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Öğe Absence of posterior mitral leaflet with secundum atrial septal defect(Elsevier Science Inc, 2010) Heper, Gülümser; Yetkin, Ertan; Şenen, KubilayA rare case of a 54-year-old woman with absence of congenital posterior mitral leaflet, moderate mitral insufficiency, and large secundum-type atrial septal defect is reported. Two-dimensional color Doppler and transesophageal echocardiography revealed complete absence of the posterior mitral leaflet, a thick muscular formation replacing the posterior leaflet, a 3.3-cm secundum type atrial septal defect, and severe pulmonary hypertension. This report describes the rare case of congenital absence of posterior mitral leaflet associated with secundum type large atrial septal defect in a middle-age woman. (Ann Thorac Surg 2010;90:2055-7) (C) 2010 by The Society of Thoracic SurgeonsÖğe Asthma-like attacks terminated by slow pathway ablation(Wolters Kluwer Medknow Publications, 2017) Ozturk, Selcuk; Turhan, Hasan; Yetkin, ErtanAsthma is a chronic airway disease in which the pathological mechanisms are reversible airway obstruction, bronchial hyper reactivity, and constriction of the lower airways. Supraventricular tachycardia (SVT) is a common arrhythmia which originates above the bundle of His and causing heart rates exceeding 150 beats/min. SVT patients present with palpitation, chest pain, chest discomfort, dyspnea, hyperventilation, and lightheadedness, occasionally. Besides, extraordinary presentations of SVT are available in literature. In this report, we describe a case of a patient presenting with treatment-resistant asthma-like attacks lasting for 20 years whom was suspected SVT as an underlying etiology and treated by slow pathway radiofrequency ablation.Öğe Bone mineral density: A potential determinant of atherosclerotic plaque morphology in established coronary artery disease?(Elsevier Ireland Ltd, 2011) Sivri, Nasir; Yalta, Tülin; Yalta, Kenan; Yetkin, Ertan; Aksoy, YükselThe potential association between low bone mineral density (BMD) and coronary artery disease (CAD) has drawn particular attention in the recent years, but has yet remained to be thoroughly established. In their recently published article, Beer S. et al. investigated the association between low BMD and angiographically determined CAD in male patients [1]. The authors concluded that neither osteoporosis nor osteopenia is independently associated with the presence of CAD [1]. Likewise, in a previous study comprising postmenopausal women, neither CAD nor cardiovascular risk factors were found to be associated with low BMD [2]. However, as described below, low BMD may be closely associated with ectopic calcification in various tissues including heart valves, coronary arteries and atherosclerotic plaques etc. Extensive calcification of plaques associated with low BMD may particularly elicit propensity to a more stable plaque morphology possibly along with a reduced incidence of acute coronary syndromes (ACSs) in patients with established CAD and osteal pathologies.Öğe Cardiac findings in Behcet's patients(Wiley, 2010) Heper, Gülümser; Polat, Mualla; Yetkin, Ertan; Şenen, KubilayBehcet's disease is a chronic multi-system inflammatory disorder and the severity and clinical manifestations of Behcet's patients may show geographic variation. We aimed to detect the cardiac findings in 30 Behcet's patients and compare them with the normal population (n = 29). We used color-doppler echocardiography and transesophageal echocardiography in combination. We calculated manually QT intervals and QT dispersion (QTd) from twelve-lead ECG recordings. There was no E/A inversion and coronary ischemia in all patients or control group. The E velocity difference between groups was not significant. The mean A velocity was significantly lower in Behcet's patients than normal group. The mean DT was 154.4 +/- 5.8 msec in Behcet's patients and 122.59 +/- 0.96 msec in control group (P < 0.0001). The mean IVRT was 75.66 +/- 1.36 msec in Behcet's patients and 69.1 +/- 0.55 msec in control group (P < 0.0001). There was no QTc time difference between the Behcet's patients and the control group. The mean QT dispersion (QTd) interval was 45.46 +/- 2.65 msec in Behcet's patients and 31.83 +/- 1.23 msec in control group (P < 0.0001). Atrial septal aneurysm, mitral valve prolapse and insufficiency, tricuspid valve insufficieny, and pulmonary hypertension frequencies in Behcet's patients were significantly higher than in the control group. We concluded that Behcet's cardiac involvement may effect cardiac structure and cause diastolic dysfunction, electrical instability and structural abnormalities. We also concluded that cardiac involvement in Behcet's disease may be specific for this geographic area.