View metadata, citation and similar papers at core.ac.uk brought to you by CORE

provided by Elsevier - Publisher Connector

Eur J Vasc Endovasc Surg 21, 550–557 (2001) doi:10.1053/ejvs.2001.1375, available online at http://www.idealibrary.com on

Non-saphenofemoral Venous Reflux in the Groin in Patients with Varicose

P. Jiang, A. M. van Rij∗, R. A. Christie, G. B. Hill and I. A. Thomson

Department of Surgery, Dunedin School of Medicine, University of Otago, New Zealand

Objectives: to investigate the incidence, clinical significance, anatomical variation and physiology of non-saphenofemoral venous reflux (non-SF reflux) in the groin. Design: prospective study. Materials: a total of 1072 vascular diagnostic workups in 680 patients with possible venous diseases to the legs were included. Methods: duplex scanning and air plethysmography. Results: a total of 1022 legs had venous diseases. Of these, 101 (9.9%) had non-SF reflux in the groin. Such reflux occurred in recurrent varicose veins (RVV) in 16.3%, in primary varicose veins (PVV) in 6.1% and in deep venous (DVT) in 8.0%. Two patterns of reflux were distinguished: epigastric reflux from lower abdominal wall veins (71 legs) and pudendal reflux from perineal and/or gluteal veins (30 legs). Pudendal reflux was almost exclusive to women and did not occur with DVT. If there was only non-SF reflux at the groin the venous filling indices (VFI) were close to normal (1.7±1.0 ml/s for RVV, 1.9±1.2 for PVV, 1.7±1.0 for DVT) and no active ulcers were observed. However, if non-SF reflux was associated with saphenofemoral or other reflux the VFIs (3.3±2.3 ml/s for RVV, 3.8±1.5 ml/s for PVV) were abnormal (p<0.05) and ulcers occurred in 11/32. Conclusion: non-SF reflux in the groin is common. Such reflux may be missed at initial surgery and lead to recurrence of varicose veins. However, the venous physiological disturbance of such reflux is mild and it is not associated with ulcers unless combined with reflux at other sites in the leg.

Key Words: Venous reflux; Duplex scanning; Air-plethysmography; Venous ulcer.

Introduction The present study examines the frequency of non- SF reflux and the impact on the venous physiology The significance of incompetence from superficial to and clinical presentation. deep connections in the pathogenesis of varicose veins in the leg has been well recognised. These incompetent sites include saphenofemoral junction (SFJ), sapheno- Methods popliteal junction (SPJ) and perforating veins in the thigh and leg. The SFJ incompetence is the commonest 1–6 From May 1992 to May 1997, patients with symp- cause of varicose veins. However, this is not the only tomatic varicose veins considered for surgical inter- source of reflux at the groin into the superficial veins vention or those requiring aetiological diagnosis were of the leg. Reflux from the pelvis and abdominal wall 7–9 referred for APG and duplex ultrasound. Patients may also cause varicose veins. with suspected deep venous thrombosis (DVT) were In a previous study of recurrent varicose veins, 12% similarly assessed. Demography and medical history of legs had non-saphenofemoral reflux (non-SF reflux) were recorded. Severity of the disease was assessed and in 50% this was the only source of incompetence. by the CEAP classification.11 Despite all legs in that study being clinically symp- tomatic, air plethysmography (APG) was generally normal and none had developed ulceration.9,10 Physiological tests

∗ Please address all correspondence to: A. M van Rij, Department of Surgery, Dunedin School of Medicine, University of Otago, P.O. APG was performed as described by Christopoulos et Box 913, Dunedin, New Zealand. al.12 In brief, the patients lay supine with the leg

