Recurrent varicose veins: patterns of reflux and clinical severity
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.
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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)
- et al.
Recurrent varicose veins following high ligation of long saphenous vein: a duplex study
Cardiovascular Surgery
(1995) - et al.
Reporting standards in venous disease: an update
Journal of Vascular Surgery
(1995) - et al.
A method of performing descending venography
Journal of Vascular Surgery
(1986) - et al.
Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein
European Journal of Vascular and Endovascular Surgery
(1996) - et al.
Recurrent varicose veins: investigation of the pattern and extent of reflux with color flow duplex scanning
Surgery
(1996) - et al.
The ankle blow-out syndrome
Lancet
(1953) - et al.
Subfascial endoscopic perforator ligation: an analysis of early clinical outcomes and cost
Journal of Vascular Surgery
(1997) - et al.
Subfascial endoscopic perforator vein surgery: a preliminary report
Annals of Vascular Surgery
(1996) - et al.
Medial calf perforators in venous disease: the significance of outward flow
Journal of Vascular Surgery
(1992) - et al.
New insights into the pathophysiologic condition of venous ulceration with colour-flow duplex imaging: implications for treatment?
Journal of Vascular Surgery
(1995)