Skip to main content
NCBI home page
Journal of Vascular Surgery: Venous and Lymphatic Disorders logoLink to Journal of Vascular Surgery: Venous and Lymphatic Disorders
. 2024 Apr 26;12(4):101897. doi: 10.1016/j.jvsv.2024.101897

Application of the ankle pump method in a sitting position to evaluate calf perforating veins by color Doppler ultrasound

Peipei Liu a,b, Jianxing Huang a, Xueju Zhang b, Ruolin Yang b, Shiyuan Yang c, Lingli Chen c, Yongyan Gao a,∗
PMCID: PMC11523340  PMID: 38679143

Abstract

Objective

We investigated the feasibility and efficacy of assessing calf perforating veins (PVs) using the ankle pump in a sitting position (AP-sit) method by color Doppler ultrasound.

Methods

We performed a multicenter prospective clinical trial between November 2022 and October 2023. Eligible patients with chronic venous disease and healthy controls were enrolled. The calf PVs were assessed using three different methods: manual compression in a standing position, manual compression in a sitting position, and AP-sit method. The reflux durations and detection rate of incompetent PVs (IPVs) were compared among the three methods. The number and diameter of calf PVs and distribution of IPVs were analyzed.

Results

A total of 50 patients with chronic venous disease and 50 healthy controls were included. There were 173 calves analyzed, including 97 healthy calves and 76 calves with chronic venous disease. The number of PVs per calf was higher in the diseased calves (median, 7.0; interquartile range [IQR], 6.0-8.0) than in the healthy calves (median, 5.0; IQR, 3.0-6.0; P < .001). The diameter of IPVs (median, 2.3 mm; IQR, 2.0-3.1 mm) was larger than that of competent PVs (median, 1.4 mm; IQR, 1.2-1.7 mm). Most of the IPVs (78.8%) were located in the medial and posterior middle of the calf. The reflux duration induced by the AP-sit method was greater than that induced by the manual compression methods (P < .001). Although the AP-sit method had a higher detection rate (92.0%) of IPVs than the manual compression methods (71.7% and 74.3% for standing and sitting, respectively; P < .001), especially in the distal lower leg, the manual compression methods found IPVs not found using the AP-sit method.

Conclusions

Diseased calves with chronic venous disease have more PVs than do healthy calves. IPVs are commonly larger than competent PVs, with most IPVs located in the medial and posterior middle of the calf. Most importantly, the AP-sit method provides a convenient and effective approach for assessing the calf PVs, especially those located in the distal calf, as an alternative or complementary method to traditional manual compression, which is valuable in the daily practice of sonographers.

Keywords: Ankle pump, Chronic venous disease, Color Doppler ultrasonography, Perforating veins of the calf, Sitting position

Article Highlights.

  • •

    Type of Research: A multicenter, prospective case-control study

  • •

    Key Findings: The number of perforating veins (PVs) per calf was higher in the diseased calf with chronic venous disease (median, 7.0; interquartile range [IQR], 6.0-8.0) than that in healthy calves (median, 5.0; IQR, 3.0-6.0). The diameter of incompetent PVs (IPVs; median, 2.3 mm; IQR, 2.0-3.1 mm) was larger than that of competent PVs (median, 1.4; IQR, 1.2-1.7 mm). The reflux duration induced by the ankle pump method was greater than that induced by manual compression methods. Although the ankle pump method had a higher detection rate (92.0%) of IPVs than the manual compression methods (71.7% and 74.3% for standing and sitting positions, respectively), especially in the distal lower leg, the manual compression methods found seven IPVs (6.2%) that were not shown using the ankle pump method.

  • •

    Take Home Message: Diseased calves with chronic venous disease have more PVs than do healthy calves. IPVs are commonly larger than competent PVs, with most calf IPVs located in the medial and the posterior middle of the calf. Most importantly, the ankle pump in a sitting position method provides a convenient and effective approach for assessing calf PVs, especially distal calf PVs, as an alternative or complementary to traditional manual compression, which is valuable in the daily practice of sonographers.

Chronic venous disease (CVD) is a collection of syndromes triggered by an increase in the venous pressure.1,2 It affects ≤80% of the population worldwide.3, 4, 5, 6, 7 Surgical management is the recommended treatment choice.8 However, the postoperative recurrence of varicose veins is notably high, ranging from 7% to 71%.9 Previous studies have shown that approximately 10.5% to 92.7% of patients with recurrent varicose veins have persistent incompetent perforating veins (IPVs).9, 10, 11, 12 Appropriate management of these IPVs could facilitate the healing of venous ulcers and reduce the recurrence rate of varicose veins and venous ulcers.13, 14, 15, 16 IPVs with major clinical significance are predominantly found in the calf.17,18 Therefore, accurate evaluation of the calf perforating veins (PVs) is a crucial step in the development of a personalized treatment strategy to manage CVD.

