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Chronic venous disease (CVD) is a common and often underappreciated problem with significant socioeconomic impact.1–3 Encompassing any abnormality of the venous system of long duration, it can manifest with symptoms and/or signs ranging from telangiectasias to mild leg discomfort to venous claudication or ulcers. At its advanced stages, it is known as chronic venous insufficiency (CVI), where abnormalities of the venous system produce edema, skin changes, or ulcers.2,3

CVD is most prevalent in western populations (50%-85%) and is a disease with a considerable rate of progression. The Bonn Vein study found that over 6 years, the incidence of varicose veins and CVD reached 14%. About 13 years of follow-up in the Edinburgh Vein Study demonstrated that 58% of 334 patients with CVD progressed to a more advanced stage. In the Framingham study of 3822 patients, the annual incidence of varicose veins was 2.6% in women and 1.9% in men. Risk factors for the development of CVD and its progression include increasing age, pregnancy, excess body weight, low physical activity, sedentary living habits or occupations, and genetics. With an aging population and increasingly sedentary habits, the already 2% to 3% of national health care budget expenditure on CVD is anticipated to increase considerably.1,4–9


The lower extremity venous system includes deep veins, superficial veins, and connecting perforating veins. The deep veins lie beneath the muscle facia and drain the leg muscles. The superficial veins are above the fascia and drain the cutaneous tissues. Perforating veins penetrate the fascia, connecting the superficial and deep veins, while communicating veins connect veins within the same compartment. Bicuspid valves are found in the deep, superficial, and most perforating veins.9,10

The main function of the venous system is to return blood to the heart. Success depends on the interaction of a central pump, a pressure gradient, a peripheral venous pump, and competent venous valves. Hydrostatic gravitational pressures in the lower limbs reflect the vertical distance below the atrium. Thus, pressure is highest in the upright and motionless positions. Actual pressures, however, also reflect several other extrinsic factors. Contraction of the diaphragm during inspiration increases intraabdominal and lower extremity venous pressures, as does obesity and the presence of ascites. Normally in the standing position, blood is pumped against gravity via the muscle pumps of the leg and venous valves ensure the blood flows only in the cephalad direction. Relaxation of the muscle pump allows blood to flow back in from the surrounding tissue. This contraction and relaxation of the muscle pump, intact valves, and healthy vein walls all work to return peripheral blood to the heart. A dysfunction in any of these components will lead to increased venous pressure.1,7,10,11

Venous pathology may result from valvular incompetence (reflux), venous obstruction, or a combination of these mechanisms. It can occur in the superficial veins, deep veins, ...

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