Chapter 4 - Gastrocnemius Reflux - Does it Really Matter?

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Welcome to the Vein Experts Online Educational CME Program.

Original Release Date: 6/6/13

Termination Date: 1/31/2016

Price: 25.00 for Vein Experts Members & $40.00 for Non-Members - Processing/CME Fees Accreditation:

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of The University of Toledo and VeinExperts.org. The University of Toledo is accredited by ACCME to provide continuing medical education for physicians. The University of Toledo designates this enduring activity for a maximum of 1.00 AMA PRA Category Credits™. Physicians should claim only credit commensurate with the extent of their participation in the activity. For nurses, we are also able to issue a certificate of attendance stating the course is AMA approved, which may be eligible for credit. Nurses are responsible for submitting the certificate to their board. Please note only one certificate can be issued for each purchase. Disclosure: Ronald Bush, MD, FACS, faculty and planning member discloses he is on the Speaker’s Bureau for Dornier/Refine USA and is employed by Midwest Vein & Laser Center. Richard L. Mueller, MD, faculty and planning member, discloses he receives grant/research support from Vascular Insights, LLC Peggy Bush, APN, planning member, has no disclosures or financial interests and is employed by Midwest Vein & Laser Center.

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Becky Roberts, planning member, has no financial interest or other relationships with any manufacturer of commercial product or service to disclose. Mission: Our objective is to provide current evidence based information, as well as new technology that is being developed for the treatment of venous disease presented in a virtual format. Target Audience: The target audience for this activity includes physicians and other health care professionals in Cardiology, Dermatology, Interventional Radiology, Phlebology, Surgery, Vascular Surgery, Wound Care Specialists who care for patients with venous disease.

CME Credit Instructions Steps to successfully complete this activity:

CME Credit Instructions Steps to successfully complete this activity:

1. Register for CME activity & pay your CME fees. 2. Read the Vein Journal entitled ‘Gastrocnemius Reflux – Does it

Really Matter’? 3. Take the post test (score of 80% or greater must be achieved. (A pdf

copy of the exam can be emailed to you if requested). 4. Scan and email post test and evaluation to [email protected] or

you can fax completed paperwork to 937-281-0200. 5. You will be contacted by the University of Toledo CME office for

instruction of how to sign on and print your certificate.

Technical Support

Email your questions/concerns to [email protected] or you can call us at 407-900-8346 and we will respond in 24 hours.

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Gastrocnemius Reflux – Does it Really Matter?

5/29/13

Ronald Bush, MD, FACS

Peggy Bush, APN, CNS, MSN

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This activity describes the gastrocnemius veins and their role in chronic venous disease.

Learning Objectives:

As a result of this activity, the participant should be able to: 1) Recognize the role of gastrocnemius vein in chronic venous insufficiency. 2) Recognize common patterns of clinical presentation and treatment options in gastrocnemius vein reflux. 3) Recognize different anatomical patterns of the gastrocnemius veins. 4) Recognize the most common manifestation – gastrocnemius vein perforator. 5) Recognize the value of ultrasound guided foam sclerotherapy.

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Ronald Bush, MD, FACS

Peggy Bush, APN, CNS, MSN

Gastroc Anatomy

• There is a mean of 4.6 veins per muscle

• In a study by Aragao, 2006, 80% of gastrocnemius trunks

drained into the popliteal vein

• Main gastrocnemius venous trunks usually contain one valve

• Approximately 35% contain no valves, although the muscle

branches do

(Aragao, 2006)

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This image demonstrates the gastrocnemius vein with the medial head

retracted.

View abstract ‘Anatomical study of the gastrocnemius venous

network and proposal for a classification of the veins.’

Anatomy

• The following slide demonstrates four variations of

gastrocnemius vein anatomy as determined by (Aragao, et al,

2006)

• What is important to remember is that most of the anatomical

presentations are Type 1

• For the most part, what is visible & important on US is the main

gastrocnemius vein trunk

• If pathology is present, it is usually at this location

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(Aragao, 2006)

Gastrocnemius vein anatomy

• The terminal branches are labeled the axial portion

• This is the final avenue before termination into the popliteal vein

• 35% of axial veins do not contain valves

• If the popliteal or SSV reflux, then reflux may also be seen here

• Medial gastrocnemius vein is more commonly affected by

pathology

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This widely referenced study showed a 29% incidence of

gastrocnemius vein reflux in a cohort of 483 patients. In my

experience, this is not the case, as will be described later.

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Gastrocnemius Reflux

• The two previous studies show a wide variation in the incidence

of gastrocnemius vein reflux

• (Labropoulos, 1995) has shown an incidence of 10%

• The reasons for wide variations may be attributable to technique

and diligence of examination

• Population variations may be responsible

• But does it really make any difference….read on!

How May Gastrocnemius Vein Reflux Present?

1) Isolated – Contained within the vein itself

2) Associated with SSV or popliteal vein reflux

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3) Associated with a perforator and superficial varicosities (Most

common in my experience)

4) Connected to the GSV

(www.veineperts.org,!2013)!

