By Alexandra Vlass
Final year student, Bachelor of Dermal Sciences, Victoria University
As we age, it is essential to stay informed about various health conditions that can impact our well-being. One such condition is chronic venous disease, a prevalent and multifaceted vascular disorder that impacts approximately 60% of the global population. This condition tends to worsen with age and manifests itself with various signs and symptoms such as varicose veins, swelling of the legs and skin changes. Other major risk factors that may increase an individual’s risk of developing chronic venous disease is obesity, prolonged periods of sitting or standing, previous leg injury and a family history. This condition exerts a substantial impact on quality of life and patients initially seek treatment to relieve symptoms of discomfort and leg pain often described as throbbing, heaviness, tiredness, dull aching, and swelling of the legs. Patients may also experience cramping, burning, tingling, and itching sensations as well as spider and varicose vein patterns and bleeding. As venous disease progresses, the demand for treatment also increases, and quality of life further diminishes as these symptoms can interfere with day-to-day activities.
I have chosen to write this article with the aim of raising awareness about the often-overlooked issue of chronic venous disease. Due to the potential lack of recognition regarding venous disorders and their severity, patients may be at risk of receiving inadequate treatment. Additionally, there have been instances where patients have not been appropriately referred to a specialist in venous conditions, as symptoms are relatively non-specific. It is disconcerting that this condition often goes unrecognized and undertreated, potentially leaving individuals unaware of the symptoms they or their loved ones may be experiencing. By reading this article, you may gain valuable insight into the signs, causes, and implications of chronic venous disease, enabling timely intervention and support before the condition progresses to more advanced stages. Your well-being is paramount, and staying informed about chronic venous disease empowers you to take control of your vascular health as you age.
Understanding the anatomy of the venous system
To comprehend chronic venous disease, it is crucial to have a basic understanding of the anatomy of the veins. The venous system is a network of veins, and this system relies on the heart to circulate blood around the body. Arteries are responsible for carrying oxygenated blood from the heart to the rest of the body and veins are responsible for carrying deoxygenated blood back to the heart. Blood from the heart naturally flows downwards due to gravity, and blood within the venous system must overcome gravity to continue circulation throughout the body. As the calf muscle contracts, deep veins squeeze and pump blood back towards the heart.
In healthy veins, tiny valves ensure the one-way flow of blood. However, major risk factors such as age, obesity, and a sedentary lifestyle can lead to valve dysfunction and impaired venous circulation, resulting in chronic venous insufficiency (CVI). In fact, the severity of chronic venous disease progresses with advanced age.
The calf muscle pump that is partially responsible for pushing blood back to the heart is often called the ‘peripheral heart’ as it plays a crucial role for blood return to the central circulation. When the valves in the leg veins damage, it results in a less effective calf muscle pump leading to backwards flow of blood towards the feet. When this excess blood builds up, it can ‘pool’ in the veins of the legs causing venous hypertension, a condition where pressure inside the veins increases due to weak and damaged valves.
Signs and symptoms
The progression as well as the signs and symptoms of chronic venous disease is due to the vicious cycle of venous hypertension and inflammation. Prolonged hypertension results in the dilation of vein walls and certain triggers within the blood that initiates an inflammatory response. This chronic inflammation, in turn, brings out further alterations in vein walls and venous valves, exacerbating venous hypertension, blood pooling, and the development of varicose veins.
Varicose veins are bulging dilated superficial veins (veins that are close to the surface of the skin) which may progress to an enlarged and tortuous appearance. They are the most common manifestation of chronic venous disease. Individuals who have varicose veins are often asymptomatic however superficial veins can thrombose, resulting in painful thrombophlebitis which is a relatively common inflammatory process associated with a blood clot.
Additionally, inflammation induces pathological changes in the microcirculation, leading to swelling, tissue damage, and the formation of venous ulcers. Chronic swelling in the legs is called chronic venous insufficiency. Over time, chronic venous insufficiency can cause various problems to your legs including skin changes such as venous eczema, discolouration of the skin and wounds such as ulcers.
Muscle pump dysfunction as well as venous hypertension appears to play a notable role for the development of complications, including venous ulcers. The area between the top of the foot and the bottom of the calf is known as the gaiter area and it is this area that is most affected by these skin changes.
