Prevalence and Risk Factors for Chronic Venous Disease in the General Russian Population

OBJECTIVE/BACKGROUND

The aim was to establish the prevalence of chronic venous disease (CVD) and its risk factors in the general population.

METHODS

This was a population based, cross sectional study. In total, 703 residents aged > 18 years from the rural community of Kryukovo (Central Russia) were enrolled. Medical history was taken and clinical examination performed, documenting venous signs/symptoms. The CEAP classification of the most affected limb was used. Duplex ultrasound was performed to register morphological changes and reflux in deep and superficial veins.

RESULTS

There were 63% women and 37% men (mean age 53.5 years). CVD was found in 69.3%. Of all participants 4.7% were C0S and 34.3% were C1. Chronic venous insufficiency (C3-C6) was found in 8.2% and venous ulcers (C5-C6) in 1.1%. Venous pain, heaviness, fatigue, itching, and the sensation of swelling were documented in 14.8%, 36.3%, 32.8%, 7.0% and 29.1% of patients respectively. Family history was the significant risk factor for both CVD (hazard ratio [HR] 1.3) and primary varicose vein disease (HR 1.6; p < .01). Female sex was a risk factor only for CVD (HR 1.3; p < .01) but not for varicose veins. Age was a risk factor for CVD (HR 1.01) and for varicose veins (HR 1.02; p < .01). For women, number of births (HR 1.05; p < .05) and menopause (HR 1.3; p < .01) were risk factors for CVD. Menopause was a risk factor for varicose veins (HR 2.0; p < .05).

CONCLUSION

This study provides data on the prevalence of CVD, venous abnormalities and risk factors in Russia. The results contribute to already established data, giving a more complete outlook on the global prevalence of CVD.

UNUSUAL POSTERIOR VARIX OF A VORTEX VEIN AMPULLA

PURPOSE

We describe a patient with an unusually posterior varix of a vortex vein ampulla.

METHODS

Case report.

RESULTS

An unusually posterior varix of a vortex vein ampulla mimicking a choroidal neoplasm was identified. The diagnosis was obscured by the presence of overlying drusen. Through a combination of indocyanine green angiography and enhanced depth imaging optical coherence tomography, the varix was identified as an engorged vascular process correlating to ophthalmoscopic and tomographic examination. Collapse of the varix after direct digital pressure on the globe was observed on enhanced depth imaging optical coherence tomography further confirming our diagnosis.

CONCLUSION

Varices of vortex vein ampullas may be incorrectly diagnosed as choroidal neoplasms. Using a combination of multimodal imaging and dynamic maneuvering, varices can be correctly identified.

Diagnosis and treatment of pelvic congestion syndrome: Single-centre experiences

BACKGROUND

One of the underestimated causes of chronic pelvic pain (CPP) in women may be pelvic congestion syndrome (PCS) that is defined as the presence of varicose of ovarian and pelvic veins associated with chronic pain in the region of the pelvis. This pain is present longer than 6 months and intensifies with prolonged standing, coitus and menstruation. The disease constitutes a diagnostic as well as therapeutic problem, thus posing a challenge for the clinician. Transcatheter ovarian vein embolization might be a safe and effective option for PCS treatment.

OBJECTIVES

The objective of this study was to evaluate the efficacy of ovarian vein embolization ovarian as a method of the PCS treatment.

MATERIAL AND METHODS

Between 2002-2012, 11 embolization procedures were performed in 10 women (age range: 34-43; median age 39) with the diagnosis of PCS. One patient underwent embolization procedure twice. In 1 case the combined therapy of endovascular embolization and surgical phlebectomy of vulvar varices was performed.

RESULTS

There were no major intrainterventional complications. In all the patients (100%) a significant improvement in the clinical status was noted. The procedure improved the quality of life in the patients. Three women (30%) had a mild recurrence of the symptoms at mid-term follow-up. Among 8 women who had complained of dyspareunia prior to embolization 6 patients reported complete pain relief, in other 2 cases the pain subsided partially. There was a significant decrease in the severity of symptoms associated with hemorrhoids.

CONCLUSIONS

We consider embolization of insufficient ovarian veins an effective and safe way of treatment in a well-selected group of patients with PCS.

Content Validity for the VVSymQ® Instrument: A New Patient-Reported Outcome Measure for the Assessment of Varicose Veins Symptoms

BACKGROUND

Varicose veins are common and can impact patients' quality of life, but consensus regarding the evaluation of varicose vein symptoms is lacking and existing measures have limitations.

OBJECTIVE

This research aimed to develop and establish the content validity of a new electronic patient-reported outcome (PRO) measure, the VVSymQ® instrument, to assess symptoms of superficial venous insufficiency (varicose veins) in clinical trials.

METHODS

The development of the VVSymQ® instrument began with qualitative interviews with patients based on the symptom domain of the VEINES-QOL/Sym, an existing PRO instrument for chronic venous disorders of the leg. Three phases of qualitative research were conducted to examine the relevance and importance of the symptoms to patients with varicose veins, and the patients' ability to understand and use the VVSymQ® instrument. The development included evaluating questions that had 1-week and 24-h recall periods, and paper and electronic versions of the new instrument.

RESULTS

Five symptoms (heaviness, achiness, swelling, throbbing, and itching [HASTI™]) were consistently reported by patients across all sources of qualitative data. The final version of the VVSymQ® instrument queries patients on the HASTI™ symptoms using a 24-h recall period and a 6-point duration-based response scale ranging from "None of the time" to "All of the time," and is administered daily via an electronic diary. Cognitive interviews demonstrated varicose vein patients' understanding of and their ability to use the final version of the VVSymQ® instrument.

CONCLUSION

Content validity was established for the VVSymQ® instrument, which assesses the five HASTI™ symptoms of varicose veins daily via an electronic diary and has promise for use in research and practice.

