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Ann Phlebology 2023; 21(2): 66-69

Published online December 31, 2023

https://doi.org/10.37923/phle.2023.21.2.66

© Annals of phlebology

Ultrasonographic Reflux Findings of Varicose Veins of the Lower Extremities - The 2023 Korean Society for Phlebology Clinical Practice Guidelines

Sangchul Yun, M.D.1, Tae Sik Kim, M.D.2, Wooshik Kim, M.D.3, Heangjin Ohe, M.D.4, Seung Chul Lee, M.D.5, Sung Ho Lee, M.D.6 and Sang Seob Yun, M.D.7

1Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, 2Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Seoul, 3Department of Thoracic and Cardiovascular Surgery, National Medical Center, Seoul, 4Division of Vascular and Transplant, Department of Surgery, Inje University Haeundae Paik Hospital, Busan, 5Easyleg Clinic, Seoul, 6Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, 7Division of Vascular and Transplant Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea

Correspondence to : Tae Sik Kim
Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital
Tel: 82-2-2626-1180, Fax: 82-2-2626-1188
E-mail: kmdphd@gmail.com

Received: November 24, 2023; Revised: November 29, 2023; Accepted: December 12, 2023

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.

Keywords Varicose veins, Ultrasonography, Lower extremity, Diagnosis, Guideline

Doppler ultrasound is used in the diagnosis of varicose veins. The lower limb veins are able to be assessed easily with ultrasound. A downside is that the results differ depending on the examiner’s skill, the testing method, and the recording method. To derive standardized testing methods and results, it will be necessary to prepare examination guidelines based on clinical research and practical expe-rience. We aim to produce evidence-based standard recommendations based on key questions from reported data, rather than individual experience. Some parts with a shortage of comparative research or excessive debate were excluded. However, for some fields with high clinical significance and where the opinions of experts were consistent, even in the absence of sufficient evidence in the literature, recommendations were prepared based on a consensus using the nominal group technique. In this review, we prepared recommendations for the definition of reflux, which is a main aspect of ultrasound diagnosis of varicose veins (Table 1).

Table 1 . Key Question 5. What are the criteria for positive reflux in each target vessels in varicose veins?

RecommendationStrength of recommendationReferences
5-1. At least 0.5 second of reflux is considered a positive result for the great saphenous vein (GSV), anterior/posterior accessory saphenous veins (AASV/PASV), small saphenous vein (SSV), perforating vein, tibial vein, and deep femoral vein.Strong1-15
5-2. At least 1.0 second of reflux is considered a positive result for the common femoral vein, femoral vein, and popliteal vein.Strong4, 8, 9, 16
5-3. Reticular veins, spider veins, and telangiectasias are commonly observed even in the absence of reflux in the saphenous veins, and their clinical significance in the measurement of reflux under ultrasound has not yet been demonstrated. As such, ultrasound diagnostic criteria for these conditions are not presented.Insufficient17-21

5-1. At least 0.5 second of reflux is considered a positive result for the great saphenous vein (GSV), anterior/posterior accessory saphenous veins (AASV/PASV), small saphenous vein (SSV), perforating vein, tibial vein, and deep femoral vein

The diagnosis of varicose veins is achieved by diagnosing reflux due to valve insufficiency. It is recommended to assess reflux in all veins of the lower limb, including not only the deep veins, the great saphenous vein (GSV), and the small saphenous vein (SSV), but also accessory saphenous veins, and the perforating vein (1). When testing for reflux due to venous insufficiency, the test is performed with the patient standing, and, either the Valsalva maneuver is used to increase abdominal pressure and induce reflux in the proximal veins, or a hand or toniquet is used to apply pressure and induce reflux in the distal veins. After applying pressure to the calf using a hand, the reflux are examined while releasing the pressure (2). Although the international consensus was previously to observe reflux for at least 0.5 s irrespective of the type of vein (3), the threshold for reflux in the femoral and popliteal veins is 1 s, in the GSV, SSV, tibial vein, and deep femoral vein is 0.5 s (2,4,5), and, likewise, 0.5 s is considered reflux in the other superficial truncal veins, including the anterior accessory saphenous vein (AASV) (6). In previous guidelines, the threshold for reflux in the perforating vein was 0.35 s (7). According to clinicians, at least 0.5 s of reflux is defined as a positive result, and many clinical guidelines and documents define perforating vein insufficiency as at least 0.5 s of reflux after applying pressure to the calf (4,8,9).

