European Journal of Ultrasound 11 (2000) 175–180

Clinical Science: Original Paper

Duplex ultrasonography in the diagnosis of incompetentCockett veins

Thomas Meyer a, Alexander Cavallaro b, Werner Lang a,*a Department of Surgery, Di6ision of Vascular Surgery, Uni6ersity Hospital Erlangen,

Krankenhausstr. 12 D-91054 Erlangen, Germanyb Institute of Diagnostic Radiology, Uni6ersity Hospital Erlangen, Krankenhausstr. 12 D-91054 Erlangen, Germany

Received 11 November 1999; received in revised form 4 February 2000; accepted 14 February 2000

Abstract

Objecti6e: Incompetent perforating veins of the medial calf, i.e. those of the Cockett groups, play a major role inthe developement of chronic venous insufficiency. The aim of the present study was to test the value of duplexultrasonography (DUS) in the diagnosis of function and localisation of those veins. Methods: Eighty-nine legs withincompetent perforating veins of the medial calf selected for subfascial endoscopic perforator surgery (SEPS) wereincluded in a prospective study. Preoperative DUS was used to determine the number and localisation of theperforator veins. Findings were compared with preoperative ascending phlebography and intraoperative endoscopyduring SEPS. Results: Nearly equal numbers of insufficient Cockett veins at each level were detected by DUS andascending phlebography (Cockett III: n, 76 vs. n, 76, P, 1.0; Cockett: II n=84 vs. n=82, P=0.569; Cockett I: n, 36vs. n, 37, P=1.0; x2-test). Findings were confirmed intraoperatively. Conclusion: The accuracy of DUS is comparableto phlebography for the diagnosis of incompetent perforating veins of the lower leg. DUS is non-invasive and avoidsthe potential risks of radiologic imaging. © 2000 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Duplex ultrasonography (DUS); Perforating vein; Chronic venous insufficiency; Subfascial endoscopic perforator surgery(SEPS); Ultrasound

www.elsevier.com/locate/ejultrasou

1. Introduction

Incompetent perforating veins, i.e. the medialcalf perforators of the Cockett group I-III (Fig.1), are regarded as an important factor in thedevelopement of chronic venous insufficiency(Browse, 1986; Pierik et al., 1997). The Cockettveins pass through the muscle fascia and connect

* Corresponding author. Tel.: +49-9131-8532968; fax: +49-9131-8539115.

E-mail address: werner.lang@rzmail.uni-erlangen.de (W.Lang)

0929-8266/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved.

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the deep and the superficial venous system bydraining into the posterior arcuate branch of thegreater saphenous vein on the lower leg. Interrup-tion of those veins, for example by subfascialendoscopic sectioning, in many cases leads toprevention or healing of chronic venous ulcers atthe lower leg (Jugenheimer and Junginger, 1992;Lang et al., 1995; Pierik et al., 1995). Beyondclinical examination, preoperative diagnosticscommonly include phlebographic imaging, that isstill regarded as the standard method, but poten-tially carries the risks of anaphylactic reaction,deterioration of renal function, radiation andthrombophlebitis. In the present study we investi-gated the use of duplex ultrasonography (DUS)for the diagnosis of incompetent perforating veinsat the lower leg in comparison with phlebographyand intraoperative endoscopic findings.

2. Patients and methods

Between 1993 and 1996 subfascial endoscopicperforator vein surgery (SEPS) at the lower legwas performed on 101 legs (87 patients, mean age

56 years). Distribution of gender was nearly bal-anced (female n, 51, male n, 50) as it was for theside of the extremity (right n, 51, left n, 50).

All patients were prospectively examined. As arule, diagnostic evaluation comprised location,number and competence of the medial calf perfo-rators as well as the condition of the deep and thesuperficial venous system. Relating to the purposeof the study, analysis concentrated on the detec-tion of incompetent perforating veins of the me-dial calf.

