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.

Lymphedema is a chronic progressive condition caused by insufficient lymphatic drainage and subsequent stasis of protein-rich interstitial fluid. When it occurs, the lymphatic fluid becomes stagnant, causing tissue fibrosis, hypertrophic fat, and lymphatic vessel destruction, ultimately leading to skin ulceration and infection. Lymphedema can be a debilitating disease in patients and has a dramatic negative effect on their quality of life. Invasive reductive procedures such as the Charles operation were previously performed, but this resulted in extensive scarring and substantial morbidity, including significant blood loss or infection. Therefore, in recent years, physiologic surgeries such as lymphaticovenular anastomosis and vascularized lymph node transfer have become increasingly popular. This article reviews recent trends in the surgical management of lymphedema from physiologic surgery to preventive lymphatic reconstruction.

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.

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.

Functional chronic venous disease (FCVD; C0 category of clinical manifestation, etiology, anatomic distribution, and pathophysiology classifications) is an underestimated syndrome that affects up to 20% of the general population. FCVD is based on the presence of venous symptoms without instrumental evidence of anatomical or morphological changes. The prevalence of FCVD is underestimated owing to a lack of awareness in Western countries. Given the inflammatory nature of FCVD, we speculate that noninvasive treatments including vasoactive drugs and elastic stockings would easily relieve C0 symptoms.

Background: This study aimed to explore the current practices and views of members of the Korean Society for Phlebology regarding incompetent small saphenous veins (SSV).
Methods: A questionnaire was sent to the Korean Society for Phlebology members via email. Of 291 members contacted, 47 responded.
Results: Preoperative duplex ultrasonography was performed by 85% of the respondents who were operating surgeons, and 92% marked the course of the SSV preoperatively using ultrasound guidance. The same treatment option was performed for all cases, regardless of anatomy or insurance coverage, by 21%. Seven members performed flush ligation at the saphenopopliteal junction (SPJ) during the surgical treatment. Four members reported positioning the terminal end of the catheter at the SPJ during the endovenous treatment. Three respondents performed endovenous thermal ablation (ETA) without tumescent instillation, and three injected tumescent solutions without ultrasound guidance. Twelve respondents performed high ligation during the ETA.
Conclusion: We verified various approaches to managing SSV among the Korean Society for Phlebology members. Evidence-based practical guidelines and education regarding the management of SSV are necessary for proper management.

Objective: To establish trust between patients and medical staff, and to reduce patient and guardian anxiety before surgery, we have developed and implemented the “Next of Kin Observation of Surgery Intervention” (NoKOSI). It includes a comprehensive process with sufficient explanation prior to surgery, especially attendance of family guardian during the operation.
Methods: We conducted a pilot study to evaluate the possibility of using the NoKOSI system before conducting the main study which will identify whether this system reduces anxiety and determine any clinical significance. The study included 133 patients (mean age, 52.3±13.8 and majority female gender, 88 [66.2%]) who underwent varicose vein surgery under local anesthesia between May 2022 and August 2022. The primary outcome was the actual observation rate of the participants with the NoKOSI system. The secondary outcomes were to analyze differences in modified Amsterdam Preoperative Anxiety and Information Score (mAPAIS) between the observing group (Group O) and non-observing group (Group NO).
Results: Of the 133 surgeries, 44 (33%) voluntarily participated in NoKOSI (Group O). There was no difference between the two groups in relation to age, sex, comorbidity, Chronic Venous Insufficiency, Quality of Life Scale-14 score, Venous Clinical Severity Score (VCSS), patient-reported symptom severity score (0~5), and surgical method. There was no statistical correlation between the preoperative mAPAIS score and the operative Visual Analogue Scale in all patients (r=0.013, p=ns). However, the preoperative anxiety score was significantly correlated with the Family Guardian Observation Request Scale (r=0.474, p=0.000). Of the 11 patients who reported their impression, ten gave a positive opinion and one a negative opinion. Of the 49 reported guardian responses, 38 (77.6%) were positive and 11 (22.4%) were negative.
Conclusion: In varicose vein surgeries performed under local anesthesia, 33% of family or guardians participated in NoKOSI. The necessity and efficacy of NoKOSI should be further investigated in larger prospective studies.

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.

Popliteal vein aneurysms are a rare vascular condition that can determine severe complications as pulmonary embolism. We report 2 cases of 56 and 33-years old women, respectively, affected by a saccular popliteal vein aneurysm. Duplex scan and angiography computed tomography have been essential for a correct diagnosis and planning of both treatments. At first, the patients were subjected to anticoagulant therapy with low-molecular-weight heparin (LMWH) pending completion of the pre-operative investigations. The patients were treated surgically with tangential aneurysmectomy with lateral venorrhaphy. Follow-up at 1 and 3 months revealed normal patency of the femoro-popliteal vein axis. Neither sensory nor motor deficit were observed. Popliteal vein aneurysms are rare but have been investigated, especially in case of recurrent thrombo-embolism events. The treatment is only surgical and can be easily approached by prone positions according to the surgeon experience.