REV I EW ARTI CLE
N on in va sive dia gn ost ic m e t h ods t o e va lu a t e ve n ou s in su fficie n cy of t h e
low e r lim bs
Or la n do Ada s Sa liba Jr .I; M a r iâ n ge la Gia n n in iI I; H a m ilt on Alm e ida RolloI I I
IMSc., Faculdade de Medicina de Bot ucat u ( FMB) , Univer sidade Est adual Paulist a ( UNESP) ,
Bot ucat u, SP, Br azil.
I IPhysician. Assist ant professor, Vascular Sur ger y, Depar t m ent of Sur ger y and Or t hopedics, FMB,
UNESP, Bot ucat u, SP, Br azil.
I I IPhysician. Assist ant professor, Vascular Sur ger y, Depar t m ent of Sur ger y and Or t hopedics, FMB,
UNESP, Bot ucat u, SP, Br azil.
Correspondence
J Vasc Bras. 2007; 6( 3) : 266- 75.
ABSTRACT
Clinical evaluat ion of low er lim bs of pat ient s w it h venous insufficiency alone m ay not ident ify involved syst em s or anat om ical sit es, t hus com plem ent ar y t est s are needed. These t est s can be invasive or noninvasive. I nvasive t est s, such as phlebogr aphy and am bulat or y venous pr essur e, despit e being accurat e, m ay pr oduce discom fort and com plicat ions. Som e of t he m ost used noninvasive t est s are cont inuous w av e Doppler ult r asound, phot oplet hysm ogr aphy, air
plet hysm ogr aphy and duplex scanning. Doppler ult r asound assesses blood flow velocit y indirect ly. Phot oplet hysm ography assesses venous r efilling t im e, providing an obj ect ive param et er of venous reflux quant ificat ion. Air plet hysm ogr aphy allow s quant ificat ion of reduct ion in venous capacit ance, reflux and per for m ance of t he calf m uscle pum p. Duplex is consider ed a gold st andar d am ong noninvasive m et hods, because it allow s quant it at ive and qualit at ive evaluat ion, supplying
anat om ical and funct ional inform at ion, t hus pr oviding a m or e com plet e and det ailed evaluat ion of bot h deep and super ficial venous syst em .
Ke yw or ds:Diagnosis, venous insufficiency, ult r asonics, plet hysm ogr aphy.
RESUM O
exam es podem ser invasivos ou não- invasivos. Os invasivos, com o flebografia e pressão venosa am bulat ór ia, apesar de t erem boa acurácia, t r azem desconfort o e com plicações. Dent re os não-invasivos, dest acam - se: Doppler ult ra- som de ondas cont ínuas, fot oplet ism ogr afia, plet ism ogr afia a ar e m apeam ent o dúplex. O Doppler ult ra- som avalia a velocidade do fluxo sangüíneo de m aneir a indiret a. A fot oplet ism ografia avalia o t em po de r eenchim ent o venoso, for necendo um parâm et ro obj et ivo de quant ificação do refluxo venoso. A plet ism ogr afia a ar per m it e quant ificar a r edução ou não da capacit ância, o refluxo e o desem penho da bom ba m uscular da pant ur r ilha. O dúplex é considerado padrão- ouro dent r e os não- invasivos, porque per m it e um a avaliação quant it at iva e qualit at iva, for necendo inform ações anat ôm icas e funcionais, dando avaliação m ais com plet a e det alhada dos sist em as venosos pr ofundo e super ficial.
Pa la vr a s- ch a ve : Diagnóst ico, insuficiência venosa, ult ra- som , plet ism ogr afia.
