Venous disease is progressive, leading to significant signs and symptoms including skin damage and ulceration (1). Superficial veins are most often involved in all CEAP classes including patients presenting with ulcers. Therefore earlier treatment may prevent/reduce such morbidity. History and physical examination are important together with ultrasound examination to provide an optimal plan for treatment. Ultrasound is crucial to determine different patterns of reflux and anatomic variations which are frequent in the superficial veins and define surrounding structures offering also good differential diagnosis. Its use is also essential for obtaining access and guiding the treatment and evaluating the effect of the treatment and disease progression. Venous reflux often originates from saphenous trunks and their tributaries (2). Great saphenous vein (GSV) is the longest vein in the body It originates from the dorsal vein of the big toe and marginal arch of the foot and joins the common femoral vein at the fossa ovalis (Fig. 1A). (3) Near saphenofemoral junction (SFJ), groin tributaries of the GSV have multiple anatomic variation (Fig. 1B). The diameter of GSV often varies as areas of aplasia and hypoplasia are common in the lower thigh, knee and calf. Small saphenous vein (SSV) originates from the dorsal vein of the fifth toe and runs along the posterior calf (Fig. 2). The GSV and SSV have major anatomical variations due to their embryological origin (4,5). Understanding of anatomic variations and reflux patterns is important to decide the treatment plan and which method to use. This will lead to better care and prevent future complications and recurrence. In this review, we purposed to review the reflux pattern of the saphenous origin and the corresponding treatment methods. Certainly, there are different ways to treat the superficial veins with comparable results in most occasion. This paper will illustrate the most common ways to address treatment in the superficial veins of the lower extremities.

Figure 1. Great saphenous vein (GSV). (A) Course of the GSV. (B) Groin tributaries of the GSV.

Figure 2. Course of small saphenous vein.

GSV is the longest vein in the body and has may patterns of reflux (Fig. 3). Patterns of GSV reflux and appropriate treatment method are as follows.

Figure 3. Patterns of great saphenous vein (GSV) reflux (A∼P).

• Reflux in the SFJ alone without any tributary being involved (Fig. 3A). Usually, no treatment is indicated.

• SFJ reflux with an accessory or tributary reflux is found in around 10% (Fig. 3B). In such cases only the tributary or the accessory vein is treated.

• Reflux in the GSV trunk and tributary (Fig. 3C, D). Both of these are common types of reflux. GSV main trunk ablation from the lowest point of reflux to 2∼3 cm below the SFJ. The tributaries are treated by phlebectomy or ultrasound guided foam sclerotherapy (UGFS).

• Uncommon type of reflux (<5%) involving the entire GSV with or without any major tributaries being involved (Fig. 3E, F). The pattern involving the entire GSV with major tributaries is more common than that without major tributaries but less prevalent than the segmental GSV reflux. The GSV is treated with ablation from upper calf to 2∼3 cm from the SFJ. The rest of the vein at the calf can be treated when necessary with UGFS, mechanochemical ablation (MOCA) or glue. The tributaries are treated by phlebectomies or UGFS.

• Common types of reflux involving the GSV but not the SFJ (Fig. 3G, H). The GSV is treated with ablation from upper calf to 2∼3 cm from the SFJ. The small competent segment proximally is not spared. The tributaries are treated by phlebectomies or UGFS.

• Common types of reflux involving the GSV and accessory veins (Fig. 3I, J). When the GSV and thigh accessory vein are involved, GSV is treated with ablation from upper calf to 2∼3 cm from the SFJ through the accessory vein. The segment below knee GSV is not treated. The tributaries are treated by phlebectomies or UGFS. When anterior accessory great saphenous vein (AAGSV) and the GSV are involved, Both the AAGSV and the GSV are ablated. The tributaries are treated by phlebectomies or UGFS.

• Reflux of the below knee segment of GSV (Fig. 3K, L). These types of reflux are more common in early chronic venous disease (CVD). No treatment is performed unless the patient is symptomatic. The below knee segment of GSV is treated in patients with skin damage or in patients with persistent or recurrent symptoms after treating the above knee GSV. The tributaries are treated by phlebec-tomies or UGFS.

• Reflux of short segment of thigh (Fig. 3M) or calf (Fig. 3N) of GSV without tributaries involvement. These types of reflux are more common in early CVD. In these cases, no treatment is performed for the GSV. If there is a tributary connecting to the refluxing GSV segment then only the tributary is being treated.