Labropoulos et al. (2) studied ultrasound to assess 80 lower limbs in 40 healthy volunteers and 60 lower limbs in 45 chronic venous disease patients. At least 0.5 s of abnormal reflux in the GSV, SSV, tibial vein, or deep femoral vein could be taken as a standard for reflux. The analysis included a total of 273 perforating veins from healthy volunteers, and the duration of reflux flow in the perforating vein, irrespective of location, was measured between 0 and 0.76 s (mean, 0.17 s), but reflux was less than 0.35 s in 97% of perforating veins. In particular, the reflux duration was longer for perforating veins in the calf than in the thigh (mean, 180 ms [95% CI, 176∼184] vs 150 ms [95% CI, 145∼155]; p<0.0001). Among the patients, there were 71 out of 312 perforating veins showing a reflux duration of at least 0.5 s. Using a threshold of 0.35 s, 82 perforating veins could be diagnosed with reflux. Although an arbitrary threshold of 0.5 s has been used to date, this study suggests that the definition of reflux for the perforating vein could be lowered to 0.35 s. Based on this study, Labropoulos et al. (10) performed follow-up research using a threshold of 0.35 s for reflux in the perforating vein.

Nevertheless, there is still debate about the definition of reflux in the perforating vein, and research is ongoing, including studies on the vein diameter. In Doppler ultrasound, generally, pathologic reflux can be considered when the reflux waveform is over 0.35 s, the vein diameter is over 3.5 mm, and especially, when accompanied by skin lesions (2,11). Sandri et al. (11) reported that the diameter was greater than 3.5 mm in over 90% of cases of perforating vein insufficiency, and the SVS/AVF guidelines define pathologic perforating vein as cases with at least 0.5 s of reflux, at least 3.5 mm diameter, and skin ulcers (12) Labropoulos et al. (13) diagnosed perforating vein insufficiency when the diameter was at least 3.9 mm under ultrasound, and reported a sensitivity of 73% and specificity of 96%. However, in one-third of cases of perforating vein accompanied by reflux, the diameter was less than 3.9 mm. Moreover, since the diameter of the perforating veins differs depending on the location, irrespective of reflux, it is difficult to diagnose perforating vein insufficiency based on diameter. We do not recommend diagnosing reflux based on only vein diameter under ultrasound, but rather using the reflux duration (1,4,5).

Labropoulos recently elucidated the characteristics of the perforating veins (14). They reported that, although the perforating vein diameter was small and reflux could be defined as 0.35 s in their study, a threshold value of 0.5 s could simply be used for superficial veins. In varicose veins, perforating veins can also dilate to handle the increased blood flow over time, and as the disease progresses, the connecting perforating veins can also show varicose changes (10). Primary reflux in the perforating veins has not been observed when the superficial veins are competent, and all cases of reflux in perforating veins are reported to be associated with reflux in superficial veins. In addition, bidirectional flow is observed in the perforating veins of healthy individuals without varicose veins. As such, reflux can be defined as reflux flow exceeding 0.5 s (net outward flow >500 ms) (15).

5-2. At least 1.0 second of reflux is considered a positive result for the common femoral vein, femoral vein, and popliteal vein

Regarding the minimum value of 1.0 s for reflux in the femoral and popliteal veins, this is the definition that has been used in several previous guidelines and studies. This committee will continue using this value without modifications (4,8,9,16).

5-3. Reticular veins, spider veins, and telangiectasias are commonly observed even in the absence of reflux in the saphenous veins, and their clinical significance in the measurement of reflux under ultrasound has not yet been demonstrated. As such, ultrasound diagnostic criteria for these conditions are not presented

Several researchers have attempted to investigate the relationship between reticular veins and telangiectasias accompanied by Doppler reflux (17-19). The researchers reported that telangiectasias, which are connected, via small perforating veins around the knee, in a superficial reticular venous network that drains into the deep veins, could be a separate venous system from the saphenous veins. As such, the pathophysiological mechanisms causing clinical symptoms such as saphenous vein insufficiency appear to have a different cause from telangiectasias. In the Edinburgh Vein Study, there was no clear causal relationship between saphenous vein reflux and telangiectasias (20). Instead, increasing telangiectasia severity was associated with increasing frequency and severity of varicose veins. The majority of clinicians have considered that, in this case, resolving varicosity of the saphenous veins is a precondition to the successful management of telangiectasias. However, 51.4% of severe telangiectasia patients and 75.7% of mild telangiectasia patients do not have accompanying saphenous vein insufficiency, suggesting that the two pathophysiological systems are different (20). The Edinburgh Vein Study showed that there was no symptomatic and anatomical relationship between the saphenous system and the reticular network, which supplies blood to telangiectasia. Varicose veins and telangiectasias shows similar symptoms that typically co-occur. We are not aware of any scientific research regarding the effects of treating one system on the other system, or of any evidence suggesting which system to treat first. This is a topic where randomized clinical studies should be conducted. The European guidelines for sclerotherapy (21) report that, while there is a trend for using Doppler ultrasound to examine telangiectasias and reticular veins before treatment, CW-doppler alone may be sufficient (recommendation 13, grade 1C. European guidelines for sclerotherapy). Nevertheless, when anatomical or hemodynamic examination is required, such as in cases of recurrent varicose veins or vascular malformation, Doppler ultrasound must be performed before sclerotherapy (recommendation 14, grade 1B).

