Patterns of reflux in patients with CEAP C2 disease compared to patients with C6 venous ulceration

Abstract

Objective

CEAP categorizes patients based on disease progression and severity. Whether disease severity is associated with specific patterns of reflux is currently unknown. We hypothesize that patterns of reflux in patients with C2 and C5/6 disease will differ.

Design

Multi-center retrospective cohort analysis.

Methods

From January 2015 to December 2020, we performed a retrospective review of reflux patterns in 21 335 patients and 31 727 limbs in symptomatic patients with C2 or C5/6 disease. Patterns of reflux in Great (GSV), Small (SSV), Deep and Perforators (Perf), were analyzed in patients with and without junctional reflux. The GSV and SSV were divided into six and three segments respectively. The number of perforators with reflux were categorized as 1-3 above and below-knee and deep system reflux was divided into three segments.

Results

Of the 21 335 patients the average age and female/male distribution was the following: C2 (54.13 ± 13.82, 21 410/5047), C5/6 (64.75 ± 14.75, 1514/1755) (p ≤ .001). When SFJ reflux is present, 6-segment GSV reflux was most prevalent (C2, 14.85% vs C5/6, 27.50). Without junctional reflux, above knee reflux was more common in C2 disease, while below knee reflux was more common in C5/6 disease (p ≤ .01). Three segment SSV reflux was more prevalent in C2 patients (26.67% vs 16.27%, p ≤ .001). Below knee perforator reflux was more prevalent in C5/6 patients (79.56% vs 73.53%, p ≤ .01). Combined CFV/FV/POPV reflux was more prevalent in C5/6 patients (38.5% vs 20.5%, p ≤ .001).

Conclusion

The presence of junctional reflux is more closely associated with disease location (above- vs below-knee) than with disease classification. SFJ reflux is more likely to present with extensive above knee disease. Isolated below-knee reflux is more significantly associated with C5/6 disease, independent of junctional reflux. Conversely, isolated above-knee superficial reflux is significantly associated with C2 disease and junctional reflux.

Keywords

CEAP (Class,Etiology,Anatomy,Pathophysiology) clinical Class reflux

Introduction

The etiology of chronic venous insufficiency (CVI) is venous hypertension secondary to combinations of obstructive and reflux patterns in the superficial, deep and/or perforating venous systems. Reflux in the lower extremity venous system is the most common cause of CVI.¹ Several population based investigations have demonstrated that patients with CVI progress to worse stages of disease over time and have identified risk factors associated with disease progression.^2–9 These investigations have reported that reflux patterns and the extent of reflux are associated with CEAP clinical class, symptom severity and disease progression.^2,8–19 The majority of these investigations are single center, retrospective analyses of small patient cohorts. In addition, the definitions of the extent of reflux are vaguely defined and variable between investigations. The purpose of this investigation is to analyze a large population of symptomatic patients with and without junctional reflux in the infra-inguinal superficial and deep axial veins, determine the extent of reflux based on the number and location of venous segments involved and determine reflux pattern differences between patients with CEAP class C2 and C5/C6 disease.

Methods

This is a retrospective review of prospectively collected data from our Office of the National Coordinator for Health Information Technology certified electronic medical record (Nextgen Healthcare Information Systems™, Irvine California) at the Center for Vein Restoration (CVR) between January 2015 and December 2020). The Center for Vein Restoration (CVR) is a multi-site, physician run, outpatient healthcare delivery organization that focuses on the diagnosis and management of patients with chronic venous disorders. Institutional review board approval for the investigation was obtained (Advarra, Columbia, MD). Informed consent was not required as per the IRB. Patient demographics, race, medical and surgical histories, presenting symptoms, pre-intervention rVCSS (revised Clinical Severity Score), types of interventions and number of interventions were all assessed. Patients included in the investigation demonstrated symptomatic chronic venous insufficiency and received an intervention and were CEAP class 2, 5/6. Patients and Limbs that were C1, C3, or C4 and patients that did not receive an intervention were excluded from this study. Reflux patterns in the Great Saphenous Vein (GSV), Small Saphenous Vein (SSV), Perforators (PV), and Deep system were subsequently analyzed and compared to each vein territory. The presence of infra-inguinal deep vein reflux in patients with evidence of post-thrombotic vein wall damage were excluded from the analysis. Similarly, patients with Anterior Accessory Great Saphenous Vein reflux were excluded from the study since the purpose of this investigation was to primarily assess reflux patterns in the superficial and deep axial venous system. The presence of outflow lesions in the supra-inguinal deep veins were not evaluated in this assessment. Data were analyzed using GraphPad prism9 with chi-square and analysis of variance tests to assess for significance.

