title: Primary avalvular varicose anomalies are a naturally occurring phenomenon that might be misdiagnosed as neovascular tissue in recurrent varicose veins.
abstract: OBJECTIVE
  The objective of this study was to report a phenomenon in patients with primary varicose veins that resembles neovascular tissue in postsurgical recurrences-primary avalvular varicose anomalies (PAVA).
  
  
  METHODS
  Between March 2012 and July 2013, 756 patients (122 men, 634 women) with primary varicose veins (mean age, 53 years; range, 18-89 years) underwent duplex ultrasonography with retrospective analysis of their reflux patterns. We diagnose PAVA as small, refluxing vessels in legs with primary varicose veins and no history of surgery, trauma, or infection in the area that show one or more of three patterns of distribution: lymph node pattern-PAVA arising directly from groin lymph nodes; peritruncal pattern-PAVA wrapping around the great, small, or anterior accessory saphenous veins; and atypical pattern. PAVA are predominantly found within the saphenous fascia, but components have been found to emerge into the superficial and deep venous compartments.
  
  
  RESULTS
  We analyzed results from 1398 legs (756 patients). Sixty-four legs (4.6%) in 58 patients exhibited PAVA, bilateral in six patients and unilateral in 52 patients. Lymph node involvement and peritruncal PAVA were seen in 23.4% and 70.3% of legs, respectively. The small saphenous vein was the most common truncal vein to be involved (48.9% of peritruncal cases). More than one pattern of PAVA could be observed in seven legs. Of the 48 women with PAVA, 42% had concurrent pelvic vein reflux.
  
  
  CONCLUSIONS
  Neovascularization has been identified as a major cause of clinically recurrent varicose veins. Neovascular tissue has been described after endovenous thermoablation. We suggest that this might represent PAVA undetected preoperatively in some cases. PAVA are thin-walled, serpiginous, incompetent vessels that resemble neovascular tissue. We conclude that neovascularization should be diagnosed as a source of recurrence after endovenous surgery only if PAVA had been actively looked for, and excluded, in the preoperative diagnostic duplex ultrasound examination.
authors.affiliation: Whiteley Clinic, Guildford, Surrey, United Kingdom.
authors.forename: Alexandra E
authors.initials: AE
authors.lastname: Ostler
authors.affiliation: Whiteley Clinic, Guildford, Surrey, United Kingdom.
authors.forename: Judith M
authors.initials: JM
authors.lastname: Holdstock
authors.affiliation: Whiteley Clinic, Guildford, Surrey, United Kingdom.
authors.forename: Charmaine C
authors.initials: CC
authors.lastname: Harrison
authors.affiliation: Whiteley Clinic, Guildford, Surrey, United Kingdom.
authors.forename: Tim J
authors.initials: TJ
authors.lastname: Fernandez-Hart
authors.affiliation: Whiteley Clinic, Guildford, Surrey, United Kingdom; Faculty of Health and Biomedical Sciences, University of Surrey, Guildford, Surrey, United Kingdom. Electronic address: mark@thewhiteleyclinic.co.uk.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Whiteley