A curious hemodynamic phenomenon emerging as a consequence of treatment of varicose veins might offer a reasonable explanation why varicose vein and reflux recurrences occur tenaciously irrespective of the applied procedure. Saphenous reflux is the most important pathological phenomenon in varicose vein disease; it causes ambulatory venous hypertension and is responsible for the severity of hemodynamic disturbance, clinical symptoms, and appearance of chronic venous insufficiency. Abolition of saphenous reflux removes the hemodynamic pathology and restores physiological conditions even in patients afflicted with the severest form of chronic venous insufficiency, with varicose ulcers.26,27,28,29,30,31
(I and II) sets an example of what had been proved a lot of times: surgical interruption of saphenous reflux in the groin removed the severest hemodynamic disturbance and restored physiological conditions immediately after surgery;26
consequently, the therapeutic goal was perfectly achieved. But curiously enough, abolition of saphenous reflux at the same time generates preconditions for the development of recurrent reflux and for progressive comeback of the previous pathological situation (, III). The excellent immediate result recorded 1
week after flawless elimination of saphenous reflux deteriorates progressively in the course of time due to the perturbing effect of recurrent reflux.16
demonstrates this progressive deterioration of the hemodynamic situation during 4-year follow-up, evaluated by strain gauge plethysmography.16
Fig. 1 Hemodynamic paradox. Strain gauge plethysmographic parameters refill time t-90 and t-50 as well as refill volumes (I and II) evaluated in patients with a grave form of chronic venous insufficiency showed the severest hemodynamic disorder before surgery, (more ...)
Fig. 2 Progressive deterioration of the hemodynamic situation during 4-year follow-up after crossectomy evaluated by strain gauge plethysmographic parameters refill time t-90 and t-50. 1 w, 1week after crossectomy; y, year(s).
In healthy persons, ambulatory pressure gradient arises during calf pump activity and separates thigh veins with a higher pressure from lower leg veins with a lower pressure,27
as shown in . Competent valves in deep lower leg veins as well as in the saphenous system preclude drainage of venous blood from the thigh into the lower leg, and ensure physiological decrease in venous pressure in the lower leg and foot during calf pump activity. In varicose vein patients, the saphenous remnant in the thigh remains patent and incompetent in most cases after interruption of saphenous reflux; it enables drainage of venous blood from the thigh into the deep lower leg veins during calf pump activity. This drainage of venous blood from superficial veins in the thigh into the deep lower leg veins is a characteristic pathological feature of varicose vein disease; as a consequence, ambulatory hypotension extends from deep lower leg veins into incompetent superficial veins in the thigh. Since the pressure in the femoral vein does not decrease during calf pump activity, a pressure gradient of 37.4
mm Hg arises between the femoral vein and incompetent superficial veins in the thigh.27
The pressure difference enhances flow rate through pre-existing minor, as yet inactive communicating channels connecting deep and superficial veins in the thigh. The increased flow increases fluid shear stress on the endothelium, which activates biochemical agents nitride oxide and vascular endothelial growth factor28,29,30,31,32
; these substances induce progressive enlargement of the tiny communicating channels (vascular remodeling), and ultimately bring about recurrent reflux. Formation of new venous communicating channels between deep and superficial veins in the upper part of the thigh after abolition of saphenous reflux has been documented in several articles, as cited above. The same process triggered by pressure difference, based on the same events, and forming collateral circulation apparently happens also in arterial occlusions, in venous thrombosis, and in congenital arteriovenous fistulas.
From this point of view, abolition of saphenous reflux should be considered as a very effective, nevertheless just a palliative therapeutic measure, because the propensity for reflux recurrence progressively attenuates and ultimately thwarts the excellent immediate therapeutic result.16
Although the pressure gradient between the femoral vein and incompetent veins in the thigh in varicose vein patients triggers biophysical and biochemical events that induce the recurrence process, other unspecified circumstances involved in the recurrence process determine which type of recurrence, as concerns amount and timing of recurrence will take place.
Neovascularization or vascular remodeling does not come about in persons with healthy veins. As set out, competent valves in healthy persons preclude drainage of venous blood from the thigh veins into the lower leg veins. That results in development of ambulatory pressure gradient during calf pump activity with a higher pressure in thigh veins and a lower pressure in lower leg veins (). Hence, no pressure difference occurs between the femoral vein and superficial veins in the thigh in healthy persons, the process of neovascularization cannot be set off. Vascular remodeling after harvesting GSV for bypass graft does not take place. The surgical intervention per se is not involved in the development of recurrent reflux.
Only a procedure which would preclude drainage of blood from superficial thigh veins into the lower leg, that means which would reinstall conditions distinctive of healthy persons would be capable to heal varicose vein disease. Because we are not able to convert incompetent superficial venous network into a competent one, we cannot assure definitive cure while treating varicose vein disease, and we have to realize that recurrent reflux tends to occur regardless of the therapeutic strategy adopted.