[Endovenous thermal interventions in treatment of patients with lower limb varicose veins]

The problem regarding treatment of patients suffering from lower limb varicose veins remains a matter of current concern and is important today because of high prevalence of the pathology concerned and a steadily growing number of newly diagnosed cases. Mention should be made that both Russian and foreign phlebologists along with an open surgical operation on veins have more and more often been using minimally invasive endovenous techniques in comprehensive management of patients presenting with varicose veins. The present article is a literature review dedicated to a detailed discussion of two most commonly performed and efficient procedures, namely, radiofrequency ablation of lower limb veins and endovasal laser coagulation. This is accompanied and followed by demonstrating advantages of these techniques, describing the immediate and remote results obtained, as well as possible complications, both typical and rarely occurring. The majority of specialists employing radiofrequency ablation of lower-limb veins and endovasal endovenous laser coagulation report high effectiveness of their use for treatment of patients with lower limb varicose veins, including those diagnosed with pronounced trophic impairments. The findings obtained by many authors while comparing efficacy of various endovenous procedures make it possible to assess them objectively and to correctly determine the indications for a particular intervention.

[Conservative treatment of chronic diseases of lower limb veins: major risks of poor patient compliance]

Presented herein are the results of the Russian part of the International Research Programme 'VEIN ACT' aimed at studying approaches to conservative treatment of chronic vein diseases in the Russian Federation, assessing its efficacy and safety, as well as monitoring the patient compliance. Also discussed are the regimen and results of conservative therapy, depending on patients' gender, age and body mass index, as well as the level of adherence to various methods of treatment in the cohorts concerned. High efficacy of conservative therapy in all patients was confirmed. However, the regimen of drug therapy needs to be adjusted depending on the disease severity, especially in patients of a more advanced age and those with obesity. The lowest patient compliance was observed in relation to compression treatment. The existing situation may be improved by be means of appropriate recommendations and a possible decrease of the level and degree of compression. This should of course be done carefully and attentively, with obligatorily taking into consideration the patients' age and body mass index.

[Experience with using cyanoacrylate glue in endovascular treatment of varicose veins]

The method of cyanoacrylate-mediated obliteration of subcutaneous veins is known to be an alternative to thermal endovascular obliteration and eliminates the need for tumescent anaesthesia. This technique is based on glue-induced damage to the venous intima, followed by immune response according to the delayed-type hypersensitivity principle. The authors report herein their first experience with using cyanoacrylate-mediated embolization in treatment of patients presenting with varicose veins. The operation was carried out using the VenaSeal closure system (Medtronic). Under ultrasonographic guidance, we performed cyanoacrylate-mediated obliteration of the trunk of the great saphenous vein, without tumescence. The procedure turned out to be well tolerated, with no pain in the zone of cyanoacrylate obliteration reported by the patients in the postoperative period. By means of ultrasonographic control carried out within 1-month of follow up we assessed obliteration of the vein, with the diameter of the obliterated portion amounting to 0.3-0.4 cm. No phlebitis, allergic reactions, nor evidence of deep vein thrombosis were observed. We also performed a morphological study of the removed suprafascial segment of the vein, containing the cyanoacrylate adhesive. The obtained findings demonstrated detachment and destruction of the intima, swelling and loosening of the media, as well active degranulation of mast cells, thus making it possible to suppose the presence of toxic damage to the venous wall induced by cyanoacrylate glue. Hence, the experience thus gained appears to be unequivocally suggestive of remarkable simplicity of performing cyanoacrylate-mediated embolization whose indisputable advantages include the painless nature of the procedure and no need for tumescent anaesthesia. In order to assess efficacy and safety of this technique, further studies are required.

Allele rs2010963 C of the VEGFA gene is associated with the decreased risk of primary varicose veins in ethnic Russians

Objective To study the association of polymorphisms rs699947, rs2010963, rs3025039 in the VEGFA gene region and rs1870377, rs2305949, rs2071559 in the VEGFR2 gene region with the risk of primary varicose veins in ethnic Russians. Methods Genotypes were determined by real-time PCR allelic discrimination. The case group consisted of 448 patients with primary varicose veins and the control group comprised 609 individuals without a history of chronic venous disease. Association was studied by logistic regression analysis. Results Allele rs2010963 C was associated with the decreased risk of varicose veins (additive model of inheritance: odds ratio = 0.73, 95% confidence interval = 0.59-0.91, P = 0.004). Conclusions Our results provide evidence that polymorphism rs2010963 located in the 5' untranslated region of the VEGFA gene can influence genetic susceptibility to primary varicose veins in Russians. Otherwise, it can be in linkage disequilibrium with another functional single nucleotide polymorphism that can alter the level of vascular endothelial growth factor A protein.

Endovenous laser ablation of the great saphenous vein comparing 1920-nm and 1470-nm diode laser

BACKGROUND

The aim of this study was to compare venous occlusion rates at a one-year follow-up comparing 1920-nm versus 1470-nm endolaser.

METHODS

Randomized prospective study with consecutive patients with varicose veins associated to great saphenous reflux. The 1470-nm laser ablation was performed in continuous mode, with power of 10 W, while for the 1920-nm it was set in 5 W. Follow-up data were collected at the 7-day, 30-day, 3-month, 6-month and 1-year visits, and involved clinical, ultrasound evaluation and measurement of occlusion length.

RESULTS

Sixty seven patients were included, with 42 limbs operated in the 1470-nm group and 48 limbs in the 1920-nm group. There were no differences in relation to age, CEAP (Clinical, Etiologic, Anatomical and Pathological Classification), VCSS (Venous Clinical Severity Score) and saphenous diameter. The resulting LEED in 1920-nm group was 17.8±0.6 J/cm and vs. 24.7±0.8 J/cm in 1470-nm group (P<0.01). Closure rates were lower for the 1920-nm group: 90.9% vs. 96.8% (P=0.06) at 30 days, 87.5% vs. 96.3% at 6 months (P=0.03), and 87.5% vs. 94.7% (P=0.05) at one year. The 1920-nm group had less ecchymosis (18.7% vs. 52.4%), induration (12.4% vs. 38.1%) and days of analgesic use (1.4±0.2 vs. 2.4±0.4). CEAP and VCSS were reduced over time in both groups.

