Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 2  |  Page : 92-94

Prediction of saphenofemoral junction incompetence by measurement of great saphenous vein size at the level of femoral condyle


Department of Surgery (CTVS), Dhulikhel Hospital Kathmandu University Hospital, Dhulikhel, Kavre, Nepal

Date of Web Publication3-May-2018

Correspondence Address:
Dr. Robin Man Karmacharya
Department of Surgery (CTVS), Dhulikhel Hospital Kathmandu University Hospital, Dhulikhel, Kavre
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_77_17

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  Abstract 


Introduction: Doppler ultrasonography (USG) is the primary modality for diagnosis of superficial venous reflux caused by incompetence of venous valves of the great saphenous vein (GSV) and usually associated with competence of saphenofemoral junction (SFJ). This study is done to know the cutoff value in size of GSV that safely predicts this junction incompetence. Methods: All varicose vein patients during the study period of January–December 2016 were included in the study. The cases underwent Doppler USG of GSV using Siemens Acuson P500 to identify GSV. The diameter of GSV was measured at the level of femoral condyle in standing position and these were compared with SFJ incompetence. Contralateral limbs which were apparently normal were taken as control limbs if there is no evidence of reflux in SFJ. Results: There were 147 patients with 16 cases (9.81%) where bilateral limb was involved making total cases as 163 limbs and controls as 131 limbs. The mean GSV diameter in disease group was 6.05 mm and in control group was 3.19 mm with P < 0.05. Receiver operating characteristic (ROC) curve of size of GSV at the level of knee and prediction of SFJ incompetence had the ideal curve depicting use of some cutoff value. The point with both best sensitivity and specificity lied on 4.95 mm with sensitivity of 82% and specificity of 83%. Conclusion: We recommend 5 mm as the cutoff value for diameter of GSV at the level of femoral condyle which successfully predicts SFJ incompetence.

Keywords: Doppler ultrasonography, great saphenous vein, saphenofemoral junction, varicose vein


How to cite this article:
Karmacharya RM, Shrestha BK, Shrestha B. Prediction of saphenofemoral junction incompetence by measurement of great saphenous vein size at the level of femoral condyle. Indian J Vasc Endovasc Surg 2018;5:92-4

How to cite this URL:
Karmacharya RM, Shrestha BK, Shrestha B. Prediction of saphenofemoral junction incompetence by measurement of great saphenous vein size at the level of femoral condyle. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2018 May 21];5:92-4. Available from: http://www.indjvascsurg.org/text.asp?2018/5/2/92/231856




  Introduction Top


Varicose vein is a common venous problem usually affecting superficial veins of the lower limb and characterized by prominent vein, swelling, itchiness, pigmentation, and ulcer. The prevalence of varicose vein in studies has shown to range from 5% to 30%.[1] In a notable Framingham study, annual incidence of 2.6% in females and 1.9% in males has been found.[2]

Of the different available diagnostic modalities, Doppler ultrasonography (USG) is the best diagnostic tool for evaluation of patients suffering from varicose veins. In Doppler USG, B-mode venous Doppler is done to note the size and course of great saphenous vein (GSV) and lesser saphenous vein along with the identification of the junction and important prominent perforators. Flow of the blood in the junction and perforators can be assessed by color flow and Doppler mode. Although scarce, there are some studies that compare the diameter of the GSV and its relation to the incompetence of the junction. Measurement of GSV diameter is easier, compared to identification of reflux in the junction. Furthermore, for identification of reflux, it requires better resolution Doppler devices, which can be difficult to find in many hospitals of our country. Hence, this study is done to know the cutoff value in size of GSV that safely predicts junction incompetence.

