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Duplex Sonographic Evaluation of the
Sapheno-femoral Venous Junction in
Patients with Recurrent Varicose Veins
after Surgical Treatment
Joseph Elias Benabou, MD, Laszlo J. Molnar, MD, Giovanni G. Cerri, PhD
Department of Imaging, Heart Institute of the University of São Paulo, Rua Dr Eneas de Carvalho Aguiar No.
44, São Paulo, Brazil
Received 14 October 1996; accepted 1 June 1998
ABSTRACT: Purpose. We used duplex sonography in
patients with recurrent varicose veins after surgical
treatment to detect any residual stump of the great
saphenous vein at the sapheno-femoral venous junction, and we compared these sonographic findings
with surgical findings as the ‘‘gold standard.’’
Methods. We prospectively studied 65 patients (54
women and 11 men) who had recurrent varicose veins
1–30 years (mean, 11 years) after surgical exploration
of the groin and ligature of the great saphenous vein
at its junction with the femoral vein. Duplex scans
were performed in all patients before surgical reexploration. Sonographic findings were compared with
surgical findings.
Results. Duplex scanning revealed a residual
stump in 47 patients (72%) and no stump in 15 patients (23%). Thirty-five (74%) of the 47 cases with a
residual stump had reflux on duplex scans, and the
remaining 12 cases (26%) showed no reflux. Findings
in all 62 of these cases were confirmed by surgery. In
only 3 patients (5%) did duplex scans fail to show a
residual stump when surgery revealed a small residual stump without reflux.
Conclusions. Duplex scanning is the noninvasive
diagnostic technique of choice to detect any residual
stump of the great saphenous vein and to diagnose
valve failure at the sapheno-femoral venous junction
in patients with recurrent varicose veins. © 1998 John
Wiley & Sons, Inc. J Clin Ultrasound 26:401–404, 1998.
Keywords: varicose veins, recurrence; Doppler ultrasonography; venous reflux
Correspondence to: J. E. Benabou, Rua Cayowaa No. 549 Apt.
42, CEP: 05018-000 São Paulo, Brazil
© 1998 John Wiley & Sons, Inc.
VOL. 26, NO. 8, OCTOBER 1998
CCC 0091-2751/98/080401-04
ecurrence of varicose veins is a common late
complication of varicose vein surgery.1 Lofgren and Lofgren2 reported a recurrence rate of
20–26% after surgery for varicose veins, and
Hobbs3 reported that 20% of patients experience
complete failure of treatment within 5 years and
that 60% of patients require further treatment
after the initial varicose vein surgery. Reflux occurs when, because of valve failure, there is a flow
inversion in the vein, which leads to increased
venous pressure and varicose veins. Most frequently, this results from a residual stump of the
great saphenous vein,4 with reflux developing in
venous branches that have not been tied off.
In cases of recurrent varicose veins, patients
who require additional surgery must undergo
specialized diagnostic investigation. Physical examination alone, even when performed by an experienced surgeon, may not reveal the site of the
reflux.5–7 Several methods are used to diagnose
and evaluate the venous system of the lower
limbs. Phlebography and varicography are considered the ‘‘gold standard’’ for determining the
patency and valve competence of the deep and
superficial veins. However, because these techniques are invasive and thus may cause complications,8–11 the use of noninvasive techniques
such as duplex sonography has been suggested.
According to data published in the medical literature, duplex sonography has a sensitivity and
specificity close to those of phlebography in the
evaluation of venous patency and competence.12–15
The purposes of this study were to use duplex
nous junction, we did not distinguish between residual and recurrent varicose veins.
Conventional sonography of the entire groin
was complemented by duplex sonography of the
residual stump, when present, to document the
reflux. We used a color Doppler ultrasound scanner (Diasonics Ultrasound, Santa Clara, CA) with
a 5-MHz transducer. The patients were placed in
the supine position to facilitate the comparison of
sonographic and surgical findings. When requested, patients performed Valsalva’s maneuver
to provoke reflux.16 The external iliac, common
femoral, superficial femoral, and deep femoral
veins were examined. We identified the presence
or absence of a residual stump of the great saphenous vein in longitudinal and transverse planes
(Figures 1 and 2) and documented the reflux during Valsalva’s maneuver (Figure 3).
