Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: a population-based study in France

Clinical outcome of short-term compression after sclerotherapy for telangiectatic varicose veins

BACKGROUND

Sclerotherapy is considered to be the method of choice for the treatment of telangiectatic varicose veins (C1 veins). Whereas the use of compression stockings after sclerotherapy is recommended, little is known about the impact of compression on the outcome of sclerotherapy. The aim of this study was to assess the influence of compression on the outcome of injection sclerotherapy of C1 varicose veins.

METHODS

There were 100 legs of 50 consecutive patients with chronic venous insufficiency (C1) included. After randomization per patient, both legs were treated with sclerotherapy in a predefined area of the thigh (measuring 100 cm²), followed by eccentric compression for 24 hours. Group A received no further compression, whereas group B was additionally equipped with compression stockings of 18 to 20 mm Hg above the ankle and continued wearing these for 1 week. Photodocumentation was performed before, 1 week after, and 4 weeks after sclerotherapy, and the clinical outcome was assessed at these postprocedure follow-up dates. The photographs were reviewed by an internal unblinded rater and an independent blinded external rater.

RESULTS

There was no discernible difference between the groups in terms of clinical outcome or side effects after 4 weeks. Whereas inter-rater reliability was high, there was no correlation between the raters and patients in terms of outcome. In 55% of the treated legs, the patients deemed the result of the treatment to be good; in 27% of the treated legs, fair; and in 18%, poor. Postprocedure hyperpigmentation occurred in 13% of patients and was comparable in both groups. Compression therapy was found to be comfortable by the majority (58%) of patients.

CONCLUSIONS

One week of postinterventional compression therapy had no clinical benefit compared with no compression.

Physiological changes during prolonged standing and walking considering age, gender and standing work experience

Occupational standing is associated with musculoskeletal and venous disorders. The aim was to investigate whether lower leg oedema and muscle fatigue development differ between standing and walking and whether age, gender and standing work habituation are factors to consider. Sixty participants (15 young females, 15 young males, 15 older males, and 15 young males habituated to standing work) were included and required to stand/walk for 4.5 hours in three periods with two seated breaks. Waterplethysmography/bioelectrical impedance, muscle twitch force and surface electromyography were used to assess lower leg swelling (LLS) and muscle fatigue as well as gastrocnemius muscle activity, respectively. While standing led to LLS and muscle fatigue, walking did not. Low-level medial gastrocnemius activity was not continuous during standing. No significant influence of age, gender and standing habituation was observed. Walking can be an effective prevention measure to counteract the detrimental effects of quasi-static standing.Practitioner summary: Prolonged standing leads to lower leg oedema and muscle fatigue while walking does not. The primary cause of fatigue may be in other muscles than the medial gastrocnemius. Walking may be an effective prevention measure for health risks of occupational standing when included intermittently.Abbreviation: BI: bioelectrical impedance; LLS: lower leg swelling; SEMG: surface electromyography; MTF: muscle twitch force; WP: waterplethysmography; Bsl: Baseline; L: Lunch; E: Evening; MTM: method times measurement; EA: electrical activity; IQR: interquartile range; p: percentile; M: mean; SE: standard error; Adj: adjusted.

Review of imaging and endovascular intervention of iliocaval venous compression syndrome

Iliocaval venous compression syndrome (ICS) is the extrinsic compression of the common iliac vein by the overlying iliac artery against the vertebra. Chronic compression can lead to venous stenosis and stasis, which manifests as chronic venous disease and treatment resistance. Therefore, early recognition of ICS and prompt treatment are essential. Clinical presentations of ICS can be ambiguous and diagnosis requires a high index of suspicion with the relevant imaging studies. The initial imaging test is typically a Duplex ultrasound for vessel assessment and pelvic ultrasound to exclude a compressive mass, which is followed by computed tomography (CT) or magnetic resonance (MR) venography. CT and MRI can identify the anatomical causes for venous compression. In patients with high clinical suspicion for ICS, negative findings on CT and MR venography would still warrant further investigations. Definitive diagnosis can be established using catheter-based venography complemented with intravascular ultrasonography but the nature of their invasiveness limits its utility as a routine imaging modality. In this review paper, we will discuss the evidence, utility and limitations of the existing imaging modalities and endovascular intervention used in the management of ICS.