Ve n ou s in su fficie n cy
Chr onic venous insufficiency ( CVI ) can be defined as a set of alt er at ions t hat occur in t he sk in and subcut aneous t issue, especially in low er lim bs, r esult ing fr om a long- t erm venous hyper t ension caused by valve insufficiency and/ or venous obst r uct ion.1
I n 1994, at t he Am erican Venous For um held in Maui ( Haw aii, USA) , t he CEAP classificat ion of venous diseases w as developed, based on clinical signs ( C) , et iology ( E) , anat om ical dist ribut ion ( A) and pat hophysiologic dysfunct ion ( P) .2 I t is considered as t he st andar d classificat ion and allow s uniform it y in report and assessm ent of differ ent m odalit ies of diagnost ic and t r eat m ent . I n 2004, a m odificat ion t o t hat classificat ion w as pr oposed, w it h t he aim of enhancing it .3 The changes
regarding w hat is called CVI are t hose included in clinical classes 2 t o 6 of CEAP classificat ion.2
CVI is a ver y com m on disease and, alt hough having m or t alit y rat e close t o zer o, it has im por t ant m orbidit y, leading t o w or sening of qualit y of life and has a large socioeconom ic im pact , including in our count ry.1
I n an epidem iologic st udy carried out in Brazil by Maffei et al.4 including pat ient s w ho sought
t reat m ent at a Healt h Cent er in Bot ucat u ( SP) for r out ine exam inat ions, t her e w as a 47.6%
prevalence of var icose veins. Aft er st at ist ical cor r ect ion, est im at ed pr evalence for t he populat ion in t he sam e socioeconom ic level in t hat m unicipalit y w as 35.5% , excluding cases of com plaint s regarding low er lim bs.
González- Faj ardo et al.5 m ent ion a st udy sponsored by t he World Healt h Organizat ion ( WHO) in
Spain, in w hich t here w as a 10.5% pr evalence of low er lim b venous diseases in a sam ple of 4,800 people aged bet w een 30- 65 year s.
Barros Jr .6 perform ed a st udy in pr egnant pat ient s at t he pr enat al car e of Hospit al Am par o
Mat ernal, w it h t he aim of analyzing pr evalence of var icose disease, risk fact ors and sym pt om s during pregnancy. The st udy show ed a high pr evalence of var icose disease ( 72.7% ) , and t he m ost prevalent r isk fact ors w er e age and posit ive fam ily hist ory for var icose veins.
Scuderi et al.7 assessed t he clinical findings of venous diseases in 2,104 individuals, according t o
apparent sym pt om s or veins, w hereas in t he age group over 48 year s only 4.67% had t hat
condit ion. Most w om en ( 62.79% ) had apparent sym pt om s and veins, w her eas m ost m en ( 65.54% ) did not have appar ent sym pt om s or veins. The aut hor s concluded t hat pr evalence is m uch higher in fem ales t han in m ales and t hat age and num ber of pr egnancies w er e im port ant fact or s in disease developm ent .
Venous diseases have peculiar char act er ist ics, since som e of t hem , w it h superficial changes, can be per ceived by pat ient s t hem selves; how ever , ot her changes involving t he deep venous syst em ( DVS) in early st ages fr equent ly do not cause signs or sym pt om s t hat reveal it s pr esence.8
Clinical assessm ent of individuals w it h venous insufficiency of t he low er lim bs, despit e being im port ant , does not independent ly ident ify affect ed syst em s or anat om ic levels.9 , 1 0 Ulcer s caused by CVI can result from obst r uct ion or reflux in t he DVS, reflux in super ficial syst em veins and in per for at ing veins, or from a com binat ion of bot h.
To have a m or e det ailed and accur at e assessm ent , besides clinical exam inat ion, com plem ent ar y exam inat ions should be applied, w hich can use invasive or noninvasive t est s or m et hods.
I nvasive t est s t hat have been used are phlebogr aphy and direct m easurem ent of am bulat or y venous pr essur e ( AVP) by punct ur ing a vein on t he back of t he foot . Phlebogr aphy, w hich has been considered t he gold st andard m et hod, allow s visualizat ion of t he venous syst em and ident ifies m or phological and funct ional alt er at ions.9 , 1 1 Wit h t hat it is possible t o obt ain im por t ant anat om ic and pat hophysiologic inform at ion not only for diagnosis, but also for choosing sur gical or
endovascular t echniques for CVI r epair . AVP per for m s a global assessm ent of CVI , but does not ident ify w het her changes ar e caused by obst r uct ion or r eflux in t he DVS.1 1 Phlebography and AVP,
because t hey are bot h invasive, can br ing discom for t and com plicat ions t o pat ient s. Therefore, such t est s have low accept ance and t heir r epet it ion is hard for pat ient follow- up or assessm ent of t herapies for CVI .
