Abstract
Background
Chronic venous insufficiency (CVI) results in complications such as pain, swelling, edema, skin changes, and ulcerations of the lower extremities. Valvular incompetence and venous obstruction are well-recognized contributors to CVI. Post-exercise venous refilling time (P-EVRT), the time to refill veins after calf muscle contractions during venous plethysmography study, is an understudied contributor to CVI.
Methods
In this cross-sectional study of 4755 patients who were evaluated with venous air plethysmography, 9510 lower limbs were categorized based on P-EVRT into two groups: rapid (<20 seconds; n = 5256) and normal (n = 4254).
Results
Rapid P-EVRT was associated with higher mean CEAP scores (3.2 vs 2.5; P < .001) and a higher prevalence of active/prior ulcers (11.6 vs 4.1%; P < .001). Univariable analysis showed that age, male sex, the severity of incompetence, obstruction, calf pump function, and rapid P-EVRT were all significantly associated with active/prior ulcers. After multivariable adjustment for these significant factors, rapid P-EVRT was an independent contributor to active/prior ulcers (odds ratio, 1.44; 95% confidence interval, 1.17-1.77). Among limbs without other venous pathology by plethysmography (incompetence, obstruction, reduced calf pump function), rapid P-EVRT remained significantly associated with higher mean CEAP scores (P < .001) and a higher prevalence of venous ulcers than limbs with normal P-EVRT (5.7% vs 2.7%; P = .001).
Conclusions
In this large contemporary study using venous air plethysmography, we demonstrate that rapid P-EVRT is an important and unique venous physiologic parameter that informs our understanding of the clinical severity of CVI.
Keywords: CEAP, Chronic venous disease, Post exercise venous refilling time, Ulcers, Venous plethysmography
Article Highlights.
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Type of Research: Cross-sectional study
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Key Findings: Rapid post-exercise venous refilling time (P-EVRT) is an independent contributor to active/prior leg venous ulcers. Each 10-second decrease in P-EVRT (from >40 seconds) corresponded with a notable rise in CEAP scores.
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Take Home Message: P-EVRT as an independent parameter that warrants further investigation to better understand its association with higher CEAP scores and venous ulcers.
Chronic venous insufficiency (CVI) affects the venous system in the lower extremities, leading to venous hypertension and a range of complications such as pain, swelling, edema, skin changes, and ulcerations.1 One of the most serious consequences of CVI is the development of venous ulcers. The prevalence of venous ulcers varies globally, ranging from 1.5% to 3% of the general population, with the highest rates observed in the United States.2 Venous ulcers are associated with a poor prognosis due to frequent delayed healing and recurrent episodes.3 The socioeconomic impact of these ulcers is profound, as they significantly impair individuals’ ability to engage in social and occupational activities, thereby diminishing quality of life and imposing substantial financial burdens.4
Post-exercise venous refilling time (P-EVRT) refers to the time it takes for veins to refill with blood after exercise-induced emptying. In prior small studies, CVI was associated with rapid refilling time on venous plethysmography.5, 6, 7 The reasons behind rapid P-EVRT and its relationship with the clinical severity of CVI have not been thoroughly investigated in large cohorts. It is unknown if P-EVRT is merely a manifestation of CVI contributors (valvular incompetence, obstruction, or reduced calf pump function [CPF]) or whether it independently contributes to the severity of the venous disease. Using a contemporary dataset of venous air plethysmography from the Mayo Clinic Gonda Vascular Laboratory, our goal was to determine if P-EVRT was an independent predictor of higher CEAP scores or the presence of active or healed venous leg ulcers.
Methods
Study design and patients
The Mayo Clinic Gonda Vascular Laboratory database was queried for patients 18 years or older with complete venous physiologic testing by air plethysmography from March 1, 2015, through July 31, 2024. The initial study was used in this analysis for patients with more than one study. The Mayo Clinic Institutional Review Board reviewed and approved this study.