High prevalence of chronic venous disease among health care workers in the United States

BACKGROUND

Health care workers spend extended times standing and walking short distances and are at risk for development of chronic venous insufficiency (CVI). We conducted a hospital-wide venous screening program designed to measure the prevalence of and risk factors for clinical manifestations of CVI and ultrasound evidence of venous reflux or obstruction in health care workers. We also determined their risk for deep venous thrombosis (DVT).

METHODS

Free venous screening and education were offered to all hospital employees; the program started in April 2016, and results are presented from the first year. Demographics, medical history, and use of compression stockings were recorded. A physical examination determined the clinical class of the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification for clinical disease, and an ultrasound test evaluated for reflux or obstruction in the common femoral vein, popliteal vein, and saphenofemoral junction. The Caprini score was recorded to evaluate risk of DVT. Descriptive statistics were reported, and logistic regression was used for multivariate analysis of risk factors.

RESULTS

We enrolled 636 participants (1272 legs); 93.0% were women. The median age was 42 years (interquartile range, 31-52 years), mean body mass index was 29.2 ± 6.6 kg/m2, and most participants were white (49.1%) or African American (39.5%); 18% reported having hypertension, 7.1% had diabetes, and 6.1% were current smokers. The majority reported occasional leg pain (72.7%) and evening leg swelling (42.3%). Only 2.7% used daily compression stockings. Clinical evidence of CVI was present in at least one leg in 69.1% (C1, 49.0%; C2, 17.7%; C3, 1.9%; C4, 0.2%; C5, 0.2%). Venous reflux was present in at least one leg in 82.1%; obstruction was rare (0.2%). Reflux in either the superficial (saphenofemoral junction) or the deep (femoral or popliteal) venous system was present in the majority (71.0%) of patients with CVI (clinical class ≥C1). Reflux and white race were risk factors for clinical disease; clinical disease, age, female sex, and white race were risk factors for reflux. On the basis of the Caprini score, 14.1% of participants were in the highest risk category for DVT when experiencing a high-risk situation (including 2.2% with history of DVT).

CONCLUSIONS

Prevalence of clinical CVI and venous reflux is high among health care workers despite a low frequency of cardiovascular comorbidities. Increased awareness about CVI and DVT and preventive strategies for venous disease must be instituted in this high-risk cohort.

Varicose veins and its risk factors among nurses at Dhulikhel hospital: a cross sectional study

Background

Women in nursing professions are at high risk for developing varicose veins as it requires physical work and prolonged standing. The aim of the study is to estimate the current prevalence of varicose veins among nurses at Dhulikhel Hospital and assess its risk factors.

Methods

A cross sectional study was carried out among 181 female nurses from different clinical settings of Dhulikhel Hospital. A structured questionnaire was administered to gather the demographic, work related and medical history information. The participants underwent Doppler ultrasound for varicose veins confirmation. Varicose veins was defined as Doppler finding of reflux or vein diameter equal or greater than 5 mm.

Results

A total of 181 nurses participated in this study and 83 (46%) had varicose veins. The mean standing time was 4.28 (0.8) hours /day, mean sitting time was 1.28 (0.6) hours/day, mean walking time was 2.37 (0.8) hours/day. In the adjusted model the odds of having varicose veins was 27 times greater with every 1 hour increase in standing time per day (adjusted OR: 27.44; 95% CI 4.09–180.77; p-value <0.00).

Conclusions

Varicose veins was prevalent among nurses’ at Dhulikhel Hospital. Prolonged standing was found to be a significant factor for varicose veins.

Role of Vascular Ultrasound in Cases of Lower Limb Hyperpigmentation

Background

Hyperpigmentation remains an important finding in cases of venous insufficiency and peripheral arterial disease (PAD) among the vascular causes.

Aims

This study aimed at finding the presence of arterial and/or venous insufficiency in patients of lower leg hyperpigmentation by using vascular ultrasound (US).

Materials and Methods

Fifty patients of lower leg pigmentation were included in the study. The detailed history, general physical examination, and laboratory investigations were done. Color Doppler ultrasonography was performed to check for venous insufficiency/PADs. Qualitative variables were correlated using chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant.