• Reflux of tributaries connecting to thigh (Fig. 3O) or calf (Fig. 3P) of the GSV. Only the tributaries are treated. In such cases, the GSV becomes normal after treating the tributary.

When there is GSV reflux, there are varicosities in most limbs which are located in the medial aspect of thigh and calf. Treatment for GSV reflux is performed when the GSV is dilated and it is associated long duration of reflux. The diagnostic cut-off value of superficial vein reflux is 0.5 sec (6), but reflux of lesser duration than 1 sec is unlikely to cause any problem but more research is needed in this area. Varicose veins of the saphenous trunks are rare and have a mean length of 4 cm (7). This is very important as most refluxing saphenous veins can be ablated. In areas of varicosities if the catheter or a wire cannot be negotiated a double puncture technique may be used and the varicose segment is treated with UGFS. Focal dilatations are more common and aneurysms are rare (6). The varicosities of the saphenous trunk, focal dilatation and aneurysms have to be marked in detail as the treatment can be altered. When performing GSV ablation, the proximal place of ablation is about few cm away from the SFJ to reduce deep vein thrombosis rate depending on the method used. The uppermost point of ablation should be confirmed by ultrasound. Access of the GSV should be in the lowest possible refluxing segment A straight segment of GSV is required to perform ablation. If there is not enough length for ablation or if the GSV is tortuous or >20 mm at the junction, ligation near the junction and phlebectomies may be performed (8). When the GSV or any of its accessories are too close to the skin thermal ablation is not performed. Although burning the skin can be avoided by placing a lot of tumescent a permanent discoloration may be seen due to carbonization of the vein. The vein segment that is closed to the skin can be surgically removed.

Hypoplastic vein segments are not suitable for thermal ablation (Fig. 4A). Dilated accessory vein is replacing the aplastic GSV segment. Saphenous hypoplasia and aplasia are related to reflux development as the accessory veins who take care of the local blood drainage may dilate and become incompetent like in this patient (Fig. 4B). At this level the accessory vein is good to access but not for thermal ablation as it touches the skin. Hybrid technique should be performed where the vein which is deeper than 4 mm can be ablated and the more superficial part can be removed surgically. When there is GSV aneurysm, it is treated by local resection (Fig. 5). Ablation is performed in the rest of the refluxing GSV. GSV reflux can be associated with chronic luminal changes from previous thrombosis with or without recanalization (Fig. 6). If the catheter or wire cannot go through the obstructed segment a double puncture technique is used to ablate the affected GSV. If the latter is performed the obstructed segment is treated with UGFS.

Figure 4. Hypoplastic (A, white arrow) or aplastic (B, arrow head) great saphenous vein (GSB). Dilated accessory vein is replacing the aplastic GSV segment (B, red arrow).

Figure 5. Aneurysm of great saphenous vein (GSV). GSV aneurysm about 5 cm in diameter pushes the skin away (A). Spontaneous contrast is seen due to stasis on B-mode ultrasound image (B).

Figure 6. Great saphenous vein reflux with chronic luminal changes. On color mode, partial recanalization with reflux (white arrow) and fibrous tissue (arow head) is observed.

Another pathology that should be considered is the lympho-venous networks in the groin area (9). They are found more often after SFJ ligation but can also exist without any previous intervention. Veins from the local lymph nodes draining into the GSV and the anterior accessory saphenous vein can dilate and become incompe-tent. These veins are very tortuous and cannot be ablated. Furthermore, as there connected with the lymph nodes surgery is avoided. Typically these veins are treated with UGFS.

In more than 90% of limbs with SSV reflux, varicosities are present. Patterns of SSV reflux and the appropriate treatment method are as follows.

• Reflux of GSV without thigh extension (TE) (Fig. 7A). The proximal place of ablation is not just 2 cm away from the SPJ, but at the beginning of the curve where the SSV dives down into the popliteal fossa to avoid peroneal and tibial nerve injuries and reduce DVT rate. The uppermost point of ablation is defined by ultrasound as there are anatomic variations in the venous and nerve anatomy. SSV is treated always to the mid-calf to avoid sural nerve injury. In cases where the skin is Class 4b or higher the SSV can be ablated to the lowest point of reflux, the refluxing vein below the mid-calf can be treated by non-thermal ablation.

