The anterior saphenous vein. Part 4. Clinical and technical considerations in treatment. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology

BACKGROUND

The decision to treat a refluxing anterior saphenous vein (ASV) should be a clinical decision based on the assessment on the ASV's contribution to patient's signs and symptoms. Once the decision to treat has been made, there are anatomic, clinical, and technical considerations in treatment planning.

METHODS

Clinical scenarios were discussed by a panel of experts and common anatomic, clinical, and technical considerations were identified.

RESULTS

There are unique clinical considerations such as whether both the great saphenous vein (GSV) and ASV should be concomitantly treated, if a normal ASV should be treated when treating a refluxing GSV and when and how to treat the associated tributary varicose tributaries. Being aware of the anatomic, clinical, and technical considerations allows development of a treatment plan that optimizes long-term outcomes in patients with ASV reflux.

CONCLUSION

Ultimately the treatment plan should be tailored to address these types of variables in a patient-centered discussion.

The anterior saphenous vein. Part 4. Clinical and technical considerations in treatment. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology

BACKGROUND

The decision to treat a refluxing anterior saphenous vein (ASV) should be a clinical decision based on the assessment on the ASV's contribution to patient's signs and symptoms. Once the decision to treat has been made, there are anatomic, clinical, and technical considerations in treatment planning.

METHODS

Clinical scenarios were discussed by a panel of experts and common anatomic, clinical, and technical considerations were identified.

RESULTS

There are unique clinical considerations such as whether both the great saphenous vein (GSV) and ASV should be concomitantly treated, if a normal ASV should be treated when treating a refluxing GSV and when and how to treat the associated tributary varicose tributaries. Being aware of the anatomic, clinical, and technical considerations allows development of a treatment plan that optimizes long-term outcomes in patients with ASV reflux.

CONCLUSIONS

Ultimately the treatment plan should be tailored to address these types of variables in a patient-centered discussion.

Assessment of residual stumps 12 months after saphenectomy without high ligation of the saphenofemoral junction

Background

Currently, the first-choice option recommended for varicose vein surgery is thermal ablation of the saphenous vein, but this procedure is not available on the Brazilian National Health Service (SUS - Sistema Único de Saúde). In an effort to improve results, surgical techniques have been developed to mimic the new technologies, without their high costs. The most prominent such method involves conventional saphenectomy, without ligation of tributaries.

Objectives

To assess progression of the residual stump after saphenectomy without high ligation of the saphenofemoral junction but with stump invagination and to assess the behavior of anterior/posterior accessory veins.

Methods

Prospective intervention study. A total of 52 limbs were treated with saphenectomy without high ligation of the saphenofemoral junction followed by invagination of the residual stump. Patients were assessed preoperatively and at 7 days, and 3, 6, and 12 months postoperatively using vascular ultrasonography with Doppler to analyze the length of the residual stump, the diameters of the residual stump and the anterior/posterior accessory vein, reflux in the accessory vein, and presence of neovascularization. Statistical analysis involved calculation of means, standard deviations, medians, minimum and maximum values, frequencies, and percentages, and Fisher's test and the binomial test.

Results

There was evidence of a significant time effect on residual stump diameter (p < 0.001) and length (p = 0.002), but the same was not observed with relation to diameter (p = 0.355) or reflux of the anterior accessory vein. Neovascularization was found in 7 (14.3%) limbs.

Conclusions

After use of the technique described, the residual stump retracted, its diameter reduced over the 1 year postoperative period, and it did not transfer reflux to the accessory vein. Neovascularization rates were in line with the literature.

Functional repair of the great saphenous vein by external valvuloplasty reduces the vein's diameter: 6-month results of a multicentre study

Objectives

External valvuloplasty (eVP) is a reconstructive surgical method to repair the function of the terminal and preterminal valves. We evaluated the 6-month outcomes of eVP regarding the diameter of the great saphenous vein (GSV).

Methods

Patients from five vein centres were included in this observational study. Follow-up involved detailed duplex sonography of the GSV. The venous clinical severity score (VCSS) and the C class of the clinical, aetiologic, anatomic and pathophysiologic (CEAP) classification were recorded.

