The 100 most-cited articles on chronic venous disease: a bibliometric analysis.

Introduction

Chronic venous disease (CVD) is a common condition in Western countries, typically affecting 164 people for every 1000 individuals.[1] Among the various clinical manifestations of CVD, varicose veins are the most common,[2] and can cause symptoms such as pain, swelling, throbbing, cramping, and itching. In more severe cases, CVD can cause superficial thrombophlebitis, bleeding, and lipodermatosclerosis, as well as ulceration, which can affect patients’ quality of life.[3] In Asian populations, the prevalence of CVD is reportedly lower than that in non-Hispanic white populations.[4] However, the lower rates of superficial venous surgery among Asians residing in the UK have been reported as resulting from cultural and religious differences rather than from inherent differences.

CVD research is a well-established field of study, which has diversified with the recent introduction of various treatment modalities. Bibliometric analysis allows research trends to be analyzed by evaluating authors, journals, countries, and trends of publication.[6] The aim of the present study was to understand the characteristics and trends in CVD research using bibliometric analysis. Given the large number of publications on CVD in the literature, we performed bibliometric analysis on the 100 most-cited articles, with citation ranking considered to reflect the level of influence.[7]

Methods

The Institutional Review Board of Hallym Medical University approved the review of medical articles using a publicly available database (approval no. HKS 2019-05-025). A search of the Thomson Reuters Web of Science citation indexing database and research platform was completed on January 17, 2019. The terms used in the search were “varicose vein”, “saphenous vein”, “chronic venous disease”, and “chronic venous insufficiency”. Inclusion criteria were CVD limited to lower extremities, superficial CVD, and multiple clinical manifestations of CVD including varicose vein, venous ulcer, and lipodermatosclerosis in the CEAP classification.[8] Synonyms included varicose, varix, varices, and varicosities. Exclusion criteria included deep vein disease and venous disease in locations other than the lower extremities. The resulting dataset was filtered to include only full-text manuscripts in English. These manuscripts were subsequently sorted by number of citations, a method initially developed by Paladugu and colleagues.[9] Analysis of individual articles was performed by two independent reviewers (HJ and JWH) to verify the relationship to CVD. The 100 most-cited manuscripts were identified, and the resulting dataset was further evaluated for title, first and senior author, institution, topic, year of publication, and country of origin. The individual and 5-year impact factors of the journals in which the papers were published were recorded. To prevent potential bias for older manuscripts having had more time to be cited, the citation rate was determined by dividing the citation number by the number of years since publication.

Results

The Web of Science database search returned 7639 full-length English language articles. Table 1 lists the 100 most cited of these articles. The number of citations ranged from 403 for Evans et al.[10] (“Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh vein study”) to 86 for Gillet et al.[11] (“Side-effects and complications of foam sclerotherapy of the great and small saphenous veins: a controlled multicenter prospective study including 1025 patients”). The mean number of citations for all articles was 150.4 ± 73.1. The citation rate was highest for the review article “The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the society for vascular surgery and the American venous forum” by Gloviczki et al.[12]

Table 1.

The 100 most-cited articles on chronic venous disease.

