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Probabilidade de refluxo nas veias safenas de mulheres com diferentes graus de insuficiência venosa crônica

Authors:

Abstract

BACKGROUND: Presence of reflux in saphenofemoral and saphenopopliteal junctions represents important data for indication of varicose vein surgery. Studies demonstrated that in most patients with chronic venous insufficiency junctions are competent and reflux is present in segments in the course of saphenous veins. OBJECTIVES: To identify the probability of different reflux patterns in the saphenous veins of women with various degrees of chronic venous insufficiency and to evaluate whether junction impairment is associated with severity of venous insufficiency. METHODS: A total of 1,184 lower limbs of 672 women were evaluated by color-flow Doppler ultrasonography and classified according to clinical, etiologic, anatomic and pathophysiological classification (CEAP). The extremities were divided according to severity of venous insufficiency into three groups: mild (CEAP C1-C2), moderate (CEAP C3) and severe (CEAP C4-C6). Bayes' theorem was used to evaluate CEAP classification as a predictor of reflux patterns. The association between CEAP clinical classification and reflux patterns with or without saphenofemoral and saphenopopliteal insufficiency was analyzed using chi-square test (p
ARTIGO ORIGINAL
Probabilidade de refluxo nas veias safenas de mulheres
com diferentes graus de insuficiência venosa crônica
Reflux probability in saphenous veins of women with different
degrees of chronic venous insufficiency
Maria Fernanda Cassou
,
Patrícia Carla Zanelatto Gonçalves
,
Carlos Alberto Engelhorn
*
Resumo
Contexto: A presença de refluxo nas junções safeno-femoral e
safeno-poplítea é um dado importante para programação da cirurgia
de varizes. Estudos mostraram que, na maioria dos pacientes com
insuficiência venosa crônica, as junções estão competentes,eorefluxo
está presente ao longo do trajeto das veias safenas.
Objetivos: Identificar probabilidade de diferentes padrões de
refluxo nas veias safenas de mulheres com vários graus de insuficiência
venosa crônica e avaliar se o comprometimento das junções das safenas
está associado com gravidade da insuficiência venosa.
Métodos: Um total de 1.184 membros inferiores de 672 mulheres
foram estudados pela ultra-sonografia vascular com Doppler colorido
e avaliados pela classificação clínica, etiológica, anatômica e patológica
(CEAP). As extremidades foram agrupadas de acordo com a gravidade
da insuficiência venosa em graus leve (CEAP C1-C2), moderado
(CEAP C3) e grave (CEAP C4-C6). Para avaliar a classificação clínica
CEAP na predição do padrão de refluxo, utilizou-se o Teorema de
Bayers. Para avaliar associação entre classificação clínica CEAP e
padrões de refluxo com ou sem comprometimento das junções das
safenas, utilizou-se o teste qui-quadrado (p < 0,05).
Resultados: Das 1.184 extremidades avaliadas, 50,2% apresentavam
varizes sem edema (CEAP C2). O padrão de refluxo segmentar foi o
mais freqüente nas veias safenas magna (35,14%) e parva (8%),
independente da gravidade da insuficiência venosa. As junções
safeno-femoral e safeno-poplítea foram fontes de refluxo em 12 e 6%
das extremidades, respectivamente. Considerando a associação entre
classificação clínica CEAP e insuficiência das junções das safenas, foi
observada diferença significativa entre presença de refluxo nas junções
safeno-femoral (p = 0,0009) e safeno-poplítea (p = 0,0006) na doença
avançada.
Conclusões: O refluxo inicia-se predominantemente em segmentos
no trajeto das veias safenas. As junções das safenas não são as
principais fontes causadoras do refluxo no sistema venoso superficial.
À medida que piora a apresentação clínica da insuficiência venosa,
aumenta a probabilidade de refluxo nas junções das safenas.
Palavras-chave: Insuficiência venosa, varizes, veia safena,
ultra-som, Doppler.
Abstract
Background: Presence of reflux in saphenofemoral and
saphenopopliteal junctions represents important data for indication
of varicose vein surgery. Studies demonstrated that in most patients
with chronic venous insufficiency junctions are competent and reflux
is present in segments in the course of saphenous veins.
Objectives: To identify the probability of different reflux patterns
in the saphenous veins of women with various degrees of chronic
venous insufficiency and to evaluate whether junction impairment is
associated with severity of venous insufficiency.
Methods: A total of 1,184 lower limbs of 672 women were
evaluated by color-flow Doppler ultrasonography and classified
according to clinical, etiologic, anatomic and pathophysiological
classification (CEAP). The extremities were divided according to
severity of venous insufficiency into three groups: mild (CEAP C1-C2),
moderate (CEAP C3) and severe (CEAP C4-C6). Bayes’ theorem was
used to evaluate CEAP classification as a predictor of reflux patterns.
The association between CEAP clinical classification and reflux
patterns with or without saphenofemoral and saphenopopliteal
insufficiency was analyzed using chi-square test (p < 0.05).
Results: Out of 1,184 lower limbs, 50.2% had varicose veins
without edema (CEAP C2). The most common reflux pattern was the
segmental in both great (35.14%) and small (8%) saphenous vein,
regardless of severity of venous insufficiency. Saphenofemoral and
saphenopopliteal junctions were the source of reflux in 12 and 6% of
lower limbs, respectively. Considering the association between CEAP
clinical class and saphenous vein insufficiency, there was significant
difference between presence of reflux in saphenofemoral (p = 0.0009)
and saphenopopliteal (p = 0.0006) junctions in advanced disease.
