Management of varicose veins: Status of clinical examination and Colour Doppler in the present Indian scenario

摘要

Varicose veins affect a significant percentage (40%) of the middle-aged population. It may not cause any mortality in the patients but causes a significant morbidity if left untreated. It is important to properly localize the problem before surgical management, to avoid recurrence of the disease. Clinical examination, if done alone for evaluation of patients of varicose veins, has a sensitivity of 90% for the saphenofemoral junction. But for perforator incompetence, it has a sensitivity of 61.5% only. There are likely chances that incompetent perforators are missed and may lead to recurrence of disease. Colour duplex ultrasound is an important non-invasive method for identification of superficial venous and perforator incompetence. It is especially valuable in detecting saphenopopliteal and perforator incompetence where accuracy of clinical examination is very low. It can help in localizing the perforators more precisely so that surgery can be performed by small incisions, especially at places where the facility for subfascial endoscopic surgery (SEPS) is not available. The authors recommend Color Doppler sonography in all patients of varicose veins before subjecting them to surgery as it is available in most of the district level centres in India. Introduction Varicose veins are part of the penalty we pay for adoption of the erect posture. Varicose veins affect 10-20% of population in the western world but in developing countries, because of their way of life, the incidence is about 2%1. Various predisposing factors have been implicated like pregnancy, prolonged standing, obesity, old age, athletics etc., but heredity also plays an important role2. In varicose veins, the problem may lie in superficial veins, deep veins or in the perforating system. If the incompetent perforators are not properly localized and ligated they may complete the circuit of varicose veins draining blood from deep to superficial veins thereby leading to recurrence.The aim of clinical examination is to localise the site of incompetence whether the superficial or deep system is affected and if the superficial system is involved whether the problem is at the saphenofemoral junction (SFJ), the saphenopopliteal junction (SPJ) or at the perforator level. Various tests are done for this purpose like Trendlenburg’s test, Perthes’ test, Fegan’s test, Pratt’s test and Schwartz’s test etc. The overall accuracy of various clinical tests in localization of the exact site of incompetence is 60-70%3.The development of duplex ultrasonography (B-Mode), especially with bidiretional colour flow mapping, provides a simple, repeatable and non-invasive investigation for the study of the venous system. By this technique both anatomic and functional aspects of the three systems including perforators can be evaluated and exact location of valvular incompetence can be determined4. With accurate localisation of the incompetent sites, surgery can be done by small incisions resulting in better wound healing. So we carried out a study to compare the efficacy of clinical examination and colour duplex ultrasonography in detecting superficial venous and perforator incompetence in patients of varicose veins. Material & Methods The study was conducted on 50 patients of varicose veins admitted in surgical wards. A total of 64 limbs were studied in 50 patients. After thorough history, clinincal examination was done by various tests to see for saphenofemoral, saphenopopliteal and perforator incompetence. Colour duplex sonography was done in all patients with a high-resolution broad-band linear transducer of a frequency of 5-12 MHz, to localise incompetent valves in the superficial system and incompetent perforators in the leg.The patients were subjected to surgery after marking all the perforators with marking ink. Incompetent saphenofemoral and saphenopopliteal junctions were flush ligated and incompetence at these levels was confirmed at the time of surgery. The leg was explored by long