Are all patients with sapheno-femoral junction incompetence the same? An ultrasound analysis to potentially predict recurrence after invasive treatments

Introduction

Reflux time is now considered the most widely used tool to detect incompetence of the great saphenous vein (GSV). ¹ Nonetheless, other parameters should be taken into consideration to better quantify the extent and severity of GSV disease. Among these, GSV and sapheno-femoral junction (SFJ) diameters may be indicated as predictors of reflux, as well as the suprasaphenic femoral valve (SFV) absence/incompetence. ² Femoral vein (FV) disease is an underdiagnosed finding, despite it being associated with varicose vein recurrence.^3–5 The aim of this report is to assess ultrasound findings (such as SFJd, GSVd, FV disease/absence, and SFJ incompetence) in order to discriminate between patients with “mild” or “severe” GSV disease, and potentially identify patients more prone to develop recurrence after invasive treatments.

Methods

All patients included in this study signed a consent document in accordance with the Declaration of Helsinki. All consecutive patients from January 2008 to May 2019 who underwent venous duplex ultrasound (DUS) evaluation, with or without venous disease, were enrolled in two vein centers (“Mauro Scarlato” Hospital, Scafati, Italy and “Andrea Tortora” Hospital, Pagani, Italy) and retrospectively analyzed. Patients with previous vein surgery and/or venous thrombosis were excluded. Patients were evaluated with the same duplex machine (MyLab ™ Seven, Esaote, Genova, Italy) using a high-resolution linear (7.5–10 MHz) probe in a standing position. Methods reported by Cappelli et al. ² and according to the ESVS guidelines were adopted for venous and reflux evaluation. SFJd was assessed in a transverse plane within 1 cm from the FV plane. GSVd at the thigh (GSVd-thigh) was assessed using a transverse plane between 10–15 cm from the SFJ, avoiding focal (<4 cm in length) dilatation due to valve presence. Both diameter measurements were assessed using an outer-to-outer manual calipers position. SFV presence and competence were also evaluated. Differences in SFJ and GSV histological specimens were observed in 20 patients (10 with and 10 without SFV disease/absence) after stripping and high ligation of the GSV.

Results

During the study period, 3546 patients were primarily enrolled. After applying the exclusion criteria, 3296 (92.9%) were included in the analysis. The median age of the patients was 51 ± 7 years, and 71.3% of them were women. Nine hundred twenty-six (28.1%) patients had SFJ and GSV reflux, with the majority of them (89.3%) having CEAP C2a/s disease and the remaining having a degree greater than C2. Table 1 summarizes the relationship between GSVd-thigh, SFJd, SFJ incompetence, and SFV incompetence/absence. As noted, the larger the GSVd-thigh, the more likely it was to have SFJ incompetence. In particular, if the GSVd-thigh was greater than 9 mm, all patients had SFJ incompetence. Furthermore, in patients with the GSVd-thigh greater than 11 mm, the SFV was always incompetent/absent. Lastly, there was a disparity between GSVd-thigh and SFJd in patients with SFV disease, with SFJd being more than twice that measured at the thigh.

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Table 1.

Relationship between the diameter of the great saphenous vein at the thigh (GSVd-thigh), incompetent SFJ, absence/incompetence of SFV and SFJ diameter (SFJd) in patients with absence/incompetent SFV. ⁺defined as with both terminal and preterminal valves incompetence; *in patients with incompetent SFJ.

Patients (%)	GSVd-thigh (mm)	Incompetent SFJ+ (%)	Absence/incompetent SFV (%)*	SFJd in patients with absence/incompetent SFV (mm)
435 (13.2)	4 ± 0.5	87 (20.0)	3 (3.4)	10 ± 0.5
490 (14.9)	5 ± 0.5	148 (30.2)	25 (16.9)	12 ± 0.5
552 (16.7)	6 ± 0.5	387 (69.1)	49 (12.6)	14 ± 0.5
464 (14.1)	7 ± 0.5	418 (90.1)	225 (53.8)	16 ± 0.5
431 (13.1)	8 ± 0.5	416 (96.5)	407 (97.8)	18 ± 0.5
355 (10.8)	9 ± 0.5	355 (100)	348 (98.0)	20 ± 0.5
312 (9.4)	10 ± 0.5	312 (100)	307 (98.4)	22 ± 0.5
105 (3.2)	11 ± 0.5	105 (100)	105 (100)	24 ± 0.5
92 (2.8)	12 ± 0.5	92 (100)	92 (100)	24 ± 0.5
38 (1.1)	13 ± 0.5	38 (100)	38 (100)	25 ± 0.5
13 (0.4)	14 ± 0.5	13 (100)	13 (100)	27 ± 0.5
9 (0.3)	15 ± 0.5	9 (100)	9 (100)	30 ± 0.5

Specimen analysis demonstrated similar findings in both SFJ and GSV from patients without SFV absence/incompetence, and in GSV from patients with SFV absence/incompetence (Figures 1(a) and (b)). On the contrary, in SFJ specimens from patients with SFV absence/incompetence, structural venous wall alterations were observed, such as diffuse fibrosis, fibroblast proliferation, collagenized extracellular matrix of the media, elastosis, loss of smooth muscle cells, as well as sclerosis and reduction of vasa vasorum in the adventitia (Figures 1(c) and (d)).OPEN IN VIEWER

Discussion

Despite the improvement in venous disease treatments, varicose vein recurrence remains a not-so-rare finding after surgery or endovenous ablation techniques. Risk factors identification and recurrence prevention should start during the first DUS examination. Hence, it is important to document baseline factors that may affect postoperative outcomes. Moreover, it also remains important to recognize elements indicating higher severity of venous disease.

With our experience, we would like to document in a descriptive way that there seem to be two types of patients with GSV incompetence (Figure 2):

- Type A (“severe” disease), with SFV incompetence/absence, with focal SFJ greater dilatation and with SFJ significant wall disease, if compared with GSV diameter and wall structure at the thigh;

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Figure 2.

Ultrasound characteristics in type A (a) and type B (b) patients. In particular, in type A (severe disease) a femoral valve incompetence/absence (red valve), focal SFJ greater dilatation (red line) and SFJ significant wall disease (red net), if compared with GSV diameter (green line) and wall structure (green net) at the thigh are present, while in type B (mild disease), a femoral valve competence (green valve), similar SFJ and GSV, in terms of diameters (green lines) and wall modifications (green nets).

Type A patients could be more prone to SFJ recurrences after high ligation, due to the loss of the so-called “dynamic fragmentation of the hydrostatic column”. ³ Furthermore, significant SFJ wall degeneration in type A patients may increase the onset or the recurrence of vein reflux and neovascularization. Despite literature does not provide discussions regarding the fate of type A or type B patients (termed and differentiated for the first time in this paper) who underwent or not an invasive treatment, it is possible to hypothesize that these groups might differ in long-term postoperative outcomes, ^{4 ,5} particularly at the SFJ level, which remains the most represented source of recurrence. ⁶

Conclusion

SFV, SFJ, and GSV could be analyzed as separate anatomical entities to better understand venous hemodynamics and venous disease patterns. In particular, not only reflux time but also the competence and diameters of both femoral vein and GSV should be interpreted as influencing factors on treatments. Moreover, stratifying patients according to preoperative DUS findings might help vascular specialists and phlebologists to understand which patients should be monitored more closely, improving postoperative outcomes. The advice could be to pay attention during preoperative DUS, to identify patients at higher risk of recurrence, although further studies are needed to assess postoperative outcomes in Type A and Type B patients.