Results

The mean age of the patients was 44.32 ± 14.16 years. Four patterns of skin changes were seen - reticulate macular, diffuse macular, lipodermatosclerosis and ulcer. Thirty-five (70%) patients had no visible varicose vein while 15 (30%) had visible varicose vein. In patients with visible varicose vein, color Doppler showed signs of venous insufficiency in all patients, but in cases of no visible varicose vein, color Doppler showed signs of venous insufficiency in 19 (54.28%) patients and showed no signs of venous insufficiency in others (P = 0.78). Only 1 (2%) patient showed atherosclerotic changes in both anterior tibial arteries.

Conclusion

All patients with lower leg pigmentation with or without visible varicose vein should undergo vascular US to rule out any venous insufficiency.

Examining risk factors and preventive treatments for first venous leg ulceration: A cohort study

BACKGROUND

Large studies that examine risk factors for first occurrence of venous leg ulcerations are needed to guide management.

OBJECTIVE

To investigate factors associated with development of first occurrence of venous leg ulcerations.

METHODS

A retrospective cohort study using a validated national commercial claims database of patients with venous insufficiency. Subjects were followed to determine whether they developed first occurrence of venous leg ulcerations, and risk and protective factors were analyzed.

RESULTS

Adjusted hazard ratio (AHR) for comorbidities demonstrated an increased risk in men (AHR 1.838; 95% confidence interval [CI] 1.798-1.880), older age (45-54 years: AHR 1.316, 95% CI 1.276-1.358; 55-64 years, AHR 1.596, 95% CI 1.546-1.648), history of nonvenous leg ulceration (AHR 3.923; 95% CI 3.699-4.161), anticoagulant use (AHR 1.199; 95% CI 1.152-1.249), antihypertensive use (AHR 1.067; 95% CI 1.040-1.093), and preexisting venous insufficiency including chronic venous insufficiency (AHR 1.244; 95% CI 1.193-1.298), edema (AHR 1.224; 95% CI 1.193-1.256), and chronic venous hypertension (AHR 1.671; 95% CI 1.440-1.939). Possible protective factors were having venous surgery (AHR 0.454; 95% CI 0.442-0.467), using compression stockings (AHR 0.728; 95% CI 0.705-0.753), using prescribed statin medications (AHR 0.721; 95% CI 0.700-0.743), and using pain medications (AHR 0.779; 95% CI 0.757-0.777).

LIMITATIONS

Risk of misclassification, given the use of International Classification of Diseases, Ninth Revision codes. Possible confounding factors such as body mass index could not be adequately controlled with these codes.

CONCLUSION

The new evidence presented supports a paradigm shift toward venous leg ulceration prevention.

Influence of polidocanol ultrasound-guided foam sclerotherapy on quality of life in lower extremity chronic venous disease: initial results

Chronic Venous Insufficiency (CVI) is not only detrimental to patients' Quality of Life (QoL) but also places a considerable burden on public health resources. Ultrasound guided foam sclerotherapy (USFS) is a good treatment option, but its effect on patients' QOL is still unclear. This article presents the results from the first 27 patients in a prospective, longitudinal, non-controlled study for evaluation of the clinical and QOL impact of USFS treatment for CEAP C4 to C6 grade CVI with contraindications for open surgery. Clinical symptoms were measured with the Venous Clinical Severity Score (VCSS) and QOL by the Assessment of Burden Chronic Disease - Venous questionnaire (ABC-V). We observed 22.2% reductions in VCSS (p<0.001) in the first week after the procedure, and a 37.8% reduction in ABC-V scores (p=0.03) over the first 3 months.

Clinical and Genetic Determinants of Varicose Veins

BACKGROUND

Varicose veins are a common problem with no approved medical therapies. Although it is believed that varicose vein pathogenesis is multifactorial, there is limited understanding of the genetic and environmental factors that contribute to their formation. Large-scale studies of risk factors for varicose veins may highlight important aspects of pathophysiology and identify groups at increased risk for disease.

METHODS

We applied machine learning to agnostically search for risk factors of varicose veins in 493 519 individuals in the UK Biobank. Predictors were further studied with univariable and multivariable Cox regression analyses (2441 incident events). A genome-wide association study of varicose veins was also performed among 337 536 unrelated individuals (9577 cases) of white British descent, followed by expression quantitative loci and pathway analyses. Because height emerged as a new candidate risk factor, we performed mendelian randomization analyses to assess a potential causal role for height in varicose vein development.