Conclusions: Venous reflux begins mainly in saphenous vein
segments. Saphenous vein junctions are not the main sources of reflux
in the superficial venous system. Risk of reflux in saphenous vein
junctions increases with clinical severity of chronic venous
insufficiency.
Keywords: Venous insufficiency, varicose veins, saphenous vein,
ultrasonics, Doppler.
* Pontifícia Universidade Católica do Paraná, Curitiba, PR. Angiolab Laboratório Vascular Não Invasivo, Curitiba, PR.
Artigo submetido em 26.02.07, aceito em 14.06.07.
J Vasc Bras 2007;6(3):238-246.
Copyright © 2007 by Sociedade Brasileira de Angiologia e de Cirurgia Vascular
238
Introdução
A presença de insuficiência venosa crônica (IVC) é
facilmente identificada pela sintomatologia apresen-
tada pelo paciente e pela inspeção dos membros inferi-
ores. O exame físico pode fornecer informações sobre a
presença, a localizaçãoeaextensão da insuficiência val-
vular. Contudo, a identificação precisa das fontes de
refluxo no sistema venoso é possível somente com a
investigação por meios diagnósticos complementares.
Essas informações complementares são importantes
para o aprimoramento do diagnóstico, para o planeja-
mento do tratamento, bem como para a melhor com-
preensão da história natural da doença. A
ultra-sonografia vascular com Doppler colorido
(UVDC) é capaz de identificar com precisão a distribui-
çãoeaextensão do refluxo venoso. Esse exame tornou-se
o método de escolha para a avaliação venosa
periférica
1,2
.
Pela UVDC, é possível a identificação dos padrões
derefluxoeomapeamento pré-operatório para a cirur-
gia de varizes. A presença de refluxo na junção safeno-
femoral (JSF) e na junção safeno-poplítea (JSP) é um
dado importante para a programação cirúrgica. Estu-
dos recentes realizados com a UVDC mostraram que,
na grande maioria dos pacientes com IVC, a JSF e a
JSP estão competentes. Esses pacientes apresentam
refluxo em segmentos isolados ou múltiplos ao longo
do trajeto das veias safenas magna e parva
3-7
.
Com a adoção da classificação clínica, etiológica,
anatômica e patológica (CEAP), tornou-se possível o
estudo de grupos específicos de pacientes com o mesmo
estágio de evolução da IVC. Tal abordagem permite defi-
nir com mais precisão as diretrizes para o tratamento
desses pacientes
8
.
Os objetivos desse estudo são identificar a probabi-
lidade de diferentes padrões de refluxo nas veias safenas
de mulheres com vários graus de IVC e avaliar se o com-
prometimento das JSF e JSP está associado com a gra-
vidade clínica da insuficiência venosa.
Método
Foram incluídos no estudo somente pacientes do sexo
feminino, com sinais ou sintomas de IVC, de etiologia
primária, decorrente de insuficiência valvular (refluxo),
avaliados consecutivamente pela UVDC.
Foram excluídos os pacientes do sexo masculino,
mulheres com história prévia de trombose venosa pro-
funda ou cirurgia de varizes e mulheres com IVC decor-
rente de malformação vascular congênita.
O estudo foi aprovado pelo Comitê de Ética em Pes-
quisa em seres humanos da Pontifícia Universidade
Católica do Paraná (PUCPR) sob o protocolo número
876.
Avaliação clínica
Os membros inferiores foram classificados clinica-
mente, no momento do exame pelo ultra-sonografista
vascular, de acordo com a classificação CEAP
8
, em sete
classes clínicas: C
0
= ausência de sinais visíveis ou pal-
veis de doença venosa; C
1
= telangiectasia ou veias
reticulares; C
2
= veias varicosas; C
3
= edema; C
4
= alte-
rações cutâneas decorrentes de doença venosa (pigmen-
tação, eczema, lipodermatoesclerose); C
5
= alterações
cutâneas com úlcera cicatrizada; C
6
= alterações cutâ-
neas com úlcera ativa.
Para avaliar a associação entre a insuficiência da JSF
edaJSPeagravidade clínica da IVC, os membros infe-
riores foram divididos em três estágios evolutivos da
doença: leve (classes CEAP C
1
eC
2
), moderado (classe
CEAP C
3
) e grave (classes CEAP C
4
aC
6
), baseados na
história natural da IVC, analogamente à classificação
de Porter et al.
8
Estudo pela ultra-sonografia vascular com Doppler
colorido
As pacientes foram avaliadas com aparelho de ultra-
sonografia com Doppler Colorido da marca Siemens
®
,
modelo Elegra
®
, inicialmente para a exclusão de trom-
bose venosa recente ou antiga, com a paciente em decú-
bito dorsal, através de cortes ultra-sonográficos
transversais em modo B e manobras de compressibili-
dade das veias, utilizando transdutores de baixa freqüên-
cia (5 Mhz).
