1. PREVALENCE OF DEEP VENOUS REFLUX AS PRIMARY AETIOLOGY IN CASE OF LOWER LIMB VARICOSE VEINS ABSTRACT ID NO 99

2. INTRODUCTION Varicose veins Chronic venous insufficiency Venous reflux

3. AIM To study the prevalence of deep venous reflux as primary aetiology in cases with lower limb varicose veins. Isolated deep venous reflux.

4. OBJECTIVES The objectives will be to see the various patterns and durations of below mentioned refluxes in patients with lower limb varicose veins. – The Deep Venous Reflux – The Sapheno-femoral & Sapheno-popliteal reflux – The Perforator Reflux

5. MATERIALS & METHODS Sample size – 110 cases of lower limb varicose veins that were managed at this tertiary care centre during June 2012- June 2014. Type of study – A descriptive cross sectional study.

6. INCLUSION CRITERIA Clinically confirmed cases of varicose veins which will be further classified on the basis of CEAP classification. Cases of chronic venous insufficiency in the form of skin changes, ulceration and lipodermatosclerosis. Patients who have not been treated earlier by medical or surgical modality of treatment for varicose veins.

7. EXCLUSION CRITERIA Patients with history of superficial and deep vein thrombosis. Patients in the age group less than 15 yrs to exclude the congenital causes of varicose veins. Patients who have been treated earlier by medical or surgical modality for varicose veins.

8. DOPPLER EXAMINATION Patients were examined in standing position. Axial scan and continuous scan was performed for superficial and deep venous system. The Valsalva maneuver was used to elicit the presence of reflux.

9. DEFINITION OF SIGNIFICANT REFLUX More than 500 msec – Superficial veins. – Deep femoral veins. – Femoro-popliteal veins. – Deep calf veins. More than 350 msec – Perforators.

10. CASE 1 33 Y / Male Varicose veins, Ulcers, Skin changes 3 years duration LLL C2, 4, 6 Ep A n Pr

11. CASE 1

12. CASE 2 46 Y / Female Varicose veins, Skin changes 2 years duration LLL C2, 4 Ep A n Pr

13. CASE 2

14. CASE 3 50 Y / Female Varicose veins, Skin changes, Ulcer 7 years duration RLL C2, 4, 6 Ep A n Pr

15. CASE 3

16. RESULTS The mean age of study population was 48.34 ± SD 12.9 years. CEAP distribution  C4-67 (60.9 %)  C5-05 ( 4.5 %)  C6-11 (10.0 %) Superficial Incompetence  SFJ-65 (59.1 %)  SPJ-11 (10.0 %)  Perforator-68 (61.8 %) DVR  Combined-42 (38.2 %)  Isolated-08 ( 7.3 %)

17. DEEP VENOUS REFLUX

18. MEAN GSV DIAMETER SFJ refluxNumber of patients (n) GSV diameter (mm) p-value MeanSD Present654.470.77 < 0.001 Absent453.750.43

19. DISTRIBUTION OF SFJ REFLUX & DVR IN C4 - C6 GRADE C4 - C6 Grade SFJ Reflux Present (n)Percentage (%) Present4467.69 Absent2132.31 Total65100.00 C4 - C6 Grade Deep Venous Reflux Present (n)Percentage (%) Present3173.81 Absent1126.19 Total42100.00

20. DISCUSSION Irodi et al. – 12 % patients in C3 grade. – 43% patients in C4 grade. – 11 % patients in C5 grade. – 34% patients in C6 grade. Mercer – Study on 89 cases of lower limbs. – Detected reflux at the SFJ in 59 legs (66 per cent) and at the SPJ in 26 (29 per cent) by duplex imaging.

21. DISCUSSION Myers et al. – Demonstrated combined prevalence of DVR and reflux in superficial system to be 48 % in cases of varicose veins. Hanrahan and associates – Total incidence of deep system reflux to be 49.5%. – Did not quantify the reflux to primary or secondary.

22. DISCUSSION Irodi et al. – Found 50 (50%) cases of deep venous reflux but none of the cases had reflux in isolation. Myers et al. (1995) – Found that out of 96 cases; 8% cases had isolated DVR. Hanrahan et al. (1991) – Conducted a doppler study on 95 patients – Found the prevalence of deep venous reflux to be 2%

23. DISCUSSION Joh & Park – used recumbent patient position. – The mean diameter of a GSV with reflux was 6.4 ± 2.0 mm. – Normal GSV mean diameter measured 5.0 ± 2.4 mm. – GSV diameter threshold of 5.05 mm and greater had the best value for predicting reflux. – The sensitivity and specificity at 5.05 mm were 76% and 60%, respectively.

24. LIMITATIONS OF STUDY No control groups of normal cases were taken Although quantitative assessment of deep venous reflux has been done, insignificant reflux in GPJ and PTV could have been due to inadequate valsalva technique. Non - availability of pneumatic cuff inflation technique in our study would have contributed to the results. Study of GSV and SSV has been primarily done at the junctional sites. Assessment of segmental reflux in these territories away from the junctional site would have given better correlation between various factors.

25. REFERENCES Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS, Ashraf Mansour M et al. Definition of venous reflux in lower extremity veins. J Vasc Surg. 2003; 38(4): 793–798. Labropoulos N, Tassiopoulos AK, Kang SS, Mansour MA, Littooy FN, Baker WH. Prevalence of deep venous reflux in patients with primary superfricial vein incompetence. J Vasc Surg. 2000; 32:663-8. Myers KA, Ziegenbein RW, Zeng GH, Matthews PG. Duplex ultrasonography scanning for chronic venous disease: patterns of venous reflux. J Vasc Surg. 1995; 21:605-12. Bergan JJ. The Vein Book. London: Elsevier; 2007. Irodi A, Shyamkumar, Keshava N, Agarwal S, Korah IP, Sadhu D. Ultrasound Doppler Evaluation of the Pattern of Involvement of Varicose Veins in Indian Patients. Indian J Surg. 2011. 73(2):125–130. Joh JH, Park HC. The cutoff value of saphenous vein diameter to predict reflux. J Korean Surg Soc. 2013; 85:169-174. Hanrahan LM, Araki CT, Fisher JB, et al. Evaluation of the perforating veins of the lower extremity using high resolution duplex imaging. J Cardiovasc Surg. 1991; 32:87-97. Mercer MG, Scott DJA, Berridge DC: Preoperative duplex imaging is required before all operations for primary varicose veins. British Journal of Surgery. 1998; 85: 1495-1497. Lees TA, Lambert D. Patterns of venous reflux in limbs with changes associated with chronic venous insufficiency. Br J Surg. 1993; 80:725-28. Masuda EM, Kistner RL, Eklof B. Prospective study of duplex scanning for venous reflux: comparison of Valsalva and pneumatic cuff techniques in the reverse Trendelenburg and standing positions. J Vasc Surg. 1994; 20:711-720. Welch HJ, Young CM, Semegran AB. Duplex assessment of venous reflux and chronic venous insufficiency: the significance of deep venous reflux. J Vasc Surg. 1996; 24: 755–762. Jeanneret C, Labs KH. Physiological reflux and venous diameter change in the proximal lower limb veins during a standardised Valsalva maneuver. Eur J Vasc Endovasc Surg. 1999; 17(5):398–403.

26. THANK YOU