Exploration of a patient with varicose veins - provocation maneuvers, sapheno-femoral junction, perforating veins

Dr Mendoza’s patient has small varicose veins on the back of the calf, no edema, no discoloration. The investigation starts in the right groin, a classical Mickey Mouse with a small ear can be seen. With color, flow in the artery is visualized. For the deep vein investigation, the goal is to elicit an anterograde flow; calf compression, toe elevation, Valsalva may be adequate maneuvers. In this case, the patient shows a reflux in the epigastric vein into the deep vein, but not into the great saphenous vein. Dr Mendoza remarks that sometimes after pregnancies or surgeries of the ovaries or appendix (when the skin was cut), there is a pathologic drainage. In this case, the pathologic drainage is physiologically drained to the deep vein and there is no flow towards the leg. Dr Mendoza emphasizes that it is important to use the proper method to elicit the blood flow during venous investigation. Use Valsalva, compression, some dynamic maneuvers, or the toe elevation. If you are in doubt, use the orthostatic maneuver. Check where the reflux comes from and where it drains.

Maneuvers performed

• Valsalva: This maneuver is not so kind in standing position, sometimes does not work in the pelvic reflux but in the epigastric vein.
• Toe elevation: In order to elicit a good anterograde flow.
• Calf compression (classical maneuver): To demonstrate that the artery is not compressable. The deep vein and the saphenous vein disappear.
• Dependency maneuver (master of reflux provocation maneuvers): Patient placed in supine position, elevation of leg for 20 seconds (veins empty). After that, the patient stands up again. In large veins the reflux will finish earlier, in tiny ones it will take longer. Maneuver can be used in patients where there should be a reflux that was not detected so far. Also it makes sense to use for tiny veins.

Take home messages

• Pathology: Pathologies of veins do not depend on the diameter but on the direction/draining of blood.
• Maneuvers: In some patients there is a difference between calf compression and toe elevation. Check both in patients with varicose veins in order to make sure there is not a problem with the muscle.
• Diagnosis: Do not diagnose based on ultrasound results - no matter how good your duplex skills are –, also consider clinical symptoms and respect patients’ wishes for the treatment.
• Reflux: A reflux is anything longer than 1 second (people with reflux usually have 2–3 secs). Recommendation: not to treat below 1 sec in order to prevent over-treatment. In general, there is more reflux in the evenings compared to mornings and in summer more than winter. Also there are many confounders in the reflux length, like time passed since the previous maneuver, the length of the reflux is very semiquantitative. Note that the reflux velocity does not play a role in the reflux source, it is random.
• Muscle veins: Do not underestimate the role of the muscle veins for DVT treatment but also as a cause of reflux, leg vein disorders, and complaints. Although we know from international trials that the lower leg muscle veins do not play such a big role, it is important to watch them anyway!
• Cave: There are often deep veins accompanying the saphenous. If one is refluxive, the other healthy, it is easy to confound them, but you cannot treat deep veins with superficial treatment.

Important observations with implications for therapy

• For reflux from epigastric, the circumflex or the pudendal vein, it is better not to touch the groin surgically, only close below.
• At the merging point of the deep vein and the small saphenous, there is a muscle vein. Do not follow the ancient rule to cut the saphenous at the junction to the deep vein (you would close the muscle vein).