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Haemodynamic and clinical impact of superficial, deep and perforator vein incompetence
V Ibegbuna1, K T Delis, A N Nicolaides
1Faculty of Medicine, Imperial College, St Mary's Hospital, Paddington, London.
Insights
Multi-system venous incompetence significantly worsens chronic venous disease (CVD) severity. Increased reflux and residual volume fraction correlate with more incompetent venous systems and perforators, detectable by duplex ultrasound.
Area of Science:
- Vascular Medicine
- Medical Imaging
- Clinical Diagnostics
Background:
- Chronic venous disease (CVD) affects numerous patients, with varying degrees of venous incompetence.
- Understanding the impact of multi-system venous incompetence on haemodynamics and clinical presentation is crucial for effective management.
Purpose of the Study:
- To evaluate the influence of combined deep, superficial, and perforator vein incompetence on venous haemodynamics and clinical status in chronic venous disease (CVD) patients.
Main Methods:
- 132 limbs from 121 patients with CEAP clinical classes C(1-6) were studied using duplex ultrasonography and air-plethysmography.
- Classification included superficial (S), deep (D), and perforator (P) vein reflux, number of incompetent systems (single, dual, triple), and number of incompetent perforators.
- Venous haemodynamics assessed via Venous Filling Index (VFI), Ejection Fraction (EF), and Residual Volume Fraction (RVF).
Main Results:
- Triple-system incompetence showed significantly higher VFI and RVF compared to dual and single-system incompetence.
- Superficial (+/-P) incompetence resulted in lower VFI and RVF than deep (+/-S+/-P) incompetence.
- Higher number of incompetent systems and perforators correlated with increased clinical severity (higher CEAP classes) and greater reflux.
Conclusions:
- Multi-system venous incompetence is associated with significantly worse venous haemodynamics and clinical severity in CVD.
- Duplex ultrasound can objectively assess the number of incompetent venous systems and perforators, providing a functional severity grade.
- Duplex ultrasound offers a practical alternative to air-plethysmography for grading venous function in clinical practice.
Objective:
The purpose of this study was to assess the effect of venous incompetence of the deep, superficial and perforator veins combined (i.e. multi-system incompetence) on the venous haemodynamics and clinical condition of limbs with chronic venous disease (CVD).
Methods:
One hundred and thirty two limbs (16-C(1); 30-C(2); 20-C(3); 25-C(4); 21-C(5); 20-C(6)) of 121 patients were studied. We excluded those with previous venous surgery/sclerotherapy, peripheral arterial disease, recent deep vein thrombosis (< or =6 months), or inability to comply with the tests. The CEAP clinical class was assessed. Duplex ultrasonography (ultrasound) enabled classification according to: the presence of superficial([S]) (+/- perforator([P])) or deep([D]) (+/-S, +/-P) reflux (>.5s); the number of incompetent venous systems (single-system([S/P/D]), dual-system([S+P/S+D/P+D]), or triple-system([S+P+D])), and the number of incompetent perforators([0/1/2/> or =3]). The amount of reflux (Venous Filling Index([VFI])); calf pump Ejection Fraction([EF]), and Residual Volume Fraction([RVF]) were studied with air-plethysmography.
Results:
VFI in limbs with triple-system incompetence (VFI median 6.68 [IQR: 4.7-9.7]ml/s) was higher than in limbs with dual-system incompetence (4.5 [2.1-7.4]ml/s), and VFI in the latter was higher than in limbs with single-system incompetence (1.3 [0.69-2.3]ml/s)(p<0.01 Kruskal-Wallis). Although EF changes were small, RVF in limbs with triple-incompetence (39 [30-51] %) was higher than in single-system incompetence (26 [16-33] %)(p<0.01 Mann-Whitney). Limbs with superficial (+/-P) incompetence had a lower VFI (p<0.01) and RVF (p<0.02) than limbs with deep (+/-S+/-P) incompetence, and limbs with > or =2 incompetent perforator veins had a higher VFI (p<0.04) than those without perforators. All limbs with single-system incompetence were C(1-3,) whereas 78% of those with triple-incompetence were C(4-6) (p<0.01). The number of incompetent systems increased with clinical class (p<0.01).
Conclusions:
The frequency of incompetence of more than one venous system increased with the clinical severity of venous disease and was accompanied by a 5-fold increase in the amount of reflux and a 50% rise in the RVF. The number of incompetent perforators per limb increased with the amount of reflux. The number of incompetent venous systems (superficial, deep, perforator) and perforator veins can be assessed by duplex ultrasound giving an objective indication of the functional severity of venous disease. In this way duplex ultrasound could be used to grade venous function in clinical practice as an alternative to APG measures which are less widely available.
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