated on at the age of 40 1/2
  • 50% of partial reflux of the great saphenous vein -high semi, low semi, middle-(SR/2) are operated on at the age of 42
  • 50% of short reflux of the great saphenous vein (SSR) are operated on at the age of 42 1/2
  • 50% of complete saphenous refluxes (LSR) are operated on at the age of 44

  • BSI = STR: saphenous tributary reflux
  • Vi= IV: isolated varicose reflux
  • C/2 = ST1: partial arch reflux (first tributary)
  • S/2 = SR/2: partial saphenous reflux
  • SIC = SSR: short saphenous reflux
  • SIL = LSR: long saphenous reflux

COMMENTARY

This study shows that complete great saphenous vein reflux only occurs in 48% of cases; in 27% of cases the great saphenous vein is not at all touched by varicose illness, and in 25% of cases the reflux only concerns a part of the trunk.

This means that preservation-orientated intervention on the saphenous vein is possible in almost one case out of two.

Out of the 150 cases of partial long saphenous reflux: the last 20 cms of the proximal saphenous vein are healthy in 22% of cases; in 20% of cases the saphenous vein is healthy between the last 20 cms and the upper part of the leg, and in 86% of cases it is healthy at leg level.

  • Study of the cumulative percentages clearly shows that the earliest operated varices are those that do not involve entirely the great saphenous vein. Varicose disease would appear to begin with a pathology of saphenous tributaries operated on at an average of 10 years before complete saphenous insufficiency. Tab. I.

Reflux of saphenous tributaries would seem to appear before reflux of the saphenous trunk itself. This hypothesis corroborates a phenomenon that is often encountered: when there is a reflux on a saphenous tributary, the downstream saphenous trunk often has a greater diameter (several mms [1]) than that of the upstream trunk, and the reflux is often long, but slow; elimination of the saphenous tributary with reflux brings the diameter of the downstream trunk back to normal and makes the reflux disappear. This justifies the utility of early treatment of these types of beginning to varicose illness with regard to preserving the function of the long saphenous vein. The idea that reflux in a tributary can deteriorate the continence of the corresponding trunk was developed by Somjen [2] with regard to the popliteal saphenous junction.

Isolated varicose pathology seems to appear approximately 7 years before saphenous pathology, and in patients with saphenous illness, over a period of approximately 5 years we find the same graduation year after year, with the beginning of partial reflux on the sapheno-femoral junction, then partial saphenous reflux, then short reflux, and then, finally, complete reflux on the corresponding saphenous vein in the last stages of the varicose illness, affecting the entire saphenous tree, both trunk and branches.

CONCLUSION

Preoperative echo mapping is fundamental in differentiating different categories of varicose illness.

Complete stripping of the great saphenous vein is only justified in 48% of cases. In 27% of cases the saphenous vein is entirely normal, and in 25% of cases it is partially healthy.

Isolated varices, and especially isolated refluxes on a saphenous tributary which respects the saphenous function, would seem to appear 10 years before truncular saphenous reflux, which leads us to think that pathology of the saphenous tree begins with a pathology of the tributaries before affecting the trunk. The ablation of these saphenous branches could be a preventive treatment for the pathology of the saphenous trunk.

REFERENCES

  1. VIDAL - MICHEL JP., BOURREL Y. , ENSALLEM J., BONERANDI JI. Aspect chirurgical des crosses saphès internes modérément incontinentes par " effet siphon" chez le patient variqueux.
    Phlébologie 1993; 46 : 143-147
  2. SOMJEN GM., ROYLE JP., FELLE G., ROBERTS AK., HOARE MC., TONG Y. Venous reflux patterns in the popliteal fossa.
  3.  Cardiovasc Surg 1992 ; 33 : 85-91
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