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.

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.

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 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.

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.

Objective: We evaluated the effects of diaphragmatic deep breathing (DB) on venous return in symptomatic patients.
Methods: A prospective study was conducted on volunteers with venous symptoms. After ultrasound confirmation of deep vein patency, the blood flow velocity (peak systolic velocity, PSV) and volume in the common femoral vein (CFV) with duplex ultrasound and wash-out time of ⁹⁹Technetium-macroaggregated albumin (⁹⁹Tc-MAA) with radioisotope (RI) venography were measured in supine and standing positions. After practicing DB for a month, the blood flow volume, velocity, and wash-out time of ⁹⁹Tc-MAA were rechecked.
Results: In the supine position, the PSV of both CFVs and the flow volume of the right CFV were significantly increased after DB (p=0.043, all), while the flow volume of the left CFV did not show a significant change after DB (p=0.138). In the standing position, the PSV of the left CFV significantly increased (p=0.029). The time-to-peak and wash-out times of ⁹⁹Tc-MAA for both CFVs were significantly shorter with DB than with normal breathing (all, p＜0.05).
Conclusion: DB may have a beneficial effect on venous return in patients with symptomatic chronic venous disease. Further research is required to evaluate whether this could be an alternative therapeutic approach.

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.

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.

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.

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.