Results

We enrolled 210 patients, with a follow-up rate of 58%; eVP was sufficient in 95.24% of the patients. The GSV diameters decreased significantly from 4.4 mm (standard deviation (SD): 1.39) to 3.9 (SD: 1.12), 4 cm distal to the saphenofemoral junction (SFJ); from 3.7 mm (SD: 1.10) to 3.5 mm (SD: 1.02) at the mid-thigh; from 3.6 mm (SD: 1.14) to 3.3 mm (SD: 0.94) at the knee and from 3.1 mm (SD: 0.99) to 2.9 mm (SD: 0.78) at the mid-calf. VCSS decreased significantly from 4.76 (SD: 2.13) preoperatively to 1.77 (SD: 1.57) 6 months postoperatively.

Conclusions

GSV function can be restored by eVP; diameters over the total length of the GSV decreased significantly.

Blood flow from competent tributaries is likely contributor to distally increasing reflux volume in incompetent great saphenous vein

OBJECTIVE

Venous reflux is the sole pathophysiologic process in primary chronic venous disease and its progression. We hypothesize that the reflux volume increases along a great saphenous vein (GSV) in a distal direction. We aimed to compare simultaneously measured reflux volume in the upper and lower GSV segments in a thigh.

METHODS

Patients meeting the inclusion criteria were enrolled (70 limbs of patients with primary incompetence of the GSV) and consented to this single-center study. Patients were stratified into two groups: incompetent terminal valve (TV_i) and competent terminal valve (TV_c). A cross-section area of the GSV was measured at the upper (CSA₁, cm²) and distal (CSA₂, cm²) points in a thigh. A cross-section area of each tributary that joined with the GSV between the points was measured, and their total cross-section area was calculated (CSA_trib). After a distal cuff compression-decompression maneuver, a time average mean velocity (TAMEAN, cm/sec) and reflux duration (RT, sec) were measured at both points simultaneously. Reflux volume RV, ml was calculated for each point (RV₁ and RV₂). The difference in absolute values of _ΔRV (ml) and its relative changing (_ΔRV, %) were calculated.

RESULTS

The main result was RV increases caudally from saphenofemoral junction to the knee level (RV₁ 12.7 ± 8.4 and RV₂ 20.5 ± 14.0 ml, P < .0001). There was no difference between CSA₁ and CSA₂ (0.34 ± 0.17 and 0.33 ± 0.17 cm², respectively, P = .9) but TAMEAN was a statistically significant different in two points (7.3 ± 3.9 and 11.4 ± 5.7 cm/sec, respectively, P < .0001). All of the tributaries between the points were competent.

CONCLUSIONS

Reflux volume in the great saphenous vein increases caudally from saphenofemoral junction to the knee level. Observed reflux volume was an aggregate of all GSV tributaries' flow and the flow via the SFJ if incompetent.

Cellular senescence at the saphenofemoral junction in patients with healthy, primary varicose and recurrent varicose veins - A pilot study

OBJECTIVES

Cellular senescence could play a role in the development of venous disease. Superficial venous reflux at the saphenofemoral junction is a common finding in patients with primary varicose veins. Furthermore, reflux in this essential area is associated with higher clinical stages of the disease and recurrent varicose veins. Therefore, this pilot study aimed to investigate cellular senescence in the immediate area of the saphenofemoral junction in patients with healthy veins, primary varicose veins and additionally in patients with recurrent varicose veins due to a left venous stump.

METHODS

We analyzed vein specimens of the great saphenous vein immediately at the saphenofemoral junction. Healthy veins were collected from patients who underwent arterial bypass reconstructions. Samples with superficial venous reflux derived from patients who received high ligation and stripping or redo-surgery at the groin, respectively. Sections were stained for p53, p21, and p16 as markers for cellular senescence and Ki67 as a proliferation marker.

RESULTS

A total of 30 samples were examined (10 healthy, 10 primary varicose, and 10 recurrent varicose veins). We detected 2.10% p53⁺ nuclei in the healthy vein group, 3.12% in the primary varicose vein group and 1.53% in the recurrent varicose vein group, respectively. These differences were statistically significant (p = 0.021). In the healthy vein group, we found 0.43% p16⁺ nuclei. In the primary varicose vein group, we found 0.34% p16⁺ nuclei, and in the recurrent varicose vein group, we found 0.74% p16⁺ nuclei. At the p < 0.05 level, the three groups tended to be significant without reaching statistical significance (p = 0.085). There was no difference in respect of p21 and Ki67.

