Prevalence of venous reflux in the general population on duplex scanning: The Edinburgh Vein Study

Purpose: The prevalence of reflux in the deep and superficial venous systems in the Edinburgh population and the relationship between patterns of reflux and the presence of venous disease on clinical examination were studied. Methods: A cross-sectional survey was done on men and women ranging in age from 18 to 64 years, randomly selected from 12 general practices. The presence of varicose veins and chronic venous insufficiency was noted on clinical examination, as was the duration of venous reflux by means of duplex scanning in 8 vein segments on each leg. Results were compared using cut-off points for reflux duration (RD) of 0.5 seconds or more (RD ≥ 0.5) and more than 1.0 second (RD > 1.0) to define reflux. Results: There were 1566 study participants, 867 women and 699 men. The prevalence of reflux was similar in the right and left legs. The proportion of participants with reflux was highest in the lower thigh long saphenous vein (LSV) segment (18.6% in the right leg and 17.5% in the left leg for RD ≥ 0.5), followed by the above knee popliteal segments (12.3% in the right leg and 11.0% in the left leg for RD ≥ 0.5), the below knee popliteal (11.3% in the right leg and 9.5% in the left leg for RD ≥ 0.5), upper LSV (10.0% in the right leg and 10.8% in the left leg for RD ≥ 0.5) segments, the common femoral vein segments (7.8% in the right leg and 8.0% in the left leg for RD ≥ 0.5), the lower superficial femoral vein (SFV) segments (6.6% in the right leg and 6.4% in the left leg for RD ≥ 0.5), and the upper SFV (5.2% in the right leg and 4.7% in the left leg for RD ≥ 0.5) and short saphenous vein (SSV) (4.6% in the right leg and 5.6% in the left leg for an RD ≥ 0.5) segments. In the superficial vein segments, there was little difference in the occurrence of reflux whether RD ≥ 0.5 or RD > 1.0 was used; but in the different deep vein segments, the prevalence of reflux was 2 to 4 times greater for RD ≥ 0.5 rather than RD > 1.0. Men had a higher prevalence of reflux in the deep vein segments than women, reaching statistical significance (P ≤ .01) in 4 of 5 segments for RD ≥ 0.5. In general, the prevalence of reflux increased with age. Those with “venous disease” had a significantly higher prevalence of reflux in all vein segments than those with “no disease” (P ≤ .001). Conclusion: The prevalence of venous reflux in the general population was related to the presence of “venous disease,” although it was also present in those without clinically apparent disease. There was a higher prevalence of reflux in the deep veins in men than the deep veins in women. Follow-up study of the population will determine the extent to which reflux is a predictor of future disease and complications. (J Vasc Surg 1998;28:767-76.)     

Prospective comparison of duplex scanning and descending venography in the assessment of venous insufficiency.

A prospective study comparing duplex scanning and descending venography was applied to 143 venous segments in 25 extremities with moderate to severe manifestations of chronic venous insufficiency (class 2 or 3). Duplex scanning was performed with the patient in the 15 degree reverse Trendelenburg position, and descending venography with the patient in the 60 degrees semi-erect position; the Valsalva maneuver was used to elicit reflux in both tests. The duplex parameter of reflux duration greater than 0.5 second correlated with venographic reflux in 94 of 105 segments (sensitivity of 90%). Conversely, reflux time less than or equal to 0.5 second correlated with venographic competence in 32 of 38 segments (specificity of 84%). A total of 17 discrepancies were identified among the 143 total segments studied, for an accuracy of 88%. The largest proportion of discrepancies was identified in the group with venographic competence and reflux duration greater than 0.5 second and less than or equal to 2.0 seconds; this was designated a gray zone. Mean peak velocities were significantly higher in the reflux group when compared with the competence group in the profunda femoris vein (p = 0.047), greater saphenous vein (p less than 0.001), popliteal vein (p less than 0.001), and tibial vein (p = 0.005). We conclude that venographic reflux correlates best with duplex scan findings of reflux duration greater than 0.5 second. Duration of reflux greater than 0.5 second and less than or equal to 2.0 seconds, however, represents a gray zone and should be interpreted with caution since this could lead to over-reading of reflux disease, in which case verification of incompetence by descending venography may be indicated.     

