Since 2000, according to the recognition of varicose vein as a disease, the number of patients was increased by about three-times and the number of surgery gradually increases annually. Accordingly, financial expenses of medical insur-ance have become excessive and rising medical costs have been a problem. Eventually, HIRA (Health Insurance Review & Assessment service) evaluates the adequacy of surgery and imposes some restriction. The operator must check the venous-reflux of varicose vein by Duplex ultrasonography. Above all, classification of operation title must be made in detail and the criteria of adequacy also must be reviewed for appropriate compensation of varicose vein surgery. (Korean J Phlebology 2014;13:1-4)

Purpose: The purpose of this study is to investigate the trends of C-class and clinical departments, which are commonly used in clinical practice, to verify classification accuracy, and to provide preventive data through them. Method: This study is conducted on outpatients who visited one of clinic in Busan for 1 year. A Chi-square test is performed to examine the relationship between the clinical classification of patients and actual reflux diagnosis. In addition, a linear by linear analysis is performed to verify the tendency. Result: As a result, the study found that the proportion of middle-aged women was high in diagnosing varicose veins. In addition, as the C-class increased, the proportion of varicose vein reflux diagnosis tended to statistically significant increase (Test for trend=4.822, p＜.05). Conclusion: When it comes to the diagnosis of CVD, it seems reasonable to apply the C-class to Koreans. Generally, there would be a tendency that perception of C1 class is decreased. However, there was a relation between C1 and reflux of GSV or SSV more than 92%. (Ann Phlebology 2017;15:1-4)

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 (v.v) shows popular prevalence and needs for treatment is increasing. Endovenous laser therapy (EVLT) and radio-frequency ablation (EVRFA) is now recognized as the standard treatment modality for v.v because of various merits. After endovenous non-invasive treatment, remnant varicosity can be the problem. So simultaneous or later foam sclerotherapy or ambulatory microphlebectomy is now added in many EVLT/EVRFA patients. The effectiveness and necessity of additional treatment is debatable in the point of timing and choice of methods. However, it may be the trend to do the additional treatment for the EVLT/EVRFA patients of varicose vein. It is new and innovated treatment modality to do the foam sclerotherapy through endovenous approach using fluoroscopy. It shows more cure rate and less complication rate. Although it may be difficult to apply this treatment method in the entire institute to have the therapeutic clinics of varicose vein, it can open the field of treatment modality of varicose vein wider. And additional treatment for the EVLT/EVRFA is increasing and should be considered. (Korean J Phlebology 2014;13:10-14)

The following are included in the 2020 update of the CEAP classification: addition of the modifier “r” to the C2 and C6 recurrent disease, addition of corona phlebectatica to the C4 class as a separate subclass (C4c,) subcategorization of ES (secondary etiology) into ESi (intravenous secondary etiology) and Ese (extravenous secondary etiology), and the use of anatomic abbreviations instead of numbering the venous segments in the anatomical classification. Researchers should understand the definition of the recurrence of varicose veins and the diagnostic criteria of corona phlebectatica.

Objective To determine hemodynamic changes after surgical treatment for great saphenous vein (GSV) incompetence.
Methods According to clinical, etiological, anatomical, and pathophysiological classification, all patients were classified as C2EpAsPr. A total of 976 limbs of 900 patients with primary varicose veins who underwent surgical treatment at the Samsung Medical Center were retrospectively reviewed. Surgical modalities were high ligation (HL) with stripping, endovenous laser ablation (EVLA), and radiofrequency ablation (RFA) of GSV. Hemodynamic changes were measured using air plethysmography preoperatively and 1 and 6 months postoperatively. Duplex scans were performed to evaluate the GSV status after surgery.
Results Of the 900 patients, 250, 139, and 511 underwent EVLA, RFA, and HL with stripping, respectively. All groups showed a significant increase in the ejection fraction (EF) and a decrease in the venous volume (VV), venous filling index (VFI), and residual volume fraction (RVF) at 1 month postoperatively, compared with the corresponding preoperative values. When the rate of reduction was compared between the treatment modalities, the 1-month postoperative rate of reduction in the VV was higher in the RFA group and those of the VFI, EF, and RVF were higher in the HL with stripping group, compared with the other groups (p<0.05). The GSV occlusion rates at 1 and 6 months were 85.6% and 97.5% in the EVLA group and 95.7% and 99.4% in the RFA group, respectively.
Conclusion All three surgical modalities improved the hemodynamic parameters after treatment for GSV incompetence. Thus, appropriate surgical methods can be selected according to the patient’s condition and physician’s preference.