1078–5884/01/060550+08 $35.00/0  2001 Harcourt Publishers Ltd. Groin Non-saphenofemoral Venous Reflux and Varicose Veins of the Leg 551 elevated to 20 degrees for 5 min to establish the base- to compare measures of venous physiology in different line. Upon standing without weight-bearing on the groups. The level of statistical significance was set leg being studied and following a series of toe stands, at 0.05. Numbers are given as mean±S.D. unless venous reflux (as venous filling time, VFT and venous otherwise noted. filling index, VFI), calf muscle pump function (ejection volume, EV, ejection fraction, EF, residual volume, RV, residual fraction, RF) were calculated. The risk of ulceration defined by our laboratory as the ulcer index, Results UI (the ratio of VFT to RF) was also calculated.13 Outflow obstruction was assessed as described with APG and duplex ultrasound were carried out in 1072 the patient supine. A thigh cuff was inflated to limbs of 680 patients over five years. The venous 50 mmHg to ensure a maximum venous filling and on abnormality was identified as recurrent varicose veins release the maximum venous outflow (MVO) and 2-s (RVV) in 350 legs, primary varicose veins (PVV) in outflow ratio (2SOR) were determined. Recordings 510 and DVT in 162. There were 50 legs without were taken using a multi-channel system (MacLab/8, venous disease. Analog Digital Instruments, Dunedin, New Zealand) connected to a Macintosh Quadra 800 (Apple Com- puter Co.). Frequency of non-SF reflux in the groin

Of 1022 legs with venous disease, 101 (9.9%, Right 55, Duplex scanning Left 46) in 79 patients (Male 20, Female 59) dem- onstrated reflux in the groin that came from the ab- Scanning was performed using an Acuson 128XP/5 dominal wall or perineal region. Such reflux occurred scanner (Acuson Inc., Mountain View, CA, U.S.A.) in both legs in 22 patients, in the right leg alone in 33 with a 7 MHz linear probe. Scanning started with the and in the left leg alone in 24. These limbs were patient lying on the bed at 30 ° reverse Trendelenburg all symptomatically class II or greater according to in the supine position for imaging veins in the groin international CEAP classification. The average age for and thigh.14 Veins in the popliteal fossa and calf were this group was 55.9±12.4 years. Non-SF reflux was scanned with the patients sitting up. Flow was aug- the only source of reflux at the groin in 69/1022 legs mented with a pneumatic cuff around the calf to a (6.8%). The remaining 32/1022 (3.1%) had both non- standard pressure of 100 mmHg and/or with Valsalva SF and SF venous reflux in the groin. Non-SF reflux manoeuvre to demonstrate reflux above the knee. To occurred more commonly in legs with RVV in 57/350 detect reflux in calf veins, manual compression of the (16.3%), in contrast to 31/510 (6.1%) with PVV and foot was used. Reflux in deep and superficial veins 13/162 (8.0%) with DVT (Table 1). was defined as retrograde flow persisting for [0.5 s. Incompetence in perforators was determined if bi- directional flow was illustrated by manual com- pression. Once incompetence in the groin which was Patterns and ultrasound features of non-SF reflux in the shown not to be due to saphenofemoral reflux (SF groin reflux) efforts were made to identify the source of such reflux. All sites of reflux were videotaped and the Two patterns of non-SF reflux in the groin were re- venous anatomy was recorded on a venous mapping cognised: (1) Epigastric reflux – reflux from the lower diagram. In addition Doppler spectral analysis of re- abdominal wall veins (71/101, 70.3%). These were flux was examined in the major varicose em- mainly superficial inferior epigastric or superficial cir- anating from the groin down the leg. cumflex iliac veins; (2) Pudendal reflux – reflux from the perineal and/or gluteal area (30/101, 29.7%). These were mainly external pudenda veins (Fig. 1, Table 1). Non-SF reflux was more common in females (78/101, Statistics 77.2%). Of 71 legs with epigastric reflux, only 19 (23.9%) were combined with SF incompetence in the Data was entered into a database (FileMaker Pro 2.1, groin. In 30 legs with pudendal reflux, 13 (43.3%) were Claris Corporation) and transferred to SPSS (SPSS combined with SF incompetence. In only 1 of the 101 6.1.1, SPSS Inc.) for analysis. Student’s t-test was used legs were both epigastric and pudendal observed in

Eur J Vasc Endovasc Surg Vol 21, June 2001 552 P. Jiang et al.

Table 1. Patterns and distribution of reflux at the groin and reflux at other sites.