Color Doppler ultrasound (CDUS) is recommended as a diagnostic test of choice to evaluate for venous reflux.19 Manual compression in the standing position is widely used to induce reflux during CDUS examinations to assess the competence of the calf PVs, because spontaneous reflux is uncommon.20 PV function is considered normal when blood from the superficial veins partially returns rapidly through the PVs into the deep veins after compression is released at the distal part of the calf.18,21,22 However, this is difficult to perform in the distal calf PVs and in patients who are unable to stand with weight on one leg.22,23 In addition, the force and location of compression by different examiners can have a significant effect on the results. Therefore, it is important to develop an alternative method.

In 1995, Staubesand et al24 first reported that the lower leg venous blood return could be induced by ankle movements, which could be evaluated by duplex ultrasound. The following advantages are offered if reflux of calf PVs is evoked by ankle motion in the sitting position. First, it is easier for the patient to remain seated than to stand with their weight on one leg. Second, when the ankle is relaxed, the deep veins, which are squeezed by the triceps muscle due to ankle dorsiflexion, are rapidly filled, and a pressure gradient is formed between the deep and superficial veins, which evokes reflux of the calf PVs. Third, the potential subjective bias of manual compression can be minimized.

Therefore, we propose that the method of ankle movement in a seated position can be used to induce calf PV reflux. We report the feasibility and diagnostic efficacy of this method with the aim of proposing a novel approach for assessing the competence of calf PVs using ultrasound.

Methods

Study design and participant selection

This research was a multicenter prospective clinical trial jointly conducted at the Third Medical Center of Chinese People's Liberation Army General Hospital, the Peking University Third Hospital, and the Capital International Airport Hospital of the Peking University Third Hospital, China, between November 2022 and October 2023. The ethics committees of the hospitals approved the study, which was registered online in the China Clinical Trial Registry (ChiCTR2200065447). All the participants signed informed consent forms.

The inclusion criteria were as follows: (1) age 18 to 75 years; (2) CVD diagnosed by vascular surgeons with a clinical classification of C0 to C5 according to the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification25; (3) no previous surgical history in the lower extremity; and (4) body mass index (BMI) of 18 to 35 kg/m2. Patients with C0 in this study were defined as those without signs but with symptoms of CVD and evidence of pathological reflux in the lower extremity veins on ultrasound. Patients with C6 were not included to avoid repeated compression on severely diseased skin. Healthy volunteers aged 18 to 75 years were recruited into the control group.

The exclusion criteria were as follows: (1) cardiac disease that could affect hemodynamic performance, including heart failure, valvular stenosis or regurgitation, left ventricular outflow tract stenosis, or atrial fibrillation; (2) an obstructed inferior vena cava, iliac vein, and/or lower extremity venous on CDUS examination; (3) severe lower extremity artery stenosis or occlusion on CDUS or abnormal flow spectra due to severe proximal stenosis or occlusion; (4) a history of diabetes or kidney disease; (5) respiratory failure or liver failure; and/or (6) an inability to stand on one leg. Healthy volunteers with ultrasound evidence of pathological reflux in the lower extremities were excluded.

Study protocol

Thresholds of pathological reflux and CVD classification

In aacordance with the 2022 European Society for Vascular Surgery Clinical Practice Guidelines on the Management of CVD,26 a previous large-sample study,27 and standards of the Polish Ultrasound Society,22 the thresholds for defining venous incompetence on ultrasound were set at reflux flow >500 ms in the superficial venous system, deep femoral vein, or calf veins, >1000 ms in the common femoral, femoral vein, or popliteal vein, or >350 ms in the PVs. The CVD classification was based on the CEAP classification system (Supplementary Table, online only).25

Equipment and method

We used the following ultrasound devices equipped with linear array transducers: LOGIQ E9, ML6-15 transducer (GE Healthcare); Aplio 500, 18L7 transducer (Toshiba Canon); Preirus, L73S transducer (Hitachi); and Aixplorer SL15-4 transducer (Supersonic Imagine).

Because ankle dorsiflexion during weight-bearing standing on one leg could increase the risk of falls, three methods were used in our study to assess the competence of the calf PVs. The three methods were manual compression in a standing position (MC-stand), manual compression in a sitting position (MC-sit), and the ankle pump in a sitting position (AP-sit) method. Differences in reflux duration and the detection rate of IPVs between the three methods were analyzed. The diameters of the PVs in the standing and sitting positions and the diameters of competent PVs and IPVs were compared for the first 50 participants. The locations of the IPVs were also documented (Fig 1, A).

Fig 1.