Öğe Cathepsin enzymes and cystatin C : Do they play a role in positive arterial remodeling?(Lippincott Williams & Wilkins, 2009) Yetkin, Ertan; Waltenberger, JohannesWe have read the impressive article recently published by Aoki et al1 evaluating the cathepsin enzyme system in cerebral aneurysm formation. By using quantitative RT-PCR and im munohistochemistry, the authors have demonstrated increased expression of cathepsin B, cathepsin K, and cathepsin S in arterial wall of the cerebral aneurysms, whereas the expres sion of cystatin C was found to be decreased. These findings suggest an imbalance between cysteine cathepsins and their inhibitor. This imbalance may cause the excessive breakdown of extracellular matrix in the arterial wall resulting in pro gressing arterial aneurysm formation. This conclusion was supported by the experimental use of the cathepsin inhibitor NC-2300.Öğe Chronotropic incompetence: An obscure cause of heart failure symptoms in survivors of critical diseases?(Elsevier Ireland Ltd, 2011) Yalta, Kenan; Yalta, Tülin; Sivri, Nasir; Aksoy, Yüksel; Yetkin, ErtanIn their recently published article, Ruiz-Bailén M et al. prospectively investigated the course of myocardial dysfunction that had developed in a group of critically ill patients, and comment on different aspects of reversible myocardial dysfunction in a critically ill patient (RMDCIP) [1]. They concluded from their study findings that myocardial segmental contractile dysfunction in response to stress may persist in some patients surviving RMDCIP indicating that myocardial dysfunction may not be totally reversible in these patients [1]. We agree with the authors on the concept of residual myocardial dysfunction in the survivors of RMDCIP. Residual myocardial contractile dysfunction may be totally asymptomatic or may elicit a variety of heart failure symptoms and signs in these patients. However, as described later, chronotropic incompetence associated with a related critical disease may also occur during the disease course, and may indefinitely persist to some degree potentially contributing to heart failure symptoms and signs in a portion of survivors of critical diseases.Öğe Copeptin (C-terminal provasopressin): A promising marker of arrhythmogenesis in arrhythmia prone subjects?(Elsevier Ireland Ltd, 2011) Yalta, Kenan; Sivri, Nasir; Yalta, Tülin; Geyik, Bilal; Aksoy, Yüksel; Yetkin, ErtanNeurohormones have drawn particular attention in the recent years possibly due to their potential diagnostic and prognostic values in a variety of clinical conditions including congestive heart failure (CHF), acute myocardial infarction (AMI), etc. Among neurohormones, arginine vasopressin (AVP) has been known to be secreted by hypothalamus in response to hypovolemia and increased plasma osmolality [1], and was also demonstrated to be a marker of the presence and severity of CHF [2]. However as described below, the potential association between AVP system and arrhythmogenesis may also confer some important therapeutic and prognostic implications in arrhthmia-prone patients. In the recent years, due to the instability and rapid clerance [1], the clinical utility of AVP has been gradually abandoned to some degree, and copeptin (CP), another novel neurohormone of the AVP system, has come into use in the clinical practice.Öğe Diabetes mellitus and female gender are the strongest predictors of poor collateral vessel development in patients with severe coronary artery stenosis(Springer, 2015) Yetkin, Ertan; Topal, Ergün; Ergüzel, Nuri; Senen, Kubilay; Heper, Gülümser; Waltenberger, JohannesBackground Coronary collateral vessel development (CVD), i.e., arteriogenesis, is regarded as one of the most important mechanisms-along with angiogenesis-to result in protection of the myocardium. Coronary CVD is associated with a reduction in infarct size, future cardiovascular events and improved survival in patients with occlusive coronary artery disease by enhancing regional perfusion in the chronically ischemic myocardium. In the present study, we aimed to investigate the relation of cardiovascular risk factors and hematological parameters with collateral development in patients with severely stenotic (>= 95 %) and totally occluded coronary artery disease including at least one major coronary artery. Materials and methods The study population was selected from the patients who underwent coronary angiography between January 2008 and March 2009. Five hundred and two patients who had at least one coronary artery stenosis >= 95 % (368 men; mean age 59 +/- 10 years) comprised the study population. Of the 502 patients, 228 had total occlusion in at least one major epicardial coronary artery. Collateral artery grading was performed by using