Plethysmography
Venous physiology was assessed in ambulatory outpatients by standard air plethysmography methods as previously described.5,8,9 Briefly, testing included three different phases: venous outflow to assess venous obstruction, passive drainage and refilling to assess valvular incompetence, and then ankle flexes followed by passive refilling to calculate CPF. Reduced CPF was defined as an ejection fraction (EF) of less than 45%. Venous outflow is classified into obstructed or patent categories, and venous incompetence per extremity was categorized into normal, mild, moderate, or severe, based on flow and volume using established laboratory criteria.8
Post-exercise venous refilling time
Following ankle flexion exercises, venous refilling is allowed until full capacitance is achieved. The time required to reach 90% of capacitance is measured from the refill tracing. According to established laboratory criteria,5,8 a P-EVRT duration of less than 20 seconds is classified as rapid; otherwise, it is classified as normal. P-EVRT is distinct from CPF, as CPF measures the volume (not time) of refilling after exercise in relation to the volume of refilling in the passive refilling phase.
CEAP classification
This system evaluates CVI based on clinical presentation, etiology, anatomy, and pathophysiology. The clinical classification was performed/supervised by a certified vascular technician at the time of the study in each limb and classified into seven groups: CEAP 0 (no signs of venous disease), 1 (telangiectasias or reticular veins), 2 (visible varicose veins), 3 (edema), 4 (A: hyperpigmentation, B: lipodermatosclerosis, or atrophy blanche), 5 (healed venous leg ulcer) and 6 (active venous leg ulcer).
Analysis
Because each limb contains independent venous hemodynamic measures and CEAP score, the analysis was performed per limb. The primary outcome of interest was the presence of C5 or C6 disease, indicating a healed or active venous ulcer at the time of the study. Descriptive characteristics were presented as mean and standard deviations for continuous variables, and numbers and percentages were used for categorical variables. Pearson’s χ2 was used to evaluate the relationship between categorical values, whereas Fisher’s exact test was used when one or more categories contained less than 10 observations. The Kolmogorov-Smirnov Test was used to test the distribution of continuous variables; Student’s t-test was used for normal distributions, and Wilcoxon Rank Sum Test was used for non-normal distributions when comparing continuous with dichotomous variables. Univariate and multivariable logistic regression analyses were performed to identify independent predictors of active/prior ulcers. First, we examined P-EVRT, venous obstruction, venous incompetence, CPF, age, and male sex through univariate analysis to assess its association with active/healed ulcers. Next, we used two multivariable logistic regression models to explore the relationship between P-EVRT categorized as a dichotomous variable (rapid vs normal P-EVRT) with additional clinical variables (age, sex) and venous variables (obstruction, incompetence, CPF). The model results are reported using odds ratios (ORs) and their corresponding 95% confidence intervals (CIs). All statistical tests were two-sided, with significance defined as P < .05. Statistical analyses were performed using Python version 3.0 and SciPy10 and Stats models libraries.11
Results
During the study period, 9510 limbs from 4755 patients who underwent venous plethysmography were included in the analysis. The mean age was 61.3 ± 15.3 years and comprised a higher proportion of females (61.3%). Among the limbs assessed, 4264 (44.8%) were classified by plethysmography as having no hemodynamic venous incompetence, 2492 (26.2%) had mild, 1801 (18.9%) had moderate, and 952 (10%) had severe venous incompetence. Venous obstruction was identified in 334 limbs (3.5%). CPF was normal in 5006 limbs (52.6%) and reduced in 4504 limbs (47.3%). The mean calf muscle EF was 47.4% ± 15.3%, and the mean P-EVRT was 21.17 ± 16.43 seconds. The average maximal recorded CEAP score per limb was 2.87 ± 1.3. Venous ulcers (healed or active) were found in 787 limbs (8.3%).
Limbs were categorized based on P-EVRT into two groups: rapid P-EVRT and normal P-EVRT (Table I). Limbs with rapid P-EVRT had a significantly shorter P-EVRT time than those with normal P-EVRT (10.2 ± 5.4 vs 34.7 ± 15.4 seconds; P < .001) and were observed more frequently in older patients (64.4 ± 14.6 vs 57.4 ± 15.3 years; P < .001). Rapid P-EVRT was associated with higher rates of venous incompetence across all categories compared with normal P-EVRT, with 28.3% vs 23.7% having mild insufficiency, 27.9% vs 7.9% with moderate insufficiency, and 16.3% vs 2.2% with severe insufficiency (P < .001). Venous obstruction was also more prevalent in limbs with rapid P-EVRT, occurring in 4.7% vs 2% in limbs with normal P-EVRT (P < .001). Limbs with rapid P-EVRT had a higher prevalence of reduced CPF than those with normal P-EVRT (65.8% vs 24.6%; P < .001). Concurrently, rapid P-EVRT had a significantly lower EF than normal P-EVRT (37.8% vs 59.3%; P < .001). Higher CEAP scores were more frequently observed in limbs with rapid P-EVRT compared with those with normal P-EVRT: 85.3% of limbs with rapid P-EVRT had a score of 1 vs 77% of those with normal P-EVRT; 44.7% vs 27.5% had a score of 2; 70.1% vs 55% had a score of 3; 30.3% vs 11.8% had a score of 4a; 11.6% vs 4.7% had a score of 4b; 8.8% vs 3% had a score of 5; and 7.2% vs 2.3% had a score of 6 (P < .001). The prevalence of venous ulcers (active/prior) was higher in limbs with rapid P-EVRT compared with limbs with normal P-EVRT (11.6% vs 4.1%; P < .001).