Fig 1

Open in a new tab

Segmentation of the calf and the three methods of evaluating perforator veins (PVs) using color Doppler ultrasound (CDUS). A, Diagram showing the calf segments. The lower leg surface is divided into three areas: medial, posterior, and anterolateral. With the palpable sharp anterior margin of the tibia as the boundary, the inner one third area along the axis is the medial zone, the outer one third area is the anterolateral zone, and the calf one third area is the posterior zone. These zones are further subdivided into the upper, middle, and lower segments with equal sizes from the level of the fibular head to the level of the highest point of the lateral malleolus. Thus, the lower leg surface has nine distinct segments: one to nine are upper medial, middle medial, lower medial, upper posterior, middle posterior, lower posterior, upper anterolateral, middle anterolateral, and lower anterolateral segments, respectively. B-D, Methods used to induce blood reflux in the calf PVs. B, The manual compression in a standing position (MC-stand) method. The participant stands on one leg, keeping the testing calf relaxed. The examiner compresses the distal calf, holds for 3 seconds, and then quickly releases, while dynamically observing the PV blood flow with the transducer. C, The manual compression in a sitting position (MC-sit) method. The participant sits at the edge of the table, with the testing lower leg freely dangling over the table edge. The examiner compresses the calf as described for the MC-standing method and observes the blood flow. D, The ankle pump in a sitting position (AP-sit) method. The participant sits in the position as described, dorsiflexes the ankle, holds for 3 seconds, and then rapidly relaxes. The examiner uses the transducer to observe the blood flow.

The three methods, which were used in a random order to assess the calf PVs, were performed as follows:

  • 1.

    MC-stand method (Fig 1, B): the participant stood with the leg being assessed kept unweighted. Calf PVs were assessed in the transverse and oblique planes, and the diameter of the PVs detected by ultrasound was recorded as D1, which was measured at the level of the deep fascia.28 Color was turned on and the flow of the PVs was monitored dynamically. Hand compression was applied to the calf, preferably 8 to 10 cm distal to the observed PVs, to avoid image instability. If the PVs were located near the ankle, the foot was compressed.27 The pressure was swiftly released after 3 seconds. The compression–release was repeated three times at 5-second intervals. Reflux was assessed on the release of compression, and the reflux duration was measured with the pulsed wave. The maximum of three durations was recorded as t1.23,29

  • 2.

    MC-sit method (Fig 1, C): the participant sat at the edge of the examination table, with the testing calf freely dangling over the table edge, without any contact to the ground. The diameter and reflux of the calf PVs were measured as described for the MC-stand method and recorded as D2 and t2, respectively.

  • 3.

    AP-sit method (Fig 1, D): the participant remained seated as described for the MC-sit method, maximally dorsiflexed the ankle, held it for 3 seconds, and then rapidly relaxed to induce reflux. Dorsiflexion–relaxation was repeated three times at 5-second intervals, and the maximum reflux duration was recorded as t3.

Statistical analysis

Statistical analysis was conducted in SPSS, version 21 (IBM Corp). Continuous variables are presented as the mean ± standard deviation or median and interquartile range (IQR). Categorical variables are presented as numbers with percentages. Differences in the diameter of the calf PVs between postures were tested using the Wilcoxon rank sum test, and differences in the diameter of competent PVs and IPVs were tested using the Mann-Whitney rank sum test. To examine differences in the reflux times of calf IPVs induced by the three methods, the Friedman rank sum test was used. To analyze differences in the detection rate of calf IPVs among the three methods, the paired χ2 test was used. P < .05 was considered to be statistically significant.

Results

Baseline characteristics of study participants

This study included 50 CVD patients (20 men and 30 women), aged 53.8 ± 9.2 years, with a BMI of 25.6 ± 3.4 kg/m2. The control group included 50 healthy participants (20 men and 30 women), aged 50.3 ± 11.2 years, with a BMI of 25.1 ± 3.3 kg/m2. There were no significant differences between the two groups in terms of gender, age, or BMI (P > .05 for all).

Only one leg was assessed for five participants (two and three in the CVD and healthy groups, respectively) due to their unwillingness to stand for longer periods of time. A total of 173 calves were analyzed, including 97 healthy calves in the normal group and 76 diseased calves in the CVD group (Fig 2). Among these 76 CVD calves, 13 were C0, 10 were C1, 33 were C2, 13 were C3, 5 were C4, and 2 were C5.

Fig 2.

Fig 2

Open in a new tab

CONSORT (Consolidated Standards of Reporting Trials) flowchart. AP-sit, Ankle pump in a sitting position; CVD, chronic venous disease; D1, diameter of perforator veins detected by ultrasound; D2, diameter of calf perforator veins measured using manual compression in a sitting position; IPVs, incompetent perforator veins; MC-sit, manual compression in a sitting position; MC-stand, manual compression in a standing position; PVs, perforator veins.