Diagnostic ultrasonography was performed by Registered Vascular Technologista in our accredited ICAVL (Intersocietal Commission for the Accreditation of Vascular Laboratories) vascular laboratories. CVR utilizes a GE Versana Premier or GE Versana Active Systems ultrasound with a linear array L6-12-RS probe (GE Medical Systems, Jiangsu China) for venous duplex scanning. The preferred angle of insonation is 60° with a sample volume gate size of 1.5 mm. The sample volume gate is placed parallel to the flow channel. Patients are first placed in the reverse Trendelenburg position and scanned for deep and superficial venous thrombosis by obtaining images with and without compression. The vessels included in the exam are the common femoral vein, femoral vein, popliteal vein, peroneal veins, posterior tibial veins, gastrocnemius veins, soleal vein, great saphenous vein and small saphenous vein. Any additional areas of pain or swelling are also imaged to assess for possible superficial venous thrombosis in any tributaries or perforators. Patients are then scanned for deep and superficial insufficiency in the standing position. Reflux measurements are taken in the common femoral vein, mid femoral vein, popliteal vein, saphenofemoral junction, great saphenous vein from proximal thigh to distal calf, anterior accessory great saphenous vein in the thigh and the small saphenous vein. Measurements in the axial Great and Small Saphenous veins are taken at the junction, proximal, mid and above knee thigh, proximal, mid and distal calf. If deep system insufficiency is identified additional reflux measurements are obtained at the proximal and distal femoral vein. Additional tributaries both saphenous in origin and non- saphenous and perforators are also interrogated for reflux. Reflux is assessed either with manual compression or a pneumatic calf pump. Reflux in the deep system is defined as retrograde flow greater than or equal to one second as assessed by spectral wave form analysis. Similarly, reflux in the superficial venous system is defined as retrograde flow greater than or equal to 0.5 seconds as assessed by spectral wave form analysis. Diameter measurements are taken in transverse position from anterior wall to posterior wall of the great saphenous, small saphenous, anterior accessory great saphenous, tributaries and perforators. The exam includes a full scan of the anterior, medial, posterior and lateral aspects of the symptomatic legs.

To determine the extent of reflux, the GSV was divided into six segments below the saphenofemoral junction: three above-knee (AK) segments: proximal-thigh (PT), mid-thigh (MT), and distal-thigh (DT), and three below-knee (BK) segments: proximal-calf (PC), mid-calf (MC), and distal-calf (DC). Limbs were then grouped into 13 unique categories using all the different combinations of the number of refluxing segments present above the knee (zero to three), and the number of refluxing segments below the knee (zero to three). Reflux in the GSV was then further assessed based on the presence or absence of reflux in the saphenofemoral junction (SFJ), resulting in a total of 26 categories.

The SSV was similarly divided into three segments below the sapheno-popliteal junction: proximal-calf (PC), mid-calf (MC), and distal-calf (DC). These were grouped into three categories: one, two, or three refluxing segments in the SSV. SSV reflux was further assessed based on the presence or absence of reflux at the sapheno-popliteal junction (SPJ).

Refluxing perforators were classified by the number of above-knee refluxing perforators (zero to three) and the number of below-knee refluxing perforators (zero to three).

The deep system was analyzed based on involvement of the three deep veins: the common femoral vein (CFV), the femoral vein (FV), and the popliteal vein (POPV). Reflux in the deep system was analyzed by placing deep vein segments into one of three categories: AK deep system reflux (CFV and/or FV), POPV reflux alone, and entire deep system reflux (CFV, FV, and POPV). Tibial vein reflux was not assessed.

Results

From January 2015 and December 2020, 160 254 patients were evaluated at CVR. Of these patients, 21 335 patients had interventions in 31 727 limbs. Table 1 outlines the patient demographics of the current cohort. The average age and male/female distribution of each group was the following: C2 (54.13 ± 13.82, 21 410/5047), C5/6 (64.75 ± 14.75, 1514/1755) (p ≤ .001). C2 disease was much more common in females than in males, while C5/6 disease demonstrated equal prevalence between males and females. The racial distribution of the entire cohort was the following: African American (9%), Asian (3%), Hispanic (16%), Undesignated (21%) and Caucasian (51%) (p ≤ .05). The prevalence of cholecystectomies, oophorectomies, hysterectomies, uterine ablations, total knee replacements and previous vein procedures differed between groups (p ≤ .001). Pre-intervention rVCSS were as follows: C2, 5.2 ± 2.0, C5/611.67 ± 4.60, (p ≤ .0001). Pre-intervention CIVIQ 20 scores were the following: C2, 47.0 ± 18.2, C5/6, 55.45 ± 20.20 (p ≤ .0001). Presenting symptoms between the two groups are outlined in Table 2.

