Lower Limb Varicose Research Articles

Gestação e varizes de membros inferiores: prevalência e fatores de risco

Contexto: Durante e após a gestação, as varizes dos membros inferiores têm aspectos peculiares, tais como o seu aparecimento, a precocidade de seu desenvolvimento, a intensidade e, no puerpério, a rapidez com que regridem. Esses aspectos têm influenciado os estudos para a compreensão dessa patologia. Objetivo: Verificar a prevalência das varizes dos membros inferiores em gestantes e os fatores de risco mais relevantes envolvidos. A prevalência na gestação é alta, atingindo cerca de 70%, quando se consideram todos os tipos de varizes. Essa alta prevalência decorre principalmente do aumento nas taxas dos estrógenos e progestágenos que ocorre durante a gravidez. Material e método: Foram avaliadas 352 gestantes no período pré-natal, durante 14 meses, escolhidas ao acaso. A doença varicosa foi diagnosticada clinicamente e classificada segundo os critérios de Widmer em varizes tronculares, reticulares e telangiectasias e reclassificadas pela classificação CEAP, segundo o critério clínico. Os resultados de prevalência e fatores de risco foram submetidos às análises univariada e multivariada. Resultados: A prevalência da doença varicosa, quando considerados todos os tipos de varizes, foi de 72,7% (256 gestantes). As 96 gestantes (27,3%) que não apresentaram doença varicosa foram consideradas, para análise estatística, como controle. Os fatores de risco de significância, após análise multivariada, foram: antecedente familiar positivo e idade. Conclusão: A prevalência da doença varicosa durante a gestação e os fatores de risco envolvidos indicam a necessidade de divulgação dessa patologia entre os profissionais envolvidos na prevenção e manutenção da saúde da mulher, especialmente aquelas em período fértil.

Evaluation of pelvic varicose veins using color Doppler ultrasound: comparison of results obtained with ultrasound of the lower limbs, transvaginal ultrasound, and phlebography

Introduction: Pelvic varicose veins, one of the main causes of chronic pelvic pain and dyspareunia, are an important source of reflux for lower limb varicose veins, especially in recurrent cases. Color Doppler ultrasound of the lower limbs and transvaginal ultrasound are the noninvasive diagnostic methods most commonly used to assess pelvic venous insufficiency, whereas phlebography is still considered as the gold standard. Objectives: To determine the prevalence of lower limb varicose veins originating from the pelvis in a group of female patients and to determine the agreement between results obtained via color Doppler ultrasound of the lower limbs, transvaginal ultrasound, and phlebography. Methods: The sample comprised female patients referred to a vascular laboratory for lower limb screening. Patients diagnosed with deep venous thrombosis were excluded. Data analysis included kappa coefficient of agreement, McNemar's test, sensitivity and specificity values. Results: Of a total of 1,020 patients, 124 (12.2%) had findings compatible with reflux of pelvic origin. Among these patients, 51 (41.2%) were recurrent cases. A total of 249 were submitted to transvaginal ultrasound. There was significant agreement between lower limb ultrasonographic findings and transvaginal findings. Phlebography was performed in 54 patients. The comparison between transvaginal ultrasound and phlebography was associated with a 96.2% sensitivity and 100% specificity. Conclusions: The authors draw attention to the relatively high prevalence of lower limb varicose veins originating from the pelvis, suggesting an important but underdiagnosed cause of recurrent varicose veins.

Abstract No. 182: Treatment of lower limb varicosities with combined use of endovenous laser and sclerosant at the same instance - A unique study of 286 patients