RESULTS

Machine learning confirmed several known (age, sex, obesity, pregnancy, history of deep vein thrombosis) and identified several new risk factors for varicose vein disease, including height. After adjustment for traditional risk factors in Cox regression, greater height remained independently associated with varicose veins (hazard ratio for upper versus lower quartile, 1.74; 95% CI, 1.51-2.01; P<0.0001). A genome-wide association study identified 30 new genome-wide significant loci, identifying pathways involved in vascular development and skeletal/limb biology. Mendelian randomization analysis provided evidence that increased height is causally related to varicose veins (inverse-variance weighted: odds ratio, 1.26; P=2.07×10^-16).

CONCLUSIONS

Using data from nearly a half-million individuals, we present a comprehensive genetic and epidemiological study of varicose veins. We identified novel clinical and genetic risk factors that provide pathophysiological insights and could help future improvements of treatment of varicose vein disease.

Association between venous reflux and diameter of great saphenous vein in lower thigh

OBJECTIVE

Venous reflux may occur in all parts of the great saphenous vein (GSV). The GSV diameter generally increases when venous reflux occurs, and the extent of venous dilation may be altered on the basis of size and location of the reflux within the GSV. We examined which part of the GSV is the most sensitive and dilated in association with venous reflux.

METHODS

We retrospectively evaluated the data of 99 patients (198 limbs) with signs and symptoms of venous insufficiency of both lower limbs from January 2016 to December 2016. We performed ultrasound to examine the venous reflux and to measure the diameter of the GSV. The GSV was divided into four locations: saphenofemoral junction, midthigh, lower thigh (LT), and below the knee. The patients were divided into two groups according to the presence or absence of reflux.

RESULTS

There were 87 limbs that had venous reflux and 111 limbs that had no reflux. The diameter of the GSV with reflux was significantly larger than that of GSVs without reflux only at the LT (4.7 mm vs 4.2 mm; P < .001), and the highest area under the receiver operating characteristic curve was 0.642 at the LT. The cutoff value of the LT diameter for association with reflux was 5 mm (P = .025).

CONCLUSIONS

The cutoff diameter of the LT was 5 mm. We recommend treatment of symptomatic reflux, and LT diameter may be useful for follow-up before and after treatment.

[Treatment of patients with lower limb varicose veins disease]

Modern data on the prevalence and pathophysiology of lower limb varicose disease are presented. The results of studies of modern approaches to the surgical correction of this state are demonstrated. Conclusions about the unresolved number of problems.

Prevalence of chronic venous pathology in healthcare workers and the role of upright standing

BACKGROUND

Chronic venous disease (CVD) affects around 25% of adult population in developed countries and it often represent a health problem for different kind of workers, in particular for who spend much of the working time in upright standing.

METHODS

The study was carried out on a population of 173 nonmedical workers of a midsize hospital in Italy (91 nurse, 31 support staff workers and 51 employees). The study protocol was taken from a previous study of our group and included a clinical examination and a questionnaire.

RESULTS

From the analysis of data it emerged a particular importance of upright standing as major risk factor for CVD. The prevalence of venous pathology seems to be greater among nurses and auxiliaries than the administrative staff and, as expected, it was significantly higher among female workers than in males.

CONCLUSIONS

The results obtained show that the clinical-diagnostic protocol described can be used by doctors for screening venous pathology at workplaces.

Therapeutic potential of natural compounds in inflammation and chronic venous insufficiency

