Patients with chronic venous disease often arrive at the clinic convinced they have a problem “with the saphenous vein”.
In fact the saphenous vein is neither the tortuous vessel the patient sees on the surface of the leg, nor the direct cause of varicose veins (Does a saphenous varicose vein exist? Phlebology 1997;12:74–77).
The saphenous vein could be described as the “motorway” used by the superficial venous system to carry blood back towards the heart and lungs. It runs inside an anatomical fascia, a sort of envelope, that protects it from developing significant dilatation and tortuosity.
The saphenous vein connects the superficial venous system — visible and palpable under the skin in case of varicosity — with the deeper venous system. What the patient sees and feels is precisely the more superficial system: a network that should carry blood into the saphenous vein, from the surface to the depth, from the feet towards the heart.
How reflux appears
Valves inside all these veins keep blood flowing in that direction (Lower limbs venous kinetics and consequent impact on drainage direction. Phlebology. 2018;33:107-114).
When those valves fail at the junctions between surface and saphenous vein, and between saphenous vein and deep system, the venous flow inverts: blood rises back towards the surface, the veins visible to the naked eye dilate, pressure inside them increases and symptoms appear (Altered velocity gradient in lower limb chronic venous disease. Phlebology. 2019 Feb;34(1):17-24).
At that point the saphenous vein may show reflux inside it, where “reflux” means the inversion of the direction of blood drainage: no longer from the surface to the depth but from the depth to the surface, no longer bottom-up but top-down.
Reflux does not mean a diseased vein
Finding reflux in the saphenous vein does not mean the vein is diseased: it simply indicates that it sits between two points of the circulation at different pressure. It is a little like a draught in a room of our house, because a window and a door are open at the same time. To stop the draught it is enough to close the door or the window, and the air goes back to circulating normally.
Look for the source, not only the symptom
During the ultrasound examination, a specialist with specific expertise can and must perform the so-called reflux elimination manoeuvres, designed to identify precisely the points affected by disease.
Too often the ultrasound examination focuses on whether or not there is reflux along the saphenous axis. Attention must instead be directed above all to identifying the source of that reflux, as well as the point where the reflux ends. Only in this way is it possible to tailor a treatment to the specific need of each patient, and to propose a treatment that repairs a diseased vein instead of removing it, with a result demonstrated to be twice as good in terms of disease recurrence, even at 10 years of follow-up (Varicose vein stripping vs haemodynamic correction (CHIVA): a long term randomised trial. Eur J Vasc Endovasc Surg 2008;35:230-7).