The verdict is reached in the JURY study!

This well-done, multi-institutional study performed by experienced leaders in the diagnosis and treatment of venous disease, with the backing and support of the American Venous Forum, has finally shown what most of us have known for many years.1Vemuri C. Gibson K. Pappas P. et al.Effect of junctional reflux on the Venous Clinical Severity Score in patients with insufficiency of the great saphenous vein (JURY Study).J Vasc Surg Venous Lymphat Disord. 2024; 12101700Google Scholar That is, in patients with varicose veins (with or without edema) who have great saphenous incompetence, their symptoms are the same as measured by the Venous Clinical Severity Score. irrespective of the presence or absence of concomitant reflux at the saphenofemoral junction. It is a well-established fact that there are multiple patterns of reflux in the great and small saphenous veins that can produce the common symptoms of varicose veins, namely, heaviness, aching, swelling, throbbing, and itching. In fact, almost 30 years ago, Labropoulos et al2Labropoulos N. Leon M. Nicolaides A.N. Giannoukas A.D. Volteas N. Chan P. Superficial venous insufficiency: correlation of anatomic extent of reflux with clinical symptoms and signs.J Vasc Surg. 1994; 20: 953-958Google Scholar showed these symptoms (and skin changes) were predominantly associated with reflux in the below knee veins. Engelhorn et al3Engelhorn C.A. Engelhorn A.L.V. Cassou M.F. Salles-Cunha S.X. Patterns of saphenous reflux in women with primary varicose veins.J Vasc Surg. 2005; 41: 645-651Google Scholar in 2005 examined patterns of reflux in women with primary varicose veins and found that only 35% of limbs with an incompetent great saphenous vein (GSV) had reflux starting at the saphenofemoral junction (SFJ) or a SFJ tributary. As pointed out in the current paper, the study by Chastanet and Pittaluga4Chastanet S. Pittaluga P. Patterns of reflux on the great saphenous vein system.Phlebology. 2013; 28: 39-46Google Scholar of 1882 limbs, 29.4% with GSV reflux had a competent SFJ. A number of health insurance payers have the presence of junctional (SFJ, saphenopopliteal junction) reflux as a determining criterion for approval of interventions for patients with C2/C3 disease.5Welch H.J. Schul M.W. Monahan D.L. Iafrati M.D. Private payers' varicose vein policies are inaccurate, disparate, and not evidenced based, which mandates a proposal for a reasonable and responsible policy for the treatment of venous disease.J Vasc Surg Venous Lymphat Disord. 2021; 9: 820-832Google Scholar Until now, there were no definitive data contradicting the requirement of junctional reflux, but this study has erased that barrier to treatment of our patients. Several years ago, I had a patient with severe GSV reflux, but at the SFJ the value was just under 0.5 seconds, and so preauthorization was denied. On a "peer-to-peer" call with the insurer's medical director, I was told to repeat the study and if there was junctional reflux at that time, he would approve the ablation. I did, there was, and he approved it. I doubt that was a rare occurrence. It was frustrations such as those that led to this study, which, as the authors have pointed out, is significant for several reasons. First, this study was a collaboration of a mix of academic and community based venous practices from across the United States in real-world practice. Second, it shows how an academic society, such as the American Venous Forum, can help sponsor and support real-world clinical research among its members. Third, it answers a common clinical issue. Fourth, junctional reflux has been, and is, a barrier to care for symptomatic patients with C2/C3 disease. The payers asked for evidence, and now they have it. This last sentence is important, but may be irrelevant. As this paper, and others, have pointed out, health insurers do not necessarily base their policies for varicose vein treatments on evidence or guidelines, but often on proprietary reviews that only they can afford, or Up-To-Date reviews on chronic venous insufficiency.1Vemuri C. Gibson K. Pappas P. et al.Effect of junctional reflux on the Venous Clinical Severity Score in patients with insufficiency of the great saphenous vein (JURY Study).J Vasc Surg Venous Lymphat Disord. 2024; 12101700Google Scholar,5Welch H.J. Schul M.W. Monahan D.L. Iafrati M.D. Private payers' varicose vein policies are inaccurate, disparate, and not evidenced based, which mandates a proposal for a reasonable and responsible policy for the treatment of venous disease.J Vasc Surg Venous Lymphat Disord. 2021; 9: 820-832Google Scholar Barriers to care mean more money in their coffers, and suffering symptomatic patients be damned. The evidence has been presented and the JURY (Effect of Junctional Reflux on the Venous Clinical Severity Score in Patients With Insufficiency of the Great Saphenous Vein) has spoken. The presence or absence of junctional reflux has no bearing on the symptoms of patients with C2/C3 disease, and therefore should not be a criterion for intervention and reimbursement. It remains to be seen if health insurance payers decide to accept the verdict, or will try to appeal on some technicality. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery: Venous and Lymphatic Disorders or the Society for Vascular Surgery. None. Effect of junctional reflux on the venous clinical severity score in patients with insufficiency of the great saphenous vein (JURY study)Journal of Vascular Surgery: Venous and Lymphatic DisordersVol. 12Issue 2PreviewEffective treatment options are available for chronic venous insufficiency associated with superficial venous reflux. Although many patients with C2 and C3 disease based on the CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification have combined great saphenous vein (GSV) and saphenofemoral junction (SFJ) reflux, some may not have concomitant SFJ reflux. Several payors have determined that symptom severity in patients without SFJ reflux does not warrant treatment. In patients planned for venous ablation, we tested whether Venous Clinical Severity Scores (VCSS) are equivalent in those with GSV reflux alone compared with those with both GSV and SFJ reflux.