The term varicose vein refers to the twisted and swollen vein visible under the skin surface which occurs most commonly in the leg. Epidemiological studies report a varying percentage of incidences from 2 to 56% in men and <1-60% in women. Venous insufficiency is most often caused by the damage to the valves and walls of the veins. The mechanism of varicose vein formation is complex. It is, however, based on hypotensive blood vessels, hypoxia, and other mechanisms associated with inflammation. This work describes mechanisms related to the formation and development of the varicose vein. It discusses risk factors, pathogenesis of chronic venous disease, markers of the epithelial and leukocyte activation, state of hypoxia and inflammation, reactive oxygen species (ROS) generation, and oxidative stress. Additionally, this paper describes substances of plant origin used in the treatment of venous insufficiency. It also considers the structure of the molecules, their properties, and their mechanisms of action, the structure-activity relationship and chemical properties of flavonoids and other substances. The flavonoids include quercetin derivatives, micronized purified flavonoid fraction (Daflon), natural pine bark extract (Pycnogenol), and others such as triterpene saponine, extracts from Ruscus aculeatus and Centella asiatica, Ginkgo biloba extract, coumarin dereivatives that are used in chronic venous insufficiency. Flavonoids are natural substances found in plants, including fruits, vegetables, flowers, and others. They are important to the circulatory system and critical to blood vessels and the blood flow. Additionally, they have antioxidant, antiinflammatory properties.

Graduated compression stockings effects on chronic venous disease signs and symptoms during pregnancy

Objectives

To evaluate the effectiveness of compression stockings in controlling the varicose veins in pregnant women.

Method

A prospective controlled randomized clinical trial was performed, including 60 women: intervention group (n = 30), who used compression stockings, and control group (n = 30). Diameters of the great saphenous vein and small saphenous vein in the lower limbs of pregnant women in an orthostatic position were analyzed using Duplex-ultrasound. The symptomatology and CEAP were evaluated.

Results

Great saphenous vein diameters in the intervention group were 0.37 cm initial and 0.32 cm final (p < 0.0001) in the right leg and 0.28 cm and 0.38 cm (p < 0.0001) in the control group. CEAP classification presented worsening in the control group (p < 0.0001). The signs and symptoms in the control vs. intervention group: pain (86.67% vs. 23.33%; p < 0.0001), edema (70.00% vs. 33.33%; p = 0.0045), and leg heaviness (93.33% vs. 13.33%; p < 0.0001).

Conclusions

Compression stockings were effective in controlling the varicose veins related to pregnancy.

Association between varicose veins anatomical pattern and procedural complications following endovascular laser photothermolysis for chronic venous insufficiency

We sought to assess clinical characteristics and pattern of collateral network involvement associated with development of truncal (systematized) versus diffuse/non-truncal (non-systematized) varicose veins (VVs) in patients undergoing endovascular laser photothermolysis for chronic venous insufficiency (CVI). Secondly, we aimed to assess whether the type of VVs influenced the procedural complications of endovascular laser therapy. A total of 508 patients with hydrostatic VVs of the lower limbs who underwent endovenous laser treatment were included, out of which 84.1% (n=427) had truncal VVs (group 1) and 15.9% (n=81) had diffuse (non-systematized) VVs (group 2). Patients with truncal varices were significantly older (47.50±12.80 vs 43.15±11.75 years, P=0.004) and those with associated connective tissue disorders were more prone to present diffuse VVs (P=0.004). Patients in group 1 presented a significantly higher number of Cockett 1 (P=0.0017), Cockett 2 (P=0.0137), Sherman (P<0.0001), and Hunter (P=0.0011) perforator veins compared to group 2, who presented a higher incidence of Kosinski perforators (P<0.0001). There were no significant differences regarding postoperative complications: thrombophlebitis (P=0.773), local inflammation (P=0.471), pain (P=0.243), paresthesia (P=1.000), or burning sensation (P=0.632). Patients with more advanced CEAP (clinical, etiologic, anatomic, pathophysiologic) classes were older (P<0.0001), more were males (39.05 vs 27.77%, P=0.0084), more were prone to present ulcers (P<0.0001) and local hyperthermia (P=0.019), and presented for endovenous phlebectomy after a longer time from symptom onset. In patients with CVI, systematized VVs were associated with a more severe clinical status and a distinct anatomical pattern of perforators network compared to non-systematized VVs, which is more common in advanced stages.

Incidence and distribution of lower extremity reflux in patients with pelvic venous insufficiency

Introduction

Women with pelvic venous insufficiency often present with lower extremity symptoms and manifestations of chronic venous disorders. The purpose of this investigation was to determine the incidence of lower extremity chronic venous disorders and the types and distribution of lower extremity veins involved in patients with a known diagnosis of pelvic venous insufficiency.

