Classification of Venous Insufficiency: Diagnosis and Treatment

  • Shunichi Hoshino
  • Hirono Satokawa


Venous insufficiency usually occurs in veins of the lower extremities and consists of mechanical problems of reflux, obstruction, or a combination of the two. The clinical process is usually slow, recurrent, and chronic. Therefore, we refer to the condition as chronic venous insufficiency. These lesions cause local venous hypertension, which results in venous stasis symptoms such as skin exanthema, pigmentation, lipodermatosclerosis, and stasis ulcers (Figures 81.1 and 81.2). The venous system consists of superficial veins, including the saphenous system, the deep vein system, and perforating veins. Reflux lesions may spread not only to the superficial venous system but also to multisegmental veins. Primary varicose veins, with reflux of superficial veins, are most often encountered clinically. Reflux flow in the deep vein system may be due to congenital valvular absences, prolapse of valves (floppy valves, primary deep vein insufficiency), dilation of valvular annuli, or postthrombotic syndrome.5 In a vein lumen occluded with thrombi, the valve cusps become fixed and are unable to function properly. If thrombolysis occurs, recanalization results in a vessel without valves. However, most obstructive disorders are caused by deep vein thrombosis due to incomplete re-canalization and the onset of acute deep vein thrombosis. Sakaguchi et al.37 reported that 80% of obstructive diseases can be improved by recanalization within 2 years, but reflux may increase. These two components, reflux and obstruction, maintain the balance of a mixed condition, but the reflux component proved superior after 10 years.


