title: Valsalva maneuver in phlebologic practice.
abstract: Forced expiration against an airway obstruction was originally described as a method for inflating the Eustachian tubes and is accredited to Antonio Maria Valsalva (1666-1723). The Valsalva maneuver is commonly applied for different diagnostic purposes. Its use for phlebologic diagnosis is the object this review. Venous reflux is the most frequent pathophysiologic mechanism in chronic venous disease. Reflux is easily visualized by duplex ultrasound when properly elicited, in standing position. A simple way to elicit reflux is the so-called "compression-release maneuver": by emptying the muscle reservoir, it determines a centrifugal gradient, dependent on hydrostatic pressure, creating an aspiration system from the superficial to the deep system. The same results are obtained with dynamics tests activating calf muscles. The Valsalva maneuver elicits reflux by a different mechanism, increasing the downstream pressure and, thus, highlighting any connection between the source of reflux and the refluxing vessel. The Valsalva maneuver is typically used to investigate the saphenofemoral junction. When the maneuver is performed correctly, it is very useful to analyse several conditions and different hemodynamic behaviours of the valvular system at the saphenofemoral junction. Negative Valsalva maneuver always indicates valvular competence at the saphenofemoral junction. Reverse flow lasting during the whole strain (positive Valsalva maneuver) indicates incompetence or absence of proximal valves. Coupling Valsalva maneuver to compression-release maneuver, with the sample volume in different saphenofemoral junction sections, may reveal different hemodynamic situations at the saphenofemoral junction, which can be analysed in detail.
authors.affiliation: 1 Centro di Flebologia, Area di Geriatria, Università Campus Bio Medico, Roma, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Ricci
authors.affiliation: 1 Centro di Flebologia, Area di Geriatria, Università Campus Bio Medico, Roma, Italy.
authors.forename: Leo
authors.initials: L
authors.lastname: Moro
authors.affiliation: 2 Fondazione San Raffaele, Cittadella Della Carità, Taranto, Italy.
authors.forename: Girolamo C
authors.initials: GC
authors.lastname: Minotti
authors.affiliation: 1 Centro di Flebologia, Area di Geriatria, Università Campus Bio Medico, Roma, Italy.
authors.forename: Raffaele A
authors.initials: RA
authors.lastname: Incalzi
authors.affiliation: 3 Departement of Dermatology, Erasmus MC, Rotterdam, the Netherlands.
authors.forename: Marianne
authors.initials: M
authors.lastname: De Maeseneer
mesh_terms: D001783:Blood Flow Velocity; D002309:Cardiology; D002908:Chronic Disease; D005268:Femoral Vein / Q000000981:diagnostic imaging*; D006439:Hemodynamics; D006801:Humans; D018482:Muscle, Skeletal / Q000473:pathology; D011187:Posture; D012501:Saphenous Vein / Q000000981:diagnostic imaging*; D015911:Sclerotherapy; D018616:Ultrasonography, Doppler, Duplex; D014636:Valsalva Maneuver; D014652:Vascular Diseases / Q000000981:diagnostic imaging*; D014689:Venous Insufficiency / Q000503:physiopathology*
keywords: Valsalva maneuver; duplex ultrasound; pelvic vein incompetence; saphenofemoral junction incompetence; venous reflux