Cohen-Rentrop method to the vessel with coronary artery stenosis of >= 95 % and patients with chronic total occlusions (CTO). Patients with grade 0-1 collateral development were regarded as the poor collateral group, and patients with grade 2-3 collateral development were regarded as the good collateral group. Results Two hundred and fifty-eight (51 %) of 502 patients had poor collateral development, and 244 (49 %) had good collateral development. Logistic regression analysis revealed that DM was independently associated with poor CVD in patients with >= 95 % stenosis (p < 0.001). Additionally, female gender and DM were found to be independently associated with poor CVD in patients with CTO (p = 0.005 and p < 0.001, respectively). Monocyte count was found to be independent of CVD neither in patients with >= 95 % stenosis nor in patients with CTO. Conclusion Our data show that DM is an independent factor for poor coronary CVD both in patients with severe coronary artery stenosis and in patients with CTO. Female gender or being in post-menopausal period is another negative risk factor for poor CVD in addition to DM in patients with CTO.Öğe Dissolution of massive intracoronary thrombus by medical therapy: case report(2012) Heper, Gülümser; Yetkin, ErtanA previously healthy 76-year-old man came to the emergency service because of abrupt chest pain for last 30 min. ST segment elevations in anterior leads and chest pain were resolved with aspirin and clopidogrel orally and metoprolol, unfractioned heparin, nitroglycerin, and tirofiban intravenously. The first coronary angiogram revealed massive proximal Left Anterior Descending thrombus formation. We did not perform stenting or ballooning in order to evade the catastrophic results of abrupt vessel closure, distal embolization and no-reflow phenomenon during Percutaneous Coronary Intervention procedures at the lesions containing thrombus. Control coronary angiography that was performed 24-hours later revealed resolution of thrombus almost completely. In conclusion, if ST-segment elevation and pain resolve with starting the GP Ilb/IIIa inhibitors in unstable patients with massive intracoronary thrombus; waiting the results of this therapy may be logical both to evade the catastrophic results of reperfusion strategies and high therapy costs of all mechanical.Öğe Golden ratio and the heart: a review of divine aesthetics(Elsevier Ireland Ltd, 2016) Yalta, Kenan; Öztürk, Selçuk; Yetkin, ErtanIn human history, certain mathematical figures or concepts had gained a significant reputation largely due to their occult and esoteric meanings. Among these, Golden Ratio and associated concepts, namely golden proportions, had elicited a tremendous breakthrough in our human awareness and perception regarding mundane and spiritual aspects of physical existence. Golden Ratio or Number (with a numerical value of 1.618) that is also referred to as the Greek letter Phi (phi), has been universally expressed on a line partitioned into two unequal lengths (L, the longer and S, the shorter) in such a manner that L / S = (L + S) / L. Besides, appearing in certain number sequences (Fibonacci Series, etc.), golden proportions, to the consternation of observers, appear to be strikingly prevalent across all levels of physical existence from the innermost structures to the colossal galaxies of the universe potentially labeling these concepts as the measures of divine aesthetics. Accordingly, the human body also serves as an epitome of these mysterious concepts as exemplified by its outward appearance including general stature and extremities along with a variety of inner organ systems. Based on preliminary studies, the human cardiovascular system might also be suggested to serve as a major predilection site of divine aesthetics as measured with Golden Ratio and its allies. This appears to be completely in line with the ancient knowledge associating the human heart with the esoteric and spiritual components of human nature including human soul. Within this context, the present paper primarily aims to discuss human manifestations of divine aesthetics as measured with 'Golden Ratio' and associated indices with a particular and detailed emphasis on their potential link with the human cardiovascular system.Öğe Golden ratio: a subtle regulator in our body and cardiovascular system?