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Published online before print March 4, 2005, 10.1148/radiol.2351031598
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(Radiology 2005;235:327-334.)
© RSNA, 2005

Vascular and Interventional Radiology

Leg Perforator Vein Incompetence: Functional Anatomy1

Konstantinos T. Delis, MD, MS, PhD, FRCSI, EBSQvasc

1 From the Department of Vascular Surgery, St Mary’s Hospital, Imperial College School of Medicine, London, England. Received October 6, 2003; revision requested November 24; final revision received July 11, 2004; accepted August 13. Address correspondence to the author, Division of Vascular Surgery, Gonda Vascular Center, Mayo Clinic, 200 First St SW, 4th Fl, Rochester, MN 66905 (e-mail: k.delis@ic.ac.uk).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To retrospectively determine the anatomic patterns of reflux of incompetent perforator veins (IPVs) at the sites of their highest prevalence in relation to the anatomic distribution of valvular incompetence in the veins of the calf and thigh, with emphasis on the deep system, across the clinical spectrum of chronic venous disease (CVD).

MATERIALS AND METHODS: This study was granted institutional ethics committee approval; the need for patient consent was waived. Five hundred five limbs in 359 consecutive subjects who were suspected of having CVD but did not have arterial disease, prior venous thrombosis (<1 year), venous or orthopedic surgery, or vascular malformations were clinically stratified for CVD according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) system and underwent venous hemodynamic investigation with duplex ultrasonography. One hundred thirty limbs were CEAP clinical classes C0–1, 262 limbs were classes C2–3, and 113 limbs were classes C4–6. IPV reflux patterns and anatomic distribution of deep venous reflux in the lower limb were determined across the clinical classes of CVD. Statistical analysis was performed with Spearman rank correlation, {chi}2, and Mann-Whitney testing.

RESULTS: Valvular incompetence in limbs with IPVs increased with CEAP clinical class (P < .01) in femoral, popliteal, posterior tibial, peroneal, gastrocnemial, and soleal veins; reflux was distributed evenly across these veins. Of 554 IPVs found, 377 (68.0%) occurred at four sites: middle third of medial calf (n = 165 [29.8%]), lower third of medial calf (n = 85 [15.3%]), middle third of medial thigh (n = 73 [13.2%]), and middle third of posterior calf (n = 54 [9.7%]). IPVs with superficial and deep reflux in adjoining veins, as compared with IPVs with superficial reflux alone, increased as clinical class increased from C2 to C6 (P < .02) at all four sites of highest IPV prevalence; determined in detail, reflux patterns of IPVs were linked to CEAP clinical class (P < .05) but not anatomic site (P > .2). Most IPVs in C1–3 limbs had superficial reflux alone. IPVs with superficial reflux outnumbered IPVs with superficial and deep reflux even in C4–6 limbs, where deep venous incompetence was most prevalent. Axial venous reflux (proximal-to-distal) changes (P > .4) were small in superficial and deep veins across the spectrum of CEAP clinical classes C2–6.

CONCLUSION: Patterns of perforator reflux were linked to clinical severity of CVD in the CEAP classification and displayed an even distribution anatomically. IPVs with deep and superficial reflux in adjoining veins increased with CEAP clinical class, in line with valvular incompetence in the deep veins of the calf and thigh.

© RSNA, 2005


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
A third of the population is affected by chronic venous disease (CVD) (1,2), and, with increasing age (>64 years), up to 10% of affected patients may sustain leg ulceration (3,4). The estimated annual loss of more than 2 million working days (5) reflects the physical impairment and sustained compromise in quality of life (6,7). Expenditures related to CVD have risen to 2.0%–2.5% of the national health care budgets of European countries (6,8). Amid mounting evidence regarding the hemodynamic (9–12) and histopathologic (13,14) constituents of CVD, the role of incompetent perforator veins (IPVs) remains controversial (15,16). Advocates of surgical intervention for the treatment of IPVs (17,18) were cautioned by the moderate long-term outcomes of pertinent multicenter studies (15) and by a proportion of published work that disputes the true hemodynamic relevance of IPVs (9,19–21).

