Int J Angiol 2012; 21(03): 181-186
DOI: 10.1055/s-0032-1325168
Invited Paper
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Hemodynamic Paradox as a Phenomenon Triggering Recurrent Reflux in Varicose Vein Disease

Cestmir Recek
1   (Retired from) Department of Surgery, University Hospital, Hradec Kralove, Czech Republic
› Author Affiliations
Further Information

Publication History

Publication Date:
19 August 2012 (online)

Abstract

A curious hemodynamic phenomenon emerging as a consequence of the treatment of varicose veins can offer a reasonable explanation why varicose vein and reflux recurrences occur tenaciously irrespective of the applied therapeutic procedure. Saphenous reflux is the most important hemodynamic factor in varicose vein disease: it is responsible for the hemodynamic disturbance, ambulatory venous hypertension, clinical symptoms, and chronic venous insufficiency. Abolition of saphenous reflux eliminates the hemodynamic disturbance and restores physiological hemodynamic and pressure conditions, but at the same time it unavoidably evokes a pressure difference between the femoral vein and the incompetent superficial veins in the thigh during calf pump activity. The pressure difference increases flow and enhances fluid shear stress on the endothelium in pre-existing minor communicating channels between the femoral vein and the saphenous system in the thigh, which triggers release of biochemical agents nitride oxide and vascular endothelial growth factor; the consequence is enlargement (vascular remodeling) of the communicating channels, and ultimately reflux recurrence.

Hence, the abolition of saphenous reflux creates preconditions for the comeback of the previous pathological situation. This phenomenon—starting the same trouble while fixing the problem—has been called hemodynamic paradox; is explains why varicose vein and reflux recurrence can occur after any mode of therapy.