Rank	Article	Citations	Citation rate
1	Evans CJ, Fowkes FGR, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health 1999; 53(3): 149–153.	403	20.2
2	Callam MJ. Epidemiology of varicose veins. Br J Surg 1994; 81(2): 167–173.	402	16.1
3	Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53: 2S–48S.	387	48.4
4	Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux: long-term results. J Vasc Interv Radiol 2003; 14(8): 991–996.	378	23.6
5	Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol 2005; 15(3): 175–184.	330	23.6
6	Nicolaides AN. Investigation of chronic venous insufficiency – a consensus statement. Circulation 2000; 102(20): E126–E63.	282	14.8
7	Brand FN, Dannenberg AL, Abbott RD, Kannel WB. The epidemiology of varicose veins – The Framingham study. Am J Prev Med 1988; 4(2): 96–101.	270	8.7
8	Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg 2001; 27(1): 58–60.	266	14.8
9	Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg 2011; 98(8): 1079–1087.	257	32.1
10	Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial. J Vasc Surg 1999; 29(4): 589–592.	256	12.8
11	Navarro L, Min RJ, Bone C. Endovenous laser: A new minimally invasive method of treatment for varicose veins – preliminary observations using an 810 nm diode laser. Dermatol Surg 2001; 27(2): 117–122.	255	14.2
12	Jones L, Braithwaite BD, Selwyn D, Cooke S, Earnshaw JJ. Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein. Eur J Vasc Endovasc Surg 1996; 12(4): 442–445.	254	11
13	Valencia IC, Falabella H, Kirsner RS, Eaglstein WH. Chronic venous insufficiency and venous leg ulceration. J Am Acad Dermatol 2001; 44(3): 401–421.	251	13.9
14	Proebstle TM, Lehr HA, Kargl A, et al. Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles. J Vasc Surg 2002; 35(4): 729–736.	245	14.4
15	Ruckley CV. Socioeconomic impact of chronic venous insufficiency and leg ulcers. Angiology 1997; 48(1): 67–69.	230	10.5
16	Min RJ, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser treatment of the incompetent greater saphenous vein. J Vasc Interv Radiol 2001; 12(10): 1167–1171.	226	12.6
17	Meissner MH, Manzo RA, Bergelin RO, Markel A, Strandness DE, Jr. Deep venous insufficiency: the relationship between lysis and subsequent reflux. J Vasc Surg 1993; 18(4): 596–605; discussion 6–8.	212	8.2
18	Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation 2005; 111(18): 2398–2409.	209	14.9
19	Rautio T, Ohinmaa A, Perala J, et al. Endovenous obliteration versus conventional stripping operation in the treatment of primary varicose veins: a randomized controlled trial with comparison of the costs. J Vasc Surg 2002; 35(5): 958–965.	197	11.6
20	Merchant RF, Pichot O. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg 2005; 42(3): 502–509; discussion 9.	186	13.3
21	Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FGR. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ 1999; 318(7180): 353–356.	184	9.2
22	Darwood RJ, Theivacumar N, Dellagrammaticas D, Mavor AID, Gough MJ. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg 2008; 95(3): 294–301.	178	16.2
23	Hamel-Desnos C, Desnos P, Wollmann JC, Ouvry P, Mako S, Allaert FA. Evaluation of the efficacy of polidocanol in the form of foam compared with liquid form in sclerotherapy of the greater saphenous vein: initial results. Dermatol Surg 2003; 29(12): 1170–1175.	178	11.1
24	Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser C. Systematic review of foam sclerotherapy for varicose veins. Br J Surg 2007; 94(8): 925–936.	177	14.8
25	Gloviczki P, Bergan JJ, Rhodes JM, et al. Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned from the North American Subfascial Endoscopic Perforator Surgery registry. J Vasc Surg 1999; 29(3): 489–499.	170	8.5
26	Rasmussen LH, Bjoern L, Lawaetz M, Blemings A, Lawaetz B, Eklof B. Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: short-term results. J Vasc Surg 2007; 46(2): 308–315.	167	13.9
27	Labropoulos N, Leon M, Nicolaides AN, Giannoukas AD, Volteas N, Chan P. Superficial venous insufficiency: correlation of anatomic extent of reflux with clinical symptoms and signs. J Vasc Surg 1994; 20(6): 953–958.	165	6.6
28	Fischer R, Linde N, Duff C, Jeanneret C, Chandler JG, Seeber P. Late recurrent saphenofemoral junction reflux after ligation and stripping of the greater saphenous vein. J Vasc Surg 2001; 34(2): 236–240.	164	9.1
29	Smith JJ, Garratt AM, Guest M, Greenhalgh RM, Davies AH. Evaluating and improving health-related quality of life in patients with varicose veins. J Vasc Surg 1999; 30(4): 710–719.	163	8.2