In 40% of cases, venous leg ulceration is due to primary superficial venous incompetence (11,12,22,23) that is amenable to ablation and definitive treatment (24). In the remaining cases, the presence of deep incompetence is invariably managed noninvasively. However, 40% of venous leg ulcers are resilient to a 24-week course of conservative treatment (25), and more than 30% of those that are healed recur within 3 years (3,25). The documented increasing occurrence of IPVs with CVD severity (10,17,26) and their convenient surgical accessibility in the subfascial space, (27) especially with dedicated endoscopic instrumentation, (28) have rekindled interest in the outcomes that follow their ablation.

The healing rate of 88% within a year after superficial reflux ablation and subfascial endoscopic perforator surgery reported for the North American subfascial endoscopic perforator surgery, or NASEPS, trial was compromised by a 28% recurrence rate after a median follow-up of 2 years that reached 46% in postthrombotic limbs (15). The NASEPS investigators have acknowledged the need to identify patient subgroups in which intervention would be effective (29). Morphologic studies focusing on the delineation of the reflux patterns and pertinent anatomy of IPVs are in keeping with the effort to define their clinical relevance.

The purpose of this study was to retrospectively determine the anatomic patterns of reflux of IPVs at the sites of their highest prevalence in relation to the anatomic distribution of valvular incompetence in the veins of the calf and thigh, with emphasis on the deep system, across the clinical spectrum of CVD.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients
This study was approved by the ethics committee (review board) of the institution, and, in light of its retrospective design, the need for patient consent was waived. Three hundred fifty-nine patients aged 18–92 years (median age, 49 years) were included: 214 women aged 18–92 years (median age, 50 years) and 145 men aged 18–91 years (median age, 47 years) (P = .9 [Mann-Whitney test]). These consecutive patients had been referred between September 1998 and May 2001 by general practitioners, physicians, and surgeons of the northwest London region for venous assessment in our blood flow laboratory.

A total of 505 limbs were investigated. The clinical severity of the condition of the limbs was stratified according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification (30) as follows: no signs or symptoms of CVD, C0; telangiectasias, C1; varicose veins, C2; varicose veins and edema, C3; skin changes, C4; healed ulcer, C5; and active ulcer, C6. One hundred thirty limbs were classified as CEAP classes C0–1; 262 limbs, as C2–3; and 113 limbs, as C4–6.

Patient assessment included their past history, a clinical examination, the resting ankle-brachial index, and detailed color flow duplex ultrasonography (US) of the lower limb venous system. Excluded were limbs with absent peripheral pulses; resting ankle-brachial indexes of less than 1.0; vascular malformations; prior varicose vein surgery or injection compression therapy for CVD; a history of fractures, wounds, infection, or deep venous thrombosis (<1 year previously); or clinically suspected venous outflow obstruction (31) confirmed with plethysmography.

Duplex US Scanning
Lower limb duplex US was performed (by K.T.D.) with a Sonos 2500 unit (Hewlett Packard, Palo Alto, Calif) fitted with a 7.5/5.5-MHz linear array transducer. Standardized (optimal) settings for gain, compression, and rejection were used with gated Doppler US. Determination of reflux duration was based entirely on optimal Doppler signals retrieved at an insonation angle of 60°. Suboptimal Doppler waveform signals and those containing noise from adjacent arterial flow or aliasing were discarded, and the measurements were repeated.

The entire length of the venous system from the groin to the ankle was scanned with duplex US. All named axial veins—superficial or deep—were scanned throughout their entire length. Similarly, the muscular veins in the thigh and the calf were meticulously investigated. The initial venous hemodynamic assessment was performed by using color flow imaging, which was particularly helpful when multiple venous structures were insonated simultaneously, enabling guidance of the investigation to the sites of abnormal retrograde venous flow. However, all data on venous flow direction and reflux duration were obtained by using real-time gated Doppler superimposed on real-time B-mode US imaging of the venous structures.