Male Female RVV PVV DVT

Reflux at the groin 350 510 162 Non-SF alone (n=69) 35 (10.0%) 25 (4.9%) 9 (5.6%) Non-SF and SFJ (n=32) 22 (6.3%) 6 (1.2%) 4 (2.5%) Total (n=101) 57 (16.3%) 31 (6.1%) 13 (8.0%) Patterns of non-SF reflux 57 31 13 Epigastric reflux (n=71) 22 49 35 23 13 Pudendal reflux (n=29)12822 7 0 Both (n=1) 01010 Reflux at other sites 57 31 13 SPJ (n=16) 9 (15.8%) 4 (12.9%) 3 (23.1%) Deep reflux (n=29) 17 (29.8%) 6 (19.4%) 6 (46.2%)∗ Perforators (n=57) 35 (61.4%) 14 (45.2%) 8 (61.5%)

∗ p<0.05. Significant difference from RVV and PVV. RVV: recurrent varicose veins, PVV: primary varicose veins, DVT: deep venous thrombosis, SFJ: saphenofemoral junction, SPJ: Saphenopopliteal junction.

Fig. 1. Anatomical patterns of non-SF reflux in the groin. Numbers in parenthesis are proportions of each type of reflux in all legs with non-SF reflum, SCIV: superficial circumflex , SEV: superficial epigastric vein, SEPV: superficial external pudendal vein, SFJ: saphenofemoral junction.

Eur J Vasc Endovasc Surg Vol 21, June 2001 Groin Non-saphenofemoral Venous Reflux and Varicose Veins of the Leg 553

Fig. 2. Duplex spectral features of both SF and non-SF reflux in the groin.

the same groin. The only distinguishing features be- Reflux at other sites tween the two patterns were that all but one of the legs with pudendal reflux were females (cf. 69% for Most of legs with groin non-SF reflux were combined epigastric reflux); and that no pudendal reflux was with reflux elsewhere in the leg. That Non-SF reflux observed in 162 legs with DVT (cf. 13/162 with epi- was the only site of reflux in the entire leg was rare gastric reflux). occurring in only 9 legs. In 32 legs an incompetent SFJ The doppler spectral waveform pattern of isolated was present. In the remaining limbs the SFJ was normal non-SF reflux was characteristic. The augmentation in 29 and absent in 40 limbs (Fig. 1). The other sites signal was generally of lower amplitude. The reverse of reflux were below the groin: at the SPJ in 16 (15.8%), flow had a very flat profile with lower velocity (nor- through perforators in 57 (56%), and in the deep mally <20 cm/s compared to the peaked velocity pro- veins in 29 (28.7%). For deep incompetence, 16 were file of 20–50 cm/s seen in SF reflux), and with a far equivalent to Grade 3 or 4 of Kistner’s classification longer duration (>6 s and often out to more than and 5 were segmental (Table 1). Not surprisingly this 20 s, Fig. 2). These features of reverse flow were best deep reflux was more common in patients with a demonstrated by standardised calf compression rather history of DVT (p<0.01). than by performing Valsalva manoeuvre. Ultrasound duplex appearances of the vessels con- tributing to reflux were also not so simple. In the superficial veins from the abdominal wall and peri- Non-SF reflux and venous physiology neum around the groin the flow was normally towards the groin entering into the SFJ. These veins were If the only demonstrable reflux in the leg was non-SF relatively small in size. In contrast when these vessels reflux in the groin then the physiology as measured contribute flow down to the varicose veins of the leg by APG was entirely normal (Table 2). If non-SF reflux or varices beyond the groin, they appeared to be larger was the only reflux in the groin but there was reflux and their path less direct and more tortuous. The elsewhere, the physiological measurements by APG direction of basal flow in these vessels was still towards were not greatly disturbed. However, when non-SF the groin in primary and recurrent varicose veins, reflux occurred alongside SF reflux in the groin then while in patients with DVT such basal flow might be APG measurements, in particular VFI and VFT, were reversed and was then away from the groin. significantly worse (Table 2). While non-SF reflux alone

Eur J Vasc Endovasc Surg Vol 21, June 2001 554 P. Jiang et al.

Table 2. Patterns of reflux and APG measurements.