Objective: Edema of the lower extremities can occur in various situations. We aim to identify the causes of edema commonly encountered in clinical practice and determine the role of vascular specialists in lower extremity edema.
Methods: From January 1, 2019, to September 30, 2019, 112 medical records were reviewed retrospectively. We referred to the algorithm for leg edema. We proposed a final diagnosis based on the medical history, physical examination, laboratory tests, imaging studies, and consultation with other specialists.
Results: Among the 112 patients, 42 (37.5%) patients were diagnosed with chronic vascular disease. Overall, 28 (25%) patients had no clearly identified causes and were considered idiopathic. Another 28 (25%) patients had musculoskeletal disorders and 10 (2.9%) patients had medical disease. There were 4 isolated cases of dermatitis, insect bites, pregnancy, and morbid obesity. 24 cases (21.4%) of the 112 patients were diagnosed with lower-extremity varicose veins, with 17 (15.2%) patients showing reflux in the saphenous vein on Doppler ultrasound.
Conclusion: In this study, various leg edema indicated the need for interdisciplinary consultations and differential diagnoses. Chronic venous disease treatment does not seem to have an absolute significance in lower extremity edema. But, vascular specialists play the role of a control tower in diagnosing lower extremity edema.

Objective This study aims to evaluate the effect of treatment for great saphenous vein incompetence with a fourth-generation 1940 nm laser with radial fiber and catheter directed foam sclerotherapy (CDFS) without a tumescent simultaneously. The procedure was termed laser assisted sclerotherapy (LAST). It is a kind of thermochemical ablation.
Methods From January 1 to June 30, 2023, 86 GSV cases from 50 patients who underwent LAST at Cheongmac hospital were enrolled in this retrospective study. Endogenous laser ablation (EVLA) was performed in the order of accessary vein, tributaries and truncal vein and then followed by CDFS which was performed with a 3% sodium tetradecyl sulfate (STS) mixed with CO₂ gas at a ratio of 1:4. The degree of pain was measured after procedure at 2 hours after the procedure. Follow-up was conducted at 1 week, 1 month, and 6 months.
Results Three of the 86 GSV observed for >6 months showed mild reflux. According to size and number of ablated vessels, various energy level was needed. Three percent STS was used 4.5±0.4 cc and operation time per GSV was about 8±2 minutes. The VAS score was 2.5±0.6 at 2 hours after surgery. The closure rate was 100% at 6 months. Symptoms improved after 6 months in all patients (6.2±1.2 to 0.9±0.2).
Conclusion LAST showed a good closure rate in the early midterm follow up period. Ablation was possible with less energy compared with EVLA and the pain index was lower at the second hour after procedure.

Jongyoung Oh

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.

Chronic venous disorder (CVD) including varicose veins is very common health problem. The aim of this article is to introduce the classification of varicose veins and venous clinical severity scoring (VCSS) and Aberdeen varicose vein questionnaire (AVVQ) as objective and subjective evaluation tools. CEAP (clinical, etiologic, anatomic, pathophysiologic) classification is basic descriptive classification of varicose veins. It was adopted worldwide to communicate between clinicians about CVD and serve a basis for more scientific analysis. VCSS is useful assessment method of severity evaluation of CVD. It can be very useful in results assessment quantitatively. VCSS was designed not to replace of CEAP classification but, to supplement it. AVVQ is patient- reported quality of life measurement system. It is a valid and reliable outcome measurement for patients with varicose veins. These classification & measurement systems, based on correct diagnosis, were also to serve as a systematic guide of patients with CVD as an orderly documentation system and to help for decision making of appropriate treatment. 

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.

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.

Chronic venous disease is a progressive condition, and long-term follow-up is essential for a comprehensive understanding. In clinical practice, conducting extended follow-ups of patients is realistically challenging, and there is still much to learn about the clinical course of varicose veins. Given the gradual progression of chronic venous disease, gaining a precise understanding is crucial for guiding patient treatment. Chronic venous disease is progressive, and early interventions such as lifestyle modifications, medication, compression stockings, or surgery help slow and prevent the progression of the disease. Our objective is to review existing long-term follow-up studies to enhance the treatment approach for patients with varicose veins.

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.