Duplex US investigation was performed with the subjects sitting comfortably on a high examining couch with their feet resting on a low chair and with their knees partially extended. The duration of reflux was measured on the release of manual foot, calf, or thigh compression (depending on the limb segment being investigated). Compression was always applied distal to the evaluated veins on a thoroughly primed (filled) venous system, defined as the presence of cephalad mean flow and mean velocity at Doppler-mode US with the limb resting in the dependent position. Reflux of greater than 0.5 second at three consecutive evaluations was considered abnormal. A detailed account of the scanning protocol has been reported elsewhere (23).

Perforator veins were identified as deep fascia gaps at cross-sectional imaging of the medial, posterior, and anterolateral portions of the calf and thigh by using real-time B-mode US. Their hemodynamic performance was initially assessed (K.T.D.) with color flow duplex US. The direction and duration of the flow waveforms within the lumen of the perforator veins on the release of manual limb compression were determined by using real-time gated Doppler superimposed on real-time B-mode US. For this purpose, the perforator lumen was insonated longitudinally. A perforator vein was considered incompetent if outward flow exceeding 0.5 second in duration was documented on sudden release of manual limb compression in three consecutive measurements.

Perforator veins were classified anatomically as medial, posterior, or anterolateral. Their location in the thigh and calf was further subdivided into the upper, middle, and lower thirds, for a total of nine anatomic sites in the calf and nine in the thigh. Allocation of IPVs topographically was assisted by the use of a measuring tape.

Statistical Analysis
Differences in proportions were evaluated by using the {chi}2 test with the Yates correction for small (<five) sample sizes. The Mann-Whitney test was used for comparing two independent groups of quantitative data. The relationships between bivariate quantitative data were investigated with the Spearman rank correlation test. Statistical analysis included the estimation of odds ratios supported with 95% confidence intervals. A two-tailed P value of less than .05 was considered to indicate a statistically significant difference. Calculations were performed with the Minitab software, release 8.2 (Minitab, State College, Pa), and the statistical principles applied were in keeping with those of Altman (32).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
A total of 554 IPVs were identified. The sites with the highest prevalences of IPVs were (a) the middle third of the medial calf (n = 165 [29.8%]), (b) the lower third of the medial calf (n = 85 [15.3%]), (c) the middle third of the medial thigh (n = 73 [13.2%]), and (d) the middle third of the posterior calf (n = 54 [9.7%]). These four sites accounted for 377 (68.0%) of the 554 IPVs detected. Figure 1 depicts the main anatomic patterns of IPVs at the four limb sites with the highest prevalence of perforator incompetence on the basis of retrograde venous flow coursing outward through the perforator lumen on the release of distal manual compression of a well-primed venous system.



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  		Figure 1a. Venous reflux patterns of IPVs at the four anatomic sites (longitudinal view) of their greatest prevalence. The prevalence of these patterns in relation to the total numbers of IPVs for each site and clinical classes C1-3 and C4-6, as documented at duplex US of 505 limbs, is also indicated. Venous reflux (>0.5 sec) and its course direction are indicated with black arrows, and numeric sample details are offered in the Table. (a) Middle third of medial thigh. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the trunk of the great saphenous vein (GSV) in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial (GSV) tributary. Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the femoral vein (FV) through the IPV enters the extrafascial space and empties directly into the trunk of the GSV. Right: Similar pattern except that the IPV empties into a superficial GSV tributary. (b) Middle third of medial calf. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the posterior arch of the GSV in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial tributary (of the GSV or another vein). Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the posterior tibial vein through the IPV enters the extrafascial space and empties directly into the posterior arch of the GSV. Right: Similar pattern except that the IPV empties into a superficial tributary (of the GSV or another vein). (c) Lower third of medial calf. Left and second-from-left: At this site, venous reflux patterns of IPVs with superficial reflux (s) alone are identical to those depicted at left and second-from-left in b. Second-from-right and right: At this site, venous reflux patterns of IPVs with both superficial and deep reflux (s+d) are identical to those depicted at right and second-from-right in b. (d) Middle third of posterior calf. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the trunk of the small saphenous vein (SSV) in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial tributary (of the small saphenous vein or another vein). Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the gastrocnemial vein through the IPV enters the extrafascial space and empties directly into the trunk of the small saphenous vein. Right: Similar pattern except that the IPV empties into a superficial tributary (of the small saphenous vein or another vein).