Chronic venous disease can have various presentations, and the extent of varicose veins, symptoms, and reflux differ between patients. Treatment decisions must, above all, be based on the patient’s symptoms. However, it is also important to check for reflux when choosing the treatment method. Nevertheless, when inappropriate treatment is selected due to concerns about recurrence or the therapeutic effects, it can lead to an increase in medical expenses and the rate of complications. For this reason, it is crucial to select the treatment method based on the results of a standardized Doppler ultrasound examination.

There were no financial conflicts of interest for any of the participants involved in revising the guidelines.

  1. Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg 2006;31:83-92.
  2. Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS, Ashraf Mansour M, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003;38:793-8.
  3. Nicolaides AN, Allegra C, Bergan J, Bradbury A, Cairols M, Carpentier P, et al. Management of chronic venous disorders of the lower limbs: guidelines according to scientific evidence. Int Angiol 2008;27:1-59.
  4. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011;53:2S-48S.
  5. Wittens C, Davies AH, Bækgaard N, Broholm R, Cavezzi A, Chastanet S, et al. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015;49:678-737.
  6. Deol ZK, Lakhanpal S, Pappas PJ. Severity of disease and treatment outcomes of anterior accessory great saphenous veins compared with the great saphenous vein. J Vasc Surg Venous Lymphat Disord 2022;10:654-60.
  7. JYK Haengjin Ohe, Lee Hogyun, Park Geunmyeong, Park Junho, Hwang Hongpil, Park Insu, Yun Sangchul, Hong Ki-Pyo, Park Jong Kwon, Jang Jae-Han, Yun Sang Seob. Draft Revision of Clinical Practice Guidelines for Varicose Veins -Diagnosis. Annals of Phlebology 2020;18:23-8.
  8. O'Donnell TF Jr., Passman MA. Clinical practice guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF)--Management of venous leg ulcers. Introduction. J Vasc Surg 2014;60:1S-2S.
  9. De Maeseneer M, Pichot O, Cavezzi A, Earnshaw J, van Rij A, Lurie F, et al. Duplex ultrasound investigation of the veins of the lower limbs after treatment for varicose veins - UIP consensus document. Eur J Vasc Endovasc Surg 2011;42:89-102.
  10. Labropoulos N, Tassiopoulos AK, Bhatti AF, Leon L. Development of reflux in the perforator veins in limbs with primary venous disease. J Vasc Surg 2006;43:558-62.
  11. Sandri JL, Barros FS, Pontes S, Jacques C, Salles-Cunha SX. Diameter-reflux relationship in perforating veins of patients with varicose veins. J Vasc Surg 1999;30:867-74.
  12. Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, et al. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2023;11:231-61 e6.
  13. Labropoulos N, Mansour MA, Kang SS, Gloviczki P, Baker WH. New insights into perforator vein incompetence. Eur J Vasc Endovasc Surg 1999;18:228-34.
  14. Labropoulos N. Current Views on the Management of Incompetent Perforator Veins. Annals of phlebology 2020;18:1-3.
  15. Sarin S, Scurr JH, Smith PD. Medial calf perforators in venous disease: the significance of outward flow. J Vasc Surg 1992;16:40-6.
  16. De Maeseneer MG, Kakkos SK, Aherne T, Baekgaard N, Black S, Blomgren L, et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg 2022;63:184-267.
  17. Thibault P, Bray A, Wlodarczyk J, Lewis W. Cosmetic leg veins: evaluation using duplex venous imaging. J Dermatol Surg Oncol 1990;16:612-8.
  18. Weiss RA, Weiss MA. Doppler ultrasound findings in reticular veins of the thigh subdermic lateral venous system and implications for sclerotherapy. J Dermatol Surg Oncol 1993;19:947-51.
  19. Somjen GM, Ziegenbein R, Johnston AH, Royle JP. Anatomical examination of leg telangiectases with duplex scanning. J Dermatol Surg Oncol 1993;19:940-5.
  20. Ruckley CV, Evans CJ, Allan PL, Lee AJ, Fowkes FG. Telangiectasia in the Edinburgh Vein Study: epidemiology and association with trunk varices and symptoms. Eur J Vasc Endovasc Surg 2008;36:719-24.
  21. Rabe E, Breu FX, Cavezzi A, Coleridge Smith P, Frullini A, Gillet JL, et al. European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2014;29:338-54.