To report short term results of combining two modes of treating varicose veins - endovenous laser treatment for Great Saphenous Vein(GSV)reflux and sclerotherapy for incompetent perforators and accessory venous channels. 186 diagnosed and symptomatic varicose veins patients (66 women, 120 men; mean age 45.5 yrs) were treated with endovenous laser (for incompetent GSV) and sclerotherapy (for incompetent perforators and accessory venous channels). 253 lower limbs (76 left, 43 right, 134 billateral) were treated. 15 patients (18 legs; 7%) had ulcers. 7 patients (9 legs) had associated saphenopopliteal reflux. 10 MHZ linear Ultrasound (US) probe was used to map GSV. A 0.035 inch J-Guidewire introduced in GSV via locally anaesthesised site in proximal leg. A 5F sheath was advacned over the guide wire. A 610 μm laser fiber was inserted into sheath, and its tip placed at SFJ, location confirmed by US. Following perivenous local anesthesia, laser energy was delivered intraluminally at 14W in continous mode. Fibre was uniformly withdrawn. Sclerosant mixed with air to produce foam, was introduced through needle in perforators and additional venous channels under US guidance. All patients were advised ibuprofen and class II full-thigh stocking for 1 week. Clinical and US follow-up was done at 1 week, 3, 6 and 12 months. Criteria for successful treatment were US features (on day 7) of noncompressible GSV with reduced calibre and thick echogenic walls, and no colour flow within it. Primary failure was defined as failure to occlude or recanalised GSV lumen along with presence of reflux. 98% GSV were ablated initally. Rest underwent successful second sitting.7% limbs required one more session of sclerotherapy for new incompetent perforators. No DVT, nerve injury or skin burns were noted. 90% patients complained of tightness along the course of treated GSV. All non-healing ulcers responded well. Patients resumed routine activities immediately. Sclerotherapy is effective in dealing with perforators and provides rapid healing of chronic venous ulcers. Laser at the same time is effective in dealing with GSV reflux. Sclerotherapy and laser together demonstrate better outcome, limiting need of any subsequent procedure.

The role of transillumination phleboscopy in the planning of cosmetic operations for varicose veins

Background: The cosmetic treatment of varicose veins is the main activity of most vascular surgeons in Brazil. In order to obtain satisfactory cosmetic results, careful planning of varicose vein operations is necessary. Objective: Marking (or "mapping") the varicose veins with indelible ink is an essential step in planning cosmetic surgeries for lower limb varicose veins. In the present study, the role of transcutaneous phleboscopy (TcPh) in planning varicose vein operations is evaluated. Methods: A series of 100 consecutive patients, all female, were evaluated with TcPH as part of their varicose vein operations planning. A total of 171 limbs with varicose veins (71 bilateral and 29 unilateral) were evaluated. The process of marking the varicose veins followed the same protocol in all cases. Firstly, the varicose veins were marked by inspection and palpation, with the patient standing, using an indelible black ink pen. Secondly, with the patients resting in supine and prone positions, the varicose veins detected with TcPh were marked again with red or blue ink. The marks made by the two methods were then compared. Results: In 41 patients, for a total of 80 limbs (46.8%), the marks were altered after use of TcPh. Reasons for such changes were: 1) identification of other varicose veins; 2) identification of reticular veins draining complex telangiectasias; and 3) changes in the position of the marks placed with the patient standing. Conclusions: TcPh has altered the planning of varicose vein surgeries in 46.8% of all limbs evaluated, especially when the patients had complex telangiectasias, associated with reticular varicose veins.

Radiofrequency Ablation vs Conventional Surgery for Varicose Veins – a Comparison of Treatment Costs in a Randomised Trial

To compare the costs involved (from procedure to recovery) following radiofrequency ablation and conventional surgery for lower limb varicose veins in a selected population. Prospective randomised controlled trial. Patients with symptomatic great saphenous varicose veins suitable for radiofrequency ablation were randomised to either RF ablation or surgery (sapheno-femoral ligation and stripping). The hospital, general practice and patient costs incurred until full recovery and the indirect cost to society, due to sickness leave after surgery, were calculated to indicate mean cost per patient under each category. Ninety three patients were randomised. Eighty eight patients (47 - RF ablation, 41 - surgery) underwent the allocated intervention. Ablation took longer to perform than surgery (mean 76.8 vs 47.0 min, p<.001). Ablation was more expensive (mean hospital cost per patient 1275.90 pounds vs 559.13 pounds) but enabled patients to return to work 1 week earlier than after surgery (mean 12.2 vs 19.8 days, p=0.006). Based on the Annual Survey of Hours and Earnings (Office of National Statistics, UK) for full time employees, the cost per working hour gained after ablation was 6.94 pounds (95% CI 6.26, 7.62). The increased cost of radiofrequency ablation is partly offset by a quicker return to work in the employed group (ISRCTN29015169http://www.controlled-trials.com).

Lasers vasculaires

After reviewing the main technical features of the lasers and flashlamps currently available, the indications for these devices are detailed, mainly port wine stains, facial telangiectasia, hemangiomas, and lower-limb varicosities. Respecting the principles of treatment (briefly reviewed herein), contributes to preventing complications, which are consequently becoming rare.