 


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  		Figure 1b. Venous reflux patterns of IPVs at the four anatomic sites (longitudinal view) of their greatest prevalence. The prevalence of these patterns in relation to the total numbers of IPVs for each site and clinical classes C1-3 and C4-6, as documented at duplex US of 505 limbs, is also indicated. Venous reflux (>0.5 sec) and its course direction are indicated with black arrows, and numeric sample details are offered in the Table. (a) Middle third of medial thigh. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the trunk of the great saphenous vein (GSV) in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial (GSV) tributary. Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the femoral vein (FV) through the IPV enters the extrafascial space and empties directly into the trunk of the GSV. Right: Similar pattern except that the IPV empties into a superficial GSV tributary. (b) Middle third of medial calf. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the posterior arch of the GSV in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial tributary (of the GSV or another vein). Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the posterior tibial vein through the IPV enters the extrafascial space and empties directly into the posterior arch of the GSV. Right: Similar pattern except that the IPV empties into a superficial tributary (of the GSV or another vein). (c) Lower third of medial calf. Left and second-from-left: At this site, venous reflux patterns of IPVs with superficial reflux (s) alone are identical to those depicted at left and second-from-left in b. Second-from-right and right: At this site, venous reflux patterns of IPVs with both superficial and deep reflux (s+d) are identical to those depicted at right and second-from-right in b. (d) Middle third of posterior calf. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the trunk of the small saphenous vein (SSV) in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial tributary (of the small saphenous vein or another vein). Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the gastrocnemial vein through the IPV enters the extrafascial space and empties directly into the trunk of the small saphenous vein. Right: Similar pattern except that the IPV empties into a superficial tributary (of the small saphenous vein or another vein).

 


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  		Figure 1c. Venous reflux patterns of IPVs at the four anatomic sites (longitudinal view) of their greatest prevalence. The prevalence of these patterns in relation to the total numbers of IPVs for each site and clinical classes C1-3 and C4-6, as documented at duplex US of 505 limbs, is also indicated. Venous reflux (>0.5 sec) and its course direction are indicated with black arrows, and numeric sample details are offered in the Table. (a) Middle third of medial thigh. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the trunk of the great saphenous vein (GSV) in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial (GSV) tributary. Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the femoral vein (FV) through the IPV enters the extrafascial space and empties directly into the trunk of the GSV. Right: Similar pattern except that the IPV empties into a superficial GSV tributary. (b) Middle third of medial calf. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the posterior arch of the GSV in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial tributary (of the GSV or another vein). Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the posterior tibial vein through the IPV enters the extrafascial space and empties directly into the posterior arch of the GSV. Right: Similar pattern except that the IPV empties into a superficial tributary (of the GSV or another vein). (c) Lower third of medial calf. Left and second-from-left: At this site, venous reflux patterns of IPVs with superficial reflux (s) alone are identical to those depicted at left and second-from-left in b. Second-from-right and right: At this site, venous reflux patterns of IPVs with both superficial and deep reflux (s+d) are identical to those depicted at right and second-from-right in b. (d) Middle third of posterior calf. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the trunk of the small saphenous vein (SSV) in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial tributary (of the small saphenous vein or another vein). Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the gastrocnemial vein through the IPV enters the extrafascial space and empties directly into the trunk of the small saphenous vein. Right: Similar pattern except that the IPV empties into a superficial tributary (of the small saphenous vein or another vein).

 