All the above inflammatory responses can lead to the advanced stage of chronic venous disease where individuals may experience the development of venous leg ulcers, with an estimated prevalence of 3 cases per 1000 Australians. The healing rates for venous ulcers are significantly low, with many patients experiencing recurring ulcerations, and lasting for a duration of approximately 8 months or longer. Therefore, it is of utmost importance to raise awareness about early recognition to improve positive outcomes for patients. In 2010, roughly 400 000 Australians were treated for venous leg ulcers, and that number has been increasing ever since.
Prevention and treatment
So, what can you do to prevent or manage chronic venous disease? Chronic venous disease can be successfully managed or prevented with the right treatment plan. Therapies can be categorized into conservative and interventional treatments. Management of chronic venous disease includes compression stockings, inelastic and elastic garments, multi-layered bandages, sclerotherapy, endovenous therapy and surgical removal.
Conservative treatments encompass a wide array of methods, such as making lifestyle modifications, utilizing pharmacological interventions, wearing compression leg garments, practicing proper wound and skin care, and considering exercise therapy, all of which should be discussed with your healthcare provider. The goals of treatment aim to alleviate discomfort and pain, improvement in skin condition and minimize the severity and extent of swelling and preventing disease progression. By achieving these goals, the overall quality of life for patients can be improved.
In general, regular exercise is highly recommended to slow down disease progression as it improves the function of the calf muscle pump. With advancing age, there is a decline in the calf muscle and venous compliance by approximately 45% as the calf muscle pump diminishes. Therefore, engaging in regular exercise, such as walking, can play a significant role in mitigating the age-related changes observed in venous compliance. An example of this is flexing the ankles 10 times while sitting or standing and to be repeated every 10 minutes or walking for 2 minutes every half-hour.
Studies have found that a body mass index greater than 30 increases the risk significantly for chronic venous insufficiency. Weight control or weight reduction is highly recommended and will assist in prevention. According to insights shared by Dr. Peter Andrianakis, an experienced medical practitioner in Melbourne, it was revealed that carrying excess weight, combined with force of gravity, causes fluid to accumulate in the legs, leading to chronic swelling. Dr. Andrianakis emphasized that, “Preventing chronic venous disease can be achieved by both weight reduction and minimizing stasis.”
Patients with chronic venous disease are often advised to elevate their legs as a means to alleviate venous stasis (slow blood flow in the legs), diminish leg swelling, alleviate symptoms and if progressed to the advanced stage, facilitate the healing of leg ulcers.Leg elevation has been demonstrated to effectively reduce leg volume and venous pressure while also improving blood flow. An example of this could involve incorporating two brief periods of leg elevation during the day, in addition to elevating the feet above the level of the heart throughout the night, with the toes positioned higher than the nose.
In the advanced stages of chronic venous insufficiency, the skin integrity may be compromised therefore it is important to use topical moisturisers/emollients to maintain skin health and prevent infection. The use of an emollient or moisturiser will assist dry skin and reduce skin breakdown. If venous eczema (known as stasis dermatitis) has developed, the management of symptoms may require the use of a topical steroid.
In cases of venous ulcers, there may be bacteria overgrowth therefore, wound care is required to avoid infection and complications. Foam dressings and hydrocolloids are used in this case to control the wound.
Compression therapy is the most common treatment due to its non-invasive nature and efficacy in managing venous hypertension which is the main pathophysiological mechanism of chronic venous disease. Compression therapy is a therapeutic leg compression of elastic stockings, including tights and elastic or non-elastic bandages. These aim to compress superficial and deep veins and improve the function of the calf muscle pump leading to improved blood circulation and a reduction in swelling. A significant number of patients struggle to endure bandaging due to itching, pain and challenges in wearing footwear, therefore medical stockings are a preferable alternative to compression bandaging. Compression stockings are available in various strengths and lengths and are tailored to meet individual treatment needs. Thigh-length stockings are known to provide the greatest efficacy in reduction of swelling, without compromising on patient comfort. Stockings between 20 and 50mmHg is usually recommended and if worn daily they need to be replaced every 6-9 months. It is crucial to consult with your doctor to determine the most suitable type of compression stocking for your specific condition. Self-diagnosing and purchasing over-the-counter stockings without proper medical guidance may pose risks, particularly for patients with other health conditions such as heart failure or if arterial disease has not been ruled out through appropriate testing.
