References

1.Bohler-Sommereger K., Karnel F., Schuller-Petrovic SS., Sautler R., “Do telengiectasias communicate with the deep venous system.” J Dermatol Surg. Oncol. 18:403, 1992Telengiectasias may receive their pulse of venous hypertention directly through minute incompetent perforating veins.

2.Tretbar LL: The origin of reflux in incompetent blue reticular Telengiectatic veins. In, Davy A, StemmerR, (eds) Phlebology 89, Montrogue,France, John Libbey Eurotext, 1989, p95.Telengiectasias may receive venous hypertension from sub dermal reticular network associated with reflux demonstrated by Doppler study.

3. Bjordal RI., Circulation patterns in incompetent perforating veins of the calf in venous dysfunction. In: May B, PartschH, Staubesant J, editors, Perforating Veins. Munich: Urban and Schwarzenberg, 1981: 71-88 Most perforating veins are thin-walled varying in diameter from less than 1 mm to 2 mm in diameter, and containing one or several valves.

4.Thompson H. The surgical anatomy and perforating veins of the lower limbs- A consensus conference. Vasa 1995; 24 (4): 313-318The number of perforating veins per leg varies greatly, with individual reports ranging from 64 to more than 15,000. The perforating veinsare more densely concentrated in distal leg and foot. (8 perforators in distal leg for every one in the thigh). For a typical patient there are 20 perforators above the knee and 200 below the knee.

5. Dinn E., Henery M., Value of lightweight elastic tights in standing occupation. Phlebology. 1989; 4: 45-47 Not all symptomatic patients will complain of pain; venous symptoms may be so insidious that after treatment, patients are surprised torealize how much chronic discomfort they had accepted as ” normal .”

6. Weiss RA., Weiss MA., Resolution of pain associated with varicose and telengiectatic leg veins after compression sclerotherapy. J.Dermatol. Sur. Onc. 1990; 16: 333-336Common symptoms of telengiectasias include burning, swelling, throbbing, cramping and leg fatigue.

7.Symptoms of Pain from Telengiectatic Webs Fatigue Heaviness Focal burning or aching Focal pruritis Sharp intermittent stabbing pain (focal) Diffuse burning Night cramps Restless legs 53 % of patients presenting with telengiectasias less than 1 mm in diameter complain of symptoms that resolve with treatment. Many common symptoms of small reticular and varicose veins are caused when high pressure reaches distal branch veins with no major run off connections.

8.Coon WW. Willis PW., Keller JB., Venous thromboembolism and other venous disease in Tecumseh community health study. Circulation 1973; 48: 839-846.Approximately 1 million persons in the United States have ulceration due to superficial venous disease, and about one out of ten are functionally disabled Incidence and prevalence of venous disease also depends on the age and sex of the population. In the Tecumseh community health study for example, varicosities were observed in 72 % of women aged 60-69, and in 43 % of men. (Between 40-49 years of age the incidence was 41 % for women and 24 % for men).

9. Evans GA., Evans DM. Seal RM., Cranen JL, Spontaneous fatal hemorrhage caused by varicose veins. Lancet 1973; 2; 1359-1361.Bleeding from lower extremity varicosities can be fatal, especially in elderly or debilitated patients. There were 23 such fatalities reported in England and Wales in 1971. Treatment for these bleeding varicosities is a medical emergency.

10. Nicoloides AN., Kakkar VV., Field ES., Fish P., Venous stasis and deep venous thrombosis. BR. J. Surg. 1972; 59 {(9): 713-717 . The lifetime incidence of superficial thrombophlebitis in patients with untreated varicose veins has been estimated at 20-50 %. This is not a benign condition, as unrecognized deep vein thrombosis is present in up to 45% of patients with what appears to be a purely superficial thrombophlebitis. The risk of DVT has been reported to be 3 times higher in patients with superficial varicosities.

11. Alexander CJ., The epidemiology of varicose veins. Med. J Aust., 1972; 1: 215-218. High prevalence of venous disease in westernized and industrialized countries.

12. Fischer H. Socio-epidemiological Study on distribution of venous disorders among a residential population. International Angiology, 1984; 3: 89-94. Symptoms may be present in up to 98% of patients with clinically relevant alteration of venous circulation but even small telengiectasias are often symptomatic.

13. Schultz-Ehrenburg U., Weindorf N., Matthes U., Hirche H., New epidemiological findings with regard to initial stages of varicose veins.(Bochum study I-III ). In: Raymond-Martimbeau P, Prescott R., Zummo M., editors. Phlebologie ’92 Paris: John Libbey Eurotext, 1992: 234-236.