Table 1.

Demographics.

CEAP Class	C2	C5/C6	Total	p-value
Patients	17797	3538	21335	<0.0001
Limbs	26086	5641	31727	<0.0001
Age	54.07 ± 13.89	64.54 ± 14.30	55.77 ± 14.48	<0.0001
Female	25780	2982	28762	<0.0001
Male	6287	3242	9529	<0.0001
Other/Unspecified	25	10	35	0.08
BMI	27.85 ± 5.72	34.60 ± 10.04	28.95 ± 7.07	<0.0001
Race
AA	2349	999	3348	<0.0001
Asian	831	91	922	<0.0001
Hispanic	4642	358	5000	<0.0001
White	15724	3204	18928	<0.001
Other	8546	1582	10128	<0.05
rVCSS	5.2 ± 2.0	11.67 ± 4.60	6.2 ± 3.5	<0.0001
CIVIQ	47.0 ± 18.2	55.45 ± 20.20	48.4 ± 18.8	<0.0001
Medical	C2	C5.6		p
Anemia	520	163		<0.0001
Anxiety	3235	685		0.03223
Depression	2998	789		<0.0001
Arthritis	7361	2442		<0.0001
Asthma	2329	581		<0.0001
CAD	16	16		<0.0001
Cancer	1626	568		<0.0001
COPD	440	420		<0.0001
Diabetes	3820	1901		<0.0001
GERD	3707	958		<0.0001
HTN	9114	3774		<0.0001
Hypercholesterolemia	4114	1011		<0.0001
PAD	24	53		<0.0001
PUD	2	2		0.24981
Stroke	297	253		<0.0001
DVT	155	124		<0.0001
History of venous ulcer	0	80		<0.0001
Gynecologic
Endometriosis	50	7		0.52461
Ovarian cysts	4	0		0.83829
Uterine fibroids	31	6		1.00000
Surgery
Abdominoplasty	228	7		<0.0001
Appendectomy	2388	585		<0.0001
Cholecystectomy	2947	646		0.00373
Diagnostic lap	8	0		0.44267
Inguinal_Hernia	78	20		0.32928
Cesarean section	4782	331		<0.0001
Salpingo-oophorectomy	34	5		0.71419
Oophorectomy	252	21		<0.001
Ovarian cystectomy	257	19		<0.0001
Hysterectomy	4025	717		0.02368
Uterine ablation	109	5		<0.001
Tubal ligation	1935	188		<0.0001
Knee arthroscopy	40	11		0.40260
Orthopedic procedure	3916	1272		<0.0001
Total hip replacement	1	0		1.00000
Total knee replacement	30	15		<0.01
Previous vein procedure	177	56		<0.01

Legend: Demographics of C2 and C5/6 patients with symptomatic reflux.

Table 2.

Presenting symptoms.

	C2	C5/6	p Value
Aching	4099	319	<0.0001
Bleeding	429	292	<0.0001
Cramping	10842	1499	<0.0001
Fatigue	9657	1769	<0.01
Heaviness	11041	2114	0.46158
Pain	24872	4209	<0.0001
Restless legs	4426	746	<0.001
Skin changes	962	3527	<0.0001
Spider veins	8161	523	<0.0001
Swelling	8529	4327	<0.0001
Varicosities	11681	538	<0.0001
Burning	1141	101	<0.0001
Dermatitis	2	80	<0.0001
Edema	928	390	<0.0001
Hyperpigmentation	39	289	<0.0001
Itching	638	127	0.83791
Pelvic	68	5	0.04304
Superficial thrombophlebitis	601	107	0.43099
Swelling	8528	4327	<0.0001
Tingling	430	35	<0.0001

Legend: Presenting symptoms of symptomatic C2 and C5/6 venous reflux patients.

