Progression of superficial venous insufficiency: analysis and implications for therapy

Vincenzo Puleo,¹ Pier Luigi Castagno<sup>2

1</sup>Servizio di Angiologia e Diagnostica Vascolare, Torino, Italy; ²S.C. Chirurgia Vascolare 1, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Torino, Italy

Abstract: Challenges to the widely accepted concept of retrograde progression of superficial venous insufficiency (SVI) have come from studies showing that the conventional descending paradigm is unable to account for many clinical presentations that would be better explained by the ascending hypothesis for the condition. Evidence substantiating this hypothesis holds therapeutic importance because, if confirmed, it would further weaken the rationale for aggressive surgery, in keeping with the general trend for alternative procedures. To evaluate the progression of SVI we performed echo Doppler examinations twice yearly for 5 years (ten examinations per patient) in 100 patients with SVI in which superficial venous branches (suprafascial) or segments of saphenous vein were incontinent, while the saphenofemoral junction was continent. Ascending progression of SVI was found in about 76% of patients. In the remaining patients, stabilization of the condition was probably due to its slow natural history. Venous insufficiency initially affecting the superficial venous branches of the leg variously progressed upward to involve the saphenous trunk in most cases and different sites in the vein, sometimes involving the saphenous ostium as well. The ascending hypothesis provides a convincing explanation for the various clinical presentations of SVI and the recurrence of varicosities after saphenectomy. In addition to intrinsic weakening of the superficial venous wall, elevated pressure in the calf venous circulation pushing on the superficial compartments, devoid of protective mechanisms, could be an alternative/complementary pathogenetic mechanism leading to structural weakening of the perforating vein valves. From a therapeutic perspective, the hypothesis for ascending progression of SVI is consistent with the use of alternative methods that halt the progression of venous disease and preserve the saphenous axis. Anatomical and functional assessment of ostial incontinence is key to achieving good outcomes after treatment. Of equal importance are the diameter and length of the incontinent saphenous trunk and the length of the continent saphenous segment below the contiguous incontinent saphenous segment. In cases of crossectomy, meticulous short or ultrashort stripping can maintain saphenous drainage through the perforators into the deep circulation.

Keywords: superficial venous insufficiency, hemodynamics, pathophysiology, surgery