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Objectives: Reflux assessment with ultrasound (U/S) is usually qualitative. Quantitative measurements of superficial venous insufficiency (SVI) include the venous arterial flow index (VAFI), recirculation index (RCI), venous filling index (VFI), and the postural diameter change (PDC) of the saphenous trunk. The aim was to investigate their relationship., Materials and Methods: This was an observational study performed on patients with varicose veins and hospital employees. Four haemodynamic parameters were measured in 21 legs from 16 subjects. Legs were divided into no reflux (n = 7) and reflux (n = 14). The VAFI is the U/S ratio of common femoral vein volume flow divided by the common femoral artery volume flow, performed supine. The RCI is the U/S ratio of reflux volume over antegrade volume within the saphenous trunk after calf compression, standing. The VFI is the rate of calf volume increase on dependency measured in mL/s, using air plethysmography. The PDC is the percentage reduction of the saphenous trunk diameter from standing to lying, using U/S., Results: The clinical part of the CEAP classification was: C 0  = 3, C 1  = 4, C 2  = 5, C 3  = 1, C 4a  = 1, C 4b  = 6, C 5  = 1. All four tests demonstrated significant differences between the two groups with minimal overlap (Mann Whitney U test): VAFI (p = .028), RCI (p < .0005), VFI (p = .001), and PDC (p = .014). Furthermore, significant correlations were observed with the tests: VAFI vs. RCI (r = .532, p = .015), VFI (r = .489, p = .025) and PDC (r = -.474, p = .030); RCI vs. VFI (r = .446, p = .043) and PDC (r = -.527, p = .014)., Conclusions: Superficial venous drainage insufficiency should not be confined to an U/S assessment of the presence of reflux, which is qualitative. Quantitative data may be provided using the VAFI, RCI, VFI, and PDC. Understanding why there are significant correlations among these parameters and the preferred objective reference test requires further work., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objectives: Treatment success for chronic superficial venous insufficiency could be defined as an improvement in three domains: (i) disease specific quality of life, (ii) clinical severity, (iii) reflux. The aim was to report these at five years using a Venn diagram to profile the outcomes: a discord outcome analysis (DOA)., Methods: Patients (n = 50 patients/legs in each treated group) were randomised to endovenous laser ablation (EVLA) with concurrent phlebectomies vs. ultrasound guided foam sclerotherapy (UGFS). Outcomes were assessed using three domains: (i) Aberdeen varicose vein questionnaire (AVVQ), (ii) venous clinical severity score (VCSS), (iii) venous filling index (VFI) of air plethysmography. Change scores were calculated by subtracting the final score after treatment from the baseline score before treatment to quantify the improvement. This was followed by a DOA profile for each patient where a discord was defined as the percentage of patients with a numerical deterioration in one or two domains., Results: The median [interquartile range] follow up was 68 [64-72] months. Follow up in all three domains was EVLA: 45/50, UGFS: 42/50. On ultrasound examination, GSV occlusion at some point above the knee was 93% for EVLA and 64% for UGFS (p = .001). There was no significant difference in improvement between the two treatment groups in the VCSS and the VFI. However, the EVLA group had a statistically significant AVVQ improvement (p = .004). Using a DOA, only 76% EVLA versus 60% UGFS had success in all three domains. Using improvement thresholds, this reduced to 54% and 39%, respectively. The commonest discord pattern was an improvement in the VCSS and VFI but deterioration in the AVVQ., Conclusions: A DOA demonstrated that the definition of success is reduced if deterioration in one or two domains is taken into account. A DOA should be considered as a reporting standard for comparative analyses., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The great saphenous vein (GSV) in patients with superficial venous insufficiency might act as a beneficial conduit for antegrade venous drainage and also as a harmful conduit for promotion of reflux and/or recirculation and subsequent skin changes. The aim of this study was to measure the antegrade and retrograde GSV volume displacements during calf compression and release maneuvers. This was used to quantify harm over benefit with a recirculation index (RCI)., Methods: Sixteen legs (nine right) from 16 patients (nine male) with primary superficial venous insufficiency were scanned standing