  Figure 7. Patterns of small saphenous vein reflux. R indicates segments with reflux and N indicates normal segment. ≠Indicates no interconnection.
  

• Reflux in the TE with SSV involvement (Fig. 7B). TE of SSV can be ablated when it is dilated, usually more than 4 mm or when there is reflux in a long segment, usually covering most of the thigh. Varicose SSV TE where a catheter cannot be negotiated it is treated usually with UGFS and or phlebectomies. The refluxing SSV portion may be treated in continuity. One puncture may be enough from the lower SSV point to TE. A second puncture is used to overcome complex anatomy and/or to avoid nerve injury in the popliteal fossa. Rarely, there is paradoxical hyper-flow from the popliteal vein to SSV TE. The latter is dilated, has antegrade flow and is connected with varicose tributaries. This vein can be ablated in the absence of deep vein obstruction. The varicose tributaries can be treated with phlebectomies and/or UGFS.

• Reflux in the SSV TE only (Fig. 7C). TE of SSV can be ablated when it is dilated, usually more than 4 mm, with reflux in a long segment, often covering most of the thigh or when it is associated with varicosities. SSV TE is ablated from the lowest point of reflux to 3 cm below SFJ or to the highest point before the TE dives to connect with deep veins. The varicose tributaries can be treated with phlebectomies and/or UGFS.

• Segmental reflux in the SSV TE (Fig. 7D). SSV TE segmental reflux is left alone or treated with UGFS and/or phlebectomies. Usually varicose tributaries connect with the vein and when these are treated the SSV TE reflux is reduced or becomes normal. Also when refluxing tributaries connecting to SSV TE or SSV but the latter two veins are normal only the affected veins are treated.

• SSV reflux due to GSV incompetence (Fig. 7E). In cases with SSV segmental reflux due to GSV incompetence the GSV always is treated first. In such a scenario the GSV is refluxing in the thigh segment and transmits refluxing blood to SSV through an inter-saphenous vein. Following treatment of the GSV, in the majority of the occasions the SSV becomes normal, occasionally may get thrombosis but hardly ever needs to be treated.

• Reflux of GSV and SSV, independently (Fig. 7F). In cases with SSV and GSV reflux where the latter does not affect the former both veins can be treated by starting with the one that is hemodynamically worst. When the varico-sities in the calf from the GSV are interconnected with the SSV, the former with its associated varicosities should be treated first to avoid thrombosis. In such a scenario the GSV is refluxing in the thigh segment and the SSV is refluxing from the popliteal fossa or higher to the calf. All refluxing varicose tributaries are treated with phlebectomies and/or UGFS.

• GSV reflux due to SSV incompetence (Fig. 7G). In some patients reflux in the GSV at the lower calf and ankle can be transmitted by an incompetent SSV. In such a scenario the SSV is treated first. The GSV reflux is reduced or disappears after the SSV treatment. In a few patients, skin damage and/or ulceration in the medial malleolus is due to this SSV reflux pattern.

• Non-saphenous veins transmitting reflux to SSV (Fig. 7H). Reflux in the SSV may be transmitted by non-saphenous veins in the groin, thigh, popliteal fossa and calf. Segmental SSV and/or SSV TE reflux when is due to non-saphenous veins should not be treated. Treatment should be performed first in the nonsaphenous veins and if reflux in the SSV is more extensive should be treated if it persists after the treatment of the non-saphenous veins. The connecting areas between the non-saphenous veins and the SSV system are illustrated in Fig. 7H. Patients with pelvic reflux need further investigation. Veins from the pelvis often connect with nonsaphenous veins in the lower extremity but also the GSV and sometimes the SSV.

• Independent SSV and non-saphenous vein reflux (Fig. 7I). Reflux in the SSV and non-saphenous veins can be independent. In this case both systems can be treated starting from the one that is hemodynamically worst. Pelvic reflux may be an important source of recurrence and in such patient careful examination of the pelvic veins may be performed.

There are numerous patterns of GSV and SSV reflux. Patient’s symptom should be considered first when deciding treatment although it is a given that many patients will be treated for aesthetic reasons. Delineating accurately the different patterns of reflux is important for planning and performing the treatment. This will result to better clinical outcomes and patient satisfaction.