Anatomical Extent of Venous Reflux
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COMMENTARY
Anatomical Extent of Venous Reflux Fedor Lurie
Received: April 28, 2020 Ó The Author(s) 2020
ABSTRACT Key Summary Points Despite the recognition of the importance of the anatomical extent of venous reflux, its description in medical literature is inconsistent in terms and classifications. Recent international consensus documents provide clear definitions for the three main classes of reflux: segmental, multi-segmental, and axial. This report addresses the most important aspects of the standard definitions of the anatomical extent of venous reflux, the differences between the three classes of reflux, and the challenges of implementing this classification in clinical practice.
Keywords: Chronic venous disease; Venous insufficiency; Venous reflux
Digital features: To view digital features for this article go to https://doi.org/10.6084/m9.figshare.12377204. F. Lurie (&) Department of Vascular Surgery, Promedica Jobst Vascular Institute, Toledo, OH, USA e-mail: [email protected] F. Lurie Division of Vascular Surgery, University of Michigan at Ann Arbor, Ann Arbor, MI, USA
Anatomical extent of venous reflux has been defined as segmental, multisegmental, and axial. Axial reflux is defined as ‘‘uninterrupted retrograde venous floor from the groin to the calf.’’ Segmental reflux may occur in the veins with competent valves. Axial reflux always involves incompetent valves.
Knowledge of the anatomical extent of venous reflux is important for several reasons. Understanding the relationship of refluxing veins to the site and severity of clinical manifestation may be the most important, for this knowledge serves as a basis for selecting appropriate treatment. For example, reflux in a short segment of the small saphenous vein (SSV) in the upper calf is unlikely to be related to a venous ulcer in the medial ankle. To make such a conclusion, however, requires knowledge of the existing connections between this segment and incompetent veins in the ulcer bed. Another example may be varicose veins causing symptoms in the lateral thigh and calf that
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more likely relate to reflux in the accessory saphenous vein than to an incompetent proximal segment of the great saphenous vein (GSV). The connection between the anatomical extent of reflux and the progression of primary chronic venous disease has been consistently demonstrated by many studies [1–4]. Axial reflux and multi-segmental reflux are more prevalent in patients with chronic venous insufficiency (CVI) than in those with less advanced disease. Retrospective and prospective cohort studies have shown a consistent pattern of reflux progression from segmental to multisegmental and axial. This trend is the same regardless of the ‘‘descending’’ or ‘‘ascending’’ direction. Despite its importance, descriptions of the anatomical extent of venous reflux in the literature are limited. The ‘‘A’’ in the abbreviated CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification describes the main groups, such as deep and superficial reflux, which are too
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