with duplex ultrasound, at the upper thigh GSV, 10 cm below the sapheno-femoral junction. The clinical, etiological, anatomical, pathophysiological class was C2 = 3, C3 = 2, C4a = 6, C4b = 4, C5 = 1. The median age (range), venous clinical severity score, and refluxing GSV diameter were 63 (21-79) years, 8 (4-16), and 7 (5-10) mm, respectively. A manual calf compression and release (MCCR) maneuver was performed once, and a cyclical calf compression and release (CCCR) three times for repeatability. With the CCCR maneuver, the calf-cuff and inflation-deflation pump provided a cyclical compression pressure of 120 mm Hg (3 seconds) with a release time of 16.4 seconds to standardize venous refilling time., Results: The results are expressed as median [interquartile range]. The CCCR compared with the MCCR resulted in longer reflux duration (16.4 [8.2-16.4] seconds vs 5.7 [3.7-6.8] seconds; P < .0005), higher time-averaged mean velocities in reflux (23.5 [14.9-27.9] cm/s vs 14.1 [9-17.6] cm/s; P < .0005) and greater reflux volume displacements (81.7 [38.8-152.8] mL vs 27.3 [16.4-53.4] mL; P < .0005). There were significant correlations between increasing antegrade volume measurements and increasing reflux volume measurements irrespective of whether CCCR, (r = 0.841; P < .0005) or MCCR (r = 0.762; P = .001) was used. This implies that the displaced antegrade volume might have a causal effect on the resulting reflux volume. The ratio of reflux volume/antegrade volume (RCI) was 2.14 [1.58-2.74] with the CCCR. This supports the recirculation phenomenon. Adjusted to a standard median for each leg, the repeatability limits (three times) of the RCI was excellent at 2.14 (95% confidence interval, 2.09-2.21)., Conclusions: In this study we measured the behavior of the GSV in terms of harmful reflux over beneficial drainage using the RCI. We recognize that reflux values depend on the type of provocation test and the amount of displaced antegrade volume. This limitation might be overcome by factoring reflux as an expression of antegrade flow using the RCI. When standardized, a test for quantifying saphenous recirculation might have many clinical applications. The next step should be a prospective study to validate the RCI with clinical and quality of life parameters., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Venous reflux is the principal hemodynamic disorder and therapeutic target in patients with superficial venous insufficiency. To date, no studies have identified where or when it stops, anatomically or regionally, along the course of the refluxive conduit. Duplex measurements of reflux are performed invariably with a single probe. Because many anatomic locations are studied, repeated provocation maneuvers are required. However, this fails to appreciate reflux as a circulation. The use of two probes placed concurrently in different regions may address this limitation. The study compared venous reflux duration and cessation, above the knee and below the knee simultaneously, with two duplex probes., Methods: Seventeen legs from 17 consecutive patients (12 female, nine left) with great saphenous vein reflux were studied. Their median (range) age was 51 (28-71) years; weight, 76.8 (63.5-189) kg; height, 169 (153-180) cm; and Venous Clinical Severity Score, 5 (1-12). The clinical class of the Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) classification was as follows: C2, 6; C3, 4; C4a, 5; and C4b, 2. After 2 minutes of elevation, the leg was assessed for reflux duration with duplex ultrasound. This occurred when the patient stood up during venous filling. One probe was positioned 10 cm below the saphenofemoral junction over the great saphenous vein (point A) and the other over a refluxive saphenous vein or tributary below the knee (point B). Concurrent images were displayed on adjacent monitors and recorded by a single video camera. Reflux duration was from the onset of dependency, indicated by the start of the video, to the termination of the red color (reflux) on video playback. The probes were swapped to negate for differences in machine sensitivity. Each leg was tested three times. Simultaneous was defined when there was <0.1 second difference between the two sites., Results: The median (range) vein diameters at points A and B were 6.1 (2.8-9.3) mm and 5.5 (2.5-8.1) mm, respectively, with an intertransducer distance of 41 (23-59) cm. There was no significant difference in reflux duration between point A with 27 (9-150) seconds and point B with 27 (10-149) seconds (P = .943 [Wilcoxon]). The correlation was excellent (r = .986; P < .0005 [Spearman])., Conclusions: This is the