The suggestion that bidirectional flow is a normal feature seen in venous perforators of the lower leg has been a longstanding debate. Newer published evidence has changed the perspective on normal perforator flow and is presented here to resolve the misunderstandings and different viewpoints previously held.
LabropoulosNMansourMAKangSS, et al.New insights into perforator vein incompetence. Eur J Vasc Endovasc Surg1999; 18(3): 228–234.
2.
RecekC. Conception of the venous hemodynamics in the lower extremity. Angiology2006; 57(5): 556–563.
3.
RecekC. Competent and incompetent calf perforators in primary varicose veins: a resistant myth. Phlebology2016; 31(8): 532–540.
4.
RecekC. The hemodynamic impact of the bidirectional flow within calf perforators and conductive veins in varicose vein disease. Journal of Theoretical and Applied Vascular Research2020; 5(3): 1–6.
5.
GianesiniSMenegattiESisiniF, et al.Comparison between duplex ultrasound and multigate quality doppler profile software in the assessment of lower limb perforating vein direction. Eur J Vasc Endovasc Surg2018; 55(5): 688–693.
6.
LeeBBNicolaidesANMyersK, et al.Venous hemodynamic changes in lower limb venous disease: the UIP consensus according to scientific evidence. Int Angiol2016; 35(3): 236–352.
7.
DelisKTHusmannMKalodikiE, et al.In situ hemodynamics of perforating veins in chronic venous insufficiency. J Vasc Surg2001; 33(4): 773–782.
8.
SarinSScurrJHSmithPD. Medial calf perforators in venous disease: the significance of outward flow. J Vasc Surg1992; 16(1): 40–46.
9.
HillBGvan RijAM. The Lower Limb Perforator Veins in Normal Subjects. J Vasc Surg Venous Lymphat Disord2022; 10: 669–675.
10.
ThomasKNAkermanAPGibbonsTD, et al.The athlete's vein: venous adaptations in the lower limbs of endurance athletes. Am J Physiol Heart Circ Physiol2023; 325(1): H66–H76.
11.
ThomasKNGibbonsTDCampbellHA, et al.Pulsatile flow in venous perforators of the lower limb. Am J Physiol Regul Integr Comp Physiol2022; 323(1): R59–R67.
12.
RajuSWalkerWMayC. Measurement of ambulatory venous pressure and column interruption duration in normal volunteers. J Vasc Surg Venous Lymphat Disord2020; 8(1): 127–136.
13.
BarberRF. The varicose disease. NY State J Med1925; 25: 16–24.
14.
HadfieldJIH. The anatomy of the perforating veins in the leg. Stoke Mandeville Symposium. 1971; 4–11.
15.
PhillipsMNJonesGTvan RijAM, et al.Micro-venous valves in the superficial veins of the human lower limb. Clin Anat2004; 17(1): 55–60.
16.
van RijAMHillBGJonesGT. Clarification of the 3D anatomy of the perforating veins using resin casting. American Venous Forum 26th Annual Meeting, New Orleans, USA, 19–22 February 2014.
17.
VincentJRJonesGTHillGB, et al.Failure of microvenous valves in small superficial veins is a key to the skin changes of venous insufficiency. J Vasc Surg. 2011;54(6 Suppl):62S-69S.
18.
JeanneretCLabsKHAschwandenM, et al.Physiological reflux and venous diameter change in the proximal lower limb veins during a standardised Valsalva manoeuvre. Eur J Vasc Endovasc Surg1999; 17(5): 398–403.
19.
van BemmelenPSBeachKBedfordG, et al.The mechanism of venous valve closure. Its relationship to the velocity of reverse flow. Arch Surg1990; 125(5): 617–619.
20.
ZervidesCNarracottAJLawfordPV, et al.The role of venous valves in pressure shielding. Biomed Eng Online2008; 7: 8.
21.
LurieFKistnerRLEklofB, et al.Mechanism of venous valve closure and role of the valve in circulation: a new concept. J Vasc Surg2003; 38(5): 955–961.
22.
LiuXLiuL. Effect of valve lesion on venous valve cycle: A modified immersed finite element modeling. PLoS One2019; 14(3): e0213012.
23.
LabropoulosNTiongsonJPryorL, et al.Definition of venous reflux in lower-extremity veins. J Vasc Surg2003; 38(4): 793–798.
24.
AlimiYSBarthelemyPJuhanC. Venous pump of the calf: a study of venous and muscular pressures. J Vasc Surg1994; 20(5): 728–735.
25.
ArnoldiCC. Venous pressure in the leg of healthy human subjects at rest and during muscular exercise in the nearly erect position. Acta Chir Scand1965; 130(6): 570–583.
26.
HojensgardICSturupH. Static and dynamic pressures in superficial and deep veins of the lower extremity in man. Acta Physiol Scand1952; 27(1): 49–67.
27.
LudbrookJ. Functional aspects of the veins of the leg. Am Heart J1962; 64: 706–713.
28.
NeglenPRajuS. Differences in pressures of the popliteal, long saphenous, and dorsal foot veins. J Vasc Surg2000; 32(5): 894–901.
29.
PollackAAWoodEH. Venous pressure in the saphenous vein at the ankle in man during exercise and changes in posture. J Appl Physiol1949; 1(9): 649–662.
30.
RecekC. A critical appraisal of the role of ankle perforators for the genesis of venous ulcers in the lower leg. J Cardiovasc Surg1971; 12(1): 45–49.
31.
RecekCKoudelkaV. Circulatory effect of saphenous reflux in primary varicose veins. Phlebologie1979; 32(4): 407–414.
32.
BjordalRI. Circulation patterns in incompetent perforating veins in the calf and in the saphenous system in primary varicose veins. Acta Chir Scand1972; 138(3): 251–261.
RajuSFredericksRLishmanP, et al.Observations on the calf venous pump mechanism: determinants of postexercise pressure. J Vasc Surg1993; 17(3): 459–469.
35.
MynardJPKondiboyinaAKowalskiR, et al.Measurement, Analysis and Interpretation of Pressure/Flow Waves in Blood Vessels. Front Physiol2020; 11: 1085.
36.
AlianAAGalanteNJStachenfeldNS, et al.Impact of lower body negative pressure induced hypovolemia on peripheral venous pressure waveform parameters in healthy volunteers. Physiol Meas2014; 35(7): 1509–1520.
37.
BonassoPCDassingerMSMcLaughlinB, et al.Fast Fourier Transformation of Peripheral Venous Pressure Changes More Than Vital Signs with Hemorrhage. Mil Med2019; 184(Suppl 1): 318–321.
38.
FranceschiC. Venous insufficiency of the pelvis and lower extremities: hemodynamic rationale of pathophysiology, diagnosis and treatment. Ferrara, Italy: Claude Franceschi, 2021.