Isolated non-SF RVV PVV DVT reflux (n=9) Non-SF Non-SF+SF Non-SF Non-SF+SF Non-SF Non-SF+SF (n=35) (n=22) (n=25) (n=6) (n=9) (n=4)

VFI (ml/s) 1.2±0.7∗ 1.7±1.0∗ 3.3±2.3 1.9±1.2∗ 3.8±1.5 1.7±1.0 2.3±1.6 VFT (s) 83±37∗ 80±39∗ 58±31 64±27∗ 34±16 82±39 62±38 VV (ml) 121±42∗ 110±37∗ 146±67 94±39 89±34 107±37 101±18 RV (ml) 35±19∗ 37±25∗ 57±41 42±38 35±23 35±22 39±28 RF 0.34±0.11 0.34±0.13 0.38±0.13 0.41±0.22 0.40±0.20 0.31±0.12 0.36±0.21 EV (ml) 69±23 63±21 75±30 47±25 49±21 64±25 54±17 EF 0.61±0.19 0.60±0.18 0.54±0.16 0.54±0.21 0.56±0.13 0.62±0.17 0.57±0.23 MVO (ml/s) 53±19 52±17 52±24 47±19 33±16 40±23 36±16 2 SOR 0.71±0.13 0.70±0.11 0.66±0.15 0.66±0.14 0.50±0.11 0.64±0.12 0.69±0.14 UI 1985±3557 1753±6250 317±669 1565±3960 129±139 317±204 238±197

∗ p<0.05.Significant difference from non-SF+SF. RVV: recurrent varicose veins, PVV: primary varicose veins, DVT: deep venous thrombosis, VFI: venous filling index, VFT: venous filling time, VV: venous volume, RV: residual volume, RF: residual fraction, EV: ejection volume, EF: ejection fraction, MVO: maximum venous outflow, 2 SOR: 2 s outflow ratio, UI: ulcer index.

Table 3. Patterns of reflux in the groin and clinical severity.

CEAP Isolated non-SF RVV PVV DVT reflux (n=9) Non-SF Non-SF+SF Non-SF Non-SF+SF Non-SF Non-SF+SF (n=35) (n=22) (n=25) (n=6) (n=9) (n=4)

C1 3 0 0 5 1 1 0 C2 4 18 4 12 1 3 1 C3 2 604042 C4 0 674000 C5 0 530210 C6 0 080201

RVV: recurrent varicose veins, PVV: primary varicose veins, DVT: deep venous thrombosis, SF: saphenofemora, CEAP: the classification and grading of chronic venous disease in the lower limbs by the Society for Vascular Surgery and International Society for Cardiovascular Surgery, C: clinical signs, E: etiological classification, A: anatomical distribution, P: pathophysiological dysfunction. appears to contribute little to the amount of reflux severity was no different whether groin reflux included because of other reflux below the groin 46 (45.5%) of non-SF reflux or not. all legs with non-SF reflux had significantly abnormal VFI (>2 ml/s). But only 6 had a VFI greater than 5 ml/ s. The venous function measurements were similar for Discussion both patterns of non-SF reflux (data not shown). The overall incidence of non-SF reflux was about 10% being greater in recurrent (16.3%) than primary (6.1%) Non-SF reflux and clinical severity varicose veins. This is comparable to the findings of others.8,9 No patient had an active ulcer (CEAP Class VI) if The higher incidence of non-SF reflux in recurrent there was only non-SF reflux in the groin compared varicose veins suggests that such reflux was possibly to 11/32 when non-SF was combined with SF reflux unrecognised at previous surgery and was associated (p<0.01, Table 3). In 5 legs with recurrent varicosities with the recurrence. Why stripping of LSV is associated in which ulcers had healed following initial surgery with greater frequency of such reflux as observed by for SF reflux, despite having non-SF reflux in the groin Myers is unclear or surprising. If indeed the surgery these legs remained ulcer-free since that surgery (post- was truly complete at the groin then neo- operative time 2.5>11.3 years). In PVV with non-SF vascularisation could have played an important role reflux alone in the groin, there was no current ulcer in the reconnection and therefore initiated the process or previous ulcer history. The frequency of Class 4 of recurrence as other studies suggested.5,6,15