O estudo das veias safenas magna e parva foi reali-
zado com a paciente em posição ortostática, com trans-
dutor de alta freqüência (7 Mhz), para a obtenção das
imagens das veias em cortes ultra-sonográficos longitu-
dinais em modo B. Com o auxilio do mapeamento a
Refluxo safênico em mulheres com insuficiência venosa - Cassou MF et al. J Vasc Bras 2007, Vol. 6, 3 239
cores do fluxo, foi realizada a pesquisa de refluxo pelas
manobras de Valsalva e de compressão muscular manual
distal ao posicionamento do transdutor. A quantifica-
ção do refluxo nas veias safenas foi baseada nos crité-
rios de van Bemmelen
9
, considerando significativo um
pico de refluxo maior ou igual a 30 cm/s ou um tempo
de duração do refluxo superior a meio segundo.
Avaliação dos padrões de refluxo das veias safenas
magna e parva
Baseado na detecção de refluxo nas veias safenas
magna e parva, foram identificados seis padrões de
refluxo
4
:
- Padrão de refluxo perijunção: caracterizado por
refluxo na JSF ou na JSP, escoado por veias tribu-
tárias da JSF ou JSP, com manutenção da compe-
tência valvular na veia safena principal.
- Padrão de refluxo proximal: caracterizado por
refluxo na JSF ou na JSP e na veia safena principal,
originado diretamente das veias femoral ou poplí-
tea via JSF ou JSP, sendo escoado por veias tribu-
tárias superficiais ou veia perfurante, na topografia
da coxa ou perna, com manutenção da competên-
cia valvular no restante da veia safena.
- Padrão de refluxo distal: caracterizado por ausên-
cia de refluxo na JSF ou na JSP e na veia safena
principal proximal. Presença de refluxo na veia
safena a a região perimaleolar, causado por veia
tributária superficial ou veia perfurante na topogra-
fia da coxa ou perna.
- Padrão de refluxo segmentar: caracterizado por um
único segmento da veia safena com refluxo, na topo-
grafia da coxa e/ou da perna, sem envolver a JSF ou
a JSP, causado e escoado por veia tributária ou per-
furante.
- Padrão de refluxo multissegmentar: caracterizado
por dois ou mais segmentos da veia safena com
refluxo na topografia da coxa e/ou da perna. Esse
padrão de refluxo subdivide-se em multissegmentar
com refluxo na JSF ou na JSP e multissegmentar
sem refluxo na JSF ou na JSP.
- Padrão de refluxo difuso: caracterizado por refluxo
em toda a extensão da veia safena principal, desde a
JSF ou a JSP a a região perimaleolar.
Análise estatística
Para avaliar a classificação clínica CEAP na predi-
ção do padrão de refluxo, foi utilizado o Teorema de
Bayers, com o objetivo de estimar a probabilidade de
cada padrão de refluxo, dada a classificação clínica. As
probabilidades de cada padrão de refluxo, bem como as
probabilidades condicionais de classificação leve, mode-
rada ou grave para cada padrão de refluxo, foram esti-
madas pelos resultados da amostra do estudo.
Para avaliar a associação entre a classificação clí-
nica CEAP e os padrões de refluxo com ou sem o com-
prometimento da JSF ou JSP, foi utilizado o teste do
qui-quadrado. Valores dep≤a0,05 foram definidos
como estatisticamente significantes.
Resultados
Foram analisados 1.184 membros inferiores de 672
pacientes do sexo feminino, com idades entre 17 e 87
anos, com média de 41 anos. Dos 1.184 membros infe-
riores avaliados, 601 foram direitos, e 583, esquerdos,
sendo 158 exames unilaterais.
De acordo com a classificação CEAP, a maioria dos
membros inferiores (50,25%) apresentava varizes sem
edema (CEAP C
2
) (Tabela 1).
Avaliação da veia safena magna
Dentre os 1.184 membros inferiores examinados, não
foi observado refluxo na veia safena magna em 29,47%
dos casos. Nas 835 veias safenas magnas com refluxo,
foram detectados os seguintes padrões de refluxo: 1,07%,
padrão de refluxo perijuncional; 7,66%, padrão proxi-
mal; 12,81%, padrão distal; 49,82% padrão segmentar;
19,40%, padrão multissegmentar não envolvendo a JSF;
5,38%, padrão multissegmentar envolvendo a JSF; e
3,83%, padrão difuso.
Tabela 1 - Agrupamento dos pacientes de acordo com a clas-
sificação CEAP (clínica)
Classificação CEAP
1 23456
288 595 273 21 4 3
24,33% 50,25% 23,05% 1,78% 0,34% 0,25%
240 J Vasc Bras 2007, Vol. 6, 3 Refluxo safênico em mulheres com insuficiência venosa - Cassou MF et al.
Das 288 veias safenas magnas nas extremidades iden-
tificadas como CEAP C
1
, 157 (54,51%) não apresenta-
ram refluxo, e 87 (30,21%) apresentaram refluxo
segmentar. As veias safenas magnas das extremidades
identificadas como CEAP C
2
,C
3
eC
4
apresentaram
refluxo segmentar, respectivamente, em 214 (35,97%) 104
(38,10%) e nove (42,86%). Das veias safenas magnas das
extremidades identificadas como CEAP C
5
, duas (50%)
apresentaram refluxo tipo multissegmentar, e, no CEAP
C
6
, foram encontrados em igual proporção os padrões
ausente, segmentar e difuso (33,33%) em cada uma das
extremidades (Tabela 2).