Methods

Between January 2012 and December 2015, we retrospectively reviewed the charts of 227 women with pelvic venous insufficiency as well as their lower extremity venous duplex investigations. Presenting symptoms, Clinical, Etiology, Anatomy, Pathophysiology (CEAP) class, initial revised Venous Clinical Severity Score (rVCSS) and the types of lower extremity veins with reflux and their locations were noted. Patients were also subcategorized according to their primary pelvic disorder as follows: Entire cohort (PVI), Ovarian vein reflux (OVR), Iliac vein stenosis (IVS) or both (OVR + IVS).

Results

The study group consisted of 227 women (454 limbs) with documented pelvic venous insufficiency. The average age was 44.71 ± 10.2 years. In decreasing order, patients presented with the following lower extremity symptoms: pain (66%), swelling (32%), heaviness (26%), limb fatigue (13%), itching (13%), leg cramps (10%), skin changes or Superficial Venous Thrombosis (SVT) (2%) and ulceration or bleeding (0.08%). Table 1 outlines the CEAP class for 215 of the 227 patients. For the entire cohort, 48% of right and 50% of left limbs demonstrated C0 or C1 disease. The incidence and type of symptomatic lower extremity veins were as follows: any axial vein, 32%; great saphenous vein (GSV), 21%; small saphenous vein (SSV), 11%; GSV and SSV, 5%; non-saphenous tributaries, 15%; saphenous tributaries, 12%; posterior or postero-lateral thigh distribution, 5%; vulvar distribution, 4%; perforators, 4%; deep veins, 2%; and anterior accessory saphenous veins, 1%. For the GSV and SSV, the following patterns of reflux were observed: entire GSV, 4%; entire above knee GSV, 2%; entire below knee GSV, 2%; above knee segmental GSV, 20%; below knee segmental GSV, 21%; above and below knee GSV segmental disease, 1%; entire SSV, 4%; and SSV segmental disease, 12%. The incidence of reflux in any axial vein, the GSV and anterior accessory GSV was greater in the OVR group compared to IVS or OVR + IVS (p ≤ 0.03). In addition, 64 of 227 (28%) patients had a history of prior lower extremity venous ablations: OVR (10/39, 26%), IVS (15/50, 30%) and OVR + IVS (39/127, 9%). The number of ablations per patient was as follows—OVR: 1.48 ± 0.5, IVS: 1.7 ± 0.7 and OVR + IVS: 1.65 ± 0.7.

Conclusion

At least 50% of patients with pelvic venous insufficiency present with lower extremity venous disease. The incidence of reflux in any axial vein is greatest in the OVR group suggesting a correlation with hormonal fluctuations and pregnancy. The majority of symptomatic patients present with segmental axial GSV or SSV disease. Although vulvar and gluteal escape veins are highly associated with pelvic venous insufficiency, they are infrequently observed. In patients who experience residual or persistent symptoms after treatment for chronic venous disorders, a pelvic venous ultrasound should be performed to assess the presence of pelvic venous insufficiency.

Effect of valve lesion on venous valve cycle: A modified immersed finite element modeling

The present study aimed to understand the effect of venous valve lesion on the valve cycle. A modified immersed finite element method was used to model the blood–tissue interactions in the pathological vein. The contact process between leaflets or between leaflet and sinus was evaluated using an adhesive contact method. The venous valve modeling was validated by comparing the results of the healthy valve with those of experiments and other simulations. Four valve lesions induced by the abnormal elasticity variation were considered for the unhealthy valve: fibrosis, atrophy, incomplete fibrosis, and incomplete atrophy. The opening orifice area was inversely proportional to the structural stiffness of the valve, while the transvalvular flow velocity was proportional to the structural stiffness of the valve. The stiffening of the fibrotic leaflet led to a decrease in the orifice area and a stronger jet. The leaflet and blood wall shear stress (WSS) in fibrosis was the highest. The softening of the atrophic leaflet resulted in overly soft behavior. The venous incompetence and reflux were observed in atrophy. Also, the atrophic leaflet in incomplete atrophy exhibited weak resistance to the hemodynamic action, and the valve was reluctant to be closed owing to the large rotation of the healthy leaflet. Low blood WSS and maximum leaflet WSS existed in all the cases. A less biologically favorable condition was found especially in the fibrotic leaflet, involving a higher mechanical cost. This study provided an insight into the venous valve lesion, which might help understand the valve mechanism of the diseased vein. These findings will be more useful when the biology is also understood. Thus, more biological studies are needed.