Number of PVs in healthy vs CVD calves

There were 450 PVs in the 97 healthy calves, with 5.0 PVs (IQR, 3.0-6.0 PVs) per healthy calf, and 535 PVs in the 76 CVD calves, with 7.0 PVs (IQR, 6.0-8.0 PVs) per CVD calf. The number of PVs per CVD calf was greater than that per healthy calf (P < .001; Fig 3, A and B).

Fig 3.

Fig 3

Open in a new tab

Number and diameter of calf perforator veins (PVs). A,B, Number of PVs in one healthy calf and chronic venous disease (CVD) calf (including competent PVs and incompetent PVs [IPVs]). C,D, Comparison of the diameters of the PVs between the standing and sitting positions. The mean diameter in the sitting position was slightly larger than that in the standing position (P < .001). E,F, Diameters of competent PVs and IPVs in the sitting position. The IPV diameters were significantly larger than those of competent PVs (P < .001).

Diameter of competent PVs and IPVs

In this study, 459 calf PVs from the first 50 participants were selected to measure the D1 in a standing position and D2 in a sitting position (416 competent PVs and 43 IPVs). The diameter was measured at a depth of 0.5 to 1.0 cm of the deep fascial level using linear array transducers of ≥7 MHz. The average value of D2 was larger than that of D1 (1.63 ± 0.60 mm vs 1.58 ± 0.54 mm; P < .001; Fig 3, C and D), with the same median of 1.2 mm (IQR, 1.5-1.9 mm). However, this difference is not meaningful because a difference of 0.05 mm is too small to be distinguished in frequently used ultrasound. In a sitting position, the diameter of the IPVs was 2.3 mm (IQR, 2.0-3.1 mm; mean, 2.56 ± 0.98 mm), which was greater than the diameter of the competent PVs (median, 1.4 mm; IQR, 1.2-1.7 mm; mean, 1.55 ± 0.48 mm; P < .001; Fig 3, E and F).

Distribution of calf IPVs

A total of 113 IPVs were detected in 76 diseased calves (23.3% of all PVs of the diseased calves), with 68 (60.2%) in the medial segments (14.2%, 21.2%, and 24.8% in the upper, middle, and lower medial segments, respectively), 21 (18.6%) in the middle posterior segment, 24 (21.2%) in the other five segments (4.4%, 3.5%, 0.0%, 4.5%, and 8.8% in the upper posterior, lower posterior, upper anterolateral, middle anterolateral, and lower anterolateral segments, respectively). Thus, most IPVs (78.8%) were located in the medial and posterior middle of the lower leg.

Valves of calf PVs and blood flow via the orifices

There were 33 PVs (3.1%) with clearly visible venous valves, of which 16 competent PVs were from healthy volunteers, 13 competent PVs were from CVD patients, and 4 IPVs were from CVD patients. Dynamic observation of blood flow at the valve orifice in these competent PVs revealed that three (10.3%) showed bidirectionality with transient reflux of <350 ms. Of these three competent PVs, two (12.5%) were from healthy volunteers and one (7.7%) was from a CVD patient. The remaining 89.7% of the competent PVs were unidirectional from the superficial to the deep veins (Supplementary Fig 1, online only).

Comparison of reflux in IPVs of CVD calves induced by the three methods

A total of 102 of 113 IPVs were included in the analysis of reflux duration. Of the 113 IPVs, 11 were not included because they showed reflux via only one or two methods (Fig 2). The median t1, t2, and t3 were 574.0 ms (IQR, 350.0-865.8 ms), 573.0 ms (IQR, 352.0-1351.5 ms), and 1437.5 ms (IQR, 612.3-2517.8 ms), respectively (P < .001). The t3 was significantly longer than both t1 and t2 (P < .001), with no significant difference between t1 and t2 (P = .259; Table I, Fig 4, and Supplementary Fig 2, online only).

Table I.

Comparison of reflux duration in incompetent perforating veins (IPVs) by the three methodsa

Reflux time of calf IPV No. Standard deviation, ms Minimum, ms Maximum, ms Median (IQR), ms
MC-stand method 102 1040.0 0.00 8771.0 574.0 (350.0-865.8)
MC-sit method 102 1070.7 0.00 7961.0 573.0 (352.0-1351.5)
AP-sit method 102 2493.8 0.00 12,787.0 1473.5 (612.3-2517.8)
Open in a new tab

AP-sit, Ankle pump in a sitting position; IQR, interquartile range; MC-sit, manual compression in a sitting position; MC-stand, manual compression in a standing position.

a

There was no statistically significant difference in the reflux times between the MC-sit and MC-stand methods (P = .259); however, the reflux time with the AP-sit method was longer than that with the MC-stand method (P < .001) and longer than that with the MC-sit method (P < .001).

Fig 4.