“The best management of varicosities and varicose veins is pressure stockings, especially when standing upright, or when you are sitting down, you must elevate your legs.” – Dr Peter Andrianakis
Compression stockings improve blood circulation and reduce leg swelling.
Sclerotherapy involves the injection of dilated veins with liquid or foam chemical agents to damage and eventually shrink and turn into scar tissue. This treatment may be used in conjunction with surgical procedures or as a primary treatment. Sclerotherapy is a treatment that is indicated for a variety of symptoms including spider veins and varicose veins.
Endovenous laser therapy
Using ultrasound guidance, the vein is punctured, and a catheter or laser fiber is then carefully placed in the targeted site of venous incompetence, usually in the mid-lower leg region. An anaesthesia solution is then injected along the vein not only providing anaesthetic effects but also protecting the surrounding tissue from thermal damage. Heat is then released from the tip of the catheter or laser fiber which results in destroying the lining of the vein and a narrowing and shrinkage of the vein.
Radiofrequency ablation aims to destroy collagen within the vein wall leading to contraction and narrowing of the vein and a reduction in the diameter. Anaesthesia is used in this treatment to prevent thermal injury to the surrounding tissues.
Laser energy is utilized to thermally ablate incompetent veins. The laser device releases heat within the vein, causing thermal injury to the vein wall leading to a narrowing and disappearance of the vein and vessel.
Phlebectomy is considered an adjunctive treatment in association with stripping or endovenous ablation of the main refluxing truncal vein, where there is removal of varicose veins through small incisions performed with hooks and forceps, done under local anaesthesia.
Surgical interventions may be considered to address insufficient veins and are typically reserved for patients who reach more advanced stages, in cases where symptoms persist or worsen despite initial conservative treatment. This may involve procedures such as removing or stripping the damaged vein, surgical repair of veins or valves or a vein bypass.
There are also other treatments available such as pharmacological therapy. All treatments may have their benefits and risks. The selection of therapy ultimately depends on factors such as the patient’s clinical presentation, the preferences of the practitioner and the patient as well as contraindications.
Chronic venous disease and venous insufficiency is a common vascular condition where there may be impaired blood flow within the veins, resulting in inefficient return of blood to the heart. This is primarily caused by defective valves within the veins and as a consequence of impaired valve function, blood tends to flow backwards into the veins rather than advancing towards the heart. Consequently, blood accumulates in the veins and primarily in the legs and feet. If chronic venous disease is left untreated, it can give rise to various other health conditions including venous eczema and open sores known an ulcers which have difficulty healing.
Some of the symptoms include:
- Varicose veins
- Blood clots
- Heavy, aching, tired legs
- Skin discolouration such as brown patches
- Swelling of the legs
- Open sores or ulcers
- Cramping, burning, tingling sensations of the legs
- Itching sensations of the legs
Causes and risk factors
Some of the causes and risk factors include:
- Sitting or standing for long periods of time
- A family history of the condition
- Advancing age
- Previous leg injury
- Having varicose veins
- Having blood clots
The optimal approach to treating chronic venous insufficiency differs for each individual, as doctors must take various factors into account when determining the most suitable treatment plan. These factors encompass the underlying cause and symptoms of venous insufficiency, as well as the individuals age and overall health condition. Treatments focus on preventing disease progression and effectively addressing symptoms to minimize the risk of future complications.
Some treatments include:
- Wearing compression bandages or stockings
- Elevating the legs above the heart
- Topical moisturisers/emollients to maintain skin health
- Laser Therapy
- Radiofrequency Ablation
- Stripping or removing damaged veins
- Repairing damages valves
Risk factors associated with chronic venous insufficiency are closely tied to an individual’s lifestyle choices. By making simple lifestyle changes, people can lower their chances of developing chronic venous disease.
Some of these adjustments include:
- Regular exercise
- Maintaining a healthy body weight
- Avoid standing or sitting for long periods of time
About the author
Alexandra is a final year Dermal Science student at Victoria University and is driven by her passion for anatomy and physiology, particularly as they relate to skin and wound healing. Throughout her academic journey and research endeavours, she has enjoyed helping many patients with their skin concerns such as pigmentary and vascular conditions.