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  		Figure 1d. Venous reflux patterns of IPVs at the four anatomic sites (longitudinal view) of their greatest prevalence. The prevalence of these patterns in relation to the total numbers of IPVs for each site and clinical classes C1-3 and C4-6, as documented at duplex US of 505 limbs, is also indicated. Venous reflux (>0.5 sec) and its course direction are indicated with black arrows, and numeric sample details are offered in the Table. (a) Middle third of medial thigh. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the trunk of the great saphenous vein (GSV) in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial (GSV) tributary. Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the femoral vein (FV) through the IPV enters the extrafascial space and empties directly into the trunk of the GSV. Right: Similar pattern except that the IPV empties into a superficial GSV tributary. (b) Middle third of medial calf. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the posterior arch of the GSV in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial tributary (of the GSV or another vein). Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the posterior tibial vein through the IPV enters the extrafascial space and empties directly into the posterior arch of the GSV. Right: Similar pattern except that the IPV empties into a superficial tributary (of the GSV or another vein). (c) Lower third of medial calf. Left and second-from-left: At this site, venous reflux patterns of IPVs with superficial reflux (s) alone are identical to those depicted at left and second-from-left in b. Second-from-right and right: At this site, venous reflux patterns of IPVs with both superficial and deep reflux (s+d) are identical to those depicted at right and second-from-right in b. (d) Middle third of posterior calf. Left and second-from-left: Venous reflux patterns of IPVs with superficial reflux (s) alone. Left: Venous reflux in the IPV enters the extrafascial space and empties directly into the trunk of the small saphenous vein (SSV) in the absence of detectable reflux (at color or gated Doppler US) in the adjoining deep system. Second-from-left: Similar pattern except that the IPV empties into a superficial tributary (of the small saphenous vein or another vein). Second-from-right and right: Venous reflux patterns of IPVs with both superficial and deep reflux (s+d). Second-from-right: Venous reflux from the gastrocnemial vein through the IPV enters the extrafascial space and empties directly into the trunk of the small saphenous vein. Right: Similar pattern except that the IPV empties into a superficial tributary (of the small saphenous vein or another vein).

 
The IPVs were then subcategorized further (Table) as IPVs with reflux (on the release of distal manual compression) only in their efferent superficial vein and IPVs with reflux in both their afferent deep and efferent superficial veins. Limbs in CEAP classes C1–3 (30) predominantly had IPVs with superficial reflux alone (Table). The prevalence of IPVs with superficial and deep reflux was significantly higher in CEAP classes C4–6 (Table) at all four anatomic sites with the highest IPV prevalence (P < .05 [{chi}2 test]). Differences in the proportions of IPVs with superficial or superficial and deep reflux among the four anatomic sites with the highest IPV prevalence (Table) were small (P > .2 [{chi}2 test]). IPVs with superficial and deep reflux were outnumbered by IPVs with superficial reflux alone, even in CEAP classes C4–6—the classes in which the prevalence of deep venous incompetence was highest (Table).


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  		Anatomic Sites with Highest Prevalence of IPVs in Relation to Anatomic Reflux Patterns of IPVs at Duplex US

 
As shown in the Table, the levels of statistical significance for differences in the reflux patterns of IPVs between CEAP clinical classes C1–3 and C4–6 at all four anatomic sites that were based on the number of IPVs were nearly identical to those that were based on the number of affected limbs (no data clustering).

The prevalence of valvular incompetence in the femoral, popliteal, posterior tibial, peroneal, gastrocnemial, and soleal veins (Fig 2) increased significantly with the CEAP clinical class (30) of CVD in limbs with IPVs (P < .01 for all, r ≥ 0.943 [Spearman rank correlation test]). The greater prevalence of reflux in the femoral and popliteal veins with increasing CEAP clinical class (30) matched the prevalence of reflux in the axial and muscular veins of the calf (P > .2 [{chi}2 test]).



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  		Figure 2. Bar graph shows the prevalence of venous reflux (vertical axis) in the femoral, popliteal, posterior tibial, peroneal, gastrocnemial, and soleal veins in limbs with perforator incompetence; prevalence increases significantly with clinical severity of CVD—from CEAP classes C1 through C6 (30) (P < .01 for all, r ≥ 0.943 [Spearman rank correlation test]).

 
Mirroring the effect of deep vein reflux on perforator incompetence, the total ratio of IPVs with superficial and deep reflux in their adjoining veins to IPVs with superficial reflux alone increased significantly (P < .02 for all, r > 0.9 [Spearman rank correlation test]) with CVD severity (CEAP clinical classes C2–6) (30) at all four sites with the highest prevalence of IPVs (Fig 3).



