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Apr 2026
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Chronic Venous Insufficiency

1
1. Arshadbhat 05 Apr 2026
  
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  Treatment of superficial vein reflux (see Varicose Veins, above) has been shown to decrease the recurrence rate of venous ulcers. Where there is substantial obstruction of the femoral or popliteal deep venous system, superficial varicosities supply the venous return and should not be removed.
  
  Failure of venous insufficiency ulcerations to heal is most often due to inconsistent use of first-line treatment methods. Ongoing control of edema is essential to prevent recurrent ulceration; the use of compression stockings following ulcer healing is critical, with recurrence rates 2–20 times higher if compression stockings are not used
  
  Duplex ultrasound evaluation should assess blood flow direction, venous reflux, and venous obstruction, and include examination of the deep venous system, great saphenous vein (GSV), small saphenous vein (SSV) and its thigh extension (Giacomini vein), accessory saphenous veins, and perforating veins. Venography is recommended primarily in patients with post-thrombotic disease, especially when intervention is planned, as it provides greater anatomic detail than duplex ultrasonograph The examination also identifies patterns of disease that have treatment implications. Axial reflux is defined as uninterrupted retrograde flow from groin to calf and can occur in either superficial or deep systems. [4] Junctional reflux is limited to the saphenofemoral or saphenopopliteal junction, while segmental reflux occurs in a portion of a truncal vein. [4] Understanding whether reflux originates from superficial junctions versus deep venous incompetence fundamentally changes treatment planning, as superficial disease is amenable to ablation while deep disease typically requires conservative management Management of secondary varicose veins from post-thrombotic syndrome (PTS) is fundamentally different and more challenging. Compression therapy, lifestyle modifications, and symptom management form the cornerstone of PTS treatment. [4-8] Elastic compression stockings (20-30 mm Hg), leg elevation, weight loss, and exercise constitute the primary therapeutic approach Endovascular interventions for PTS—including percutaneous transluminal venoplasty and stenting—are reserved for select patients with significant iliofemoral obstruction who have failed conservative management. [7] These procedures require careful patient selection and standardized criteria. The role of superficial venous ablation in PTS patients with concomitant superficial reflux remains controversial and should be approached cautiously, as the underlying deep venous pathology may limit benefit
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Management of secondary varicose veins from post-thrombotic syndrome (PTS) is fundamentally different and more challenging. Compression therapy, lifestyle modifications, and symptom management form the cornerstone of PTS treatment. [4-8] Elastic compression stockings (20-30 mm Hg), leg elevation, weight loss, and exercise constitute the primary therapeutic approach

The examination also identifies patterns of disease that have treatment implications. Axial reflux is defined as uninterrupted retrograde flow from groin to calf and can occur in either superficial or deep systems. [4] Junctional reflux is limited to the saphenofemoral or saphenopopliteal junction, while segmental reflux occurs in a portion of a truncal vein. [4] Understanding whether reflux originates from superficial junctions versus deep venous incompetence fundamentally changes treatment planning, as superficial disease is amenable to ablation while deep disease typically requires conservative management

Endovascular interventions for PTS—including percutaneous transluminal venoplasty and stenting—are reserved for select patients with significant iliofemoral obstruction who have failed conservative management. [7] These procedures require careful patient selection and standardized criteria. The role of superficial venous ablation in PTS patients with concomitant superficial reflux remains controversial and should be approached cautiously, as the underlying deep venous pathology may limit benefit

Venography is recommended primarily in patients with post-thrombotic disease, especially when intervention is planned, as it provides greater anatomic detail than duplex ultrasonograph

Duplex ultrasound evaluation should assess blood flow direction, venous reflux, and venous obstruction, and include examination of the deep venous system, great saphenous vein (GSV), small saphenous vein (SSV) and its thigh extension (Giacomini vein), accessory saphenous veins, and perforating veins.

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Arshadbhat

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accessmedicine.mhmedical.com/content.aspx
Mar 2026
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Varicose Veins

4
1. Arshadbhat 30 Mar 2026
  
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  Venoactive drugs (diosmin, hesperidin, horse chestnut seed extract) may be considered as adjuncts to compression for symptomatic relief in countries where available
  
  Vein diameter: Thermal ablation (EVLA or RFA) is preferred for large veins >10 mm in diameter, as nonthermal techniques show lower success rates in this population. [5] Conversely, veins <2 mm may not be suitable for some thermal ablation devices. [6] Vein location and depth: Veins located <0.5 cm from the skin surface have increased risk of thermal injury with traditional thermal ablation. [5] For these superficial veins, nonthermal techniques (cyanoacrylate, mechanochemical ablation) or miniphlebectomy/limited stripping are preferred. [5] Below-knee reflux: Patients with below-knee GSV reflux benefit from ablation to the lowest point of reflux, but nonthermal techniques are preferred to avoid thermal nerve injury.
2. Arshadbhat 30 Mar 2026
  
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  Endovenous Thermal Ablation (RFA/EVLA)
  
  Relative contraindications include inappropriate vein size, with veins <2 mm and >15 mm representing potential contraindications for RFA specifically. [1] A history of superficial thrombophlebitis resulting in a partially obstructed saphenous vein may preclude thermal ablation. [1] Significant tortuosity of the GSV on duplex examination can make catheter delivery difficult.
  