Eur J Vasc Endovasc Surg Vol 21, June 2001 Groin Non-saphenofemoral Venous Reflux and Varicose Veins of the Leg 555

In patients with DVT epigastric reflux is the only including selective ovarian, transuterine and per os- pattern of non-SF reflux observed in the groin, whereas seous venography have also been utilised to diagnose pudendal reflux is almost exclusive to women. Another this condition.24,25 More recently, Richardson et al. used feature of non-SF reflux is that the two patterns occur duplex ultrasound to diagnose PCS and demonstrated independently with the two patterns rarely being seen an accuracy equivalent to that by venography.26 In together. The aetiology for each is likely to be quite some rare cases, laparoscopy is required to help diag- different. nose PCS and exclude other possible causes for pelvic Epigastric reflux from abdominal wall veins is the pain. These earlier studies confirmed a relationship of more common. The normal flow from the lower ab- ovarian vein or reflux to varicose dominal wall is towards the SF junction into the deep veins in the leg. The separate anatomical distribution, system. In primary varicose veins when there is in- i.e. possibly unrelated to LSV, suggests that this is a competence at the SFJ down the LSV it is not surprising separate entity to reflux from the abdominal wall and that epigastric reflux is also preferentially down the necessitates more detailed investigation. If un- leg. More often non-SF reflux in primary varicose veins recognised at the time of initial surgical treatment in is the only reflux in the groin and continues down the groin there will be no benefit for the pelvic con- into more distal varicosities in the leg. The mechanism gestion syndrome and rapid recurrence of varicose for this is not clear but is dependent on there being a veins in the leg will be inevitable. competence at the SF junction and the loss of valvular Although it is well accepted that these non-SF pat- competency below this. Any surgical correction should terns of reflux contribute to clinical varicose veins, of course take this into account. Consequently the whether such reflux significantly impair venous func- greater frequency of this non-SF reflux in recurrent tion of the leg and have a substantial role in the varicose veins may simply reflect the failure to re- development of venous insufficiency with ulcer for- cognise this entity at initial surgery. It may also be the mation is not clear. The present study has shown that consequence of ligation at the SF junction which does in general non-SF venous reflux has little effect on not adequately deal with possible interconnection of venous physiological function measured by calf APG. Only when combined with SF reflux in the groin was the proximal tributaries to other venous channels of venous physiology markedly affected and this was the thigh including a residual incompetent LSV. The regardless of the type of venous problems, i.e. RVV, crosectomy procedure which takes a more rigorous PVV or DVT. This relatively minor influence of non-SF approach in dealing with these collateral connections reflux on venous physiology may be the result of a may have some advantages. The possibility of re- number of factors: (a) these veins are normally relatively connection through neovascularisation following sur- tortuous and small in diameter as they enter the groin gery cannot be excluded. The aetiology of non-SF region; (b) in the thigh their continuation is often reflux of the epigastric type in recurrent varicose veins through small and tortuous vessels; (c) in some cases suggests incomplete surgery while for primary var- these veins terminated above knee and therefore have icose veins it is simply secondary to reflux through no impact on venous volumetric change in calf; (d) the SFJ into LSV. when there is a normal SFJ at the groin, a proportion Pudendal reflux is of greater interest. It is almost of venous flow in these veins still drains into CFV via exclusive to women and is associated with pelvic the competent SFJ. The use of APG may also influence congestion syndrome (PCS) with ovarian or internal the magnitude of the changes observed. One of the iliac vein reflux. PCS was first described by Taylor in limitations of calf APG is its insensitivity to any changes 1949 who suggested a possible vascular involvement confined to the thigh. Similarly it is less sensitive to the 16–19 in the aetiology. By postmortem study and selective influence of incompetent perforators in the calf on renal venography Ahlberg and Chidekel et al. in 1965 venous physiology in the calf.10 Despite this we believe confirmed that the incompetence was these observations using APG provide evidence that 20–22 the cause for the problem. They observed that non-SF reflux is modest. The pattern of prolonged but women more often than men had incompetent valves low velocity with only slow flow as observed with and wider veins on both sides of the pelvis and duplex scanning (Fig. 2) in the non-SF refluxing vessels considered that the absence of competent valves in would also suggest this. This would result in a very the gonadal veins was related to pelvic varicosities in slow refilling and delayed contribution to the VFT. women and scrotal varicosities in men. By using vulval The modest contribution of non-SF reflux to venous varicography, Hobbs in 1976 identified an incidence insufficiency is also reflected by the apparent lack of of PCS of 2% in 5000 patients with peripheral var- serious clinical impact in the lower leg. Neither oed- icosities in the leg.7,23 Other venographic investigations ema, skin changes nor ulceration occurred in legs with

