Journal of Vascular Surgery
Volume 43, Issue 2 , Pages 327-334, February 2006

Presentation of the patient with recurrent varices after surgery (REVAS)

  • Michel R. Perrin, MD

      Affiliations

    • Clinique du Grand Large, Decines, France
    • Corresponding Author InformationReprint requests: Michel Perrin, MD, Vascular Surgery, 26, Chemin de Decines F - 69680 Chassieu, France
    • ,
  • Nicos Labropoulos, PhD, DIC, RVT

      Affiliations

    • Department of Surgery, Loyola University Medical Center, Maywood, Ill
    • ,
  • Luis R. Leon Jr, MD, RVT

      Affiliations

    • Department of Surgery, Loyola University Medical Center, Maywood, Ill

Received 1 June 2005; accepted 19 October 2005.

Article Outline

Aim

To identify in patients with recurrent varices after surgery (REVAS) the clinical, etiologic, anatomic, and pathophysiologic patterns according to the CEAP classification, as well as the site, source, causes of recurrence, and contributory factors by using the REVAS classification.

Methods

Centers from eight countries enrolled patients with superficial vein reflux that had had a previous operation. A physical examination and a duplex ultrasound scan were performed at the first visit. This was repeated between 2 to 8 weeks after by the same physician and by another physician within the same time frame. The perforator, deep, and superficial veins systems as well as their accessories and tributaries were examined. A form based on the CEAP and the REVAS classification was used and the data were entered in a customized database.

Results

Fourteen institutions enrolled 170 patients (199 lower limbs) in 1 year. Their mean age was 56 years, and 69% were women. Most of them had undergone one surgical procedure before enrollment (76.6%). Most had varicose veins and swelling (70.9%), and the rest had skin damage (29.1%). More than 90% had primary etiology. The saphenofemoral junction (47.2%) and leg perforators (54.7%) were the areas most often involved by recurrent reflux. Reflux in deep veins was detected in 27.4%. Class 2 (varicose veins) alone was present in 24.6% of limbs, two classes were present in 43%, and three in 24%. Neovascularization was as frequent as technical failure (20% vs 19%); both were seen in 17%. In 35%, the cause was uncertain or unknown. When recurrence occurred at a different site, development of reflux in new sites was found in 32% of limbs. Of the contributing factors, family history and lifestyle had the highest prevalence. Women had significantly more procedures than men, despite a clear trend toward more severe disease in the latter.

Conclusions

Most patients were symptomatic with several clinical forms of presentation. The REVAS classification, together with CEAP, gives significant and more appropriate information for evaluating and following-up patients with chronic venous disease who have had an intervention.

 

Residual and recurrent varicose veins are a common problem after interventions to correct reflux in patients with chronic venous disease (CVD). 1 In 1998, an international consensus group met in Paris and developed a classification for patients with recurrent varices after surgery (REVAS) 1 to be used in complement with the CEAP classification. 2 REVAS is a clinical definition that includes true recurrences, residual refluxing veins, and varicose veins caused by progression of the disease. Until the CEAP and REVAS classifications, it was difficult to report these occurrences. The frequency of REVAS has been reported to be between 20% and 80%, depending on the definition of the condition and the duration of the follow-up. 1 The current data in the literature suffer from the lack of uniformity when defining recurrences, and different lengths of follow-up and methods used for pre- and postoperative assessment make this assessment difficult.

This study was designed to identify in patients with REVAS (1) the clinical, etiologic, anatomic, and pathophysiologic patterns according to the CEAP classification, and (b) the site, source, causes of recurrence, and possible contributory factors according to the REVAS classification.

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Patients and methods 

Multiple centers from different countries were selected for the study. These centers were chosen for their long-standing experience in diagnosing and treating patients with CVD. All patients were consecutive and had a previous operation and therefore could be classified according to REVAS. These patients were not asked to come to the vascular clinic, but they presented to the different centers seeking advice for their signs and symptoms of CVD. All patients presented with at least varicose veins.

A form based on the CEAP and the REVAS classification was filled in at the first assessment, which included a physical examination and a duplex investigation. The REVAS form was completed again 2 to 8 weeks after the first examination by the same physician and by another physician within the same time frame.