(Elsevier Ireland Ltd, 2016) Öztürk, Selçuk; Yalta, Kenan; Yetkin, ErtanGolden ratio, which is an irrational number and also named as the Greek letter Phi (phi), is defined as the ratio between two lines of unequal length, where the ratio of the lengths of the shorter to the longer is the same as the ratio between the lengths of the longer and the sum of the lengths. The so-called formula is a mathematical ratio and there exist a variety of examples in natural andman-made structures of great beauty. Moreover, golden ratio is expressed throughout the human body in some ways, including digits, uterus, teeth, and cardiovascular system. Although the association of Fibonacci series or golden ratio with systems and organs of human being has not been assessed in depth yet, the mainstream regulation of cardiovascular system seems to be associated with golden ratio. This raises the idea that there might have been a fine and subtle regulator in our body. In this article, we aimed to elaborate the relationship between the existence of golden ratio and the human body and to discuss the golden ratio and its association with cardiovascular system. (C) 2016 Elsevier Ireland Ltd. All rights reserved.Öğe Identifying symptoms in chronic venous diseases(Elsevier Science Bv, 2016) Öztürk, Selçuk; Yetkin, ErtanDear Editors, We have read the article published by Hansrani et al. [1] with great interest. In their well defined case control study, they have evaluated the venous symptoms in patients with pelvic vein incompetence (PVI) and varicose veins (VV). They have recruited 40 premenopausal women with PVI and VV, 40 premenopausal women only with VV and 40 healthy controls without PVI and VV. They have found that, PVI patients suffer more pelvic pain than the VV patients and healthy controls. They have also found that quality of life in PVI patients are lower than healthy controls and these patients need more national health system resources. According to these results, there are several take home messages. Peripheral varicose veins and pelvic peins are linked by a volume or pressure load or direct connections. In the light of this association, we can state that venous reflux or dilatation in these vascular systems might be originated from a generalized vascular wall disease [2]. It is very important to identify the symptoms in this patient group because of the decreased quality of life and increased hospital admissions in these patients as the authors mentioned in their study [1]. These patients should be assessed with a more detailed history of their complaints. The prevalence of chronic venous diseases is high in elderly population and these patients have comorbid diseases. Also assessment of venous symptoms is difficult in this population [3]. Due to the selection of younger patients and the absence of comorbid diseases like pregnancy, renal failure, heart failure, liver failure, venous thromboembolism, malignancy, hysterectomy allowed the authors to evaluate the venous symptoms more detailed. This condition makes their study more valuable. However, we need further studies to explain the symptomatology and pathophysiology of chronic venous diseases.Öğe Koroner arter ektazisi olan ve olmayan hastalarda plazma von willebrand faktör (VWF) ve plazminojen aktivatör inhibitör-1 (PAI-1) düzeylerinin karşılatırılması(2011) Yolcu, Mustafa; Yetkin, Ertan; Heper, GülümserKoroner arter ektazisi (KAE) spesifik semptomu olmayan, rutin koroner anjiyografi sırasında saptanan, koroner arterlerin lokalize yada diffüz genişlemesi olarak tanımlanır. Çalışmamızın amacı KAE olan ve olmayan hastalarda endotel fonksiyonu, koagülasyon sistemi ve fibrinolitik aktivite göstergeleri olarak PAI-1 ve vWF kan düzeylerini değerlendirmekti. Çalışmamıza 157 KAE'li hasta, 52 normal koroner artere sahip birey ve 50 KAH'lı hasta alındı ve istatistiksel analiz yapıldı. Tüm grupların plazma vWF ve PAI-1 seviyeleri ölçüldü. Çalışmamızda vWF düzeyleri izole KAE'de 1,51±0,95 lli/ml, KAE+KAH'de 1,43±0,89 lU/ml, KAH'da 1,22±1,02 lU/ml ve NKA'da 1,06±0,73 lU/ml olarak tespit edildi. PAI-1 düzeyleri ise gruplar arasında izole KAE'de 10,93±6,53 ng/ml, KAE+KAH'de 9,68±5,60 ng/ml, KAH'da 15,63±8,93 ng/ml ve NKA'da 15,40±6,68 ng/ml olarak tespit edildi. CAE'li hastalarda KAH'dan bağımsız olarak PAI-1 düşük, vWF ise yüksek olarak tespit edildi. Çalışmamızda ektazili hastalarda KAH olsun ya da olmasın vWF düzeyinin arttığını, PAI-1 düzeyinin ise azaldığını gösterdik. Endotel dis-fonksiyonu için iyi bir gösterge olan vWF'nin bu hastalarda artışı ED ve beraberinde koagülasyon sisteminin aktif olduğunu göstermektedir. PAI-1 azalması ise fibrinolitik sistem ve beraberinde MMP'nin aktif olduğunu, aktif plazminin M MP aktivasyonuna yol açıp ESM yıkımı ile ektazi gelişiminde önemli rol oynadığını düşündürmektedir.