Eur J Vasc Endovasc Surg Vol 21, June 2001 556 P. Jiang et al. isolated non-SF reflux where there was no other reflux Acknowledgements in the groin or elsewhere in the leg. Symptoms of discomfort, aching and cosmetic concern are certainly We acknowledge the financial assistance of Health Research Council of New Zealand. consequences for these patients. However, isolated non-SF reflux is very uncommon occurring in only 9% of all groins with non-SF reflux in this study. This is less than 1% of our entire population in our venous clinic. In contrast when non-SF reflux occurs in com- References bination with incompetence elsewhere more severe 1Quigley FG, Raptis S, Cashman M, Faris IB. Duplex ultrasound changes are not uncommon particularly when there mapping of sites of deep to superficial incompetence in primary is recurrent disease. The worst combination is when varicose veins. AustNZJSurg 1992; 62: 276–278. there is both non-SF and saphenofemoral reflux at the 2Wills V, Moylan D, Chambers J. The use of routine duplex scanning in the assessment of varicose veins. Aust N Z J Surg groin whether in primary or recurrent varicose veins 1998; 68: 41–44. ulcers present in 35% of this series. 3Englund R. Duplex scanning for recurrent varicose veins. Aust The treatment for non-SF reflux is to adequately N Z J Surg 1996; 66: 618–620. 4Tong Y, R oyle J. Recurrent varicose veins following high ligation obliterate the refluxing vessels. Reflux from within the of long saphenous vein: a duplex ultrasound study. Cardiovasc pelvis, in particular as part of the pelvic congestion Surg 1995; 3: 485–487. syndrome, should be dealt with primarily by control 5Jones L, Braithwaite BD, Selwyn D, Cooke S, Earnshaw JJ. Neovascularization is the principle cause of varicose vein 7,27–29 of the sites of reflux in the . Without recurrence: results of a randomised trial of stripping the long this, local control in the groin will be ineffective saphenous vein. Euro J Vasc Surg 1996; 12: 442–445. 6Glass GM. Neovascularization in recurrence of varices of the resulting in early recurrence. Correction of non-SF great saphenous vein in the groin: phlebology. Angiology 1988; reflux from the abdominal wall should be carried 39: 577–582. out locally and in conjunction with SF ligation and 7Hobbs JT. The pelvic congestion syndrome. Br J Hosp Med 1990; 43: 200–206. LSV stripping when SF reflux is also present in the 8Myers KA, Zeng GH, Ziegenbein RW, Matthews PG. Duplex groin. The operative approach in the groin should ultrasound scanning for chronic venous disease: recurrent var- encompass all sites of reflux. The most important icose veins in the thigh after surgery to the long saphenous vein. Phlebology 1996; 11: 125–131. determinant of success, however, is the correct 9Jiang P, van Rij AM, Christie R et al. Recurrent varicose veins: diagnosis of the non-SF reflux and identifying the patterns of reflux and clinical severity. Cardiovasc Surg 1999; 7: specific type. This can only be done adequately 332–339. 10 Jiang P, van Rij AM, Christie RA, Hill GB, Thomson IA. from careful clinical assessment followed by duplex Venous physiology in the different patterns of recurrent varicose scanning as a work up for surgery. As these variant veins and the relationship to clinical severity. Cardiovasc Surg patterns of groin reflux occur in up to 16% of 2000; 8: 130–136. 11 Porter JM, Moneta GL. Reporting standards in venous disease: patients attending a varicose vein clinic we re- an update. J Vasc Surg 1995; 21: 635–645. commend routine ultrasound scanning for all varicose 12 Christopoulos D, Nicholaides AN, Szendro G. Venous reflux: quantification and correlation with the clinical severity of chronic vein patients requiring surgery or similar invasive venous disease. Br J Surg 1988; 75: 352–356. procedures. This approach is further supported by 13 van Rij AM, Solomon C, Christie R. Anatomic and physiologic the additional definition of any incompetent per- characteristics of venous ulceration. J Vasc Surg 1994; 20: 759–764. 14 Kalodiki E, Calahoras L, Nicholaides AN. Make it easy: forators as well as other anatomical variations in duplex examination of the venous system. Phlebology 1993; 8: the popliteal region and posteriorly into the gluteal 17–21. region provided by ultrasound imaging. 15 Proceedings of XIII World Congress of Phlebology (Sydney). Histopathology correlates with duplex appearance at sites of In conclusion, non-SF reflux in the groin is common recurrent venous reflux – more evidence of neovascularisation. and is a significant contributor to varicose veins of 1998: 82. the leg. Such reflux alone impacts little on venous 16 Taylor HC Jr. Vascular congestion and hyperemia; their effect on function and structure in the female reproductive organs. physiological functions measured with calf APG and Part I. Physiological basis and history of the concept. Am J Obstet this group of patients rarely proceed to ulceration Gynecol 1949; 57: 211–230. unless combined with saphenofemoral reflux in the 17 Taylor HC Jr. Vascular congestion and hyperemia; their effect on function and structure in the female reproductive organs. groin. If a patient is female and presents with pudendal Part II. Clinical aspects of the congestion-fibrosis syndrome. Am reflux, extending duplex scanning to pelvis and ab- J Obstet Gynecol 1949; 57: 637–653. 18 Taylor HC Jr. Vascular congestion and hyperemia; their effect domen is indicated in order to identify PCS. Patients on function and structure in the female reproductive organs. with isolated non-SF reflux in the groin are unlikely Part III. Etiology and therapy. Am J Obstet Gynecol 1949; 57: to go on to develop skin changes of venous in- 654–668. 19 Taylor HC Jr. Pelvic pain based on a vascular and autonomic sufficiency and in the absence of PCS they may not nerve disorder. Am J Obstet Gynecol 1954; 67: 1177. warrant surgical intervention. 20 Ahlberg NE, Bartley O, Chidekel N. Circumference of the left