14. Schultz-Ehrenbuegh U., Weindorf N., von Uslar D., Hirsch H., Prospektic epidemiologische studie uber die entstehunsweise der krampfadern bei kindern und jegendichen (Bochumer Studie I und II ). Phlebol Proktol. 1989; 18: 10-25 Development of Varicose and Telengiectatic Leg Veins by age Abnormality Age 10-12 Age 14-16 Age 18-20 Telengiectasias 0 3.7 % 12.9 % Reticular 10.2 % 30.3 % 35.3 % Perforator 0 4.1 % 5.2 5 Varicose tributary 0 0.8 % 5.0 % Varicose truncal vein 0 1.7 % 3.3 % Saphenofemoral reflux 0 12.3 % 19.8 %

15. Arnoldi C.C. The Aetiology of Primary Varicose Veins. Dan. Med. Bull. 1957, 4, 102-107 Varicosities are, “any dilated, elongated or tortuous veins, irrespective of size.” Telengiectasias and reticular veins should be included in epidemiological studies. Reticular varices, telengiectasias and major varicose veins have incompetent valves and have a common origin and respond to the same physical forces and acquired influences.

16. Faria J.L., Moraes I.N., Histopathology of the Telengiectasias associated with Varicose Veins. Dermatologica 1963, 127; 321-329 . Telengiectasias are associated with elevated venous pressure. Telengiectasias are linked to varicose veins.

17. Moraes I.N., Puech-Leao L.E., Simone J.C., Martins de Toledo. O., Correa Netto A., Microangiographic Study of Telengiectasia. J. Cardiovasc. Sueg. 1962. 3, 415-419 Showed, Direct connection of the telengiectasias with named veins such as greater saphenous and other superficial veins. Also demonstrated communicating veins directly connecting the Telengiectasias to the sapheno-femoral junction. Conclusion: Telengiectasias and varicose veins are pathologically identical and only differ in size.

18. Bergan J.J. Management of External Hemorrhage from Varicose Veins. Vasc. Surg. 1997, 31, 413-418

19. Sandager, G.; Williams L.R..; Mcarthy, W.R.; Flinn, W.R.; Yao, J.S.T.; Assessment of Venous Valve Function by Dulex Scan. Bruit 1986, 10, 238-241.

20. Depalma, R.G.; Hart, M.T.; Zannin, L.; Massarin, E.H. Physical Examination, Doppler Ultrasound and Color Flow Duplex Scanning: Guides to therapy for Primary Varicose Veins. Phlebology. 1993, 8, 7-11. Varicose Vein Surgery appears best guided by color flow Duplex Scanning.

21. Georgieve, M. The Preoperative Duplex Examination .Dermatol. Surg. 1998, 24, 433-440.

22. Stonebridge, P.A, Chambers, N.; Beggs, I.; Bradbury, A.W.; Ruckley, C.V.; Recurrent Varicose Veins; A Varicographic Analysis Leading to a New Practical Classification. Br. J. Surg. 1995, 82, 60-62. 70 % of recurrent varicose veins are in the territory of the greater saphenous vein. 60 % of the patients with recurrence in this area after saphenous ligation have a persistent refluxing saphenous vein.

23. Jon C. Walsh, MD., John J. Bergan, MD., Sue Berman, RVT, and Thomas P. Cones, MD., Femoral Venous Reflux Abolished by Greater Saphenous Vein Stripping. Ann Vasc Surg 1994; 8: 566-570. In 27 of 29 limbs with preoperative femoral reflux, that reflux was abolished by greater saphenous stripping. In patients with popliteal reflux both femoral and popliteal reflux was abolished. Improvement of deep venous hemodynamics by ablation of superficial reflux supports the reflux circuit theory of venous overload.

24. Sales M. MD. Billof M.L. Pattillo A. Luka N.L. Correction of lower extremity deep venous incompetence by ablation of superficial venous reflux. Ann. Vasc. Surg. 1996; 10: 186-89. Postoperative interrogation of the venous system revealed that in 16 (94%) of 17 patients, coexistent femoral venous insufficiency completely resolved. Thus ablation of the superficial venous reflux eliminated incompetence in the deep venous system in patients with combined diseased. These preliminary results suggest that superficial venous incompetence may be a cause of deep venous insufficiency.