Duplex ultrasonography scanning for chronic venous disease: Patterns of venous reflux

Purpose: Patterns of flow in superficial and deep veins and outward flow in medial calf perforators were studied by duplex ultrasonography scanning in 1653 lower limbs in 1114 consecutive patients. This study compares results in 776 limbs with primary uncomplicated varicose veins with those in 166 limbs with the complications of lipodermatosclerosis or past venous ulceration.Methods: Duplex scanning determined whether superficial and deep veins were occluded or showed reflux and whether outward flow occurred in medial calf perforators with calf muscle contraction.Results: Two proximal deep veins were occluded. When limbs with primary uncomplicated varicose veins, lipodermatosclerosis, or past ulceration were compared, superficial reflux alone was seen in 55%, 39%, and 38%, deep reflux alone was seen in 2%, 7%, and 8%, and combined superficial and deep reflux was seen in 18%, 34%, and 48%, respectively. Superficial reflux affected the long saphenous system alone in 58%, 57%, and 40%, the short saphenous system alone in 18%, 18%, and 26%, and both the long and short saphenous systems in 24%, 25%, and 34%, respectively. Limbs with ulceration more frequently showed superficial reflux (p < 0.05), and all limbs with complications more frequently showed short saphenous reflux (p < 0.05) and deep reflux (p < 0.01) specifically in the posterior tibial veins (p < 0.01). Outward flow was seen in medial calf perforators in 57%, 67%, and 66%, respectively; it occurred more frequently in all limbs with complications (p < 0.05). Isolated outward flow in perforators without superficial or deep reflux was seen in 10%, 10%, and 2%, respectively.Conclusions: Most limbs with complications had superficial reflux either alone or combined with deep reflux, and few had deep reflux alone. Reflux was more frequent in posterior tibial veins for limbs with complications compared with those with uncomplicated primary varicose veins. Outward flow in perforators was common in limbs with complications and with uncomplicated primary varicose veins, but isolated outward flow in perforators was uncommon. Treatment directed to the superficial veins alone may be sufficient for most patients with complications. (J VASC SURG 1995;21:605-12.)     

Comparison of manual compression release with distal pneumatic cuff maneuver in the ultrasonic evaluation of superficial venous insufficiency.

BACKGROUND: Venous reflux can be elicited either manually or by pneumatic tourniquet, and previous studies did not indicate any significant difference between these manoeuvres in patients with superficial venous insufficiency (SVI). PURPOSE: To investigate if two methods correlate in patients with CVI. MATERIALS AND METHODS: Venous reflux was studied in 94 venous segments of 57 limbs in 52 consecutive patients with SVI. Limbs were divided into two groups: group I (CEAP C2-C3) and group II (CEAP C4-C6). A colour duplex scanner was used to determine quantitative venous reflux at the sapheno-femoral junction (SFJ), at the sapheno-popliteal junction (SPJ), and in the greater saphenous vein in the thigh (GSV). Patients received both manual compression and cuff deflation method in eliciting venous reflux. The parameters assessed were the duration of reflux (second) and the peak reflux velocity (cm/s). STATISTICS: Paired t-test was used to evaluate differences between the two methods. Statistical significance was recorded when the p-value was <0.05. Bland and Altman plot was also used to assess the agreement of the same measurement. RESULTS: There were 58 venous segments in group I and 36 in group II. In group I, there were no significant differences in the duration of reflux at the SFJ, SPJ, and in the GSV. On the contrary, peak reflux velocity was found to be significantly higher at the SFJ and in the GSV (p=0.022 and 0.006, respectively). In group II, there was no significant difference in the duration of reflux at the SFJ and SPJ between the two methods. On the contrary, manual compression maneuver produced significantly higher peak reflux velocity than at the SFJ and in the GSV (p=0.023 and 0.002, respectively). Bland and Altman plot analysis, manual compression method displayed a relatively good agreement with cuff deflation manoeuvre both in group I and group II. In contrast, concerning the peak reflux velocity, relative wide limits of agreement were found between the two methods. CONCLUSIONS: Unlike previously published reports, our results lead to apparent discrepancies in the quantitative evaluation of venous reflux using different methodology.     

Color-flow duplex scanning for the surveillance and diagnosis of acute deep venous thrombosis.

