The impact of isolated lesser saphenous vein system incompetence on clinical signs and symptoms of chronic venous disease

Purpose: The purpose of this study was to determine the patterns of isolate d lesser saphenous vein (LSV) system incompetence and correlate the distrib ution and extent of such reflux with symptoms and signs of chronic venous d isease (CVD). Methods: During a 3-year period, 2254 limbs in 1682 patients with signs and symptoms of CVD were evaluated with color flow duplex scanning. Extremitie s with isolated reflux in the LSV system were selected for this study Limbs with perforating venous reflux connected to this system only were also inc luded. Limbs that had marked reflux in the greater saphenous or deep vein, that had a documented history of deep venous thrombosis, and that previousl y underwent surgery or sclerotherapy were excluded. The clinical severity o f the limbs was graded with the CEAP classification system. Results: There were 226 limbs in 200 patients with reflux in the LSV system ; 61% were female patients with a mean age of 49 years (range, 18-82 years) . There mere 174 patients (87%) with unilateral and 26 with bilateral disea se, and 41% of the limbs belonged in CVD class 2, 26% in class 3, 12% in cl ass 4, 3.5% in class 5, and 3% in class 6. Classes 0 and 1 were present in 14.5% of the limbs. Symptoms were present in 139 limbs (61.5%). Some degree of ache or burning sensation was the most frequent symptom (41%), followed by itching (32%), heaviness (29%), cramps (24%), and restless limbs (18%). Reflux in the main trunk of the LSV was the most prevalent (177 limbs [78% ]), followed by the saphenopopliteal junction (146 limbs [64.6%]), the vein of Giacomini (39 limbs [17%]) and the gastrocnemial vein (23 limbs [10%]). Reflux involving both the saphenopopliteal junction and the LSV was seen i n 50% of limbs, but almost any other combination of reflux was present, whi ch indicated the complexity of this system. Perforator vein incompetence wa s detected in 56 limbs (25%). We found 83 perforator veins, resulting in a mean of 1.5 veins per limb. Both the number of incompetent perforator veins and the extent of superficial reflux correlated with clinical severity. Fo ur main types of termination of the LSV were identified with at least nine variations. The LSV was duplicated for at least half of its length in five limbs (2.2%). Nonsaphenous reflux was detected in seven limbs (3.1%). Super ficial vein thrombosis in the LSV system was found in eight limbs (3.5%), a nd in the gastrocnemial vein it was found in four (1.8%). Conclusions: Isolated LSV system incompetence can cause the entire range of signs and symptoms of CVD. Clinical deterioration is associated with a lon ger extent of reflux and perforator incompetence. Classes 2 to 4 are the mo st frequent clinical presentations, whereas classes 5 and 6 are uncommon. T he complex anatomy of this system and the great variation in the patterns o f reflux warrant the use of color flow duplex scanning before planning trea tment.