A probabilidade de encontrar refluxo tipo segmen-
tar na veia safena magna nas classes C
1
,C
2
,C
3
,C
4
,C
5
e
C
6
é de, respectivamente, 30,21, 35,97, 38,10, 42,86, 28,57
e 28,57% (Tabela 3).
Dentre as extremidades com refluxo, foi identificada
a presença de refluxo na JSF em apenas 12,67%. Consi-
derando a associação entre a classificação CEAP e a
insuficiência da JSF, foi observada diferença estatistica-
mente significativa (p = 0,0009) entre a presença de
refluxo na JSF e estágios mais avançados da doença. O
percentual de veias safenas magnas com refluxo na JSF
foi menor nos casos com classificação CEAP leve
(10,65%), aumentando nos casos com classificação
moderada (17,95%) e grave (25%).
Avaliação da veia safena parva
Dentre as 1.184 extremidades avaliadas, 79,81% não
apresentavam refluxo na veia safena parva. Nos mem-
bros inferiores com refluxo na veia safena parva, 41%
apresentavam padrão de refluxo segmentar.
Tabela 2 - Associação entre os padrões de refluxo na veia safena magna e a classificação CEAP
Classificação CEAP (clínica)
123456
Padrão de
refluxo n (%) n (%) n (%) n (%) n (%) n (%) Total (%)
Sem 157 (54,51) 140 (23,53) 51 (18,67) 0 (0,00) 0 (0,00) 1 (33,33) 349 (29,47)
I-
Perijuncional
2 (0,69) 4 (0,67) 3 (1,10) 0 (0,00) 0 (0,00) 0 (0,00) 9 (0,76)
II - Proximal 5 (1,74) 32 (5,38) 24 (8,79) 2 (9,52) 1 (25,00) 0 (0,00) 64 (5,41)
III - Distal 18 (6,25) 65 (10,92) 23 (8,42) 1 (4,76) 0 (0,00) 0 (0,00) 107 (9,04)
IV - Segmentar 87 (30,21) 214 (35,97) 104 (38,10) 9 (42,86) 1 (25,00) 1 (33,33) 416 (35,14)
V-
Multissegmentar
com JSF
2 (0,69) 34 (5,71) 8 (2,93) 1 (4,76) 0 (0,00) 0 (0,00) 45 (3,80)
V-
Multissegmentar
sem JSF
13 (4,51) 95 (15,97) 46 (16,85) 6 (28,57) 2 (50,00) 0 (0,00) 162 (13,68)
VI - Difuso 4 (1,39) 11 (1,85) 14 (5,13) 2 (9,52) 0 (0,00) 1 (33,33) 32 (2,70)
Total 288 (100) 595 (100) 273 (100) 21 (100) 4 (100) 3 (100) 1184 (100)
JSF = junção safeno-femoral; multissegmentar com JSF = padrão multissegmentar com comprometimento da JSF; multissegmentar
sem JSF = padrão multissegmentar sem comprometimento da JSF;n=número de casos; % = percentual de casos; sem = ausência de
refluxo.
Refluxo safênico em mulheres com insuficiência venosa - Cassou MF et al. J Vasc Bras 2007, Vol. 6, 3 241
Das 288 pernas classificadas como grau CEAP C
1
,
265 (92,01%) não apresentaram refluxo na veia safena
parva, e oito (2,78%) apresentavam refluxo segmentar.
Refluxo segmentar foi observado em 61 (10,25%), 24
(8,79%) e quatro (19,05%) das 595 extremidades classi-
ficadas como CEAP C
2
,C
3
eC
4
, respectivamente. Das
veias safenas parvas classificadas como CEAP C
5
, duas
(50%) apresentaram refluxo tipo distal, e, no CEAP C
6
,
duas (66,67%) apresentaram o padrão difuso (Tabela 4).
Se a classe clínica for C
1
, então a probabilidade de o
paciente não apresentar refluxo na veia safena parva é
de 92,01%. Se for C
2e
C
4
, a probabilidade de o paciente
apresentar padrão de refluxo tipo segmentar na veia
safena parva é de 10,25% e 19,05%, respectivamente. Se
a classe for C
3
, a probabilidade de o paciente apresentar
refluxo tipo distal na veia safena parva é de 10,26%. Para
as classes C
5
eC
6
, o paciente apresenta igual probabili-
dade de apresentar os padrões de refluxo difuso, distal
ou ausência de refluxo (28,57%).
A probabilidade de não encontrar refluxo na veia
safena parva nas classes C
1,
C
2,
C
3,
C
4,
C
5
eC
6
é de, res-
pectivamente, 92,01, 79,66, 70,70, 52,39 e 28,57%
(Tabela 5).
Dentre os casos com refluxo, foi identificada a pre-
sença de comprometimento da JSP em apenas 5,66%.
Considerando a correlação entre a classificação CEAP
e a insuficiência da JSP, foi observada diferença estatis-
ticamente significativa (p = 0,0006) entre insuficiência
da JSP e estágios mais avançados da IVC. O percentual
de veias safenas parvas com refluxo na JSP foi menor
nos membros com classificação CEAP leve (4,19%),
aumentando nos casos com classificação moderada
(8,06%) e grave (17,86%) (Tabela 5).