Varicose Vein Great Saphenous Vein Venous Insufficiency Chronic Venous Insufficiency Postthrombotic Syndrome 
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  1. 1.
    Abramowitz HB, Queral LA, Flinn WR, et al. The use of photoplethysmography in the assessment of venous insufficiency: a comparison to venous pressure measurements. Surgery. 1979;86:434–441.PubMedGoogle Scholar
  2. 2.
    Beckwith TC, Richardson G, Sheldon M, Clarke GH. A correlation between blood flow volume and ultrasonic Doppler wave forms in the study of valve efficiency. Phlebology. 1993;8:12–16.Google Scholar
  3. 3.
    Beebe HG, Bergan JJ, Bergqvist D, et al. Classification and grading of chronic venous disease in the lower limbs: a consensus statement. Int Angiol. 1995;14:197–201.PubMedGoogle Scholar
  4. 4.
    Bergan JJ. Primary vs. secondary cause. Sträub Foundation Proceedings. 1993;57:28–29.Google Scholar
  5. 5.
    Browse NL, Burnand KG, Lea Thomas ML. Primary (non-thrombotic) deep vein incompetence. In Diseases of the Veins: Pathology, Diagnosis, and Treatment. London: Edward Arnold; 1988:253–269.Google Scholar
  6. 6.
    Elem B, Shorey BA, Lloyd Willams K. Comparison between thermography and fluorescein test in the detection of incompetent perforating veins. BMJ. 1971;4:651–652.PubMedCrossRefGoogle Scholar
  7. 7.
    Ferris EB, Kistner RL. Femoral vein reconstruction in the management of chronic venous insufficiency. Arch Surg. 1982;117:1571–1579.PubMedCrossRefGoogle Scholar
  8. 8.
    Folse R, Alexander RH. Directional flow detection for localizing venous valvular incompetency. Surgery. 1970;67:114–121.PubMedGoogle Scholar
  9. 9.
    Gloviczki P, Marrell SM, Bower TC. Femoral vein valve repair under direct vision without venotomy: a modified technique with use of angioscopy. J Vasc Surg. 1991;14:645–648.PubMedCrossRefGoogle Scholar
  10. 10.
    Hanrahan LM, Kechejian GJ, Cordts PR. Patterns of venous insufficiency in patients with varicose veins. Arch Surg. 1991;126:687–691.PubMedCrossRefGoogle Scholar
  11. 11.
    Hauer G, Barkun J, Wisser I. Endoscopic subfascial dissection of perforating veins. Surg Endosc. 1988;2:5–12.PubMedCrossRefGoogle Scholar
  12. 12.
    Herman RJ, Neiman HL, Yao JST, Egan TJ, Bergan JJ, Malave SR. Descending venography: a method of evaluating lower extremity venous valvular function. Radiology. 1980;137:63–69.PubMedGoogle Scholar
  13. 13.
    Hoshino S, Satokawa H, Iwaya F, Igari T, Ono T, Takase S. Valvuloplastie externe sous controle angioscopique preoperatoire. Phlebologie. 1993;46:521–530.PubMedGoogle Scholar
  14. 14.
    Husni EA. In situ saphenopopliteal bypass graft for incompetence of the femoral and popliteal veins. Surg Gynecol Obstet. 1970;120:279–284.Google Scholar
  15. 15.
    Jacobsen BH. The value of different forms of treatment for varicose veins. Br J Surg. 1979;66:182–184.CrossRefGoogle Scholar
  16. 16.
    Jessup G, Lane RJ. Repair of incompetent venous valves: a new technique. J Vasc Surg. 1988;8:569–575.PubMedGoogle Scholar
  17. 17.
    Jones JW, Kerstein MD. Triangular venous valvuloplasty. Arch Surg. 1982;11:1250–1251.CrossRefGoogle Scholar
  18. 18.
    Jones NAG, Webb PK, Rees RI, Kakkar W. A physiological study of elastic compression stockings in venous disorders of the leg. Br J Surg. 1980;67:569–572.PubMedCrossRefGoogle Scholar
  19. 19.
    Kistner RL. Surgical repair of the incompetent femoral vein valve. Arch Surg. 1975;110:1136–1142.CrossRefGoogle Scholar
  20. 20.
    Kistner RL. Surgical technique of external venous valve repair. Straub Foundation Proceedings. 1990;55:15–16.Google Scholar
  21. 21.
    Kistner RL. Valve repair and segment transposition in primary valvular insufficiency. In: Bergan JJ, Yao JST, eds. Venous Disorders. Philadelphia, Pa: WB Saunders; 1991:261–272.Google Scholar
  22. 22.
    Kistner RL, Sparkuhl MD. Surgery in acute and chronic venous disease. Surgery. 1979;85:31–43.PubMedGoogle Scholar
  23. 23.
    Koyano K, Sakaguchi S. Selective stripping operation based on Doppler ultrasonic findings for primary varicose veins of the lower extremities. Surgery. 1988;103:615–619.PubMedGoogle Scholar
  24. 24.
    Kriessmann A. Ambulatory venous pressure. In: Nicolaides AN, ed. Investigation of Vascular Disorders. London: Churchill Livingstone; 1981:461–477.Google Scholar
  25. 25.
    Labropoulos N, Leon M, Nicolaides AN, et al. Venous reflux in patients with previous deep venous thrombosis: correlation with ulceration and other symptoms. J Vasc Surg. 1994;20:20–26.PubMedCrossRefGoogle Scholar
  26. 26.