Compared with conventional duplex imaging, color-flow scanning facilitates the identification of veins (especially below the knee), decreases the need to assess Doppler flow patterns and venous compressibility, and allows veins to be surveyed longitudinally. These advantages translate into a less demanding and time-consuming examination. This study was designed to determine the accuracy of color-flow scanning for detecting acute deep venous thrombosis in patients in whom the diagnosis is clinically suspected and in asymptomatic patients at high risk for developing postoperative deep venous thrombosis. The diagnostic group included 77 limbs of 75 patients, and the surveillance group included 190 limbs of 99 patients undergoing total hip or knee replacement. All patients were prospectively examined with color-flow scanning and phlebography. In the diagnostic group, the incidence of thrombi in below-knee veins (47%) was approximately equal to that in above-knee veins (43%); but in the surveillance group, the incidence of thrombi in below-knee veins (41%) far exceeded that in veins above the-knee (3%). Nonocclusive clots and clots isolated to a single venous segment were more common in the surveillance group. In symptomatic patients, color-flow scanning was 100% sensitive and 98% specific above the knee and 94% sensitive and 75% specific below the knee. In the surveillance group, color-flow scanning was significantly (p less than 0.001) less sensitive (55%) for detecting thrombi, 93% of which were confined to the tibioperoneal veins. Negative predictive values were 100% and 88% for the diagnostic and surveillance limbs, respectively. Positive predictive values were 80% for the diagnostic limbs and 89% for the surveillance limbs. Color-flow scanning effectively excludes above-knee deep venous thrombosis in symptomatic patients and asymptomatic high-risk patients and predicts the presence of above-knee thrombi in patients in the diagnostic group with reasonable accuracy (97%). We conclude that color-flow scanning is as accurate as conventional duplex imaging and, because of its advantages, is the noninvasive method of choice for evaluating patients with suspected deep venous thrombosis. Its role in the surveillance of patients at high risk remains to be determined and awaits further clinical evaluation.     

The place of duplex scanning for varicose veins and common venous problems.

Duplex scanning has become the 'gold standard' for confirming reflux and demonstrating anatomy in cases of lower limb venous disease. However, the large numbers of patients presenting with varicose veins (or with skin changes and ulcers) mean that routine use of duplex is impractical, and this investigation has still not become well established in many hospitals. In order to determine the proportion of patients likely to require duplex scanning (and other special tests-photoplethysmography and ascending venography) we reviewed a consecutive series of 201 patients referred to the vascular clinic of a district general hospital with 283 symptomatic limbs affected by varicose veins and/or skin changes and ulcers. Patients were examined clinically and with hand-held Doppler. Duplex scanning was then requested to check for reflux in the popliteal fossa and to examine the groin and residual long saphenous vein in some cases of recurrent varicose veins. Duplex scanning was required in 51 (18%) limbs, venography in 8 (3%), and photoplethysmography in only one limb. In total, special tests were needed in 60 (21%) limbs. Subsequently, 198 (70%) limbs were referred for surgery. We would now (in 1996) duplex scan every case with popliteal fossa reflux and most recurrences. Had all these been scanned, then 79 (28%) would have had special tests. This knowledge should help in planning the implications of a duplex scanning service for varicose veins, skin changes and ulcers.     

Target selection for surgical intervention in severe chronic venous insufficiency: comparison of duplex scanning and phlebography