As part of her final year in the dermal science degree, Alexandra has undertaken an independent project focused on educating the community about a topic she deems crucial. In this endeavour, she aims to raise awareness and impart valuable knowledge to individuals, contributing to their understanding and well-being.
Alexandra discovered that chronic venous disease, significantly affects the quality of life for many individuals and that there is a general lack of understanding and inadequate education surrounding this condition. Towards this Alexandra has engaged in meaningful conversations with various medical professionals, including dermatologists and general practitioners, only to find a prevailing knowledge gap within the public.
Alexandra strives for an improved quality of life for all affected individuals, and with this article she intends to impart the necessary knowledge to the general community on this critical condition.
- Molnár AA, Nádasy GL, Dörnyei G, Patai BB, Delfavero J, Fülöp GA et al. The aging venous system: from varicosities to vascular cognitive impairment. GeroScience [Internet]. 2021 [cited 2023 June 5];43(6):2761-2784.doi:10.1007/s11357-021-00475-2
- Ortega MA, Fraile-Martínez O, García-Montero C, Álvarez-Mon MA, Chaowen C, Ruiz-Grande F et al. Understanding chronic venous disease: a critical overview of its pathophysiology and medical management. J Clinical Med [Internet]. 2021 [cited 2023 June 14];10(15):3239.doi:10.3390/jcm10153239
- Carman TL, Al-Omari A. Evaluation and management of chronic venous disease using the foundation of CEAP. Curr Cardiol Rep [Internet]. 2019 [cited 2023 June 15];21(10):114. doi:10.1007/s11886-019-1201-1
- Eberhardt RT, Raffetto J. Chronic venous insufficiency. Circulation [Internet]. 2014 [cited 2023 June 7];130(4):333-346.doi:10.1161/CIRCULATIONAHA.113.006898
- Seager MJ, Busuttil A, Dharmarajah B, Davies AH. Editor’s choice – a systematic review of endovenous stenting in chronic venous disease secondary to lliac vein obstruction. Eur J Vasc and Endovasc Surg [Internet]. 2016 [cited 2023 June 20]; 51(1):100-120.doi:10.1016/j.ejvs.2015.09.002
- Liu G, Xu XKR, Ziegenbein R, Clough A, Parsi Y, Oomens D et al. A critical appraisal of chronic venous insufficiency ultrasound guidelines – views of Australian sonographers. Sonography [Internet].2022 [cited 2023 June 6];9(4):166-174.Doi:10.1002/sono.12330
- Davies AH. A seriousness of chronic venous disease: a review of real-world evidence. Adv in Ther [Internet]. 2019 [cited 2023 June 6];36: 5-12.doi:10.1007/s12325-019-0881-7
- De Maeseneer MG, Kakkos SK, Aherne T, Urbanek T, Van Rij AM, Vuylsteke ME et al. Editor’s choice – European society for vascular surgery (ESVS) 2022 clinical practice guidelines on the management of chronic venous disease of the lower limbs. Eur J Vasc and Endovas Surg [Internet]. 2022 [cited 2023 June 14];63(2):184-267.doi:10.1016/j.ejvs.2021.12.024
- Youn YJ, Lee J. Chronic venous insufficiency and varicose veins of the lower extremities. Korean J of Intern Med [Internet]. 2019 [cited 2023 June 6]; 34(2): 269-283.doi: 10.3904/kjim.2018.230
- Aloi TL, Camporese G, Izzo M, Kontothanassis D, Santoliquido A. Refining diagnosis and management of chronic venous disease: outcomes of a modified Delphi consensus process. Eur J of Intern Med [Internet]. 2019 [cited 2023 June 15];65:78-85.doi:10.1016/j.ejim.2019.03.005
- McArdle M, Hernandez-Vila E. Management of chronic venous disease. Tex Heart Instit J [Internet]. 2017 [cited 2023 June 14];44(5):347-349.doi:10.14503/THIJ-17-6357
