Forced expiration against an airway obstruction was originally described as a method for inflating the Eustachian tubes and is accredited to Antonio Maria Valsalva (1666-1723). The Valsalva maneuver is commonly applied for different diagnostic purposes. Its use for phlebologic diagnosis is the object this review. Venous reflux is the most frequent pathophysiologic mechanism in chronic venous disease. Reflux is easily visualized by duplex ultrasound when properly elicited, in standing position. A simple way to elicit reflux is the so-called "compression-release maneuver": by emptying the muscle reservoir, it determines a centrifugal gradient, dependent on hydrostatic pressure, creating an aspiration system from the superficial to the deep system. The same results are obtained with dynamics tests activating calf muscles. The Valsalva maneuver elicits reflux by a different mechanism, increasing the downstream pressure and, thus, highlighting any connection between the source of reflux and the refluxing vessel. The Valsalva maneuver is typically used to investigate the saphenofemoral junction. When the maneuver is performed correctly, it is very useful to analyse several conditions and different hemodynamic behaviours of the valvular system at the saphenofemoral junction. Negative Valsalva maneuver always indicates valvular competence at the saphenofemoral junction. Reverse flow lasting during the whole strain (positive Valsalva maneuver) indicates incompetence or absence of proximal valves. Coupling Valsalva maneuver to compression-release maneuver, with the sample volume in different saphenofemoral junction sections, may reveal different hemodynamic situations at the saphenofemoral junction, which can be analysed in detail.

Differences in the factors correlating with cIMT >0.8 mm and FMD <10% might have implications for cardiovascular risk reduction. A lower antioxidant to caloric intake ratio might be a risk factor for impaired FMD.

A 52-year-old woman was admitted to the surgery unit because of abdominal pain. She had a history of smoking (10 cigarettes/day), high blood pressure, and hypothyroidism. Her current drug regimen included L-thyroxine 100 lg/day, ramipril 10 mg/day, and atenolol 50 mg/day. Routine blood examination revealed the presence of anemia (Hb 8.3 g/dl, serum iron 10 lg/dl, ferritin 5.46 ng/ml), high ESR (49 mm) with normal PCR values (0.36 mg/dl) and coagulation tests, and negative occult fecal blood. Chest X-ray study revealed the presence of dilated aortic arch, and gastroscopic examination showed a hiatus hernia. Electrocardiogram and transthoracic echocardiography were normal, while transesophageal echocardiography disclosed a thrombotic formation (Fig. 1a, b) in the first tract of the descending aorta, which appeared as a ''thrombotic snake'' fluctuating in the lumen in the longitudinal projection (Fig. 1c-e). A CT scan confirmed the diagnosis of aortic thrombosis with an extension of about 7 cm. Lower limb echo-color Doppler revealed occlusion of the popliteal artery and collateral revascularization of the tibial arteries. Abdominal pain was interpreted as ischemic in origin due to celiac-mesenteric hypoperfusion or embolus, but completely resolved within few days from admission. The patient underwent an extensive screening for pro-thrombotic states that did not reveal any significant abnormality (plasma omocistein 7.55 nmol/l, normal range 3.36-20.44; lupus anticoagulant negative; factor V mutation G1691A absent; factor II mutation G20210A absent; antithrombin III 111.5%, normal range 70-120%; protein C 112.5%, normal range 70-120%; protein S 105.7%, normal range 60-120%; activated protein C resistance 2.69%, normal values [2.00; anti-cardiolipin IgM 5.4, normal range 0.0-12.5; anti-cardiolipin IgG 9.9, normal range 0.0-15.0).

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