Discussão
A IVC é uma doença prevalente e de repercussões
sociais relevantes, responsável por custos elevados com
tratamento e absenteísmo, principalmente nos casos de
úlcera venosa. Estima-se que acometa cerca de5a20%
da população adulta de países desenvolvidos, sendo 1 a
3,6% de casos de úlcera venosa ativa ou cicatrizada
10,11
.
A classificação mais utilizada para avaliação clínica
da IVC é a classificação CEAP. A estratificação de paci-
entes em classes clínicas diferentes permite que popula-
ções específicas com IVC possam ser estudadas nas suas
particularidades. No entanto, questões relacionadas à
Tabela 3 - Probabilidade dos padrões de refluxo na veia safena magna em diferentes graus de IVC
Padrão de refluxo C
1
(%) C
2
(%) C
3
(%) C
4
(%) C
5
eC
6
(%)
Sem 54,51 23,53 18,68 0,00 14,29
I - Perijuncional 0,69 0,67 1,10 0,00 0,00
II - Proximal 1,74 5,38 8,79 9,52 14,29
III - Distal 6,25 10,92 8,42 4,76 0,00
IV - Segmentar 30,21 35,97 38,10 42,86 28,57
V-
Multissegmentar
com JSF
0,69 5,71 2,93 4,76 0,00
V-
Multissegmentar
sem JSF
4,52 15,97 16,85 28,57 28,57
VI - Difuso 1,39 1,85 5,13 9,53 14,29
Total 100 100 100 100 100
IVC = insuficiência venosa crônica; JSF = junção safeno-femoral; multissegmentar com JSF = padrão multissegmentar com compro-
metimento da JSF; multissegmentar sem JSF = padrão multissegmentar sem comprometimento da JSF;n=número de casos; % =
percentual de casos; sem = ausência de refluxo.
242 J Vasc Bras 2007, Vol. 6, 3 Refluxo safênico em mulheres com insuficiência venosa - Cassou MF et al.
Tabela 4 - Associação entre os padrões de refluxo na veia safena parva e a classificação CEAP (clínica)
Classificação CEAP (clínica)
123456
Padrão de
refluxo
n (%) n (%) n (%) n (%) n (%) n (%) Total
Sem 265 (92,01) 474 (79,66) 193 (70,70) 11 (52,38) 2 (50,00) 0 (0,00) 945 (79,81)
II - Proximal 6 (2,08) 30 (5,04) 14 (5,13) 0 (0,00) 0 (0,00) 0 (0,00) 50 (4,22)
III - Distal 5 (1,74) 22 (3,70) 28 (10,26) 3 (14,29) 2 (50,00) 0 (0,00) 60 (5,07)
IV -
Segmentar
8 (2,78) 61 (10,25) 24 (8,79) 4 (19,05) 0 (0,00) 1 (33,33) 98 (8,28)
V-
Multissegmentar
com JSP
1 (0,35) 0 (0,00) 2 (0,73) 0 (0,00) 0 (0,00) 0 (0,00) 3 (0,25)
V-
Multissegmentar
sem JSP
1 (0,35) 8 (1,34) 5 (1,84) 0 (0,00) 0 (0,00) 0 (0,00) 4 (1,19)
VI - Difuso 0 (0,00) 0 (0,00) 6 (2,20) 3 (14,29) 0 (0,00) 2 (66,67) 11 (0,93)
I-
Perijuncional
2 (0,69) 0 (0,00) 1 (0,37) 0 (0,00) 0 (0,00) 0 (0,00) 3 (0,25)
JSF = junção safeno-femoral; multissegmentar com JSF = padrão multissegmentar com comprometimento da JSF; multissegmentar
sem JSF = padrão multissegmentar sem comprometimento da JSF;n=número de casos; % = percentual de casos; sem = ausência de
refluxo.
Tabela 5 - Probabilidade dos padrões de refluxo na veia safena parva em diferentes graus de IVC
Classificação (%)
Leve (C
1
eC
2
) Moderada (C
3
)Grave(C
4
,C
5
eC
6
)
Padrão de refluxo n (%) n (%) n (%)
Sem 739 (83,69) 193 (70,70) 13 (46,42)
II - Proximal 36 (4,08) 14 (5,13) 0 (0,00)
III - Distal 27 (3,06) 28 (10,26) 5 (17,86)
IV - Segmentar 69 (7,81) 24 (8,79) 5 (17,86)
V - Multissegmentar com
JSP
1 (0,11) 2 (0,73) 0 (0,00)
V - Multissegmentar sem JSP 9 (1,02) 5 (1,83) 0 (0,00)
VI - Difuso 0 (0,00) 6 (2,20) 5 (17,86)
I - Perijuncional 2 (0,23) 1 (0,36) 0 (0,00)
Total 883 (100) 273 (100) 28 (100)
IVC = insuficiência venosa crônica; JSF = junção safeno-femoral; multissegmentar com JSF = padrão multissegmentar com compro-
metimento da JSF; multissegmentar sem JSF = padrão multissegmentar sem comprometimento da JSF;n=número de casos; % =
percentual de casos; sem = ausência de refluxo.
Refluxo safênico em mulheres com insuficiência venosa - Cassou MF et al. J Vasc Bras 2007, Vol. 6, 3 243
origem do refluxo no sistema venoso superficialearela-
ção entre a gravidade clínica da IVC e as fontes de refluxo
ainda precisam ser melhores investigadas.
