Einfluss des Refluxursprungs auf die Hämodynamik, Klinik und Therapie der primären Varikose

Zusammenfassung

Hintergrund

Die Mechanismen von Reflux und Rezirkulation der primären Varikose sind nach wie vor nicht vollständig geklärt.

Patienten und Methoden

Als Refluxursachen wurden ein junktionaler Phänotyp (JP, Mündungsreflux der V. saphena magna [VSM oder Leistenrezidiv] mit oder ohne suspekte Perforansvenen [SPV]) und ein Perforansphänotyp (PP, ausschließlich SPV oder aus Gründen der statistischen Zuordnung die V. saphena parva [VSP] als Refluxquelle) gegeneinander abgegrenzt. Flussrichtung und -stärke wurden unter Valsalva (JP) oder als spontan/unter distaler Kompression/Dekompression (SPV) erfasst und im Falle von SPV mit jeweils 1 oder 2 Punkten als Reflux (+) oder Reentry (−) mit resultierenden möglichen Nettoflüssen von +6 bis −6 Punkten bewertet. Refluxquelle und axiale Refluxausdehnung sowie Durchmesser und Flussrichtung von SPV wurden multivariat mit den klinischen Stadien nach CEAP-Klassifikation verglichen.

Ergebnisse

An 107 unteren Extremitäten fand sich 68× JP, in 49 Fällen davon vergesellschaftet mit SPV, und 39× PP. CEAP C3–C6 war im Falle von 45/65 (11/22) Erstmanifestationen (Rezidiven) mit SPV (JP und PP) vergesellschaftet oder in 3/16 (0/4) ohne, p < 0,01 (p = 0,01). Fortgeschrittene klinische Stadien C4–C6 waren im Falle einer Erstmanifestation von JP häufiger vertreten, wenn der axiale Reflux bis distal (14/39; p = 0,01) oder proximal des Kniegelenkes (3/11; p = 0,12) reichte verglichen mit PP (5/31). Die Flussrichtung von SPV war im Falle einer Erstmanifestation von JP sowie axialem Reflux bis distal des Kniegelenkes Reentry (Schätzer −1,62; p = 0,02) oder bis proximal des Kniegelenkes Reflux (0,29; p = 0,81) verglichen mit PP. Der Durchmesser der am meisten dilatierten Perforansvene war jedoch größer im Falle von JP und axialem Reflux bis proximal (Schätzer 0,20; p < 0,01) oder distal des Kniegelenkes (0,04; p = 0,30) verglichen mit PP. Vorherrschende Flussrichtungen von SPV waren Reentry bzw. Reflux während peripherer Kompression oder Dekompression (p = 0,009).

Schlussfolgerungen

Die Daten sprechen für einen Zusammenhang zwischen Refluxquelle und Ausdehnung eines axialen Refluxes mit dem Durchmesser und der Flussrichtung von SPV sowie dem klinischen Stadium der primären Varikose.

Abstract

Purpose

Reflux and recirculation in primary varicose veins are not yet completely understood, and the contribution of perforator veins is dual.

Methods

Reflux origin was assessed as junctional (JP, reflux of the greater saphenous junction or groin recurrences) with/without suspect perforator veins (SPV), or perforator phenotype (PP, reflux from SPV only or for statistical purposes from the small saphenous vein). Flow direction and intensity were recorded under Valsalva (JP) or as spontaneous/under distal compression/decompression (SPV) and weighted with one/two points as reflux/reentry, respectively, in the case of SPV. We compared the origin and extent of axial reflux and diameter/flow direction of SPV with the clinical stage by multivariate analysis.

Results

Of 107 limbs, 68 presented with JP, 49 combined with SPV, and 39 with PP. CEAP C3–C6 was associated with the presence of SPV (JP and PP) in 45/65 (11/22) limbs with primaries (recurrences) or in 3/16 (0/4), p < 0.01 (p = 0.01), without SPV. C4–C6 at first manifestation, however, was more frequent in JP and axial reflux below the knee in 14/39 limbs (p = 0.01) or above the knee in 3/11 (p = 0.12) compared with PP (5/31). SPV flow at first manifestation was reentry in the case of JP and axial reflux below the knee (estimate −1.62, p = 0.02) or above the knee (0.29, p = 0.81) compared with PP, but diameter of the most dilated perforator vein was higher in the case of JP and axial reflux above the knee (estimate 0.20, p < 0.01) or below the knee (0.04, p = 0.30) compared with PP. Predominant SPV flow was reentry/reflux during peripheral compression/decompression, respectively (p = 0.009).

Conclusions

The data suggest that the reflux origin and extent of axial reflux are associated with diameter/flow direction of SPV and clinical stage in primary varicose veins.