CONCLUSIONS

Treatment with endolaser 1920-nm was feasible and with reduced complications. The use of low endoluminal energy resulted in lower vein occlusion rates comparing to the 1470-nn laser. Clinical outcome scores were similar between groups.

Patients with Klippel-Trenaunay syndrome

Klippel-Trenaunay syndrome is the most frequent systemic venous angiodysplasia. It is characterized by cutaneous capillary malformations - naevus flammeus, excessive growth of soft and bone tissue, venous and lymphatic malformations. Investigative methods include: clinical examinations, venography as the evidence of dysplastic changes of superficial and / or deep venous system, the Moyne obstruction and venous insufficiency perforator. Treatment is conservative, related to that of chronic venous disease. The surgery is aimed at removing the varices and insufficient perforators (Fig. 9, Ref. 8).

The Venous Reflux

Venous reflux is the most common cause of venous hemodynamic disorders. In this paper 2 issues are discussed: how and where does reflux arise and what are the hemodynamic consequences of retrograde flow. Pressure gradient and incompetent vein connecting both poles of the gradient are the prerequisite for venous reflux to arise. Ambulatory pressure gradient occurs during the activity of the calf muscle venous pump between deep veins of the thigh and the lower leg. Thus the incompetent reflux-carrying vein must connect the popliteal, femoral, profunda femoris, or iliac vein with 1 of the deep veins of the lower leg. Reflux can be considered as shunting of blood from thigh veins into the lower leg veins. The most frequently found incompetent veins are the long and short saphenous veins and perforators communicating with deep veins of the thigh. On the other hand, calf perforators emptying into the deep veins of the lower leg, where the lower pole of the pressure gradient is located, cannot be the feeding source of reflux. A physiological bidirectional flow takes place in calf perforators connecting superficial and deep veins of the lower leg and making them conjoined vessels. Venous reflux produces ambulatory venous hypertension. The quantity of reflux volume and not the localization of retrograde flow in superficial or deep veins is the most important hemodynamic factor. Reflux in superficial veins, when large enough, can cause the most serious symptoms of chronic venous insufficiency including leg ulcers. Plethysmographic findings have shown that incompetence of the femoral and calf perforating veins is hemodynamically unimportant. Large incompetent calf perforators are not the cause of venous abnormality but are the consequence of saphenous retrograde flow.

[Linee guida flebo-linfologiche SIF-SICVE 2016 della Società Italiana di Flebologia e della Società Italiana di Chirurgia Vascolare ed Endovascolare]

Phlebology is not a specialty for its own in Italy. Phlebological patients are treated by vascular and general surgeons, dermatologists, phlebologists, angiologists, internists and even general practitioners. Even tough guidelines present a series of recommendations based on evidence-based medicine, guidelines may also be a tool to unify the diagnostic and therapeutic approach in a vast medical field like phlebology. Since vascular surgeons and phlebologists are particularly involved in phlebology-related pathologies the scientific societies of the Italian Society of Phlebology (SIF) and the Italian Society for Vascular and Endovascular Surgery (SICVE) decided to cooperate for the preparation of phlebo-lymphological guidelines. These guidelines comprehend also an important chapter dealing with the lymphology of the lower extremities; phlebological active physicians are often faced with lymphatic pathologies and a good differential diagnosis can be sometimes very helpful. Sclerotherapy and Surgery as the major therapeutical alternatives are extensively analyzed, but also the compression therapy, the medical and physical therapy are presented under the critical view of evidence based analyses. Separate chapters deal with the treatment alternatives for superficial and deep venous thromboses and the recommendations for the treatment of venous ulcers. The current scientific evidences were confronted with the experiences of Italian specialists and the particular practice and reality in Italy. They represent therefore the actual valid positions and recommendations in Italy which shall be updated regularly.

Anorectal emergencies

Anorectal emergencies refer to anorectal disorders presenting with some alarming symptoms such as acute anal pain and bleeding which might require an immediate management. This article deals with the diagnosis and management of common anorectal emergencies such as acutely thrombosed external hemorrhoid, thrombosed or strangulated internal hemorrhoid, bleeding hemorrhoid, bleeding anorectal varices, anal fissure, irreducible or strangulated rectal prolapse, anorectal abscess, perineal necrotizing fasciitis (Fournier gangrene), retained anorectal foreign bodies and obstructing rectal cancer. Sexually transmitted diseases as anorectal non-surgical emergencies and some anorectal emergencies in neonates are also discussed. The last part of this review dedicates to the management of early complications following common anorectal procedures that may present as an emergency including acute urinary retention, bleeding, fecal impaction and anorectal sepsis. Although many of anorectal disorders presenting in an emergency setting are not life-threatening and may be successfully treated in an outpatient clinic, an accurate diagnosis and proper management remains a challenging problem for clinicians. A detailed history taking and a careful physical examination, including digital rectal examination and anoscopy, is essential for correct diagnosis and plan of treatment. In some cases, some imaging examinations, such as endoanal ultrasonography and computerized tomography scan of whole abdomen, are required. If in doubt, the attending physicians should not hesitate to consult an expert e.g., colorectal surgeon about the diagnosis, proper management and appropriate follow-up.

[COEXISTENCE OF ORBITAL VARICOSE VEIN AND THYROID ORBITOPATHY]

PURPOSE

To describe a thyroid orbitopathy patient who had asymmetric progression of exophthalmos due to orbital varicose vein.

