Key words
Varicose veins - radiofrequency ablation - duplex ultrasound - PAVA
Schlüsselwörter
Varikose - Radiofrequenzablation - Sonographie - PAVA
Introduction
Primary avalvular varicose anomaly (PAVA) is a new phenomenon defined as tortuous,
thin-walled and incompetent veins in patients presenting with primary varicose veins
(VVs), resembling neovascularized tissue on ultrasound and surgical examination
[1].
The concept of PAVA was introduced to justified saphenofemoral junction (SFJ)
recurrence with an aspect of neovascularization, after endovenous or surgical
saphenous intervention. In particular, the misdiagnosis of a PAVA – already present
before surgery – mistaken for neovascularized tissue in recurrent VVs, may lead to
underestimating the role of these avalvular residual SFJ collaterals after ablative
intervention as a source of recurrence. The recognition of SFJ collaterals’
incompetence has a greater relevance in case of endovenous procedure, in which only
saphenous axis is treated. We present a case of PAVA, originating from SFJ, in a
patient who underwent radiofrequency ablation (RFA) for incompetent great saphenous
vein (GSV) and describe Doppler ultrasound scan (CDUS) PAVA modifications during
follow-up period.
The patient provided written consent for the publication of this paper in a medical
journal.
Case report
A 39-year-old man presented to our attention with primary varicose veins (C2-S; Ep;
As; Pr2,5). He has a past medical history of appendectomy and adenoidectomy during
his youth, prior episode of prostatitis and occasional asthma treated with
bronchodilator medication (Salmeterol and Fluticasone) when needed. He also reported
a familiar asymptomatic Fahr’s syndrome, genetically diagnosed with mutation in
SLC20A2 gene, with no basal ganglia or electrolyte homeostasis involvement, as
demonstrated by head computed tomography scan and blood test performed one month
before the procedure. Intolerance to acetylsalicylic-acid was reported.
A preoperative CDUS analysis revealed SFJ reflux with incompetence of both terminal
and preterminal valves during Valsalva maneuver. A pathological reflux > 0.5 s
extending along the course of GSV, up to the knee, was detected. Extra-saphenous
varicose vein along the leg were also present. GSV diameter was measured at
proximal, middle and distal thigh, being 8.7 mm, 10.7 mm and 9.5 mm, respectively.
GSV-skin distances were also measured at same thigh levels: 17 mm, 19 mm and 8 mm,
respectively. Neither thigh GSV incompetent collaterals nor anterior accessory
saphenous vein (AASV) were detected.
During the CDUS exam, a SFJ collateral, next to the connection with femoral vein,
was
noted ([Fig. 1]). It was a serpiginous, avalvular,
dilated, refluxing collateral, extending from SFJ to saphenous space, wrapping the
GSV in its proximal tract. Its maximum diameter was 9.9 mm proximal to the SFJ.
Distally at middle third level of the thigh, the collateral became suprafascial,
with a marked decrease in caliber and the abolition of reflux. It was not possible
to describe neither where this collateral originated from nor which district it
drained. The patient underwent endovenous ablation of GSV using radiofrequency with
ClosureFAST™ catheter (Medtronic, San Jose, CA, USA) and concomitant phlebectomies
of the leg under local anesthesia ([Fig. 2]).
Neither intraprocedural nor postprocedural complications occurred. Patient was
discharge the same day of the procedure with compression stockings (20–30 mmHg) for
two weeks and prophylactic dose of low molecular weight heparin for twelve days.
Fig. 1 Preoperative CDUS analysis of saphenofemoral junction with
femoral vein (asterisk), great saphenous vein (hashtag) and PAVA (arrow),
proximal cross section, A and B. Longitudinal section of incompetent PAVA,
C. Graphic overview of preoperative saphenofemoral junction with its
collaterals, great saphenous vein and PAVA, D.
Fig. 2 Endovenous ablation of GSV was performed using radiofrequency
ablation technique with ClosureFAST™ catheter (Medtronic, San Jose, CA,
USA), A. Concomitant phlebectomies of the leg under local anesthesia were
also performed, B
After six months, the patient underwent CDUS control examination that revealed good
results of endovenous ablation, with patency of SFJ through the superficial
epigastric vein. The tortuous SFJ collateral was still patent, with maximum diameter
of 7.8 mm and partial circumferential thrombosis of the distal portion, with a
residual lumen of 4.8 mm in diameter ([Fig. 3]).
