1. Clinical Case nlabrop@yahoo.com Nicos Labropoulos
Professor of Surgery and Radiology
Director, Vascular Laboratory
Division of Vascular Surgery
Stony Brook Medicine
Stony Brook, New York, USA

2. Female patient, 57 years old presented with symptomatic
varicose veins in the right lower limb. She noticed the
varicosities over 30 years ago.
Signs and symptoms
-Swelling
-Burning sensation
-Itching
-Heaviness
The veins are larger and the symptoms are worst
at the end of the day. She gets relief with limb elevation.
The left lower limb is asymptomatic with spider
and reticular veins that do not bother her.

3. She had 2 children with normal pregnancies and delivery.
Her mother had varicose veins and skin discoloration.
The right limb developed symptoms gradually after
the second pregnancy.
She had SFJ ligation and phlebectomies 12 years ago.
The patient remained asymptomatic for a few years
but over time her veins became larger.
She started developing new symptoms 7 years ago
that are far more intense now.

4. Because of the worsening of her symptoms she
went to a vascular specialist.
She was given compression stockings but she could not
tolerated them well. She felt better with the stockings on however, there was no change in her limb after 3 months.
No other pertinent history, surgeries or medications.
The arterial exam was normal and she had
no mobility problems.
Venous ultrasound was ordered

5. Right groin varicose veins with reflux
Cross-sectional view
Longitudinal view
Multiple varicose veins connect with the SFJ stump and CFV.
Very tortuous course with many small channels of flow and
larger veins anterior, superior and medial to CFV.

6. Right groin varicose veins with reflux
Reflux after release of thigh compression
Reflux during Valsalva
When reflux is induced with distal limb compression followed by
sudden release the Valsalva maneuver is not needed. However,
when the former is negative then the latter is performed.

7. Lympho-venous networks with reflux
Veins within the lymph nodes are tortuous
and dilated. They are connected with
incompetent tributaries of the GSV and AASV.
Other connections may occur through the CFV,
FV and tributaries extending from pelvic veins.
Uhl JF, Lo Vuolo M, Labropoulos N. Anatomy of the lymph node venous networks of the groin and their investigation by ultrasonography. Phlebology Jun;31(5):

8. Lympho-venous networks with reflux occur
Sclerotherapy
In the majority of the cases without previous interventions
After groin surgery (SFJ ligation)
After endovenous ablation

9. Lympho-venous networks with reflux occur
Sclerotherapy
In the majority of the cases without previous interventions
After groin surgery (SFJ ligation)
After endovenous ablation
The refluxing lympho-venous networks are more often seen after SFJ ligation with or without GSV stripping but can also be found without any previous procedure.
Uhl JF, Lo Vuolo M, Labropoulos N. Anatomy of the lymph node venous networks of the groin and their investigation by ultrasonography. Phlebology Jun;31(5):

10. LNVN are characterized by transnodal networks connected to the GSV and/or AAGSV.
They exist prior to any treatment and can be found, thin and competent, in any healthy patient.
Uhl JF, Lo Vuolo M, Labropoulos N. Anatomy of the lymph node venous networks of the groin and their investigation by ultrasonography. Phlebology Jun;31(5):

11. Lympho-venous networks with reflux
9.2mm
4.3mm
3.7mm
3.6mm
5.2mm
6.8mm
Uhl JF, Lo Vuolo M, Labropoulos N. Anatomy of the lymph node venous networks of the groin and their investigation by ultrasonography. Phlebology Jun;31(5):

12. What most likely has happened?
1. Development of new varicose veins
2. Residual varicose veins from incomplete treatment
3. Neovascularization due to SFJ ligation
4. Neovascularization, residual and recurrent disease

13. What most likely has happened?
1. Development of new varicose veins
2. Residual varicose veins from incomplete treatment
3. Neovascularization due to SFJ ligation
4. Neovascularization, residual and recurrent disease
van Rij AM, Jones GT, Hill GB, Jiang P. Neovascularization and recurrent varicose veins: more histologic and ultrasound evidence. J Vasc Surg 2004;40:296–302
Perrin MR, Labropoulos N, Leon LR Jr. Presentation of the patient with recurrent varices after surgery (REVAS). J Vasc Surg 2006;43:327–34;
De Maeseneer M, Pichot O, Cavezzi A, 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

14. LNVN seem to be venous ‘‘remodeling’’, with dilation and dystrophic changes of normal pre-existing networks, as an adaptive response to surgical approach due to angiogenic factors, and thus could be a consequence rather than a cause of recurrence.
When they are found to be dilated and refluxing, surgery of the groin is contraindicated, and echoguided foam sclerotherapy is the method of choice.
Perrin MR, Labropoulos N and Leon LR Jr. Presentation of the patient with recurrent varices after surgery (REVAS). J Vasc Surg 2006; 43: 327–334.
Pittaluga P, Chastanet S, Locret T, et al. Retrospective evaluation of the need of a redo surgery at the groin for the surgical treatment of varicose vein. J Vasc Surg 2010;51: 1442–1450.