Table I.
Comparison of characteristics between limbs with normal and rapid post-exercise venous refilling time (P-EVRT)
| Variable | Rapid P-EVRT |
Normal P-EVRT |
Total |
P value |
|---|---|---|---|---|
| n = 5256 | n = 4254 | 9510 | ||
| Age, years | 64.4 (14.6) | 57.4 (15.3) | 9510 | <.001 |
| Female | 3196 (60.8) | 2641 (62.1) | 5837 | .20 |
| Race | ||||
| Other | 364 (6.9) | 363 (8.5) | 727 | .003 |
| White | 4892 (93.1) | 3891 (91.5) | 8783 | |
| Circumference | 254.4 (37.3) | 249.8 (32.8) | 9330 | <.001 |
| Extremity | ||||
| Left | 2677 (50.9) | 2078 (48.8) | 4755 | .04 |
| Right | 2579 (49.1) | 2176 (51.2) | 4755 | |
| Venous incompetence | ||||
| Normal | 1446 (27.5) | 2818 (66.2) | 4264 | |
| Mild | 1485 (28.3) | 1008 (23.7) | 2493 | |
| Moderate | 1467 (27.9) | 334 (7.9) | 1801 | |
| Severe | 858 (16.3) | 94 (2.2) | 952 | <.001 |
| Obstruction | 247 (4.7) | 87 (2.0) | 334 | <.001 |
| Reduced CPF | 3456 (65.8) | 1048 (24.6) | 4504 | <.001 |
| EF, % | 37.8 (21.0) | 59.3 (21.0) | 9510 | <.001 |
| P-EVRT | 10.2 (5.4) | 34.7 (15.4) | 9510 | <.001 |
| Highest CEAP | 3.2 (1.3) | 2.5 (1.3) | 9510 | <.001 |
| CEAP categories | ||||
| C1 | 4484 (85.3) | 3277 (77.0) | 7761 | <.001 |
| C2 | 2349 (44.7) | 1170 (27.5) | 3519 | <.001 |
| C3 | 3684 (70.1) | 2341 (55.0) | 6025 | <.001 |
| C4A | 1593 (30.3) | 502 (11.8) | 2095 | <.001 |
| C4B | 609 (11.6) | 202 (4.7) | 811 | <.001 |
| C5 | 460 (8.8) | 128 (3.0) | 588 | <.001 |
| C6 | 376 (7.2) | 98 (2.3) | 474 | <.001 |
| Active/prior ulcer | 612 (11.6) | 175 (4.1) | 787 | <.001 |
CPF, Calf pump function; EF, ejection fraction.
Data are presented as number (%) or mean (standard deviation).
The Mosaic Graph analysis showed that for each 10-second decrease from P-EVRT of 40 seconds or more, there was an increase in CEAP scores (Fig). P-EVRT durations of less than 20 seconds were associated with a higher prevalence of scores 4, 5, and 6, with a prevalence of C6 disease reaching 9.8% for P-EVRT times less than 10 seconds.
Fig.
Relationship of post-exercise venous refilling time (P-EVRT) with highest CEAP score per limb.
Univariable analysis with logistic regression revealed several factors significantly associated with ulcers, including age (OR, 1.02; 95% CI, 1.01-1.03), male sex (OR, 1.69; 95% CI, 1.43-1.98), mild venous insufficiency (OR, 1.53; 95% CI, 1.20-1.95), moderate venous insufficiency (OR, 3.23; 95% CI, 2.57-4.05), severe venous insufficiency (OR, 6.69; 95% CI, 5.30-8.45), venous obstruction (OR, 1.93; 95% CI, 1.34-2.77), reduced CPF (OR, 2.83; 95% CI, 2.37-3.37), and rapid P-EVRT (OR, 3.14; 95% CI, 2.58-3.83). In the multivariable logistic regression model, adjusting for age, sex, incompetence, obstruction, and CPF, rapid P-EVRT remained independently associated with ulcers, with an OR of 1.44 (95% CI, 1.17-1.77) (Table II).