PURPOSE: The goal of this study was to determine whether duplex scanning (DS) alone, compared with ascending phlebography (AP) and descending phlebography (DP), would have been sufficient to guide treatment of severe chronic venous insufficiency (CVI), CEAP Clinical Classes 5 and 6. METHODS: Beginning in 1994, patients presenting to the VA Sierra Nevada Vascular Clinic with ulceration due to CVI, CEAP Clinical Classes 5 and 6, were examined with DS, AP, and DP. Phlebography mainly guided surgical interventions. The ability of DS findings to select surgical interventions, with the aims of diversion of reflux from area of trophic skin or reduction of global venous hypertension was compared with phlebography. Of the 33 male patients (age, 29-70 years; average, 55 years) considered for operative interventions between January 1994 and November 1999, 30 were selected for operative treatment. RESULTS: DS was 100% sensitive and specific for detection of complete occlusion of the superficial femoral vein (10/10) and for saphenous incompetence; sensitivity was 95% (19/20); and specificity was 100%. However, DS failed to reveal subtle changes in recanalized femoral veins because of prior thrombophlebitis, which was uncovered by AP in six of 23 patent femoral veins. There were 16 positive findings on AP of residual thrombophlebitis, of which six were not read on DS. Sensitivity was 63%, specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 53%. Reflux grading with DP agreed with DS in 23 of 33 cases or varied by one grade in five of 33 cases: sensitivity, 82%; specificity, 75%; positive predictive value, 96%; and negative predictive value, 37%. Kistner grade 4 reflux involving the superficial femoral and popliteal veins was noted by DP in five of the 33 cases when DS described reflux as "moderate." Incompetent superficial femoral vein valve stations in the upper third of the vein, which caused primary reflux, were clearly defined by DP in four of 33 cases; valve location was not well defined by DS. Below-knee perforator identification with DS was difficult; this was related to the severity of lipodermatosclerosis and the presence of ulceration. The number of perforators described at operation with subfascial endoscopic perforator surgery (n = 13) averaged 6 +/- 2, whereas AP identified an average of 4 +/- 2 in supramalleolar area. In four men, two previously undiagnosed caval and two iliac obstructions were detected with AP; one was corrected with Palma bypass grafting. Follow-up at 4 to 60 months (average, 40 months) showed four ulcer recurrences among 30 patients who were operated on. Two patients underwent repeat operations on the basis of repeated phlebographic study and are cured at this time, one patient was healed with conservative therapy, and one patient is lost to follow-up. CONCLUSIONS: DS would have been inadequate for identifying surgical targets in CVI, CEAP Clinical Classes 5 and 6. DS overlooked iliac and caval lesions. Potential valveplasty sites, which were only delineated on DP, resulted in four valveplasties in the upper third of the superficial femoral vein for grade 4 reflux. AP localized mid- to upper-leg perforators, but neither AP nor DP detected perforators in the range of 5 to 10 cm above the calcaneus. The net effect of phlebography was a choice for deep interventions in five (17%) of 30 cases, which would not have been possible with DS alone. The identification of iliocaval occlusion influenced the decision, based on prior experience, not to perform distal procedures in three cases.     

Quantitative measurements of venous reflux by duplex scanning of the incompetent long saphenous vein before and after high ligation at the saphenofemoral junction.

OBJECTIVE: To assess the effect of high ligation of the saphenofemoral junction (SFJ) on the amount of reflux in the long saphenous vein using quantitative duplex scanning. DESIGN: Prospective study. SETTING: Teaching hospital, The Netherlands. SUBJECTS: 23 patients presented with 29 limbs showing signs of isolated insufficiency of the long saphenous vein. INTERVENTION: High ligation of the SFJ. MAIN OUTCOME MEASURES: Duration of reflux (s), peak velocity (m/s), mean velocity (m/s) and mean flow (ml/s) at the SFJ, and in the mid-thigh, the distal thigh and the proximal lower leg before and four weeks after high ligation. RESULTS: All variables except duration of reflux improved significantly at all levels in the 29 limbs studied. One limb showed no improvement in flow at the level of the SFJ, 9 in the mid-thigh, 13 in the distal thigh, and 15 in the proximal lower leg (just below the knee). CONCLUSION: High ligation was effective in reducing reflux at the SFJ, but in about half the limbs the distal reflux in the long saphenous vein remained.     

Comparison of duplex scanning and contrast arteriography: a community hospital experience

In this study the results of ultrasonic scanning combined with spectral analysis (duplex scanning) are compared with contrast arteriograms. From an initial experience of more than 1000 duplex examinations 78 patients were identified who had independently interpreted carotid arteriograms within 1 month of their duplex study. Duplex and arteriogram reports were then compared on 156 individual carotid arteries. This study demonstrated that duplex scanning can identify hemodynamically significant carotid lesions with a high degree of accuracy. These lesions of greater than 50% diameter reduction were recognized with a sensitivity and specificity of 95%, compared with contrast radiography. We were also able to distinguish carotid occlusion with an accuracy of 93% (10 of 11). These results independently confirm the findings of other investigators and demonstrate the validity of duplex scanning in a community hospital as an accurate noninvasive examination in cerebral vascular disease.     