- Nicolaides A, Kakkos S, Baekgaard N, Comerota A, De Maeseneer M, Eklof B et al. Management of chronic venous disorders of the lower limbs. Guidelines according to scientific evidence. Part I. Int Angiol [Internet].2018 [cited 2023 June 20];37(3):181-254.doi:10.23736/S0392-9590.18.03999-8
- Wittens C, Davies AH, Baekgaard N, Broholm R, Cavezzi A, Chastanet S et al. Editor’s choice – management of chronic venous disease clinical practice guidelines of the European society for vascular surgery (ESVS). Eur J Vas and Endovas Surg [Internet]. 2015 [cited 2023 June 19];49(6):678-737.doi:10.1016/j.ejvs.2015.02.007
- Spiridon M, Corduneanu D. Chronic venous insufficiency: a frequently underdiagnosed and undertreated pathology. Maedica [Internet]. 2017 [cited 2023 June 20];12(1):59-61.url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574075/
- Nicolaides AN, Labropoulos N. Burden and suffering in chronic venous disease. Adv Ther [Internet]. 2019 [cited 2023 June 19];36:1-4.doi:10.1007/s12325-019-0882-6
- Weller CD, Bouguettaya A, Britt H, Harrison C. Management of people with venous leg ulcers by Australian general practitioners: an analysis of the national patient-encounter data. Wound Repair Regen [Internet]. 2020 [cited 2023 June 20];28(4):553-560.doi:10.1111/wrr.12820
- Wenceslau CF, McGarthy CG, Earley S, England SK, Filosa JA, Goulopoulou S et al. Guidelines for the measurement of vascular function and structure in isolated arteries and veins. Am J Phsiol Heart Circ Physiol [Internet]. 2021 [cited 2023 June 15];321(1):H77-H111.doi: 10.1152/ajpheart.01021.2020
- Raffetto JD, Khalil RA. Mechanisms of lower extremity vein dysfunction in chronic venous disease and implications in management of varicose veins. Vessel Plus [Internet]. 2021 [cited 2023 June 19];5:36.doi:10.20517/2574-1209.2021.16
- Bellmunt-Montoya S, Escribano JM, Bustillos PEP, Tello-Díaz C, Martinez-Zapata MJ. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database Syst Rev [Internet]. 2021 [cited 2023 June 15];9.doi:10.1002/14651858.CD009648.pub4
- Williams KJ, Ayekoloye O, Moore HM, Davies AH. The calf muscle pump revisted. J Vasc Surg Venous Lymphat Disord [Internet]. 2014 [cited 2023 June 6];2(3):329-334.doi:10.1016/j.jvsv.2013.10.053
- Orr L, Klement KA, McCrossin L, Drombolis DO, Houghton PE, Spaulding A et al. A systematic review and meta-analysis of exercise intervention for the treatment of calf muscle impairment in individuals with chronic venous insufficiency. Ostomy Wound Manage [Internet]. 2017 [cited 2023 June 7];63(8):30-43.doi:10.25270/owm.2017.08.3043
- Das A, Sil A, Kumar P, Neema S. Chronic venous disease. Part 2: diagnosis and treatment. Clin Exp Dermatol [Internet]. 2022 [cited 2023 June 20];47(7):1240-1255.doi:10.1111/ced.15152
- Labropoulos N. How does chronic venous disease progress from the first symptoms to the advanced stages? A review. Adv Ther [Internet]. 2019 [cited 2023 June 14];36:13-19.doi:10.1007/s12325-019-0885-3
- Costa D, Lelapi N, Minici R, Peluso A, Bracale UM, Andreucci M et al. Risk factors for bleeding varicose veins in patients with chronic venous disease. Medicina [Internet].2023 [cited 2023 June 15];59(6):1034.doi:10.3390/medicina59061034
- Raetz J, Wilson M, Collins K. Varicose veins: diagnosis and treatment. Am Fam Physician [Internet]. 2019 [cited 2023 June 20];99(11):682-688.url:https://www.aafp.org/pubs/afp/issues/2019/0601/p682.html
- Di Niso M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database of Syst Rev [Internet]. 2018 [cited 2023 June 20];2(2):1465-1858.doi:10.1002/14651858.CD004982.pub6
- Santler B, George T. Chronic venous insufficiency – a review of pathophysiology, diagnosis and treatment. J Dtsch Dermatol Ges [Internet]. 2017 [cited 2023 June 14];15(5):538-556.doi:10.1111/ddg.13242
