Significant differences in patients with a complete insufficiency of the great versus small saphenous vein

Abstract

Objectives

Most studies on diagnostics and therapy of saphenous veins focus on great saphenous vein or sum up great and small saphenous vein. This study compares patients with an insufficiency of the great saphenous vein versus small saphenous vein.

Methods

Prospective study including 50 patients with untreated insufficiency of the great saphenous vein or small saphenous vein, respectively. Patients got a standardised phlebological examination and filled a vein-specific life quality questionnaire (SQOR-V).

Results

Great saphenous vein patients were significantly younger (p = 0.001), had more visible varicose veins (p < 0.001), a higher Venous Clinical Severity Score (p = 0.002) and had more symptoms, especially at midday (p = 0.0030) and evening (p = 0.078). They had significantly more concerns about worsening of their varicose veins (p = 0.009) and a vein disease in family members (p = 0.005).

Conclusion

Great saphenous vein patients have more and sooner symptoms than small saphenous vein patients. This study discusses if the difference in symptoms is related to the difference in tributaries and a therapy of the tributaries is able to reduce the symptoms.

Keywords

Chronic venous insufficiency varicose veins venous symptoms tributaries vein therapy

Introduction

Varicose veins and chronic venous insufficiency (CVI) are among the great widespread diseases of our time. In Germany, 20% of the population are affected by a venous disease requiring treatment,^1,2 and comparable figures exist in other countries with a western lifestyle. In recent years, numerous studies have investigated the effectiveness and safety of different types of treatment for saphenous incompetence. Most of these studies have investigated patients with incompetence of the great saphenous vein (GSV) or summed up incompetence of the GSV and the small saphenous vein (SSV), without distinction.^3,4 Comparison of patients with insufficiency of the GSV versus the SSV in clinical studies is seldom and only done with focus on post-surgical or post-interventional findings, but not with an analysis of the untreated patients.⁵ Therefore, there is a need to investigate to what extent patients with untreated varicosity in the GSV or SSV can be differentiated by clinical findings, symptoms and quality of life with potential consequences for their therapy. To address this question, a prospective, monocentre, open pilot study was planned in the outpatient department of a specialist phlebology clinic.

Patients and methods

Fifty patients each with untreated insufficiency of the GSV or SSV were included and evaluated between May 2014 and July 2014. The patients were recruited consecutively under the inclusion and exclusion criteria of Table 1. The following standardised information was determined for all patients:

Table 1.

Inclusion and exclusion criteria, summary.

Inclusion criteria	Exclusion criteria
Minimum age of 18 years Venous disease classifiable by CEAP Complete incompetence of the GSV or SSV classifiable by Hach Written consent to participate in the study Physically and mentally capable of understanding and answering the questionnaire	No consent Recurrent veins in the affected leg Incompetence of GSV and SSV in the same leg Co-morbidities or medication which might substantially influence the venous symptoms (e.g. BMI>30 kg/m², restricted mobility, NYHA II cardiac insufficiency, diabetes mellitus) Regular administration of NSAR, steroids or anticoagulants Previous deep vein thrombosis or acute deep vein thrombosis in the affected leg Known thrombophilia or hypercoagulability Prior vein treatment in the affected leg

Inclusion criteria

Exclusion criteria

Minimum age of 18 years

Venous disease classifiable by CEAP

Complete incompetence of the GSV or SSV classifiable by Hach

Written consent to participate in the study

Physically and mentally capable of understanding and answering the questionnaire

No consent

Recurrent veins in the affected leg

Incompetence of GSV and SSV in the same leg

Co-morbidities or medication which might substantially influence the venous symptoms (e.g. BMI>30 kg/m², restricted mobility, NYHA II cardiac insufficiency, diabetes mellitus)

Regular administration of NSAR, steroids or anticoagulants

Previous deep vein thrombosis or acute deep vein thrombosis in the affected leg

Known thrombophilia or hypercoagulability

Prior vein treatment in the affected leg

GSV: great saphenous vein; SSV: small saphenous vein; BMI: body mass index; NYHA: New York Heart Association; NSAR: non-steroidale antirheumatics.

phlebological history

clinical picture (by classification of chronic venous disease regarding clinical signs, etiology, anatomy and pathophysiology (CEAP) and Venous Clinical Severity Score (VCSS))

duplex ultrasound findings (vein diameter 2 cm below the saphenous junction, Hach state)

The duplex examination was done with the patient standing in an upright position and the leg in slight external rotation using a linear probe with 10 MHz (GE Healthcare Logiq S7 and S8). The reflux was provoked by manual calf compression and release.

