LOWER LIMB VARICOSE VEIN and UVDE

Background: To evaluate the effectiveness of ultrasonic venous duplex examination (UVDE) for lower limb varicose vein.

Materials and methods: Sixty-five patients with varicose vein of the lower limb during a 2-year period were enrolled in this study. There were 21 men and 44 women with an age range from 20 to 80 years and a mean age of 60 years. All patients received UVDE to determine the causes of varicose vein, including valvular incompetence, incompetent perforating vein, deep vein thrombosis, and congenital abnormality.

Results: In these 65 patients with 80 abnormal lower limbs, valvular incompetence was observed in 40 lower limbs (50%), valvular incompetence combined with incompetent perforating vein was observed in 22 lower limbs (27.5%), incompetent perforating vein only was observed in 13 lower limbs (16.3%), deep vein thrombosis in four lower limbs (5%), and congenital abnormality in one lower limb (1.2%).

Conclusion: Ultrasonic venous duplex examination (UVDE) is a safe and effective technique for evaluating lower limb varicose veins before planning the treatment course.

ª 2013, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. All rights reserved.

Discussion

Among the methods used to treat lower limb varicose vein, surgical treatment is the standard management [6e8].

However, curative resection is frequently precluded because of medical comorbidities that render patients inoperable and cause cosmetic problems for young individuals after surgery. Under these circumstances, alternative minimally invasive therapies such as percutaneous injection sclerotherapy, endovenous radiofrequency ablation and laser therapy were developed [9e11]. The treatment course for varicose vein depends on the etiology and severity of the varicose vein. To prevent local recurrence, patients with lower limb varicose vein need to be evaluated to assist in determining the etiology.

Because of technological advances in US, several studies have supported UVDE as an efficient and valuable technique for diagnosing the presence and determining the etiology of varicose veins [3e5]. The deep venous system is not involved in patients with primary varicose vein. Patients with secondary varicose vein develop this condition because of damage to the deep venous system, usually caused by deep vein thrombosis [12]. UVDE is a noninvasive, simple and reproducible diagnostic tool that can demonstrate the cause and location of lower limb varicose vein before planning the treatment course and post-treatment follow-up [2e5].

Incompetence of the greater or lesser saphenous vein or both has been reported to be the most common cause of lower limb varicose vein [1]. Our study results also demonstrated that 50% of the lower limbs with varicose veins resulted from sapheno-femoral valvular incompetence. On B-mode and color flow imaging, the dynamic motion of venous valve was well demonstrated. On spectral Doppler imaging, the direction of flow during the Valsalva’s maneuver also could be assessed well [1,12].

In addition to incompetence of the venous valve, incompetent perforating vein appears to have a role in the cause of lower limb varicose vein.

Manfred et al [2] used ascending venography and color-coded duplex sonography for detection of incompetent perforating vein and demonstrated more incompetent perforating veins were found by ascending venography. In our study, the incidence of perforating vein with reflux in the perforators with diameters 4 mm was high (8/10, 80%). Phillips et al [13]suggested that the difficulty in demonstrating reflux with US in all incompetent perforating veins is because of the small volume and low velocity of flow involved. This may explain, in part, why the two perforators with diameter 4 mm, but without reflux demonstration on UVDE was probably incompetent.

One of the limitations of the present study was that it was performed as a retrospective single-center study with limited patients. Another limitation was that 40% of patients received conservative treatment after UVDE, the location and diameter of incompetent perforating vein could not be confirmed, which possibly led to the bias.

In conclusion, UVDE is a safe and effective examination for detection of valvular  incompetence and the anatomic location of incompetent perforating vein of lower limb varicose vein before planning the treatment course.