CONCLUSION

We found significantly higher expression rates of p53 in primary varicose veins at the saphenofemoral junction than in healthy veins. p16 expression tended to be increased in the recurrent varicose vein group. These preliminary findings indicate that cellular senescence may have an impact in the development of varicose veins or recurrence. Further studies addressing this issue are necessary.

Anatomie der V. saphena magna und parva

In der Phlebologie ist die Varikose die häufigste Erkrankung. Dabei sind die V. saphena magna und V. saphena parva meist in die pathologische Rezirkulation involviert. Ihre Anatomie ist relativ konstant, bis auf Feinheiten im Mündungsbereich und Verlauf, die jedoch in einer Zeit, in der es verschiedene Techniken und Strategien zur Behandlung der Varikose gibt, mit ins Kalkül gezogen werden müssen. Somit kann man es erlauben, den Patienten den möglichst nebenwirkungsarmen Eingriff mit der geringsten Rezidivhäufigkeit anzubieten. Der Ultraschall ist heute der Goldstandard in der Untersuchung der Beinvenen; daher muss die Anatomie der Venen immer auch im Ultraschall verstanden werden. Der Artikel beleuchtet schematisch die Anatomie und ergänzt die Beschreibung mit typischen Schallbildern zur V. saphena magna und parva.

Classification of reflux patterns in patients with great saphenous vein insufficiency and correlation with clinical severity

PURPOSE

This study aims to establish a clinically applicable classification of reflux patterns in patients with great saphenous vein insufficiency and to evaluate the relationship between this classification, the demographics, and severity of clinical findings.

METHODS

This is a retrospective study from prospectively collected data of 503 patients who had the complaint of varicose vein. All patients had complete physical examination and their medical history was recorded. Lower limbs of all patients were examined with Doppler ultrasonography. A total of 787 limbs with great saphenous vein insufficiency were included in the analysis. The reflux patterns of great saphenous vein insufficiency were classified into 4 types as: type 1, great saphenous vein reflux without involvement of malleolar region and saphenofemoral junction (SFJ); type 2, reflux involving malleolar region with competent SFJ; type 3, reflux involving SFJ with competent malleolar region; and type 4, reflux involving both the SFJ and the malleolar region. We evaluated the association between the classification of great saphenous vein insufficiency and age, sex, body mass index (BMI), disease duration, clinical, etiological, anatomical and pathophysiological elements (CEAP) classification and venous clinical severity score (VCSS).

RESULTS

The mean age of the patients was 45.3±11.7 years, with a male-to-female ratio of 2:3. The most common reflux pattern in patients with great saphenous vein insufficiency was type 3 (48.9%), while 14.8% of patients had type 1, 10.4% had type 2, and 25.7% had type 4. Patients with type I reflux pattern were younger in age (p = 0.002), had lower BMI (p = 0.002), fewer number of children (p = 0.008), as well as milder clinical severity score (p = 0.002) compared to other reflux types. Duration of disease symptoms was not significantly correlated with the reflux patterns, but VCSS increased with the involvement of malleolar region as in type 2 compared to type 1 (2.82±1.67 vs. 2.74±2.31), and further increased with the involvement of SFJ as in type 3 (4.13±2.92 vs. 2.82±1.67). Patients with diffuse reflux pattern (type 4) had the most severe clinical presentation (4.59±2.9).

CONCLUSION

We developed a clinically applicable classification of reflux patterns in patients with great saphenous vein insufficiency based on the involvement of malleolar region and/or SFJ. We showed an association between weight, BMI, VCSS, CEAP classification and the extent of insufficiency.

Venous reflux in the great saphenous vein is driven by a suction force provided by the calf muscle pump in the compression-decompression maneuver

OBJECTIVE

The gravitational pressure gradient is considered the driving force of venous reflux. The results from our previous study demonstrated that gravitational force is not a necessary condition for the occurrence of venous reflux. We hypothesized that a force exists in addition to gravity that drives venous reflux. The present study was designed to test this hypothesis by measuring the acceleration of blood flow during venous reflux in a clinical study and by simulating reflux ex vivo in physical models.