Wit h t he aim of per for m ing a noninvasive and r eliable diagnosis, t hroughout t he last decades of t he past cent ur y, som e noninvasive m et hods w er e developed t o assess venous funct ion in pat ient s w it h venous insufficiency, such as cont inuous- w ave Doppler ult r asound ( CWD) ,
phot oplet hysm ogr aphy ( PPG) , air plet hysm ogr aphy ( APG) and duplex scanning ( DS) , am ong ot hers.2 , 8 , 1 1 - 1 4
Noninvasive t est s ar e m or e econom ical, fast and do not br ing m uch discom fort t o pat ient s w hen com par ed w it h invasive t est s.1 5
Next , t he m ain noninvasive m et hods and t heir capacit ies for CVI diagnosis are descr ibed.
Con t in u ou s- w a ve D opple r u lt r a sou n d
CWD w as developed by Sat om ur a & Kaneko in 1960.1 6 I t assesses art erial or venous blood flow velocit y by det ect ing change or var iat ion in frequency of r eflect ed ult rasound beam based on m oving red cells. The inst rum ent pr oduces an audible sound signal or a w avefor m t hat can be regist ered. Nor m al st andar d of venous flow is a spont aneous and phasic sound w it h breat hing. I t is audible w it h Doppler pr obe in all locat ions, except in super ficial and sm all- caliber veins.1 7
qualit at ive and non- quant it at ive m et hod, w hen t he follow- up is not perform ed by t he sam e professional, assessm ent is even m ore difficult .1 9 - 2 2
Lucas et al.2 3 assessed 210 low er lim bs by auscult at ion of t he gr eat saphenous vein using Doppler during Tr endelenbur g m aneuver . I n 10 lim bs w it h prim ary var icose veins, phlebogr aphy
exam inat ions w er e also perform ed, w it h t he aim of com par ing r esult s, and t he cor r elat ion w as obser ved in all cases. One hundred low er lim bs t hat had prim ary var icose veins w er e classified according t o var icose vein ext ension and caliber ; t he ot her 100 low er lim bs did not present clinically det ect able var icose veins. The aut hor s obser ved gr eat saphenous vein insufficiency in 57.3% of 89 lim bs w it h bilat er al prim ary varicose veins and 18.18% in 11 norm al lim bs of pat ient s w it h unilat er al var icose veins. Wit h r egar d t o t he 100 lim bs w it hout var icose veins, 2% had
saphenous vein insufficiency on exam inat ion.
Bart olo et al.2 4 st udied 9,178 low er lim bs and assessed venous pr essur e using CWD. They verified
t hat venous pr essur e values at rest gradually incr eased fr om nor m al lim bs t o var icose lim bs, reaching higher levels in pat ient s w it h post phlebit ic syndrom e.
Menezes & Sales1 9 assessed 96 low er lim bs of 50 pat ient s w it h venous insufficiency using CWD.
They verified pr esence of changes in DVS in 14 pat ient s ( 28% ) , t hr ee of w hom had bilat er al lesions, in a t ot al of 17 lim bs w it h alt er at ions ( 17.7% of 96 lim bs) . Reflux w as pr esent in 9.37% of lim bs, and w as associat ed w it h pr esence of clinical com plicat ions of var icose veins; obst ruct ion in 8.33% w as not associat ed w it h a m or e sever e clinical st at us.
Cheng et al.2 5 used CWD and PPG t o assess 1,583 lim bs of 878 pat ient s w ho present ed CVI
sym pt om s. Com binat ion of valve insufficiency in super ficial and per for at ing syst em s w as found in m ost pat ient s. The aut hor s consider ed t hat t he r esult s of applied exam inat ions w er e useful for pat ient assessm ent .