Öğe Mean platelet volume: Controversies in coronary artery disease and acute coronary syndrome(Elsevier Ireland Ltd, 2010) Yetkin, Ertan; Heper, Gülümser; Şenen, KubilayDear Editor, We have read the article published by De Luca et al. [1] with great interest. In their report, they have investigated the possible association of mean platelet volume (MPV) with coronary artery disease (CAD) in a very large consecutive cohort of patients undergoing coronary angiography. Briefly, they have used the number of diseased vessels as a measure of extent of CAD and carotid intima-media thickness to assess the relation between atherosclerosis and MPV. It has been concluded out that MPV is not related to the extent of CAD, carotid intima-media thickness and cannot be considered as a risk factor for CAD. Additionally no relationship has been observed between MPV and platelet aggregation in a subgroup of patients.Öğe Molecular and cellular mechanisms of aortic stenosis(Spandidos Publ Ltd, 2009) Yetkin, ErtanCalcific aortic stenosis is the most common cause of aortic valve replacement in developed countries, and this condition increases in prevalence with advancing age. The fibrotic thickening and calcification are common eventual endpoint in both non-rheumatic calcific and rheumatic aortic stenoses. New observations in human aortic valves support the hypothesis that degenerative valvular aortic stenosis is the result of active bone formation in the aortic valve, which may be mediated through a process of osteoblast-like differentiation in these tissues. Additionally histopathologic evidence suggests that early lesions in aortic valves are not just a disease process secondary to aging, but an active cellular process that follows the classical “response to injury hypothesis” similar to the situation in atherosclerosis. Although there are similarities with the risk factor and as well as with the process of atherogenesis, not all the patients with coronary artery disease or atherosclerosis have calcific aortic stenosis. This review mainly focuses on the potential vascular and molecular mechanisms involved in the pathogenesis of aortic valve stenosis. Namely extracellular matrix remodeling, angiogenesis, inflammation, and eventually osteoblast-like differentiation resulting in bone formation have been shown to play a role in the pathogenesis of calcific aortic stenosis. Several mediators related to underlying mechanisms, including growth factors especially transforming growth factor-β1 and vascular endothelial growth factors, angiogenesis, cathepsin enzymes, adhesion molecules, bone regulatory proteins and matrix metalloproteinases have been demonstrated, however the target to be attacked is not defined yet.Öğe Plasma viscosity and mean platelet volume in patients undergoing coronary angiography(Ios Press, 2010) Şenen, Kubilay; Topal, Ergün; Kılınç, Evren; ten Cate, Hugo; Tek, İbrahim; Yetkin, ErtanBackground: Markers of platelet activation and haemorrheological indices have been demonstrated to play a role in the pathophysiology of atherosclerosis and cardiovascular events. In this study, we aimed at investigate the association between plasma viscosity and platelet indices in patients undergoing coronary angiography. Materials and methods: Three hundred and eighty four consecutive patients scheduled to undergo coronary angiography were included in the study. Prior to coronary angiography, blood samples were withdrawn to determine routine biochemical markers, blood cell analyses and viscosity measurements. According to the results of coronary angiography, patients were classified either in a subgroup with coronary artery disease (CAD; 1 or more stenoses > 50%) or normal coronary arteries (NCA; no stenoses or < 50%). Results: There was a statistically significant correlation between plasma viscosity and mean platelet volume levels in all patients undergoing coronary angiography (r = 0.199, p < 0.001). Additionally, when correlation analysis was performed within each group, plasma viscosity significantly correlated with MPV both in patients with CAD (r = 0.18, p = 0.004) and in patients with NCAs (r = 0.272, p = 0.002). Linear regression analysis revealed that plasma viscosity was positively associated with MPV while platelet number was inversely but significantly associated with MPV. Conclusion: We have shown for the first time that MPV correlates with plasma viscosity in patients undergoing coronary angiography, suggesting a relation with plasma proteins and activation of circulating platelets or peripheral consumption of platelets. To evaluate this relation further controlled studies also in patients with acute coronary syndromes are warranted.