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.

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.

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.

In diagnosing varicose veins, accurate ultrasound examinations and meticulous recording of findings are crucial, as they play a significant role in determining treatment methods. Therefore, the Korean Society of Phlebology, in collaboration with related societies, has developed guidelines for the ultrasound diagnosis of varicose veins, including standard recommendations for documenting examination records. After examining varicose veins, it is mandatory to record in writing the name of the blood vessel that was measured. For penetrating veins, it is also necessary to precisely record both the size and location. Additionally, during a provocation test involving compression, the augmented waveform and the regurgitation waveform must be documented so that they are distinctly visible in opposite directions around the baseline. Lastly, the reflux time should be specified in seconds or milliseconds.

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.

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.

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.

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.

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.