Duplex ultrasonography examination on theupright standing patient was performed preopera-tively by screening the superficial (epifascial) andperforating veins as well as the deep veins. Equip-ment used in this study: 7.5 MHz probe, lineararray, low flow detection, Kranzbuhler Logic 500.A perforating vein was defined as being incom-petent if a pathological reflux of more than 2 swas detected, i.e. a reverse (retrograde) flow di-rected from the deep to the superficial venoussystem (Pierik et al., 1997). If necessary, refluxwas provoked by manual compression (Fig. 2).

Preoperative radiologic imaging was done byascending phlebography (Hach and Hach-Wun-derle, 1994). The presence of an incompetent per-forating vein was stated when the criteriaaccording to Hach were fulfilled (Table 1). Clini-cal, phlebographic and sonographic findings wereregistered in a prospective SEPS data base. Inorder to optimize planning of the surgical proce-dure, ultrasound examinations were performed bythe responsible surgeon himself just as the resultsof phlebographic studies were known to the sur-geon preoperatively.

During the SEPS procedure the perforatorveins were verified under direct vision. After par-tial deprivation of blood supply by an Esmarch’sbandage and a silicon cuff a 2 cm-incision wasmade at the proximal third of the line of Linton.The endoscope (Storz, Germany; 11 mm endo-scope shaft with straight view) was inserted andmoved in distal direction below the fascial layer todivide the connective tissue and isolate the perfo-rating veins which were cut after coagulationthrough the 5 mm-working channel of the endo-scope. No gas insufflation or fluid instillation wasused. Identification of a perforating vein includedFig. 1. Medial calf perforators: the Cockett veins group I-III.

T. Meyer et al. / European Journal of Ultrasound 11 (2000) 175–180 177

Fig. 2. Duplex ultrasonography of a perforator vein. Note the transfascial course of the vein connecting the deep and superficialvenous system with bidirectional blood flow during manual compression test.

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the presence of a serpentine vessel (varicose mor-phology) in typical position, usually filled withblood despite an anemic operation field. In con-trast, competent veins were defined as small cal-iber veins, with a straight configuration withoutblood inside.

3. Results

In 89 cases phlebography and DUS were com-plete so that comprehensive evaluation of all rele-vant aspects was possible. These 89 cases wereanalysed in detail. Only in ten instances (11 %)isolated insufficiency of perforating veins was ob-served. In the remaining 79 cases (89 %) a combi-nation of varicose disease of the saphenous veins(due to valve dysfunction) with incompetent per-forating veins was found so that additional opera-tive treatment was necessary beyond SEPS. Inalmost three quarters of the studied legs (n, 62,70%) chronic venous insufficiency was advanced,38 times an active venous ulcer was present. Thedeep veins were found to be normal in 65 legs(73%), incompetent due to valve dysfunction in 10

(11%) and incompetent due to postthromboticchanges in 13 cases (15 %).

The frequency of incompetent perforating veinsat the lower leg diagnosed by phlebography andDUS is shown in Table 2. The figures at thedifferent levels of Cockett veins were almost iden-tical indicating that the accuracy of DUS is com-parable to phlebography. Chi-square test revealedno difference for each level between both methods(Cockett I P, 1.0, Cockett II P, 0.569, Cockett IIIP, 1.0). Lower numbers of Cockett veins at level Iwere seen at endoscopy due to the known techni-cal difficulties of the procedure in the area at themedial malleolus (Lang et al., 1995). The higherincidence of interrupted Cockett III veins is ex-plained by the fact that all visible, perforatingveins including few competent ones were sec-tioned in order to prevent developement of in-sufficiency in those veins.

4. Discussion

Pathological reflux of incompetent perforatorveins at the lower leg and subsequent increase ofsuperficial venous pressure are among the maincauses for the developement of nutritive lesions ofthe skin and chronic venous ulceration. The me-dial calf perforators, i.e. the Cockett groups I-III,are most relevant in terms of pathophysiology(Browse, 1986; Pierik et al., 1997).