30	Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. J Vasc Surg 2005; 42(3): 488–493.	163	11.6
31	Scott TE, Lamorte WW, Gorin DR, Menzoian JO. Risk factors for chronic venous insufficiency – a dual case-control study. J Vasc Surg 1995; 22(5): 622–628.	162	6.8
32	Raju S, Fredericks R. Valve reconstruction procedures for nonobstructive venous insufficiency: rationale, techniques, and results in 107 procedures with two- to eight-year follow-up. J Vasc Surg 1988; 7(2): 301–310.	153	4.9
33	Rose SS, Ahmed A. Some thoughts on the etiology of varicose veins. J Cardiovasc Surg 1986; 27(5): 534–543.	151	4.6
34	Labropoulos N, Delis K, Nicolaides AN, Leon M, Ramaswami G, Volteas N. The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency. J Vasc Surg 1996; 23(3): 504–510.	148	6.4
35	Forlee MV, Grouden M, Moore DJ, Shanik G. Stroke after varicose vein foam injection sclerotherapy. J Vasc Surg 2006; 43(1): 162–164.	144	11.1
36	Frullini A, Cavezzi A. Sclerosing foam in the treatment of varicose veins and telangiectases: history and analysis of safety and complications. Dermatol Surg 2002; 28(1): 11–5.	144	8.5
37	van Rij AM, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography. J Vasc Surg 2003; 38(5): 935–943.	138	8.6
38	Weiss RA, Weiss MA. Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up. Dermatol Surg 2002; 28(1): 38–42.	135	7.9
39	Proebstle TM, Vago B, Alm J, Gockeritz O, Lebard C, Pichot O. Treatment of the incompetent great saphenous vein by endovenous radiofrequency powered segmental thermal ablation: first clinical experience. J Vasc Surg 2008; 47(1): 151–156.	133	12.1
40	Mundy L, Merlin TL, Fitridge RA, Hiller JE. Systematic review of endovenous laser treatment for varicose veins. Br J Surg 2005; 92(10): 1189–1194.	133	9.5
41	Proebstle TM, Krummenauer F, Gul D, Knop J. Nonocclusion and early reopening of the great saphenous vein after endovenous laser treatment is fluence dependent. Dermatol Surg 2004; 30(2 Pt 1): 174–178.	131	8.7
42	Diehm C, Trampisch HJ, Lange S, Schmidt C. Comparison of leg compression stocking and oral horse-chestnut seed extract therapy in patients with chronic venous insufficiency. Lancet 1996; 347(8997): 292–294.	130	5.7
43	Mozes G, Kalra M, Carmo M, Swenson L, Gloviczki P. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques. J Vasc Surg 2005; 41(1): 130–135.	127	9.1
44	Sarin S, Scurr JH, Smith PDC. Assessment of stripping the long saphenous vein in the treatment of primary varicose veins. Br J Surg 1992; 79(9): 889–893.	126	4.7
45	Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: late results of a randomized controlled trial of stripping the long saphenous vein. J Vasc Surg 2004; 40(4): 634–639.	125	8.3
46	Ruckley CV, Evans CJ, Allan PL, Lee AJ, Fowkes FGR. Chronic venous insufficiency: clinical and duplex correlations. The Edinburgh Vein Study of venous disorders in the general population. J Vasc Surg 2002; 36(3): 520–525.	124	7.3
47	Raju S. Venous insufficiency of the lower limb and stasis ulceration. Changing concepts and management. Ann Surg 1983; 197(6): 688–697.	123	3.4
48	van Rij AM, Jones GT, Hill GB, Jiang P. Neovascularization and recurrent varicose veins: more histologic and ultrasound evidence. J Vasc Surg 2004; 40(2): 296–302.	122	8.1
49	Fowkes FGR, Evans CJ, Lee AJ. Prevalence and risk factors of chronic venous insufficiency. Angiology 2001; 52: S5–S15.	121	6.7
50	Manfrini S, Gasbarro V, Danielsson G, et al. Endovenous management of saphenous vein reflux. Endovenous Reflux Management Study Group. J Vasc Surg 2000; 32(2): 330–342.	121	6.4
51	Hingorani AP, Ascher E, Markevich N, et al. Deep venous thrombosis after radiofrequency ablation of greater saphenous vein: a word of caution. J Vasc Surg 2004; 40(3): 500–504.	121	8.1
52	Nyamekye I, Shephard NA, Davies B, Heather BP, Earnshaw JJ. Clinicopathological evidence that neovascularisation is a cause of recurrent varicose veins. Eur J Vasc Endovasc Surg 1998; 15(5): 412–415.	121	5.8
53	Padberg FT, Johnston MV, Sisto SA. Structured exercise improves calf muscle pump function in chronic venous insufficiency: a randomized trial. J Vasc Surg 2004; 39(1): 79–87.	117	7.8
54	Lim CS, Davies AH. Pathogenesis of primary varicose veins. Br J Surg 2009; 96(11): 1231–1242.	117	11.7