    Lea Thomas M, Keeling FP. Varicography in the management of recurrent varicose veins. Angiology. 1986;37:570–575.CrossRefGoogle Scholar
  27. 27.
    Lea Thomas M, Keeling FP, Ackroyd J. Descending phlebography: a comparison of three methods and an assessment of the normal range of deep vein reflux. J Cardiovasc Surg. 1986;27:27–30.Google Scholar
  28. 28.
    Linton R. The postthrombotic ulceration of the lower extremity: its etiology and surgical treatment. Ann Surg. 1953;138:415–426.PubMedGoogle Scholar
  29. 29.
    Masuda EM, Kistner RL. Long-term results of venous valve reconstruction: a four-to twenty-one-year follow-up. J Vasc Surg. 1994;19:391–403.PubMedCrossRefGoogle Scholar
  30. 30.
    Monreal M, Montserrat E, Salvador R, et al. Real-time ultrasound for diagnosis of symptomatic venous thrombosis and for screening of patients at risk: correlation with ascending conventional venography. Angiology. 1989;6:527–533.CrossRefGoogle Scholar
  31. 31.
    Nicolaides AN, Christopoulos DC. Methods of quantification of chronic venous insufficiency. In: Bergan JJ, Yao JST, eds. Venous Disorders. Philadelphia, Pa: WB Saunders; 1991:77–90.Google Scholar
  32. 32.
    Nicolaides AN, Zukowski AJ. The value of dynamic venous pressure measurements. World J Surg. 1986;10:919–924.PubMedCrossRefGoogle Scholar
  33. 33.
    Palma EC, Esperon R. Vein transplants and grafts in surgical treatment of the postphlebitic syndrome. J Cardiovasc Surg. 1960;1:94–107.Google Scholar
  34. 34.
    Porter JM, Rutherford RB, Clagett GP, et al. Reporting standards in venous disease. J Vasc Surg. 1988;8:172–181.Google Scholar
  35. 35.
    Raju S. Venous insufficiency of the lower limb and stasis ulceration: changing concepts and management. Ann Surg. 1982;6:688–697.Google Scholar
  36. 36.
    Raju S, Fredericks R. Valve reconstruction procedures for nonobstructive venous insufficiency: rationale, techniques, and results in 107 procedures with two-to eight-year follow-up. J Vasc Surg. 1988;7:301–310.PubMedGoogle Scholar
  37. 37.
    Sakaguchi S. Phlebothrombosis and its sequelae: patho-physiology and surgical treatment. J Cardiovasc Surg. 1973;(suppl):576.Google Scholar
  38. 38.
    Sakaguchi S, Ishitobi K, Kameda T. Functional segmental plethysmography with mercury strain gauge. Angiology. 1972;23:127–135.PubMedCrossRefGoogle Scholar
  39. 39.
    Satokawa H, Hoshino S, Ogawa T, et al. Venous valve an-gioscopic reconstruction: techniques and long-term results. Japanese Journal of Phlebology. 1996;7:63–70.Google Scholar
  40. 40.
    Satokawa H, Iwaya F, Igari T, et al. Endoscopie venous surgery [in Japanese]. Jpn J Vasc Surg. 1994;3:613–618.Google Scholar
  41. 41.
    Schanzer H, Skladany M. Varicose vein surgery with preservation of the saphenous vein: a comparison between high ligation-avulsion versus saphenofemoral banding valvuloplasty-avulsion. J Vasc Surg. 1994;20:684–687.PubMedCrossRefGoogle Scholar
  42. 42.
    Shull KC, Nicolaides AN, Fernandes JF, et al. Significance of popliteal reflux in relation to ambulatory venous pressure and ulceration. Arch Surg. 1979;114:1304–1306.PubMedCrossRefGoogle Scholar
  43. 43.
    Sottiurai VS. Surgical correction of recurrent venous ulcer. J Cardiovasc Surg. 1991;32:104–109.Google Scholar
  44. 43.
    Sullivan ED, Peter DJ, Cranley JJ. Real-time B-mode venous ultrasound. J Vasc Surg. 1984;1:465–471.PubMedGoogle Scholar
  45. 45.
    Taheri SA, Elias S. Descending phlebography. Angiology. 1983;3:299–305.CrossRefGoogle Scholar
  46. 46.
    Taheri SA, Lazar L, Elias S, Marchand P, Hefner R. Surgical treatment of postphlebitic syndrome with vein valve transplant. Am J Surg. 1982;144:221–224.PubMedCrossRefGoogle Scholar
  47. 47.
    Train JS, Schanzer H, Pierce EC, Dan SJ, Mitty HA. Radiologic evaluation of the chronic venous stasis syndrome. JAMA. 1987;258:941–944.PubMedCrossRefGoogle Scholar
  48. 48.
    Van der Stricht J. Ambulatory stripping. Phlebologie. Paris: John Eurotext; 1992:1064–1066.Google Scholar
  49. 49.
    Vasdekis SN, Clarke GH, Nicolaides AN. Quantification of venous reflux by means of duplex scanning. J Vasc Surg. 1989;10:670–677.PubMedGoogle Scholar
  50. 50.
    Welch HJ, Faliakou EC, McLaughlin RL, Umphley SE, Belkin M, O’Donnell TF. Comparison of descending phlebography with quantitative photoplethysmography, air plethysmography, and duplex quantitative valve closure time in assessing deep venous reflux. J Vasc Surg. 1992;16:13–20.Google Scholar

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© Springer Science+Business Media New York 2000

Authors and Affiliations

  • Shunichi Hoshino
  • Hirono Satokawa

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