The CEAP classification can be used in two ways. In the basic CEAP, only the single highest class of the C is used; and only the first descriptor is used for E (etiology), A (anatomy), and P (pathophysiology). In the advanced CEAP, all the signs described in the clinical classes are provided, and for A or P (or both) the 18 named venous segments are used to locate venous pathology.

The duplex investigation was performed at each investigation. Investigations were performed either by technologists (in most cases) or by the investigator. The physicians had a written report and images when they completed the REVAS form. As the patients in this study were evaluated twice (duplex scan and clinical exam), information concerning the reproducibility of the data collected was assessed. These data have been currently submitted to the European Journal of Vascular and Endovascular Surgery.

Most of the patients consulting for REVAS in this study had previous operations in other centers. Often it was impossible to know precisely the type of the procedure performed because the time elapsed between the last operation and the inclusion in the survey varied from 1.8 to 692 months (average, 136 months). Consequently, any type of surgical procedure was included such as ligation, stripping, and phlebectomy. Endovenous laser and radiofrequency ablation were not included.

The clinical significance of reflux was determined in a subjective manner by the physician as it was described in original publication of REVAS. 1 Clearly, it is not easy to quantify the degree of reflux from various sites. The significance of reflux was based on the estimate from the duplex scanning (DS) information and the physicians’ evaluations of how the degree of reflux related to the overall clinical situation. R+ was used for clinical significance probable, R– for clinical significance unlikely, and R? for clinical significance uncertain. For example, a patient who had varicosities but only knee pain was classified as R–, whereas a patients with calf varicosities and swelling and pain around the involved area was classified as R+.

Technical failure was defined as an incorrect procedure, mostly nonflush ligation of the saphenofemoral or saphenopopliteal junctions (SFJ, SPJ) that could be identified easily by DS investigation. The presence of a stump at the previous SFJ or SPJ with refluxing tributaries connecting to these junctions was classified as a technical failure.

Neovascularization was identified on DS as the presence of reflux in thin, serpentine veins in previously ligated SFJ or SPJ. No quantitative criteria (size of the vessels) were used.

Imaging was performed in the different centers by using linear array transducers. The method of evaluating reflux in the superficial, 3 tributary, 4 perforator, 5 and deep 6 veins has been previously described. Briefly, the femoropopliteal, deep calf veins, the great (GSV) and small saphenous (SSV) and nonsaphenous veins, as well as their accessories and tributaries, were examined with the patient in the standing position. Veins that were not a part of the GSV or SSV were termed nonsaphenous. 7 Reflux in the recurrent or residual varicose veins was defined as a retrograde flow >0.5 seconds. 8 Patients often had to rotate to trace these veins circumferentially and encompass all their trajectories. The distribution and extent of reflux in these veins and their tributaries, as well as their connections with perforating and deep veins, were recorded in detail.

The REVAS form (Fig) includes six items: T is for topographic sites of REVAS; S is for sources of reflux; R is for degree of reflux; N is for nature of sources (Nss for same site of previous surgery and Nds for different sites); P is for contribution from a persistent incompetent saphenous trunk; and F is for possible contributory factors Fg for general and Fs for specific factors). 1

All the recorded information was sent to the core center in Clinique du Grand Large, Decines, France. All data were entered in a customized database designed for the study.

Statistical analysis 

Analysis of the patients’ characteristics was performed by descriptive statistics. Differences in proportions were analyzed with the χ2 test, the likelihood ratio, and trend analysis. Fisher’s exact test was used when the expected value in any cell was <5. The difference in age was compared with unpaired t test. The statistical significance was set at P = .05.

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Results 

Fourteen institutions from eight countries enrolled 170 patients (199 lower limbs) in 1 year. Their mean age was 55.6 ± 12 years (SD) (range, 27 to 82 years) and 69% were women. Most of these patients had undergone one surgical procedure before enrollment (76.6%), 21.9% had two procedures, and 1.5% had three. High ligation, stripping, and phlebectomies were the main interventions performed. The mean time between the last surgical intervention and office consultation was 136 months (range, 1.8 to 692 months).