Endovenous therapy of varicose veins: A better outcome than standard surgery?

In the UK approximately one million people are affected with varicose veins. Nearly half a million patients seek advice from their GPs about lower limb varicose veins related symptoms every year. Therefore, they constitute an important part of the elective operations and waiting lists in NHS hospitals. About 40,000 operations for varicose veins were performed in the NHS in 2001. The majority (60-70%) of those patients had an incompetent saphenofemoral junction (SFJ) and great saphenous vein (GSV) reflux. The traditional and most common approach for treating SFJ incompetence and GSV reflux is saphenofemoral disconnection and GSV stripping to the knee. Despite being considered a minor surgical procedure, complications are not uncommon. The minimally invasive endovenous treatment of lower limb's varicose veins has been used over the last few years in many centres across the world. It would appear to be equal to, if not superior to, traditional surgery. It has also been proven to be safe with few serious complications. The most common treatments are endovenous laser ablation and endovenous radiofrequency ablation and chemical sclerotherapy. The case for minimally invasive strategies appears to have been accepted by many patients already and it would appear in trials that they are 'voting with their feet'. Rigorous scientific evidence remains elusive and not yet conclusive. As in all other branches of surgery new technology should be embraced but cautiously, with all results collected and disseminated to finally prove the utility or otherwise of this technique.

Pelvic Vein Embolisation in the Management of Varicose Veins

Pelvic vein incompetence is common in patients with atypical varicose veins, contributing to their recurrence after surgery. Therefore, refluxing pelvic veins should be identified and treated. We present our experience with pelvic vein embolisation in patients presenting with varicose veins. Patients presenting with varicose veins with a duplex-proven contribution from perivulval veins undergo transvaginal duplex sonography (TVUS) to identify refluxing pelvic veins. Those with positive scans undergo embolisation before surgical treatment of their lower limb varicose veins. A total of 218 women (mean age of 46.3 years) were treated. Parity was documented in the first 60 patients, of whom 47 (78.3%) were multiparous, 11 (18.3%) had had one previous pregnancy, and 2 (3.3%) were nulliparous. The left ovarian vein was embolised in 78%, the right internal iliac in 64.7%, the left internal iliac in 56.4%, and the right ovarian vein in 42.2% of patients. At follow-up TVUS, mild reflux only was seen in 16, marked persistent reflux in 6, and new reflux in 3 patients. These 9 women underwent successful repeat embolisation. Two patients experienced pulmonary embolisation of the coils, of whom 1 was asymptomatic and 1 was successfully retrieved; 1 patient had a misplaced coil protruding into the common femoral vein; and 1 patient had perineal thrombophlebitis. The results of our study showed that pelvic venous embolisation by way of a transjugular approach is a safe and effective technique in the treatment of pelvic vein reflux.

Recurrent Lower-Limb Varicose Veins: Effect of Direct Contrast-enhanced Three-dimensional MR Venographic Findings on Diagnostic Thinking and Therapeutic Decisions

To assess the effect of direct three-dimensional (3D) magnetic resonance (MR) venographic findings on diagnostic thinking and therapeutic decisions in patients with complex recurrent varicose vein anatomy who were being evaluated for surgical treatment. The study was approved by the Institutional Review Board; informed consent was obtained from patients. MR venography was performed before surgery in 22 legs of 14 patients (seven women: mean age, 53 years; seven men: mean age, 59 years) thought to have recurrent varicose veins. Two radiologists assessed image quality and evaluated sites and sources of varicose veins on MR venograms. One vascular surgeon completed a questionnaire before and after MR venography and noted diagnosis and therapeutic decisions. Diagnoses at MR venography were compared with surgical results in 19 legs that underwent surgery. Differences between diagnosed and treated varicose veins per leg before and after MR venography were analyzed with logistic regression for survey data. kappa Values were calculated to illustrate interobserver agreement for grading image quality of venous segments and for diagnosing recurrent varicose veins. Mean graded image quality of the deep venous system and the recurrent varicose veins was good or excellent in 89% of segments. There was good agreement between readers regarding grading of image quality of venous segments (kappa = 0.80). After MR venography, diagnosis of the sites and sources of recurrent varicose veins changed in 17 of 22 legs of nine of 14 patients. In one of 14 patients, the preoperative diagnosis of recurrent varicose veins was withdrawn. A change in treatment plan occurred in 17 of 22 legs after MR venography. The number of diagnosed and treated sources of reflux increased significantly after MR venography. MR venographic diagnoses were confirmed at surgery in all 19 legs. MR venographic results have a substantial effect on diagnostic thinking and therapeutic decisions when recurrent lower-limb varicose veins are suspected.