Reflux was regarded as pathological when it has a duration of more than 0.5 s and a distance of more than 1 cm.

The reflux status according to Hach is given with four stages for the GSV and with three stages for the SSV. It is used to classify a complete truncal vein incompetence starting in the sapheno-femoral/sapheno-popliteal junction and marking the distal end point of the reflux.

and a vein-specific quality of life questionnaire (SQOR-V).

The study protocol was designed in accordance with the usual standards and in compliance with the recommendations and laws applicable to clinical studies and was approved by the ethics committee of the Ruhr-University Bochum, Bad Oeynhausen (Decision No. 6/2014).

The data were collected standardised, converted to anonymity and pooled for analysis. First, a descriptive analysis was made of the whole sample and the two groups with totals, means and standard deviations. The groups (GSV versus SSV) were compared according to the following parameters:

t-Test for independent samples (age, height, weight, body mass index, sex, affected leg, CEAP classification, diameter, SQOR-V and VCSS questionnaires)

Chi-square test (presence of varicose tributaries, family medical history)

Correlations

A finding was treated as statistically significant with p < 0.05.

Results

Patients

During the study period (May–July 2014), daily about 60–70 patients were examined in the specialised vein centre coming by recommendation of their practitioner or an outpatient vascular specialist. Most of them did not fulfil the inclusion criteria as they had prior therapies, more than one affected truncal vein or co-morbidities that excluded the participation in the study. About 10% of the patients seen in the study centre were able to be included in the study. About 30% of the highly preselected patients coming for examination had no clinical relevant venous disease to be treated.

The study sample included 66 women and 34 men, average age 46.94 years with clinical CEAP states C1–C4 (Table 2). Both groups included more women than men.

Table 2.

Tabulated presentation of the findings in the two groups.

	GSV group, n=50	SSV group, n=50	Comparison between groups GSV vs. SSV
Male	24	13	n.s.
Age (years)	42.3 (±12.6)	51.9 (±14.4)	p = 0.001
Height (cm)	175.5 (±9.7)	172.5 (±9.7)	n.s.
Weight (kg)	75.9 (±14.0)	73.2 (±12.7)	n.s.
BMI (kg/m²)	24.5 (±2.9)	24.4 (±2.6)	n.s.
Right leg affected (%)	50.0	56.0	n.s.
Hach state (%)
I	8	4	No analysis or significance since the distribution of states was not comparable
II	12	64
III+IV	80	32
Maximum C state under CEAP classification (%)	4	4	n.s.
C1	50	40
C2	18	22
C3	28	34
C4	0	0
Mean diameter 2 cm below the saphenous junction (mm)	8.79 (±3.1)	7.73 (±2.5)	n.s.
Mean total VCSS	5.02 (±2.4)	3.64 (±1.9)	p = 0.002
Mean total SQOR-V (the lower the score, the more severe the discomfort)	93.5 (±29.0)	86.18 (±26.8)	n.s.

GSV: great saphenous vein; SSV: small saphenous vein; BMI: body mass index; VCSS: Venous Clinical Severity Score; n.s.: not significant.Note: The bold values are significant.

Vein findings

In the GSV group there were more patients with varicose tributaries (detected by clinical examination and/or duplex). The Hach state of the majority of patients in both groups was at least II. The distribution of the patients by clinical CEAP stage and by vein diameter 2 cm below the saphenous junction gave no significant differences between the groups (Table 2). However, there were significant differences in the VCSS. Patients with GSV incompetence had a higher total score (Table 2) and more frequently presented visible varices (Figure 1).