PATIENT

A 55-year-old patient with thyroid orbitopathy had asymmetric progression of exophthalmos without complaints over 4 years of follow-up.

RESULTS

In repeated computerized tomography (CT) of the orbit, a dilation of the superior ophthalmic vein was noted on the more proptotic eye, in addition to bilateral excessive orbital fat. This finding was also confirmed on color Doppler imaging in valsalva manoeuver.

CONCLUSIONS

In patients with thyroid orbitopathy who have atypical progression course of their exophthalmos, repeated orbital CT scan is advocated to rule out other concurrent orbital disorders such as varicose veins.

PREVENTION OF VENOUS THROMBOEMBOLIC COMPLICATIONS IN REPLACEMENT ARTHROPLASTY PERFORMANCE IN PATIENTS WITH ASSOCIATED CHRONIC DISEASES OF LOWER EXTREMITIES VEINS

A number of patients with problems of major joints increases every year. These patients need the replacement arthroplasty. The rate of thrombotic complications rises in given category of patients simultaneously with the increase of the number of performed operations. There weren’t well-defined instructions of management of the patients with associated chronic vein diseases at the preparation period for arthroplasty performance in spite of the presence of clinical recommendations for prevention of thromboembolic complications. The authors analyzed the experience of management of such patients and presented these data for doctors from polyclinic and hospitals in order to apply the common treatment strategy.

[Lower limb varicose veins as a manifestation of undifferentiated connective tissue dysplasia]

Analysed herein are the data of 737 patients (a total of 745 lower limbs) suffering from lower-limb varicose veins (LLVV) and subjected to treatment at the Surgical Department consisting of crossectomy, truncal and tributary phlebectomy, dissection of perforant veins exclusively in the basin of the great saphenous vein. Relapses during five-year follow up occurred in 13.8% (102/745) of cases. Based on clinical signs and laboratory findings we studied the effect of the factor of undifferentiated connective tissue dysplasia (UDCTD) on the development of lower-limb varicosity. We carried out comparative analysis in the groups with relapsing LLVV (n=43), without relapses (n=39) and control group comprising volunteers not suffering from LLVV (n=37). The median of blood serum total oxiprolin concentration in LLVV patients both with and without relapses was elevated and amounted to 18.4 (IR 14.9-19.65) and 14.3 (IR 13.1-16.5) versus 8.35 (5.75-9.75) μmol/l, respectively. The mode of the clinical parameter of UDCTD degree in accordance with the rating scale of Smolnova T.Yu. (2003) in the group of patients with LLVV relapses turned out to be higher (Mo=19) than in the group of patients without relapses (Mo=10, p=0.003). The lowest score was in the control group. In patients having immediate relatives with LLVV the level of blood serum total oxiprolin and clinical scores of LLVV turned out to be statistically significantly higher. Hence, based on the obtained during the study clinical and laboratory findings it may be supposed that undifferentiated connective tissue dysplasia plays an important part in the development of both lower limb varicosity and relapses thereof.

[Antegrade diastolic blood flow and classic reflux in varicose dilatation of the intersaphenous vein]

INTRODUCTION

In the intersaphenous vein (ISV) there may take place the so-called "antegrade" or "paradoxical" reflux. This type of blood flow is revealed in a series of patients during muscular diastole and is a link of the pathogenesis of varicose disease, but has, as distinct from the "classical" reflux, an antegrade direction. An incompetent saphenopopliteal junction (SPJ) is a source of the antegrade diastolic blood flow (ADBF) through the ISV. Descriptions of possible variants of impaired blood flow through the ISV are fragmentary and their interpretations are controversial. Prevalence and pathogenesis of these disorders impairments have not yet been studied.

MATERIAL AND METHODS

A cross-sectional study: over 4 years three centres examined a total of 1,413 patients diagnosed with class C2-C6 varicose veins according the CEAP classification. All patients underwent ultrasound duplex scanning of lower limb veins. The ADBF was determined as a unidirectional antegrade blood flow with the duration of not more than 0.5 second, observed after the crus was relived of compression (in the diastole). Of the patients included into the study who had no varicose veins on the contralateral extremity with the ISV being spotted we sequentially selected 40 subjects including them into the Study Group for the analysis of blood flow and the diameter of the ISV in health.

RESULTS

Impairments of blood flow in the ISV were revealed in 61 (4.8%) of 1,265 extremities included into the study: the "classical" reflux in 9 (14.8%) limbs, ADBF was revealed in 37 (60.7%) limbs, a combination of the "classical" blood flow and ADBF - in 15 (24.6%) limbs. Hence, the patients were subdivided into three groups. Studying the nature of blood flow through the ISV in the control group on 40 lower limbs revealed no blood flow disorders. The mean ISV diameter amounted to 1.68 mm (ME=1 mm). The ISV diameter was considerably higher in all studied groups as compared with the control one (p<0.0001). The diameter of the ISV in its proximal portion averagely amounted to 4.48 mm (SD 1.337 mm, SE 0.171 mm). The diameter in the distal portion amounted to 5.39 mm (SD 1.725 mm, SE 0.221 mm).

Confirmation of Choroidal Varix Through Divot Sign on Spectral-Domain Optical Coherence Tomography

Enhanced depth imaging spectral-domain optical coherence tomography (EDI SD-OCT) provides a rapid and easily accessible measure to evaluate suspicious choroidal lesions. A 60-year-old woman was referred for evaluation of an inferotemporal slightly pigmented lesion that showed a large hyporeflective elevation in the deep choroid on EDI SD-OCT. After applying pressure to the globe, repeat EDI SD-OCT showed flattening of the lesion with a prominent depression or "divot" within the choroid of the center of the lesion. If noted on imaging, this divot sign is an additional reproducible diagnostic finding that can correctly identify a suspicious choroidal lesion as a benign choroidal varix.