A st udy carried out at t he laborat ory of Hospit al das Clínicas da Faculdade de Medicina de Bot ucat u ( FMB) assessed 71 low er lim bs of 50 pat ient s w it h var icose v eins and/ or CVI using CWD com par ed w it h DS t o assess venous r eflux or v alv e incom pet ence.2 6 Result s w er e: sensit ivit y of 71 and 78% , specificit y of 87 and 81% and accur acy of 84 and 79% , r espect ively, for poplit eal and gr eat
saphenous veins.
Based on w hat has been described, CWD can be used in angiologist s' and vascular surgeons' daily pract ice as an inst r um ent t o com plem ent clinical exam inat ion of pat ient s w it h venous insufficiency, allow ing t o select t hose w ho should be r efer r ed for m or e accur at e diagnost ic t est s, such as DS. Therefore, CWD, w hen used by experienced exam iners, m ay pr ovide im port ant infor m at ion about pr esence of venous reflux.
Ph ot ople t h ysm ogr a ph y
PPG, int r oduced in venous hem odynam ic st udies by Bar nes et al.,2 7 is a m et hod t o assess venous funct ion t hat can be easily perform ed, does not r equir e ext ensive t r aining for t he oper at or and evaluat es venous filling t im e ( VFT) , pr oviding an obj ect ive param et er t o quant ify venous r eflux.2 8
I t is used in som e ser vices t o diagnose venous diseases of t he low er lim bs and follow- up of candidat es t o var icose vein surgery befor e and aft er t he sur ger y.6 , 2 8 - 3 4
hemodynamics.28
VFT is measured and registered in a curve based on a baseline. VFT value is an indirect
measurement of venous reflux and valve incompetence.35 Many researchers used PPG to assess
venous disease of the lower limbs31,34,36-39 and postoperative follow-up, with the aim of verifying
surgical efficacy.25,40-44 Most authors consider VFT values greater then 20 s as normal, such as
Gaitini et al.,45 Evangelista & Fonseca,28Sakurai et al.33and Welch et al.11 Other researchers, such
as Sanches & Gomes,32Gonz€les-Fajardo6and Lane et al.,44 consider values above 23 s as normal.
In cases of venous system filling through incompetent valves (reflux), there is an abnormally fast
return of the examination curve to the initial baseline.35PPG is useful to assess superficial venous
system reflux in patients with normal DVS, since it does not assess well the degree of reflux in the
DVS.46
This examination can also be performed by placing tourniquets or automatic pressure cuffs attached to the device, in a position that prevents reflux of the superficial venous system (short and great saphenous veins), obtaining predictive values for reduction in reflux with venous surgery
in the superficial system.46,47 Reflux measurement is based on venous emptying caused by calf
contractions due to exercises, and it can be affected by the following factors:
-Obstructions in deep veins can prevent adequate calf emptying, which can cause a reduced filling time and will be interpreted as reflux.
-Patient's inability to perform the movements with his feet in the right position (neurological problems, arthritis, anchylosis, etc.) prevents adequate calf emptying, which will cause a reduced filling time, which can be interpreted as reflux.
-Patients with high levels of exercise-induced hyperemia will have a faster VFT, which may seem as
reflux.47
Sarin et al.30compared PPG examination curves with clinical evaluation and with DS in patients
with venous insufficiency and found a good correlation in observed results. Patients with severe venous insufficiency invariably had quite altered VFT data, and this assessment parameter was considered reliable.
Sanches & Gomes,32in 1991, studied 35 lower limbs of 18 individuals without previous history of
venous disease, with the aim of establishing a clinical routine for the PPG examination. Stages were established according to VFT value, thus allowing estimate of venous sectors. Values ≥ 23 s were considered normal. The authors concluded that an elaborate clinical routine allows diagnosis of valve insufficiency when one or more segments are affected.
Tucker et al.38performed a study with PPG to assess normal patients, patients who had leg pain,
with or without CVI. The method proved to be quite reproducible.
Dunn et al.41 applied PPG to assess six patients submitted to valve transplantation of lower limbs
before and after the surgery. Such patients had altered VFT (< 20 s) and, after the surgery, there was improvement in VFT of 100% or more.
