The role of venous reflux and calf muscle pump function in nonthrombotic chronic venous insufficiency. Correlation with severity of signs and symptoms

N. Labropoulos, A. D. Giannoukas, A. N. Nicolaides, M. Veller, M. Leon and N. Volteas
Academic Vascular Surgery Unit, St. Mary's Hospital Medical School, London, England.

OBJECTIVE: To determine the lower-limb venous hemodynamics in patients with varying grades of chronic venous insufficiency (CVI), not due to deep vein thrombosis, when matched for age and duration of disease. DESIGN: Case-control study. SETTING: Normal volunteers and patients with different grades of CVI referred to the vascular unit of a university hospital. MATERIALS: Fifty-one legs (40 patients) with CVI, but without a history of deep vein thrombosis, and 24 normal legs (20 volunteer subjects). These selected legs were grouped according to the severity of CVI (classes 0 - through 3) so that each class was matched for age (all study participants <60 years) and duration of signs and symptoms (<10 years). INVESTIGATIONS: Air plethysmography and color flow duplex imaging. MAIN OUTCOME MEASURES: Venous volume, venous filling index, and outflow, ejection, and residual volume fractions were assessed in all limbs with air plethysmography. The presence of reflux was confirmed by the results of color flow duplex imaging. RESULTS: Ten (42%) of 24 limbs in class 0 had no reflux. Twenty-five (57%) of the 44 limbs in classes 0 and 1 had superficial reflux alone, while all the limbs in class 1 had some degree of reflux in the superficial veins. The sites of reflux in these limbs were similar. The patterns of reflux in classes 2 and 3 were more complex. Eight (26%) of the 31 limbs had superficial reflux alone, whereas 10 (32%) had all three systems involved (superficial, deep, and perforating). The venous volume, venous filling index, and residual volume fraction worsened with progression of CVI. Significant statistical differences could, however, only be demonstrated between classes 0 and 1 vs classes 2 and 3. No changes could be found in the ejection and outflow fractions. CONCLUSIONS: Patients (age <60 years) with CVI of less than 10 years' duration and with no history of deep vein thrombosis had venous hemodynamic changes that correlated well with the clinical severity of the disease. This was owing to the increased reflux, as the ejecting ability of the calf muscle pump remained intact, and the venous outflow was normal.