Deep venous reflux and incompetent perforators: significance and implications for therapy

Abstract

Objectives: To define the significance of perforator and deep vein pathology in patients with chronic venous disease (CVD).

Methods: Consecutive patients with CVD were referred for venous evaluation (group A). Both saphenous veins and all the deep veins including those in the calf area were evaluated. A separate group of patients with deep venous reflux and/or obstruction was identified from our database and analysed separately (group B). The CEAP classification (clinical, aetiological, anatomical and pathological) was used to grade the clinical severity of CVD.

Results: Age, duration of disease and history of thrombosis increased significantly with disease severity (P <0.02). Reflux in the superficial veins was the most common pathology in group A and it was present in 75% of limbs in group B. The overall contribution of deep venous disease was 26% in group A and it increased significantly with the severity of disease in both groups. Isolated deep vein disease in group A was significantly less compared with group B (8% vs 23%, P<0.0001). Reflux in deep veins of post-thrombotic limbs was significantly longer compared with those with primary disease. The prevalence of incompetent perforator veins was higher in patients with skin damage from both groups. No patient had isolated perforator vein reflux. Reflux was the most common pathology in both groups, while obstruction alone was rare. Other than superficial reflux, which is very common, ipsilateral recurrent deep venous thrombosis (DVT), combined reflux and obstruction, and popliteal vein reflux were the strongest predictors for development of skin damage.

Conclusions: Perforator and deep vein involvement increases significantly with the severity of CVD. Isolated deep vein disease in post-thrombotic limbs is more common than in consecutive venous patients. Reflux is the most common pathology and obstruction alone is rare. In post-thrombotic limbs, the most important predictors for skin damage are ipsilateral recurrent DVT, popliteal vein reflux and a combination of reflux and obstruction.