GSV reflux

Reflux of the GSV with and without coexisting SFJ reflux was analyzed between C2 and C5/6 disease (Figures 1 and 2 respectively). There was no difference in the prevalence of junctional reflux between groups (p ≤ .99). In patients with junctional reflux and C2 disease, the most prevalent reflux patterns were the following: 3-segment above-knee reflux with 1-segment below-knee reflux (18.45%), isolated 3-segment above-knee reflux (15.44%), and 6-segment reflux (14.85%). A similar pattern was observed in C5/C6 disease: The most common pattern was entire 6-segment reflux (27.50%), followed by 3-segment above-knee with 1-segment below-knee reflux (13.37%), and lastly isolated 3-segment above-knee reflux (8.07%). The least common patterns observed in patients with SFJ reflux were primarily below-knee disease (2+ refluxing segments) and minimal above-knee disease (≤1 refluxing segment) regardless of C2 and C5/6 designation.

Figure 1.

Prevalence of GSV reflux patterns in C2 and C5/6 patients with junctional reflux.

Figure 2.

Prevalence of GSV reflux patterns in C2 and C5/6 patients without junctional reflux.

In patients with GSV reflux without coexisting SFJ reflux C2 disease demonstrated primarily below-knee reflux, with isolated 1-, 2-, or 3-segment reflux being the most common patterns observed: 9.83%, 18.21%, and 27.68%, respectively. The same pattern was observed in C5/C6 disease: 15.87%, 18.96%, 20.24%, respectively (p ≤ .05).

The prevalence of isolated two or three segment below knee GSV reflux, with or without SFJ reflux was greater in C5/C6 patients (p ≤ .01). Similarly, single segment below knee GSV reflux was greater in C2 patients (p ≤ .01).

When comparing the two GSV reflux patterns with and without SFJ reflux, six findings became evident: (1) There is no difference in the proportion of SFJ reflux between C2 (62.25%) and C5/C6 disease (61.53%). (2) When SFJ reflux exists, the patterns of disease shifts to a higher percentage of limbs with above-knee reflux in both C2 and C5/C6 limbs. (3) In the absence of SFJ reflux, the patterns shifted to a higher percentage of limbs with below-knee reflux, in both C2 and C5/C6 limbs. (4) Irrespective of SFJ involvement, when all three below-knee segments of the GSV were refluxing, there was a higher prevalence of this pattern in patients with C5/C6 disease. (5) Isolated above-knee disease (1-, 2-, or 3-segment) is conversely more likely observed in C2 limbs. (6) Finally, single segment reflux, regardless of location, is more likely to be seen in C2 limbs.

SSV reflux

SSV reflux was analyzed in the same way as GSV reflux; however, the saphenopopliteal junction (SPJ) was used in place of the saphenofemoral junction. Due to the location of the SSV sitting entirely below the knee, it was divided into three segments, proximal-, mid-, and distal- calf. In the presence of SPJ reflux, C2 disease was seen in nearly equal proportions among 1-, 2-, and 3-segment disease. C5/C6 disease, however, was directly correlated with the number of refluxing segments. In the absence of SPJ reflux, both C2 and C5/C6 disease were inversely related to the number of refluxing segments (Figure 3).

Figure 3.

Prevalence of reflux patterns in the SSV in symptomatic C2 and C5/6 patients.

SSV reflux with or without SPJ reflux demonstrated similar reflux patterns observed in the GSV. Single segment reflux in the SSV was more likely to be observed in C2 limbs, regardless of SPJ reflux 53.7% versus 42.8%, p ≤ .001). Reflux of all three segments of the SSV was more likely to be seen in conjunction with junctional reflux with a greater prevalence in C5/6 patients (16.2% vs 26.7%, p ≤ .001). Interestingly, 2-segment SSV reflux did not demonstrate a difference with or without the presence of SPJ reflux, but the presence of junctional reflux in 2-segment disease slightly favored C2 disease over C5/C6 disease (p < .05). Conversely, 2-segment disease without junctional reflux was significantly more likely to be seen in C5/C6 limbs than C2 limbs (p < .001).

Perforator reflux

The perforator system was assessed similarly to the great saphenous vein, with three above-knee segments (proximal, middle, and distal thigh) and three below-knee segments (proximal, middle, and distal calf). The patterns analyzed included isolated above-knee reflux, isolated below-knee reflux, and mixed above and below knee reflux. The most common pattern of refluxing perforators in both C2 and C5/C6 disease was a single refluxing perforator below the knee, with nearly 75% of limbs presenting this way (73.53% of C2 limbs, 79.56% of C5/C6 limbs, p ≤ .001). However, all patterns of isolated below-knee reflux (1-, 2-, or 3-segments) were significantly more likely to be observed in C5/C6 limbs than in C2 limbs (93.3% vs 79.8%, p ≤ .001) . Conversely, above-knee refluxing perforators were significantly more common in C2 disease than in C5/C6 disease (15.4% vs 3.4%, p ≤ .001) (Figure 4).