The clinical, etiologic, anatomic, and pathophysiologic characteristics of this cohort are summarized in Table I. Most patients had varicose veins and swelling (70.9%), and the rest had skin damage (29.1%). More than 90% had primary etiology. By definition from the study design, all patients had superficial vein involvement, and their pathophysiology was reflux. Reflux in perforator veins was detected in 54.7% and in the deep veins in 27.4%. With the advanced CEAP classification, more information can be given in the clinical class as presented in Table II. Only one quarter presented with class 2 alone, and two clinical classes were present in 43%, three in 24%, and four classes in 9% of limbs. Symptoms were more likely to be present in classes 3 to 6 compared with class 2 (Table III).

Table I. Classification of limbs according to basic CEAP
C⁎n (%)E †n (%)An (%)Pn (%)
00(0)EC8(4)AS70(35.3)R190(95.4)
10(0)EP181(91)AS+P74(37.3)O0(0)
299(49.8)ES10(5)AP0(0)R+O9(4.6)
342(21.1)EP+S0(0)AS+D20(10)
439(19.5) AD0(0)
515(7.6) AS+P+D35(17.4)
64(2)
Total limbs: 199

C, Clinical classification; E, etiologic classification (EC, congenital; EP , primary; E S , secondary); A, anatomic classification (A S , superficial; A P , perforator; A D , deep); P, pathophysiologic classification (R, reflux; O, obstruction); n, number of patients.

⁎ Symptoms were present in 76.8%.

† EP was found in 125 women and 45 men (P < .001), ES in 5 women and 4 men, and EC in 1 woman and 7 men (P < .001 when ES and EC are combined).

Table II. Clinical classification using advanced CEAP
Clinical classNumber of limbsPercentage
C24924.62
C2,C621.01
C2,C552.51
C2,C4115.53
C2,C3189.15
C2,C3,C610.50
C2,C3,C510.50
C2,C3,C484.02
C1,C25025.13
C1,C2,C531.51
C1,C2,C4105.03
C1,C2,C32412.16
C1,C2,C3,C610.50
C1,C2,C3,C563.02
C1,C2,C3,C4105.03
Total199100
Table III. Association between symptomatology and CEAP class C
AsymptomaticSymptomaticTotal
C230(15.6)62(32.3)92(47.9)
C3-610(5.2)90(46.9)100(52.1)
Total40(20.8)152(79.2)192(100.0)

C2 vs C3-C6 for the presence of symptoms P = .0001.

The numbers in parenthesis are percentages of the total number at the last column.

Reflux was identified at the groin region in 37% of cases, at the thigh in 68%, at the popliteal fossa in 23%, at the lower leg in 85%, and in other areas in 11%. The different sources of reflux are summarized in Table IV. The SFJ and leg perforators were the areas most frequently involved by recurrent reflux. This reflux was found to be of probable clinical significance in 164 limbs (82%), unlikely to be significant in 20 (10%), and its clinical importance was uncertain in 15 (8%). One or two sources of reflux were identified in 68% of patients and more than two in 22%.

Table IV. Sources of reflux
Number of limbsPercentages
Source of reflux
No source199.55
Pelvic or abdominal3316.58
Saphenofemoral junction9447.24
Thigh perforators6030.15
Saphenopopliteal junction4924.62
Popliteal perforators94.52
Gastrocnemial veins178.54
Lower leg perforators8542.71
Sources of reflux-number
Unknown199.55
17336.68
26331.66
32914.57
4147.04
510.5
Total199100

When the recurrence occurred on the same site of a previous operation, the cause was ticked uncertain in 20%, mixed in 17%, and unknown in 14%. The numbers for technical failure, tactical failure, and neovascularization were, respectively, 19%, 10%, and 20%. When the varices were present on the site not previously operated on (different site), the answers were persistent (known to have been present at the time of previous surgery) in12%, new (known to have been absent at the time of previous surgery) in 32%, uncertain/unknown in 21%, and information was not given in 35%.

Ultrasound assessment of the sources of reflux and their nature was performed (Table V). Technical or tactical failure accounted for 29% of all recurrences at the same site, and neovascularization was found to be responsible for 20%. When a different site of reflux was diagnosed, newly incompetent segments were found in 32% of cases.

Table V. Nature of sources
SiteNatureNumber of limbsPercentages
SameTechnical failure3819.1
Tactical failure199.6
Neovascularization4020.1
Uncertain3919.6
Mixed3316.6
Unknown3015.1
DifferentPersistent2311.6
New6331.7
Uncertain/unknown4221.1
Info not given7135.7

Persistent reflux in the above-knee GSV was found in 78 limbs (39.2%), in the below-knee segment in 60 (30.2%), in the SSV in 48 (24.1%), and in nonsaphenous trunks in 73 (36.7%). The below-knee saphenous trunks had a higher prevalence than did the above-knee (P < .01).

