Varicose vein is a prevalent disease and a cause of substantial morbidity. Venous reflux often originates from saphenous trunks and their tributaries. The great saphenous vein and small saphenous vein have major anatomical variations due to their embryological origin. Understanding of anatomic variation and reflux pattern is important to decide the target lesions for treatment and treatment modalities for symptom relief effectively and to prevent the future complications and recurrence. In this review, we purposed to review the reflux pattern of the saphenous origin and the corresponding treatment methods.

Ultrasound is a diagnostic tool of choice for venous disease. As treatment is based on ultrasound results, accurate examination is essential and image optimization is necessary to provide objective information. Understanding the physical properties and knobology of ultrasound helps to obtain good images. To begin with, comfortable placement of the ultrasound for the examiner to use and the appropriate positioning of the patient is also important. The next step for an optimal ultrasound image is to attain good resolution to a given depth. It is also essential to appropriately utilize the provocation maneuvers when diagnosing a suspected disease, especially for the chronic venous disease.

Varicose vein is a disease with a high prevalence that is commonly seen in everyday life. Accurate diagnosis using ultrasound is essential for venous diseases, but due to the nature of the disease and ultrasonographic techniques, there are a lot of intervention in subjective judgment. Therefore, it is necessary to establish clear standards for the diagnosis methods and standardize procedures of varicose veins. Recently, the diagnosis and treatment of venous diseases has increased rapidly, and the resulting social costs have become a problem. In celebration of its 20th anniversary, the Korean Society for Phlebology published this guideline, ‘The 2023 Korean Society for Phlebology clinical practice guidelines for the ultrasonographic evaluation of varicose veins of the lower extremities’ because it was determined that the establishment of accurate diagnostic standards using ultrasonography was urgently needed.

The calf muscle pump is the motive force enhancing venous blood return from the lower extremity to the heart. It causes displacement of venous blood in both vertical and horizontal directions, generates ambulatory pressure gradient between the thigh and lower leg veins, and bidirectional streaming within calf perforators. Ambulatory pressure gradient triggers venous reflux in incompetent veins, inducing ambulatory venous hypertension in the lower leg and foot. Bidirectional flow in calf perforators enables quick pressure equalization between deep and superficial veins of the lower leg; the outward (into the superficial veins) oriented component of the bidirectional flow taking place during calf muscle contraction is not a pathological reflux but a physiological centripetal flow streaming via the great saphenous vein into the femoral vein. Calf perforators are communicating channels between both systems, making them conjoined vessels; they are not involved in generating pathological hemodynamic situations and do not cause ambulatory venous hypertension. Pressure gradient arising during calf pump activity between the femoral vein and the saphenous remnant after abolishing saphenous reflux triggers biophysical and biochemical events, which might induce recurrence. Thus, abolishing saphenous reflux removes the hemodynamic disturbance but simultaneously generates a precondition for reflux recurrence and the return of the previous pathological situation; this chain of events has been termed the hemodynamic paradox. But this review showed that varicose veins could be improved quickly through lower leg muscles (especially calf muscle) regeneration by increasing mitochondrial cellular energy (adenosine triphosphate) of leg muscles without removing varicose veins.

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.

Venous hypertension, caused by venous reflux, often leads to heaviness, swelling, and pain in the legs. However, the hemodynamics of venous flow are complex and incomprehensible, with a frequently unclear correlation between reflux and symptoms. Regarding treatment options, removal of saphenous veins (SVs) based on a few seconds of reflux can adversely affect patients. Further, indiscriminate removal of SVs in aging populations may complicate future treatment of arterial diseases. Patients should be treated selectively based on ultrasound examinations and hemodynamic principles. The CHIVA strategy, which involves treating patients without removing SVs, is a potential treatment option for patients with mild chronic venous insufficiency. In this context, we introduce the Teupitz shunt classification, which forms the basis for hemodynamic correction.

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.

Treatment decision of varicose veins should be made based on the patient’s symptoms, but it is important to confirm the presence of reflux when selecting a treatment method. The definition of reflux, which is the core of ultrasound diagnosis of varicose veins, is recommended as follows. In the case of the great saphenous vein, anterior and posterior accessory saphenous vein, small saphenous vein, perforating vein, tibial vein, and deep femoral vein, reverse flow of more than 0.5 seconds is considered as reflux. In the case of the common femoral vein, femoral vein, and popliteal vein, reverse flow of more than 1.0 seconds is considered as reflux. In cases of reticular veins, spider veins, and telangiectasia, because the clinical significance of measuring reflux through ultrasound has not yet been proven and they are often observed regardless of saphenous vein reflux, ultrasound diagnostic criteria are not provided.