The duplex criteria for paediatric reflux testing

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Dawn Coleman

Primary chronic venous disease is poorly documented in paediatric patients, excluding those diagnosed with Klippel-Trenaunay syndrome (KTS) and post-thrombotic syndrome, writes Dawn Coleman. The Bochum Study previously studied 136 children (aged 10–12 years) longitudinally out to 31 years and identified a 2.5% incidence of preclinical saphenous reflux (without associated varicose veins) that was associated with a 30% risk for the development of truncal varicosities over time.

These authors also identified that the incidence of venous disease increased with age and that the onset of varicose veins appeared to correlate with puberty in these patients.1 On occasion young patients may present with a variety of symptoms like lower extremity oedema or venous varicosities for which the differential diagnosis is broad and the role for venous reflux study remains unclear.

We previously reviewed all venous reflux studies (n=20) performed on children (mean age 13 years) presenting to our centre for a variety of symptoms, including varicose veins, swelling and dependent rubor/acrocyanosis. Of these patients, eight had bilateral symptoms and two carried a pre-existing diagnosis of KTS.2 Importantly, no patient had a pre-existing history of deep vein thrombosis (DVT) or phlebitis and no patient had open wounds or stigmata of chronic inflammation. The majority (90%) of these patients demonstrated some degree of venous reflux by duplex examination. Adjunctive studies were often utilised (including magnetic resonance venogram and lymphoscintography) to secure the appropriate medical diagnosis. In total, nine patients were diagnosed with chronic venous disease and, interestingly, despite the presence of venous reflux on imaging, an alternate medical diagnosis was made in nine of 18 children, including, postural orthostatic tachycardia syndrome (n=2), vascular malformation (n=2), lymphoedema (n=2), complex regional pain syndrome (n=1) and acrocyanosis of disuse (n=1). Bilateral symptoms were present in only a minority of patients with chronic venous disease (including those with KTS) while the majority of patients that received an alternative medical diagnosis had bilateral symptoms. Regardless of the diagnosis, the majority of patients demonstrated evidence of bilateral venous insufficiency by duplex. Maximum superficial valve closure time of the affected limb was significantly increased in the patients with primary cardiovascular disease and those with KTS (median 3,292 vs. 1,975 msec; p=0.0282). For those patients with unilateral symptoms and bilateral reflux, maximum valve closure time was significantly increased in the affected limb (median 2,979 vs. 1,705 msec; p=0.0297).

We then sought to identify if this prolific venous reflux in children is clinically significant and specifically aimed to identify “normal venous parameters” in healthy paediatric controls. We performed a comprehensive venous reflux study on healthy paediatric volunteers aged 5–17 years to elicit what we anticipated would be “normal” venous parameters. We studied 18 volunteers and identified that great saphenous vein diameter at the saphenofemoral junction significantly increased with age and that deep vein valve closure time did not differ significantly between age groups while great saphenous vein valve closure time was significantly higher in the 9–12 year age group. Incidental venous insufficiency was identified in 60% of children aged 5–8 (n=3), 50% of children aged 9–12 (n=3) and 57% of children aged 13–17 (n=4), including six boys and four girls. All superficial venous reflux was confined to the great saphenous vein and there were no cases of isolated deep venous reflux. Superficial venous reflux was identified at multiple great saphenous vein stations (60%). Additionally, accessory superficial veins were identified in 39% of children with saphenous reflux and, importantly, this accessory saphenous anatomy was not associated with deep venous reflux in any patient.

We have concluded that the great saphenous vein continues to grow in diameter through the teenage years. Incidental valvular incompetence and great saphenous vein reflux is common. Also, the presence of accessory saphenous veins is similarly common in children and not associated with venous reflux. The differential diagnosis for paediatric lower extremity oedema and venous varicosities in the paediatric age group is broad, and often there is venous reflux present despite an alternate medical diagnosis. Pre-pubescent children with varicose veins, oedema, and a valve closure time <3,000 msec should be considered for further diagnostic study (ie. magnetic resonance venogram) to secure the most appropriate medical diagnosis. Importantly, superficial valve closure time may help differentiate a primary venous abnormality which could influence treatment options like routine measures of vein health and risk factor modification (education to prevent obesity, tobacco abuse and mechanical/professional risks). Despite this work, the clinical significance and natural history of incidental paediatric venous reflux remains unclear and ongoing research is necessary to determine if these changes seen in the paediatric age group are “pre-clinical” and lead to cardiovascular disease during later life.

Dawn Coleman is a vascular surgeon at the University of Michigan, Ann Arbor, USA

References

  1. Schultz-Ehrenburg U, Weindorf N, Matthes U, Hirche H. Phlebologie 1992;45:497–500.
  2. Andraska EA, Horne DC, Campbell DN, Eliason JL, Wakefield TW, Coleman DM. J Vasc Surg Venous Lymphat Disord 2016;4:422–5.