METHODS

A total of 80 lower extremities of 80 patients with primary incompetence of the great saphenous vein were included in the present study. The cross-sectional area of the great saphenous vein, peak velocity of venous reflux (PV), and time required to achieve the PV (_Δt, seconds) were measured on duplex ultrasound scans taken with the patient in the standing rest position. Noncycling operator-dependent distal cuff inflation-deflation was used as the reflux provoking maneuver. The acceleration of venous reflux (a_reflux) was calculated as a_reflux = PV/_Δt in m/s². Physical models were used to demonstrate the difference in acceleration between the free-fall stream and the flow forced by suction.

RESULTS

The magnitude of a_reflux was greater than gravity in 24 of 80 extremities (30%), with a range of 9.83 to 24.13 m/s². The maximum observed value of a_reflux was approximately 2.5g (24.13 m/s²). The a_reflux weakly, but statistically significant inversely, correlated with the subject height (r = -0.26; P = .001). The difference in water flow acceleration was 2.5 times between the free-fall model and suction model (9.07 ± 0.2 m/s² vs 23.32 ± 2.6 m/s², respectively).

CONCLUSIONS

The acceleration of blood flow during reflux exceeded the value of gravitational acceleration, suggesting the action of an additional nongravitational force. The calf muscle pump might create such force by negative pressure during muscle diastole.

External valvuloplasty of the saphenofemoral junction in insufficient great saphenous veins - six weeks results of a prospective multicentre trial

Background: Varicosis of the great saphenous vein (GSV) is a common disease. Most of the therapeutic concepts attempt to remove or destroy the truncal vein. However, the absence of the GSV could be harmful for further treatments of artherosclerotic disease as the GSV is often used as bypass graft in lower extremity or coronary artery revascularisations. External valvuloplasty (EV) is one of the vein-sparing treatment options. The aim of this clinical study was to describe the outcome, safety and complications of this procedure in a prospective multicentre trial. Patients and methods: The function of the terminal and preterminal valve was restored by external valvuloplasty. Furthermore, multiple phlebectomies of tributaries were performed. Patients were reinvestigated six weeks after surgery. Primary endpoint was the function of the external valvuloplasty measured by diameter of the GSV and the prevalence of reflux in the GSV. The eligibility of the vein as a potential bypass graft was noticed. CEAP class and VCSS scores were analysed. Results: A total of 359 patients were included in the study. After six weeks 297 patients could be reinvestigated. The function of the external valvuloplasty was sufficient in 284 patients (95.6%). Treatment failed in 8 patients (2.6%) due to an occlusion or junctional reflux despite valvuloplasty. The GSV was estimated as suitable as a bypass graft in 261 patients (87.8%). Reflux at the saphenofemoral junction was significantly reduced after treatment and the diameter of the GSV near the saphenofemoral junction significantly decreased from 4.4 mm to 3.8 mm (p < 0.05). The VCSS was significantly reduced from 4.6 preoperatively to 2.6 postoperatively. Conclusions: External repair of the great saphenous vein can reduce venous symptoms and may preserve the great saphenous vein as a bypass graft. Nevertheless, this treatment option is only suitable for a limited number of patients.

Elevated c-fos expression is correlated with phenotypic switching of human vascular smooth muscle cells derived from lower limb venous varicosities

BACKGROUND

Lower limb venous varicosities (VVs) are clinically common; however, their molecular underpinnings are far from well elucidated. Previous studies have demonstrated that the phenotypic transition of vascular smooth muscle cells (VSMCs) plays a critical role in VV pathogenesis and that c-fos is upregulated in VSMCs from VVs. The present study investigated the histologic and cytologic changes in VVs and the correlation between c-fos upregulation and VSMC phenotypic switching.

METHODS

Thirty-four patients with VVs (VV group) and 13 patients undergoing coronary artery bypass using autologous great saphenous vein segments (normal vein [NV] group) were enrolled in the present study. The great saphenous veins of both groups were harvested for subsequent experiments. Hematoxylin and eosin staining was performed for vein morphologic analysis. Real-time quantitative polymerase chain reaction, immunohistochemistry, and Western blot assays were used to assess mRNA and protein expression of c-fos, α-smooth muscle actin (α-SMA), and osteopontin (OPN). Simple linear regression was used to evaluate the correlation between c-fos and OPN/α-SMA. Primary VSMCs were isolated from both groups and cultured in vitro. A cell counting kit-8 assay and scratch-wound assay were used to analyze the proliferation and migration abilities of the cells, respectively.