25. Frank T. Padberg, Jr., MD., Peter L Pappas, MD., Clifford T. Araki, PhD., Thomas L. Backe, MS., and Robert W. Hobson II, MD., Hemodynamic and clinical improvement after superficial vein ablation in primary combined venous insufficiency with ulceration. J Vasc Surg 1996; 24: 711-8 Superficial and perforating vein incompetence accounts for a substantial and correctable component of venous insufficiency in limbs with combined deep and superficial vein reflux and venous ulceration. These data indicate that surgical correction of this component significantly improves clinical symptoms and venous hemodynamics. Superficial and perforator ablation is an appropriate initial step in the management of combined deep and superficial incompetence.

26. Nicos Labropoulos, PhD, Apostolos K, Tassiopoulos, MD, Steven S. Kang, MD, Ashraf Mansour, MD, Fred N. Littooy, MD, and William H. Baker, MD. Maywood, III Journal of Vascular Surgery 2000; Prevalence of deep venous reflux in patients with primary superficial vein incompetence The prevalence of deep venous insufficiency in patients with primary superficial venous reflux and without history of DVT is 22%. The most common etiology of chronic venous disease (DVI) is reflux in the superficial, deep, or perforator veins. With the advent of duplex ultrasound scan in the last decade, it became obvious that the superficial venous system is the site most commonly affected. In recent studies (30, 34,), investigators have reported that reflux in the superficial system is present in approximately 90% of limbs with CVD, whereas reflux in the deep system is detected in only 30% of limbs. The prevalence of deep venous insufficiency (DVI) (reflux in the deep veins) in limbs with reflux in the superficial system is reported to be approximately 20 %.( 22) In some limbs with combined superficial and deep venous reflux, there is no history of or sonographic appearance consistent with a previous episode of deep venous thrombosis (DVT). In these limbs it has been suggested that DVI may result from volume overload due to the reflux of blood in the superficial system. (22). More specifically, it has been hypothesized that incompetence of the superficial system results in increased venous return through the perforating veins into the deep system. This creates a volume overload in those veins that leads to venous dilatation and eventually to incompetence. In support of this theory, investigators of two studies (22, 23,) have reported that surgical correction of reflux in the superficial system abolished the reflux in the deep system in more than 90% of the affected limbs.

27. Takashi Yamaki, MD., Motohiro Nozaki, MD., Osamu Fujiwara, MD., Eika Yashida,Md., Comparative Evaluation of Duplex -Derived Parameterson Patients with Chronic Venous Insufficiency: Correlation with Clinical Manifestations. J Am Coll Surg 2002; 195:822-830 This study has suggested the importance of superficial venous insufficiency in the development of advanced Chronic Venous Insufficiency (CVI). Superficial insufficiency is predominant in both early and advanced CVI. These reports suggest that superficial incompetence produces an overflow of venous return through perforating veins into the deep system. Superficial venous insufficiency might play a major role in the development of advanced DVI.

28. Robert M. Kaplan, PhD, Michael H. Criqui, MD., Julie O Denenberg,MA., John J. Bergan, MD., and Arnost Fronek, MD., San Diego, Calif., Quality of life in patients with chronic venous disease: San Diego Population Study: J Vasc. Surg. 2003: 37: 1047-53 In summary, venous disease of the lower extremities is a prevalent condition. The health consequences of venous disease are not fully understood, but it is clear that it increases risk for venous thrombotic events, which can be fatal. Even modest venous disease is associated with significant limitations on the functional scales of SF-36.

29. Kees-Peter DE Roos, MD., Fred H.M. Nieman, PhD., and H.A. Martino Neuman, MD., PhD. Ambulatory Phlebectomy Versus Compression Sclerotherapy: Results of a Randomized Controlled Trial. Dermatol. Surg. 2003: 29: 221-226 Our results show that ambulatory phlebectomy is an effective therapy for varicose veins of the legs. Recurrence rates are significantly lower than for compression schlerotherapy. If varicose veins persist 2 weeks after compression scleroyherapy, it can be argued that to reduce the risk of future recurrence ambulatory phlebectomy should be considered as the better treatment option.