O estudo irlandês Edinburg Vein Study avaliou, den-
tre a população geral, 1.566 pessoas com idade entre 18
e 64 anos, das quais 124 apresentaram queixas compa-
tíveis com IVC. A prevalência da doença nessa popula-
ção foi de 9,4% nas mulheres e 6,6% nos homens, sendo
que aproximadamente 1/3 desses pacientes apresentou
refluxo isolado no sistema venoso superficial. Ainda
nesse estudo, foi observada maior incidência de refluxo
com a maior gravidade da IVC
12
.
A UVDC é considerada o método de escolha para
avaliação do refluxo venoso, uma vez que permite detec-
tar e medir o refluxo, fornecer detalhes anatômicos e fun-
cionais das veias, além de identificar os padrões de
refluxo, suas principais fontes de causa e seus pontos de
drenagem, e possibilitar o mapeamento venoso
13
. Todas
essas características possibilitam que o paciente tenha
tanto diagnóstico quanto tratamento individualizados.
O refluxo venoso pode originar-se a partir da insufi-
ciência valvular nos pontos de comunicação entre o sis-
tema venoso profundo e o superficial (JSF, JSP e veias
perfurantes diretas) ou de fontes independentes de
refluxo, tais como veias pudendas, perineais, glúteas e
perfurantes indiretas (sem comunicação direta com as
veias safenas). Labropoulos et al.
13
avaliaram o sistema
venoso superficial de 860 pacientes através da UVDC e
observaram a presença de refluxo em veias tributárias
superficiais originadas de fontes de refluxo independen-
tes das veias safenas em 9,7% dos casos.
Em um estudo semelhante, Seidel et al.
14
estudaram
em 1.712 pacientes as fontes de refluxo superficial em
pacientes com as veias safenas normais e encontraram
43% de refluxo independente das veias safenas. De
acordo com os autores, a provel explicação pela maior
incidência de refluxo em relação ao estudo anterior pode
estar relacionada às características individuais das popu-
lações estudadas.
Neste estudo, foram avaliadas as fontes de refluxo
dependentes das veias safenas magna e parva e sua rela-
ção com a gravidade da IVC, portanto, sem a preocupa-
ção de identificar as fontes independentes de refluxo.
Foram identificados os padrões de refluxo nas veias safe-
nas magna e parva e o comprometimento da JSF e JSP
como fontes diretas de refluxo.
A identificação dos padrões de refluxo nas veias safe-
nas permite a individualização diagnóstica e a terapêu-
tica nas diferentes classes de IVC. Contudo, não
padronização na literatura quanto à maneira de classi-
ficar o refluxo superficial. Baseado na classificação ado-
tada neste trabalho, o refluxo segmentar isolado foi o
mais freqüentemente encontrado, tanto na veia safena
magna (35%) quanto na parva (8%). Esses dados são
corroborados pelos achados de Labropoulos et al.
5
, que
identificaram 68% do refluxo localizado nos segmentos
infrapatelares da veia safena magna, seguido de 55% do
refluxo localizado nos segmentos suprapatelares da veia
safena magna. A incompetência da JSF e da JSP, de
acordo com esses autores, foi detectada, respectiva-
mente, em 32 e 6% das extremidades avaliadas.
Em relação ao envolvimento da JSF e da JSP na
gênese do refluxo nas veias safenas, Jutley et al.
6
,emum
estudo retrospectivo de 223 extremidades de 176 paci-
entes com varizes primárias, encontraram incompetên-
cia da JSF e da JSP em 30 e 9%, respectivamente. Por
outro lado, Wills et al.
15
estudaram 315 extremidades
de 188 pacientes com queixas de IVC e encontraram um
maior comprometimento da JSF e da JSP em, respecti-
vamente, 63 e 19% dos membros inferiores avaliados.
Contudo, deve-se ressaltar que, no estudo de Wills et
al., foram incluídos pacientes (38%) com tratamento pré-
vio das varizes dos membros inferiores.
Abu-Own et al.
16
, em um estudo com 190 membros,
e Cooper et al.
17
, em um estudo de 706 membros, rela-
taram alteração na JSF em 67 e 54% dos casos, respec-
tivamente. Em ambos os estudos, foram avaliados
pacientes de ambos os sexos, com média de idade de 48
e 50 anos, com varizes primárias.
No presente estudo, o comprometimento da JSF e
da JSP nas 1.184 extremidades avaliadas foi de, respec-
tivamente, 12,6 e 5,6%. A explicação para a menor inci-
dência de refluxo na JSF e na JSP pode estar relacionada
à seleção das populações nos diferentes estudos. Nos cri-
térios de seleção, foram incluídas somente mulheres, com
IVC primária, sem história de cirurgia de varizes ou
trombose venosa profunda. Portanto, foi estudada uma
244
J Vasc Bras 2007, Vol. 6, 3 Refluxo safênico em mulheres com insuficiência venosa - Cassou MF et al.
população específica de pacientes, diferentemente dos
outros autores que selecionaram populações mistas com
mulheres, homens, pacientes com história prévia de
trombose ou cirurgia, entre outros fatores
5,6,15
.