Fig 4

Open in a new tab

Comparisons of blood reflux in incompetent perforator veins (IPVs) induced by three different methods. Reflux time induced using the manual compression in a standing position (MC-stand), manual compression in a sitting position (MC-sit), and ankle pump in a sitting position (AP-sit) methods recorded as t1, t2, and t3, respectively. The difference between t1 and t2 was not statistically significant (P = .259). However, t3 was longer than both t1 and t2 (P < .001 for both).

Detection rate of calf IPVs by the three methods

A total of 113 calf IPVs were detected in 50 CVD patients, with 81 (71.7%), 84 (74.3%), and 104 (92.0%) detected using the MC-stand, MC-sit, and AP-sit method, respectively. The detection rate of calf IPVs by the MC-stand method and MC-sit method was not significantly different (P = .664), with moderate consistency (kappa, 0.529). The detection rate of calf IPVs using the AP-sit method was higher than that of the other two methods (P < .001; Table II).

Table II.

Detection rates of calf incompetent perforating veins (IPVs) by three different methodsa

Methods compared (A vs B)b A+, B+ vs A−, B−, No. A+, B− vs A−, B+, No. Detection rate, % P value
MC-stand vs MC-sit 72 vs 20 9 vs 12 71.7 vs 74.3 .664
AP-sit vs MC-sit 81 vs 6 23 vs 3 92.0 vs 74.3 < .001
AP-sit vs MC-stand 74 vs 2 30 vs 7 92.0 vs 71.7 < .001
Open in a new tab

+, Method able to detect incompetent perforator veins; −, method failed to detect incompetent perforator veins; AP-sit, ankle pump in a sitting position; MC-sit, manual compression in a sitting position; MC-stand, manual compression in a standing position.

a

Paired χ2 test used to compare detection rates of 113 calf IPVs by the three methods (P = .05/3 = 0.017 after Bonferroni correction); consistency analysis was conducted for the pair of methods with P > .017, with a kappa value of 0.529 (moderate consistency).

b

“A” indicates first method in pair of methods compared and “B,” the second.

The AP-sit method had a higher IPV detection rate than the MC-stand method, as evidenced by the following. First, for eight IPVs (7.1%) located near the ankle, manual foot compression failed to induce reflux; however, the reflux exceeded 350 ms when it was evoked using the AP-sit method. Second, 22 IPVs (19.5%) showed reflux exceeding 350 ms with the AP-sit method but <350 ms with the MC-stand method. However, the MC-stand method detected seven IPVs (6.2%) not found using the AP-sit method. Two IPVs (1.8%) were pressed to close in the AP-sit method; however, the reflux was >350 ms when evoked using the MC-stand method. Also, one IPV (0.9%) was shifted during the AP-sit method and a stable pulsed wave spectrum could not be obtained. However, the IPV showed >350 ms reflux with the MC-stand method. Finally, four IPVs (3.5%) had reflux >350 ms with the MC-stand method but <350 ms with the AP-sit method.

Discussion

PVs <1 mm in diameter have no valves, and these PVs might not have hemodynamic function. Only valves in larger PVs can be demonstrated on ultrasound.30 In our study, the diameter of the PVs with visible valves was 1.9 mm (IQR, 1.5-2.2 mm). Also, 12.5% of the competent PVs in healthy individuals showed physiological bidirectional flow, which might help to balance pressure fluctuations between the deep and superficial veins of the lower limbs. However, IPVs can disrupt this balance and contribute to the development of CVD, and IPVs are an independent predictor of the severity of CVD and postoperative prognosis.31 Large amounts of blood leakage through IPVs from the deep veins to the superficial veins during muscle contraction produce venous hypertension in the skin and subcutaneous tissues. Increased vein pressure and vein dilatation promote a complex vascular response that leads to stasis, vein wall stiffness, aging, and inflammatory and hypoxic responses in the vein wall and surrounding tissues.4

In the present study, we found the following. Diseased calves with CVD have more PVs than do the healthy calves. IPVs are commonly larger than competent PVs, with most of the calf IPVs located in the medial and the posterior middle of the calf (ie, mostly at the site of the paratibial perforators connecting the great saphenous vein with the posterior tibial veins, and the posterior tibial perforators connecting the posterior accessory great saphenous vein with the posterior tibial veins), which is where most of the clinical symptoms of CVD occur.32 These results are consistent with those from previous studies.23,26 Our study further showed that a novel AP-sit method could detect the calf IPVs, which could be applied with the MC-stand method to improve the assessment of the calf PVs in CVD patients.

