Primary varicose veins are commonly considered a progressive disease starting from the saphenous junctions and extending to tributaries in a retrograde fashion along the saphenous trunks. This theory has been criticized by studies indicating different patterns of development and progression of varicose veins. To contribute to the understanding of the pathogenesis of the disease, the anatomy of the venous bed was comparatively evaluated by duplex sonography in patients with varicose veins with a marked difference in age.
The study included 100 varicose limbs in 82 patients aged < 30 years and 238 limbs in 183 patients aged > 60 years. Veins were designated as saphenous veins (SVs), tributaries of the SVs (STVs), and veins not connected with the SVs (NSVs). Four main anatomic patterns were comparatively evaluated: (1) varicose changes only along SVs, (2) varicose changes along SVs and STVs, (3) varicose changes only in STVs, and (4) varicose changes only in NSVs.
SVs were normal in 44% of varicose limbs. In most limbs from young subjects, varicose changes afflicted only SVTs (25%) and NSVs (36%). Varicose SVs were more frequent in the older group (62%) than in younger one (39%) owing to a higher prevalence of limbs with combined SV and STV varicosities (respectively, 59% and 37%). In the older group, varicosities in the STVs were more frequently observed in association with incompetence of the SV trunks.
The frequent occurrence of normal SVs in varicose limbs of all patients does not support the crucial role commonly credited to SVs in the pathogenesis of primary varicosities. Moreover, the SV trunks were normal in most varicose limbs from young patients. These findings suggest that varicose disease may progressively extend in an antegrade fashion, spreading from the STVs to the SVs. This hypothesis suggests that the saphenous trunks could be spared in the treatment of a relevant number of varicose legs. Prospective longitudinal studies with serial duplex evaluations of large series of extremities are necessary to confirm this hypothesis.