Non-saphenous veins refer to veins other than the great saphenous vein or small saphenous vein. Emerging evidence suggests that non-saphenous vein reflux may be more prevalent than previously thought, occurring in 9∼35% of patients with chronic venous disease. We purposed to review the anatomical distribution, diagnostic methods, and treatment options for non-saphenous vein reflux and the importance of differentiating it from saphenous vein reflux in clinical practice. Various types of non-saphenous vein reflux are discussed, including posterolateral thigh perforator vein reflux, vulvar vein reflux, gluteal vein reflux, sciatic nerve/tibial nerve vein reflux, popliteal fossa vein reflux, and knee perforator vein reflux. Individualized treatment approaches are recommended, with sclerotherapy and phlebectomy being common options. Increasing awareness and understanding of non-saphenous vein reflux can lead to improved diagnosis, management, and outcomes for patients with venous disease.

Pelvic vein disorder (PeVD) encompasses symptoms originating from the pelvic veins. It significantly impacts quality of life despite not always being life-threatening, necessitating accurate diagnosis and effective management. PeVD may result from pelvic vein incompetence (PVI), or conditions like left common iliac vein compression or Nutcracker syndrome can contribute to PeVD. Chronic pelvic pain, lasting over six months, is a common symptom, affecting various aspects of health and often linked to lower urinary tract, sexual function, and gynecological issues. Diagnosis involves ultrasound, computed tomography, magnetic resonance venography, and catheter venography. Transvaginal or abdominal ultrasound can identify enlarged veins and reflux, while catheter venography is the gold standard for diagnosing PVI. Treatment options include medical and endovascular treatments. Medications like micronized purified flavonoid fraction, medroxyprogesterone acetate, and goserelin acetate offer symptom relief, though effects are temporary. Endovascular treatment provides favorable outcomes, with coil embolization being effective.

Objective: Most causes of lower extremity varicose veins are associated with saphenous veins. However, there are several unusual causes of varicose veins that are not related to the saphenous veins. This study reports rare cases of varicose veins originating from intraosseous perforating vein incompetence. The purpose of this study is to examine the clinical manifestations, diagnostic methods, and appropriate treatments.
Methods: A total of 5,481 patients with lower extremity varicose veins visited our clinic from June 2016 to October 2021. Among them, seven patients were identified to have intraosseous perforating vein incompetence. Color Doppler ultrasound was performed to diagnose reflux at the site of the perforating vein through the tibial cortex.
Results: Varicose veins were observed in the pretibial area, and they were connected to the tibial perforating vein with venous reflux. The patients experienced common symptoms associated with lower extremity varicose veins, such as heaviness, cramping, tingling, swelling and discomfort. However, in our cases, there were no localized symptoms specifically related to the tibia area. The surgical procedure performed involved perforating vein ligation and phlebectomy with an incision under local anesthesia.
Conclusion: Intraosseous perforating vein incompetence is a very rare cause of pretibial varices, primarily observed on the anteromedial side of the mid-shaft of the tibia. It is easily overlooked due to its rarity. However, with sufficient knowledge, intraosseous perforating vein incompetence can be accurately diagnosed using Doppler ultrasound alone, and it can be easily treated through perforating vein ligation and phlebectomy.

Endovenous laser ablation therapy (EVLT) is an effective and safe treatment for varicose veins. Most reported complications are self-limiting. Here we report a rare case of a 29-year-old woman who was recently treated with EVLT and had a retained guidewire up to the petrosal sinus causing a severe headache.

In the diagnosis of varicose veins, duplex ultrasound scanning is recommended as the diagnostic test of choice. Both superficial and deep veins must be tested accurately and consistently in a standardized manner. Ultrasonography, while effective, is highly dependent on the examiner and requires standardization. To ensure reliable results, it is crucial to obtain high-quality images of superficial veins using a high-frequency linear array transducer during ultrasound examinations of the lower extremities. Image optimization techniques should be employed to minimize artificial images and enhance diagnostic quality. When conducting ultrasound examinations of the lower extremities, specifically for varicose veins, performing the venous reflux test in a standing position is essential. This positioning allows for testing under conditions more similar to physiological ones, ensuring a more accurate assessment of pathological reflux influence.

Venous flow normally circulates from the skin to superficial veins, which drain into the deep veins and the heart. Venous reflux refers to blood flow that flows in the opposite direction. Venous reflux is caused by gravity and valvular insufficiency. Diagnosing venous reflux is important to determine treatment for lower extremity venous disease. Unlike arteries, venous reflux is greatly affected by the relative position of the probe and the vessel. Standardized ultrasound images are required to verify venous reflux using ultrasound. It is important to perform the reflux provocation test using the standardized posture and method.

Flebogrif^® is a new modality of mechanochemical ablation for incompetent saphenous vein treatment. With our experiences, it offers advantages such as reduced sclerosant dosage, shorter procedure times, lower catheter costs and in terms of closure rate as well. However, the potential for increased pain and thrombophlebitis due to more potent mechanical injury is apparent.

Venous ulcer, a condition caused by chronic venous disorder, is the most common form of leg ulcer, accounting for approximately 70% of all leg ulcer cases. The prevalence of venous ulcer is known to range between approximately 0.06% and 2%, and even when treated, it is known to recur in approximately 75% of cases. Reflux and obstruction caused by a venous disorder are both key pathophysiological factors of venous ulcer, and in particular, obstruction causes venous ulcer at a high frequency. The diagnosis of venous ulcer is based mostly on medical history, clinical presentations, and physical examination. Venous ulcers typically occur in the gaiter region and are often accompanied by telangiectasia, corona phlebectatica, atrophie blanche, and lipodermatosclerosis. Duplex ultrasonography is the most commonly used method for diagnosing chronic venous insufficiency (CVI) and assessing its causes. It can also be used to diagnose reflux and obstruction and evaluate the severity and distribution of reflux. However, although longer reflux time is typically observed in CVI, it is not always consistent with the clinical presentations. Recently, intravascular ultrasound is being adopted rapidly since it is capable of providing more accurate diagnosis and being very helpful in endovascular intervention. Treatment for venous ulcer involves reducing edema, promoting healing, and preventing recurrence of ulcer. Compression therapy is the standard therapy for CVI and venous ulcer. Elastic compression therapy is more effective than inelastic compression therapy because it offers the advantage of maintaining compression both at rest and during activities, adjusting to changes in leg size. Compressive stockings, which comprise the core component of elastic compression therapy, help to reduce residual volume fraction, an indicator of calf muscle pump improvement, and promote healing of venous ulcers by reducing reflux in venous segments. Proper wound care and dressings play a vital role in venous ulcer treatment. The wound should be kept moist at all times, while various dressings can be applied to promote healing of the ulcer. Moreover, faster healing of venous ulcer can be achieved by compression therapy with additional intravenous or surgical treatment, as compared to compression therapy alone.

Chronic venous ulcers are a debilitating condition that often significantly impacts the quality of life due to their tendency to recur. Recently, we encountered a case of challenging chronic obstructive iliofemoral venous disease, presenting as postthrombotic syndrome with a venous ulcer. Venous duplex ultrasound revealed evidence of venous reflux in the left great saphenous vein and small saphenous vein. A CT venogram indicated occlusion in the proximal femoral vein, common femoral vein, and external iliac veins, with collateral veins in the lower abdomen. This lesion was treated using a combination of two types of venous stents. A one-month follow-up revealed improvement in the patient’s edema and ulcer.