Review Article

Ann Phlebology 2023; 21(2): 66-69

Published online December 31, 2023 https://doi.org/10.37923/phle.2023.21.2.66

Copyright © Annals of phlebology.

Ultrasonographic Reflux Findings of Varicose Veins of the Lower Extremities - The 2023 Korean Society for Phlebology Clinical Practice Guidelines

Sangchul Yun, M.D.1, Tae Sik Kim, M.D.2, Wooshik Kim, M.D.3, Heangjin Ohe, M.D.4, Seung Chul Lee, M.D.5, Sung Ho Lee, M.D.6 and Sang Seob Yun, M.D.7

1Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, 2Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Seoul, 3Department of Thoracic and Cardiovascular Surgery, National Medical Center, Seoul, 4Division of Vascular and Transplant, Department of Surgery, Inje University Haeundae Paik Hospital, Busan, 5Easyleg Clinic, Seoul, 6Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, 7Division of Vascular and Transplant Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea

Correspondence to:Tae Sik Kim
Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital
Tel: 82-2-2626-1180, Fax: 82-2-2626-1188
E-mail: kmdphd@gmail.com

Received: November 24, 2023; Revised: November 29, 2023; Accepted: December 12, 2023

Abstract

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.

Keywords: Varicose veins, Ultrasonography, Lower extremity, Diagnosis, Guideline

Introduction

Doppler ultrasound is used in the diagnosis of varicose veins. The lower limb veins are able to be assessed easily with ultrasound. A downside is that the results differ depending on the examiner’s skill, the testing method, and the recording method. To derive standardized testing methods and results, it will be necessary to prepare examination guidelines based on clinical research and practical expe-rience. We aim to produce evidence-based standard recommendations based on key questions from reported data, rather than individual experience. Some parts with a shortage of comparative research or excessive debate were excluded. However, for some fields with high clinical significance and where the opinions of experts were consistent, even in the absence of sufficient evidence in the literature, recommendations were prepared based on a consensus using the nominal group technique. In this review, we prepared recommendations for the definition of reflux, which is a main aspect of ultrasound diagnosis of varicose veins (Table 1).

Table 1 . Key Question 5. What are the criteria for positive reflux in each target vessels in varicose veins?.

RecommendationStrength of recommendationReferences
5-1. At least 0.5 second of reflux is considered a positive result for the great saphenous vein (GSV), anterior/posterior accessory saphenous veins (AASV/PASV), small saphenous vein (SSV), perforating vein, tibial vein, and deep femoral vein.Strong1-15
5-2. At least 1.0 second of reflux is considered a positive result for the common femoral vein, femoral vein, and popliteal vein.Strong4, 8, 9, 16
5-3. Reticular veins, spider veins, and telangiectasias are commonly observed even in the absence of reflux in the saphenous veins, and their clinical significance in the measurement of reflux under ultrasound has not yet been demonstrated. As such, ultrasound diagnostic criteria for these conditions are not presented.Insufficient17-21

Key Question 5. What are the criteria for positive reflux in each target vessels in varicose veins?

5-1. At least 0.5 second of reflux is considered a positive result for the great saphenous vein (GSV), anterior/posterior accessory saphenous veins (AASV/PASV), small saphenous vein (SSV), perforating vein, tibial vein, and deep femoral vein