RESULTS

The mean age of the patients in the NV and VV groups was 61.4 ± 3.8 years and 59.5 ± 10.4 years, respectively. The vein cavities of the VV group were dilated, and the arrangement of the cells was disordered. The tunica media of the VV group was thicker than that of the NV group owing to the accumulation and proliferation of VSMCs. Significantly elevated mRNA levels of c-fos and OPN were observed in the VV group compared with the NV group, and a positive correlation was further demonstrated between the mRNA levels of c-fos and OPN/α-SMA (R², 0.5524; P < .001). The VSMCs derived from the VV group were more numerous (as shown by the cell counting kit-8 assay) and had a significantly greater migration speed (as shown by the scratch-wound assay) than those derived from the NV group. Moreover, the protein expression of c-fos was significantly upregulated in VSMCs derived from the VV group, and this change was accompanied by a decrease in α-SMA and an increase in OPN expression.

CONCLUSIONS

Both mRNA and protein expression of c-fos were upregulated in VV specimens, and the phenotypic biomarkers (OPN/α-SMA) were altered concurrently. VSMCs derived from VVs showed increased proliferation and migration abilities. Upregulation of c-fos might play a role in the phenotypic switching of VSMCs and subsequently participate in the pathogenesis of VVs.

CLINICAL RELEVANCE

C-fos is an immediate early gene owing to the transient and rapid change in its expression in response to stimuli. It is involved in the regulation of cell proliferation, cell growth, and cell movement. In the present study, varicose vein specimens showed increased mRNA and protein expression of c-fos, accompanied by altered phenotypic biomarkers. The upregulation of the c-fos gene in smooth muscle cells cultured from varicose vein specimens might be associated with phenotypic switching and functional disturbance. These results could contribute to the exploration of the molecular mechanisms underlying the pathogenesis of varicose veins and the development of new therapeutic strategies.

Diagnosis of recurrent reflux within the remnant non-treatment stump after bilateral cyanoacrylate ablation of the great saphenous veins

Cyanoacrylate ablation, along with mechanochemical ablation, is one of the best-known non-thermal ablation treatment methods for superficial venous reflux. Cyanoacrylate ablation is comparable to thermal ablation in terms of efficacy and safety, and offers the benefit of not requiring tumescent injections and the use of compression stockings. Here, we report about a patient who developed recurrent reflux in the residual stump after cyanoacrylate ablation. As a refluxing long residual stump can be a risk factor for late recurrence, improvements are needed to make the protocol more refined, including leaving the stump as short as possible.

CHIVA with endoluminal procedu res: Laser versus VNUS

Introduction: Since it’s description the CHIVA strategy was performed with surgical techniques. After the introduction of endoluminal heat techniques these might be applied also in the CHIVA context.

Method: 104 patients were investigated before and 3–6 months after the treatment of the great saphenous vein (GSV) with CHIVA strategy using enoluminal heat techniques to close the groin segment (VNUS Closure-Fast™ or LASER [1470 nm, Intros radial]). General data (age, sex, BMI) and phlebological data (QoL as reflected in VCSS, clinics as C[CEAP], refilling time after muscle pump measured with light reflection rheography, diameters of GSV at the groin and proximal thigh, as well as diameters of the common femoral vein) were measured and compared.

Results: Significant reduction of diameters of GSV at proximal thigh from 6.5 ± 1.6 to 3.7 ± 1.1 and VFC from 15.2 ± 2.3 to 14.8 ± 2.2 were recorded, as well as reduction of clinical scores (VCSS from 5.6 ± 3.1 to 2.2 ± 2 and C[CEAP] from 3.2 ± 1 to 2.1 ± 1.1). Refilling time improved from 20.3 ± 11 to 28.8 ± 10.2. Results are comparable to those achieved after surgical crossectomy and published in other series.

Conclusion: The disconnection of the insufficiency point at the saphenofemoral junction seems to be possible in the context of CHIVA Strategy applying endoluminal heat technique. No difference could be found between both techniques, Laser or VNUS Closure-Fast™.