However, incompetence of the epifascial andthe perforator veins often occurs simultaneously,so that isolated perforator insufficiency is uncom-mon (Padberg et al., 1996). In this series only 11%demonstrated isolated insufficiency of perforatingveins and in a quarter of cases changes of thedeep venous system were present.

Clinical examination seems to be of low accu-racy for diagnosis and localisation of incompetentperforating veins as is the use of cw-Doppler. In aformer, blind prospective study on 39 limbsO’Donnell et al., (1977) found a high correlationof clinical examination, bidirectional Doppler ul-trasound and phlebography in predicting the siteof perforating veins in comparison to intraopera-tive findings. In a recent observational cohortstudy, however, sensitivity and specificity of clini-

Table 1Radiologic criteria for the diagnosis of incompetent perforat-ing veins by ascending phlebography (Hach and Hach-Wun-derle, 1994)

Loss of valvesReverse (retrograde) flowSingle veinHorizontal angle (\60°)Cylindric configuration

Table 2Incompetent Cockett veins-pathological findings (n=89)a

DUSVenography SEPS

n n n7676 83Cockett III

Cockett II 8184 8236 37Cockett I 32

a DUS, duplex ultrasonography; SEPS, subfascial endo-scopic perforator surgery

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cal examination and cw-Doppler ultrasound wasvery low (29% resp. 15%) when compared to theresults of duplex ultrasonography (Schultheiss etal., 1997).

For a long time phlebography has been thegold standard for imaging of all components ofthe venous system, but has been associated withthe risk of side effects and radiation. Meanwhile,duplex ultrasonography is considered as a widelydistributed and generally approved method in thediagnosis of different aspects of venous disease(Becker et al., 1997). In comparison to bidirec-tional cw-Doppler particularly diagnosis of thevariable anatomic localisation of the perforatorveins in the presence of varicose epifascial veins isimproved (Lang et al., 1995). Reflux, i.e. reversedirection of blood flow, has been regarded as themain criterium for incompetence of perforatingveins (Grabs et al., 1996; Phillips and Cheng,1996; Pierik et al., 1997). According to Phillipsand Cheng (1996) reflux is correlated with thediameter of the veins, which is observed in 60% ofperforators with a diameter greater than 4 mm.This parameter was not evaluated in this series.

The purpose of the present study was to investi-gate the value of duplex ultrasonography for lo-calisation of incompetent perforator veins at thelower leg, i.e. those of the Cockett groups, incomparison with phlebographic imaging. In addi-tion, SEPS could be taken to confirm some preop-erative diagnostic findings intraoperatively bydirect vision, e.g. localisation and varicose mor-phology. Nearly equal numbers of incompetentperforator veins at each Cockett level were diag-nosed by DUS and phlebography, indicating thatthe accuracy of the diagnostic procedures is notsubstantially different.

In a prospective study on 20 consecutive pa-tients, Pierik et al. (1995) found a sensitivity andspecificity of duplex ultrasonography in predictingthe site of perforating veins on the medial side ofthe lower leg of 79.2 and 100%, respectively, forincompetent perforating veins and of 82 and100%, respectively, for competent and incom-petent perforating veins. Full endoscopic surgicalexploration on the medial side of the lower legwas referred to as the ‘gold standard forcalculation’.

In the present study, correspondance with intra-operative findings was high, as was alreadydemonstrated by Hanrahan et al. (1991) in asmaller series when perforating veins were evalu-ated by high resolution duplex imaging. A wellknown problem in SEPS is imaging of incom-petent perforator veins at the Cockett I level dueto the increasing narrowness of the subfascialspace near the medial malleolus that rendersstump dissection difficult above all when there isconcomitant sclerosis of the fascia (Lang et al.,1995).