Table II.
Logistic regression analysis for active/healed ulcer
| Univariate |
Multivariate |
|||
|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | |
| Age | 1.02 | 1.01-1.03 | 1.02 | 1.01-1.02 |
| Male sex | 1.69 | 1.43-1.98 | 1.53 | 1.32-1.78 |
| Incompetence | ||||
| Mild | 1.53 | 1.20-1.95 | 1.24 | 0.99-1.55 |
| Moderate | 3.23 | 2.57-4.05 | 2.34 | 1.88-2.91 |
| Severe | 6.69 | 5.30-8.45 | 4.32 | 3.43-5.45 |
| Normal | ref | Ref | ||
| Obstruction | 1.93 | 1.34-2.77 | 1.00 | 0.71-1.41 |
| Reduced CPF | 2.83 | 2.37-3.37 | 1.44 | 1.41-1.99 |
| Rapid P-EVRT | 3.14 | 2.58-3.83 | 1.44 | 1.17-1.77 |
CI, Confidence interval; CPF, calf pump function; OR, odds ratio; P-EVRT, post-exercise venous refilling time.
In the electronic health record, an option to discretely record the Venous Clinical Severity Scores (VCSS) per limb has been available since 2018, and patients in this study with available scores were extracted. Among these patients, a score was available within 2 years of the plethysmography study for 554 limbs. The median VCSS was 5 and ranged from 0 to 27. Limbs with rapid P-EVRT had higher severity scores than limbs with normal P-EVRT (6.6 vs 4.6; P < .001), corroborating findings from technician-recorded CEAP score data with clinically reported data. In a multivariable linear regression model, P-EVRT remained a significant predictor of VCSS (P = .01), along with venous obstruction (P = .01), venous incompetence (P < .001), CPF (P = .007), and sex (P = .02), but not age (P = .22).
Next, we sought to further examine P-EVRT in limbs without other venous pathology as determined by plethysmography. In this analysis, 2580 limbs without incompetence, obstruction, or reduced CPF were identified and classified based on their P-EVRT into two groups: those with rapid P-EVRT and those with normal P-EVRT. Similar to the overall analysis, limbs with rapid P-EVRT had a significantly shorter P-EVRT than those with normal P-EVRT (14.78 ± 3.57 vs 38.5 ± 17.1 seconds; P < .001) and were more likely to be from older patients (63.2 ± 14.9 vs 57.8 ± 14.9 years; P < .001) (Table III). Higher CEAP scores were again more common in limbs with rapid P-EVRT compared with those with normal P-EVRT: 84.7% of limbs with rapid P-EVRT had a score of 1, vs 78.1% with normal P-EVRT; 32.7% vs 24.5% had a score of 2; 57.3% vs 50.2% had a score of 3; 17% vs 9.2% had a score of 4a; 5.7% vs 3.6% had a score of 4b; 4% vs 1.8% had a score of 5; and 3.6% vs 1.6% had a score of 6 (P < .001). Additionally, limbs with rapid P-EVRT had a higher prevalence of active/prior ulcers at 5.7%, compared with 2.7% in limbs with normal P-EVRT (P < .001).
Table III.
