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Objective: The purpose of this study was to determine the prevalence, distribution, and extent of varicosities and focal dilatations in the saphenous trunks, their association with the sites of reflux, and their correlation with CEAP classes., Methods: This prospective study included patients belonging to different CEAP classes (2-6) and a control group of age- and gender-matched healthy volunteers (group C). Color-flow duplex scan imaging was used to evaluate the entire venous system from groin to ankle for reflux and obstruction. Varicose segments and focal dilatations of the great and small saphenous veins (GSV and SSV) were recorded, and the diameters throughout the length of the saphenous trunks were measured. The presence of varicosities in the tributaries and accessory veins were documented., Results: From the 739 consecutive patients, 239 were excluded due to superficial venous thrombosis (SVT), deep venous thrombosis (DVT), both SVT and DVT, previous interventions, or C3-C6 presentation with no chronic venous disease (CVD). The included 500 patients (681 limbs) were divided into two groups based on CEAP class: group A (C2 + C3) and group B (C4-6). Group A had significantly more women than group B and a younger mean age (48 vs 56 years). Overall, GSV reflux (86%) was more prevalent than SSV reflux (17%), P < .0001. Saphenous trunk diameters, saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) involvement were greater in group B, (P < .01). Group C had smaller saphenous diameters compared to group A in all locations (P < .05) but the malleoli. The prevalence of the saphenous varicose segments in both groups was small with the GSV in group B being the highest (4.3%) and the SSV in group A being the smallest (1.2%). Focal dilatations were significantly more prevalent than varicosities in the saphenous trunks (P < .0001). Varicosities of tributaries and accessory veins were more prevalent than those of saphenous trunks (P < .0001). The mean length of varicose segments in the saphenous trunks was short (3.8 cm, range, 2.1-6.4 for group A vs 4.1 cm, range, 2.3-8.3 for group B, P = .09)., Conclusion: A novel definition for varicosities in the saphenous trunks was established. Using this definition, it was determined that focal dilatations are far more common than varicosities. Because both of these entities are more prevalent in the accessory saphenous veins and tributaries, and CEAP class correlates positively with the extent of reflux and saphenous trunk diameter, studies on earlier interventions are warranted to prevent CVD progression., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Several studies have evaluated the natural history of deep vein thrombosis (DVT), but few have correlated the clinical progression using duplex ultrasound (DU) imaging during the first year. This study was designed to determine the relationship of changes in the venous system and correlate them with long-term progression of disease., Methods: Consecutive patients with a first episode of proximal DVT documented by DU imaging were included prospectively. Clinic examinations were performed at 3, 6, and 12 months, and yearly thereafter. The CEAP system was used to grade disease severity. DU imaging was performed at least once, 1 year after the diagnosis, and repeated at 5 years. The proximal veins were divided the common femoral vein, femoral vein, and popliteal vein segments for analysis. Thrombosed veins were subsequently graded as completely, partially, and fully recanalized. Recurrent DVT cases were also recorded., Results: The study included 64 patients with 73 involved limbs; of which, skin damage was documented in three (4%) at 1 year and in 18 (25%) at 5 years (P = 0.0006; relative risk [RR], 3.92; 95% confidence interval [CI], 1.36-11.3). Overall from 1 to 5 years, 50 limbs remained the same. A change in clinical class occurred in 23 limbs (31.5%), including five limbs that progressed from class 0 to 3, 15 limbs from class 3 to 4 and 6, and three from class 4 to 5 and 6. DU imaging of these 23 limbs progression showed that the most important predictor for class progression was ipsilateral recurrent DVT (RR, 4.4; 95% CI, 1.4-13.3). Recurrent DVT at 1 year occurred in 21.9%, including ipsilateral in 15.6% and contralateral in 6.3%. Total recurrence at 5 years was 31.3%, including ipsilateral in 23.4% and contralateral in 7.8%. Limbs with ipsilateral recurrence were more likely to have partial recanalization, reflux, and more vein segments involved compared with those with contralateral recurrence or no recurrence (11 of 15 vs 16 of 58; RR, 4.7; 95% CI, 1.7-13.3)., Conclusion: Clinical class progression from year 1 to 5 occurs in 30% of post-thrombotic limbs. The most important predictor for progression in clinical class was ipsilateral recurrent DVT.

