The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency

Purpose: The purpose of this study was to identify the distribution of venous reflux in patients with different grades of chronic venous insufficiency (CVI) and correlate the different patterns of reflux with each class. Methods: Color-flow duplex imaging was used to evaluate the entire venous system from groin to ankle in 465 patients (594 limbs) belonging to different clinical CVI classes (O, 1, 2, and 3). A history of previous superficial thrombophlebitis was present in five limbs and past deep vein thrombosis in 70. Results: One hundred seventy eight (30%) limbs were normal and the remaining 416 (70%) had venous incompetence. Deep reflux was present exclusively in 19 limbs (3.2%), and the perforating system alone was involved in only three limbs (0.5%). However, isolated superficial incompetence was seen in 186 limbs (31.3%) and a combination of superficial with perforating system alone was involved in 45 (7.6%). Incompetence in all three systems was seen in 99 extremities (16.7%). In addition, the superficial system was involved in 390 limbs, the perforators in 151, and the deep system in 178 limbs. Only a small percentage of those in class 0 had reflux, and most of them had a single site of incompetence. In class 1 the majority of the limbs had superficial reflux (90.3%), 10.3% of the limbs had deep venous reflux, and 6.9% were competent. Reflux in the superficial system only was seen in 80.7% of the limbs in class 1 and in one fifth of the limbs in classes 2 and 3. Isolated deep or perforator incompetence was rare in all classes. Variable combined patterns of reflux were seen more often in classes 2 and 3 (p < 0.0001). In classes 2 and 3 there were no differences in the number of incompetent sites in the superficial and deep venous systems or the patterns of reflux (p > 0.1). The number of incompetent perforators in class 3 tended to be higher than that in class 2, especially in the below-knee segment, but no significant differences were seen. Distal reflux was present in the majority of the limbs in all symptomatic classes (1, 2, and 3). Conclusions: The distribution and extent of reflux is strongly associated with clinical severity of CVI through class 2. Distal venous reflux is present in at least 80% of the symptomatic limbs. Deep venous thrombosis may not be a prerequisite for the development of skin changes or ulceration in about 75% of the limbs. Superficial venous surgery could be beneficial to at least one third of patients with skin changes or ulceration.