55	Timperman PE, Sichlau M, Ryu RK. Greater energy delivery improves treatment success of endovenous laser treatment of incompetent saphenous veins. J Vasc Interv Radiol 2004; 15(10): 1061–1063.	117	7.8
56	Raffetto JD, Khalil RA. Mechanisms of varicose vein formation: valve dysfunction and wall dilation. Phlebology 2008; 23(2): 85–98.	116	10.5
57	Erickson CA, Lanza DJ, Karp DL, et al. Healing of venous ulcers in an ambulatory care program – the roles of chronic venous insufficiency and patient compliance. J Vasc Surg 1995; 22(5): 629–636.	116	4.8
58	Maffei FHA, Magaldi C, Pinho SZ, et al. Varicose veins and chronic venous insufficiency in Brazil – prevalence among 1755 inhabitants of a country town. Int J Epidemiol 1986; 15(2): 210–217.	114	3.5
59	Cavezzi A, Frullini A, Ricci S, Tessari L. Treatment of varicose veins by foam sclerotherapy: two clinical series. Phlebology 2002; 17(1): 13–18.	113	6.6
60	Yamaki T, Nozaki M, Iwasaka S. Comparative study of duplex-guided foam sclerotherapy and duplex-guided liquid sclerotherapy for the treatment of superficial venous insufficiency. Dermatol Surg 2004; 30(5): 718–722; discussion 22.	113	7.5
61	Proebstle TM, Moehler T, Gul D, Herdemann S. Endovenous treatment of the great saphenous vein using a 1,320 nm Nd:YAG laser causes fewer side effects than using a 940 nm diode laser. Dermatol Surg 2005; 31(12): 1678–1683; discussion 83–84.	111	7.9
62	Pichot O, Kabnick LS, Creton D, Merchant RF, Schuller-Petroviae S, Chandler JG. Duplex ultrasound scan findings two years after great saphenous vein radiofrequency endovenous obliteration. J Vasc Surg 2004; 39(1): 189–195.	111	7.4
63	Jantet G, Grp RS. Chronic venous insufficiency: Worldwide results of the RELIEF study. Angiology 2002; 53(3): 245–256.	111	6.5
64	Neglen P, Raju S. A comparison between descending phlebography and duplex doppler investigation in the evaluation of reflex in chronic venous insufficiency – a challenge to phlebography as the gold standard. J Vasc Surg 1992; 16(5): 687–693.	111	4.1
65	Darke SG. The morphology of recurrent varicose veins. Eur J Vasc Surg 1992; 6(5): 512–517.	110	4.1
66	Proebstle TM, Gul D, Lehr HA, Kargl A, Knop J. Infrequent early recanalization of greater saphenous vein after endovenous laser treatment. J Vasc Surg 2003; 38(3): 511–516.	109	6.8
67	Wright D, Gobin JP, Bradbury AW, et al. Varisolve (R) polidocanol microfoam compared with surgery or sclerotherapy in the management of varicose veins in the presence of trunk vein incompetence: European randomized controlled trial. Phlebology 2006; 21(4): 180–190.	108	8.3
68	Cabrera J, Cabrera J, Garcia-Olmedo MA. Treatment of varicose long saphenous veins with sclerosant in microfoam form: long-term outcomes. Phlebology 2000; 15(1): 19–23.	108	5.7
69	Kabnick LS. Outcome of different endovenous laser wavelengths for great saphenous vein ablation. J Vasc Surg 2006; 43(1): 88–93.	108	8.3
70	Myers KA, Jolley D, Clough A, Kirwan J. Outcome of ultrasound-guided sclerotherapy for varicose veins: medium-term results assessed by ultrasound surveillance. Eur J Vasc Endovasc Surg 2007; 33(1): 116–121.	106	8.8
71	Gandhi RH, Irizarry E, Nackman GB, Halpern VJ, Mulcare RJ, Tilson MD. Analysis of the connective-tissue matrix and proteolytic activity of primary varicose veins. J Vasc Surg 1993; 18(5): 814–820.	106	4.1
72	Sarin S, Scurr JH, Smith PDC. Stripping of the long saphenous vein in the treatment of primary varicose veins. Br J Surg 1994; 81(10): 1455–1458.	105	4.2
73	Badier-Commander C, Verbeuren T, Lebard C, Michel JB, Jacob MP. Increased TIMP/MMP ratio in varicose veins: a possible explanation for extracellular matrix accumulation. J Pathol 2000; 192(1): 105–112.	105	5.5
74	Proebstle TM, Moehler T, Herdemann S. Reduced recanalization rates of the great saphenous vein after endovenous laser treatment with increased energy dosing: definition of a threshold for the endovenous fluence equivalent. J Vasc Surg 2006; 44(4): 834–839.	104	8
75	Goldman MP, Mauricio M, Rao J. Intravascular 1320-nm laser closure of the great saphenous vein: a 6- to 12-month follow-up study. Dermatol Surg 2004; 30(11): 1380–1385.	104	6.9
76	Marston WA, Carlin RE, Passman MA, Farber MA, Keagy BA. Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency. J Vasc Surg 1999; 30(3): 491–498.	104	5.2
77	Rutgers PH, Kitslaar PJ. Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein. Am J Surg 1994; 168(4): 311–315.	103	4.1