Figure 1.

Frequency of symptoms at the study leg in both groups in the VCSS.

Quality of life

The results of the SQOR-V questionnaire also showed differences between the two groups. In general, five aspects were evaluated on a five-level scale (most concerning = 1 to least concerning = 5). The lower the mean score, the greater the patient’s concern.

GSV patients returned a lower total score in this questionnaire. They suffered greater concern with respect to appearance, health risk, movement restriction and emotional distress. The scores of SSV patients were higher for discomfort/pain in the leg (Figure 2). However, there were no significant differences in these categories.

Figure 2.

Rating of leg symptoms of the legs in the SQOR-V. The lower the value, the greater the patient’s concern (most concerning = 1 to least concerning = 5).

The intensity of symptoms was perceived as more frequent and more intense by GSV patients. Significantly more patients with SSV incompetence reported no discomfort in the leg (p < 0.001).

There were no significant differences in intensity of pain, heaviness, itching, night calf cramps, swelling, warm/burning sensation, tingling, stinging or stabbing sensation, or restlessness in the affected leg. The differences in the categories: effects on appearance of legs, influence on choice of clothing, effects of choice of activities, overall restrictions, restrictions on activities at work, at home, and sport and leisure activities were also not significant. The same was true of activities involving prolonged standing, prolonged sitting, walking, using stairs, during sleep and social activities. However, there was a trend for GSV patients to be more severely affected or suffer greater discomfort than SSV patients in all categories.

A significant difference did exist in patient evaluation of discomfort at different times of day. GSV patients reported significantly more frequent and severe discomfort in the middle of the day (p = 0.030) and tended to suffer more in the evening (p = 0.078).

There were no significant differences between the two groups in the following items: changes since last year, emotional consequences of vein problems, being on edge, being irritable, feeling a burden to others and overall worry about vein problems.

Significant differences were found for the items “Does the possible worsening of your vein disease worry you?” (p = 0.009) and “Does it worry you that someone related to you suffers from vein disease?” (p = 0.005), and a trend for the question “Does the possibility of your condition causing complications worry you?” (p = 0.056).

Data summary

To summarise the data collected from the two groups, the following significant differences were found: GSV patients

were younger on average

had more visible varicose veins

reported a higher VCSS

suffered more discomfort overall in the affected leg, especially in the middle of the day and in the evening

were more worried about a possible worsening of their venous disease and about venous problems among their relations

Discussion

Varicose veins are of significance among the general population and in clinical practice due to their high incidence and prevalence.¹ However, many questions referring to this scientific field have not been satisfactorily answered. The majority of studies on symptoms, clinical relevance and quality of life in patients with varicose veins refer to the GSV or to saphenous veins in general without distinguishing between GSV and SSV.^1,6–9 In clinical practice, however, there are indications that differences exist in the subjective symptoms and clinical relevance of incompetence in the GSV as opposed to the SSV. The findings of the present investigation confirmed the impressions of clinical practice and found significant differences between the clinical findings, symptoms and quality of life in patients with insufficiency of the GSV or SSV.

Patients with SSV incompetence are older

The average age of the whole sample was 46.9 years. The most frequent age-bracket was 40–49 years; younger patients were clearly less frequent. In this respect the data for the whole sample are comparable with those of the Bonn vein study.¹ However, in separation of the two groups, the mean age of the GSV group was 42.3 years, nearly 10 years younger than in the SSV groups (51.58 years, p = 0.001). These data suggest that that GSV incompetence either appears earlier than SSV incompetence or is perceived as a problem earlier. The difference is especially surprising because the percentage of women in the SSV group is (tendentially) higher, from which it may be inferred that women in general react earlier and with greater sensitivity to varicosity and the associated symptoms.¹⁰ From this it might be supposed that those in the women-dominated SSV group tend to consult a doctor earlier. Interestingly, this was not the case in this study. If this remarkable finding on age is taken together with the findings of clinical discomfort, it could be presumed that GSV incompetence produces more discomfort and visible varicose veins, leading patients to an earlier consultation.

