What is venous reflux and how is it treated?

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Venous Reflux: Diagnosis and Treatment

Venous reflux is a condition where blood flows backward in the veins due to damaged or incompetent valves, and it is best treated with endovenous thermal ablation as the first-line intervention for symptomatic patients with confirmed reflux on duplex ultrasound. 1

What is Venous Reflux?

Venous reflux occurs when the one-way valves in veins become damaged or dysfunctional, allowing blood to flow backward (retrograde) instead of returning efficiently to the heart. This condition leads to blood pooling in the veins, causing increased venous pressure and various symptoms.

Diagnostic Criteria:

  • Retrograde venous flow exceeding 500 milliseconds on duplex ultrasound is considered abnormal reflux 1
  • Vein diameter >4.5 mm is a criterion supporting intervention 1
  • Evaluation should be performed with the patient in standing position or at 60° Trendelenburg position 1

Clinical Presentation

Patients with venous reflux commonly present with:

  • Varicose veins (dilated, twisted superficial veins)
  • Leg heaviness and fatigue
  • Swelling (edema)
  • Skin changes (hyperpigmentation, eczema)
  • Pain or discomfort, especially after prolonged standing
  • In severe cases: venous ulcers, bleeding, or superficial thrombophlebitis

Diagnostic Approach

Duplex ultrasound is the gold standard for diagnosing venous reflux:

  • Evaluates the entire venous system (deep veins, superficial veins, perforators)
  • Measures reflux duration (>500 ms is abnormal)
  • Assesses vein diameter (>4.5 mm supports intervention)
  • Rules out deep vein thrombosis (DVT) 1

Treatment Options

1. Conservative Management

  • Compression therapy (30-40 mmHg graduated compression stockings) for symptom relief 1
  • Leg elevation
  • Regular exercise
  • Weight management
  • Avoiding prolonged standing or sitting

2. Interventional Treatments

  • Endovenous thermal ablation (radiofrequency or laser) - first-line treatment for saphenous vein reflux due to higher efficacy, lower complications, and faster recovery 1
  • Ultrasound-guided foam sclerotherapy - effective for tributary veins and as adjunctive treatment 1, 2
  • Microphlebectomy - for visible varicosities 1
  • Traditional surgical approaches (ligation and stripping) - higher recurrence rates (15-35% within 2 years) compared to endovenous techniques 1

3. Advanced Surgical Options for Deep Venous Reflux

For severe cases with deep venous reflux that don't respond to standard treatments:

  • Internal valvuloplasty - 70% good results for primary reflux 3
  • Transposition or transplantation - 50% good results for post-thrombotic syndrome 3

Treatment Algorithm

  1. Confirm diagnosis with duplex ultrasound

  2. Begin with conservative management:

    • Compression therapy (30-40 mmHg)
    • Lifestyle modifications

  3. For persistent symptoms with confirmed reflux:

    • First-line: Endovenous thermal ablation (radiofrequency or laser)
    • Adjunctive: Ultrasound-guided foam sclerotherapy for tributary veins
    • For visible varicosities: Microphlebectomy

  4. For deep venous reflux:

    • Primary reflux: Consider valvuloplasty
    • Post-thrombotic syndrome: Consider transposition or transplantation
    • Only after failure of conservative treatment and superficial vein procedures

Treatment Outcomes

  • Endovenous laser treatment achieves 93-98% occlusion rates at one-year follow-up 2, 4
  • Foam sclerotherapy shows 77-83% success rates at one year 2
  • Vein diameter affects treatment success - foam sclerotherapy is less effective for veins >6.5mm 2
  • Post-procedure ultrasound should be performed within 1-2 weeks to confirm successful vein closure 1

Important Considerations

  • The presence of deep venous reflux (DVR) is associated with increased risk of endovenous heat-induced thrombosis (EHIT) after saphenous vein ablation 5
  • Approximately 20% of patients undergoing saphenous vein ablation have concomitant deep venous reflux 5
  • Regular follow-up is essential to monitor for recurrence and disease progression 1
  • All recurrences typically occur within the first 9 months after treatment, with most noted within 3 months 4

By following this evidence-based approach to diagnosis and treatment, venous reflux can be effectively managed to improve symptoms and prevent complications.

References

1
Guideline

Varicose Vein Treatment Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Research

[Surgery for deep venous reflux in the lower limb].

Journal des maladies vasculaires, 2004

4
Research

Endovenous laser treatment of saphenous vein reflux: long-term results.

Journal of vascular and interventional radiology : JVIR, 2003

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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