Lasers vasculaires

After reviewing the main technical features of the lasers and flashlamps currently available, the indications for these devices are detailed, mainly port wine stains, facial telangiectasia, hemangiomas, and lower-limb varicosities. Respecting the principles of treatment (briefly reviewed herein), contributes to preventing complications, which are consequently becoming rare.

Coil Protruding into the Common Femoral Vein Following Pelvic Venous Embolization

Pelvic venous embolization is performed for pelvic congestion syndrome and prior to lower limb varicose vein surgery in females with associated pelvic venous insufficiency. The procedure is analogous to varicocele embolization in males, although refluxing internal iliac vein tributaries may also be embolized. We report a case of inadvertent coil placement in the common femoral vein while embolizing the obturator vein, during pelvic vein embolization for recurrent lower limb varicose veins. There were no clinical consequences and the coil was left in situ. We advise caution when embolizing internal iliac vein tributaries where there is clinically significant communication with veins of the lower limb.

The Usefulness of Preoperative Doppler Ultrasonographic Evaluation of Saphenofemoral Complex For Improving Lower Limb Varicose Veins Surgery

The Usefulness of Preoperative Doppler Ultrasonographic Evaluation of Saphenofemoral Complex For Improving Lower Limb Varicose Veins Surgery

A variabilidade hemodinâmica venosa detectada pelos parâmetros da pletismografia a ar nas classes clínicas da classificação CEAP

CONTEXTO: A variabilidade hemodinâmica da pletismografia a ar é conhecida, mas o exato papel dessa variabilidade no cotidiano clínico não foi investigado, podendo ter algum significado clínico ainda não explorado. Sabe-se que há sobreposição entre as classes clínicas (C0 a C6) da classificação CEAP e mesmo entre membros inferiores de uma mesma classe clínica. OBJETIVO: Avaliar a variabilidade hemodinâmica dos parâmetros da pletismografia a ar nas classes clínicas da classificação CEAP. MÉTODO: Este estudo retrospectivo confronta a doença varicosa de membros inferiores classificada de C0 a C6 pela classificação CEAP com os parâmetros hemodinâmicos venosos obtidos pela pletismografia a ar. Os dados obtidos foram tabulados e analisados em suas classes clínicas pelos testes de variância de Kruskal-Wallys e Barllett. RESULTADOS: Foram realizados 310 exames em 230 pacientes cujas idades variaram entre 19 a 81 anos, com uma média de 46,2 anos. Os parâmetros índice de enchimento venoso e volume venoso funcional mostraram aumento da variabilidade hemodinâmica quando analisados na classe clínica C0 do CEAP, demonstrada por meio do coeficiente de variabilidade que, para o índice de enchimento venoso foi de 28,12% na classe clínica C0 e se manteve acima de 57% nas classes de C2 a C6. A fração de ejeção e a fração de volume residual não aumentaram a variabilidade quando comparados com a classe clínica C0 do CEAP. CONCLUSÃO: O índice de enchimento venoso foi o melhor parâmetro para avaliação e triagem de pacientes com insuficiência venosa crônica, mas tem grande variabilidade nas classes clínicas C2 a C6 do CEAP.

Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment for Varicose Veins

We report an anaphylactic reaction following ultrasound guided foam sclerotherapy (UGFS) to lower limb varicosities. A tortuous anterolateral thigh vein of a 62 year-old woman was unsuccessfully ablated with UGFS. A further session of UGFS, 6 months later, resulted in a non-fatal anaphylactic reaction that required resuscitation with adrenaline. The patient was not known to be allergic to the sclerosant used and had not suffered any adverse effects after her initial treatment. This case demonstrates the possibility of anaphylaxis following UGFS. Those performing sclerotherapy require appropriate resuscitation equipment and training. Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose VeinsEJVES ExtraVol. 13Issue 6PreviewWe report an anaphylactic reaction following ultrasound guided foam sclerotherapy (UGFS) to lower limb varicosities. A tortuous anterolateral thigh vein of a 62 year-old woman was unsuccessfully ablated with UGFS. A further session of UGFS, 6 months later, resulted in a non-fatal anaphylactic reaction that required resuscitation with adrenaline. The patient was not known to be allergic to the sclerosant used and had not suffered any adverse effects after her initial treatment. This case demonstrates the possibility of anaphylaxis following UGFS. Full-Text PDF Open Access

Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose Veins

We report an anaphylactic reaction following ultrasound guided foam sclerotherapy (UGFS) to lower limb varicosities. A tortuous anterolateral thigh vein of a 62 year-old woman was unsuccessfully ablated with UGFS. A further session of UGFS, 6 months later, resulted in a non-fatal anaphylactic reaction that required resuscitation with adrenaline. The patient was not known to be allergic to the sclerosant used and had not suffered any adverse effects after her initial treatment. This case demonstrates the possibility of anaphylaxis following UGFS. Those performing sclerotherapy require appropriate resuscitation equipment and training.

Leg Varices Originating from the Pelvis: Diagnosis and Treatment

This article reports the investigation and treatment of 24 women presenting with recurrent lower limb varicosities secondary to reflux within the pelvic venous circulation. Diagnosis based on selective retrograde pelvic phlebography enabled precise identification and classification of sites of incompetence. A total of 74 veins were treated by embolization with platinum coils and glue prior to repeat surgery to the lower limb veins. At 4-year follow-up, signs of stasis had disappeared in all patients. Repeat phlebography revealed no evidence of recurrent reflux at the sites of treatment. One patient developed recurrent varices due to incomplete embolization of incompetent pelvic veins. Endovascular occlusion of incompetent pelvic veins is an effective treatment for varicose veins secondary to pelvic venous incompetence.

The Treatment of Varicose Veins

Over the past few years, there has been a move to less invasive endoluminal methods in the treatment of lower limb varicose veins combined with a renewed interest in sclerotherapy, with the recent addition of foam sclerotherapy. The development of these new techniques has led many to question some of the more conventional teaching on the treatment of varicose veins. This review examines these new treatments for lower limb varicose veins and the current evidence for their use. An extensive search of available electronic and paper-based databases was performed to identify studies relevant to the treatment of varicose veins with particular emphasis on those published within the last 10 years. These were analysed by both reviewers independently. There is no single method of treatment appropriate for all cases. Conventional surgery is safe and effective and is still widely practised. Whilst the new treatments may be popular with both surgeons and patients, it is important that they are carefully evaluated not only for their clinical benefits and complications when compared to existing treatments but also for their cost prior to their wider acceptance into clinical practice.

Primary varicose vein of upper limb: A rare entity

Received 04/10/06; Review Completed 29/10/06; Accepted 08/11/06. A healthy 6-years-old male child reported to us with complaint of soft compressible swellings (four years duration) of right forearm and arm, which were progressively increasing in size. This was not associated with pain and discomfort. Patient did not give history of antecedent trauma or weight lifting. On examination, there were multiple soft, cystic, compressible swellings of approximately 2 x 2 cms. on the medial aspect of right forearm and arm along basilic vein distribution. These swellings disappeared on raising the arm above the head and reappeared on applying the pressure. These varicosities were starting form little finger base and extending upto right axilla (Fig. 1). Surrounding skin was normal. No bruit was audible and both arms were of equal size. Bilateral pulses were normal. Opposite upper limb and bilateral lower limbs were normal. There was no family history of lower limb varicosities. On Duplex examination, there was no evidence of venous reflux or proximal dilation. Ascending phlebography (Varicography) also documented basilic vein varicosities with saccular enlargements. There were no signs suggestive of arterioverious fistula and haemangimatous malformations on both the studies. The patient underwent successful treatment of these varicose veins by sclerotherapy. A varicose vein may be defined as a vein that becomes elongated, dilated, tortuous and thickened due to continuous dilatation under pressure. Primary varicose veins are a common affliction of the lower extremities whereas the upper extremities are rarely affected. The literature has little reference as regards the number of cases, causes and management of upper limb varicose veins1,2. Congenital arteriovenous fistulae or iatrogenic arterioverious fistulae for haemodilaysis causes upper extremity varicose veins. Congenital vascular anomalies, the Klippel Trenaunay Syndrome and the Parkes Weber syndrome are other rare causes of arm varicose veins. Venous outflow obstruction caused by subclavian vein thrombosis can be another uncommon cause2,3. The diagnosis of upper extremity varicose veins can be made by means of a good history and physical examination, besides these, non invasive Doppler Ultrasound or duplex allows visualization and quantification of incompetence or obstruction. Invasive investigations are generally unnecessary but may be required in unusual situations like congenital and anatomical variants, to further define the pathology. Arteriovenous fistulae and congenital vascular anomalies are recognized by these investigations1,2,3. Treatment of upper limb varicosities is similar to that of varicose veins in the legs. The treatment of varicosities due to upper limb arterioverious fistulae is usually surgical and entails either ligation of distal venous limb of a side to side fistula or division of the fistula itself and provides excellent cosmetic and functional outcomes2,3. Sclerotherapy with agents like Sodium tetradecyl sulphate and Polidocanal are useful alternatives to surgery4.