Comparison of characteristics between normal and rapid post-exercise venous refilling time (P-EVRT) in limbs without incompetence, obstruction, or reduced calf pump function (CPF)
| Rapid P-EVRT |
Normal P-EVRT |
Total | P value | |
|---|---|---|---|---|
| n = 471 | n = 2109 | |||
| Age, years | 63.2 (14.9) | 57.8 (14.9) | 2580 | <.001 |
| Female | 317 (67.3) | 1325 (62.8) | 1642 | .07 |
| Race | ||||
| Other | 26 (5.5) | 159 (7.5) | 185 | .12 |
| White | 445 (94.5) | 1950 (92.5) | 2395 | |
| Extremity | ||||
| Left | 227 (48.2) | 1045 (49.5) | 1272 | .60 |
| Right | 244 (51.8) | 1064 (50.5) | 1308 | |
| Circumference | 245.2 (30.5) | 247.7 (49.2) | 2525 | .28 |
| EF, % | 61.0 (14.0) | 68.9 (15.6) | 2580 | <.001 |
| P-EVRT | 14.8 (3.6) | 38.5 (17.1) | 2580 | <.001 |
| Highest CEAP | 2.65 (1.36) | 2.3 (1.3) | 2580 | <.001 |
| CEAP categories | ||||
| C1 | 399 (84.7) | 1648 (78.1) | 2047 | .001 |
| C2 | 154 (32.7) | 516 (24.5) | 670 | <.001 |
| C3 | 270 (57.3) | 1059 (50.2) | 1329 | .005 |
| C4A | 80 (17.0) | 195 (9.2) | 275 | <.001 |
| C4B | 27 (5.7) | 76 (3.6) | 103 | .03 |
| C5 | 19 (4.0) | 39 (1.8) | 58 | .004 |
| C6 | 17 (3.6) | 33 (1.6) | 50 | .004 |
| Active/prior ulcer | 27 (5.7) | 57 (2.7) | 84 | .001 |
EF, Ejection fraction.
Data are presented as number (%) or mean (standard deviation).
Discussion
Our study demonstrates that P-EVRT is an important and independent determinant of CVI. P-EVRT was associated with higher rates of venous incompetence, venous obstruction, and reduced CPF, indicating that these parameters also influenced P-EVRT. Importantly, we found higher CEAP scores and an increased prevalence of venous ulcers (healed or active) in limbs with rapid P-EVRT. After multivariable adjustment for other etiologies of CVI (incompetence, obstruction, reduced CPF), rapid P-EVRT was still associated with higher CEAP scores and venous ulcers than in limbs with normal P-EVRT. These findings highlight P-EVRT as an independent parameter that warrants further investigation to better understand its association with higher CEAP scores and venous ulcers.
P-EVRT refers to the duration required for blood to re-enter the lower leg following emptying by the calf muscle. In patients without venous disease who are sitting, limb refilling mainly relies on arterial inflow and typically takes at least 20 seconds or more. It is recognized that rapid P-EVRT can be a result of venous incompetence or obstruction. Venous incompetence or obstruction, along with changes in venous wall compliance and vasomotor tone, is associated with the failure of venous valves. Venous valvular incompetence contributes to retrograde venous refilling added to arterial inflow, resulting in a shortened refilling time.12,13 Additionally, Ghorbanzadeh et al showed that decreased CPF was associated with worse chronic venous disease.14 In the present study, rapid P-EVRT was significantly associated with a higher prevalence of valvular incompetence and venous obstruction, which is consistent with findings from other studies where limbs with venous disease consistently showed shorter venous refilling times compared with those with normal veins.5,7 Interestingly, we observed that rapid P-EVRT was present in some limbs that did not exhibit valvular incompetence, obstruction, or reduced CPF, supporting the hypothesis that P-EVRT as an independent parameter that warrants further investigation to better understand its association with CVI severity and progression.
Rapid P-EVRT (less than 20 seconds) was significantly correlated with increased clinical severity, as indicated by CEAP scores. Specifically, for every 10-second reduction in P-EVRT from greater than 40 seconds, there was a notable rise in CEAP scores. Patients with P-EVRT between 50 and 20 seconds generally exhibited lower CEAP scores. In contrast, those with P-EVRT of less than 20 seconds were more likely to present with higher CEAP scores of 4, 5, and 6. Refilling times under 10 seconds were strongly associated with a greater prevalence of skin changes and healed or active venous leg ulcers (see Fig).
Our findings are consistent with data from small studies over 3 decades ago, which employed strain gauge plethysmography on 86 limbs and showed an inverse relationship between CVI severity and refilling time.5 A study by Rosfors et al conducted a decade ago on 56 patients indicated that plethysmographic measures of venous reflux, including refilling time, correlated more closely with skin changes (CEAP scores 4, 5, 6) than with edema, further supporting our results. What strengthens our study is our examination of the correlation between P-EVRT and clinical severity of CVI as a primary outcome in a large cohort of 9510 limbs from 4755 patients, making it the largest study to explore this relationship. Notably, in our cohort, P-EVRT remained associated with higher CEAP scores and the presence of active or healed venous ulcers, even after adjusting for other etiologies of CVI, such as incompetence, obstruction, and reduced CPF. Furthermore, we investigated rapid P-EVRT in patients without valvular incompetence, obstruction, or reduced CPF and found it was still associated with higher CEAP scores and venous ulcers.