Serum estradiol/free testosterone ratio can be important predictor for varicose vein recurrence in men

AIM

Recurrent varicose veins are a frustration for both the patient and the surgeon. More investigation of the exact diagnosis, proper practice, and causes for the recurrence of varicose veins is needed.

METHODS

We investigated a total number of 187 patients in a five year period with an estradiol-2/free testosterone (E2/fT) ratio relationship on recurrent varicose veins in men between the ages of 20-50. Fifity years was the maximum age due to the age dependent sex steroid hormone regression that occurs after this age, which may interefere with the assessment. Fifty three men with an elevated E2/fT ratio (group A), and 143 men with no endocrinologic problems (group B) were enrolled in the study and had surgery for varicose veins. After 5 years follow up (mean 3 years), Group A (N.=29) and group B (N.=43) had recurrent varicose veins by clinical and radiologic findings. Venous blood samples were driven from all patients of both groups in the morning to detect the levels of serum E2 and fT levels. Patient history of surgery for varicose veins, physical examination, color duplex ultrasound of both limbs, and classification of CEAP were performed in both groups.

RESULTS

The serum E2/fT ratio was significantly higher in Group A (5.21 ± 0.56) compared to group B (2.54±0.27) in the recurrent varicose vein groups (p ≤ 0.05). Moreover, there was a high correlation between serum E2/fT ratio and the CEAP clinical classification in group A (5) compared to group B (2) (P≤0.05). Also, recurrence rate was higher in group A (54%) compared to group B (32%)(P≤0.05).

CONCLUSION

Elevated serum E2/fT ratio is a precipitating factor for recurrent varicose veins in male patients.

Endovenous ablation of incompetent truncal veins and their perforators with a new radiofrequency system. Mid-term outcomes

This is a prospective trial investigating endovenous radiofrequency ablation with the EVRF system for the treatment of symptomatic varicose veins. Primary endpoints include one-year anatomical and clinical success and procedure-related complications. Secondary endpoints include adjunctive procedures and recanalization rates, periprocedural pain assessment, and time return to normal activities. In 60 patients with 74 limbs, 58 great saphenous vein, 11 small saphenous vein, 2 anterior accessory saphenous vein, and 3 perforators were ablated. Additional ablations for further improvement were necessary in 28.4%. Clinical success was 94.6%. Anatomical success was 96.0% at one month and 89.2% at one year. Primary ablation success was 77%. Revascularization occurred in 12.1%. Clinically driven repeat ablation rate was 4.0%. Perforator ablation due to segmental revascularization was performed in 5.4%. Complications included one puncture-site infection, three scars, two cases of transient paresthesia, and one skin pigmentation. Periprocedural mean pain score was 2.4 ± 2.6. In 27.0% cases, the patients used analgesics and mean time return was 1.2 ± 0.5 days. The EVRF system yields satisfactory clinical and anatomical midterm outcomes with very low complication rates.

Five-year follow-up of a randomized, controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia

OBJECTIVE

The objective of this study was to compare the long-term results (groin-related recurrence, great saphenous vein [GSV] occlusion rate, Clinical class, Etiology, Anatomy, and Pathophysiology [CEAP] staging, and quality of life [QoL]) after the treatment of a GSV incompetence by saphenofemoral ligation and stripping (SFL/S) with endovenous laser ablation bare fiber, 980 nm (EVLA).

METHODS

Patients with GSV insufficiency and varicose veins were randomized to either undergo SFL/S or EVLA, both of which were performed under tumescent anesthesia. The long-term results, which included the anatomic occlusion rate, varicose vein recurrence at the saphenofemoral junction (SFJ), relief of venous symptoms and QoL, were compared up to 5 years after treatment.

RESULTS

A total of 130 legs of 121 patients were treated with either SFL/S (n = 68) or EVLA (n = 62). In the first 12 months, three recanalizations of the GSV were observed after EVLA. Up to 5 years later, more recurrent varicose veins caused by neoreflux in incompetent tributaries of the SFJ were observed in after EVLA (31%; 19/61) compared with SFL/S (7%; 4/60; P < .01). Neovascularization in the groin with clinically visible recurrence identified at 3 and 5 years post-treatment follow-up was only observed in the SFL/S group (n = 6). After 5 years, clinically visible recurrences originating from the SFJ region after EVLA were observed 33% (20/61) compared with 17% of patients (10/60) after SFL/S (P < .04). In both treatment groups, venous symptoms improved significantly. Patients in both groups reported a continuing significant cosmetic improvement measured on a visual analog scale of 1 to 10 (mean, 7.49; P < .01). There was no difference in the CEAP staging and a standardized, non-disease-specific instrument for describing and valuing health states (EuroQol-5D), between the groups up to 5 years after follow-up.

CONCLUSIONS

At the 5-year follow-up, a significantly higher varicose vein recurrence rate originated at the SFJ region after EVLA compared with SFL/S. There were no differences in the relief of venous symptoms, CEAP staging, or general QoL between the groups.

Small bowel varices secondary to chronic superior mesenteric vein thrombosis in a patient with heterozygous Factor V Leiden mutation: a case report

INTRODUCTION

Bleeding ectopic small bowel varices pose a clinical dilemma for the physician, given their diagnostic obscurity and the lack of evidence-based medicine to guide therapy. They often occur in the context of portal hypertension, secondary to either liver disease or extrahepatic causes. Rarely is their presence associated with chronic superior mesenteric vein thrombosis and hereditary coagulopathies.

CASE PRESENTATION

A 74-year-old white woman, with a heterozygous Factor V Leiden mutation and no underlying liver disease or portal hypertension, presented over the course of 13 months for recurrent episodes of melena and per rectal bleeding. An initial endoscopy showed a clean-based chronic gastric ulcer, while colonoscopies showed multiple, non-bleeding angioectasias which were treated with argon plasma coagulation. Subsequent video capsule endoscopy and double balloon enteroscopy revealed red wale marks overlying engorged submucosal veins in her distal ileum, consistent with ectopic varices. A chronic superior mesenteric vein thrombus, found via computed tomography venogram, was the cause of the ileal varices. She underwent curative surgical resection of the affected bowel, with no re-bleeding episodes 17 months post-surgery, despite needing lifelong anticoagulation for recurrent venous thromboembolisms.

