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.

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.

Although varicose veins are known to have a very high prevalence, there are many different treatment methods available. The optimal extent of treatment for the incompetent great saphenous vein has not yet been clearly established. Recent guidelines recommend the proper extent and method of treatment based on expert opinion. Considering complications and subjective data, such as symptoms and quality of life, above-the-knee treatment could be suggested. However, in terms of recurrence and objective data, below-the-knee treatment might be preferred. It would be better to approach treatment on a customized basis for each patient by carefully analyzing the results based on both subjective and objective data.

미국혈관외과학회(Society for Vascular Surgery), 미국정맥포럼(American Venous Forum), 미국정맥림프학회(American Vein and Lymphatic Society)는 2022년 하지정맥류에 대한 임상 진료 지침 파트 1을 발표하였다. 권고사항들은 체계적 문헌고찰 및 메타분석을 통한 최신 과학적 근거를 바탕으로 대상 환자, 중재시술, 비교시술, 그리고 결과시스템을 사용하여 하지 정맥류 치료에 영향을 미치는 5가지 중요 이슈와 관련된 중요 질문들에 대한 답변을 기반으로 한다. 파트 I에서는 하지정맥류의 평가와 얕은줄기정맥역류 치료에서 혈관초음파의 역할을 논의했다. 파트 II에서는 압박 치료, 약물치료 및 영양보충치료, 정맥류 분지의 진단 및 치료, 얕은정맥꽈리 치료, 정맥류의 합병증 관리 및 치료를 기반으로 정맥류 환자의 예방 및 치료를 뒷받침하는 증거에 중점을 둔다. 모든 지침은 체계적 문헌고찰들을 기반으로 GRADE 방법을 이용하여 근거수준과 권고 등급의 강도에 따라 평가되었다. 모든 권고 등급이 없는 합의문은 광범위한 문헌 검토와 전문가, 다학제 패널의 합의로 결정되었다. 권고 등급이 없는 적정 진료 권고사항은 간접적 증거만으로 뒷받침되었다. 그러나, 대다수 이해당사자들이 논란의 여지없이 동의하는 제안이다. 시행요점들에는 특정 권고사항들의 실행을 지지하는 기술 정보가 포함되어 있다. 이 포괄적인 문서에는 실무자가 하지 정맥류 환자에서 최신의 적정 진료를 하는 데 도움이 되는 모든 권고사항 목록(파트 I–II), 권고 등급이 없는 합의문, 시행요점 및 모범사례보고가 포함되어 있다.

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.

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.

Iliofemoral venous outflow obstruction, arising from nonthrombotic iliac vein lesions (NIVLs) or post-thrombotic disease (PTs), is a frequent culprit behind chronic venous signs and symptoms. In response, the adoption of deep venous stenting has gained traction, demonstrating commendable technical success and acceptable complication rates in the management of both acute and chronic venous obstruction. However, the focus on venous stent failure has intensified due to concerns related to in-stent restenosis or thrombosis. Such complications elevate the risks of symptom recurrence and thrombosis relapse, necessitating a judicious approach. The identified contributors to venous stent failure encompass multifaceted factors, including insufficient coverage of the affected area, inadequate vein inflow, inappropriate stent sizing, suboptimal drug therapy, patient non-compliance, stent migration, or fracture. This paper provides a comprehensive exploration of these factors associated with venous stent failure, shedding light on the complexities surrounding the efficacy and longevity of deep venous stenting in the context of iliofemoral venous outflow obstruction.

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.

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.

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.