Although the specific anatomy responsible for rapid P-EVRT remains unclear, at least four potential mechanisms could be contributing. The first hypothesis relates to perforator vein valvular incompetence. Isolated incompetence in these veins would not be measured well by the passive drainage and refill that grades the severity of venous incompetence. During calf muscle contractions, venous blood in the deep veins could be pushed through perforators to the superficial veins, but instead of continuing to flow outward, these veins immediately reflux back with muscle relaxation accounting for rapid refilling. A second hypothesis relates to inefficient and inappropriate CPF. This could be explained by distal displacement of venous blood towards and into the foot, rather than proximal, possibly secondary to isolated deep vein incompetence that may not be well-captured by the more global passive drainage and refill (due to competent proximal valves). A third hypothesis could be related to abnormally increased arterial inflow after calf contractions. This would be most analogous to the pathophysiology of calcium channel blocker-associated edema. Although exercise is known to cause arterial dilation for optimal muscle perfusion, the calf contractions performed in plethysmography testing realistically represent minimal muscle exertion. However, some patients may have inappropriately pronounced arteriole dilation that overwhelms venous outflow response, contributing to venous hypertension and CVI. A fourth hypothesis relates to vein wall compliance. A less compliant vein, due to intrinsic or extrinsic factors, might fill faster due to decreased capacitance. One underrecognized contributor to venous pathology is lymphedema, either primary or secondary, which can lead to venous insufficiency through chronic lymphatic obstruction and impaired interstitial fluid clearance. In such cases, compromised lymphatic drainage may elevate interstitial pressure, promote inflammatory changes, and decrease venous wall compliance. These factors may collectively predispose to rapid P-EVRT. A Japanese case series on primary lymphedema reported early venous return patterns in approximately 60% of patients.15 These findings support the notion that primary lymphedema may promote P-EVRT even in the absence of typical chronic venous disease risk factors.
Indeed, rapid P-EVRT may result from a combination of each of these factors in various proportions and may differ between individuals. Precise mechanisms may be better understood by examining the characteristics of the post-exercise tracings and comparing passive vs exercise pump function, but it will be difficult to further study based on the limitations of current testing. Regardless of the etiology, this analysis demonstrates the importance of this parameter in CVI.
As a cross-sectional study, we could not distinguish between risk factors and disease outcomes, making establishing causality difficult. The study methods also do not allow us to predict future complications from CVI nor assess the likelihood of future ulcers or the impact on ulcer healing. Additionally, our study comprised of individuals referred to for testing, signs, or symptoms potentially consistent with CVI and does not represent the prevalence of venous disease or the characteristics of CVI that might be present in the general population. Baseline activity levels and adherence to compression therapy likely add to discordance between plethysmography findings and CEAP scores. Unfortunately, due to the retrospective and cross-sectional nature of this study, we do not have any data available that can help answer questions about patients’ baseline activity levels. This fact, however, does not alter the validity of our conclusions. A strength of our analysis was the additional confirmation of findings related to CEAP scoring using clinically reported signs and symptoms from the VCSS.
Venous air plethysmography remains an important tool for understanding venous pathology; however, it has largely been abandoned with the clinical preference for ultrasonography. Although ultrasonography provides vital information on anatomic locations of valvular incompetence and venous obstruction, it does not capture whole limb physiology compared with plethysmography. Specifically, important measures of CPF or P-EVRT are not assessed by ultrasound. Given the independent relationship between rapid P-EVRT and ulcers, regardless of valvular incompetence, obstruction, or reduced CPF, it is clear that integrating venous plethysmography with physical examinations is crucial for enhancing the evaluation and management of patients with CVI. Venous plethysmography’s unique ability to detect P-EVRT reinforces its role as the gold standard for diagnosing and assessing patients with CVI.
Author contributions
Conception and design: HE, AG, DL, PW, RM, DH
Analysis and interpretation: HE, AG, DL, PW, RM, DH
Data collection: HE, AG, DL, PW, RM, DH
Writing the article: HE, AG, DL, PW, RM, DH
Critical revision of the article: HE, AG, DL, PW, RM, DH
Final approval of the article: HE, AG, DL, PW, RM, DH
Statistical analysis: HE, AG, DL, PW, RM, DH
Obtained funding: Not applicable
Overall responsibility: HE
Funding
None.
Disclosures
None.
Footnotes
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.
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