New research outlines correlation between venous reflux patterns and clinical severity

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Certain reflux patterns in patients with chronic venous disease can be associated with increased clinical severity and a lower quality of life, according to the results of a recent study conducted at Imperial College London, UK. As part of the study, a significant difference was discovered between patients with isolated superficial reflux, and those with reflux of the deep, superficial and perforator venous systems.

Presented at the European Venous Forum (EVF; 27–29 June, Zurich, Switzerland) by Matthew Tan (London, UK), these findings support the relationship demonstrated in previous studies between clinical severity and such factors as venous diameter, junctional incompetence and reflux patterns in the superficial venous system.

Using duplex ultrasound imaging, which according to Tan “provides us with both anatomical and haemodynamic information, and allows us to assess deep, superficial and perforating venous systems,” Tan and colleagues set out to further explore the correlation of specific reflux patterns to clinical severity and health-related quality of life (HRQoL) scores, as well as the impact of deep, perforator and venous incompetence.

In order to conduct the study, 490 symptomatic patients with chronic venous disease and 105 asymptomatic volunteers were recruited over a four-year period. Tan explained the methods used to assess each participant once selected: “On the day of recruitment, all participants had their limbs assessed with a duplex ultrasound and this was done by either a vascular scientist or a vascular surgeon. At the same time, clinical severity was determined by a trained clinician using the CEAP classification and venous clinical severity score (VCSS).”

For the purposes of statistical analysis, patients and volunteers taking part in the study were categorised into eight reflux patterns that ranged from those with no reflux to those with deep, superficial, perforator reflux. Tan also underlined that the only notable difference between the patient and volunteer demographics was in terms of age, with the group showing no symptoms of chronic venous disease significantly younger on average.

Focusing on the distribution of reflux patterns across CEAP classes, all of which were represented in the study, Tan said: “The majority of participants in the C0 and C1 clinical classes had no reflux, and the extent of reflux increased across the clinical classes. For example, with the deep, superficial, perforator reflux pattern there were no participants in C0 and C1, and the proportion of participants with this pattern increased from C2 to C6. This trend holds true for most of the other reflux patterns.”

In terms of VCSS, patients with different forms of reflux were once again compared to those with none. According to the statistical analysis performed, all patterns except for deep reflux only and perforator, deep reflux—which could be anomalous due to the small number of participants in these groups—showed a significantly higher score compared to participants with no reflux.

Additionally, the only significant difference in VCSS between patterns was with the superficial only group and deep, superficial, perforator group, a distinction that was also recorded in the comparison of the Aberdeen Varicose Vein Questionnaire (AVVQ) score, which assesses the perceived health of patients with varicose veins. “We decided to do a subgroup analysis, dividing the patients in these groups further based on their junctional competence,” said Tan. While all scores were higher in the deep, superficial, perforator pattern—regardless of junctional competence—the difference was significant when compared to those with superficial only and competent junctions.

Tan concluded: “What we have shown today is that most reflux patterns are associated with increased clinical severity and a worse quality of life, when we compare them with individuals with no reflux whatsoever. However, there are only significantly higher scores when the extent of reflux increases from superficial reflux only, to deep, perforator and superficial reflux.”


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