More numerous visible varicose veins in the GSV group

Patients suffering venous disease feel cosmetically impaired by visible alterations to their legs such as varicose veins, spider veins or associated skin alterations. Sixty percent of the population suffer slight vein alterations which cause no health risk but represent a cosmetic problem.¹¹ Flawless legs are an ideal of beauty for women rather than men. This leads to a desire for treatment in the early stages of the disease.¹¹ Augustin et al. show that quality of life impairment in the form of physical discomfort increases with the severity of this disease.⁷ The fact that visible varicose veins in the affected leg may reduce quality of life has never previously been described in these terms.

The findings of the present investigation showed that significantly more patients in the GSV group (mean 2.32) than the SSV group (mean 1.06) had visible varicose veins (p < 0.001). It can be discussed if either presented GSV patients are in a more advanced stage of their disease or the insufficiency of the GSV is associated with a higher rate of tributaries. However, we found that GSV patients consulting a doctor are significantly younger than SSV patients. It therefore seems more probable that GSV incompetence arises at a younger age and then follows a progression with visible alterations. A prospective longitudinal study would be necessary to investigate these hypotheses further.

More discomfort and worry about worsening in GSV patients

In the whole sample, overall discomfort in the affected leg, discomfort around the middle of the day and worry about further worsening were all significantly more frequent in the GSV group (p < 0.001; p = 0.030; p = 0.009, respectively). The GSV group felt significantly more restricted by their legs in their everyday activities. The answer “symptom not experienced” was given more frequently by patients in the SSV group than the GSV group.

The discomfort resulting from SSV incompetence seems to be less and appears later. This phenomenon may possibly be explained by the positions of the two saphenous veins. While the GSV courses through the subcutaneous fatty tissue on the inside of the leg, the SSV is not only embedded in the subcutaneous fatty tissue but is also surrounded by calf muscle tissue which is generally tighter, as well as being close to the working calf muscle pump. Other studies dealing with the clinical symptoms of CVI have made no distinction between incompetence of the GSV or SSV.⁶ In a clinical study by Klyscz et al. in CVI patients in Widmer state III, specific distress was predominant, e.g. pain while walking, hypersensitivity to the touch, tight skin and swelling in the legs, with “slight” to “moderate” degree of severity on average. However, individual symptoms of venous disease, e.g. pain when sitting and unpleasant heaviness, as well as calf cramps, impair patients in CVI states I and II even more severely that patients in CVI state III.⁶ Augustin et al. on the other hand established in their quality of life profile for CVI state II that discomfort had only a slight influence on physical sensations.⁷ The findings presented here showed no significant differences between the two groups in terms of pain in the affected leg, heaviness, itching, night cramps, swelling, warm or burning sensation, tingling, stinging or stabbing pain, restless leg, and worsening with heat or improvement with cold. In a study by Miszczak, calf cramps and pain when sitting and standing were the most frequent and most intense preoperative symptoms in the whole sample with mean scores of 4.1 and 3.9, respectively. Paresthesia and pain when lying were the least frequently mentioned problems.¹²

Worry among GSV patients that their relations may suffer venous disease

A final criterion in the SQOR-V questionnaire was the question “Does it worry you that someone related to you suffers from vein disease?” The GSV group were significantly more worried than the SSV group (p = 0.005). This finding may be related to the comparably more frequent occurrence of discomfort and symptoms in the GSV group. If people with the disease are familiar with the discomfort from their own experience, they may perceive it as more dangerous or unpleasant for their family members than if they themselves suffered no discomfort due to their varicose veins. Thus, early diagnosis and treatment of varicose veins are necessary and desirable. Treatment can achieve good, long-lasting results and avoid complications associated with CVI, giving vein disease patients a better quality of life. Patients and their families should be able to recognise possible vein symptoms early, and obtain rapid diagnosis, and treatment if necessary, to avoid resulting damage, complications and severe findings.