78	Travers JP, Brookes CE, Evans J, et al. Assessment of wall structure and composition of varicose veins with reference to collagen, elastin and smooth muscle content. Eur J Vasc Endovasc Surg 1996; 11(2): 230–237.	103	4.5
79	Critchley G, Handa A, Maw A, Harvey A, Harvey MR, Corbett CRR. Complications of varicose vein surgery. Ann R Coll Surg Engl 1997; 79(2): 105–110.	102	4.6
80	Rabe E, Otto J, Schliephake D, Pannier F. Efficacy and safety of great saphenous vein sclerotherapy using standardised polidocanol foam (ESAF): a randomised controlled multicentre clinical trial. Eur J Vasc Endovasc Surg 2008; 35(2): 238–245.	101	9.2
81	Stonebridge PA, Chalmers N, Beggs I, Bradbury AW, Ruckley CV. Recurrent varicose veins – a varicographic analysis leading to a new practical classification. Br J Surg 1995; 82(1): 60–62.	100	4.2
82	Proebstle TM, Gul D, Kargl A, Knop J. Endovenous laser treatment of the lesser saphenous vein with a 940-nm diode laser: early results. Dermatol Surg 2003; 29(4): 357–361.	99	6.2
83	Raju S, Owen S, Neglen P. The clinical impact of iliac venous stents in the management of chronic venous insufficiency. J Vasc Surg 2002; 35(1): 8–14.	98	5.8
84	Lees TA, Lambert D. Patterns of venous reflux in limbs with skin changes associated with chronic venous insufficiency. Br J Surg 1993; 80(6): 725–728.	96	3.7
85	Jawien A, Grzela T, Ochwat A. Prevalence of chronic venous insufficiency in men and women in Poland: multicentre cross-sectional study in 40,095 patients. Phlebology 2003; 18(3): 110–122.	95	5.9
86	Lee AJ, Evans CJ, Allan PL, Ruckley CV, Fowkes FGR. Lifestyle factors and the risk of varicose veins: Edinburgh Vein Study. J Clin Epidemiol 2003; 56(2): 171–179.	95	5.9
87	Shepherd AC, Gohel MS, Brown LC, Metcalfe MJ, Hamish M, Davies AH. Randomized clinical trial of VNUS (R) ClosureFAST (TM) radiofrequency ablation versus laser for varicose veins. Br J Surg 2010; 97(6): 810–818.	94	10.4
88	Siribumrungwong B, Noorit P, Wilasrusmee C, Attia J, Thakkinstian A. A Systematic review and meta-analysis of randomised controlled trials comparing endovenous ablation and surgical intervention in patients with varicose vein. Eur J Vasc Endovasc Surg 2012; 44(2): 214–223.	94	13.4
89	Royle JP. Recurrent varicose veins. World J Surg 1986; 10(6): 944–953.	93	2.8
90	Bountouroglou DG, Azzam M, Kakkos SK, Pathmarajah M, Young P, Geroulakos G. Ultrasound-guided foam sclerotherapy combined with sapheno-femoral ligation compared to surgical treatment of varicose veins: early results of a randomised controlled trial. Eur J Vasc Endovasc Surg 2006; 31(1): 93–100.	92	7.1
91	Van den Oever R, Hepp B, Debbaut B, Simon I. Socio-economic impact of chronic venous insufficiency. An underestimated public health problem. Int Angiol 1998; 17(3): 161–167.	92	4.4
92	MacKenzie RK, Paisley A, Allan PL, Lee AJ, Ruckley CV, Bradbury AW. The effect of long saphenous vein stripping on quality of life. J Vasc Surg 2002; 35(6): 1197–1203.	91	5.4
93	Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation 2014; 130(4): 333–346.	91	18.2
94	Negus D. Recurrent varicose veins – a national problem. Br J Surg 1993; 80(7): 823–824.	90	3.5
95	van Rij AM, Chai J, Hill GB, Christie RA. Incidence of deep vein thrombosis after varicose vein surgery. Br J Surg 2004; 91(12): 1582–1585.	90	6
96	Ihme N, Kiesewetter H, Jung F, et al. Leg oedema protection from a buckwheat herb tea in patients with chronic venous insufficiency: a single centre, randomised, double blind, placebo controlled clinical trial. Eur J Clin Pharmacol 1996; 50(6): 443–447.	89	3.9
97	Padberg FT, Jr., Pappas PJ, Araki CT, Back TL, Hobson RW, 2nd. Hemodynamic and clinical improvement after superficial vein ablation in primary combined venous insufficiency with ulceration. J Vasc Surg 1996; 24(5): 711–718.	88	3.8
98	Doganci S, Demirkilic U. Comparison of 980 nm laser and bare-tip fibre with 1470 nm laser and radial fibre in the treatment of great saphenous vein varicosities: a prospective randomised clinical trial. Eur J Vasc Endovasc Surg 2010; 40(2): 254–259.	88	9.8
99	Hinchliffe RJ, Ubhi J, Beech A, Ellison J, Braithwaite BD. A prospective randomised controlled trial of VNUS closure versus surgery for the treatment of recurrent long saphenous varicose veins. Eur J Vasc Endovasc Surg 2006; 31(2): 212–218.	87	6.7
100	Gillet JL, Guedes JM, Guex JJ, et al. Side-effects and complications of foam sclerotherapy of the great and small saphenous veins: a controlled multicentre prospective study including 1,025 patients. Phlebology 2009; 24(3): 131–138.	86	8.6