 
  • References

  • 1 El Wajeh Y, Giannoukas AD, Gulliford CJ, Suvarna SK, Chan P. Saphenofemoral venous channels associated with recurrent veins are not neovascular. Eur J Vasc Endovasc Surg 2004; 28 (6) 590-594
  • 2 Geier B, Stücker M, Hummel T , et al. Residual stumps associated with inguinal varicose vein recurrences: a multicenter study. Eur J Vasc Endovasc Surg 2008; 36 (2) 207-210
  • 3 Jones L, Braithwaite BD, Selwyn D, Cooke S, Earnshaw JJ. Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein. Eur J Vasc Endovasc Surg 1996; 12 (4) 442-445
  • 4 Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: late results of a randomized controlled trial of stripping the long saphenous vein. J Vasc Surg 2004; 40 (4) 634-639
  • 5 Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial. J Vasc Surg 1999; 29 (4) 589-592
  • 6 Egan B, Donnelly M, Bresnihan M, Tierney S, Feeley M. Neovascularization: an “innocent bystander” in recurrent varicose veins. J Vasc Surg 2006; 44 (6) 1279-1284 , discussion 1284
  • 7 Joshi D, Sinclair A, Tsui J, Sarin S. Incomplete removal of great saphenous vein is the most common cause for recurrent varicose veins. Angiology 2011; 62 (2) 198-201
  • 8 Sarin S, Scurr JH, Coleridge Smith PD. Stripping of the long saphenous vein in the treatment of primary varicose veins. Br J Surg 1994; 81 (10) 1455-1458
  • 9 Frings N, Nelle A, Tran VTP, Glowacki P. Unavoidable recurrence and neoreflux after correctly performed ligation of the saphenofemoral junction: neovascularization? (German). Phlebologie 2003; 32: 96-100
  • 10 Frings N, Nelle A, Tran P, Fischer R, Krug W. Reduction of neoreflux after correctly performed ligation of the saphenofemoral junction. A randomized study. Eur J Vasc Endovasc Surg 2004; 28 (3) 246-252
  • 11 Fischer R, Linde N, Duff C, Jeanneret C, Chandler JG, Seeber P. Late recurrent saphenofemoral junction reflux after ligation and stripping of the greater saphenous vein. J Vasc Surg 2001; 34 (2) 236-240
  • 12 Glass GM. Prevention of sapheno-femoral and sapheno-popliteal recurrence of varicose veins by forming a partition to contain neovascularization. Phlebology 1998; 13: 3-9
  • 13 Turton EP, Scott DJ, Richards SP , et al. Duplex-derived evidence of reflux after varicose vein surgery: neoreflux or neovascularisation?. Eur J Vasc Endovasc Surg 1999; 17 (3) 230-233
  • 14 van Rij AM, Jones GT, Hill GB, Jiang P. Neovascularization and recurrent varicose veins: more histologic and ultrasound evidence. J Vasc Surg 2004; 40 (2) 296-302
  • 15 Allegra C, Antignani PL, Carlizza A. Recurrent varicose veins following surgical treatment: our experience with five years follow-up. Eur J Vasc Endovasc Surg 2007; 33 (6) 751-756
  • 16 Recek C. Saphenofemoral junction ligation supplemented by postoperative sclerotherapy: a review of long-term clinical and hemodynamic results. Vasc Endovascular Surg 2004; 38 (6) 533-540
  • 17 Nyamekye I, Shephard NA, Davies B, Heather BP, Earnshaw JJ. Clinicopathological evidence that neovascularisation is a cause of recurrent varicose veins. Eur J Vasc Endovasc Surg 1998; 15 (5) 412-415
  • 18 Heim D, Negri M, Schlegel U, De Maeseneer M. Resecting the great saphenous stump with endothelial inversion decreases neither neovascularization nor thigh varicosity recurrence. J Vasc Surg 2008; 47 (5) 1028-1032
  • 19 Winterborn RJ, Foy C, Heather BP, Earnshaw JJ. Randomized trial of flush saphenofemoral ligation for primary great saphenous varicose veins. Eur J Vasc Endovasc Surg 2008; 36: 477-484
  • 20 Sheppard M. A procedure for the prevention of recurrent saphenofemoral incompetence. Aust N Z J Surg 1978; 48 (3) 322-326
  • 21 Gibbs PJ, Foy DM, Darke SG. Reoperation for recurrent saphenofemoral incompetence: a prospective randomised trial using a reflected flap of pectineous fascia. Eur J Vasc Endovasc Surg 1999; 18 (6) 494-498
  • 22 De Maeseneer MG, Philipsen TE, Vandenbroeck CP , et al. Closure of the cribriform fascia: an efficient anatomical barrier against postoperative neovascularisation at the saphenofemoral junction? A prospective study. Eur J Vasc Endovasc Surg 2007; 34 (3) 361-366
  • 23 Earnshaw JJ, Davies B, Harradine K, Heather BP. Preliminary results of PTFE patch saphenoplasty to prevent neovascularization leading to recurrent varicose veins. Phlebology 1998; 13: 10-13
  • 24 Bhatti TS, Whitman B, Harradine K, Cooke SG, Heather BP, Earnshaw JJ. Causes of re-recurrence after polytetrafluorethylene patch saphenoplasty for recurrent varicose veins. Br J Surg 2000; 87 (10) 1356-1360
  • 25 Winterborn RJ, Earnshaw JJ. Randomized trial of polytetrafluorethylene patch insertion for recurrent great saphenous varicose veins. Eur J Vasc Endovasc Surg 2007; 34: 367-373
  • 26 Recek C. Saphenous reflux as the cause of venous hemodynamic disturbance in primary varicose veins and chronic venous insufficiency (German). Acta Chir Austriaca 1998; 30 (2) 76-77
  • 27 Recek C, Pojer H. Ambulatory pressure gradient in the veins of the lower extremity. Vasa 2000; 29 (3) 187-190
  • 28 Schaper W. Collateral circulation: past and present. Basic Res Cardiol 2009; 104 (1) 5-21
  • 29 Pipp F, Boehm S, Cai WJ , et al. Elevated fluid shear stress enhances postocclusive collateral artery growth and gene expression in the pig hind limb. Arterioscler Thromb Vasc Biol 2004; 24 (9) 1664-1668
  • 30 Schaper W, Scholz D. Factors regulating arteriogenesis. Arterioscler Thromb Vasc Biol 2003; 23 (7) 1143-1151
  • 31 Resnick N, Gimbrone Jr MA. Hemodynamic forces are complex regulators of endothelial gene expression. FASEB J 1995; 9 (10) 874-882
  • 32 Schierling W, Troidl K, Troidl C, Schmitz-Rixen T, Schaper W, Eitenmüller IK. The role of angiogenic growth factors in arteriogenesis. J Vasc Res 2009; 46 (4) 365-374