Mobile activities more frequent in GSV patients; sedentary jobs more frequent in SSV group

A statistically significant difference was found between sedentary and mobile activities in the groups (p = 0.000445; p = 0.023). Almost twice as many patients in the SSV group carried out mainly sedentary activities. We therefore need to ask what influence sedentary activity has on the appearance of venous problems. It is known that the intertriginous pressures in the groin increase. The increased pressure in the peripheral venous system correlates with intertriginous measurements in the groin region. In the so-called dependency syndrome, prolonged sitting leads to the formation of oedemas in the foot and lower leg region due to lack of calf muscle pump activity. This may also occur with competent veins, and the simple lack of leg muscle pump activity may lead to symptoms of CVI, from oedema through obstructive dermatosis to leg ulcer.¹³

Thus, on the one hand it is known that immobility has a negative effect on venous problems, but on the other it is quite unknown what are the most important factors influencing sedentary activity. The possibilities might include the number of hours spent sitting per day, the occupation or activity during time not spent in the sedentary activity, and the age, sex and weight of the respondent. It is therefore difficult to prove a direct relation between sedentary activity and venous disease.

It must also be considered that people with a principally sedentary activity also have various opportunities to move about intermittently, for example during breaks or when fetching and carrying about the office in the course of their work. It may be argued that these mobile phases, albeit often only short, in which the calf muscle pump is activated are sufficient to palliate discomfort in the affected leg.

In the GSV group on the other hand there was a particularly high number of patients whose activity was mainly standing or mobile. It is firmly established that people with standing jobs, for example hairdressers, suffer negative effects on vein health.¹⁴ Standing activities however are seen as an aggravating factor for varicose veins, not as the principal cause of their appearance.¹⁵ It is much more difficult to assess the findings with respect to mobile activity. On the one hand, mobility is good for people with venous problems because it activates the calf muscle pump. It improves the ejection fraction, reduces venous obstruction, etc. However, there may be a critical limit above which mobility causes venous problems to worsen.¹⁶ Further studies are necessary to investigate the impact of sports and mobility on venous symptoms.

No significant differences in vein diameter

The vein diameter 2 cm below the junction was 8.79 mm in the GSV group and 7.73 mm in the SSV group (not statistically significant). Taken together with the clinical symptoms, this is a surprising finding. It might have been assumed that GSV patients, who presented more numerous visible varicose veins and venous discomfort, would have a significantly larger vein diameter than SSV patients. Apparently, a dilated SSV causes less discomfort than an equally dilated GSV. As discussed above, the embedding of the vessels in different surrounding tissue may play a part. It may also be that other factors, not yet investigated, are important, for example the condition of the tributaries and perforators that bring in and carry off blood flow or the length of the incompetent stretch. A further hypothesis might be that the discomfort experienced is due less to the dilation of the saphenous vein, where as we have seen there is no difference, and more to the size of the corresponding tributaries (GSV > SSV).

Thigh extension of the SSV and SSV without SPJ

The reviewers asked for differences in SSV with thigh extension or without sapheno-popliteal junction (SPJ). Unfortunately, we are not able to answer this question since we did just include patients with an SPJ and without thigh extension into this study as we stated in the Patients and methods section.

Limitations

There are several limitations in the study design:

Patients were selected in a highly specialised vein centre. Most of them came by recommendation of a practitioner or another vascular specialist

Patients were selected with inclusion and exclusion criteria

Only patients with complete truncal insufficiency, reflux coming from the deep femoral or popliteal vein, were included

It is a small number of patients

Conclusions

To summarise, the data collected show that patients with incompetent GSV are younger than those with incompetent SSV when they first consult a doctor; they already have severe clinical findings, more clinical discomfort and visible varices, and feel that their quality of life is more strongly impaired.

However, it may be that the relevant issue for these comparatively more severe symptoms is not primarily the varicose saphenous vein but rather the significantly more numerous visible (and in most cases dilated) varicose tributaries. Further comparative studies to determine whether early treatment of varicose tributaries alone (with sparing of the incompetent saphenous trunk) has a beneficial effect on the evolution of varicose vein symptoms and progress of disease may be of interest.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Acknowledgement

We thank Willie Barne for kind support in the revision of the English manuscript.

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