Ultrasound is the reference standard for the diagnosis of CVD6 but requires provocative maneuvers because spontaneous reflux is uncommon.21 The theoretically ideal approach would use standardized pneumatic compression techniques to induce reflux of calf PVs in patients placed in a standing position. However, practically, this is difficult for both the patient and the sonographer. In daily practice, the MC-stand method is widely recommended. However, the MC-stand method has several limitations.21 First, some patients might not be able to maintain single-legged weight-bearing standing or might not have access to an examination table that can be maintained in the reverse Trendelenburg position.2,33,34 Second, some patients with severe varicose veins can experience a significant amount of blood reflux in legs while standing, which could lead to orthostatic hypotension, dizziness, or fainting.22 Considering these situations, some guidelines have suggested that a seated position can be used for patients who are unable to stand up.22 In our study, the MC-sit method showed no statistically significant difference in detecting calf IPVs compared with the MC-stand method, with both methods demonstrating moderate consistency in the results. In addition, it is feasible to measure the diameter of the calf PVs in a sitting position.

However, the MC-sit method still has some limitations. First, for the PVs located at the distal calf, manual compression is impractical and less effective due to insufficient volume in the ankle or foot veins to create a pressure gradient.23 Second, the strength and location of the compression can affect the results. The AP-sit method recommended in the present study, not only simulates the effect of muscle activity on calf veins under physiological status, but also applies to distal calf PVs (Supplementary Fig 3, online only). Although the AP-sit method is easy to perform while minimizing operator effect, it relies on the patient's correct dorsiflexion of the ankle. The ejection of blood from the calf muscles is maximal during dorsiflexion of the ankle in a seated position compared with standing or plantar flexion.35,36 Subsequent rapid relaxation creates a greater pressure gradient between the deep veins and superficial veins, which better evokes reflux in the PVs. Our study showed that the reflux induced by the AP-sit method significantly exceeded that induced by manual compression, thereby providing a more effective and convenient approach for detecting IPVs. This means that the AP-sit method had the highest detection rate of IPVs, especially in the distal calf. However, seven IPVs (6.2%) in the study were still missed using the AP-sit method, probably due to slight movement or compression closure of these IPVs during ankle movement.

It is important to note several limitations to our study. First, pneumatic pressurization equipment, which could be considered a standard, was not used. Second, although the order of the three methods was randomly selected, the subsequent assessment results might have been affected by the previous examinations. Third, different centers used different frequency transducers in this multicenter study, which might have caused variations in the measurements. Fourth, the patients could have individual variations when performing dorsiflexion, which could also affect the measurement accuracy in the AP-sit method. An optimal degree of dorsiflexion should be defined to standardize the AP-sit method in future studies. Fifth, the sample size was small, especially for patients with advanced CVD. Further studies are needed to clarify whether our study results could be applied to patients with advanced CVD.

Conclusions

The larger competent PVs with visible valves on ultrasound can show physiological bidirectional flow. The diseased calves with CVD have more PVs than do the healthy calves. IPVs are commonly larger than competent PVs, with most of the calf IPVs located in the medial and posterior middle of the calf. Most importantly, the AP-sit method could provide a convenient and effective approach for assessing the calf PVs, especially the distal calf PVs, as an alternative or complementary to traditional manual compression, which would be valuable in the daily practice of sonographers.

Author contributions

Conception and design: PL, JH, YG

Analysis and interpretation: PL, YG

Data collection: PL, JH, XZ, RY, SY, LC, YG

Writing the article: PL, XZ, SY, YG

Critical revision of the article: PL, JH, RY, SY, LC, YG

Final approval of the article: PL, JH, XZ, RY, SY, LC, YG

Statistical analysis: Not applicable

Obtained funding: Not applicable

Overall responsibility: YG

Disclosures

None.

Footnotes

Additional material for this article may be found online at www.jvsvenous.org.

The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.

Appendix

Additional material for this article may be found online at www.jvsvenous.org.

The CME exam for this article can be accessed athttp://www.jvsvenous.org/cme/home.

Appendix (online only)

Supplementary Fig 1.

Supplementary Fig 1

Open in a new tab

Supplementary Fig 2.

Supplementary Fig 2

Open in a new tab

Supplementary Fig 3.

Supplementary Fig 3

Open in a new tab
Supplementary Table
mmc1.docx (22.5KB, docx)