Figure 4.

Prevalence of perforator reflux in symptomatic C2 and C5/6 patients in the above and below knee regions of the leg.

Deep system reflux

The evaluated segments of the deep system consisted of the CFV and FV, and the POPV. Tibial vein reflux was not investigated. Reflux in the deep system was most likely to be contained to the CFV and FV. However, this pattern was significantly more prevalent in C2 limbs compared to C5/C6 limbs (63.07% vs 47.01%, p ≤ .001). When reflux was observed throughout the entire deep system (CFV, FV, POPV), this was significantly more likely to present as C5/C6 disease than C2 disease (38.50% vs 20.47%, p ≤ .001). The least common pattern observed was isolated reflux of the POPV which demonstrated no difference in prevalence between C2 and C5/C6 limbs (16.36% vs 14.49%, p > .05) (Figure 5).

Figure 5.

Prevalence of symptomatic deep vein reflux by vein segment in C2 and C5/6 patients.

Discussion

Numerous population based investigations have demonstrated the prevalence of CVI in the general population, the rate of disease progression over time and risk factors associated with disease progression.^{2,4–9,12–14,20–22} The Edinburgh vein study reported that in a general population, 33.2% and 6% of subjects demonstrated CEAP C2/3 and C4-6 disease respectively.⁸ In a 13.4 year follow-up report, the authors reported that 57.8% progressed to C4-6 disease with an annual rate of progression of 5%.⁴ Similarly, The Bonn vein study reported that 32% of patients with C2 disease progressed to C4 disease at 6 years with an annual incidence of 4.8%.²² Both investigations reported a higher prevalence of superficial and deep disease in women and men respectively, with age, BMI, pregnancy and gender as independent risk factors associated with disease progression.^5–8,22

To our knowledge, the current investigation is the largest evaluation of reflux patterns in symptomatic C2 and C5/6 patients with over 21,335 patients and 31,727 limbs analyzed. We analyzed patients with and without junctional reflux, divided the Great and Small Saphenous veins into seven and four distinct segments respectively and then analyzed the prevalence of various combinations of refluxing segments. Similar to previous publications, our data indicate that the prevalence of above knee segmental GSV reflux is greater in C2 compared to C5/6 patients and is slightly higher in the presence of junctional reflux.^17,18,23 Yilmaz et al investigated GSV reflux patterns in 787 limbs with varicose veins. The cohort consisted of 85.7% C2 patients and 14.3% C3-C6 patients however, the authors assessed reflux patterns of the entire cohort and did not analyze reflux patterns by CEAP class. The most common reflux patterns identified by these authors was the following: SFJ and above knee reflux (48.9%), entire segment GSV reflux (25.7%), below knee GSV reflux in the proximal and mid calf region alone (14.8%) and GSV reflux in the entire below knee GSV (10.4%). In the current investigation we observed the following: In patients with junctional reflux and C2 disease, the most prevalent reflux patterns were 3-segment above-knee reflux with 1-segment below-knee reflux (18.45%), 3-segment above-knee reflux (15.44%), and 6-segment reflux (14.85%). A similar pattern was observed in C5/C6 disease: The most common pattern was entire 6-segment reflux (27.50%), followed by 3-segment above-knee with 1-segment below-knee reflux (13.37%), and lastly isolated 3-segment above-knee reflux (8.07%). The discrepancy between the two investigations is that we compared reflux patterns based on CEAP class whereas Yilmaz analyzed reflux patterns in patients with varicose veins regardless of CEAP class. Despite this difference, above knee GSV and proximal calf reflux appears to be the most common pattern of reflux observed in C2 patients.

Contrary to previous publications, we observed segmental reflux in the below knee GSV alone with a higher prevalence in patients without junctional reflux. Previous publications have reported that reflux in C5/6 patients was only observed if the entire GSV demonstrated reflux.¹⁵ Although entire GSV reflux was the most common pattern observed in C5/6 patients and demonstrated a higher prevalence compared to C2 patients, below knee reflux alone was observed in up to 20% of C5/6 patients. Labropoulos et al reported that the prevalence of skin changes was 44% in patients with below knee GSV reflux alone and increased to 73% when reflux occurred throughout the entire segment.¹⁵ In their series all venous ulcer patients demonstrated GSV reflux in the entire above and below knee segments. We also observed a higher incidence of reflux in the CFV, FV and POPVs in C5/6 patients where CFV or FV reflux alone was more common in C2 patients.