Injection sclerotherapy of the lower limb: 25 years of experience with 115000 injections

The author began to deal with injection sclerotherapy 25 years ago, which is still being practised by him to this day. Experience is drawn from 115 000 injections given to 4025 limbs of 3107 patients. The mean age is 41.7 years, 80.3% of patients were women. For decades, medicines necessary for sclerotherapy (polidocanol, tetradecylsulphate) have been available in Hungary. At the same time diagnosis and method have developed both abroad and in Hungary. Instead of the previously used standard standing position, the patient is either sitting or lying during the puncture. The diameter of the needle used is smaller than earlier. Previously at the injection the patient was lying and her leg was raised, but now usually she is in the same position as during the puncture. The amount of given medicine at one session was 1 x 0.2 ml, later 4 and 6 x 0.5 ml, but now the allowed maximal dosage is 28 ml 0.5%. Treatments were successful in every case and there were not any serious complications. This method has an outstanding importance in the treatment of intracutaneous venectases and reticular varicosis but side branches and perforators can be cured as well. As is well known, varicosity is a progressive disease and the sclerotherapy can be repeated unrestricted. It is therefore suitable for its treatment in the long run. Strong reactions and complications: The most common strong reactions are fainting, suffusion, phlebitis and pigmentation at the site of the injection. Very rarely blistering, allergic reaction and deep venous thrombosis. The latter is highly focused, therefore the patient's thrombophilic history is revealed. The authors' results and the survey in Hungary showed 1.5% complication in treated patients including one non serious deep venous thrombosis. The recently introduced ultrasound-guided foam sclerotherapy of the leg is suitable for the injection of stem varicosities. Successful treatments were carried out not only in the lower leg but also in upper limb varicosities, vascular malformations, venous lake of the lip and hemorrhoidal nodes. The sclerotherapy and operation rather supplement each other than compete. Sclerotherapy has proved to be suitable for the therapy of lower limb varicosity and some other venous dilatations.

An “All-Comers” Venous Duplex Scan Policy for Patients with Lower Limb Varicose Veins Attending a One-stop Vascular Clinic: Is It Justified?

Objective To determine whether clinical assessment could predict the correct management of patients with varicose veins (VVs), select those who would need duplex scanning, and identify deep venous reflux (DVR). Methods Prospective study of 342 consecutive limbs with VVs. These were divided into 3 groups: 170 (50%) limbs with primary VVs without skin changes (group I), 37 (11%) with recurrent VVs without skin changes (group II), and 135 (39%) with primary or recurrent VVs with skin changes (group III). Clinicians were asked to document whether they would normally request a duplex scan because of clinical uncertainty. Agreement between decision-making based on clinical and on duplex findings was documented. Results Agreement between clinical and duplex findings for groups I, II, and III was 82%, 59%, and 67%, respectively. In 112 cases (66%) in group I, clinicians felt certain about the diagnosis and yet duplex scanning revealed they were wrong in 12% of cases. In group II, clinicians would request a duplex scan because of clinical uncertainty in 30 (81%) cases. In group III, the sensitivity, specificity, positive and negative predictive value of clinical assessment in detecting DVR was 32%, 77%, 24%, and 83%, respectively. Conclusions Clinical evaluation of patients with VVs is unreliable in planning their management. Clinicians can neither predict those who will require duplex scanning nor correctly identify DVR. Even experienced surgeons often “get it wrong” when assessing primary uncomplicated veins despite being certain about the diagnosis. Therefore, an “all-comers” duplex imaging policy should be implemented if optimal management is to be achieved.