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Young Phlebology
Focus Duplexsonography
Popliteal reflux in incompetent small saphenous veins E. Mendoza Venenpraxis Wunstorf/Germany
Keywords
Schlüsselwörter
Duplexsonography, popliteal reflux, small saphenous vein
Duplexsonographie, poplitealer Reflux, Vena saphena parva
Summary
Zusammenfassung
Introduction: Incompetent trunk veins usually fill from the deep veins of the leg via their junctions. When there is reflux into the small saphenous vein, reflux can also be seen in the popliteal vein, from which the small saphenous vein fills the muscular diastole. Case report: Flow in the refluxing small saphenous vein was demonstrated with duplex ultrasound in a female patient, before and after interruption of a tributary vein with CHIVA, resulting in a reversal of the flow in the saphenous trunk. Results: Immediately after ligating the tributary vein, the direction of flow in the small saphenous vein reversed to give an orthograde flow. Likewise in the popliteal vein, reflux was no longer detected postoperatively. Conclusion: The popliteal vein is the reservoir from which the incompetent small saphenous vein fills. Reflux can therefore also be demonstrated proximal to the saphenopopliteal junction – but is no longer detectable after correction of the incompetent small saphenous vein.
Einleitung: Insuffiziente Stammvenen füllen sich in der Regel über ihre Mündung aus der tiefen Beinvene. Bei Reflux in der V. saphena parva beobachtet man dabei ebenso einen Reflux in der V. poplitea, aus der sich die V. saphena parva in der muskulären Diastole füllt. Fallbeispiel: Bei einer Patientin wurde der Fluss in der refluxiven V. saphena parva vor und nach Unterbrechung eines Seitenastes nach CHIVA mit dem Ergebnis der Flussumkehr im Saphena-Stamm mit Duplex dargestellt. Ergebnis: Unmittelbar nach Ligatur des Seitenastes stellt sich in der V. saphena parva eine Flussumkehr ein mit orthogradem Fluss. Ebenso in der V. poplitea, in der postoperativ kein Reflux mehr zu finden ist. Conclusio: Die V. poplitea ist das Reservoire, aus dem sich die insuffiziente V. saphena parva füllt, daher ist proximal der Mündung der V. saphena parva in der V. poplitea ein Reflux darstellbar – und nach Korrektur der Insuffizienz der V. saphena parva ist dieser nicht mehr nachweisbar.
Correspondence to Dr. Erika Mendoza Venenpraxis Wunstorf Speckenstr. 10, 31515 Wunstorf, Germany E-Mail:
[email protected]
© Schattauer 2013
Phlebologie 2013; 42: 37–41 DOI: 10.12687/phleb2126_1_2013 Received: November 25, 2012 Accepted: December 20, 2012
Venous incompetence is caused by pathological flow in the veins. This can be observed by duplex ultrasonography of standing subjects when provocation manoeuvres (manual compression of the calf or toe movements (1)) are performed. Initially one sees flow towards the heart. If the valves close correctly this is followed at most by a short flow of blood towards the feet, if at all, until the venous valves prevent any further flow in this direction. If the valves no longer close correctly reflux develops, i.e. the flow of blood in the opposite direction, which can no longer be stopped by normally functioning valves. We find this situation in the deep and superficial veins of the legs. Reflux in the popliteal vein is frequently observed in association with incompetence of the small saphenous vein (SSV). The following paper illustrates this phenomenon more closely in a specific case.
Flow patterns in the SSV and popliteal vein with reflux in the SSV A 72-year-old female with visible varicosis over the posterior surface of the left calf, a slight tendency towards swelling, and early brown discolouration around the lateral malleolus presented for surgery of the varices (Cs2,3 Ep As4,5 Pr). After the duplex examination it was agreed that we would perform a CHIVA 2 procedure because no draining perforator vein was found on the SSV, and all the reflux filled the side branch. We first ligated the side branch of the saphenous trunk. The immediate result of this was reversal of the flow in the SSV because the reflux could no longer drain disPhlebologie 1/2013
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E. Mendoza: Duplexsonography: Popliteale Reflux in incompetent V. saphena parva Ab bbildu ung g 1a
VS SP
tie efe A Ach hse e
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Fig. 1a Schematic representation of the flow patterns before and after a CHIVA 2 procedure in this case. Left: preoperative findings, right flow pattern following ligature and division of the side branch. („tiefe Achse“: deep axis)
Fig. 1b Muscular diastole with reflux in the small saphenous vein and the proximal popliteal vein (arrow), artery coloured red, distal popliteal vein not coloured (no reflux here).
tally (2) as can be seen in the schematic ▶ Figure 1a. ▶ Figure 1b with the patient standing shows the preoperative diameter 2 cm distal to the popliteal fossa and before the disconnection of the side branch.