There is little data on reflux patterns in the SSV. Neto et al evaluated 2027 duplex scans with 1196 patients reported as C2 patients.¹⁷ The majority of patients did not demonstrate any axial vein reflux therefore the prevalence patterns should be evaluated in the context of a general population evaluation. Of the 2027 scans, Neto et al reported that the most common reflux patterns observed in the SSV were reflux in the proximal and mid-calf SSV (3.7%) followed by segmental reflux (1.1%). The current investigation assessed symptomatic patients who were intervened on, therefore the patient populations are not comparable. Our investigation indicated that single segment reflux in the SSV was more likely to be observed in C2 limbs, regardless of the presence of SPJ reflux (53.7% vs 42.8%, p ≤ .001). Reflux of all three segments of the SSV was more likely observed in conjunction with junctional reflux with a greater prevalence in C5/6 patients (16.2% vs 26.7%, p ≤ .001).

An extensive evaluation of perforator reflux was reported by Garcia-Gimeno et al.¹⁶ Duplex scans of 2036 patients with varicose veins identified 238 incompetent perforator veins. The most common locations were located at the femoral vein and posterior tibial veins. In our investigation, the most common pattern of refluxing perforators in both C2 and C5/C6 disease was a single refluxing perforator below the knee, with nearly 75% of limbs presenting this way (73.53% of C2 limbs, 79.56% of C5/C6 limbs, p ≤ .001). However, all patterns of perforator reflux with isolated below-knee reflux (1-, 2-, or 3-segments) were significantly more likely to be observed in C5/C6 limbs than in C2 limbs (93.3% vs 79.8%, p ≤ .001). Conversely, above-knee refluxing perforators were significantly more common in C2 disease than in C5/C6 disease (15.4% vs 3.4%, p ≤ .001).

Limitations

This investigation did not investigate reflux patterns in patients with C3 and C4 disease. The authors presumed that major differences in reflux patterns would be observed by comparing mild CVI (C2 patients) to severe CVI (C5/6) disease. Therefore, subtle differences in patients with C3 and C4 disease may have been missed. In addition, we did not assess combinations of superficial, deep and perforator disease. The presence of reflux in more than one region may be associated with disease severity and should be investigated in future studies. Furthermore, this investigation did not assess other co-morbid conditions that may affect reflux patterns such as poor ankle range of motion, calf muscle pump dysfunction, morbid obesity, phlebo-lymphedema, supra-inguinal outflow obstruction or medical conditions such as congestive heart failure. Finally, we did not assess reflux patterns in asymptomatic patients. We were therefore unable to determine if reflux patterns differ between symptomatic and asymptomatic patients.

Conclusions

This investigation is the largest examination of symptomatic lower extremity venous reflux and unique in that differences in reflux patterns were assessed based on CEAP class. Single segment or entire above knee GSV reflux is more commonly observed in patients with C2 disease whereas reflux in the entire GSV and isolated three segment below knee reflux is more common in C5/6 patients. Similarly, entire segment SSV reflux, below knee perforator reflux and reflux in the deep system that includes the CFV, FV and POPV is more common in C5/6 disease. Isolated single segment above knee GSV reflux, above knee perforator reflux and CFV or FV reflux is more common in C2 patients. These data indicate severity of disease is associated with increasing number of refluxing segments and that progression of reflux is associated with increases in refluxing superficial, deep and perforator veins.

Footnotes

Authors note

Presented at the 34^th Annual Meeting of the American Venous Forum, San Antonio, Texas, February 17^th, 2023.

Author contributions

Conception and design: PJP, SL, RK, Analysis and interpretation: NG, GL, LS, RK, SL, SB, PJP, Data collection: NG, LS, SB, Writing the article: NG, GL, LS, RK, SL, PJP, Critical revision of the article: NG, GL, LS, RK, SL, PJP, Statistical analysis: NG, LS, SB, Funding: RK, SL, PJP, Overall responsibility: PJP.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by a grant from the Lakhanpal Vein Foundation.

IRB approval statement

Addvara IRB approved the investigation.

ORCID iD

Peter J Pappas

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