Comparison of each bundle of the spring ligament complex between the standing and supine positions: A multiposture magnetic resonance imaging study

BackgroundThe spring ligament complex (SLC) supports the medial longitudinal arch of the foot, particularly in standing. We evaluated posture-related changes in the thickness and length of the three SLC bundles and their histology.MethodsThe thickness and length of the supramedial calcaneonavicular ligament (smCNL), medioplantar oblique calcaneonavicular ligament (mpoCNL), and inferoplantar calcaneonavicular ligament (iplCNL) were measured in the supine and standing positions, using a multiposture magnetic resonance imaging system, in 72 healthy adult feet. Histological examination was performed for 10 feet from five cadavers.ResultsThe smCNL thickness decreased and its length increased from the supine to the standing position (P < 0.001); no other posture-related effects were noted. Histologically, smCNL fibers overlapped along multiple directions while mpoCNL and iplCNL, fibers were oriented horizontally along the longitudinal axis and vertically along the short axis, respectively.ConclusionThe complex, multidirectional, orientation of the smCNL allows an adaptive response to changes in loading.     

Enoxaparin treatment in high-risk trauma patients limits the utility of surveillance venous duplex scanning

OBJECTIVE: The aim of this study was to determine the independent impact of surgeon speciality training (vascular, cardiac, or general surgery) on the 30-day risk-adjusted mortality rate after elective abdominal aortic aneurysm (AAA) surgery. PATIENTS AND METHODS: All patients undergoing elective AAA surgery in Ontario between April 1, 1992, and March 31, 1996, were included. A retrospective cohort study with linked administrative databases was undertaken. RESULTS: The average 30-day mortality rate was 4.1%. Of the 5878 cases studied, 4415 (75.1%) were performed by 63 vascular surgeons, 1193 (20.3%) by 53 general surgeons, and 270 (4.6%) by 14 cardiac surgeons. After the adjustment for potential confounding factors of annual surgeon AAA volume, type of hospital, and patient age, sex, Charlson comorbidity score, and transfer status, the odds of patients dying were 62% higher when the surgery was performed by a general surgeon than when it was performed by a vascular surgeon. Cardiac surgeons' patient outcomes were similar to those of vascular surgeons. CONCLUSIONS: Patients who undergo elective AAA repair that is performed by vascular or cardiac surgeons have significantly lower mortality rates than patients who have their aneurysms repaired by general surgeons. These results provide evidence that surgical specialty training in vascular procedures leads to better patient outcomes.     

Comparison of duplex ultrasonography and venography in the diagnosis of deep venous thrombosis

Sixty-five patients with suspected deep venous thrombosis (DVT) in 68 limbs were entered consecutively into a study to compare venography with duplex ultrasonography scanning. Both tests were performed on 64 limbs, venography being contraindicated in four. Overall, duplex scanning correctly identified 86 per cent of DVTs diagnosed on venography and correctly excluded 80 per cent with negative venograms. Nearly all errors arose in the diagnosis of calf DVT. In the femoral vein duplex scanning had a specificity of 100 per cent and a sensitivity of 95 per cent. In addition, duplex scanning provided data on the limb not undergoing venography. Of 55 limbs that underwent bilateral duplex scanning, five had thrombus in the femoropopliteal segment and a negative contralateral venogram. In addition, three Baker's cysts were diagnosed. Duplex scanning can be used in patients in whom venography is contraindicated and may also provide information about the contralateral limb. We regard femoropopliteal duplex scanning as sufficiently accurate that treatment can be initiated on the basis of the scan. Duplex scanning should replace venography as the standard method of diagnosing femoropopliteal DVT; radiographic studies should now be required only when the scan result is in doubt.     

Durability of venous valve reconstruction techniques for "primary" and postthrombotic reflux

Purpose: The durability of the variety of valve reconstruction techniques in “primary” reflux and postthrombotic reflux was studied.Methods: A total of 423 valve repairs in 235 patients with a follow-up period ranging from 1 to 12 years were analyzed. End points for assessment consisted of ulcer recurrence and Doppler competence in serial duplex examination. Multivariate analysis with Cox proportional hazards model was used.Results: Ulcer-free survival curves were similar for “primary” and postthrombotic reflux. No significant difference in ulcer recurrence was seen regardless of the technique used. Different results were obtained when valve competence instead of ulcer recurrence was used for assessment of durability. Reconstructions in “primary” reflux were more durable than those in postthrombotic reflux. Durability differences were also noted among different techniques. A cohort of posterior tibial repairs proved extraordinarily durable (0 failures in 23 repairs).Conclusion: Valve reconstruction in postthrombotic reflux can yield clinical results similar to those in “primary” reflux. Although any of the several described techniques can produce similar clinical results, Doppler competence suggests the following order for choice of procedures: (1) internal valvuloplasty, (2) prosthetic sleeve in situ, (3) external valvuloplasty, and (4) axillary vein transfer. (J VASC SURG 1996;23:357-67.)     