Eur J Vasc Endovasc Surg Vol 21, June 2001 Groin Non-saphenofemoral Venous Reflux and Varicose Veins of the Leg 557

gonadal vein, an anatomical and statistical study. Acta Radiol 25 Lea Thomas M, Hobbs JT. Vulval phlebography in the pelvic 1965; 3: 503–512. congestion syndrome. Clin Radiol 1974; 25: 517. 21 Ahlberg NE, Bartley O, Chidekel N. Right and left gonadal 26 Richardson GD, Beckwith TC, Sheldon M. Ultrasound win- veins, an anatomical and statistical study. Acta Radiol 1966; 4: dows to abdominal and pelvic veins. Phlebology 1991; 6: 111–125. 1–9. 27 Schraibman IG. Pelvic congestion syndrome and ligation of 22 Chidekel N. Female pelvic veins demonstrated by selective ovarian veins (Correspondence). Br J Hosp Med 1990; 44: 14. renal phlebography with particular reference to pelvic var- 28 Grabham JA, Barrie WW. Laparoscopic approach to pelvic icosities. Acta Radiol 1968; 193: 1–20. congestion syndrome. Br J Surg 1997; 84: 1264. 23 Hobbs JT. The pelvic congestion syndrome. The Practitioner 1976; 29 Sichlau MJ, Yao JST, Vogelzang RL. Transcatheter embolo- 216: 529–540. therapy for the treatment of pelvic congestion syndrome. Obstet 24 Chidakel N, Ediundh KO. Transuterine phlebograpy with par- Gynecol 1994; 83: 892–896. ticular reference to pelvic varicosities. Acta Radiol 1968; 7: 1–12. Accepted 27 March 2001

Eur J Vasc Endovasc Surg Vol 21, June 2001