Os resultados deste estudo demonstram que, diferen-
temente do que se pensava, o refluxo no sistema venoso
superficial não é originado predominantemente nas JSF
e JSP, mas, na maioria dos casos, em segmentos isola-
dos ou múltiplos, ao longo do trajeto das veias safenas,
causado por veias tributárias ou veias perfurantes dire-
tas. Foi observado que, à medida que ocorre piora clí-
nica da IVC, aumenta a probabilidade de refluxo na JSF
e na JSP, uma vez que houve diferença significativa na
prevalência da insuficiência da JSF e da JSP em está-
dios mais avançados da doença.
Neste estudo, apenas 2,37% (n = 28) dos membros
inferiores apresentavam-se em estágios mais avançados
de IVC (classes CEAP C
4
,C
5
eC
6
). A prevalência de
membros inferiores nas classes CEAP C
4
,C
5
eC
6
encon-
trada neste estudo corrobora os achados da literatura,
que referem prevalência de 1 a 3,6% de casos de úlcera
venosa ativa ou cicatrizada nos pacientes com IVC
10,11
.
No entanto, apesar dessa grande diferença em rela-
ção à prevalência de membros inferiores nas classes
CEAP C
1
,C
2
eC
3
, a análise estatística demonstrou uma
tendência de maior probabilidade de refluxo nas JSF e
JSP nos estágios mais avançados da doença venosa
10,11
.
Os achados dessa pesquisa reforçam a necessidade
da abordagem individualizada dos diferentes graus de
IVC em populações específicas. Mulheres em diferentes
classes clínicas podem apresentar características peculi-
ares quando comparadas entre si ou com populações
masculinas. Mulheres com qualquer grau de IVC devem
ter refluxo segmentar pesquisado no exame de UVDC,
uma vez que esse padrão apresenta a maior probabili-
dade de ser o responsável pelos achados clínicos. Além
disso, a baixa probabilidade de refluxo nas JSF e JSP
apresenta um grande potencial de preservação das veias
safenas nos pacientes com indicação de cirurgia de
varizes.
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Correspondência:
Carlos Alberto Engelhorn
Rua Deputado Heitor Alencar Furtado, 1720/901
Refluxo safênico em mulheres com insuficiência venosa - Cassou MF et al. J Vasc Bras 2007, Vol. 6, 3 245
CEP 81200-110 Curitiba, PR
Tel.: (41) 3279.1241
E-mail: carlos.engelhorn@pucpr.br
246
J Vasc Bras 2007, Vol. 6, 3 Refluxo safênico em mulheres com insuficiência venosa - Cassou MF et al.
... Cassou et al. 13 Labropoulos et al. 16 compararam o refluxo venoso e as manifestações clínicas da IVCr em 255 membros inferiores de 217 pacientes sem a definição exata dos diferentes padrões de refluxo, e sim com a atribuição dos refluxos como abrangendo ou não JSF e supra ou infrapatelar. Esses autores encontraram associação entre a ocorrência de refluxo infrapatelar e a presença de sinais clínicos de IVCr mais avançada. ...
... Já nas classes C2 ou C3, três padrões se destacaram com porcentagens muito próximas de incidência: distal, proximal e segmentar. Em C4, C5 ou C6, os padrões distal e proximal foram os mais incidentes, com o mesmo percentual (33,33%), padrões estes não identificados na população feminina13 . ...
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Chronic venous insufficiency affects approximately 5% and chronic leg ulcer approximately 1% of the adult population of developed countries. Not only do recent quality of life studies highlight major disability and social impairment but, since this is a condition characterized by chronicity and relapse, it gives rise to massive health care expenditure amounting in the UK to around Pounds 400 million per annum. Venous disease consumes 1-2% of the health care budgets of European countries. Imprecise disease classifications and codings impede the acquisition of accurate data but there is a compelling need for better quality socioeconomic data concerning this long-neglected health care problem.
Article
This study was designed to identify the origin of lower limb primary venous reflux in asymptomatic young individuals and to compare patterns of reflux with age-matched subjects with prominent or clinically apparent varicose veins. Forty age- and sex-matched subjects with no symptoms (age, 15 to 35 years; 80 limbs; group A), 20 subjects (age, 19 to 32 years; 40 limbs) with prominent but nonvaricose veins (n = 26 limbs; group B), and 50 patients (age, 17 to 34 years; 100 limbs) with varicose veins (n = 64; group C) were examined with color flow duplex imaging. All proximal veins (above popliteal skin crease), superficial, perforator, and deep, in the lower limb were examined in the standing position, and all the distal veins in the sitting position. Patients who had a documented episode of superficial or deep vein thrombosis, previous venous surgery, or injection sclerotherapy were excluded from the study. The prevalence of reflux in group A was 14% (11 of 80), in group B 77% (31 of 40), and in group C 87% (87 of 100). In more than 80% of limbs in the three groups, reflux was confined to the superficial veins alone. Deep venous reflux or combined patterns of reflux were uncommon even in group C. Reflux was detected in all segments of the saphenous veins and their tributaries. In the 125 limbs that had superficial venous incompetence, the below-knee segment of the greater saphenous vein was the most common site of reflux (85, 68%), followed by the above-knee segment of greater saphenous vein (69, 55%) and the saphenofemoral junction (41, 32%). Nonsaphenous reflux was rare (3, 2.4%). Reflux in the lesser saphenous vein (21, 17%) was seen in all groups, whereas involvement of both greater and lesser saphenous veins (8, 6.4%) was seen in group C alone. The incidence of multisegmental reflux was significantly higher in group C (61 of 64, 95%) than in group A (two of 11, 18%) or group B (14 of 26, 54%). The prevalence of distal reflux was comparable in all groups. Primary venous reflux can occur in any superficial or deep vein of the lower limbs. The below-knee veins are often involved in asymptomatic individuals and in those who have prominent or varicose veins. These data suggest that reflux appears to be a local or multifocal process in addition to or separate from a retrograde process.