  Anatomic contraindications include saphenous veins located <0.5 cm from the skin surface, which carry high risk of skin burns, hyperpigmentation, and induration despite tumescent anesthesia Special considerations apply to below-knee GSV ablation, where nonthermal techniques are preferred to avoid thermal nerve injury. [3] For large nonaneurysmal saphenous veins >10 mm, thermal ablation with EVLA or RFA should be performed rather than nonthermal techniques. [3]
3. Arshadbhat 30 Mar 2026
  
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  Endovenous ablation is the preferred treatment for symptomatic varicose veins with axial reflux, offering less postprocedure pain, reduced morbidity, and earlier return to activity
  
  Endovenous thermal ablation (radiofrequency ablation [RFA] and endovenous laser ablation [EVLA]) has largely replaced surgery as the standard of care
  
  Ultrasound-guided foam sclerotherapy (UGFS) represents a less invasive option but has higher recurrence rates
  
  Duplex ultrasound is essential for proper evaluation and treatment planning. [1] Anatomic factors such as aneurysmal dilation near the saphenofemoral junction, subcutaneous location of truncal veins, and significant tortuosity may represent relative contraindications to certain endovenous procedures.
4. Arshadbhat 30 Mar 2026
  
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  highest incidence occurs in women after pregnancy. Varicosities develop in over 20% of all adults
  
  involved, typically the great saphenous vein and its tributaries, but the short saphenous vein (posterior lower leg) may also be affected
  
  Perforating veins that connect the deep and superficial systems may become incompetent, allowing blood to reflux into the superficial veins from the deep system, increasing venous pressure and distention.
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Special considerations apply to below-knee GSV ablation, where nonthermal techniques are preferred to avoid thermal nerve injury. [3] For large nonaneurysmal saphenous veins >10 mm, thermal ablation with EVLA or RFA should be performed rather than nonthermal techniques. [3]

Perforating veins that connect the deep and superficial systems may become incompetent, allowing blood to reflux into the superficial veins from the deep system, increasing venous pressure and distention.

Duplex ultrasound is essential for proper evaluation and treatment planning. [1] Anatomic factors such as aneurysmal dilation near the saphenofemoral junction, subcutaneous location of truncal veins, and significant tortuosity may represent relative contraindications to certain endovenous procedures.

Vein diameter: Thermal ablation (EVLA or RFA) is preferred for large veins >10 mm in diameter, as nonthermal techniques show lower success rates in this population. [5] Conversely, veins <2 mm may not be suitable for some thermal ablation devices. [6] Vein location and depth: Veins located <0.5 cm from the skin surface have increased risk of thermal injury with traditional thermal ablation. [5] For these superficial veins, nonthermal techniques (cyanoacrylate, mechanochemical ablation) or miniphlebectomy/limited stripping are preferred. [5] Below-knee reflux: Patients with below-knee GSV reflux benefit from ablation to the lowest point of reflux, but nonthermal techniques are preferred to avoid thermal nerve injury.

Anatomic contraindications include saphenous veins located <0.5 cm from the skin surface, which carry high risk of skin burns, hyperpigmentation, and induration despite tumescent anesthesia

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Arshadbhat

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accessmedicine.mhmedical.com/content.aspx
May 2024
quoteinvestigator.com quoteinvestigator.com

Writing Is Easy; You Just Open a Vein and Bleed – Quote Investigator®

1
1. chrisaldrich 14 May 2024
  
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  Walter Wellesley “Red” Smith used a version of this quote by 1949. In April of that year the influential and widely syndicated newspaper columnist Walter Winchell wrote. Boldface has been added to excerpts:[1]1949 April 06, Naugatuck Daily News, Walter Winchell In New York, Page 4, Column 5, Naugatuck, Connecticut. (NewspaperArchive) Red Smith was asked if turning out a daily column wasn’t quite a chore. …”Why, no,” dead-panned Red. “You simply sit down at the typewriter, open your veins, and bleed.”
  
  via 1949 April 06, Naugatuck Daily News, Walter Winchell In New York, Page 4, Column 5, Naugatuck, Connecticut. (NewspaperArchive)
  
  https://quoteinvestigator.com/2011/09/14/writing-bleed/
  
  Walter Wellesley "Red" Smith writing bleeding typewriters quotes Walter Winchell veins
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chrisaldrich

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quoteinvestigator.com/2011/09/14/writing-bleed/