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  		Figure 3. Bar graph shows the total ratio (vertical axis) of IPVs with superficial and deep reflux in their adjoining vessels to IPVs with superficial reflux alone in the middle third of the medial thigh (73 IPVs), the middle third of the medial calf (165 IPVs), the lower third of the medial calf (85 IPVs), and the middle third of the posterior calf (54 IPVs); the ratio increases significantly with clinical severity of CVD—from CEAP classes C2 through C6 (30) (P < .02 for all; r > 0.9 [Spearman rank correlation test]).

 
To investigate the possibility that changes in axial reflux (from deep to superficial veins through IPVs) may occur increasingly with CVD severity, the proximal-to-distal ratio of venous incompetence, calculated separately in the axial (long) superficial and deep veins of limbs with IPVs, was determined (Fig 4). This ratio, which was consistently high in both the axial superficial veins (>83% [30 of 36 limbs]) and the axial deep veins (from 71% [five of seven limbs] to 94% [31 of 33 limbs]) in the spectrum of CEAP clinical classes C2–6 (30) did not change significantly in either system (P > .4 for both [{chi}2 test]).



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  		Figure 4. Bar graph shows prevalence of venous incompetence, expressed as a ratio (vertical axis) of total proximal to total distal reflux, in the superficial (saphenous trunks and their named tributaries) and deep axial veins of limbs with perforator incompetence across the CEAP clinical classes of CVD—from class C2 through class C6 (30). Overall, the changes in both the superficial (P > .4 [{chi}2 test]) and the deep (P > .5 [{chi}2 test]) axial veins were not significant.

 
Venous leg ulceration (CEAP clinical class C6) was associated with deep venous incompetence in 20 (43%) of 46 limbs, which is more than twice as often as the likelihood of deep venous incompetence in limbs with uncomplicated varicose veins (CEAP clinical class C2) (20% [42 of 210 limbs]; P < .01; odds ratio = 3.1; 95% confidence interval: 1.57, 6.02). The rate of superficial venous incompetence in CEAP clinical class C6 limbs (91% [42 of 46 limbs]) was similar to that in C2 limbs (95% [200 of 210 limbs]; P > .5; odds ratio = 0.525; 95% confidence interval: 0.16, 1.75).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
REFERENCES
 
IPVs are mainly located in the middle and lower thirds of the medial calf (23,27,33), followed by the middle thirds of the medial thigh and posterior calf (23,34). Their prevalence increases with the clinical severity of CVD (11,23), paralleling the global prevalence of deep incompetence (23); however, IPVs often occur in the presence of superficial incompetence alone (10,35). A link between perforator incompetence and global deep venous insufficiency has been reported (10–12,23,26); however, studies on the specific patterns of reflux of IPVs in relation to the valvular status of the deep axial and muscular veins—particularly the reflux status of the afferent deep veins of IPVs across the CEAP spectrum—are currently unavailable.

The results of this study show that the prevalence of IPVs with deep and superficial reflux in their adjoining veins, in relation to the prevalence of IPVs with superficial reflux alone, increases significantly with CEAP clinical class. The increasing occurrence of reflux in the deep veins of IPVs with increasing clinical severity is yet another indication of the bonds between perforator vein incompetence and deep venous reflux. Ablation of superficial incompetent veins in the absence of deep reflux reportedly improves the hemodynamic performance of perforator veins by way of an otherwise natural renormalization of reflux in a significant proportion of IPVs (35). However, in the presence of deep reflux, superficial reflux ablation is far less effective in controlling IPVs (35).

In the present study, only one in five to six IPVs in limbs with varicose veins (CEAP class C2) had superficial and deep reflux. The prevalence of reflux in the afferent deep veins of IPVs increased significantly with the CEAP clinical class of CVD, with up to 60% of IPVs in ulcerated limbs (CEAP class C6) having superficial and deep reflux. This trend with increasing CVD severity was fairly consistent in all four anatomic sites with the highest occurrence of IPVs, with some emphasis on the middle third of the posterior calf peaking in C3–4 limbs. Although the prevalence of IPVs with deep reflux increased with clinical severity, overall, there were far more IPVs with superficial reflux alone. More than 79% of IPVs in C1–3 limbs and more than 51.5% of IPVs in C4–6 limbs had superficial reflux alone in the four most prevalent IPV sites combined.