Risk factors for the development of oedema and lymphoedema

An important symptom of ill health in clinical medicine is the development of oedema, which represents an imbalance in the amount of fluid entering and leaving the tissues of the body. Although medical treatment for the underlying cause of oedema is required, in both cancer and non-cancer settings risk factors that may increase or decrease the potential for oedema to develop or worsen can be identified. For the patient who has risk factors for the development of oedema, advice and education can enable the risk to be modified. Reducing the risk of oedema formation will help avoid long-term problematic oedema and complex skin conditions, as well as maintaining the patient's quality of life. This article discusses some of the risk factors for oedema and lymphoedema and concludes with an outline of how the risk can be managed.

Endovenous ablation and surgery in great saphenous vein reflux: a systematic review and network meta-analysis of randomised controlled trials protocol

INTRODUCTION

Endovenous ablations are the new standard procedures for treatment of great saphenous vein reflux including endovenous laser ablation (EVLA), radio frequency ablation (RFA), endovenous steam ablation (EVSA), mechanochemical ablation (MOCA), cyanoacrylate injection and ultrasound-guided foam sclerotherapy (UGFS). EVLA and RFA have demonstrated similar anatomical success for short-term outcome, but results are controversial for longer term (≥5 years). Additional evidences from randomised controlled trials have been published. This study is, therefore, conducted to, directly and indirectly, compare outcomes among all procedures stratifying by short-term and long-term follow-up.

METHODS AND ANALYSIS

Medline and Scopus will be searched from 2000 to September 2018 with predefined search strategy. Interventions of interest are open surgery (ie, saphenofemoral or high ligation (HL) with stripping) and endovenous ablations (ie, EVLA, RFA, EVSA, MOCA, cyanoacrylate injection and UGFS). The primary outcome is anatomical success. Two independent reviewers will select studies, extract data and assess risk of bias. Disagreement will be adjudicated by the third party. Outcomes will be directly pooled if there are at least three studies in that comparison. A fixed-effect model will be used unless heterogeneity is present, in which case a random-effect model will be applied. Sources of heterogeneity will be explored using meta-regression analysis, and sub-group analysis will be done accordingly. Publication bias will be assessed using Egger's test and funnel plot. A network meta-analysis will be applied to indirect compare all interventions including RFA, EVLA, EVLA with HL, UGFS, UGFS with HL and HL with stripping. Probability of being best intervention will be estimated and ranked. Inconsistency assumption will be checked using a design-by-treatment interaction model.

ETHICS AND DISSEMINATION

Ethical approval is not required for systematic review and network meta-analysis. The study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018096794.

Vein Size and Disease Severity in Chronic Venous Diseases

Given the high prevalence of chronic venous diseases (CVD), defining criteria to screen patients who are in need for intervention is attaining primacy. An important clinical criterion for treating CVD is incompetence of larger veins. We have assessed the association of size of afflicted veins with disease severity in patients with CVD to define an acceptable criterion to identify patients who need intervention. Demographic characteristics and risk factors were recorded from 6350 patients. Based on physical examination and venous duplex ultrasound study, patients were classified into clinical severity, etiology, anatomy, and pathophysiology (CEAP) classes and grouped according to the size of the veins which had varicosities. Patients with reflux in smaller veins (vein size <4 mm diameter) were considered as type I and those with varicosities in truncal veins (>4 mm diameter) as type II. Risk ratio was determined by multivariate regression analysis. About 47.67% of patients in this study were found to have CEAP class 3 disease. Compared with varicose veins of large truncal veins, patients with varicosities in smaller superficial veins had 2.85-fold ( p  < 0.01) more risk of edema and 5.71-fold ( p  < 0.01) higher prevalence of hyperpigmentation. Varicosities in small superficial veins were associated with higher risk of ulceration (odds ratio 3.93, 95% confidence interval 2.51-6.18) compared with truncal vein reflux. Our study reveals that presence of small varicose veins in patients without truncal saphenous reflux involvement is associated with severe manifestations of venous insufficiency such as edema and skin lesions even in the absence of varicosities in truncal saphenous veins.