Of the possible contributing factors (Table VI), family history and lifestyle had the highest prevalence. Multiple factors were present in many patients, however. One factor was present in 99 limbs (49.25%), and the rest had multiple factors.

Table VI. Possible contributory factors
Factor typeFactorNumber of limbsPercentages
GeneralNone3115.4
Family history13567.8
Lifestyle factors8542.7
Obesity4723.6
Pregnancy2110.6
Contraceptives115.5
SpecificPrimary deep reflux2412.1
Calf muscle pump dysfunction2010.1
Post-thrombotic syndrome105.0
Angiodysplasia52.5
Lymphatic insufficiency10.5

Gender had a significant influence on the number of procedures performed. Women had a significantly higher number of procedures than men, despite a clear trend toward more severe disease in male patients (Table VII).

Table VII. Gender, number of procedures, and disease severity
Males (%)Females (%)Total (%)
Number of procedures
149(84.5)95(72.5)144
27(12.1)36(27.5)43
32(3.5)0(0)2
Total58131189
P = .006
Disease severity
C225(13.4)72(38.5)97(51.9)
C39(4.8)31(16.6)40(21.4)
C414(7.5)21(11.2)35(18.7)
C57(3.7)4(2.1)11(5.9)
C61(0.5)3(1.6)4(2.1)
Total56(29.9)131(70.1)187(100.0)

χ2 for trend, P = .049; likelihood ratio, P = .064.

Perforator vein and SSV trunk incompetence were associated with a greater number of procedures; conversely, the presence of symptoms and deep vein abnormality were not (Table VIII).

Table VIII. Number of procedures, presence of symptoms and perforator, small saphenous vein trunk incompetence, and deep vein involvement
1(%)2(%)3(%)Total
Perforator vein
No79(88.8)10(11.2)0(0)89
Yes73(66.4)34(30.9)3(2.7)110
Total152443199
P = .0008
SSV
Yes29(60.4)18(37.5)1(2.1)48
No123(81.5)26(17.2)2(1.3)151
Total152443199
P = .011
Symptoms
Symptomatic115(75.7)34(22.4)3(2.0)152
Asymptomatic31(77.5)9(22.5)0(0)40
Total146433192
P = .669
Deep vein
Yes41(74.6)14(25.5)0(0)55
No111(77.1)30(20.8)3(2.1)144
Total152443199
P = .458

SSV, Small saphenous vein.

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Discussion 

Recurrence is common after varicose vein surgery. Van Rij et al 9 prospectively studied 92 consecutive patients with symptomatic varicose veins that required superficial vein surgery. Recurrence was seen in 14% of limbs at 3 months, 32% at 1 year, and 52% after 3 years. A uniform identification of the causes and patterns of recurrence has not been reported, however. Disparate results have often been found, mainly because of the lack of consistency in defining recurrence, initial therapy, and the method and duration of follow-up.

This prompted a consensus meeting led by one of the authors (M. P.) in 1998 that proposed guidelines for REVAS. Only one report so far has been published using these guidelines. Kostas et al 10 studied 113 operated legs and found a 25% recurrence rate in a 5-year follow-up. Because of the small sample size with recurrences (n = 28), only a descriptive analysis was performed.

The mean age (55 years) of patients in our study was higher than that in previous reports. Labropoulos et al 11 found among 90 patients before surgical intervention a mean age of 49, and Kostas et al 10 found a mean age of 48 years. This is not surprising, because patients who seek treatment after their first intervention are likely to be older as a significant time elapses for the recurrence of the disease.

Clinical grade based on CEAP system was higher in men, but women underwent significantly more interventions. Those differences may be explained by the fact that women care more about the appearance of their legs than men and seek medical advice at an earlier stage. Women also had a higher primary and lower congenital etiology compared with men as seen in Table I. A possible explanation for the higher congenital etiology is the male preponderance in cases of Klippel-Trenaunay syndrome. 12, 13

The use of the advanced CEAP is more appropriate for REVAS patients as it allows a more defined description and better comparison among different patient groups. This is evident from Table I, Table II, where in the latter the whole clinical spectrum of the disease is given for each limb. For example, the advanced CEAP system offers the ability to identify patients with varicose veins only, which in our patients was 25%. Likewise, edema was present in 35% of REVAS limbs, whereas when the basic system was used, many cases of limb edema were missed (21% only). The basic CEAP provides limited and inaccurate information.

