Duplex ultrasonography was used to assess patients with primary varicose veins to determine whether varicosities of the long saphenous vein (LSV) occurred without saphenofemoral junction (SFJ) incompetence. Some 167 consecutive patients with the clinical diagnosis of primary varicose veins were investigated. Of 190 limbs with LSV reflux 63 had no SFJ incompetence, of which only five had incompetent perforators; these were midthigh perforators in two limbs and medial calf perforators in three. LSV reflux often occurs in the presence of a competent SFJ. This indicates that, in such circumstances, saphenofemoral ligation alone is unlikely to control varices associated with LSV reflux. It also suggests that the development of primary varicose veins may be an ascending rather than a descending phenomenon.

Leg elevation is advised in the treatment of venous disease associated with edema. We have used laser Doppler fluxmetry to assess the effects of leg elevation on the skin microcirculation. Methods: Fifteen patients with lipodermatosclerosis caused by chronic venous insufficiency and 15 control subjects were studied. Measurements were made from the liposclerotic skin of patients and 8 cm above the medial malleolus in control subjects. Laser Doppler flux, blood cell velocity, and concentration of moving blood cells were recorded with the subject lying in the supine position and after elevating the foot 30 cm above the heart level. Results: In subjects in the horizontal position, the resting laser Doppler flux was significantly higher in patients with lipodermatosclerosis than in control subjects (median difference 63 arbitrary units; 95% confidence interval: 36, 108). This difference was due to a higher concentration of moving blood cells in the patient group (median difference 6.5 arbitrary units; 95% confidence interval: 3.4, 9). The blood cell velocity was not statistically significant between the two groups. On leg elevation, there was a substantial increase in the laser Doppler flux in the patient group; the median percentage increase in flux was 45% (p < 0.01). This was due to an increase in blood cell velocity; the median percentage increase was 41% (p < 0.01). There was no corresponding change in the concentration of moving blood cells. The results in the control group showed a similar trend but have not reached statistical significance. Conclusion:We conclude that limb elevation enhanced the microcirculatory flow velocity in liposclerotic skin of patients with chronic venous insufficiency. (J VAsc SURG 1994; 20:705-10.) Limb elevation is often used in the treatment of venous disease associated with edema, ls It is lcnown to accelerate the healing of venous ulceration. In the treatment of venous leg ulceration associated with severe local edema, some authors recommend that patients are admitted to hospital for 48 hours' bed rest with limb elevation and physiotherapy, followed by compression treatment and mobilization. 4 Other authors have suggested vertical leg elevation for

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