CONCLUSIONS

Clinicians should consider ectopic varices in patients who present with obscure gastrointestinal bleeding, even in the absence of portal hypertension or liver disease. In those with a known thrombophilia, patients should be screened for splanchnic thrombosis, which may precipitate ectopic varices.

Polymorphisms of MMP9 and TIMP2 in Patients with Varicose Veins

BACKGROUND

Genetic predisposition is a suggested risk factor in the etiology of varicose veins. The matrix metalloproteinase (MMP) family degrades extracellular matrix (ECM) and may lead to disturbances in vein wall structure. The activity of MMPs in the ECM are controlled by specific tissue inhibitors of MMPs (TIMP). The present study aimed to investigate the relationship between MMP9 and TIMP2 gene polymorphisms and varicose vein risk.

MATERIALS AND METHODS

Genotyping of the polymorphisms of MMP9 (1562 C/T) and TIMP2 (418G/C) was performed using polymerase chain reaction and restriction-fragment length polymorphism assays in a group of patients with varicose veins (n=63) and healthy controls (n=70).

RESULTS

The frequencies of MMP9 alleles and genotypes did not differ significantly between patient and control groups. However, TIMP2 -418 C allele was associated with increased risk for varicose vein formation (p=0.007). It was also shown that the frequency of the GG genotype was significantly higher in the control group than in the patient group (odds ratio=0.333, 95% confidence interval=0.14-0.78, p=0.012).

CONCLUSION

TIMP2 -418 C allele is associated with susceptibility for varicose vein formation and individuals with GG genotype may have a lower risk for varicose vein formation.

[Pelvic venous congestion syndrome - diagnosis and management. Guidelines of the angiology section of slovak medical chamber (2015)]

Pelvic congestion syndrome: chronic symptoms, which may include pelvic pain, perineal heaviness, urgency of micturition, and post-coital pain, caused by ovarian and/or pelvic vein reflux and/or obstruction, and which may be associated with vulvar, perineal, and/or lower extremity varices. The VEIN-TERM consensus document was developed by a transatlantic interdisciplinary faculty of experts under the auspices of the American Venous Forum (AVF), the European Venous Forum (EVF), the International Union of Phlebology (IUP), the American College of Phlebology (ACP), and the International Union of Angiology (IUA). It provides recommendations for fundamental venous terminology. Project Vessels of AS SMC.

Successful hemostasis of intractable rectal variceal bleeding using variceal embolization

Portal hypertension causes portosystemic shunting along the gastrointestinal tract, resulting in gastrointestinal varices. Rectal varices and their bleeding is a rare complication, but it can be fatal without appropriate treatment. However, because of its rarity, no established treatment strategy is yet available. In the setting of intractable rectal variceal bleeding, a transjugular intravenous portosystemic shunt can be a treatment of choice to enable portal decompression and thus achieve hemostasis. However, in the case of recurrent rectal variceal bleeding despite successful transjugular intravenous portosystemic shunt, alternative measures to control bleeding are required. Here, we report on a patient with liver cirrhosis who experienced recurrent rectal variceal bleeding even after successful transjugular intravenous portosystemic shunt and was successfully treated with variceal embolization.

[A varix of the vortex vein ampulla is a rare differential diagnosis of malignant melanoma of the choroid]

Melanoma of the choroid is the most frequent primary intra-ocular malignancy whereas a varix of the vortex vein ampulla is a benign, rare and asymptomatic condition requiring no treatment. A varix of the vortex vein ampulla is usually found accidentally and can easily be mistaken for a choroidal melanoma, a naevus or a haemorrhage. We present a case of a varix of the vortex vein ampulla, which can be distinguished from other more serious conditions by using simple clinical methods.

Ultrasound-guided catheter-directed foam sclerotherapy for great saphenous vein

AIM

The problem of varicose veins in the lower leg is a common disease and associated with long-term morbidity. It has usually been treated using high ligation with stripping and endovenous ablation surgery of the great saphenous vein. The aim of this paper is to report our own series of patients treated by ultrasound guided catheter directed foam sclerotherapy for the chemical ablation of great saphenous vein.

METHODS

The study involved 108 legs with symptomatic varicose veins (C2-4) secondary to great saphenous vein insufficiency. The great saphenous vein was accessed at knee level. With the method of Tessari sclerosant foam was made (2 mL 3% polidocanol and 8 mL air) and delivered along the great saphenous vein while the catheter was withdrawn. At two and fifty two weeks after treatment the patients were evaluated.

RESULTS

Catheter-directed foam sclerotheraphy was successfully performed in all of the patients. Venous Clinic Severity Score was reduced significantly (P<0.05). Eighty nine percent of the GSV were completely occluded, 4% were partly occluded and 7% were recanalized. No serious side-effects occurred.

CONCLUSION

Catheter-directed foam sclerotheraphy is a safe, simple and minimally invasive procedure. Patient satisfaction was good and the occlusion rate is promising after a single treatment.

Recurrent varicose veins: causes and neovascularisation. A 17-year experience

AIM

The aim of the paper was to determine the causes of varicose vein recurrence and, when neovascularisation is suspected, to confirm or exclude its presence and to establish its contribution to the recurrence of varicose veins.

METHODS

A retrospective analysis of a set of 217 legs reoperated in our department over a period of 17 years with a two-year prospective histological and histochemical (nestin) analysis of resected veins.