The 100 selected articles were published between 1983 and 2014, with half of the articles published after 2000 (n  =  60) (Figure 1). The oldest article was published in 1983 by Raju et al.[13] (“Venous insufficiency of the lower-limb and stasis ulceration – changing concepts and management”). The most recent article, published in 2014 by Eberhardt et al.,[14] was a review article on chronic venous insufficiency.

Figure 1.

Number of publications in each 5-year period.

The 100 articles were published across 25 journals in total, with the number of manuscripts published per journal ranging from 1 to 36 (Table 2). The Journal of Vascular Surgery published the most articles (n = 36) and had the most citations (n = 5356). Circulation had the highest impact factor (18.881) and 5-year impact factor (17.902), and had published three of the most influential articles (582 citations).

Table 2.

Journals of the 100 most-cited chronic venous disease articles.

Journal title	Impact factor	5-year impactfactor	Number of manuscripts	Number of citations
Journal of Vascular Surgery	3.294	3.477	36	5,356
British Journal of Surgery	5.433	6.051	13	1,965
Dermatologic Surgery	2.471	2.587	10	1,536
European Journal of Vascular and Endovascular Surgery	3.877	3.498	9	1,046
Phlebology	1.513	1.413	6	626
Journal of Vascular and Interventional Radiology	2.758	3.078	3	721
Circulation	18.881	17.902	3	582
Angiology	3.022	2.250	3	462

The country with the greatest number of publications among the top 100 articles was the United Kingdom, with 32 articles, closely followed by the United States with 30 publications. Among the 100 articles, 98 research studies has been performed in Western countries and the remaining 2 research studies had been performed in Japan and Turkey (Figure 2). Imperial College London was the institution with the highest number of publications among the top 100 articles, with 6 publications, followed by the University of Edinburgh with 5 publications (Table 3). Thirteen authors contributed to four or more papers, among which Thomas Michael Proebstle contributed to seven publications as a senior author (Table 4).

Figure 2.

Distribution of the 100 most-cited articles by the country of origin of the contributors.

Table 3.

Institutions with the most articles in the 100 most-cited articles.

Institution	Number of publications	Total number of citations
Imperial College London	6	779
University of Edinburgh	5	927
Mayo Clinic	4	847
Gloucestershire Royal Hospital	4	756
University of Mainz	4	584
University of Mississippi	4	485
University of Otago	3	350
University of Heidelberg	3	345

Table 4.