Explanation of the CHIVA procedure If there is a dilatated perforator connected with the refluxing trunk vein the procedure Phlebologie 1/2013
Fig. 2a Longitudinal section through the popliteal fossa showing the saphenopopliteal junction. a muscular systole with blue colouration of the popliteal vein (orthograde flow (*)) and systolic reflux in the small saphenous vein (**). Red shaped: popliteal artery (***).
Fig. 2b Muscular diastole with reflux in the small saphenous vein and in the proximal popliteal vein (arrow), artery coloured red, distal popliteal vein not coloured (no reflux here).
is performed at the transition to the deep vein of the leg (ligature and division or alternatively thermal occlusion of a short segment) and ligature of the side branch. If the refluxing trunk vein does not have a dilatated perforator (as in this case), initially only the side branch is interrupted because permanent reversal of the flow occurs in 80 % of cases.
Preoperative sonogram During muscular systole we find blue colouration of the popliteal vein (▶ Fig. 2a), during muscular diastole it is coloured red (▶ Fig. 2b). The SSV sometimes shows retrograde (i.e. „red“) flow even during muscular systole, as is shown in Figure 2a. ▶ Figure 3 shows the corresponding flow curves in the popliteal vein proximal to the saphenopopliteal junction, distal to © Schattauer 2013
E. Mendoza: Duplexsonography: Popliteale Reflux in incompetent V. saphena parva
the junction, and in the SSV itself. The flow curves in the SSV (▶ Fig. 3c) are similar to those in the proximal popliteal vein (▶ Fig. 3a). The distal popliteal vein (▶ Fig. 3b) shows a normal flow curve without reflux.
Postoperative colour duplex ultrasound Immediately after the operation (interruption of the side branch in the middle of the calf) the examination showed that there was no longer any reflux in the small saphenous vein or in the popliteal vein (▶ Fig. 4)
Fig. 3a Longitudinal section as in Figure 2, but with a pulsed wave: flow in the popliteal vein proximal to the saphenopopliteal junction.
Interpretation The blood that refluxes into the SSV during muscular diastole originates in the deep vein of the leg. The proximal segment of the popliteal vein at the saphenopopliteal junction empties into the SSV, and the blood flows towards the feet (▶ Fig. 5). In my experience this is always inverted after correcting the flow in the SSV, be it by interruption at its junction or by reversal of the flow in this vein by the CHIVA 2 procedure – always assuming the deep venous system is competent. In my opinion, incompetence of the popliteal vein with additional reflux in the SSV only presents if the deep axis distal to the saphenopopliteal junction still refluxes, or if the femoral vein also has reflux with the result that several valve segments are incompetent.
Fig. 3b Flow in the popliteal vein distal to the saphenopopliteal junction.
Conclusion In the presence of incompetence of the small saphenous vein the mere presence of reflux in the proximal segment of the popliteal vein does not prove the presence of incompetence in the deep axis. Acknowledgement
Fig. 3c Flow in the small saphenous vein.
I would like to thank Dr. Felizitas Pannier, whose question at the DGP Congress in Lübeck gave me the idea to write this article. © Schattauer 2013
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E. Mendoza: Duplexsonography: Popliteale Reflux in incompetent V. saphena parva
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Fig. 4 Longitudinal section through the popliteal fossa of the same patient immediately after ligature of the side branch varicosis of the small saphenous vein. a. Colour duplex ultrasonography during muscular systole, orthograde flow in the popliteal vein, no longer any systolic reflux in the small saphenous vein. b. Colour duplex ultrasonography during muscular diastole, no flow is visualised (normal finding in veins when standing). c. Black-and-white duplex with a pulsed wave (PW) flow curve in the proximal popliteal vein, no reflux seen. d. PW flow curve in the distal popliteal vein. e. PW flow curve in the small saphenous vein, also without reflux.
© Schattauer 2013
E. Mendoza: Duplexsonography: Popliteale Reflux in incompetent V. saphena parva
References 1. Mendoza E, Berger HA. Provokationsmanöver für die duplex-sonographische Diagnostik der Varikosis. Gefäßchirurgie 2001 (6): 43–46. 2. Mendoza E. Einteilung der Rezirkulationen im Bein: anatomische und physiologische Grundlagen der CHIVA-Methode. Phlebologie 2002, 31: 28–35.
Fig. 5 Left: Schematic representation of the saphenopopliteal junction, left muscular systole with orthograde flow (blue arrow), right muscular diastole. If the valves of the small saphenous vein are incompetent the segment proximal to the junction empties into the small saphenous vein – and the popliteal vein shows retrograde flow until this segment of the vein has emptied. (From „CHIVA ein Handbuch“, Mendoza E, with the kind permission of the Arrien publishing company)
© Schattauer 2013
The translation of this article was made possible by courtesy of: • Covidien Germany GmbH • Bauerfeind AG • Medi Germany • Sigvaris Germany • Bayer GmbH • Ofa Bamberg • Biolitec AG
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