30. Veins Task Force. The Management of Chronic Venous Disorders of the Leg. Commonly Ascribed Causes of Varicose Veins________ Hereditary Tight underclothes Pregnancy Raise toilet seats Obesity Lack of exercise Standing occupation Smoking Chair sitting Oral contraceptives Low-fiber diet/constipation

31. Kistner, R.L.; Eklof, B.; Masuda, E.M. Diagnosis of Chronic VenousVenous Disease of the Lower Extremities: The “CEAP” Classification. Mayo Clin, Proc. 1996, 71 (4), 338-345

32. Porter, J. M., Montana, G.L., Reporting Standards in Venous Disease : An Update. International Consensus Committee on Chronic Venous Disease. J. Vasc. Surg. 1995 21, (4), 635-645

33. Classification and Grading of Chronic Venous Disease, A Consensus Statement. J. Vasc. Surg., 1995, 21, 635-645

34. Michael A. Ricci MD, Joseph Emmerich, MD, PhD, Peter W. Callas, PhD, Frits R. Rosendaal,MD, Andrew C. Stanley, MD, Shelly Naud, PhD, Carla Vossen, MSc, and Edwin G. Bovilli, MD, Burlington, Vt. Paris, France, and Leiden, The Netherlands.Evaluating chronic venous disease with a new venous severity scoring system.J Vasc.Surg 2003;38:909-15

35. Labropoulos, N. CRAP in clinical practice. Vasc. Surg. 1997, 31: 224-5

36. Labropoulos, N., Clinical Correlation to Various Patterns of Reflux. Vasc. Surg., 1997, 71 (10), 754-755

37. Sthia, K.K.; Darke S.G., Long Saphenous Incompetence as a cause of Venous Ulceration. Br. J. Surg. 1984 71 (10), 754-755 30-50 % of the leg ulcers are caused by superficial reflux in the saphenous or saphenous plus perforator veins with no involvement of deep system.

38. Navarro, T.P., Arch. Surg. 2002 Size of Great Saphenous Vein: Great saphenous vein diameter is a relatively accurate measure of Hemodynamic impairment and clinical severity. Predicts not only the absence of abnormal reflux, but also the presence of critical venous incompetence assisting in clinical decision making before considering high ligation and partial selective stripping of the great saphenous vein. A great saphenous vein diameter of 5.5 mm or less predicts the absence of abnormal reflux with a sensitivity of 78 % and a specitivity of 87 %. A great sphenous vein diameter of 7.3 mm or greater predicted critical reflux with an 80 % sensitivity and an 85 % specitivity. The great saphenous vein diameter proved to be a relatively accurate measure of hemodynamic impairment.

39. Ambulatory Phlebectomy. A Practical Guide for Treating Varicose Veins. Stefano Ricci, MD. And Miheal Georgiev, MD. With Michel P. Goldman, MD. Chapter 5 Staging of Surgery. In cases of widespread varicosities the best way to achieve maximum safety is to divide vein avulsion into several operations of limited extent and to perform these operations during separate sessions.

40. Manfrini S. .Endovenous management of saphenous vein reflux. Endovenous Reflux Management Study Group. J.Vasc. Surg. 2000 Closure treatments were associated with paresthesias Thigh 9 % Leg 51 % It is therefore recommended not to treat below Boyds Perforator.

41. Negus D. Phlebologie. 1987 Groin to ankle strippings of Long Saphenous Vein are subject to an unacceptable percentage (25-58%) of neurological complications due to trauma of the saphenous nerve

42. Conrad P. Aust. N.Z. Invaginating Stripping of the Long and Short Saphenous Vein using the PIN Stripper. J. Surg. 1996 ” Less tissue trauma ” Less bruising ” Less post-op pain ” No trauma to saphenous and sural nerve

43. Oesh A (1993) “Pin-stripping”: a novel method of atraumatic stripping. Phlebology, 1993; 8:171-173

44. Tretbar LL A 5-year critical evaluation of microincisional phlebectomy for the treatment of varicose veins larger than 1.5 cm in diameter. Dermatol. Sueg 21: 98-99

45. Engel A, Johnson ML, Haynes SG. Health effects of sunlight exposure in the United States: Results from the first national health and nutrition examination surveys. 1871-1974. Arch Dermatol 1988; 124: 72-79. The incidence of spider veins in women approaches 50 percent.

46. Olsen T. Peripheral vascular diseases and vascular-related diseases. In Moschella SL. Hurley HJ, Eds: Dermatology, 2nd ed. Vol 2. Philadelphia: WB Saunders, 1985, pp 1000-1086. Spider veins of the lower extremities differ from telengiectasias in other areas of the body in morphology as well as physiology. The spider telengiectasias usually found on the face, hands, and arms but rarely below the umbilicus is formed by a central arteriole.

47. Bodian EL. Techniques of schlerotherapy for sunburst venous blemishes. J Dermatol. Surg Oncol 1985; 11: 696-704. Biopsies of spider veins on the lower extremities have confirmed their identity as small veins rather than arteries. Since they are actually small veins, they are subject in a dampened fashion to the ambulatory venous pressure that is developed in the standing position. These differences between spider veins of the lower extremities and telengiectasias elsewhere on the body may account for the differences in effectiveness of various treatment modalities that have been applied to each.

