1. Clinical Case Symptomatic CVD without varicose veins
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Clinical Case
Symptomatic CVD without varicose veins

2. A 39 years old female patient, presented with symptomatic
right lower limb. She noticed the symptoms 5 years ago.
Signs and symptoms
-Tenderness
-Local pain
Worst at the end of the day and during standing
Symptoms are relieved with limb elevation
She had 3 pregnancies 2005, 2011 and 2013
Symptoms started 5 years ago after the 2nd pregnancy
She is feeling worse after her last pregnancy 3 years ago

3. Family history
Her mother has spider veins
Medical history
None
Medications
Surgical history
Minor foot surgery
Social
Alcohol occasionally

4. Physical examination Both lower limbs were warm and well perfused
Distal palpable pulses
No prominent varicosities, skin changes or ulcers
Motor and sensory were intact
Feeling of swelling but not measurable difference between the lower limbs
Athletic type, moderate activity at home and work
BMI 22

5. No varicose veins

6. Revised VCSS: 3 Pain None: 0 Mild: 1 Moderate: 2 Severe: 3
Pain or other discomfort (ie, aching, heaviness, fatigue, soreness, burning)
Occasional pain or other discomfort (ie, not restricting regular daily activity)
Daily pain or other discomfort (ie, interfering with but not preventing regular daily activities)
Daily pain or discomfort (ie, limits most regular daily activities
Use of compression therapy 1 2 3
Not used
Intermittent use of stockings
Wears stockings most days
Full compliance: stockings
Vasquez MA, et al. Revision of the venous clinical severity score: venous outcomes consensus statement: Special communication of the American Venous Forum Ad Hoc Outcomes Working Group. J Vasc Surg 2010;52:1387–1396.

7. GSV reflux in the lower thigh
The GSV was not dilated.
There were no intraluminal findings to indicate previous
Injury or thrombosis.
No tortuous segments were found.

8. GSV reflux at the knee and upper calf
Long reflux duration induced by calf compression
Labropoulos N, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003;38:793–8.

9. GSV diameters in the lower thigh, knee and upper calf

10. GSV increase wall thickness at the area of reflux
17MHz linear frequency transducer – 0.9mm axial resolution

11. C0S EP AS PR No varicose veins GSV reflux
4.6mm
4.2mm
No varicose veins
GSV reflux
SSV and deep veins were normal
No venous obstruction
4.2mm
4.1mm
6.2mm
1.2mm
3.4mm
1.7mm
3.3mm
0.9mm
GSV reflux extended from the
pre-terminal valve to upper calf.
A small 1st order and a few
2nd and 3rd order tributaries had reflux.
2.5mm
3.0mm

12. Treatment plan Follow-up
The patient has subclinical segmental disease.
She may benefit from
-Elastic compression stockings
Follow-up
She should be followed-up to determine the effects of treatment.
If the patient feels better and tolerates the treatment
she should continue the above management.
Treating such patients with endovenous techniques is
controversial and no guidelines exist for their management.