by Nicos Labropoulos, PhD, DIC, RVT, Professor of Surgery and Radiology, Stony Brook Universtiy Medical Center. and Antonios P. Gasparis, MD, Associate Professor of Surgery, Director, Stony Brook Vein Center
Chronic venous disease (CVD) is the most prevalent form of vascular disease, affecting about a third of adult Americans. Most patients present with varicose veins but swelling and skin damage are common as well. The signs and symptoms of CVD are result of venous hypertension that develops from reflux, obstruction or a combination of both. In patients with CVD, around 70-80% will have superficial reflux with or without perforator vein incompetence and 10% isolated deep reflux. Combined superficial and deep vein disease has been reported to occur in about 10-20%. Congenital CVD and chronic venous obstruction are rare (Figure 1). While treatment of the isolated superficial venous system in patients with CVD is expected and has been shown to have good outcomes, the role, efficacy and complications of superficial intervention in patients with combined disease has been controversial. In patients with mixed pathology, deep venous obstruction occurs in a small number of limbs, which is either primary or secondary. The majority though, will have underlying reflux which will be segmental and is likely to occur due to volume overload from the recirculating reflux blood in the superficial veins. However, axial vein reflux, which is most often a result of previous thrombosis, also is seen, as about two thirds of patients with proximal vein thrombosis will develop reflux at one year. Patients with a previous episode of thrombosis may have vein segments without or with partial recanalization leading to obstruction or to a combination of reflux and obstruction.
Segmental deep-vein reflux due to superficial vein incompetence is most often seen at the saphenofemoral (SFJ) and saphenopopliteal junctions (SPJ). It also can be due to reflux in the gastrocnemius veins (almost always the medial) and perforator veins (Figure 2). The reflux in the perforator veins is not isolated but it occurs only in the presence of reflux in superficial veins that are connected with the affected perforators. Longstanding reflux in the superficial and perforator veins may lead to reflux development in the deep veins that are connected with the affected perforators. This is the same phenomenon as in the case of SFJ, SPJ and gastrocnemial veins. Deep vein reflux which is induced by the superficial vein incompetence is easily eliminated in >95% of patients after treating the superficial veins. This has been demonstrated in different studies and it does concur with our experience as well. It has to be noted that many patients may have deep vein reflux due to previous thrombosis. In such occasions the deep vein reflux may improve in some cases after elimination of the superficial reflux, but it does not disappear. The latter is more prevalent in the presence of axial reflux, such as when there is reflux in continuity from the common femoral vein to popliteal or more distal (Figure 3).
Traditional advice has been against saphenous ablation in the presence of deep venous obstruction. This was felt because of the thought that secondary saphenous varices result from deep venous obstruction and function as collaterals. Therefore, it was feared that obstructive disease may be made functionally more severe by removing the saphenous vein that may be functioning as important collateral. When testing venous outflow function in patients with previous deep vein thrombosis, Labropoulos et al. demonstrated that only 9.6% of limbs had their venous outflow reduced by occlusion of the superficial veins. The deep collaterals seem to be more important than the superficial venous system in bypassing the obstruction. Raju et al.,when comparing patients with and without deep obstruction who underwent saphenectomy, found similar outcomes in the two groups with no clinical deterioration in those with obstruction. In addition, the risk of DVT following saphenous ablation does not seem to be increased in patients with previous thrombotic events as shown by Puggioni et al. Therefore, the saphenous vein plays an insignificant role as a collateral pathway in patients with deep venous obstruction and can be safely treated to correct underlying hemodynamic pathology.
In patients with advanced CVD (C4-6) and superficial reflux, interrogation of the deep venous system for proximal obstruction, even in the absence of previous DVT, is warranted. Marston et al. found that as many as 30% of patients with chronic venous insufficiency have iliac vein obstruction on CT scan. When obstruction is in the iliac veins, consideration for its significance and intervention should be considered. The presence of such combined disease (superficial reflux and iliac vein obstruction) may warrant treatment of both levels of disease, as it is impossible to identify the pivotal diseased segment that contributes to the clinical presentation. In fact, we are presently unable to quantify segmental reflux or obstruction or describe how they interact. It is, therefore, reasonable to treat the superficial reflux and the proximal obstruction with iliac vein stenting. This can be done in a staged or combined fashion. Neglen et al. reported combined saphenous ablation and iliac vein stenting in 99 limbs with significantly improved hemodynamic parameters, improved clinical symptoms (pain and swelling) and significant improvement in all quality-of-life categories after treatment. This was achieved with good 4-year patency (>90%) and low complication rate.
Patients with mixed superficial and deep pathology and significant clinical symptoms (especially C4-6) should be offered not only treatment of their superficial system but also evaluation and therapy of any underlying iliac vein obstruction with excellent clinical outcomes. When evaluating the superficial veins in patients with deep vein obstruction it is necessary to demonstrate significant reflux in the superficial veins prior to intervening. This is very important as superficial veins can be dilated in order to compensate for the deep vein obstruction. In such patients the diameter change should not be compared with the studies on patients with primary superficial vein reflux. Therefore, superficial veins with large diameter should not be removed unless there is significant reflux that may contribute to the patients’ signs and symptoms. Patients with deep vein obstruction are evaluated in the supine position. However, when these patients are tested for reflux, this must be done in the standing position. This is paramount as reflux should be evaluated in the standing position in all patients. We overemphasized this for the patients with venous obstruction as many centers still examine reflux in the supine position in such patients.