In a study by Engelhorn et al., three different thresholds of diameter of GSV in predicting the junction incompetence were mentioned. Size more than 4 mm predicted 74% of the junction incompetence.[3] In a study by Mendoza et al., GSV diameter more than 10.9 mm at saphenofemoral junction (SFJ) and 6.3 mm at proximal thigh had high sensitivity and specificity for prediction of reflux.[4] In study by Jin Hyun Joh, GSV diameter of more than 5 mm had best positive predictive value for reflux in junction.[5]


  Methods Top


All the patients presenting in vascular surgical outpatient department (OPD) for evaluation of prominent veins/venous ulcer were included in the study during the study period of January–December 2016. All these cases underwent Doppler USG of GSV using Siemens Acuson P500 ultrasound with patients in standing position in “Doppler stand”. The “Doppler stand” here signifies a standing area where feet are placed more than two feet apart and the stand height lies 20 inches above base so that there is better ergonomics during Doppler USG. Initially, B-mode USG was done to identify GSV, and GSV diameter was measured at the level of femoral condyle. In case of the presence of branch or distal insufficiency point at that level, measurements were taken about 5 cm above the femoral condyle. All these cases had Doppler USG at SFJ to note the diameter and reflux. Reflux was noted to be present if there is reflux seen in Valsalva maneuver with reflux time more than 500 ms and/or reflux velocity more than 30 cm/s. Patients with recurrence of varicose veins following surgical treatment and patients with venous disease in short saphenous system were excluded from the study. For the control limbs, in case of unilateral varicose veins, the contralateral limbs were also screened to note the GSV diameter at the level of femoral condyle, and the SFJ was seen to note the diameter and reflux. These cases were placed in control group only if there are no features of varicose vein and there is no reflux in SFJ.


  Results Top


There were 147 patients who presented in vascular surgical OPD for the evaluation of venous prominence and/or venous ulcer. There were 16 cases (9.81%) where bilateral limb were involved, and for further analysis, these cases have been split in both the right and left legs so as to make total of 163 limbs shown in [Figure 1]. Of them, 23 had concomitant venous ulcer (14.11%). Of these cases, 75 (46.01%) had come to our center directly while the rest 88 (53.99%) were referred to our center. Remaining 131 limbs were taken as control limbs for Doppler USG as these are apparently normal limbs. Baseline characteristics of male and female patients are shown in [Table 1].
Figure 1: Total cases and division into disease and control limbs

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Table 1: Patient characteristics

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The mean GSV diameter in disease group was 6.05 mm (standard deviation [SD] 1.93., range 4–9 mm) while that in control group was 3.19 mm (SD 1.94, range 1–6 mm) with P < 0.05. If only female patients/controls are accounted, the mean GSV at the level of knee was 6.11 mm (SD 2.06, range 4–9 mm) for limbs with clinical features of varicose vein while that in control limbs was 3.39 mm (SD 2.13, range 1–6 mm) with P < 0.05. Similarly, if only the male patients/controls are accounted, the mean GSV diameter at the level of knee in cases was 6.01 mm (SD 1.83, range 4–8.6 mm) while that in control limbs was 3.05 (SD 1.78, range 1–5 mm).

Receiver operating characteristic (ROC) curve of size of GSV at the level of knee and prediction of SFJ incompetence is shown in [Figure 2]. The curve shape is of typical curve depicting use of some cutoff value. Area under the curve is 89.8. The point with both best sensitivity and specificity lied on 4.95 mm with sensitivity of 82% and specificity of 83%. Similarly the ROC curve of GSV diameter at the level of knee and SFJ incompetence for female and male ([Figure 3] and [Figure 4] respectively) has also typical shape with clear cutoff value as 4.85 and 4.95 respectively.
Figure 2: Receiver operating characteristic (ROC) curve for all patients to know the cutoff value of great saphenous system diameter to detect saphenofemoral junction incompetence

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Figure 3: Receiver operating characteristic (ROC) curve of great saphenous system diameter at the level of knee and varicose vein prediction in females. Area under the curve: 0.816 cutoff point as 4.85 with sensitivity as 0.83 and specificity as 0.82