48. Burnard KG, Whimster I, Clemenson G, Thomas ML, Browse NL, The relationship between the number of capillaries in the skin of the venous ulcer-bearing area of the lower leg and the fall in foot vein pressure during exercise. Br. J. Surg. 68:297-300, 1981. The vascular proliferation seen in the skin of patients with venous disease has been known for many years but has not been explained.

49. Pardoe HD, The expression of angiogenic growth factors in the skin of patients with chronic venous disease of the lower limb. M. Sc. Thesis. London: University College London, September, 1996, pp 1-66. In recent years many angiogenic factors that stimulate the growth of blood vessels have been recognized . In a further study conducted in the department of surgery at UCL, immunohistochemistry was used to evaluate the presence of a number of such factors in the skin of patients with venous disease. Considerable up-regulation of the production of vascular endothelial growth factor (VEGF) was noted in the epidermis of patients with venous disease, being most marked in those with skin changes. It seems likely that VEGF may account for at least some of the vascular proliferation seen in the skin of patients with venous disease.

50. Myers KA, Ziegenbein RW, Zeng GH, Mathews PG, Duplex ultrasonography, scanning for chronic venous disease: patterns of venous reflux. J Vasc Surg 1995;21:605-12.

51. Bays R, Healy O, Atnip R, Neumyer M, Thicle B, Validation of air plethysmography, photoplethysmography, and duplex ultrasonography in the evaluation of severe venous stasis. J Vasc Surg 1994;20:721-7.

52. Beckman, J. A. Diseases of the veins. Circulation, 2002, 106(17), 2170-2172.

53. London N.J.M. &Nash, R. Varicose veins, British Medical Journal, 2000, 320 (7246), 1391-1394. The Framingham Heart Study found the 2-year incidence of varicose veins was 39.4 per 1000 men and 51.9 per 1000 women.

54. Callam, M.J. Epidemiology of varicose veins, British Journal of Surgery, 1994, 81(2), 167-173 Lower extremity symptoms are not always the direct result of the presence of varicose veins, but may be related to underlying venous disease. The study states that symptoms may occur in people with venous disease even when there are no visible varicose veins.

55. Jacob, M. et al. Plasma Matrix Matelloproteinase-9 as a marker of blood stasis in varicose veins. Circulation, 2002, 106(5), 535-538.

56. Sansilvestri-Morel, P. et al. Synthesis of collagen is dysregulated in cultured fibroblasts derived from skin of subjects with varicose veins as it is in venous smooth cells. Circulation, 2002, 106(4), 479-483.

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58. Anderson F.A. & Spencer F. A. Circulation, Risk factors for venous thromboembolism. Ciculation, 2003,107(23), 19-116.

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65. Goren G. Injection sclerotherapy for varicose veins: history and effectiveness. Phlebology 1991;6:7-11

66. Rutger, P.H., Kitslaar PT Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein. Am I Surg 1994; 168:311-15

67. Reymond-Martimbeau P. Two different techniques for sclerosing the incompetent sapheno femoral junction: a comparative study. I Derniatol Surg Oncol 1990; 16:626-631

68. Bishop CCR, Fronek HS, Fronek A eta]. Real-time color duplex scanning after sclerotherapy of the great saphenous vein. I Vasc. Surg. 1991; 14:505-508

69. Gongolo A, Giraldi E, Buttazzoni L, et al. 11 sistema duplex nelfollow up deela terapia sclerosante della venagrande safena. Radiol Med 1991;81:303-308 (Italian)

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72. Oesch A. PIN stripping: a novel method of a traumatic stripping. Phlebology 1993; 8: 71-3

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74. Goren G, Yellin AE Ambulatory stab evulsion Phlebectomy for truncal varicose veins Am, J. Surg. 1991;162:166-174

75. Goren G, Yellin AE. Invaginated axial stripping and stab avulsion (hook) Phlebectomy: a definitive outpatient procedure for primary varicose veins. Amb Surg 1994; 2:27-35

76. Goren G. Primary varicose veins: hemodynamic principle of surgical care. The case for the ambulatory stab evulsion technique. VASA 1991; 20:365-368

77. Creton D. Study of the limits of local anesthesia in one-day surgery in the case of 1500 strippings of the great saphenous vein. Amb Surg 1993; 1: 132-35

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