The saphenofemoral junction in ultrasound

Die Untersuchung der Mündung der V. saphena magna in der Leiste in die tiefe Beinvene ist einer der Kernbestandteile der phlebologischen Duplexsonographie. Die Mündungs -varianten der Venensternseitenäste sind vielfältig, ebenso die möglichen Refluxquellen in Abhängigkeit der Kompetenz der beiden Klappen im Mündungsbereich der terminalen Klappe unmittelbar am Übergang zur tiefen Beinvene und der präterminalen Klappe distal des Venensterns. Die Duplexsonographie bietet die Möglichkeit, den Fluss in jeder dieser Venen einzeln darzustellen und ihr Zusammenspiel zu analysieren. Im vorliegenden Beitrag werden die verschiedenen Einteilungen der Mündungsinsuffizienz zusammengestellt und schematisch vorgestellt und an-hand der duplexsonographischen Bilder erläutert.

Frequency of refluxive tributaries of the junction region in the groin in patients with recurrent varicose veins of the thigh

Background A long stump and neovascularisation are commonly discussed reasons for recurrence of varicosis in the groin after “disconnection” of the saphenofemoral junction (SFJ) and stripping of the great saphenous vein (GSV). A third possible reason for recurrence with non femoral reflux emerging from tributaries of the junction region, is often underrated. The aim of the study was to report on the source of reflux for recurrent varicose veins of the thigh in patients who already had a history of disconnection of the SFJ and stripping of the GSV.

Methods In this two-centre study, consecutive patients with a history of disconnection of the SFJ, stripping of the GSV and visible or palpable varicose veins of the thigh region were included. Their data and venous diagnostics (DPPG, duplex scan) were recorded and evaluated by a standardised protocol.

Results 101 legs were included. In 58.4 % there was a long stump of the GSV as a source for variose veins of the thigh. In the other legs (42,6 %) the source for the reflux was not a long stump with contact to the femoral vein but residual tributaries of the SFJ, e.g. the superficial epigastric vein or the superficial circumflex iliac vein.

Conclusions Residual refluxive tributaries of the SFJ seem to be an important source for recurrent varicose veins of the thigh. Further prospective studies should focus on suitable therapeutic options.

Association between Clinical and Ultrasonic Characteristics of Varicocele and Lower Extremity Varicose Vein in Men

BACKGROUND

The study investigated the association between lower extremity varicose veins in men and varicocele.

METHODS

A total of 100 patients who presented to the Department of Vascular Surgery in the First Affiliated Hospital of Anhui Medical University with the diagnosis of lower extremity varicose veins were included in the study group. A total of 100 adults without vascular disease were included as controls. The prevalence of varicocele between the study group and the control group was compared. We compared the prevalence of varicocele and the mean diameter of spermatic veins between the patients with and without reflux in the saphenofemoral junctions. We analyzed the association between the maximum spermatic vein diameter and the maximum diameter of lower extremity varicose veins in patients who had both lower extremity varicose vein and varicocele in the study group. According to their clinic signs, patients with lower extremity varicose veins were divided into C1-C6 by clinic sign grade of Clinical-Etiology-Anatomy-Pathophysiology (CEAP), and we investigated the trend of the incidence of varicocele and the mean diameter of spermatic veins in different grades.

RESULTS

The patients with lower extremity varicose veins had a statistically significant (χ² = 20.05, P < 0.01) higher rate of varicocele when compared with controls. We compared the prevalence of varicocele and the mean diameter of spermatic veins between the patients with and without reflux in the saphenofemoral junctions and found no statistically significant differences between them (prevalence of varicocele P > 0.05, diameter P > 0.05). We found a linear correlation between the maximum spermatic vein diameter and the maximum diameter of lower extremity varicose veins in the patients who had both lower extremity varicose veins and varicocele in the study group (coefficient of rank correlation r = 0.4072, P < 0.01). The patients in the study group were classified into 6 grades by CEAP. After the analysis by trend chi-square, we found that the prevalence of varicocele had no statistical trend in different grades (χ² = 0.8798, P > 0.05), and the mean diameter of spermatic vein also had no statistical trend in different grades (F = 1.59, P > 0.05).

CONCLUSIONS

In conclusion, we demonstrated that the prevalence of varicocele is higher in patients with varicose veins in lower extremity than the patients without vascular diseases. The reason for the association between varicose vein in lower extremity and varicocele remains uncertain.