The Importance of Deep Venous Reflux Velocity as a Determinant of Outcome in Patients with Combined Superficial and Deep Venous Reflux Treated with Endovenous Saphenous Ablation

Background: Patients with symptomatic chronic venous insufficiency (CVI) and saphenous reflux are commonly treated with endovenous ablative techniques (EVLA). In approximately 20% of cases, saphenous reflux is found in association with deep venous reflux. It is currently unclear whether EVLA will result in correction of CVI without addressing the deep venous reflux. In this study we examined deep venous reflux velocities to determine whether these would predict outcome after EVLA.
Methods: Patients with symptomatic CVI and both saphenous and deep venous reflux were identified using duplex ultrasonography in the standing position. A reflux time of greater than 0.5 seconds was the threshold for abnormal reflux. Maximal reflux velocity (MRV) in each examined vein segment was determined from duplex reflux tracings by taking the highest reflux velocity occurring more than 0.5 seconds after release of compression. Venous filling indexes (VFI) were obtained using air plethysmography at baseline and 4 to 6 weeks after laser ablation of the great and/or small saphenous veins. Venous clinical severity scores (VCSS) were obtained before and at 6 month intervals after EVLA. Preoperative deep venous reflux times were correlated with improvement in VFI and VCSS after ablation.
Results: From a total of 351 consecutive limbs treated with EVLA, 75 limbs were identified with both deep and superficial venous reflux. Seventy-five percent of limbs were CEAP clinical class 3 or 4 and 25% were class 5 or 6. EVLA was technically successful in all 75 cases. The average pre-procedure VFI for all cases (6.37±3.8 cc/sec) decreased significantly after EVLA to 2.67 ± 2.3 cc/sec (P < 0.01). In 35 limbs, deep venous reflux was identified only in the common femoral vein (CFV). In this group, the average pre-procedure VFI (6.5 ± 3.9 cc/sec) decreased significantly to 2.2 ± 1.9 cc/sec (P<0.001) and the VCSS improved markedly from 7.0 ± 2.8 to 1.3 ± 1.4 (P<.001). This improvement was not dependant on MRV in the CFV. However, in 40 limbs demonstrating reflux in the popliteal vein, the improvements in VFI and VCSS after EVLA was dependant on the popliteal vein MRV. When this was < 10 cm/sec, limbs had significantly better outcomes than limbs with MRV > 10 as measured by both VFI and VCSS (see table). The VFI in 6 of 7 limbs with a popliteal MRV > 20 cm/sec remained abnormally high after EVLA.
Conclusions: EVLA of the saphenous veins can be performed in patients with concomitant deep venous insufficiency with hemodynamic and clinical improvement in most cases. Patients with deep reflux confined to the CFV and those with popliteal reflux velocities lower than 10 cm/sec usually experience correction of the VFI and improvement in their VCSS. Patients with higher popliteal reflux velocities have a high incidence of persistent CVI after EVLA. Popliteal MRV is a significant predictor of outcome after EVLA in patients with combined deep and superficial venous insufficiency.