References

  • 1.Orhurhu V., Chu R., Xie K., et al. Management of lower extremity pain from chronic venous insufficiency: a comprehensive review. Cardiol Ther. 2021;10:111–140. doi: 10.1007/s40119-021-00213-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Baliyan V., Tajmir S., Hedgire S.S., Ganguli S., Prabhakar A.M. Lower extremity venous reflux. Cardiovasc Diagn Ther. 2016;6:533–543. doi: 10.21037/cdt.2016.11.14. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Zolotukhin I.A., Seliverstov E.I., Shevtsov Y.N., et al. Prevalence and risk factors for chronic venous disease in the general Russian population. Eur J Vasc Endovasc Surg. 2017;54:752–758. doi: 10.1016/j.ejvs.2017.08.033. [DOI] [PubMed] [Google Scholar]
  • 4.Ortega M.A., Fraile-Martínez O., García-Montero C., et al. Understanding chronic venous disease: a critical overview of its pathophysiology and medical management. J Clin Med. 2021;10:3239. doi: 10.3390/jcm10153239. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.De Maeseneer M.G.R., van der Velden S.K. Managing chronic venous disease: an ongoing challenge. Eur J Vasc Endovasc Surg. 2015;49:676–677. doi: 10.1016/j.ejvs.2015.02.014. [DOI] [PubMed] [Google Scholar]
  • 6.Wittens C., Davies A.H., Bækgaard N., et al. Editor’s choice - management of chronic venous disease: clinical practice guidelines of the european society for vascular surgery (ESVS) Eur J Vasc Endovasc Surg. 2015;49:678–737. doi: 10.1016/j.ejvs.2015.02.007. [DOI] [PubMed] [Google Scholar]
  • 7.Meyer T., Cavallaro A., Lang W. Duplex ultrasonography in the diagnosis of incompetent cockett veins. Eur J Ultrasound. 2000;11:175–180. doi: 10.1016/s0929-8266(00)00085-9. [DOI] [PubMed] [Google Scholar]
  • 8.Gloviczki P., Comerota A.J., Dalsing M.C., et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the society for vascular surgery and the American venous forum. J Vasc Surg. 2011;53:2S–48S. doi: 10.1016/j.jvs.2011.01.079. [DOI] [PubMed] [Google Scholar]
  • 9.Lv W., Wu X.J., Collins M., Han Z.L., Jin X. Analysis of a series of patients with varicose vein recurrence. J Int Med Res. 2012;40:1156–1165. doi: 10.1177/147323001204000336. [DOI] [PubMed] [Google Scholar]
  • 10.Hua W.R., Yi M.Q., Jun W.X., Xing J., Xuan L.Z., Bo L. Causes of recurrent lower limb varicose veins after surgical interventions in 141 limbs - five-year retrospective analysis of two centers. Vascular. 2014;22:267–273. doi: 10.1177/1708538113484023. [DOI] [PubMed] [Google Scholar]
  • 11.Rutherford E.E., Kianifard B., Cook S.J., Holdstock J.M., Whiteley M.S. Incompetent perforating veins are associated with recurrent varicose veins. Eur J Vasc Endovasc Surg. 2001;21:458–460. doi: 10.1053/ejvs.2001.1347. [DOI] [PubMed] [Google Scholar]
  • 12.Zan S., Varetto G., Maselli M., Scovazzi P., Moniaci D., Lazzaro D. Recurrent varices after internal saphenectomy. physiopathological hypothesis and clinical approach. Minerva Cardioangiol. 2003 Feb;51:79–83. 83-6. [PubMed] [Google Scholar]
  • 13.Cina G., Narese D., Amicucci V., Filipponi M., Snider F. Recurrent varicose veins of the legs: a single centre experience. Clin Ter. 2014;165:183–186. doi: 10.7417/CT.2014.1730. [DOI] [PubMed] [Google Scholar]
  • 14.Englund R. Duplex scanning for recurrent varicose veins. Aust N Z J Surg. 1996;66:618–620. doi: 10.1111/j.1445-2197.1996.tb00832.x. [DOI] [PubMed] [Google Scholar]
  • 15.Harlander-Locke M., Lawrence P., Jimenez J.C., Rigberg D., DeRubertis B., Gelabert H. Combined treatment with compression therapy and ablation of incompetent superficial and perforating veins reduces ulcer recurrence in patients with CEAP 5 venous disease. J Vasc Surg. 2012;55:446–450. doi: 10.1016/j.jvs.2011.08.009. [DOI] [PubMed] [Google Scholar]
  • 16.DePopas E., Brown M. Varicose veins and lower extremity venous insufficiency. Semin Intervent Radiol. 2018;35:56–61. doi: 10.1055/s-0038-1636522. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Delis K.T. Leg perforator vein incompetence: Functional anatomy. Radiology. 2005;235:327–334. doi: 10.1148/radiol.2351031598. [DOI] [PubMed] [Google Scholar]
  • 18.Delis K.T., Ibegbuna V., Nicolaides A.N., Lauro A., Hafez H. Prevalence and distribution of incompetent perforating veins in chronic venous insufficiency. J Vasc Surg. 1998;28:815–825. doi: 10.1016/s0741-5214(98)70056-4. [DOI] [PubMed] [Google Scholar]
