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A systematic review of anatomical reflux patterns in primary chronic venous disease
Matthew K H Tan1, Roshan Bootun2, Roy Wang1
1Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, London, UK.
Insights
Chronic venous disease (CVD) severity is linked to reflux patterns. Deep and perforator reflux strongly predict advanced CVD and leg ulcers, guiding risk stratification and earlier treatment for better outcomes.
Area of Science:
- Vascular Medicine
- Medical Research
- Clinical Epidemiology
Background:
- Chronic venous disease (CVD) encompasses diverse hemodynamic abnormalities in deep, superficial, and perforator veins.
- Understanding the correlation between specific reflux patterns and clinical CVD manifestations is crucial for effective patient management.
Approach:
- A systematic review and meta-analysis of 18 studies (11,177 participants) was conducted, analyzing English-language research from 1946 to April 2024.
- Studies included participants aged 16+, documenting reflux patterns in multiple venous systems and their relation to clinical presentation and severity.
- Exclusion criteria focused on isolating CVD from conditions like deep venous thrombosis or post-thrombotic syndrome.
Key Points:
- Meta-analysis revealed significant associations between advanced CVD (C4-6) and deep reflux (OR 2.41) and perforator reflux (OR 3.37).
- Superficial reflux showed a non-significant association with advanced CVD (OR 2.11).
- Combined deep and superficial reflux demonstrated the highest risk for CVD progression, including varicose vein development and increased severity.
Conclusions:
- Reflux patterns are significant predictors of clinical CVD classification and severity.
- Higher stages of CVD correlate with increased prevalence of superficial, deep, and perforator reflux.
- Isolated deep and combined reflux patterns may predict the onset of leg ulceration, suggesting a need for risk stratification and early intervention.
Objective:
Patients with chronic venous disease (CVD) can present with different underlying hemodynamic abnormalities affecting the deep, superficial, and perforator veins. This review explores the relationship between reflux patterns, extent of venous reflux, and clinical manifestations of CVD.
Methods:
The Medline and EMBASE databases were searched systematically from 1946 to April 1, 2024. References of shortlisted papers were searched for relevant articles. Studies were included if they were in English language, included participants ≥16 years of age, documented reflux patterns in two or more of the following: deep, superficial, and/or perforator systems, and related patterns to presentation or severity. Exclusion criteria included patients with isolated deep venous thrombosis, post-thrombotic syndrome or stenotic or obstructive disease.
Results:
We identified 18 studies (11,177 participants; range, 55-3016). Meta-analysis showed significant odds ratios (OR) for C4-6 disease being associated with deep reflux (OR, 2.41; 95% confidence interval [CI], 1.53-3.78) and perforator reflux (OR, 3.37; 95% CI, 2.16-5.27), but not superficial reflux (OR, 2.11; 95% CI, 0.87-5.14), vs C0-3 disease. Severe CVD (C4-6) was significantly associated with isolated deep, combined deep and superficial, and combined superficial and perforator reflux. The greatest risk of CVD progression (defined as de novo development of varicose veins and progression to greater CVD severity) was shown by two studies to be related to combined deep and superficial reflux.
Conclusions:
Although limited by the heterogenous nature of the studies, this review confirms that reflux pattern is a significant predictor of clinical class, and higher clinical, etiological, anatomical, and pathophysiological stages are associated with a higher prevalence of superficial, deep, and perforator reflux. Isolated deep and combined reflux also seem to be to predict the onset of leg ulceration. Future studies should relate reflux patterns to treatment outcomes, including recurrence risk. This work could help to inform health policies and management guidelines so that reflux patterns, in conjunction with other demographic and hemodynamic parameters, could be used to risk stratify patients and identify individuals who may benefit from earlier treatment.
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