Öğe Plasminogen activator inhibitor-1 levels in patients with primary varicose vein(Edizioni Minerva Medica, 2012) Ergüzel, Nuri; Yetkin, Ertan; Erdem, Gülnur; Erdil, Nevzat; Yetkin, Gülay İmadoğlu; Heper, Gülümser; Şenen, KubilayAim. Plasmin is involved in extracellular matrix remodeling by activating some matrix metallo-proteinases and degrading extracellular matrix; therefore component of fibrinolytic system such as tissue plasminogen activator and plasminogen activators inhibitors (PAI-1) might have a role in the pathogenesis of vascular remodeling. In our study we aimed to investigate the levels of PAI-1 levels in patients with primary varicose veins (VV) and in their age and gender matched control group. Methods. Forty-one consecutive patients with peripheral varicose veins and 37 healthy age and gender-matched control subjects were included in the study from the outpatient cardiology and cardiovascular surgery clinic. Study population consisted of 41 consecutive patients who met the inclusion criteria and diagnosed as having class II primary VV according to CEAP classification. Routine biochemical and hematological analysis were performed in all patients and control subjects. Results. Plasma levels of PAI-1 were found to be lower in patients than those in control subjects (5.19 +/- 2.2 ng/mL vs. 6.47 +/- 2.6 ng/mL, P=0.025). Logistic regression analysis revealed that only the plasma levels of PAI-1 were found to be independently but inversely associated with the presence of primary VVs (Odds ratio: 0.80 CI: 0.64-0.99, P=0.04). Conclusion. We have shown that PAI-1 levels are significantly decreased in patients with pVVs and it has an independent association with the presence of pVVs. However, its exact relation and role via matrix metlalloproteinases on the pathogenesis of the disease remains to be elucidated in further studies. [Int Angiol 2012;31:176-80]Öğe Thromboembolic complications in patients with newly diagnosed dilated cardiomyopathy immediately after initiation of congestive heart failure treatment: Just a coincidence or should we pay more attention?(Sage Publications Inc, 2010) Yetkin, Ertan; Topal, Ergün; Yanık, Ahmet; Özten, MahmutRecently, we have experienced cerebrovascular embolic events in 2 consecutive patients in our outpatient clinic. Accordingly, we want to share our comments with literature on these 2 patients. Both patients had newly diagnosed left ventricular (LV) dysfunction, sinus rhythm, and cerebrovascular event within the first week after initiation of heart failure treatment. Although, our cases are not enough to make a general statement or conclusion, we can recommend that patients with newly diagnosed severe LV dysfunction with normal sinus rhythm and without echocardiographically visible thrombus should also be closely followed up for thromboembolic complications at least during the first weeks of congestive heart failure treatment.Öğe Valvular calcification and atherosclerosis(Japan Atherosclerosis Soc, 2009) Yetkin, Ertan; Senen, Kubilay; Heper, Gülümser[No Abstract Available]Öğe Varicose vein or non-varicose vein: that is the question(W B Saunders Co Ltd, 2016) Öztürk, Serkan Utku; Yetkin, ErtanWe read the article published by Dzieciuchowicz et al.1 with great interest. In their study, they assessed the possible association between the presence of a non-thrombotic iliac vein lesion (NIVL) and primary varicose veins (PVV), and the frequency of NIVLs in asymptomatic and PVV limbs. Intra-vascular ultrasonographic evaluation of venous structures including the femoral, external iliac, common iliac vein, and inferior vena cava showed that NIVLs were not more common in limbs with PVV than in limbs without PVV. They also confirmed both the existence and left-sided predomi-nance of anatomical compression of the common iliac vein by the right common iliac artery. Regarding the pathophysiology, significant associations of varicose veins with other dilating vascular diseases, such as varicocele and coronary artery ectasia, have been reported.2,3 These reports raise concerns that PVVs are a local manifes- tation of a systemic vascular abnormality. Therefore, assuming the non-PVV limb to be normal might lead to misinterpretation of the Dzieciuchowicz et al. report. Adding Duplex ultrasonographic results of both limbs would make things clearer for discussion of the pathophysiological aspect of disease. Likewise the authors reported comparable luminal areas of external iliac veins in PVV limb and non-PVV limb.1 We believe that the non-PVV limb might have clinically si-lent venous insufficiency at an earlier stage than the PVV limb. Symptoms of peripheral venous insufficiency are another debate in the clinical evaluation of patients. Although it is not within the scope of the study under discussion here, it would be useful to know which lower limb symptoms were taken into consideration when determining the non-PVV limb as asymptomatic. The presence and severity of varicose veins may not show a particular association with lower limb symptoms and even with duplex ultrasound scanning.4 In conclusion, assessment of “normal vein” and “varicose vein” in the same individual could make it more difficult to improve our understanding of venous disease or varicose veins.