Prolonged outward perforator flow (>.5 sec) on the release of distal manual compression, which was defined as perforator incompetence (23), implies that blood is shifted from the deep to the superficial veins. When competent, the deep veins feeding a perforator vein do not leak and thus appear normal at duplex US.

Anatomically connected to the lumen of IPVs, such deep veins may act as small reservoirs, storing blood from the superficial veins through the perforators, particularly when marked superficial reflux exists. Most of this blood volume, trapped by the cusps of deep vein valves, is forwarded centrally through the deep axes, with the rest leaking out. In deep venous valvular impairment, blood flows into the deep system through a perforator’s lumen during distal compression but reexits again at the moment compression is released. This reexiting is detected as a stream of deep and superficial reflux crossing the lumen of the IPV.

The functional anatomy of IPVs at the four sites in which they occurred most often was investigated in this study. In the middle third of the medial thigh, most IPVs had superficial reflux alone—91.5% leaked either to the GSV or to a superficial tributary in C1–3 limbs. This pattern was less common (57.7%) among IPVs in C4–6 limbs. Deep reflux, noted in 8.5% of IPVs in C1–3 limbs and in 30.8% of IPVs in C4–6 limbs, appeared to leak from the femoral vein through an IPV to the extrafascial space and into either the GSV or a superficial tributary.

Outward flow in most IPVs (73.0%) in the middle third of the medial calf in C1–3 limbs and less often (44.4%) at the same site in C4–6 limbs refluxed into the posterior GSV arch or a superficial tributary in the absence of deep incompetence. Deep reflux in the posterior tibial vein was detected in 8.5% of IPVs in C1–3 and in 27.8% of IPVs in C4–6. Similar reflux patterns of perforator incompetence were documented in the lower third of the medial calf: Posterior tibial vein reflux was present in 10.6% of IPVs in C1–3 and in 31.6% of IPVs in C4–6, while superficial reflux alone was noted in 78.7% of IPVs in C1–3 and in 55.3% of IPVs in C4–6.

Finally, IPVs in the middle third of the posterior calf leaked most often into the small saphenous vein or into a saphenous tributary in the absence of deep reflux; 80.0% of IPVs in C1–3 and 63.2% of IPVs in C4–6 had this pattern. A similar pattern, except that an incompetent gastrocnemial vein was filling the IPV with outward flow, was documented in 37.0% of IPVs with superficial and deep reflux in C4–6 and in 8.5% of equivalent IPVs in C1–3 at this site.

The study data indicate that, irrespective of specific anatomic differences, the reflux patterns of IPVs are significantly linked to the severity of CVD but not to the anatomic site. The functional anatomy of IPVs, simplified into either (a) IPVs with superficial reflux or (b) IPVs with deep and superficial reflux, shifts from the first pattern in C1–3 limbs toward the second in C4–6 limbs, irrespective of location. This shift in IPV pattern occurs in roughly equal proportions at the four anatomic locations with the highest IPV prevalences.

This study has revealed that the prevalence of valvular incompetence in the deep veins of the posterior calf compartment increases significantly with the CEAP clinical severity of CVD in limbs with IPVs. More than a third of such limbs with active or healed ulcers (CEAP classes C5–6) had demonstrable reflux in the axial deep veins of the posterior compartment; by contrast, fewer than one in 15 limbs with varicose veins (CEAP class C2) had reflux either in the posterior tibial or the peroneal veins. The prevalence of reflux in the gastrocnemial and soleal veins also increased with CVD severity, being close to that in the posterior tibial veins. The study data indicate that valvular incompetence in limbs with IPVs is, overall, evenly distributed in the veins of the posterior compartment, showing only some predilection for the posterior tibial vein in C5–6 limbs.

The uniform distribution of deep reflux in CEAP classes C2–6 limbs that is matched by equal uniformity in the reflux patterns of IPVs (which are mainly determined by the global CVD severity) supports the hemodynamic links between perforator and deep incompetence. These data also offer an insight into the pathophysiology of reflux propagation in perforator veins. Axial deep reflux, when imposed on perforators, could well be the primary cause of their failure, particularly in the presence of efferent superficial vein incompetence. An IPV might cause competent adjoining deep veins to sustain segmental reflux, yet normal valvular function would prevent long (axial) reflux. Because the majority of IPVs occur with superficial incompetence in the absence of deep reflux, it could be speculated that primary superficial incompetence could also lead to perforator incompetence. Primary failure may well be another mechanism of perforator incompetence.

