Med. J. Cairo Univ., Vol. 88, No. 1, March: 51 -62, 2020 www.medicaljournalofcairouniversity.net Great Saphenous Vein Diameter at Different Regions and its Relation to Reflux SAID I. EL MALLAH, M.D.*; YAHIA MOHAMMED AL-KHATEEP, M.D.* and KAREEM HADY KAMEL, M. S c. * * The Department of Vascular Surgery, Faculty of Medicine, Menoufia University* and El-Sahel Teaching Hospital**, Egypt Abstract ulceration. These manifestations are the conse- quence of long standing volume overload and Background: Great saphenous vein incompetence is in- hypertension in cutaneous veins caused by wall volved in the majority of cases of varicose disease. Standard pre-interventional assessment is required to decide the treat- distension, valve incompetence, blood flow abnor- ment modalities. GSV diameter measured at sapheno-femoral mality and secondary phenomena such as allergy junction, proximal thigh, distal thigh, knee, proximal leg, and inflammation [2] . distal leg. Analysis done to find at which diameter size the reflux expected to occur. Treatment is directed towards abolition of ve- Aim of Study: To investigate a possible correlation of nous reflux. For decades, this has been accom- GSV diameters measured at sapheno-femoral junction, prox- plished by ligation of the GSV at its junction with imal thigh, distal thigh, below knee and at mid leg and there the Common Femoral Vein (CFV) and vein strip- relation to the reflux. ping, first of the entire GSV, later limited to its Patient and Methods: Study involved 100 limbs from refluxing part. In the last decades, alternative outpatient vascular clinic, GSV diameter measurement at the options became available, such as haemodynamic sapheno-femoral junction, at the proximal thigh, at the distal thigh, below the knee, mid leg in correlation to reflux. surgery, [3] endovenous thermal ablation [4] and foam sclerotherapy [5] . Duplex ultrasound is widely Results: SFJ reflux (group I) at 7.16±2.30mm, proximal ± employed to guide these interventions. thigh (group II) at 6.60 1.89mm, distal thigh (group IIIa) at 6.12± 1.63mm, knee (group IIIb) at 5.78 ± 1.60mm, proximal ± leg (group IV) at 4.6 1.24mm, and mid leg (group V) at 3.59± Comparison of treatment modalities requires 1.16mm. exact documentation of the clinical, anatomical Conclusions: Measurement at six sites revealed higher and functional situation prior to whichever treat- sensitivity and specificity to predict reflux, GSV diameter ment is given [6] . correlates with reflux. Reflux and GSV diameter measurements may Key Words: Varicose veins – Great saphenous vein – Vein serve as surrogate parameters for disease severity diameter at different regions – Comparison of and provide criteria for planning interventions and clinical trials. monitoring outcome. GSV diameters have been Introduction assessed at various sites with different techniques: Upright or recumbent patient position, cross sec- VARICOSE disease affects one third of the pop- tional or longitudinal imaging, and various sites ulation and has an impact on morbidity, quality of of interest [2] . life and health costs. The Great Saphenous Vein (GSV) is involved in the majority of cases [1] . A consensus-based manual recommends two Symptoms include distressing feelings of swell- sites where GSV diameters should be measured, 3 ing and heaviness and frank pain. Objective find- cm below the SFJ and mid-thigh, [6] while earlier studies used a site 15cm below the SFJ [7] . Thus ings are meandering and dilated superficial veins, far, neither the clinical relevance of these measure- oedema, dermatitis, dermatosclerosis and skin ments nor the relative significance of the site of Correspondence to: Dr. Kareem Hady Kamel, measurement has been clarified. In this thesis, E-Mail: [email protected] investigation done to find a possible correlation 51 52 Great Saphenous Vein Diameter at Different Regions of GSV diameters measured at different regions should not be compressed by excessive pressure and there relation to the reflux. of the probe on the skin. The diameters of the common femoral artery and common femoral vein Various investigations have been carried out to are then measured in transverse view. Volume flow establish the duration of reflux standing which is measured in longitudinal view. correlates with venous disease [8-10] . Artery it is recommended to measure the flow In general, no difference was found between over several pulses to calculate the Time-Averaged durations of 0.5 and 1s. In other words, the number Mean Velocity (TAMV). This function is usually of legs determined to suffer from reflux did not configured in the machine. alter significantly depending on whether the dura- tion of reflux was set at 0.5 or 1s. Vein the typical flow pattern is slow and rela- tively constant, modulated by respiration. It should Although the cut-off value was set at 0.5s, a be measured over several seconds and then the definition of reflux set at 1s may avoid diagnosing