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(www.veineperts.org,!2013)

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(www.veineperts.org, 2013)

Gastrocnemius Vein Reflux

• In instances where the gastrocnemius vein reflux is associated

with insufficiency of the SSV, thermal or chemical ablation

should result in cessation of the gastrocnemius vein reflux

• Popliteal venous reflux associated with gastrocnemius reflux is

probably secondary to lack of valve in axial trunk

• In this instance, the pathophysiology is related to popliteal

venous reflux

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• In instances where the gastrocnemius vein reflux is associated

with a refluxing GSV, cessation of reflux will occur after ablation

of the saphenous vein or interruption of the communication from

the GSV to the gastrocnemius vein

• This situation has been reported to occur in some patients with

venous ulceration

Contained Gastrocnemius Vein Reflux

• In instances where the gastrocnemius is contained and is not

associated with either a perforator or SSV reflux the treatment

depends on the symptomatology

• If symptoms exist, it is usually calf swelling, tenderness and

possible venous claudication

• Only treatment described to date is surgical – See following slide

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Isolated Gastrocneimus Vein Reflux

• Symptoms are calf tenderness & swelling

• Venous claudication may occur

• In this situation, there is ‘no escape valve’

• Visible varicosities will not be present

• This requires a therapeutic decision based on size of vein and

size of communication to the popliteal vein

• In effect, is there a saccular aneurysm of the popliteal vein?

• We know from history of gastrocneimus vein thrombosis after

sclerotherapy, there is no need for treatment

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Gastrocnemius Reflux

! The two previous studies show a wide variation in the incidence

of gastrocnemius vein reflux

! Labropoulos, 1995 Has shown an incidence of 10%

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Gastrocneimus Reflux

• In over 7,000 patients that I have personally performed

ultrasounds on, I find the incidence of gastrocneimus muscle

vein reflux much lower than what is reported

• In order to define gastrocneimus reflux, it is necessary to

categorize the pathophysiology and clinical presentation

• If there is an associated perforator with or without SSV and

popliteal insufficiency…the treatment is to foam the perforator in

association phlebectomies or foam sclerotherapy to the varices


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Gastrocneimus Vein Reflux

• Not uncommonly gastroc vein reflux is associated with superficial

reflux in the GSV or SSV

• SSV reflux can produce reflux into gastroc veins that lack

valves…in this situation, correction of SSV reflux is totally

curative

• GSV reflux, by way of perforator, can also cause gastroc vein

reflux

• Correct all superficial reflux first

• Correction of superficial venous reflux may correct segmental

DVR in up to 50% of cases

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So What Do You Do With Gastrocneimus Vein Reflux?

• If it is asymptomatic, which many are, do nothing

• If superficial venous reflux is present, correct it and gastroc

reflux will abate

• If a perforator is associated, do foam sclerotherapy and

phlebectomy

• If superficial reflux has been corrected and symptomatic gastroc

muscle vein reflux persists, then therapy depends on the size of

the vein and the connection to the popliteal vein

• Foam sclerotherapy is appropriate if the connection to the

popliteal vein is small

•

So What Do You Do With Gastrocneimus Vein Reflux?

• If symptomatic gastrocneimus vein reflux persists after all the

above corrections have been done and the diameter of the

connection is > 4 mm, then surgical ligation should be

considered

• Although doing this will result in at least a 50% recurrence rate

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References Aragao JA, Reis FP Pitta GB, Miranda F Jr, Poli de Figueiredo LF. Anatomical study of the gastrocnemius venous network and proposal for a classification of the veins. Eur J Vasc Endovasc Surg. 2006 apr;31(4):439-42. Garcia-Gimeno M, Rodriguez-Camarero S, Tagarro-Villalba S et al. Duplex mapping of 2036 primary varicose veins. J Vasc Surg. 2009 Mar;49(3):681-9. Hobbs J T, Vandendriessche W. Incompetence of the gastrocnemius vein. Phlebology. 2004 19(2):57-64. Images retrieved online from http://www.veinexperts.org. Juhan C, Barthelemy P, Alimi Y, Morati N, Lelong B, Dominguez M, Flori A. Prevalence of gastrocnemius vein insufficiency using color-coded Doppler ultrasound (modifications of the therapeutic strategy). Bull Acad Natl Med. 1993 Feb;177(2):233-9;discussion 240-1. Juhan C, Barthelemy P, Alimi Y, Di Mauro P. (Recurrence following surgery of the gastrocnemius veins). J Mal Vasc. 1997 Dec:22(5):326-9. Labropoulos N, Delis KT, Nicolaides AN. Venous reflux in symptom-free vascular surgeons. J Vasc Surg. 2995 Aug;22(2):150-4. Perrin M, Gillet, J. Management of recurrent varices at the popliteal fossa after surgical treatment. Phlebology. 2008;23(2):64-8. !!!

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Complete the exam & evaluation below and email your results

to [email protected] along with your contact information.

A score of 80% or greater must be achieved on the post-test

and be completed in less than 3 attempts.

Chapter 4 – Gastrocnemius Reflux – Does it Really Matter?

1. Most gastrocneimius veins drain into:

a. SSV

b. Popliteal vein

c. Variable branch anatomy, precludes definitive

determination

2. The incidence of gastrocnemius reflux in the general population

is:

a. 35%

b. Decreases with popliteal insufficiency

c. Wide variation exists in literature and in patient

populations

3. In patients with gastroc reflux and associated perforator:

a. Ligate perforator through a posterior approach

b. Foam sclerotherapy to the perforator

c. Laser ablation of the perforator as long as post tibial nerve

is > 2cm from perforator

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4. In patients with isolated gastro reflux that is symptomatic:

a. Always do open approach with ligation

b. Foam sclerotherapy is contraindicated

c. Treatment depends on size of communication between

gastroc vein and popliteal vein

5. In patients with SSV reflux and gastrocnemius vein reflux:

a. Reflux usually ceases after SSV thermal ablation

b. Reflux in gastrocnemius vein unchanged for most part

c. The lateral gastrocnemius vein more more commonly

affected

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Chapter 4 - Gastrocnemius Reflux - Does it Really Matter?