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.

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.

The objectives of ultrasound follow-up encompass several critical aspects. Primarily, ultrasound is employed post-surgery to assess the efficacy of the treatment and ascertain the potential occurrence of complications and recurrence. Furthermore, the gathered data serves as valuable material for research and facilitates outcome analysis. Fundamentally, long-term follow-up aids in comprehending the natural progression of varicose veins. Immediate postoperative observation is typically conducted within a week to a month following surgery, with the primary aim of verifying the success of the ablation procedure. Late follow-up, typically conducted after one month, focuses on varicose vein recurrence and assesses the long-term outcomes of the surgery. Short-term recurrence (occurring in less than one year), often serves as a predictor for long-term recurrence, extending beyond five years. Given the low incidence of deep vein thrombosis after saphenous ablation, routine surveillance may not be deemed cost-effective. While long-term follow-up may be conducted as needed, it serves a dual purpose of not only monitoring treatment effectiveness and potential recurrences but also contributing to our understanding of the natural course of chronic venous disease, which is often associated with aging.

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.

Varicose veins are consistent with physically dilated superficial veins ≥3 mm. Physiologically, chronic venous insufficiency is an advanced chronic venous disease with functional abnormalities. Essentially, the shape of the vein is directly influenced by hydrostatic pressure. Ambulatory venous pressure is increased as shunt formation and vein will be dilated by the connection with deep venous refluxes. Hydrostatic parodox in varicose veins is that the ambulatory venous pressure is not directly related with vein diameter but with shunt formation with valve insufficiency. Mean ambulatory venous pressure of 10–30 mmHg is considered as normal, 31–45 mmHg as intermediate and >45 mmHg as severe venous hypertension. Diameter measurement is used in the diagnosis of varicose veins, but treatment need to be more focused to remove hydrostatic pressure rather than diameter of vein in respect to improve symptoms related with varicose veins. Nevertheless, there are some concerns for the treatment of large veins. From the guidelines endothermal ablation is recommended than non-thermal ablation for >10 mm large varicose vein. Large veins might increase the incidence of endothermal heat induced thrombosis. Caprini score more than 7 will be benefited from chemoprophylaxis for large vein. For the compression therapy, inelastic compression is recommended than elastic compression to improve the function of calf muscle pump.

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.

Objective: This study aimed to determine the correlation between nocturnal leg cramps and duplex ultrasound scanning (DUS) findings in patients with lower-extremity chronic venous disease with incompetent saphenous veins.
Methods: A total of 1668 limbs from 888 patients with signs and symptoms of chronic venous disease (CVD) were evaluated using DUS from April 2017 to December 2020. Limbs with saphenous vein reflux were selected for this study. Patients with a history of treatment for varicose veins, including sclerotherapy, were excluded from the study. The clinical data and DUS results were obtained retrospectively from medical records and analyzed.
Results: Nine hundred and forty limbs from 582 patients were included in this study, 66% were female patients, and the mean age was 55 (19∼86) years. There were no statistically significant differences in the distribution of sex, laterality, and CEAP clinical stage between the legs with or without nocturnal leg cramps. Age and body mass index were significantly different between legs with and without nocturnal leg cramps (p=0.02 for age and p=0.03 for BMI), but the correlations were weak (Cramer’s V=0.11 for age and 0.08 for BMI). The distribution of incompetent saphenous veins, deep vein insufficiency, and the diameter and reflux duration of incompetent saphenous veins did not correlate with nocturnal leg cramps.
Conclusion: Nocturnal leg cramps were not correlated with the distribution of valve failure in the venous system of the lower extremities.

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.

Misnomers, erroneous or inappropriate designations, are a common occurrence in the medical field, often leading to confusion, misdiagnosis, and misguided treatment approaches. Within the realm of venous diseases, misnomers frequently arise in the form of inaccurate names assigned to conditions or clinical findings. The use of accurate terminology becomes essential in facilitating effective communication between venous specialists and patients. Employing precise and descriptive language improves the accuracy of diagnoses, enabling the implementation of appropriate treatment strategies and reduces cost and use of staff resources. This article aims to present prevalent misnomers in venous disease and to rectify them by employing the correct terminology, thereby enhancing patient care.