Objective: To describe the anatomic variations, symptomatology, and pathophysiology associated with the sciatic nerve (SN), and report the results after treatment of the incompetent veins., Patients and Methods: Retrospective analysis of prospectively collected data from patients with signs and symptoms of chronic venous disease that had superficial varicosities associated with incompetent veins along the SN. Patients were evaluated with duplex ultrasound scans. In patients with enlarged veins along the SN, the anatomy of the incompetent veins, their size and association with superficial varicosities, and the severity of insufficiency were analyzed. The symptoms associated with their presence and the treatment results were also noted. Patients were re-evaluated following treatment for recurrence of varicosities and symptoms., Results: We identified 24 limbs in 21 patients with varicosities along the SN and its branches. The duration of signs and symptoms was 4.5 years ranging from 1 to 14. Reflux was detected in 18 veins of the SN, in three persistent sciatic veins and in three veins of the tibial nerve. All limbs with sciatic and tibial nerve veins had varicosities in the lateral and posterior aspect of thigh and calf and were symptomatic. Ten limbs presented with CEAP class 2, 5 with class 3, 2 with class 4, and 1 with class 1. Pain or tingling was reported in 15 limbs, itching in 8, and heaviness in 7. The distribution of pain and tingling was present along the nerves in 19 limbs. One patient had acute thrombosis in a persistent sciatic vein and died from pulmonary embolism. Of the 21 limbs with SN veins, 16 were treated with subfascial vein ligation and phlebectomies. Three patients had sclerotherapy, 1 refused treatment, and 1 had mild symptoms not requiring treatment. Of the 19 treated limbs, in 11 there was relief of their symptoms, 6 had significant improvement, and 2 had no change. Within a year, 4 patients required additional treatment for veins along the same area. Eleven limbs had a follow-up duplex scan 3 to 19 months after their treatment. All limbs showed significant diameter reduction in the nerve veins while mild reflux was present in 3 (4.1 mm vs 2.1 mm, P < .001)., Conclusion: Reflux is the most common pathology of the sciatic and tibial nerve veins which produces significant symptoms along the distribution of the nerves. Treatment of the varicosities offers significant relief while recurrence or residual varicosities are easily managed.

Purpose: To compare the progression rate of primary with secondary chronic venous disease (CVD)., Methods: Patients with a first episode of proximal deep vein thrombosis (DVT), diagnosed by duplex ultrasound (DU) were included in group A - secondary CVD (41 patients, 46 limbs). DU was performed at least once, 1 year after the diagnosis, and repeated at 5 years. Group B - primary CVD (41 patients, 50 limbs) included age- and sex-matched patients with primary CVD and duration of 5 to 10 years to be comparable with that of group A. They had no history of DVT and were referred for reflux evaluation. All their veins were free of postthrombotic signs upon DU examination. Group C (15 patients, 30 limbs) had no signs and symptoms of CVD and were examined at baseline and 5 years later. This group of patients was also matched for age and sex. Clinic examinations were performed at 3, 6, and 12 months and yearly thereafter. The CEAP system was used to grade disease severity. The proximal veins were divided in the CFV, FV, and POPV segments for analysis. Thrombosed veins were subsequently graded as complete, partial, and fully recanalized. Recurrent DVT cases were also recorded., Results: At 5-year follow-up, the prevalence of skin damage was significantly higher in group A (11/46 vs group B 3/50, P = .019 and vs group C 0/30, P < .01). The progression to skin damage in group A was faster as it changed from 4% (2/46) at 1 year (P = 0.014) compared with the two other groups. In group A, 22 limbs had reflux, three had obstruction, 19 had combine reflux and obstruction, and two were normal. In group B, superficial, deep, and perforator vein reflux were seen in 50, 4, and 15 limbs, respectively. In group C, five limbs in four patients developed superficial reflux in which only two had symptoms. The CEAP class in this group was C0N = 25, C1 = 3, and C2 = 2. In group A, skin damage was significantly higher in limbs with combined proximal and distal obstruction as well as in limbs with combined reflux and obstruction (P = .012 and P = 0.013, respectively). DVT was found in 108 segments (25 CFV, 40 FV, and in 43 POPV), 82 at the first episode and 26 as an ipsilateral recurrence. Ipsilateral and contralateral recurrences were seen in 21.9% and 9.8% of patients, respectively. Complete recanalization occurred in 43 segments, partial in 55, and none in 10. Reflux occurred in 85.5% and 60.5% of the partially and completely recanalized segments, respectively (P = .006)., Conclusions: The progression of CVD is more rapid in postthrombotic limbs when compared with those with primary CVD. The incidence of CVD in normal individuals is small and its progression is slow. Poor prognostic factors for progression to advanced CVD include the combination of reflux and obstruction, ipsilateral recurrent DVT, and multi-segmental involvement.

Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease (P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group (P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls (P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.

Objective: To determine the patterns by which perforator vein (PV) reflux develops in patients with primary chronic venous disease (CVD)., Methods: Patients with CVD who had at least two examinations with duplex ultrasonography before any treatment were included in this study. These were patients who were offered an operation at their first visit, but for various reasons treatment was postponed. All affected limbs were classified by the CEAP classification system. A detailed map of normal and refluxing sites was drawn on an anatomic chart by using several landmarks of the skin, muscle, and bone. Reflux was induced by distal limb compression followed by sudden release by using rapid-inflation pneumatic cuffs and dorsiplantar flexion. All new reflux sites were documented. The PV reflux was divided into ascending type, descending type (re-entry flow), and those that developed in new locations, which did not have reflux in any system at that level., Results: The total number of patients studied was 127 (158 limbs). There were 29 limbs (18%) in 26 patients with reflux development in the PV. In total, 38 new incompetent PVs were identified. The median time for the examination was 25 months (range, 9-52 months). Reflux in a previously normal PV at a re-entry site was detected in 15, in an ascending manner from an extension of superficial vein reflux in 18, and in a new, previously intact location in 5. At the new sites, reflux in the superficial veins connected to the incompetent PVs was always present. PVs connected to the great saphenous vein system were most common (n = 27), followed by those connected to short saphenous (n = 8) and nonsaphenous (n = 3) veins. Worsening in the clinical class was observed in 11 limbs: 5 from class 2 to 3, 2 from class 2 to 4, 2 from class 3 to 4, and 2 from class 4 to 6. The worsening could not be attributed to the PV reflux alone, because other veins became incompetent as well., Conclusions: Reflux in PVs develops in ascending fashion through the superficial veins, at re-entry points, and at new sites. Worsening of CVD is observed with new PV reflux, but many other factors play a major role, and therefore a causative association is difficult to prove.

Background: Information on nonsaphenous superficial venous reflux is lacking. This study was designed to determine the prevalence of reflux in nonsaphenous veins, their association and correlation with risk factors, and signs and symptoms of chronic venous disease (CVD)., Methods: Information on 835 limbs in patients with signs and symptoms of CVD were prospectively entered into a customized database. These patients had been referred from the venous clinic to the vascular laboratory for color-flow duplex scanning evaluation of the lower-limb veins. All patients were examined for reflux in the standing and sitting positions. Nonsaphenous reflux was defined as that in superficial veins that are not part of the greater or lesser saphenous systems. Particular attention was paid to the patterns of reflux and anatomy of the nonsaphenous veins from the proximal to the distal ends, including their connections with the saphenous and deep veins., Results: Nonsaphenous venous reflux was found in 84 limbs (10%) of 72 patients, 67 of whom were women. The mean number of pregnancies in these patients was higher than that of 100 randomly selected women with saphenous reflux (3.2 vs 2.2). According to CEAP classification, 90% of the limbs were in CVD classes 1 through 3 and only 10% had skin damage (classes 4-6). Symptoms were present in 67 limbs (80%). Forty-two limbs (50%) had reflux in tributaries of lateral, posterior, and medial thigh. These veins were connected with perforators uniting with the deep femoral, femoral, and muscular veins of the thigh in 36 limbs. Reflux in these perforators was detected in 19 limbs. Reflux arising from the pelvic veins was found in 29 limbs (34%), 18 of which were from vulvar veins medial to saphenofemoral junction and 11 of which were from veins in the gluteal area. Incompetent veins from the sciatic nerve were found in nine limbs (10%). Reflux in the vein of the popliteal fossa was found in seven limbs (8%). Reflux in knee tributaries was detected in three limbs (4%), two of which were connected with posterolateral knee perforators and one with the posterior tibial nerve veins., Conclusions: The prevalence of nonsaphenous reflux in our practice was 10%. The vast majority of these patients (93%) were women with a mean of 3.2 pregnancies. Ninety percent of these limbs have signs and symptoms assigned to CVD classes 1 to 3. These data may simply reflect the referral pattern, but also a possible association with female sex and number of pregnancies. The unusual anatomy of these veins stresses the importance of color-flow duplex scanning before surgery.