Relation between clinical findings and diagnostic parameters in patients undergoing superficial venous intervention for symptomatic chronic venous disease due to isolated venous reflux

OBJECTIVE: Although a multitude of techniques exist for the treatment of superficial venous reflux in symptomatic patients with chronic venous disease (CVD), metrics used to determine and quantify superficial reflux and thereby assess the need for intervention remain unclear. This study explores this topic by evaluating duplex ultrasound (DUS) and air plethysmography (APG) metrics in terms of their relation to clinical parameters in the setting of isolated lower extremity venous reflux. METHODS: Analysis of retrospectively collected data of patients who underwent successful endovenous laser ablation of superficial venous reflux with/without stab phlebectomies for symptomatic CVD from venous reflux was carried out to determine predictors of initial clinical presentation and outcomes after successful intervention. Characteristics evaluated included the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class, venous clinical severity score (VCSS), grade of swelling (GOS), and visual analog scale pain; DUS characteristics included superficial vein diameter, total reflux volume in the limb, and venous segmental disease score (VSDS). APG metrics included venous volume (VV) and venous filling index, in addition to calf pump function metrics (ejection fraction [EF] and residual volume fraction). Bivariate correlation analysis, paired/unpaired t tests, and regression analysis were used to evaluate the data. RESULTS: There were 131 patients (134 limbs) with a median age of 61 (25-87) years, of whom 96 were women and 35 men. The median body mass index was 28.3 (18-57). There were 44 limbs in the C2 class, 38 limbs in the C3 class, 42 limbs in the C4 class, 2 limbs in the C5 class, and 8 limbs in the C6 class. All limbs had superficial reflux, including 80 with superficial reflux in the great saphenous vein (GSV) alone, and 54 had reflux in both GSV and small saphenous vein (SSV). There were no limbs with isolated reflux in the SSV. A total of 57 limbs had additional reflux in the deep veins (30 axial deep venous reflux). There were 21 limbs with reflux in the perforator veins. All limbs underwent successful ablation of the GSV, whereas 120 underwent additional stab phlebectomies at the same time, 1 limb had additional sclerotherapy (also at the time of the index procedure), and 5 limbs underwent treatment of the SSV. The median follow-up was 188 days. The correlation between DUS metrics (GSV diameter and total reflux volume) and clinical parameters (CEAP clinical class, VCSS, GOS, and visual analog scale pain score) was weak (r = 0.1-0.3; P > .05), although VSDS had a moderate correlation (r = 0.4; P = .004) with VCSS. A weak correlation was also noted between the clinical parameters and APG metrics (venous filling index, EF, residual volume fraction), except VV, which had a moderate correlation (r = 0.4; P < .001). At baseline, while VSDS was found to be a significant predictor for CEAP clinical class (hazard ratio [HR] = 8.1; P = .005) and VCSS (HR = 5.3, P = .03), VV was noted to be a significant predictor for GOS (HR =17; P < .001). After successful superficial venous intervention, there was improvement in clinical, DUS (VSDS), and APG metrics. VSDS was again a significant predictor of improvement in VCSS (HR = 9.3; P = .003), whereas both VV (HR = 5.5, P = .02) and EF (HR = 6.2; P = .01) were significant predictors for improvement in GOS after intervention. CONCLUSIONS: In symptomatic patients with CVD from isolated venous reflux, initial clinical presentation and improvement after successful superficial venous intervention can be predicted by DUS (VSDS) and APG (VV and EF) metrics. After such intervention, there is improvement in clinical, DUS, and APG metrics.