15. GSV reflux at mid-thigh and below
Proximal GSV is normal
GSV reflux at mid-thigh and below
The GSV diameter at the proximal
non-refluxing segment measures 3.6mm
while the incompetent segment below
has a larger diameter of 6.8mm.
The larger the GSV diameter the higher
the chance for reflux. However, many
patients with normal size or even small
diameter GSV may have reflux.
Therefore, diameter should not be used
to determine reflux.
Labropoulos N, Kokkosis AA, Spentzouris G, et al. The
distribution and significance of varicosities in the saphenous
trunks. J Vasc Surg 2010;51:

16. Reflux in lower extremity veins develops
1. Ascending manner
2. Descending manner
3. Through perforator veins
4. Ascending and descending manner

17. Reflux in lower extremity veins develops
1. Ascending manner
2. Descending manner
3. Through perforator veins
4. Ascending and descending manner
Labropoulos N, et al. Where does venous reflux start? J Vasc Surg Nov;26(5):
Labropoulos N, et al. Study on the venous rfeflux progression. J Vasc Surg Feb;41(2):291-5.

18. GSV reflux at mid-thigh and below
Proximal GSV is normal
GSV reflux at mid-thigh and below
9.2mm
3.6mm
6.8mm

19. Focal GSV eccentric dilatation
GSV is enlarged posterior to the valve. The valve is frozen and does not move. Focal dilations are common but varicosities of the saphenous trunk are rare (<5%)
8.9mm
Labropoulos N, Kokkosis AA, Spentzouris G, et al. The
distribution and significance of varicosities in the saphenous
trunks. J Vasc Surg 2010;51:

20. aplasia, which is often seen in the thigh and calf segments.
GSV is exiting the saphenous canal at the Knee and continues its course as a dilated accessory vein ( mm) that connects with many calf varicose veins.
The GSV is not seen from the knee to the lower calf. This is segmental GSV
aplasia, which is often seen in the thigh and calf segments.
It is easy to confuse the accessory vein
with the GSV. The accessory vein in this patient was outside the saphenous canal and run medial to GSV.
Cavezzi A, Labropoulos N, Partsch H, et.al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg 2006;31:

21. 8.3mm
GSV
Aplasia
7.6mm
Cavezzi A, Labropoulos N, Partsch H, et.al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg 2006;31:

22. Accessory vein in the calf is 6mm below the skin
High velocity reflux with long duration >5s
Thermal ablation is performed for veins that
are ≥4mm from the skin in order to avoid
-skin burns
-induration
-feeling a palpable cord
Labropoulos N, Tiongson J, Pryor L, et al. Definition of venous reflux in lower-extremity veins.
J Vasc Surg 2003;38:793–8.

23. Multiple calf varicosities with prolonged reflux
8.3mm
7.6mm
Labropoulos N, Tiongson J, Pryor L, et al. Definition of venous reflux in lower-extremity veins.
J Vasc Surg 2003;38:793–8.

24. SSV has a small diameter.
2.2mm
1.4mm
3.9mm
1.9mm
3.7mm
1.8mm
SPJ and thigh extension are dilated and have reflux.
Labropoulos N, Giannoukas AD, Delis K, et al. The impact of isolated lesser saphenous vein system incompetence on clinical signs and symptoms of chronic venous disease. J Vasc Surg 2000;32:
Cavezzi A, Labropoulos N, Partsch H, et.al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg 2006;31:

25. C1-3S EP AS+P+D PR
The small “normal” GSV segment in the upper thigh is usually treated together with the refluxing segment below.

26. How this patient should be treated?
1. Conservative treatment
2. Groin exploration and stripping
3. EVA, phlebectomies and sclerotherapy
4. Modified stripping and phlebectomies

27. How this patient should be treated?
1. Conservative treatment
2. Groin exploration and stripping
3. EVA, phlebectomies and sclerotherapy
4. Modified stripping and phlebectomies
Gloviczki P, Comerota AJ, Dalsing MC, 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(5 Suppl):2S-48S
Marsden G, Perry M, Kelley K, Davies AH; Guideline Development Group. Diagnosis and management of varicose veins in the legs: summary of NICE guidance. BMJ. 2013;347:f4279.

28. Treatment plan Follow-up RFA of the GSV and accessory saphenous vein
Multiple phlebectomies for the tributaries
Ultrasound-guided foam sclerotherapy for the neovascularization
Follow-up
Phlebectomies of two residual tributaries at 1 month
Ultrasound-guided foam sclerotherapy at 1, 8 and 23 months
At 36 months she was asymptomatic with a few reticular and spider veins.

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