双功彩超、腘静脉穿刺造影、光电容积描记检查下肢静脉倒流的比较

目的　了解双功彩超、经皮静脉穿刺造影、光电容积描记 (PPG)在检测下肢静脉倒流中的优缺点及相对适应证。　方法　对 40例下肢慢性静脉疾病的患者 ,术前应用双功彩超、经皮静脉穿刺造影和PPG的方法进行检测 ,并对检测的结果进行比较分析。　结果　双功彩超与经皮静脉穿刺造影探测股 静脉段静脉倒流性疾病的结果差异无显著性意义 (P >0 0 5 ) ;与双功彩超相比 ,PPG探测下肢静脉倒流性疾病的精确度为 6 7%。　结论　PPG可作为下肢慢性静脉疾病的初步筛选检查 ;双功彩超可为大部分患者的治疗提供较充分的信息 ;对于前 2种方法不能确诊的病例仍需用经皮静脉穿刺造影。     

双功彩超、静脉穿刺造影、光电容积描记检查下肢静脉倒流的比较

目的 了解双功彩超、经皮Ｇｅ静脉穿刺造影、光电容积描记（ＰＰＧ）在检测下肢静脉倒流中的优缺点及相对适应证。方法 对４０例下肢慢性静脉疾病的患者,术前应用双功彩超、经皮Ｇｅ静脉穿刺造和ＰＰＧ的方法进行检测,并对检测的结果进行比较分析。结果 双功彩超与经皮Ｇｅ静脉穿刺造影探测股－Ｇｅ静脉段静脉倒流性疾病的结果差异无显著性意义。与双功能超相比性 ＰＰＧ探测下肢静脉倒流性疾病的精度度６７％。结论 ＰＰＧ可     

Physiological reflux and venous diameter change in the proximal lower limb veins during a standardised Valsalva manoeuvre.

OBJECTIVES: the aim of this study was to provide normal values for venous diameter at rest, and venous diameter and physiologic venous reflux during a standardised Valsalva manoeuvre. The impact of the patient's sex, body mass index (BMI), and family history was investigated. MATERIAL AND METHODS: eighty legs of 40 healthy volunteers were investigated in a supine position. The median age was 28 years (range 20-66 years). The common femoral vein (CFV), the proximal superficial femoral vein (SFV) and the proximal long saphenous vein (LSV) were investigated by duplex sonography. The following parameters were assessed: resting diameter (VDrest) and maximum diameter (VDmax) as well as reflux time (tr) during the Valsalva manoeuvre. The Valsalva manoeuvre was elicited by a forceful expiration into a tube system. The standard values used were a pressure of 30 mmHg, established within 0.5 seconds (s) and maintained over a time period of at least 3 s. RESULTS: mean VDrest and VDmax were 8.3+/-2.2 and 11.1+/-2.8 mm in the CFV, 5.9+/-1. 3 and 7.2+/-1.6 mm in the SFV and 3.5+/-0.9 and 4.3+/-1.4 mm in the LSV. Mean values for tr were 0.61+/-0.63 s in the CFV, 0.25+/-0.26 s in the SFV and 0.28+/-0.40 s in the LSV. A BMI >22.5 kg/m2 was associated with statistically significant larger values for VDrest and tr. If adjusted for BMI, tr in the SFV and the LSV did not differ by sex. For healthy subjects with first-degree relatives suffering from varicose veins (n=19), mean VDrest in the SFV as well as VD in the LSV was significantly larger (p=0.02, 0.05, respectively). Coefficients of variation for repeated measurements (VDrest, VDmax, tr) in the same segment varied between 3.3% and 16. 4% for the three investigated sites. CONCLUSIONS: normal values for VDrest and VDmax as well as reflux time during a standardised Valsalva manouevre were assessed in the proximal lower limb veins. The influences of BMI, sex and family history were investigated. The described standardised Valsalva manoeuvre led to highly reproducible results and can be recommended for further research projects or as a routine procedure for the assessment of venous reflux.