- Alvarez OM, Markowitz L, Parker R, Wendelken ME. Faster healing and a lower rate of recurrence of venous ulcers treated with intermittent pneumatic compression: results of a randomized controlled trial. Eplasty [Internet]. 2020 [cited 2023 June 20]; 20:e6.url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322110/
- Jun, D. Pathophysiology and conservative treatment of venous ulcers: a review. J Wound Manag Research [Internet]. 2022 [cited 2023 June 5];18(3):161-169.doi: 10.22467/jwmr.2022.02145
- Kolluri R, Lugli M, Villalba L, Varcoe R, Maleti O, Gallardo F et al. An estimate of the economic burden of venous leg ulcers associated with deep venous disease. Vasc Med [Internet]. 2022 [cited 2023 June 5];27(1):63-72.doi:10.1177/1358863X211028298
- Nelzén O. Chapter 4- venous ulcers of the lower extremity: epidemiology and socioeconomic burden. Venous Ulcers [Internet]. 2023 [cited 2023 June 20];2:63-81.doi:10.1016/B978-0-323-90610-4.00025-2
- Nicolaides AN. The most severe stage of chronic venous disease: an update on the management of patients with venous leg ulcers. Adv Ther[Internet].2020 [cited 2023 June 14];37(1):19-24.doi:10.1007/s12325-020-01219-y
- Chan KS, Lo ZJ, Wang Z, Bishnoi P, Ng YZ, Chew S et al. A prospective study on the wound healing and quality of life outcomes of patients with venous leg ulcers in Singapore -interim analysis at 6 month follow up. Int Wound J [Internet]. 2023 [cited 2023 June 20];1-10.doi:10.1111/iwj.14132
- Kim Y, Png CYM, Sumpio BJ, DeCarlo CS, Dua A. Defining the human and health care costs of chronic venous insufficiency. Semin Vasc Surg [Internet]. 2021 [cited 2023 June 15];34(1):59-64.doi:10.1053/j.semvascsurg.2021.02.007
- Lee AJ, Robertson LA, Boghossian SM, Allan PL, Ruckley CV, Fowkes GR et al. Progression of varicose veins and chronic venous insufficiency in the general population in the Edinburgh Vein Study. J Vasc Surg[Internet]. 2015 [cited 2023 June 20];3(1):18-26.doi: 10.1016/j.jvsv.2014.09.008
- Andrianakis P. General Practitioner. Personal communication. 13th June 2023.
- Gao RD, Qian SY, Wang HH, Liu YS, Ren SY. Strategies and challenges in treatment of varicose and venous insufficiency. World J Clin Cases [Internet]. 2022 [cited 2023 June 20]:10(18):5946-5956.doi:10.12998/wjcc.v10.i18.5946
- O’Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, et al. Management of venous leg ulcers: clinical practice guidelines of the society for vascular surgery and the American venous forum. J Vasc Surg [Internet]. 2014 [cited 2023 June 19];60(2):3S-59S.doi:10.1016/j.jvs.2014.04.049
- Rabe E, Breu FX, Cavezzi A, Smith PC, Frullini A, Gillet JL et al. European guidelines for sclerotherapy in chronic venous disorders. Phlebology [Internet]. 2013 [cited 2023 June 20];29(6):338-354.doi:10.1177/0268355513483280
- Stücker M, Debus ES, Hoffman J, Jünger M, Kröger K, Mumme A et al. Consensus statement on the symptom-based treatment of chronic venous diseases. J Dtsch Dermatol Ges [Internet]. 2016 [cited 2023 June 23];14(6):575-583.doi:10.1111/ddg.13006
- Gujja K, Kayiti T, Sanina C, Wiley JM. Chronic venous insufficiency. In: Dangas GD, Di Mario C, Thiele H, Barlis P, Addo T, Claessen B, Hengstenberg C, Kipshidze N, editors. Interventional Cardiology. John Wiley & Sons;2022.p835-843.doi:10.1002/9781119697367.ch87
- Chait J, Kibrik P, Alsheekh A, Ostrozhynskyy Y, Marks N, Rajaee S et al. Radiofrequency ablation increases the incidence of endothermal heat-induced thrombosis. Ann Vasc Surg [Internet]. 2020 [cited 2023 June 24];62:263-267.doi:10.1016/j.avsg.2019.05.059