Residual reflux was detected in this tributary vein during Valsalva maneuver. No
clinical signs of residual or recurrent VVs was present. Reviewing
pre-interventional CDUS images and comparing them with the follow-up images, a
truncal PAVA was then diagnosed.
Fig. 3 Post-RFA six-month CDUS analysis, revealing patency of femoral
vein (asterisk), saphenofemoral junction, proximal great saphenous vein
(hashtag) and proximal PAVA (arrow), A. Total occlusion of great saphenous
vein due to RFA (hashtag), with partial PAVA occlusion (arrow), still
incompetent, B and C. Graphic overview of postoperative saphenofemoral
junction with its collaterals, great saphenous vein, PAVA and their cross
sectional lumen view, D.
Discussion
Varicose veins recurrence remains one of the most undisclosed and debated topic in
phlebology with a wide incidence range from 7 % to 65 % [2]. Moreover, the pathogenesis of recurrent SFJ reflux remains
incompletely understood, even if several studies have proposed different
pathological causes [3], [4], [5], [6], [7]. Among
these, neovascularization has been reported to account from 8 % to 60 % of recurrent
VVs [2], [8],
[9]. Tactical and technical errors were
detected in 80 % of cases, although incidences remain very heterogeneous among
studies [2], [10],
[11] with unclear correlation between recurrent
VVs defined with CDUS, surgical or histological examination [12].
PAVA is a new anatomical entity consisting of serpiginous, avalvular and usually
incompetent veins arising from SFJ or directly from femoral vein, detected during
preoperative CDUS evaluation [1]. Three patters of
PAVA were described by Ostler and collaborators [1]:
-
Lymph node pattern: PAVA emerge directly from a groin lymph nodes
-
Peritruncal pattern: PAVA wrap around truncal veins (the GSV, small saphenous
vein, or anterior accessory saphenous vein)
-
Atypical pattern: PAVA have the same appearance as the other two patterns but
lie in various locations and are not connected to lymph nodes or truncal
veins.
The incidence of PAVA is around 5 % among CDUS examinations, with a female-to-male
ratio of about 5:1 and with no significant correlation with CEAP grade [1].
The recognition of PAVA during CDUS examination is challenging because it may be
confused with SFJ collateral or with GSV groin tributaries with poor or none
clinical significance. The differences have not yet been clearly defined. PAVA
differs from AASV for the absence of valves and the serpiginous course, not parallel
to GSV.
We report a case of a patient with truncal PAVA undergoing to a RFA procedure.
PAVA was not treated because it was recognized only during retrospective imaging.
At 6-month CDUS follow-up, a good clinical and instrumental result were evident,
although PAVA was still incompetent, with distal partial circumferential vein lumen
thrombosis (residual lumen of 4.8 mm) and a decrease in maximum diameter (from 9.9
mm to 7.8 mm). The reasons for these two changes remains unknown. Furthermore, we
do
not know if in future this collateral could become a source of recurrent VVs, but
we
would like to introduce the hypothesis that some recurrent VVs cases considered as
neovascularization, could be a residual PAVA. The misdiagnosis derives from
similarity in recurrent VVs and PAVA appearance (avalvular, shaped, next to SFJ, …).
The fact that, 6 month after endovenous procedure, PAVA is still incompetent may
justify its role as a future source of reflux in the SFJ thus creating recurrent
VVs.
For these reasons, it should be recommended to detect PAVA during preoperative CDUS
examination and during follow up controls, in order to clarify:
-
if PAVA is primarily observed as a patent and competent/incompetent vessel,
and remains or become incompetent after RFA or others venous treatment
-
if PAVA modifies its diameter after intervention, producing new varices or
dilated veins
-
if PAVA represents a potential new source of pathological/symptomatic
reflux
-
if it is necessary to remove PAVA in case of surgery or sclerotherapy for
recurrent VVs.
The answers to these questions might strongly modify CDUS approach and change
management and treatment of primary and recurrent VVs.
Primary Avalvular Vein Anomalies are not so rare in patients performing a CDUS
analysis for varicose veins. It is important to detect PAVA during preoperative
examination and report its presence in order to correlate it to a possible
recurrence of VVs. The need for new studies that could identify a correlation
between recurrent VVs patters and preoperative PAVA is necessary to confirm the
role of these veins in the recurrence of symptomatic chronic venous disease.