Being at the outflow of the calf veins and thus a natural recipient of the results of more distal venous valvular incompetence, the popliteal vein had reflux that overall mirrored the venous hemodynamic status of the calf in limbs with IPVs. The prevalence of reflux in the popliteal vein also increased significantly with the CEAP clinical class of CVD; it fell within the range of reflux prevalence in the calf veins in C3 and C5 limbs and was even higher in C2, C4, and C6 limbs. This variation indicates that popliteal vein incompetence can occur in isolation from incompetence of adjacent calf veins and also that reflux in adjacent calf veins may not affect the popliteal vein. The steep increase in the prevalence of popliteal reflux in CEAP classes C4–6 and its relative rarity (13%) in the spectrum of early CVD corroborate the protective role that the popliteal vein may play in CVD (36). However, more than half of the patients with active ulcers in this series had a normal popliteal vein. This highlights the importance in CVD progression of alternative conduits of incompetence through superficial, perforator, and other deep veins (22,24,31).

The study data show that the even distribution of deep reflux in the veins of the posterior calf compartment and the thigh is matched by an equivalent distribution of IPVs with reflux in their deep afferent veins, their prevalence increasing with CVD severity in the CEAP classification; this appears to bridge the gap between deep and perforator vein incompetence by linking their hemodynamic performance anatomically.

Since IPVs may reroute reflux from deep axial veins to superficial ones, the relative distribution of reflux in the main axial venous conduits in CVD was examined in this study. Even competent perforators may allow reflux to shift from superficial trunks proximally to deep veins distally. In C2–6 limbs with IPVs, the proximal-to-distal ratio of axial superficial reflux involving the saphenous trunks and their named tributaries exceeded 83%. The proximal-to-distal ratio of axial deep reflux was 71%–94% in C2–6 limbs. The consistently high prevalence of superficial and of deep axial reflux in both the calf and the thigh veins militates against a clinically relevant (CEAP classes C2–6) axial reflux pattern change in limbs with IPVs. Reflux from a proximal deep axial vein via an IPV to a distal superficial vein or from the superficial axial veins proximally via a perforator to the deep axial veins distally does occur, yet the evenness of axial reflux ratios in CEAP classes C2–6 refutes an increasing role of such patterns with clinical severity.

The retrospective data collection in this study, which could potentially be seen as a limitation, is offset by the high standards applied in patient investigation, the detailed patient records, the application of strict exclusion criteria, the uniformity of CEAP clinical stratification, and, ultimately, the fact that all duplex US and clinical assessments were performed and recorded in detail by a single investigator (K.T.D.). The study focus on four anatomic locations enabled a confident elaboration of the reflux patterns of perforator incompetence where it most frequently occurred and was thus most likely to have clinical relevance.

In conclusion, the prevalence of reflux in the veins of the thigh and the posterior calf compartment increases with clinical severity in limbs with IPVs. Popliteal vein incompetence mirrors the status of venous incompetence in the calf yet may as well occur in isolation. The prevalence of IPVs with deep and superficial reflux in adjoining veins increases linearly with CVD severity; however, IPVs with superficial reflux alone outnumber IPVs with deep and superficial reflux, even in limbs in CEAP classes C4–6, in which deep incompetence occurs most often. The anatomic patterns of IPV reflux and their proportions at the sites of greatest IPV occurrence were defined. These patterns, beyond their specific anatomic differences, have a relatively even anatomic distribution, yet their relative proportion is strongly related to the CEAP clinical class of CVD.


   FOOTNOTES
 
Abbreviations: CEAP = clinical, etiologic, anatomic, and pathophysiologic, CVD = chronic venous disease, GSV = great saphenous vein, IPV = incompetent perforator vein

Author stated no financial relationship to disclose.

Author contribution: Guarantor of integrity of entire study, K.T.D.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 

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