RESULTS

Reflux as a cause of varicose vein recurrence was identified in 93% of the limbs. It was most commonly found in the area of the saphenofemoral junction, followed by the area of the saphenopopliteal junction. Reflux in the perforating veins was almost invariably linked to that in the saphenofemoral junction or saphenopopliteal junction; an isolated damage to the perforating veins was only present in three limbs. Histological and histochemical analysis was performed for the samples of eleven veins in which neovascularisation was suspected based on preoperative duplex ultrasonography evaluation. Neovascularisation was confirmed in none of these veins and none of them was the cause of recurrence.

CONCLUSION

The major cause of varicose vein recurrence is a reflux left unresolved during the primary surgery, particularly in the area of the saphenofemoral junction. A less common cause is progression of the disease and the occurrence of a new reflux. Neovascularisation is of no importance for the recurrence of varicose veins.

Protein C deficiency related obscure gastrointestinal bleeding treated by enteroscopy and anticoagulant therapy

Obscure gastrointestinal bleeding is an uncommonly encountered and difficult-to-treat clinical problem in gastroenterology, but advancements in endoscopic and radiologic imaging modalities allow for greater accuracy in diagnosing obscure gastrointestinal bleeding. Ectopic varices account for less than 5% of all variceal bleeding cases, and jejunal variceal bleeding due to extrahepatic portal hypertension is rare. We present a 47-year-old man suffering from obscure gastrointestinal bleeding. Computed tomography of the abdomen revealed multiple vascular tufts around the proximal jejunum but no evidence of cirrhosis, and a visible hypodense filling defect suggestive of thrombus was visible in the superior mesenteric vein. Enteroscopy revealed several serpiginous varices in the proximal jejunum. Serologic data disclosed protein C deficiency (33.6%). The patient was successfully treated by therapeutic balloon-assisted enteroscopy and long-term anticoagulant therapy, which is normally contraindicated in patients with gastrointestinal bleeding. Diagnostic modalities for obscure gastrointestinal bleeding, such as capsule endoscopy, computed tomography enterography, magnetic resonance enterography, and enteroscopy, were also reviewed in this article.

[Lesion of pelvic organs in secondary varicose veins of the small pelvis]

The authors studied peculiarities of pelvic organs lesions in patients presenting with secondary small pelvic varicose veins (SPVV) induced by endured thrombosis of iliac veins. The study included a total of 70 patients after endured thrombosis of iliac veins verified by radiodiagnostic methods. The average duration of thrombosis amounted to 3.8 years. The patients were subdivided into two groups. The Study Group comprised 48 patients presenting with small pelvic varicose veins revealed by duplex scanning; the Control Group was composed of 22 patients with no varicose pelvic veins. It was determined that characteristic features of patients with secondary SPVV having developed after iliac veins thrombosis included chronic pelvic pain, dilatation of cavernous veins of the rectum, inguinal vein varicosity and varicose veins of the groin and anterior abdominal wall. Formation of secondary SPVV after endured iliac vein thrombosis leads to disorders of pelvic organs, similar to those in primary varicosity, but more often being functional. Endured iliac veins thrombosis in formation of secondary SPVV leads to urination impairments with prevalence of moderately pronounced symptomatology. Small pelvic organs dysfunction in women with secondary SPVV due to endured iliac veins thrombosis manifests itself in dyspareunia, leukorrhea, and dysmenorrhea.

[Thrombotic complications in severe forms of varicose disease: diagnosis, surgical treatment, using miniinvasive methods]

Actual issues of surgical treatment of patients, suffering complications of varicose disease severe forms, are discussed. The causes of unsatisfactory results of treatment of patients, suffering varicothrombophlebitis, the main of which is the absence of common tactics of operative treatment and anticoagulant therapy, were analyzed. There were formatted the groups of patients, suffering severe forms of varicose disease of various localization of thrombotic process, a differentiated tactics of their surgical treatment was proposed.

[A patient with abnormal skin discolouring around a colostomy]

In this article we present a case of a 83-year-old female patient with an abnormal skin discolouring around the colostomy, which we diagnosed as ectopic parastomal varices due to underlying primary biliary cirrhosis.

[A former bodybuilder with a swelling on the forearm]

A 56-year-old man came to the general practitioner with a solitary compressible swelling on his left forearm, which enlarged during exercise. The patient reported a history of bodybuilding and he worked as a plasterer. Physical examination revealed primary varicose of the upper extremity, a rare localisation of a common vascular disease.

Cryosclerosis. A forgotten endovenous procedure for treating the incompetence of the great saphenous vein. Short term results

AIM

The aim of the present study was to prove the effectiveness, reliability and minimal invasiveness of cryosclerosis.

METHODS

A prospective non-randomized study had been performed. The study enrolled 96 patients; 48 patients were treated by cryosclerosis and the other 48 by conventional stripping. Every time high ligation and phlebectomy of varices were done, in 1 patient the incompentence of the small saphenous vein was treated also by cryosclerosis. During the follow-up visits the obliteration of the great saphenous saphenous vein (GSV) was investigated; as primary objective of the study, secondary outcome measures were the most frequent complications of the conventional surgery, postoperative pain and recovery. Color-Duplex scan of the operated lower extremity was performed into 30 patients of the study group. Additionally, the vein wall (unhandled and frozen) was analyzed by transmission electron microscope in one case. All of the involved patients were examined at a follow-up visit (7 days after surgery) and sent back a questionnaire (6-8 weeks after surgery).

RESULTS

Recanalization was observed only in 2 patients (success rate after 6 weeks: 93.3%). Thromboembolic events occurred only in the control group (1 patient, minor pulmonary embolism). Regarding mild wound healing disorder and lymphorrhea there were no significant differences between the groups. Concerning postoperative pain, bruising and recovery the cryosclerosis was found significantly favorable. The incidence of limb swelling after surgery was the same in each group. Temporary sensory abnormalities seem to be frequent in the study group, but the results show that the rate of permanent saphenous nerve injury is higher in the patients operated with the conventional method. The histological examination showed changes in the frozen vein wall.