The diagnosis of varicose veins is achieved by diagnosing reflux due to valve insufficiency. It is recommended to assess reflux in all veins of the lower limb, including not only the deep veins, the great saphenous vein (GSV), and the small saphenous vein (SSV), but also accessory saphenous veins, and the perforating vein (1). When testing for reflux due to venous insufficiency, the test is performed with the patient standing, and, either the Valsalva maneuver is used to increase abdominal pressure and induce reflux in the proximal veins, or a hand or toniquet is used to apply pressure and induce reflux in the distal veins. After applying pressure to the calf using a hand, the reflux are examined while releasing the pressure (2). Although the international consensus was previously to observe reflux for at least 0.5 s irrespective of the type of vein (3), the threshold for reflux in the femoral and popliteal veins is 1 s, in the GSV, SSV, tibial vein, and deep femoral vein is 0.5 s (2,4,5), and, likewise, 0.5 s is considered reflux in the other superficial truncal veins, including the anterior accessory saphenous vein (AASV) (6). In previous guidelines, the threshold for reflux in the perforating vein was 0.35 s (7). According to clinicians, at least 0.5 s of reflux is defined as a positive result, and many clinical guidelines and documents define perforating vein insufficiency as at least 0.5 s of reflux after applying pressure to the calf (4,8,9).

Labropoulos et al. (2) studied ultrasound to assess 80 lower limbs in 40 healthy volunteers and 60 lower limbs in 45 chronic venous disease patients. At least 0.5 s of abnormal reflux in the GSV, SSV, tibial vein, or deep femoral vein could be taken as a standard for reflux. The analysis included a total of 273 perforating veins from healthy volunteers, and the duration of reflux flow in the perforating vein, irrespective of location, was measured between 0 and 0.76 s (mean, 0.17 s), but reflux was less than 0.35 s in 97% of perforating veins. In particular, the reflux duration was longer for perforating veins in the calf than in the thigh (mean, 180 ms [95% CI, 176∼184] vs 150 ms [95% CI, 145∼155]; p<0.0001). Among the patients, there were 71 out of 312 perforating veins showing a reflux duration of at least 0.5 s. Using a threshold of 0.35 s, 82 perforating veins could be diagnosed with reflux. Although an arbitrary threshold of 0.5 s has been used to date, this study suggests that the definition of reflux for the perforating vein could be lowered to 0.35 s. Based on this study, Labropoulos et al. (10) performed follow-up research using a threshold of 0.35 s for reflux in the perforating vein.

Nevertheless, there is still debate about the definition of reflux in the perforating vein, and research is ongoing, including studies on the vein diameter. In Doppler ultrasound, generally, pathologic reflux can be considered when the reflux waveform is over 0.35 s, the vein diameter is over 3.5 mm, and especially, when accompanied by skin lesions (2,11). Sandri et al. (11) reported that the diameter was greater than 3.5 mm in over 90% of cases of perforating vein insufficiency, and the SVS/AVF guidelines define pathologic perforating vein as cases with at least 0.5 s of reflux, at least 3.5 mm diameter, and skin ulcers (12) Labropoulos et al. (13) diagnosed perforating vein insufficiency when the diameter was at least 3.9 mm under ultrasound, and reported a sensitivity of 73% and specificity of 96%. However, in one-third of cases of perforating vein accompanied by reflux, the diameter was less than 3.9 mm. Moreover, since the diameter of the perforating veins differs depending on the location, irrespective of reflux, it is difficult to diagnose perforating vein insufficiency based on diameter. We do not recommend diagnosing reflux based on only vein diameter under ultrasound, but rather using the reflux duration (1,4,5).

Labropoulos recently elucidated the characteristics of the perforating veins (14). They reported that, although the perforating vein diameter was small and reflux could be defined as 0.35 s in their study, a threshold value of 0.5 s could simply be used for superficial veins. In varicose veins, perforating veins can also dilate to handle the increased blood flow over time, and as the disease progresses, the connecting perforating veins can also show varicose changes (10). Primary reflux in the perforating veins has not been observed when the superficial veins are competent, and all cases of reflux in perforating veins are reported to be associated with reflux in superficial veins. In addition, bidirectional flow is observed in the perforating veins of healthy individuals without varicose veins. As such, reflux can be defined as reflux flow exceeding 0.5 s (net outward flow >500 ms) (15).

5-2. At least 1.0 second of reflux is considered a positive result for the common femoral vein, femoral vein, and popliteal vein

Regarding the minimum value of 1.0 s for reflux in the femoral and popliteal veins, this is the definition that has been used in several previous guidelines and studies. This committee will continue using this value without modifications (4,8,9,16).

