Elsevier

Cardiovascular Surgery

Volume 7, Issue 3, April 1999, Pages 332-339
Cardiovascular Surgery

Recurrent varicose veins: patterns of reflux and clinical severity

https://doi.org/10.1016/S0967-2109(98)00149-5Get rights and content

Abstract

Duplex scanning was used to determine patterns of recurrent varicose veins in 264 limbs and to relate these to clinical factors. All limbs had previously undergone sapheno-femoral ligation in the groin. A recurrent sapheno-femoral junction was present in 172 (65.2%). Incompetence was found in long or short saphenous veins in 232 limbs (87.9%), perforators in 176 (66.7%), and deep veins in 156 (59.1%). Residual long saphenous veins were present in 43.4% and 73.6% of limbs that were with and without stripped long saphenous veins, respectively. An incompetent thigh perforator was present in 14.0% and 15.3% of these two groups, respectively. Multiple sites of incompetence were observed in the majority (75.4%). In general, no particular reflux pattern in the groin was related to an increased incidence of ulceration. However, ulceration was more frequent in limbs with deep reflux to knee or below-knee levels. None of those with isolated reflux in the groin that was unrelated to the common femoral vein had ulceration. The pattern of reflux was unrelated to striping or non-striping of the long saphenous veins and the time since initial surgery. A history of deep vein thrombosis was invariably associated with some degree of deep reflux. A system of recurrent patterns in the groin is described for the purpose of surgical audit. In 15.1%, recurrence was attributed with some confidence to inadequate surgery. These results indicate that the pattern of recurrence is highly variable and often with multiple sites of incompetence. In a few instances, the pattern of recurrence was associated with specific clinical factors. A full work-up including duplex scanning is recommended.

Introduction

Recurrence of varicose veins continues to be a significant dilemma and contributes substantially to the workload in venous surgery. The recurrence rate at 5 years after surgery is frequently up to 50% and nearly one-quarter of the patients attending venous clinics are seen for recurrent problems 1, 2, 3. Once they have occurred, a clear definition of the sites of venous reflux should be made before re-operation is embarked upon. Various methods have been advocated, but the development of duplex ultrasonography has offered a non-invasive approach providing both anatomical and functional detail 4, 5, 6, 7, 8, 9, 10. This approach now is accepted as an effective method for improving surgical outcome.

Recurrence patterns have been described by several groups, including those based on ultrasonography, varicography or phlebography, to assist in the surgical management of recurrent varicose veins 2, 7, 8, 9, 10, 11, 12. Different approaches to classification have been taken; however, their relation to clinical factors and in particular to severity of venous insufficiency have not been well defined. Whether the pattern of recurrence may indicate the risk of venous ulceration and hence priority for venous surgery has not been addressed. Whereas high recurrence rates are uniformly reported with the cause often attributed to inadequate surgery, it may be possible that patterns of reflux in the groin may help to distinguish the adequacy of previous surgery from true recurrence, new disease or previously unrecognized reflux.

This study compares clinical features, including the type of initial surgery and severity of venous disease, with the distribution of reflux sites as determined by complete duplex scanning of the lower limb in order to determine whether specific patterns of recurrent varicose veins are associated with a greater severity of venous insufficiency. A classification of the recurrence in the groin, which might be useful for auditing the surgeon's contribution to recurrence of varicose veins, was also developed.

Section snippets

Patients and methods

From February 1992 to June 1996, patients attending the general surgical clinics at Dunedin Hospital with symptomatic recurrent varicose veins after previously undergoing superficial venous surgery in the groin were clinically assessed. Those judged to have disease warranting surgery, in an environment of restricted resources and long waiting lists, were referred for vascular laboratory assessment including duplex scanning. All subjects consented to the study, which had been approved by the

Results

A total of 163 patients (female 103, male 60) with 264 affected limbs were studied. The average age was 63.2±12.3 years. A history of varicose veins was present for 34.0±13.6 years. Varicose veins had recurred in both legs in 101 patients, in the left leg only in 30 patients and in the right leg only in 32. Ulceration occurred in 119 limbs (45.1%) with current ulcer in 78 and healed ulcer in 41 limbs. The average time from noticeable varicose veins to ulceration was 20±8.7 years. A history of

Discussion

This series was clinically characterized by an older population with a longer history of varicose veins and a high ulceration rate, which reflects the pattern of referral to a vascular clinic. The distribution of gender was similar to that in primary varicose veins and recurrence did not favour a particular side.

In general, the patterns of reflux observed in this study were hardly predictable from clinical factors. Age, duration of symptoms and time from initial surgery had no effect on any of

Acknowledgements

The authors are grateful to the participants in the study. This work was supported by the Health Research Council of New Zealand.

References (34)

  • S. Rivlin

    Recurrent varicose veins

    Medical Journal of Australia

    (1966)
  • A.W. Bradbury et al.

    Recurrent varicose veins: correlation between preoperative clinical and hand-held Doppler ultrasonographic examination, and anatomical findings at surgery

    British Journal of Surgery

    (1993)
  • C. Juhan et al.

    Recurrent varicose veins

    Phlebology

    (1990)
  • A.J. McIrvine et al.

    The demonstration of saphenofemoral incompetence: Doppler ultrasound compared with standard clinical tests

    British Journal of Surgery

    (1984)
  • J.P. Royle

    Recurrent varicose veins

    World Journal of Surgery

    (1986)
  • M. Lea Thomas et al.

    Incompetent perforating veins: comparison of varicography and ascending phlebography

    Radiology

    (1985)
  • K.A. Myers et al.

    Duplex ultrasound scanning for chronic venous disease: recurrent varicose veins in the thigh after surgery to the long saphenous vein

    Phlebology

    (1996)
  • Cited by (0)

    View full text