Authors that contributed four or more articles in the 100 most-cited articles.

Author	No. of articles	Position on author list
Proebstle TM	7	Senior author (7)
Ruckley CV	7	First (2), third (1), fourth (1), fifth (3)
Lee AJ	6	First (1), third (1), fourth (3), senior author (1)
Fowkes FGR	5	First (1), second (1), fifth (1), senior author (2)
Evans CJ	5	First (1), second (3), senior author (1)
Earnshaw JJ	4	Senior author (4)
Raju S	4	First (3), senior author (1)
Gloviczki P	4	First (2), fifth (2)
Raffetto JD	4	First (1), second (2), fourteenth (1)
Nicolaides AN	4	First (1), third (2), eighth (1)
Gul D	4	Second (2), third (2)
Allan PI	4	Third (4)
Knop J	4	Fourth (2), fifth (1), seventh (1)

The number of articles in each main research area is shown in Figure 3. Endovenous thermal ablation (ETA) was the most widely studied specialty, with 30 articles among the top 100, followed by nonthermal ablation (NTA) and symptoms, with 14 articles each. Twelve articles studied surgical therapy, whereas 11 were related to epidemiology. Nine articles examined disease recurrence after treatment, five articles were on pathogenesis, and five on other topics.

Figure 3.

Number of publications among the 100 most-cited articles by topic (ETA: endovenous thermal ablation, NTA: nonthermal ablation).

Regarding the number of publications in each 5-year period as shown in Figure 1, 2001 to 2005 had the highest number of publications, with 39 articles (39%). Twenty articles out of 39 (51.2%) were on techniques such as ETA and NTA. During this period, research on treatment modalities was actively introduced. As shown in Figure 3, ETA and NTA were the most widely studied topics. In the 10 years from 2006 to 2015, 17 out of 21 articles (80.9%) were on ETA and NTA.

Discussion

Regarding the history of surgical treatment for CVD, Trendelenburg introduced saphenous vein ligation in 1890 while Homan introduced ligation of the saphenofemoral junction in 1916. In the 1890s, excision of the great saphenous vein was introduced by Charles Mayo, and can be considered as the beginning of stripping. In the 1990s, ETA techniques including laser ablation and radiofrequency were introduced and adapted as an alternative treatment to traditional stripping.[15] More recently, ETA techniques have undergone rapid development, and in 2013, the National Institute for Health and Care Excellence recommended endovenous thermal ablation as the preferred treatment for symptomatic varicose veins.[16] NTA, including ultrasound guided foam sclerotherapy with a lower risk of nerve injury, has recently been adopted and is widely used at present while research is ongoing. Furthermore, NTA alternatives such as mechanochemical endovenous ablation and endovenous delivery of cyanoacrylate tissue adhesive are also being studied.[17]

Bibliometric analysis is a research method that allows the analysis of publication quality as well as the scientific productivity in a field of research.[18] The citation of articles, in particular, is a robust method for analyzing the quality and impact of publications.[19] For these reasons, the 100 most-cited articles were analyzed to evaluate the characteristics and trends in CVD research in the present study. In Table 2, the top four cited journals on CVD were related to surgery. To date, surgical journals have played an important role in CVD research. Although new treatment modalities for CVD have recently been adopted, the cited manuscripts discuss the ongoing role of surgeons with a general understanding of the disease and ability to provide appropriate treatment.

Our study found that CVD research initially focused on the characteristics of the disease, including epidemiology, symptoms, recurrence, and pathogenesis. With recent developments in technology, treatment for CVD is becoming less invasive and less complex. Alongside this trend, CVD research is becoming more focused on new treatment modalities. Thus, comparative studies and meta-analyses on newly developed modalities are likely to continue to increase.

Limitations of this research include potential biases related to the bibliometric analysis, including language bias, institutional bias, and influential researcher bias. Older articles have a greater potential for citation because of their relatively longer period of time in the publication domain. To control for this, the number of citations was divided by the number of years after publication to yield a citation rate, which is provided alongside the citation number in Table 1. Despite these mitigations, more recent relevant articles may have been underrepresented in this study.

Conclusion

Our bibliometric analysis of CVD research examined the characteristics and trends of publications. Research on CVD is typically carried out in Western countries and is continuing to increase with the introduction of new treatment modalities.