5-3. Reticular veins, spider veins, and telangiectasias are commonly observed even in the absence of reflux in the saphenous veins, and their clinical significance in the measurement of reflux under ultrasound has not yet been demonstrated. As such, ultrasound diagnostic criteria for these conditions are not presented

Several researchers have attempted to investigate the relationship between reticular veins and telangiectasias accompanied by Doppler reflux (17-19). The researchers reported that telangiectasias, which are connected, via small perforating veins around the knee, in a superficial reticular venous network that drains into the deep veins, could be a separate venous system from the saphenous veins. As such, the pathophysiological mechanisms causing clinical symptoms such as saphenous vein insufficiency appear to have a different cause from telangiectasias. In the Edinburgh Vein Study, there was no clear causal relationship between saphenous vein reflux and telangiectasias (20). Instead, increasing telangiectasia severity was associated with increasing frequency and severity of varicose veins. The majority of clinicians have considered that, in this case, resolving varicosity of the saphenous veins is a precondition to the successful management of telangiectasias. However, 51.4% of severe telangiectasia patients and 75.7% of mild telangiectasia patients do not have accompanying saphenous vein insufficiency, suggesting that the two pathophysiological systems are different (20). The Edinburgh Vein Study showed that there was no symptomatic and anatomical relationship between the saphenous system and the reticular network, which supplies blood to telangiectasia. Varicose veins and telangiectasias shows similar symptoms that typically co-occur. We are not aware of any scientific research regarding the effects of treating one system on the other system, or of any evidence suggesting which system to treat first. This is a topic where randomized clinical studies should be conducted. The European guidelines for sclerotherapy (21) report that, while there is a trend for using Doppler ultrasound to examine telangiectasias and reticular veins before treatment, CW-doppler alone may be sufficient (recommendation 13, grade 1C. European guidelines for sclerotherapy). Nevertheless, when anatomical or hemodynamic examination is required, such as in cases of recurrent varicose veins or vascular malformation, Doppler ultrasound must be performed before sclerotherapy (recommendation 14, grade 1B).

Conclusion

Chronic venous disease can have various presentations, and the extent of varicose veins, symptoms, and reflux differ between patients. Treatment decisions must, above all, be based on the patient’s symptoms. However, it is also important to check for reflux when choosing the treatment method. Nevertheless, when inappropriate treatment is selected due to concerns about recurrence or the therapeutic effects, it can lead to an increase in medical expenses and the rate of complications. For this reason, it is crucial to select the treatment method based on the results of a standardized Doppler ultrasound examination.

Conflict of interest

There were no financial conflicts of interest for any of the participants involved in revising the guidelines.

Table 1 . Key Question 5. What are the criteria for positive reflux in each target vessels in varicose veins?.

RecommendationStrength of recommendationReferences
5-1. At least 0.5 second of reflux is considered a positive result for the great saphenous vein (GSV), anterior/posterior accessory saphenous veins (AASV/PASV), small saphenous vein (SSV), perforating vein, tibial vein, and deep femoral vein.Strong1-15
5-2. At least 1.0 second of reflux is considered a positive result for the common femoral vein, femoral vein, and popliteal vein.Strong4, 8, 9, 16
5-3. Reticular veins, spider veins, and telangiectasias are commonly observed even in the absence of reflux in the saphenous veins, and their clinical significance in the measurement of reflux under ultrasound has not yet been demonstrated. As such, ultrasound diagnostic criteria for these conditions are not presented.Insufficient17-21

References

  1. Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg 2006;31:83-92.
  2. Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS, Ashraf Mansour M, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003;38:793-8.
  3. Nicolaides AN, Allegra C, Bergan J, Bradbury A, Cairols M, Carpentier P, et al. Management of chronic venous disorders of the lower limbs: guidelines according to scientific evidence. Int Angiol 2008;27:1-59.
  4. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011;53:2S-48S.
  5. Wittens C, Davies AH, Bækgaard N, Broholm R, Cavezzi A, Chastanet S, et al. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015;49:678-737.
  6. Deol ZK, Lakhanpal S, Pappas PJ. Severity of disease and treatment outcomes of anterior accessory great saphenous veins compared with the great saphenous vein. J Vasc Surg Venous Lymphat Disord 2022;10:654-60.
  7. JYK Haengjin Ohe, Lee Hogyun, Park Geunmyeong, Park Junho, Hwang Hongpil, Park Insu, Yun Sangchul, Hong Ki-Pyo, Park Jong Kwon, Jang Jae-Han, Yun Sang Seob. Draft Revision of Clinical Practice Guidelines for Varicose Veins -Diagnosis. Annals of Phlebology 2020;18:23-8.
  8. O'Donnell TF Jr., Passman MA. Clinical practice guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF)--Management of venous leg ulcers. Introduction. J Vasc Surg 2014;60:1S-2S.
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Vol.21 No.2 Dec 31, 2023, pp. 53~98

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