CONCLUSION

Lacking long-term results, we can only consider that cryosclerosis allows the occlusion of the great saphenous vein, is minimal invasive and should be considered among endovenous procedures for treating GSV incompetence.

[Modern methods of diagnosis of thrombophylic states and complex treatment of patients with thrombotic complications of severe forms of varicose disease]

Actual issues of surgical treatment of patients, suffering complications of severe forms of varicose disease of the lower extremities (VDLE) are discussed. The causes of unsatisfactory results of treatment in patients, suffering varicothrombophlebitis (VTHPH), the main of which--absence of the only one tactics for operative treatment and anticoagulant therapy, were analyzed. The results of patients examination, suffering thrombotic complications of severe forms of VDLE, while its recurrent course, in conjunction of VTHPH and thrombosis of deep veins of the lower extremities, using diagnostic complex "PLR genetics thrombophilia", are adduced. Differential tactics of treatment in patients, suffering severe forms of VDLE, while various localization of thrombotic process, concerning the presence of thrombophilic states, is proposed.

Quality of live as measured by the CIVQ 20. Questionnaire following oral mesoglycan treatment of patients with chronic venous disease

AIM

Several studies have demonstrated the effective antithrombotic action of mesoglycan to treat chronic venous disease (CVD). The study aimed to assess clinical and quality of life (QoL) (CIVIQ 20 questionnaire) improvements in mesoglycan-treated patients with clinical, etiological, anatomical and pathophysiological (CEAP) stages 2 and 3.

METHODS

The open, multicentre, uncontrolled, observational, prospective study involved treating patients with 50 mg x 2/day mesoglycan for 2 months and measuring improvement to lower-limb edema and QoL in the Global, Physical, Pain, Psychological, and Social Dimensions of the Chronic Venous Disease Quality-of-Life Questionnaire (CIVIQ 20) at the first, baseline visit (V1), at the end of treatment (V2) and 2 (V3) and 4 months after treatment completion (V4). At the last visit (V4), patient disease status was assessed objectively (by the treating physician) and subjectively (by the patient). The study population was divided into three groups: 1) patients with only varicose veins; 2) patients with only lower-limb edema; 3) patients with varicose veins and edema (ITT population).

RESULTS

Seventy-five centers enrolled 1066 patients (ITT population); 914 patients completed the study. Mesoglycan treatment produced significant improvement of edema and lower-limb circumference at every visit, in both patients with edema alone and those with edema and varicose veins (paired sample t-test P<0.001). QoL improved significantly in all questionnaire dimensions in all three patient groups even after treatment was concluded (V2). Improvement continued up to the end of the study observation period (V4) (paired sample t-test P<0.001). Objective clinical improvement of the underlying CVD was found in 76.82% of patients with varicose veins alone, in 82.83% of patients with edema alone, and in 76.7% of patients with varicose veins and edema. Patients' own subjective assessment of improvement was 82.0%, 79.39% and 79.39% respectively for the three groups.

CONCLUSION

Results showed mesoglycan treatment to improve QoL significantly in patients with CVD as measured by a specific questionnaire like the CIVIQ 20. The extent of average edema reduction observed at the last visit (4 months after the end of drug treatment), suggests mesoglycan might have an etiological role, modifying the physiological factors underlying CVD and not just affording temporary improvement of symptoms.

Massive epidural varix mimicking lumbar disc herniation: case report and literature review

Sciatica is generally caused by such well-recognized entities as lumbar disc herniation and degenerative stenosis. A rarely reported alternative cause of lumbar nerve root compression is by distended epidural veins. A case is presented of sciatica produced by such a mechanism, successfully treated by decompressive laminotomy.

[Disabling pathogenetic causes in postthrombotic disease of the lower extremities]

Prospective investigation of etiological and pathogenetic causes of the disabling complications incidence in the lower extremities postthrombotic disease (LEPTHD), influencing activity of these patients, was conducted. The examined patients were divided into two groups, in 62 (58.5%) patients a disability was absent, and in 44 (41.5%) disability was established. Profound clinical examination was conducted, including determination of subfascial pressure on the shin, ultrasound duplex scanning of venous system, electroneuromyography of the lower extremities, estimation of the D-dimer, levels antithrombine-III activity in general and regional blood flow. The leading factors, which causes the LEPTHD patients activity restriction, were determined, basing on the results analysis.

Glycosaminoglycan sulodexide modulates inflammatory pathways in chronic venous disease

Inflammation represents an important epiphenomenon in the etiopathogenesis of chronic venous disease, a worldwide debilitating condition affecting millions of subjects. The pathophysiology of chronic venous disease (CVD) is based on the hemodynamic abnormalities in conjunction to alterations in cellular and extracellular matrix biocompounds. The endothelial dysfunction results from early perturbation in the endothelium linked to glycocalyx injury and promoted by inflammatory cells and mediators (such as matrix metalloproteinases and interleukins), which lead to progressive dilation of the vein resulting in chronic venous insufficiency. Activated leukocytes during the inflammatory process release enzymes, free radicals, chemokines and inflammatory cytokines in the vessel microenvironment, which are responsible for the changes of the venous wall and venous valve, reflux and venous hypertension, and the development/progression of tissue destruction and skin changes. Sulodexide, a highly purified mixture of glycosaminoglycans composed by 80% fast moving heparin and 20% of dermatan sulphate, exhibits anti-thrombotic and profibrinolytic properties, restoring also the essential endothelial glycocalyx. Glycosaminoglycan sulodexide has been also characterized to reduce the release of inflammatory cytokines/chemokines and to inhibit the matrix metalloproteinases-related proteolytic cascades, counteracting endothelial dysfunctions. The pleiotropic effects of sulodexide set the basis for a very promising agent in treating the spectrum of CVD.