Einfluss des Refluxursprungs auf die Hämodynamik, Klinik und Therapie der primären Varikose

Zusammenfassung

Hintergrund

Die Mechanismen von Reflux und Rezirkulation der primären Varikose sind nach wie vor nicht vollständig geklärt.

Patienten und Methoden

Als Refluxursachen wurden ein junktionaler Phänotyp (JP, Mündungsreflux der V. saphena magna [VSM oder Leistenrezidiv] mit oder ohne suspekte Perforansvenen [SPV]) und ein Perforansphänotyp (PP, ausschließlich SPV oder aus Gründen der statistischen Zuordnung die V. saphena parva [VSP] als Refluxquelle) gegeneinander abgegrenzt. Flussrichtung und -stärke wurden unter Valsalva (JP) oder als spontan/unter distaler Kompression/Dekompression (SPV) erfasst und im Falle von SPV mit jeweils 1 oder 2 Punkten als Reflux (+) oder Reentry (−) mit resultierenden möglichen Nettoflüssen von +6 bis −6 Punkten bewertet. Refluxquelle und axiale Refluxausdehnung sowie Durchmesser und Flussrichtung von SPV wurden multivariat mit den klinischen Stadien nach CEAP-Klassifikation verglichen.

Ergebnisse

An 107 unteren Extremitäten fand sich 68× JP, in 49 Fällen davon vergesellschaftet mit SPV, und 39× PP. CEAP C3–C6 war im Falle von 45/65 (11/22) Erstmanifestationen (Rezidiven) mit SPV (JP und PP) vergesellschaftet oder in 3/16 (0/4) ohne, p < 0,01 (p = 0,01). Fortgeschrittene klinische Stadien C4–C6 waren im Falle einer Erstmanifestation von JP häufiger vertreten, wenn der axiale Reflux bis distal (14/39; p = 0,01) oder proximal des Kniegelenkes (3/11; p = 0,12) reichte verglichen mit PP (5/31). Die Flussrichtung von SPV war im Falle einer Erstmanifestation von JP sowie axialem Reflux bis distal des Kniegelenkes Reentry (Schätzer −1,62; p = 0,02) oder bis proximal des Kniegelenkes Reflux (0,29; p = 0,81) verglichen mit PP. Der Durchmesser der am meisten dilatierten Perforansvene war jedoch größer im Falle von JP und axialem Reflux bis proximal (Schätzer 0,20; p < 0,01) oder distal des Kniegelenkes (0,04; p = 0,30) verglichen mit PP. Vorherrschende Flussrichtungen von SPV waren Reentry bzw. Reflux während peripherer Kompression oder Dekompression (p = 0,009).

Schlussfolgerungen

Die Daten sprechen für einen Zusammenhang zwischen Refluxquelle und Ausdehnung eines axialen Refluxes mit dem Durchmesser und der Flussrichtung von SPV sowie dem klinischen Stadium der primären Varikose.

Abstract

Purpose

Reflux and recirculation in primary varicose veins are not yet completely understood, and the contribution of perforator veins is dual.

Methods

Reflux origin was assessed as junctional (JP, reflux of the greater saphenous junction or groin recurrences) with/without suspect perforator veins (SPV), or perforator phenotype (PP, reflux from SPV only or for statistical purposes from the small saphenous vein). Flow direction and intensity were recorded under Valsalva (JP) or as spontaneous/under distal compression/decompression (SPV) and weighted with one/two points as reflux/reentry, respectively, in the case of SPV. We compared the origin and extent of axial reflux and diameter/flow direction of SPV with the clinical stage by multivariate analysis.

Results

Of 107 limbs, 68 presented with JP, 49 combined with SPV, and 39 with PP. CEAP C3–C6 was associated with the presence of SPV (JP and PP) in 45/65 (11/22) limbs with primaries (recurrences) or in 3/16 (0/4), p < 0.01 (p = 0.01), without SPV. C4–C6 at first manifestation, however, was more frequent in JP and axial reflux below the knee in 14/39 limbs (p = 0.01) or above the knee in 3/11 (p = 0.12) compared with PP (5/31). SPV flow at first manifestation was reentry in the case of JP and axial reflux below the knee (estimate −1.62, p = 0.02) or above the knee (0.29, p = 0.81) compared with PP, but diameter of the most dilated perforator vein was higher in the case of JP and axial reflux above the knee (estimate 0.20, p < 0.01) or below the knee (0.04, p = 0.30) compared with PP. Predominant SPV flow was reentry/reflux during peripheral compression/decompression, respectively (p = 0.009).

Conclusions

The data suggest that the reflux origin and extent of axial reflux are associated with diameter/flow direction of SPV and clinical stage in primary varicose veins.

Schlüsselwörter

Varikose - Operationsplanung - statistische Auswertung - Hämodynamik

Keywords

varicosis - classification - statistical evaluation - hemodynamics

Publication History

Received: 15 May 2023

Accepted after revision: 11 January 2024

Article published online:
20 March 2024

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