first study to investigate reflux cessation by introducing a novel two-probe technique. It has demonstrated that reflux may stop simultaneously above and below the knee with use of the elevation to dependency maneuver to provoke reflux. It has shown that either site may be used to measure reflux duration. Furthermore, the two-probe technique confirms the belief that the mechanism of refluxive venous filling is through the descending path of a recirculation circuit., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: It is strongly recommended that patients wear compression after foam sclerotherapy, but pulling up a stocking may inadvertently flush foam into the femoral vein, which may increase the risk of systemic side effects and reduce great saphenous vein (GSV) occlusion rates., Objective: The hypothesis was that a stocking pull-up maneuver would increase flow in the GSV. The aim was to quantify this using duplex ultrasound., Methods and Materials: Twelve consecutive patients with primary varicose veins were studied. A below-knee 23- to 32-mmHg graduated elastic compression stocking was placed over the foot, leaving a cuff of redundant stocking around the ankle. Duplex ultrasound over the saphenofemoral junction was used to measure peak velocity (PV) and volume flow (VF) before and while the stocking was being pulled up., Results: The pull-up maneuver caused a median 17.7 times increase in PV (interquartile range (IQR) 14.2-23.9), from 7.6 cm/seconds (IQR 6.4-9.8 cm/seconds) to 150.5 cm/seconds (IQR 110-187 cm/seconds) and a 9.4 times increase in VF (IQR 7.7-10.3), from 50.9 mL/minutes (IQR 33.8-78.9 mL/minutes) to 458.7 mL/minutes (IQR 292.1-593 mL/minutes) (p = .002)., Conclusion: A stocking causes significant hemodynamic changes within the GSV. These forces could be avoided by the partial application of a stocking to knee level before foam injection. Further work may establish the implication of these findings in patients treated with foam sclerotherapy., (© 2012 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Background: Pulsatile flow in deep, perforating veins and varicose veins (VVs) has been described previously to support a hypothesis of arteriovenous (AV) fistulae in the pathogenesis of VVs. Its presence has also been suggested as a cause of failure of VV treatments. However, AV communications have never been adequately visualized and direct pressure tracings within leg veins have been inconclusive. The present study was observational aiming to investigate the prevalence and rate of spontaneous pulsation within the great saphenous vein (GSV) in volunteers and patients using color duplex and compare this to reflux and markers of disease severity., Methods: Twenty-seven consecutive patients (32 legs, median Venous Clinical Severity Score (VCSS) = 5 [0-11]) attending the VV clinic and 23 consecutive ambulatory normal volunteers (46 legs) had their GSV assessed at midthigh using color duplex. Subjects were examined standing with the hips resting against an adjustable couch, bearing weight on the contralateral leg, with the test leg touching the ground. The presence of flow and reflux were initially determined using manual calf compression. Saphenous pulsation (SP) was defined as a cyclical change in velocity. The GSV diameter and SP rate were then recorded after 2 minutes of dependency. The number of pulsations was counted from video recordings., Results: The resting SP, if present, was discrete, monophasic, of variable amplitude, antegrade, and irregular, irrespective of respiration. Pulsation was detected in 2/44 (4.5%) legs with C(0-1) (C part of CEAP), 9/17 (52.9%) legs with C(2-3), and 16/17 (94.1%) legs with C(4-6) (P < .05, z test of column proportions). Reflux occurred in 8/32 (25%) legs without SP (C(0) = 2, C(1) = 1, C(2) = 3, C(3) = 2). The median GSV diameter was significantly elevated in the presence of SP (no pulse: 3.5 [range, 1.5-8.1] mm; pulse: 7 [range, 4-9.4] mm; P < .0005). The median refluxing GSV diameter in GSV pulsators compared with nonpulsators was 7 (range, 4-9.4) mm; vs 5.1 (range, 2.7-8.1) mm, respectively (P = .003). The median SP rate in refluxing GSVs was 52 (range, 22-95) beats per minute., Conclusions: The high prevalence of pulsatile antegrade saphenous flow is a novel observation in patients with severe superficial chronic venous insufficiency. It is detectable in 75% of patients with GSV reflux and significantly increases with clinical severity and saphenous diameter. It may be a marker of advanced venous disease and, as it is easy to record, it could supplement duplex evaluations of reflux. Further work is needed to establish