Anatomical Extent of Venous Reflux

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

Verständnis, Prävention und Behandlung von venösen und lymphatischen Erkrankungen basieren auf der Arbeit von Grundlagenforschern

Zweck Die Rolle der Grundlagenforschung in allen Bereichen der Medizin war, ist und wird auch immer kritisch sein. Die Grundlagenforschung leistet einen Beitrag zu Wissen und Fortschritt. In der Phlebologie ist es nicht anders. Das Manuskript beschreibt die neuesten Errungenschaften der Grundlagenforschung zum Thema Phlebologie.

Methode Der vorliegende Beitrag beleuchtet Publikationen mit dem Thema Grundlagenforschung in der Phlebologie aufgrund einer PubMed-Suche. Die gefundenen Artikel sowie die verschiedenen Schritte, die für Grundlagenforschung angewendet werden, werden diskutiert. Die Relevanz dieser Arbeiten in Bezug auf die tägliche Arbeit in der Phlebologie wird beleuchtet, insbesondere in Bezug auf die Veränderungen der Venenklappen, der Venenwand und den darauffolgenden Störungen des Blutstroms.

Ergebnisse Veränderte Venenwände bei Varizen sind das Ergebnis eines Umbauprozesses aufgrund von Veränderungen der Venenwand auf Zellebene sowie im Interstitium. An diesem Prozess sind glatte Muskelzellen beteiligt. Ferner wurde eine Transformation vom kontraktilen zum sekretorischen Phänotyp beschrieben. In diesem Umbaustadium sind Matrix-Metalloproteinasen (MMP) aktiv beteiligt. Sie tragen zur beobachteten endgültigen Veränderung der Venenwand bei Varizen bei. Die Eigenschaften des Blutstroms und die Funktion der Venenklappen haben sich als zusammenhängendes System erwiesen.

Schlussfolgerungen Die wissenschaftliche Methode ist der Grundpfeiler der Grundlagenforschung. Varizen entstehen durch einen veränderten Blutstrom und einen Umbau der Venenwand.

Blood flow from competent tributaries is likely contributor to distally increasing reflux volume in incompetent great saphenous vein

OBJECTIVE

Venous reflux is the sole pathophysiologic process in primary chronic venous disease and its progression. We hypothesize that the reflux volume increases along a great saphenous vein (GSV) in a distal direction. We aimed to compare simultaneously measured reflux volume in the upper and lower GSV segments in a thigh.

METHODS

Patients meeting the inclusion criteria were enrolled (70 limbs of patients with primary incompetence of the GSV) and consented to this single-center study. Patients were stratified into two groups: incompetent terminal valve (TV_i) and competent terminal valve (TV_c). A cross-section area of the GSV was measured at the upper (CSA₁, cm²) and distal (CSA₂, cm²) points in a thigh. A cross-section area of each tributary that joined with the GSV between the points was measured, and their total cross-section area was calculated (CSA_trib). After a distal cuff compression-decompression maneuver, a time average mean velocity (TAMEAN, cm/sec) and reflux duration (RT, sec) were measured at both points simultaneously. Reflux volume RV, ml was calculated for each point (RV₁ and RV₂). The difference in absolute values of _ΔRV (ml) and its relative changing (_ΔRV, %) were calculated.

RESULTS

The main result was RV increases caudally from saphenofemoral junction to the knee level (RV₁ 12.7 ± 8.4 and RV₂ 20.5 ± 14.0 ml, P < .0001). There was no difference between CSA₁ and CSA₂ (0.34 ± 0.17 and 0.33 ± 0.17 cm², respectively, P = .9) but TAMEAN was a statistically significant different in two points (7.3 ± 3.9 and 11.4 ± 5.7 cm/sec, respectively, P < .0001). All of the tributaries between the points were competent.

CONCLUSIONS

Reflux volume in the great saphenous vein increases caudally from saphenofemoral junction to the knee level. Observed reflux volume was an aggregate of all GSV tributaries' flow and the flow via the SFJ if incompetent.