Most of the REVAS patients were symptomatic (77%). Labropoulos et al 11 reported a 85% prevalence of symptomatic nonoperated limbs. Kostas et al 10 reported a 72% prevalence of symptomatic operated limbs. Although early after intervention the prevalence of symptoms should be lower, in our study it was high owing to the long follow-up period. The presence of symptoms was not related to a higher number of interventions.

The number of REVAS patients consulting for skin changes was higher than that of patients screened for epidemiologic studies who had varices and had not been operated on. Carpentier et al 14 found a 2.8% occurrence of skin changes in women and 5.4% in men in a random sample of 835 subjects in the general population in France. Kaplan et al 15 reported a 6.3% prevalence among 2404 patients screened in the San Diego study who had a similar mean age with our cohort. However, patients who are referred to clinics seeking treatment may have a similar prevalence of skin damage compared with the REVAS patients. Labropoulos et al 11 found a prevalence of 25% (29/116), which was comparable to the 29% (58/159) in the current study (P = .5). The preponderance of skin changes in the REVAS patients may be due to their older age (49 vs 55.6 years, P < .01).

Pelvic or abdominal reflux was detected in 17%. The prevalence of this reflux is not known. Its frequency may be higher in this study than is usually seen because one of the centers has many referrals. Nonsaphenous vein reflux is found in about 10% of people presenting with CVD. 8 Often, tributaries of such veins in the leg are thought to be part of the saphenous system, and technical and tactical failure can occur. In REVAS patients, the higher occurrence was expected given that 70% of our patients were women, who have significantly higher prevalence of nonsaphenous veins than men. 8

Reflux was present in the SFJ in 47% of cases. Up to 60% of limbs of patients surviving >30 years after ligation and stripping demonstrate incompetence at or near the SFJ. 16 This has been attributed to neovascularization, to failure in ligating the SFJ, or to overlooked junctional tributaries. In our study, neovascularization occurred as often as incorrect ligation (20% and 19% respectively).

Perforator incompetence was identified in 55% of REVAS limbs. Reflux in these veins is very common and has been described in many studies. Labropoulos et al 17 showed that 57% had incompetent perforator veins among 134 REVAS limbs. In a prospective study of patients operated on for varicose veins, van Rij et al 9 found that reflux in perforator veins increased progressively. The same group 13 studied 822 incompetent perforators after intervention. At a 3-year follow-up, 397 incompetent perforators were noted, with the main cause for recurrence being changes in pre-existing perforators in other locations, followed by neovascularization at sites of ligation and a very small number of missed vessels. Furthermore, the number of incompetent perforators correlated significantly with the clinical severity of the disease.

The exact cause of reflux has been subject of intense debate. Poor surgical technique 18 and neovascularization were the most common reasons accounting for most cases of REVAS. 19 Neovascularization accounted for 20% of REVAS cases in our series when reflux was identified in the same site and technical or tactical failure for 29%.

The item concerning the nature of sources was difficult to complete, as the investigators did not always have information on the previous interventions. Consequently, the answers uncertain, unknown, or information not given were frequently notched. Only a prospective study using the REVAS classification can provide accurate information.

The below-knee saphenous trunks had a higher prevalence of reflux compared with the above knee. This is because the GSV is most often stripped to the knee level, and the SSV is often ligated without stripping. High prevalence of recurrent GSV varicosities in the thigh can be attributed to ligation of the SFJ without stripping. It has been shown that GSV stripping correlates with less recurrence in long-term follow-up. 17

Reflux recurrence in the popliteal region has been attributed to insufficient excision of an incompetent SSV. Among REVAS patients, SSV reflux was responsible for 29% of cases. 17 An analysis of 125 popliteal interventions for REVAS after excision of an incompetent SSV identified 14% of patients with an intact SSV. 20 A retrospective study 21 of 59 patients after saphenopopliteal junction (SPJ) disconnection revealed that 47% had reflux after the operation because of tactical or technical failure at the SPJ and persisting superficial vein incompetence. The survey by the Vascular Surgical Society of Great Britain and Ireland showed a wide variation in the management of SSV owing to the lack of proper clinical trials in this area. 22

Gastrocnemial vein incompetence has a prevalence of up to 30% among patients with varicose veins. 23 Most practitioners do not treat this vein. Also, incompetent perforators through this vein at the posteromedial calf may be overlooked or missed.

