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In Chronic Venous Disease Micro is Probably Bigger than Macro!

      The microcirculation constitutes 99% of the circulation in our bodies. It is the most important part of the circulation as it is the exchange surface for nutrients, O2, and CO2, and without it there is no life. In patients with chronic venous disease (CVD), the development of signs and symptoms are also dependent on the state of microcirculation. Multiple studies have used different techniques and histological findings from biopsies to demonstrate microvascular alterations. The work on microvenous reflux in the current paper demonstrates, in a detailed manner, its importance in CVD.
      • Hall N.
      • Krysa J.
      • Lesche S.
      • Hill B.G.
      • Letts J.A.
      • McNaughton A.
      • et al.
      Near infrared fluorescence imaging to demonstrate reflux in the superficial microvenous network of the leg.
      It also confirms previous work on the importance of microvenous reflux in patients with skin damage.
      • Vincent J.R.
      • Jones G.T.
      • Hill G.B.
      • van Rij A.M.
      Failure of microvenous valves in small superficial veins is a key to the skin changes of venous insufficiency.
      Despite the limitations of using amputated limbs, multiple methods were employed to study the venous system and microvenous network fully. The methods included Xray ascending venography to demonstrate the anatomy of the venous system using continuous slow infusion of contrast allowing 40 second exposures. Near infrared fluorescence (NIRF) imaging was employed through the same cannula used for the venography by injecting indocyanine green. Then, retrograde resin casting was performed by injecting blue resin via the great saphenous vein (GSV). Sutures were placed in skin areas with superficial fluorescence and skin biopsies were taken to demonstrate whether there was resin or not. At the end, microcomputed tomography and histology of the vascular cast specimens was performed, and three dimensional volume images were reconstructed. The limbs used were from nine patients (five women) with a mean age of 66 years. One limb was CEAP C4b, another was C2, and the rest were C0. Venography showed the larger veins and NIRF reticular veins to dermal capillaries, while corrosion casting showed both. Detailed macroscopic and microscopic imaging demonstrated reflux and incompetent valves in veins < 1 mm in diameter, defined here as the microvenous network. Boundary valves were found about three generations from GSV as demonstrated by the same group in 2011.
      • Vincent J.R.
      • Jones G.T.
      • Hill G.B.
      • van Rij A.M.
      Failure of microvenous valves in small superficial veins is a key to the skin changes of venous insufficiency.
      An important new finding of the current study was the presence microvenous network reflux in older patients with C0 disease. This also provides evidence for ascending development of the disease,
      • Labropoulos N.
      • Giannoukas A.D.
      • Delis K.
      • Mansour M.A.
      • Kang S.S.
      • Nicolaides A.N.
      • et al.
      Where does venous reflux start?.
      as shown previously, but, more importantly, puts a new focus on targeting treatment.
      • Labropoulos N.
      How does chronic venous disease progress from the first symptoms to the advanced stages? A review.
      Veins < 1 mm in diameter can now be imaged with very high resolution ultrasound. We have such experience in our centre, and are able to show reflux in veins with a diameter of < 0.3 mm.
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      References

        • Hall N.
        • Krysa J.
        • Lesche S.
        • Hill B.G.
        • Letts J.A.
        • McNaughton A.
        • et al.
        Near infrared fluorescence imaging to demonstrate reflux in the superficial microvenous network of the leg.
        Eur J Vasc Endovasc Surg. 2022; 64: 377-386
        • Vincent J.R.
        • Jones G.T.
        • Hill G.B.
        • van Rij A.M.
        Failure of microvenous valves in small superficial veins is a key to the skin changes of venous insufficiency.
        J Vasc Surg. 2011; 54 (Suppl. 6):62S–9S
        • Labropoulos N.
        • Giannoukas A.D.
        • Delis K.
        • Mansour M.A.
        • Kang S.S.
        • Nicolaides A.N.
        • et al.
        Where does venous reflux start?.
        J Vasc Surg. 1997; 26: 736-742
        • Labropoulos N.
        How does chronic venous disease progress from the first symptoms to the advanced stages? A review.
        Adv Ther. 2019; 36: 13-19

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