All patients underwent surgical reexploration
of the groin by the same surgical team, whose
members were unaware of the results of the vascular sonographic examination. Surgery was performed using epidural anesthesia. To enable access to the residual stump of the great saphenous
vein, the common femoral vein was dissected from
the common femoral artery17 using a medial apFIGURE 1. Longitudinal color Doppler sonogram of the common
femoral vein (1). A residual stump (2) of the great saphenous vein is
sonography to detect any residual stump of the
great saphenous vein at the sapheno-femoral venous junction in patients with recurrent varicose
veins after surgical treatment and to compare
these sonographic findings with surgical findings
as the ‘‘gold standard.’’
This prospective study involved 65 consecutive
patients who were referred for evaluation of
symptomatic recurrent varicose veins, especially
in the thigh, after surgical treatment. All patients
gave informed consent per institutional guidelines. The patients were 54 women (83%) and 11
men (17%) whose ages ranged between 26 and 59
years (mean, 42 years). All patients had undergone a single surgical exploration of the groin and
ligature of the great saphenous vein at the sapheno-femoral venous junction 1–30 years (mean,
11 years) earlier. Because an objective of the
study was to verify whether the initial surgery
had adequately treated the sapheno-femoral ve402
FIGURE 2. Transverse color Doppler sonogram showing the superficial femoral artery (3), deep femoral artery (4), common femoral vein
(1), and residual stump of the great saphenous vein (2). Note the
presence of branches of the residual stump.
FIGURE 3. Longitudinal color duplex sonogram showing the common femoral vein (1) and the residual stump
(2). Spectral analysis shows venous-type flow (3); retrograde flow (5) is noted in the residual stump immediately after Valsalva’s maneuver (4).
proach. The residual stump, when present, was
isolated, and the patient performed Valsalva’s
maneuver so that the presence or absence of reflux in the stump could be verified. The residual
stump was then ligated next to the common femoral vein.
47 cases in which sonography had detected a residual stump. Valve incompetence was confirmed
during surgery in all 35 cases. In the 12 remaining cases (26%), reflux was not detected on duplex
scans or at surgery.
Of the 65 patients, a residual stump was revealed
by sonography and confirmed by surgery in 47
(72%) (true positives). Sonography did not detect
a residual stump in 15 patients (23%), and reexplorative surgery in these patients revealed fibrosis on the anterior aspect of the common femoral
vein, which confirmed the absence of a stump
(true negatives). In 3 patients (5%), sonography
did not reveal a residual stump, but a small residual stump without reflux was found during
surgery (false negatives). There were no falsepositive sonographic findings.
Sonographically detected reflux in a residual
stump was also confirmed during surgery. Doppler examination revealed reflux in 35 (74%) of the
VOL. 26, NO. 8, OCTOBER 1998
Imaging of the groin is needed in patients who
require a second operation for varicose veins following previous exploration of the groin and ligature of veins at the sapheno-femoral venous junction. The scar tissue that results from the first
operation complicates the approach to any residual stump during surgical reexploration and
may provoke bleeding. Sonographic scanning in
the longitudinal and transverse planes provides
detailed information on venous anatomy. Transverse sonograms often provide more information
than longitudinal sonograms, especially in the detection of a small residual stump. Doppler examination provides information regarding the presence or absence of reflux.
In most of our cases, surgical reexploration re403
vealed residual venous structures, indicating that
an inappropriate surgical technique had been
used during the first surgery. However, the high
prevalence of valve incompetence in the identified
residual stumps (74%) was also a contributing
factor to recurrent varicose veins.
In this study, sonography had a sensitivity of
94%, a specificity of 100%, and an overall accuracy of 95% in the detection of residual stumps.
These findings show that surgical reexploration
of residual stumps can be avoided when no reflux
is shown by duplex scanning because reflux is not
the principal cause of recurrent varicose veins in
such cases. On the other hand, because of the absence of false-positive results in this study, the
demonstration by duplex scanning of a residual
stump with reflux should prompt surgical reexploration.
We conclude that duplex scanning is the noninvasive diagnostic technique of choice to detect
any residual stump of the great saphenous vein
and to diagnose valve failure at the level of the
sapheno-femoral venous junction in patients with
recurrent varicose veins.
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