Article
Clinical assessment has been shown to compare poorly with results of hand-held Doppler examination or venography in the evaluation of varicose veins. Although the use of duplex scanning has been well described in the assessment of varicose veins, there are few data comparing clinical and Doppler assessment with results of duplex scans. A total of 188 patients were referred with varicose veins to a sole specialist vascular surgeon over a 1-year period. After clinical and Doppler assessment, all patients were referred for a duplex scan which was performed by a trained vascular technician. The results of the duplex scan were compared retrospectively with the clinical and Doppler findings. A total of 315 legs were assessed over this period, with 38.7% having recurrent disease and 31.4% having trophic skin changes or ulceration. On duplex scanning, 198 legs (62.9%) had saphenofemoral junction incompetence, 61 legs (19.4%) had saphenopopliteal junction incompetence, 94 legs (29.8%) had perforator incompetence and 24 legs (7.6%) had deep venous incompetence. The respective sensitivity of clinical and Doppler assessment at these sites was 71.2, 36.1, 43.6 and 29.2%. If patients who were felt to have sole saphenofemoral junction incompetence clinically were treated by high ligation, stripping to the knee and stab avulsions, 28.9% would have had sites of reflux untreated. Clinical and Doppler assessment is unreliable. Routine duplex scanning is likely to reduce recurrence by identifying sites of reflux with greater accuracy.
Article
because reflux in superficial vein tributaries is most often collectively reported with the main saphenous veins, its importance remains largely unrecognised. This study was designed to identify the distribution and extent of non-truncal superficial venous reflux and its association with the signs and symptoms of chronic venous disease (CVD). eighty-four limbs in 62 patients with signs and symptoms of CVD and evidence of reflux on continuous-wave Doppler were subsequently examined with colour-flow duplex imaging. Incompetent superficial vein tributaries were imaged throughout their extent and both ends were identified. Limbs with reflux in the main trunk of the saphenous veins or the deep, perforator or muscular veins, superficial or deep vein thrombosis, injection sclerotherapy, varicose-vein surgery, arterial disease and inflammation of non-venous origin were excluded from the study. The CEAP classification system was used for staging clinical severity of CVD. the prevalence of tributary reflux alone was 9.7% (84/860). Reflux was detected in 171 tributaries. The number of incompetent tributaries ranged from 1 to 5 per limb. Most prevalent were the tributaries to the greater saphenous (111, 65%<0. 0001), followed by those of lesser saphenous (33, 19%) or a combination of both (12, 7%). Incompetent non-saphenous tributaries were uncommon (15, 9%). Among the named tributaries in the lower limb the posterior arch vein was most often incompetent (46, 27%) followed by the anterolateral vein of the thigh (30, 18%), the medial accessory vein (16, 9%) and the anterior arch vein (14, 8%). Reflux in above-the-knee tributaries alone was found in 18 limbs (21%), in below the knee in 23 (28%) and in both sites in 43 (51%). The vast majority of the limbs (71%,p <0.0001) belonged to CVD class 2, 14% in class 3, 9% in class 1 and only 6% in class 4. Class 3 and 4 patients tended to have a longer duration of signs and symptoms, higher number of incompetent tributaries per limb and also a higher prevalence of combined above- and below-knee reflux. these data indicate that reflux confined to superficial tributaries is found throughout the lower limb. Because this reflux is present without greater and lesser saphenous trunk, perforator and deep-vein incompetence or proximal obstruction, it shows that reflux can develop in any vein without an apparent feeding source. Greater saphenous tributaries are affected significantly more often than those of lesser saphenous, while non-saphenous reflux is uncommon. Most limbs have signs and symptoms of CVD class 2 and 15% belong in classes 3 and 4.
Article
we investigated the importance of preoperative duplex scanning in primary uncomplicated varicose vein surgery by evaluating the incidence of superficial venous imcompetence and significant anatomical variations that may be difficult to detect clinically and therefore might be expected to contribute to recurrence. a retrospective study of a prospectively collected database. over 15 consecutive months, patients attending the non-invasive vascular laboratory for duplex scanning of their primary uncomplicated varicose veins were assessed. vascular laboratory case notes were assessed and incidence of superficial venous incompetence and any significant anatomical variations that would have been difficult to detect clinically +/-HHD were documented. Any correlation with clinical findings was also evaluated. a total of 223 limbs (176 patients) were assessed. Sixty-seven limbs (30%) in fact had a competent sapheno-femoral junction. Sixty-one limbs (27%) had pure sapheno-femoral reflux and nil else. Fifty-three limbs (24%) had significant anatomical variations. Forty-two limbs (19%) had short saphenous vein incompetence, of which 67% were clinically unsuspected. preoperative duplex scanning is indicated in all patients with uncomplicated primary varicose veins if appropriate venous surgery is contemplated. There are obvious resource and recurrence rate implications. Further evaluation in the form of randomised trials are required.