Rodriguez et al.43 used PPG in patients with venous ulcers of the lower limbs before and after
Froneck et al.,3 9 in 2000, pr oposed a m odificat ion in t he convent ional t echnique of PPG, allow ing t o quant ify drained blood flow induced by elevat ion of t he low er lim b above hear t level, affect ing hydrost at ic pr essur e on t he leg. When a plat eau is r eached in t he gr aphic r egist er , t he lim b is quickly low er ed and left at a r est ing posit ion, t hus causing venous filling due t o increased
hydrost at ic pr essur e. The aut hor s concluded t hat t his t echnique allow ed assessm ent of pr esence or absence of deep venous t hr om bosis and v alv e insufficiency of t he DVS.
PPG has been used as a follow- up m et hod in m any vascular labor at or ies because VFT is a sensit ive indicat or of r eflux, but PPG is unable t o dist inguish degrees of clinical sever it y of t he disease.4 8
Scriven et al.,3 1 in a pr ospect ive longit udinal st udy, perform ed PPG exam inat ions befor e and 30
days aft er t he surgery t o evaluat e efficacy of per for at ing vein surgery. Seven ulcer at ed m em ber s w it h per for at ing and deep vein insufficiency w er e subm it t ed t o sur ger y. The aut hor s obser ved t hat PPG show ed abnorm alit ies of venous reflux of t he low er lim bs before t he sur ger y, w hich per sist ed aft er t he surgeries, suggest ing t hat per for at ing vein surgery alone does not adequat ely t reat pat ient s w it h low er lim b ulcer s and w ho have sim ult aneous deep vein insufficiency.
Based on w hat has been present ed above, PPG is st ill being used and has pr oved t o be a useful m et hod for CVI assessm ent , as w ell as for assessm ent of sur gical t echniques or ot her pr ocedur es t o t r eat venous insufficiency.
Air ple t h ysm ogr a ph y
APG is a relat ively new noninvasive m et hod, used for quant it at ive assessm ent of t he venous syst em of low er lim bs and ar t er ial per fusion4 9 and t hat allow s quant ifying reduct ion or not of
venous capacit ance, and calf m uscle pum p reflux and perform ance.5 0 APG devices perform such quant ificat ion by det er m ining t he follow ing par am et er s: venous volum e ( VV) , ej ect ed volum e by a
t ipt oe( EV) , m ean residual volum e ( RV) and filling t im e unt il r eaching 90% of VV ( VFT90) . Based
on t hose par am et er s, t he follow ing indexes are calculat ed: venous filling index ( VFI ) , ej ect ion fract ion ( EF) and residual v olum e fract ion ( RVF) .
As advant ages, t his is an exam inat ion w hose equipm ent and m aint enance are not ver y expensive, it is less exam iner- dependent , easier t o be per for m ed and, alt hough it does not pr ovide anat om ic inform at ion as pr ecisely as DS, it allow s pat ient follow- up t o evaluat e perform ed t r eat m ent .5 1 , 5 2
Christ opoulos et al.5 3 com par ed APG w it h out pat ient venous pr essur e m easurem ent in a st udy t o
evaluat e t he effect of w ear ing m edium and high com pr ession st ockings , r espect ively, for pat ient s w it h super ficial and deep venous insufficiency. The aut hor s ver ified APG r epr oducibilit y and
concluded t hat it is not only a m et hod of diagnost ic value, but also allow ed evaluat ion of hem odynam ic effect s of differ ent form s of elast ic com pr ession.
I n anot her st udy, Christ opoulos et al.5 4 obser ved a good cor r elat ion ( r = 0.81) of APG par am et er s
w it h out pat ient venous pr essur e m easur em ent , analyzing 30 nor m al lim bs, 110 w it h pr im ar y varicose veins and 65 w it h DVS occlusion of insufficiency. They concluded t hat APG is an accur at e m et hod t o ident ify pr edom inant hem odynam ic fact or ( alt er at ion of calf m uscle pum p and r eflux or bot h) , r esponsible for t he pat ient 's clinical st at us.
