title: Development of primary superficial venous insufficiency: the ascending theory. Observational and hemodynamic data from a 9-year experience.
abstract: BACKGROUND
  Hemodynamic principles suggest that primary venous insufficiency follows the hydrostatic column of venous pressure of the limbs, and therefore, venous reflux begins at the lower points and rises upwards. To test the hypothesis of an "ascending development" of reflux, we carried an observational study to analyze the natural evolution of lower limb venous insufficiency.
  
  
  METHODS
  During 9-year period patients with primary superficial venous disease who refused treatment were followed prospectively with 6-month scheduled clinical and duplex ultrasound examinations. Localization, stage, and evolution of the venous patterns were compared.
  
  
  RESULTS
  A total of 104 limbs in 99 patients were analyzed (12 males, 92 female; mean age 48.7 years). Prevalence of reflux was (p < 0.001) more frequent along great-saphenous and its tributaries (78/104, 75%) than nonsaphenous veins. The time of re-examination ranged from 1 to 13 years (mean 4 +/- 3.1 years). With the exception of six remaining stable, all the veins showed a progression of insufficiency (94%); 47 involved deep circulation. In all the worsened refluxes, an extension to reach one or more venous segments at an upper level, uninvolved before, was found. There was no downward oriented pattern of progression. There was no significant difference in age, gender, and type of vein between the stable and progressive diseases.
  
  
  CONCLUSIONS
  Natural history of primary venous insufficiency is that of a progressive disease, which begins at lower levels of the limbs and develops in an antegrade manner as venous stasis is higher where force of gravity is higher. This data do not support the aggressive and widespread treatment of terminal valve as first approach, but need to be supported by larger studies.
authors.affiliation: Interuniversitary Phlebology Center, University of Perugia, Perugia, Italy.
authors.forename: Eugenio
authors.initials: E
authors.lastname: Bernardini
authors.forename: Paola
authors.initials: P
authors.lastname: De Rango
authors.forename: Riccardo
authors.initials: R
authors.lastname: Piccioli
authors.forename: Carlo
authors.initials: C
authors.lastname: Bisacci
authors.forename: Valentino
authors.initials: V
authors.lastname: Pagliuca
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Genovese
authors.forename: Roberto
authors.initials: R
authors.lastname: Bisacci
mesh_terms: D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006112:Gravitation; D006439:Hemodynamics; D006801:Humans; D006874:Hydrostatic Pressure; D007558:Italy; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012501:Saphenous Vein / Q000000981:diagnostic imaging / Q000503:physiopathology*; D013997:Time Factors; D018615:Ultrasonography, Doppler, Color; D014689:Venous Insufficiency / Q000000981:diagnostic imaging / Q000503:physiopathology*; D014690:Venous Pressure