Schlüsselwörter

Varikose - Operationsplanung - statistische Auswertung - Hämodynamik

Keywords

varicosis - classification - statistical evaluation - hemodynamics

Publication History

Received: 15 May 2023

Accepted after revision: 11 January 2024

Article published online:
20 March 2024

• Literatur

• 1 Myers KA, Ziegenbein RW, Zeng GH. et al. Duplex ultrasonography scanning for chronic venous disease: patterns of venous reflux. J Vasc Surg 1995; 21: 506-512
• 2 Labropoulos N, Delis K, Nicolaides AN. et al. The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency. J Vasc Surg 1996; 23: 504-510
• 3 Moore DJ, Himmel PD, Sumner DS. Distribution of venous valvular incompetence in patients with the postphlebitic syndrome. J Vasc Surg 1986; 3: 49-57
• 4 Nelzén O, Fransson I. Varicose vein recurrence and patient satisfaction 10–14 years following combined superficial and perforator vein surgery: a prospective case study. Eur J Vasc Endovasc Surg 2013; 46: 372-377
• 5 Labropoulos N, Mansour MA, Kang SS. et al. New insights into perforator vein incompetence. Eur J Vasc Endovasc Surg 1999; 18: 228-234
• 6 Hanrahan LM, Clifford TA, Rodriguez AA. et al. Distribution of valvular incompetence in patients with venous stasis ulceration. J Vasc Surg 1991; 13: 805-812
• 7 Magnusson MB, Nelzén O, Risberg B. et al. A colour doppler ultrasound study of venous reflux in patients with chronic leg ulcers. Eur J Vasc Endovasc Surg 2001; 21: 353-360
• 8 Labropoulos N, Tiongson J, Pryor L. et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003; 38: 793-798
• 9 Abu-Own A, Scurr JH, Coleridge Smith PD. Saphenous vein reflux without incompetence at the saphenofemoral junction. Br J Surg 1994; 81: 1452-1454
• 10 Dwerryhouse S, Davies B, Harradine K. et al. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: Five-year results of a randomized trial. J Vasc Surg 1999; 29: 589-592
• 11 Hach W, Hach-Wunderle V. [Stripping and rival procedures for surgical treatment of truncal varicosity]. Gefässchirurgie 2000; 5: 56-61
• 12 Beale RJ, Gough MJ. Treatment options for primary varicose veins – a review. Eur J Vasc Endovasc Surg 2005; 30: 83-95
• 13 Theivacumar NS, Darwood R, Gough MJ. Neovascularisation and recurrence 2 years after varicose vein treatment for sapheno-femoral and great saphenous vein reflux: a comparison of surgery and endovenous laser ablation. Eur J Vasc Endovasc Surg 2009; 38: 203-207
• 14 Wilmanns C, Cooper A, Wockner L. et al. Morphology and progression in primary varicose vein disorder due to 677C>T and 1298A>C variants of MTHFR. EBioMedicine 2015; 2: 158-164
• 15 Wilmanns C, Casey A, Schinzel H, Walter PK. Superficial thrombophlebitis in varicose vein disease: the particular role of methylenetetrahydrofolate reductase. Phlebology 2011; 26: 135-139
• 16 Eklöf B, Rutherford RB, Bergan JJ. et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg 2004; 40: 1248-1252
• 17 Basmajian JV. The distribution of valves in the femoral, external iliac, and common iliac veins and their relationship to varicose veins. Surg Gyn Obst 1952; 95: 537-542
• 18 Gloviczki P, Comerota AJ, Dalsing MC. et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53 (Suppl. 5) 2S-48S
• 19 Mendoza E. Duplex ultrasound investigation of perforating veins. Phlebologie 2014; 43: 206-209
• 20 Van Rij AM, Hill G, Gray C. et al. A prospective study of the fate of venous leg perforators after varicose vein surgery. J Vasc Surg 2005; 42: 1156-1162
• 21 Blomgren L, Johansson G, Dahlberg-Åkerman A. et al. Changes in superficial and perforating vein reflux after varicose vein surgery. J Vasc Surg 2005; 42: 315-320
• 22 Stuart WP, Lee AJ, Allan PL. et al. Most incompetent calf perforating veins are found in association with superficial venous reflux. J Vasc Surg 2001; 34: 774-778
• 23 Labropoulos N, Leon L, Kwon S. et al. Study of the venous reflux progression. J Vasc Surg 2005; 41: 291-295
• 24 Kolvenbach R, Ramadan H, Schwierz E. Redone endoscopic perforator surgery: feasibility and failure analysis. J Vasc Surg 1999; 30: 720-726
• 25 Iafrati MD, Welch HJ, O'Donnell jr TF. Subfascial endoscopic perforator ligation: an analysis of early clinical outcomes and cost. J Vasc Surg 1997; 25: 995-1001
• 26 O'Donnell TF. The role of perforators in chronic venous insufficiency. Phlebology 2010; 25: 3-10
• 27 Whiteley MS, O'Donnell TF. Debate: Whether venous perforator surgery reduces recurrences. J Vasc Surg 2014; 60: 796-803
• 28 Fletcher A, Cullum N, Sheldon TA. A systematic review of compression treatment for venous leg ulcers. BMJ 1997; 315: 576-580
• 29 Zajkowski PJ, Proctor MC, Wakefield TW. et al. Compression stockings and venous function. Arch Surg 2002; 137: 1064-1068
• 30 Neglén P, Einarsson E, Eklöf B. The functional long-term value of different types of treatment for saphenous vein incompetence. J Cardiovasc Surg 1993; 34: 295-301