  • 19.Gloviczki P., Lawrence P.F., Wasan S.M., et al. The 2022 society for vascular surgery, American venous forum, and american vein and lymphatic society clinical practice guidelines for the management of varicose veins of the lower extremities. part I. duplex scanning and treatment of superficial truncal reflux: endorsed by the society for vascular medicine and the international union of phlebology. J Vasc Surg Venous Lymphat Disord. 2023;11:231–261.e6. doi: 10.1016/j.jvsv.2022.09.004. [DOI] [PubMed] [Google Scholar]
  • 20.De Maeseneer M., Pichot O., Cavezzi A., et al. Duplex ultrasound investigation of the veins of the lower limbs after treatment for varicose veins - UIP consensus document. Eur J Vasc Endovasc Surg. 2011;42:89–102. doi: 10.1016/j.ejvs.2011.03.013. [DOI] [PubMed] [Google Scholar]
  • 21.Adler C., Mousa A., Rhee A., Patel M.D. Varicose veins of the lower extremity: Doppler US evaluation protocols, patterns, and pitfalls. Radiographics. 2022;42:2184–2200. doi: 10.1148/rg.220057. [DOI] [PubMed] [Google Scholar]
  • 22.Małek G., Nowicki A. Standards of the polish ultrasound society - update. sonography of the lower extremity veins. J Ultrason. 2014;14:287–296. doi: 10.15557/JoU.2014.0029. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Necas M. Duplex ultrasound in the assessment of lower extremity venous insufficiency. Australas J Ultrasound Med. 2010;13:37–45. doi: 10.1002/j.2205-0140.2010.tb00178.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Staubesand J., Heisterkamp T., Stege H. Use of duplex sonography to investigate the effect of active and passive movement at the ankle joint for promoting venous return. Clin Anat. 1995;8:96–101. doi: 10.1002/ca.980080203. [DOI] [PubMed] [Google Scholar]
  • 25.Lurie F., Passman M., Meisner M., et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord. 2020;8:342–352. doi: 10.1016/j.jvsv.2019.12.075. [DOI] [PubMed] [Google Scholar]
  • 26.De Maeseneer M.G., Kakkos S.K., Aherne T., et al. Editor’s choice - European Society for Vascular Surgery (ESVS) 2022 clinical practice guidelines on the management of chronic venous disease of the lower limbs. Eur J Vasc Endovasc Surg. 2022;63:184–267. doi: 10.1016/j.ejvs.2021.12.024. [DOI] [PubMed] [Google Scholar]
  • 27.Labropoulos N., Mansour M.A., Kang S.S., Gloviczki P., Baker W.H. New insights into perforator vein incompetence. Eur J Vasc Endovasc Surg. 1999;18:228–234. doi: 10.1053/ejvs.1999.0812. [DOI] [PubMed] [Google Scholar]
  • 28.Tolu I., Durmaz M.S. Frequency and significance of perforating venous insufficiency in patients with chronic venous insufficiency of lower extremity. Eurasian J Med. 2018;50:99–104. doi: 10.5152/eurasianjmed.2018.18338. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Meissner M.H. Lower extremity venous anatomy. Semin Intervent Radiol. 2005;22:147–156. doi: 10.1055/s-2005-921948. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Hill B.G., van Rij A.M. The lower limb perforator veins in normal subjects. J Vasc Surg Venous Lymphat Disord. 2022;10:669–675.e1. doi: 10.1016/j.jvsv.2022.01.010. [DOI] [PubMed] [Google Scholar]
  • 31.Delis K.T. Perforator vein incompetence in chronic venous disease: a multivariate regression analysis model. J Vasc Surg. 2004;40:626–633. doi: 10.1016/j.jvs.2004.07.006. [DOI] [PubMed] [Google Scholar]
  • 32.van Neer P.A.F.A., Veraart J.C.J.M., Neumann H.A.M. Venae perforantes: a clinical review. Dermatol Surg. 2003 Sep;29:931–942. doi: 10.1046/j.1524-4725.2003.29273.x. discussion: 942. [DOI] [PubMed] [Google Scholar]
  • 33.Labropoulos N., Tiongson J., Pryor L., et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg. 2003;38:793–798. doi: 10.1016/s0741-5214(03)00424-5. [DOI] [PubMed] [Google Scholar]
  • 34.Labropoulos N., Leon L.R. Duplex evaluation of venous insufficiency. Semin Vasc Surg. 2005;18:5–9. doi: 10.1053/j.semvascsurg.2004.12.002. [DOI] [PubMed] [Google Scholar]
  • 35.Lattimer C.R., Franceschi C., Kalodiki E. Optimizing calf muscle pump function. Phlebology. 2018;33:353–360. doi: 10.1177/0268355517709410. [DOI] [PubMed] [Google Scholar]
  • 36.Suehiro K., Morikage N., Harada T., et al. Effects of leg compression and calf muscle contraction by active ankle motion on venous hemodynamics in sitting individuals. Phlebology. 2022;37:361–366. doi: 10.1177/02683555221077741. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Table
mmc1.docx (22.5KB, docx)

Articles from Journal of Vascular Surgery: Venous and Lymphatic Disorders are provided here courtesy of Elsevier

RESOURCES