Reflux volume is determined by ejected blood volume from the calf venous reservoir Roman A. Tauraginskii, MD, a,b Fedor Lurie, MD, PhD, RPVI, RVT, FSVS, c,d Konstantin Zhdanov, MD, e Sergei Simakov, PhD, f,g Rishal Agalarov, MD, b Denis Borsuk, MD, PhD, e and Konstantin Mazayshvili, MD, PhD, b Irkutsk, Surgut, Chelyabinsk, and Moscow, Russia; Toledo, Ohio; and Ann Arbor, Mich ABSTRACT Objective: This study investigated the relationship between the ejected blood volume from the calf venous reservoir and the reflux volume (RV) during the automatic cuff inflation-deflation maneuver in limbs with incompetent great saphe- nous vein. Methods: There were 48 patients with chronic venous disease (C 1-5 , F r , A s ,P r2,3 ) included in the study. A noncycling operator-dependent distal cuff inflation-deflation was used as the reflux-provoking maneuver. Duplex ultrasound was used to measure the cross-sectional area of the common femoral vein and great saphenous vein as well as hemody- namic parameters (time-averaged mean velocity and flow duration) of the outflow during cuff inflation and reflux during cuff deflation. The cuff pressure was set at 60, 90, and 120 mm Hg sequentially. The RV flow rate (Q), RV, anterograde ejection volume (EV), and ratio RV/EV (reflux index, IR) were calculated for each pressure setting. Results: RV correlated with EV and Q reflux (r 2 ¼ 0.366 and r 2 ¼ 0.647, respectively; P < .0001). Q reflux was not significantly different between different cuff inflation pressures. RV and EV were statistically different at different cuff pressure settings (analysis of variance, P < .0001). The IR was almost identical at different pressure settings (0.43 6 0.23 at 60 mm Hg, 0.43 6 0.20 at 90 mm Hg, and 0.42 6 0.19 at 120 mm Hg). Conclusions: The amount of reflux is primarily determined by the value of EV in a distal cuff compression-decompression maneuver. Both the ratio RV/EV (IR) and RV were related to the severity of the disease, more severe forms having larger IR and RV values. (J Vasc Surg: Venous and Lym Dis 2020;-:1-7.) Keywords: Venous reflux; Ejection volume; Reflux volume; Duplex ultrasound; Calf muscle pump; Varicose veins Retrograde venous blood flow (reflux) is a dominant feature of primary chronic venous disease (CVD) and its progression. 1,2 Results of several studies have suggested that reflux volume (RV) has a stronger association with the clinical severity of CVD than other parameters (dura- tion, time-averaged velocity, peak velocity). 3-6 Part of the reason for this is that RV integrates several reflux param- eters as it is a product of reflux duration (reflux time) and reflux flow rate. The reflux flow rate is determined, among other factors, by the diameter of the vein 1,6 and the pressure gradient across the valve produced by a provoking maneuver. However, both reflux duration and the reflux flow rate depend on the volume of the venous reservoir that is filled simultaneously by refluxing flow and arterial inflow. 7 Reflux-provoking maneuvers, such as distal compression-decompression, can empty the reservoir to various degrees. We hypothesized that RV is directly proportional to the value of the ejection volume (EV) dur- ing the reflux-provoking maneuver or during physiologic work of the calf muscle pump. The aim of this study was to investigate the relationship between EV and RV in incompetent great saphenous vein (GSV) using a cuff distal compression-decompression maneuver. METHODS Study design. This prospective experimental multi- center study was approved by the local ethics commit- tees. All participants provided informed consent. Patients were evaluated by the Clinical, Etiology, Anat- omy, and Pathophysiology (CEAP) classification. 8 Those patients who had C 1 to C 6 clinical classes of CVD with primary incompetence of the GSV and varicose veins present only below knee level were included in the study. From the International Institution of Health Care and Additional Education Research Institute of Clinical Medicine, Irkutsk a ; the Phlebology Department, LLC Vein Center “Antireflux,” Surgut b ; the Education and Vascular Laboratory, Jobst Vascular Institute, Toledo c ; the Division of Vascular Surgery, University of Michigan, Ann Arbor d ; the Clinic of Phlebology and Laser Surgery, “Vasculab” Ltd, Chelyabinsk e ; and the Department of Computational Physics, Moscow Institute of Physics and Technology, f and the Institute of Personalized Medi- cine, Sechenov University, g Moscow. Author conflict of interest: none. Correspondence: Roman A. Tauraginskii, MD, Research Associate, Clinical and Scientific Department, International Institution of Health Care and Additional Education Research Institute of Clinical Medicine, Kommunarov Str 16, 664005 Irkutsk, Russia (e-mail: rtaureg@mail.ru). The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 2213-333X Copyright Ó 2020 Published by Elsevier Inc. on behalf of the Society for Vascular Surgery. https://doi.org/10.1016/j.jvsv.2020.01.005 1