Gillespie et al.56 also used APG to assess 25 lower limbs before and after varicose vein surgery, defined according to clinical examinations and DS. The method proved to be efficacious in the assessment of hemodynamic changes, especially regarding VFI and VV.
Studies have been performed with the aim of verifying correlation of APG and DS and
phlebography.11,13,14,57 Van Bemmelen et al.13 assessed 32 lower limbs of 28 patients and
obtained poor correlation between VFI findings of APG and presence of insufficient veins and their
diameters measured by DS. However, Weingarten et al.14obtained good results with APG in the
assessment of 122 limbs of 61 patients with different degrees of venous insufficiency, with statistically significant correlation between VFI of APG and reflux time determined by DS.
Welch et al.11 concluded, in a study in 28 upper limbs, that APG, when compared with
phlebography, was able to detect presence of venous insufficiency, but it was not able to
distinguish severity degrees of the disease. Kalodiki et al.,58 in a retrospective study in 224 limbs
that had suggestive signs of deep venous thrombosis and 41 limbs without varicose veins and no evidence of DVT in venography, compared APG with the gold standard (phlebography) and observed that there was no difference between both methods.
Yang et al.59 tested variability of APG parameters in patients with CVI by repeating examinations in
patients at different times and observed that there were variations in determinations that were repeated in the same patient. According to those authors, this result suggests that APG is not likely to be able to detect small variations in evaluated parameters.
In our country, Engelhorn et al.,60in a study in 88 limbs of 48 patients, aimed at determining
which APG parameters allowed differentiation of mild, moderate and severe CVI classes, according to CEAP clinical classification. The patients were divided into three groups: group A – mild venous insufficiency (classes 1 and 2); group B – moderate venous insufficiency (class 3); and group C – severe venous insufficiency (classes 4, 5 and 6). There was no statistically significant difference between mild and moderate CVI degrees, but there was difference between group C, when compared with groups A and B.
Seidel61 studied 100 limbs of 81 patients to correlate APG examinations with clinical findings and
with color-flow DS in the diagnosis of great saphenous vein insufficiency. It was not possible to assess APG correlation with clinical status, since most (61%) patients belonged to CEAP class 2. Correlation of APG results with DS was very weak.
Therefore, it could be seen that most studies using APG have shown that it is useful to assess CVI,
despite some authors13,59still questioning its validity, since APG has not been a method able to
identify small differences.
D u ple x sca n
DS is a combination of B-mode ultrasonography (US) and pulsed Doppler, thus allowing a simultaneous assessment of a bidimensional image of vessels and adjacent tissues and of flow
characteristics through analysis of Doppler spectral curve.62
B-mode image is used for anatomic assessment of presence of intraluminal thrombus or changes in venous wall and valves, and pulsed Doppler allows detection of presence of reflux due to valve
incompetence.26 In lower limb varicose veins, DS examination allows assessment of changes in the
syst em , from pat ient s w it h secondar y var icose veins, in w hich t he DVS is t he sit e of pat hological alt erat ions. This diagnost ic t est has a pot ent ial of assessing bot h venous anat om y and
physiology.6 2
I n t he color- flow DS, st at ic t issues are show n in a gr ay scale, w her eas t he Doppler effect is codified in color s. Codificat ion of flow colors, red or blue, is dependent on flow dir ect ion in relat ion t o sound beam orient at ion.1 7 This r esour ce facilit at es US exam inat ion, since it allow s bet t er vessel
visualizat ion, especially t hose of sm aller diam et er , m aking t his exam inat ion fast er .