the clinical relevance of the SP in terms of disease progression, recurrence after treatment, and as a hemodynamic marker of severity., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The long-term results of a prospective, randomized controlled trial in patients with primary varicose veins are reported., Methods: Saphenofemoral ligation (SFL) was done in 73 patients (82 legs). In addition, 43 (23 women; age, 47) underwent stripping and multiple phlebectomies under general anesthesia (group S), and 39 (32 women; age, 49) had concurrent sclerotherapy under local anesthesia (group F). Assessments included CEAP C status, Venous Clinical Severity Score (VCSS), Venous Segmental Disease Score (VSDS), Aberdeen Varicose Vein Questionnaire (AVVQ), and 36-Item Short-Form (SF-36) scores., Results: CEAP C was similar between groups (C(2-6)). In group S, 40% of legs required 25 additional foam sessions (mean volume, 11 mL). In group F, 47.5% of legs required 33 sessions (mean volume, 9 mL) The groups had equivalent preoperative VCSS scores and similar changes at 3 (P = .504) and 5 years (P = .484), as were the absolute VCSS scores at 3 (P = .313) and 5 years (P = .104; Mann-Whitney U). The VSDS score improved (median [interquartile range]) preoperatively vs 3 years (group S, 16.32 [14.7] vs 8.94 [11.51], P = .003; group F, 12.28 [10.37] vs 4.97 [6.19]; P < .0005, Wilcoxon). Above knee obliteration occurred in 17 of 26 (65.4%) for group S and in 16 of 33 (48.5%) for group F at 3 years, and in 14 (53.8%) and 19 (57.6%) at 5 years. AVVQ scores were similar before and at 3 years (P = .703) but significantly favored group S at 5 years (P = .015; Mann-Whitney U). The AVVQ also improved within both groups. The SF-36 mental summary score over 3 years deteriorated in group S (P = .04). However, the physical summary scores did not change between groups (S, P = .361; F, P = .889) or the mental score in group F (P = .285). Changes in the physical (P = .724) and mental (P = .354, Mann-Whitney U) scores did not differ between the groups due to treatment., Conclusion: At 3 and 5 years of follow-up, the treatment was equally effective in the surgical and foam groups, as demonstrated with VCSS, VSDS, and the SF-36 physical component score. At 5 years, the AVVQ was significantly better in the surgical group. The additional foam sessions were also similar. Because traditional surgery for varicose veins does not provide a definitive treatment, foam sclerotherapy could be offered as in a dental care treatment model: "treat as and when the problem appears.", (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives It has been proposed that varicose veins may be caused by a degree of impeded proximal venous drainage (pelvic venous obstruction) in the same way that biological tubes dilate in response to an obstruction. The venous drainage index (VDI) of air-plethysmography (APG) was used to test this hypothesis. A dependency to elevation manoeuvre was used to provoke gravitational venous drainage. A rapid reduction in calf volume implied good drainage. Methods This was a single centre, proof-of-concept study comparing gravitational venous drainage in varicose vein patients and controls. Leg filling and drainage manoeuvres (elevation to dependency and dependency to elevation) were performed three times per leg in 15 patients (7 male, 8 right) and 16 controls (3 male, 8 right). The VDI was measured in the same way the established venous filling index (VFI) is calculated to quantify filling: VDI = 90% of venous drainage volume (90VDV)/90% venous drainage time (VDT90). Results The patients were significantly older at 58 (41–75) years versus the controls 47 (18–58), p = 0.001. There was no significant difference between the groups in weight, height, BMI or common femoral vein diameter. The patients were (C2 = 8; C3 = 1, C4 = 6), VCSS 4 (1–11) with a median refluxing proximal thigh saphenous diameter of 6 (5–11) mm. The median (inter-quartile range) VFI and VDI (both in mL/s) in the control tests (n = 48) were 1.3 (0.9–1.9) and 33.8 (21.5–55), respectively. The VFI and VDI in the patient tests (n = 41) were significantly faster at 6.2 (3.5–9.4), p < 0.0005, and 47.1 (36.1–66.3), p = 0.002, respectively. Adjusted to a standard mean for each leg, the reproducibility limits (×3) of the VDI was very good at 39.7 (95% CI: 36.5–42.9) in controls and 52.9 (95% CI: 49.7–56.1) in patients. Conclusion The VDI was significantly greater in patients with varicose veins compared to controls. It is unlikely that impeded gravitational drainage is a significant factor in the pathophysiology of varicose veins. [ABSTRACT FROM AUTHOR]