Eccentric Venous Ectasias of the Intra- and Epifascial System – Does Insufficiency Always Begin This Way?

Introduction, Objectives, and/or Purpose: The "typical" symmetrical bulge of a venous valve sinus is not present at birth and develops slowly during the first decade of life under the influence of upright posture and gravitational forces. Today, eccentric dilated shapes of valvular areas observed in up to 82% of vein patients but usually described as nonspecific morphology ("ectasia" or even "aneurysm") of a sinus.

Methods: In a retrospective analysis of HD ultrasound video scans (16 - 23 MHz) of consecutive cases (n = 758, 258 with follow-up > 3 yrs.), incidence, size and adjacent vein wall changes were registered. Using A.I. software (A.I.M., VeinBrain), all findings were correlated with patient age. Interferences with damage of other origin (pressure-induced or stasis-related) were filtered out.

Results: Unilateral commissural leakage without eccentric valve ectasia was found predominantly in younger children ( < 12 yrs; 78.1%), slowly increasing with body growth and age (12-16 yrs.), developing mild ectasia (92.1%) and eventually (16-30 yrs.) expanding to a large unilateral bulge of the vein wall adjacent to the valve gap with increased reflux (96.5%). In adolescents and young adults up to 40 years of age, larger eccentric ectasias with a maximum diameter of more than 25 mm were found in 18.3% of cases, whereas patients older than 50 years had such ectasias in 28.8% of cases. Veins with multiple primary leaks had significantly faster progression (conversion from C0 to C2-C3).

Conclusion(s): The frequent finding of "eccentric valvular ectasia" of leg veins originates from an initial unilateral commissural gap. Of different pathomechanisms leading to insufficiency, this one represents the most frequent pattern. As the basic morphology occurs in the youngest subjects, this entity is most likely congenital, resulting from minor embryonic variations in valve shape and wall attachment. Progression and clinical severity increase as a function of the size and number of the initial leaks, distance to the nearest functioning valve, and exposure time (age).