The treatment of a refluxing perforator is indicated in the setting of severe chronic venous insufficiency, but there are limited data on the presence of multilevel disease in these patients. This study sought to evaluate whether the presence of a pathologic perforator is predictive of the presence of central venous pathology.

This study was a retrospective review of the institutional vascular quality initiative (VQI) database. Consecutive patient-limbs were identified who underwent intervention of refluxing perforators. The patients who underwent imaging, including MRI or CT (Group A) were compared to those who did not undergo imaging (Group B). The treated limbs in Group A were also compared to the contralateral limbs as an internal control. Anatomical findings on imaging were analyzed by two independent investigators. The primary outcome was the presence and degree of central venous stenosis as measured by an orthogonal diameter reduction of > 50% by axial imaging. Secondary outcomes included demographic and clinical differences between the two groups, frequency of central venous intervention, and duration of ulcer healing. Standard statistical analysis was performed.

Ninety-three patient-limbs underwent treatment of a pathologic perforator, with 30 in Group A and 63 in Group B. The following demographic and clinical variables were higher in Group A compared to Group B: Male gender, BMI, deep venous thrombosis history, recent or active anticoagulation use, perforator diameter, Clinical Etiology Anatomy Pathophysiology class 4, 5 or 6, and Venous Clinical Severity Score. Radiographic analysis of Group A revealed concordance of a treated pathological perforator with an ipsilateral central venous stenosis in 53.3% of patients, and a higher frequency of common iliac vein stenosis (50% vs 21.4%, P = 0.024) and external iliac vein stenosis (20% vs 0%, P = 0.012) compared to the contralateral limbs. When separated by left or right limb, the left limbs exhibited a greater degree of common iliac vein stenosis as compared to the contralateral limbs (50.7±20.9% vs 16.3±16.5%, P < 0.001) as well as a greater frequency of >50% common iliac vein stenosis (46.7% vs 13.3%, P = 0.046). The right limbs exhibited a greater frequency of > 50% external iliac vein stenosis as compared to contralateral limbs (33.3% vs 0%, P = 0.022).

This study suggests that patients with severe chronic venous insufficiency who undergo treatment for a pathologic perforator may have additional ipsilateral central venous pathology, supporting the presence of multilevel disease. Additional axial imaging might unmask central venous pathology and provide another option for treatment.