Calf muscle dysfunction may cause recurrence or persistence of ulcerations. 24, 25 Rhodes et al 26 demonstrated significantly lower hemodynamic improvement in calf muscle pump function with perforator interruption alone than when performed with concomitant saphenous ablation. However, no specific test was used for identifying calf pump failure in our study other than known joint and muscle problems and, therefore, some cases may have been missed.

Multiple factors contribute in the development of recurrent disease. The weight of each factor has not been determined, as there are no prospective studies with adequate sample size. Family history of venous disease had by far the highest prevalence (68%), however. This is not surprising, as a prominent role of heredity in the development of venous disease has been shown. 27

A higher number of procedures were performed in our patients with perforator vein and SSV incompetence. These findings may be explained by the fact that perforator veins can be easily missed on preoperative assessment. Gloviczki et al 28 found a 30% rate of persistent or new incompetent perforator veins in 30 patients at a mean time of 16 months after surgery (1 to 50 months). Neovascularization and the development of new veins from dilatation of those missed at surgery have been proposed as the most likely mechanisms. 13, 29, 30 Van Rij and Hill, 13 in a 3-year follow-up, identified 397 recurrent incompetent veins that were most often in the medial paratibial compartment. Changes in pre-existing perforator veins at other sites were responsible for 61% of cases, followed by neovascularization in 35%, and inadequate surgery accounted for only 0.4%.

Small saphenous vein reflux has been recognized as an important cause of CVD. 31 Iafrati et al 32 recognized that a more conservative attitude to treat SSV reflux was a contributor for CVD recurrence after surgical intervention. Inaccurate preoperative duplex examination and surgeons’ bias towards certain types of surgical interventions might have a role in our recurrence rates.

Deep vein involvement was not associated with a higher number of procedures. The importance of deep venous reflux in CVD has been better identified only recently, and the benefit of deep reconstructive surgery remains controversial. 33 This type of surgery is only performed by very few selected centers worldwide; therefore, patients with deep vein reflux may have not been adequately treated in most centers in our study.

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Conclusion 

Most patients were symptomatic with various clinical patterns of presentation. There was female preponderance for primary CVD and number of interventions. The use of the advanced CEAP is more appropriate for the REVAS patient. The sources of reflux feeding the recurrence were of multiple origins, and present at the SFJ in almost half of the patients. Ten percent had no apparent source of reflux; in 17%, it was of pelvic or abdominal origin. About 75% of limbs have incompetent perforator veins. Neovascularization was as frequent as technical failure (20% vs 19%), and a combined presentation was found in 17%. In 35% of cases, the cause was uncertain or unknown. When recurrence occurred at a different site, development of reflux in new sites was found in 32% of limbs. The use of the REVAS classification together with CEAP gives significant information for evaluating and following-up patients with CVD who underwent an intervention.

REVAS group 

Coordinator 

Michel Perrin, France.

Investigators 

USA: Nicos Labropoulos, Robert F Merchant and Jay Murray; Spain: Marc A. Cairols, Javier Leal Monedero and Jordi Maeso y Lebrun; Italy: P.L. Antignani and Ugo Baccaglini; France: R. Milleret and Philippe Nicolini; Argentina: Ermenegildo Enrici; Portugal: C. Pereira Alves; Canada: Louis Grondin; Belgium: I. Staelens.

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Author contributions 

Conception and design: M.P.

Analysis and interpretation: M.P., N.L., L.R.L.

Data collection: M.P., ore center

Writing the article: N.L., L.R.L.

Critical revision of the article: M.P., N.L., L.R.L.

Statistical analysis: N.L.

Obtained funding: M.P.

Overall responsibility: M.P.

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References 

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 Competition of interest: none.

PII: S0741-5214(05)01881-1

doi:10.1016/j.jvs.2005.10.053

Journal of Vascular Surgery
Volume 43, Issue 2 , Pages 327-334, February 2006

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