DS has been consider ed an exam inat ion w it h sim ilar accur acy t o phlebogr aphy in t he ident ificat ion of venous r eflux pr oduced by valve insufficiency of t he deep and superficial syst em and per for at ing veins or a com binat ion of t hem .5 7 I t can also det ect sm all r efluxes in isolat ed segm ent s in
asym pt om at ic pat ient s, and also w het her t he reflux is locat ed in veins above or below t he knee or w het her it ext ends t hr ough t he w hole lim b. I n t he absence of deep venous obst r uct ion, lim bs w it h reflux r est r ict ed t o veins above t he knee r ar ely develop skin alt erat ions or ulcer s. The st andar d of reflux involving at least t w o venous syst em s ( super ficial and deep; super ficial and per for at ing; superficial, per for at ing and deep) is found in around 2/ 3 of pat ient s w it h skin alt er at ions or
ulcers.6 3 DS has been consider ed not only t he m ost specific noninvasive exam inat ion, but also t he m ost w idely accept ed by pat ient s.
Neglen & Raj u6 4 assessed r eflux in 56 lim bs of pat ient s w it h venous insufficiency using DS com par ed w it h phlebogr aphy. DS posit ive pr edict ive value w as 77% , com par ed w it h 35- 44% of descending phlebogr aphy, w hich confir m s bet t er accur acy of t he form er. Baker et al.6 5 com par ed
t he findings of r eflux obt ained by DS and ascending phlebogr aphy and concluded t hat DS w as m or e sensit ive t o det ect super ficial and deep venous r eflux and, at t he t high level, also allow ed
assessm ent of isolat ed segm ent s w it h r eflux, as w ell as gr eat saphenous vein reflux.
Delis et al.6 6 used DS for hem odynam ic assessm ent of per for at ing veins in venous insufficiency of
t he low er lim bs. Result s of t he exam inat ions w er e r elat ed t o CEAP classificat ion levels. The aut hor s claim ed t hat neit her per for at ing vein diam et er , nor reflux t im e and ot her hem odynam ic param et ers invest igat ed had cor r elat ion w it h CEAP classes, w hich indicat es t hat severit y of venous insufficiency does not prim arily depend on per for at ing vein funct ion alone, but on m ult iple fact or s, occur r ing sim ult aneously in t he venous syst em .
Engelhorn et al.,6 0 in a ret rospect ive st udy in 500 lim bs of 301 pat ient s w it h pr im ar y var icose veins, perform ed DS exam inat ions before t he sur ger y, w it h t he aim of analyzing a new
classificat ion of super ficial venous insufficiency. The aut hor s st r essed t he im por t ance of
st andardizing t he classificat ion of super ficial venous insufficiency for sur gical planning, avoiding possible recurrences or unnecessary st r ipping of gr eat saphenous veins.
DS is considered as t he gold st andard am ong noninvasive exam inat ions, because it allow s ident ifying and locat ing pat hophysiological alt erat ions, obst r uct ions or r efluxes, bot h in t he DVS and in t he super ficial venous syst em . Over t he past years, it has r eplaced phlebogr aphy in m any of it s indicat ions.6 2 How ever , it requires m uch t im e, is exam iner- dependent , needs m or e t r aining t im e and has a high cost , since t he equipm ent is m or e sophist icat ed and it s m aint enance is m or e
expensive. For t hat reason, it s use for long- t erm follow - up of pat ient s w it h CVI is difficult , especially if follow- up exam inat ions should be perform ed fr equent ly.
Fin a l con side r a t ion s
anatomic and functional parameters that should be considered in venous insufficiency of the lower limbs.
DS, which is considered the gold standard among noninvasive diagnostic methods for venous diseases of the lower limbs, is currently the most widely indicated because it allows qualitative and quantitative assessment. It provides both anatomic and functional information, thus allowing a more complete and detailed assessment of the venous system.
In cases in which it is not possible to perform DS, due to device inexistence or financial restrictions, practitioners should use PPG or APG to help diagnosis and follow-up of patients with venous
disease. Such plethysmographies are a quite useful method to assess venous disease, as well as in the follow-up of lower limb surgeries.
Re fe r e n ce s
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Cor r e spon de n ce :
Orlando Adas Saliba Jr.
Departamento de Cirurgia e Ortopedia Faculdade de Medicina de Botucatu – UNESP CEP 18618-970 – Botucatu, SP, Brazil Tel.:
Fax: +55 (14) 3815.7428
Email: osalibajr@terra.com.br