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Figure 4: Receiver operator curve for male patients to know cutoff value to detect saphenofemoral junction incompetence from great saphenous system diameter at the level of knee. Area under the curve: 0.875 cutoff value as 4.95 with sensitivity as 0.80 and specificity as 0.82

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  Discussion Top


Varicose veins occur in superficial veins of the lower limbs, most commonly in GSV, and sometimes in short saphenous vein. Of the varicose vein involving GSV, SFJ incompetence is usual main anatomical and pathological factor. This will cause reflux on column of blood into GSV and the size of GSV gradually increases. There have been several studies that have set some cutoff value for normal diameter of GSV. Engelhorn et al. concluded that GSV diameter thresholds ≥7 mm, 4 mm, and 4 mm at the SFJ, thigh, and calf, respectively, predict the reflux.[3] The use of single measurement as proposed in our study, however, will ease the procedure and decrease the time taken for the procedure.

In a study done by Navarro et al., they found that GSV diameter of 5.5 mm or less precludes reflux.[6] This has a sensitivity of 78%, a specificity of 87%, positive and negative predictive values of 78%, and an accuracy of 82%. On the other hand, GSV diameter of 7.3 mm or greater predicted reflux and this had 80% sensitivity, 85% specificity, and 84% accuracy. This finding is in contary to our finding by having nuch higher cut off value mentioned in the study.

A recent study done by Jin Hyun Joh has mentioned cutoff value of 5.05 mm to predict reflux in SFJ, the finding very similar to our study.[5] In their study, the SFJ reflux has been classified into three different types as Type 1 with no reflux, Type 2 as typical reflux, and Type 3 as SFJ with features of reflux by only one criterion (among reflux velocity more than 30 cm/s or reflux duration more than 0.5 s). They have also proposed the use of cutoff values to specifically aid in diagnosis in the dubious SFJ findings.

In recommendation by consensus of the Union Internationale de Phlebologie, it is mentioned that two sites where GSV diameters should be measured as 3 cm below the SFJ and at the midthigh.[7] However, in our opinion finding, the ideal “mid” location in thigh is also not ideal. As in most of the studies, it is recommended to measure the diameter in upright position. The use of proper “Doppler stand” as in our study where patients can easily stand with the foot parted by more than 2 feet and is above about 20 inches from ground helps in the better ergonomics of the operator and uniformity and should be an essential part of the vascular laboratory.


  Conclusion Top


Based on our study, it is recommended to have cutoff value for GSV at the level of the femoral condyle as more than 5 mm for both male and female patients so as to predict SFJ incompetence and varicose vein with good sensitivity and specificity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol 2005;15:175-84.  Back to cited text no. 1
[PUBMED]    
2.
Brand FN, Dannenberg AL, Abbott RD, Kannel WB. The epidemiology of varicose veins: The framingham study. Am J Prev Med 1988;4:96-101.  Back to cited text no. 2
[PUBMED]    
3.
Engelhorn C, Engelhorn A, Salles-Cunha S, Picheth E, Castro N Jr., Dabul N Jr., et al. Relationship between reflux and greater saphenous vein diameter. J Vasc Technol 1997;21:167-71.  Back to cited text no. 3
    
4.
Mendoza E, Blättler W, Amsler F. Great saphenous vein diameter at the saphenofemoral junction and proximal thigh as parameters of venous disease class. Eur J Vasc Endovasc Surg 2013;45:76-83.  Back to cited text no. 4
    
5.
Joh JH, Park HC. The cutoff value of saphenous vein diameter to predict reflux. J Korean Surg Soc 2013;85:169-74.  Back to cited text no. 5
[PUBMED]    
6.
Navarro TP, Delis KT, Ribeiro AP. Clinical and hemodynamic significance of the greater saphenous vein diameter in chronic venous insufficiency. Arch Surg 2002;137:1233-7.  Back to cited text no. 6
[PUBMED]    
7.
Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A, et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs – UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg 2006;31:83-92.  Back to cited text no. 7
    


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