Summarizing the strengths and shortcomings,DUS is non-invasive, repeatable at any time withdynamic evaluation and documentation of venousfunction even on inflammated skin which is oftenpresent in chronic venous insufficiency and maybe a contraindication to intravenous injection.Beyond this, it avoids the risks and side effects ofradiation and application of contrast media, but itis dependent on the experience of the examiner,may be time consuming for evaluation of the deepvenous system and also painful over extensiveskin ulcers. An advantage of phlebography maybe imaging of larger areas of interest, i.e. thelower leg with measurable distances between sin-gle pathological findings. SEPS, in the first place,is a therapeutic procedure with excellent view andlocalisation of perforating veins on the lower legexcept the very distal localisations as mentionedabove, although evaluation of morphology andfunction of the veins to be dissected may betermed subjective. On the other side, no harm willemerge for the patient by dissection of few com-petent perforating veins in addition.

In conclusion, the results of this study demon-strate that diagnosis and localisation of incom-petent medial calf perforator veins can beaccomplished by DUS with equal accuracy incomparison with phlebographic imaging. In com-bination with an exact evaluation of the epifascialand deep venous system, DUS is well suited forplanning varicose vein surgery, each surgeon mayget crucial informations for planning varicose veinsurgery by himself to study flow pattern of refluxwithout injection of contrast medium. In addition,postoperative follow-up is easily performed, e.g.to detect recurrent or residual incompetent perfo-rator veins.

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References

Becker D, Gunter E, Strauss R, et al. Color doppler imagingversus phlebography in the diagnosis of deep leg and pelvicvein thrombosis. J Ultra Med 1997;16:31–7.

Browse NL. The etiology of venous ulceration. World J Surg1986;10:938–43.

Grabs AJ, Wakely MC, Nyamekye I, Ghauri ASK, PoskittKR. Colour duplex ultrasonography in the rational man-agement of chronic venous leg ulcers. Br J Surg1996;83:1380–2.

Hach and Hach-Wunderle V, 1994. Phlebographie der Bein-und Beckenvenen. Schnetztor: Konstanz.

Hanrahan LM, Araki CT, Ficher JB, et al. Evaluation of theperforating veins of the lower extremity using highresolution duplex imaging. J Cardiovasc Surg 1991;32:87–97.

Jugenheimer M, Junginger Th. Endoscopic subfascial section-ing of incompetent perforating veins in the treatment ofprimary varicosis. World J Surg 1992;16:971–5.

Lang W, Bockler D, Meister R, Schweiger H. Endoscopicsectioning of perforating veins. Chirurg 1995;66:131–4.

O’Donnell TF, Burnand KG, Clemenson G, Thomas ML,Browse NL. Doppler examination versus phlebographicdetection of the location of incompetent perforating veins.Arch Surg 1977;112:31–5.

Padberg FT, Pappas PJ, Araki CT, Back TL, Hobson RW.Hemomodynamic and clinical improvement after superfi-cial vein ablation in primary combined insufficiency withulceration. J Vasc Surg 1996;24:711–8.

Phillips GW, Cheng LS. The value of ultrasound in theassessment of incompetent perforating veins. Australas Ra-diol 1996;40:15–8.

Pierik EGJM, Wittens CHA, vanUrk H. Subfascial endo-scopic ligation in the treatment of incompetent perforatingveins. Eur J Vasc Surg 1995;9:38–41.

Pierik EGJM, Toonder IM, vanUrl H, Wittens CHA. Valida-tion of duplex ultrasonography in detecting competent andincompetent perforating veins in patients with venous ul-ceration of the lower leg. Vasc Surg 1997;26:49–52.

Schultheiss R, Billeter M, Bollinger A, Franzeck UK. Com-parison between clinical examination, cw-Doppler ultra-sound and colour-duplex sonography in the diagnosis ofincompetent perforating veins. Eur J Vasc Endovasc Surg1997;13:122–6.

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