average calculated as with the artery. pathology at borderline values when there are no clinical signs. Since the artery and the vein flow in opposite directions, the flow in the vein appears as a negative Reflux duration decreases with severity of value. It must be treated as positive for calculating disease and has been described as the time taken the VAFI. The flow velocity is given in m/s, m/min for the anti-gravitational mechanisms of the leg to or cm/s, at the site of the measured vessel diameter fail [11] . (d). The Volume Flow (VF) in each vessel is cal- culated from the diameters and flow velocities Venous Arterial Flow Index (VAFI): using the following formula: The first non-invasive option for a quantitative 3 2 2 measurement of haemodynamic parameters is du- VF [cm /s] = TAMV [cm/s] X II d /4 [cm ] 3 3 3 plex ultrasound. This can measure the velocity of 1cm = 1ml area is II X r or II X d /4. blood flow in a vein. This parameter can be used to calculate the volume flow (l/min) by multiplying If the volume flow in the common femoral vein the average blood flow velocity (cm/s) by the cross- and common femoral artery are designated VFa sectional area of the vein. and VFv, respectively, then VAFI = VFv [ml/min] / VFa [ml/min] Cross-sectional area = n X r2 or n X d2/4. Once the diameter (d=2r) is measured by positioning the < In subjects with healthy veins, the VAFI is 1.0. cursors on the machine, the Time-Averaged Mean In patients with haemodynamically significant Velocity (TAMV) and Volume Flow (VF) are impairment, the VAFI increases >1.2. It can even automatically calculated and displayed on the increase up to 2.0 [13] . This means that the flow in screen. the femoral vein is much higher than the arterial inflow into the leg. This occurs when there is a The common femoral vein can be taken as a recirculation loop. The VAFI is also very useful representative vessel from which the volume flow for measuring the haemodynamic situation before can be measured. Volume flow can also be meas- and after intervention. The influence of intervention ured in the saphenous vein [12] . on haemo-dynamics is seen after only a few days when the high preoperative values return to normal. Conclusions can then be made on the venous The non-invasive nature of ultrasound in measuring haemodynamics draining the affected leg. Arterial VF is a clear advantage compared to invasive parameters should be included in the quantitative assessment since they influence venous haemody- measurement techniques. namics. For this reason, a ratio can be calculated Validation of the VAFI: for the venous and arterial volume flow in the The index was measured in patients with dif- common femoral vein and the common femoral ferent venous diseases under different conditions. artery, respectively. This ratio is called the Venous It was shown that with primary varicose veins, Arterial Flow Index (VAFI). significantly higher values were measured than Volume Flow (VF) is measured in the relaxed, those found in healthy subjects [13] . A similar lying patient, with the leg rotated slightly outwards pattern was found in patients with postthrombotic and the head supported on a pillow. While the syndrome compared to healthy subjects [13] and measurements are taken, it is important that the that the level of the VAFI values correlated with patient should breathe calmly and that the vein the clinical severity of the disease. In the above Said I. El Mallah, et al. 53 studies, subjects with healthy veins were found to • Acute disorders (thrombosis/phlebitis/cellulitis). ≤ have an average VAFI 1.0. This may be interpreted • Lymphedema, pregnancy. to mean that there is a point of equivalence between arterial inflow per unit of time and the correspond- • Below 18y, above 60y. ing venous outflow per unit of time. The high VAFI Assessment: History taking will involve previ- values found in varicose patients may be an index ous DVT, surgery, any comorbidity, clinical exam- of recirculation which normalises after intervention. ination general and local including CEAP classifi- With respect to the reliability of the measurement cation, Duplex u/s. results, it was shown that the VAFI remained stable both during uninterrupted examination for 1h and Examination: over 3 consecutive days [13] . The VAFI is a repeat- able, sensitive parameter for venous haemodynam- • History taking. ics which has been confirmed with modern phase- • Clinical examination: General and local. contrast MR techniques [14] . • Clinical findings were documented: CEAP clas- The great saphenous vein at the proximal thigh sification. was more uniform, easier to measure and more • Protocol examination of varicose vein with duplex representative as a single measurement point. The U/S: (Standing position). average diameter in subjects with healthy veins ± was 7.5mm ( 1.8) at the sapheno-femoral junction Superficial system: SFJ, GSV reflux, vein di- ± and 3.7mm ( 0.9) in the proximal thigh.