Compliance with NICE guidelines when commissioning varicose vein procedures

Background

Varicose veins impair quality of life and can lead to chronic leg ulcers. National Institute for Health and Care Excellence (NICE) guidelines (CG168) set out evidence-based standards for patient management. In England, Clinical Commissioning Groups (CCGs) fund NHS care within their locality. The objective of this study was to evaluate CCGs' commissioning policies and compare them with CG168.

Methods

Searches were made for the published policies of all 206 English CCGs. They were reviewed for compliance with NICE guidelines and the associated quality standard. Areas of disagreement were analysed for themes.

Results

Some 203 CCGs (98·5 per cent) had a published policy and 190 (93·6 per cent) of these were published after publication of CG168. Only 73 of the policies (36·0 per cent) were compliant with CG168. Treatment was restricted on the basis of clinical disease severity in 119 CCGs (58·6 per cent); 29 (14·3 per cent) stipulated delay of treatment using a 'trial' of conservative treatment; 22 (10·8 per cent) used lifestyle-related factors such as BMI and smoking status to ration treatment. Treatment was commissioned for uncomplicated symptomatic varicose veins in 87 CCGs (42·9 per cent), but some applied additional rationing mechanisms; 109 CCGs (53·7 per cent) would treat oedema, 183 (90·1 per cent) would treat skin and soft tissue damage, 202 (99·5 per cent) healed ulceration, and all would allow active ulcers to be treated.

Discussion

The majority of CCGs in England have commissioning policies that contradict NICE guidelines. Rationing strategies include disease severity, delay and patient lifestyle-related factors, creating unwarranted geographical variation for varicose vein treatment, disregarding the NHS Constitution for England, and perhaps leading to an increase in costly treatment of chronic complications in the long term.

The Center for Vein Restoration Study on presenting symptoms, treatment modalities, and outcomes in Medicare-eligible patients with chronic venous disorders

BACKGROUND

Chronic venous disorders (CVDs) have been estimated to affect up to 20 million Americans. Despite this huge prevalence, the signs, symptoms, and treatment outcomes in patients 65 years of age and older are not well defined. Our goal was to determine the presentation and treatment outcomes in elderly patients compared with a cohort of patients younger than 65 years.

METHODS

From January 2015 to December 2016, we retrospectively reviewed prospectively collected data from 38,750 patients with CVD from the Center for Vein Restoration's electronic medical record (NextGen Healthcare Information Systems, Irvine, Calif). We divided patients into two groups; group A patients were younger than 65 years, and group B patients were 65 years of age or older. Medical and surgical history, presenting symptoms, treatment modalities, and revised Venous Clinical Severity Score before and after intervention were evaluated. A multivariate logistic regression analysis was performed to determine the predictive value of presenting and associated symptoms. Groups A and B were subdivided by Clinical, Etiology, Anatomy, and Pathophysiology class for subgroup analysis. Data were analyzed with GraphPad Prism (GraphPad Software Inc, La Jolla, Calif) or SAS version 9.4 statistical software package (SAS Institute, Cary, NC).

RESULTS

There were 27,536 patients in group A and 11,214 in group B. Women constituted 78% of all patients. Group B demonstrated a higher incidence of chronic diseases compared with group A (P ≤ .003). As initial presenting symptoms, pain, heaviness, fatigue, and aching were more common in group A than in group B (61% vs 55%, 30% vs 27%, 27% vs 24%, and 17% vs 12%, respectively; P ≤ .001). Swelling, skin discoloration, and venous ulceration were more common in group B than in group A (29% vs 23%, 12% vs 6%, and 5% vs 2%; P ≤ .001). Ablations were more commonly performed in group B patients with C4 to C6 disease (P ≤ .004). The revised Venous Clinical Severity Scores before and 1 month after intervention were similar between groups. Treatment improvement was statistically significant in both groups (P ≤ .001). Multivariate logistic regression analysis indicated that varices, bleeding, swelling, skin changes, venous ulceration, aching, heaviness, pain, fatigue, cramping, and restless legs were associated with the presence of CVD (P ≤ .001).

CONCLUSIONS

Medicare beneficiaries presented with more chronic diseases and more severe disease. Initial and associated symptoms were highly associated with the presence of CVD. Despite requiring more interventions than patients younger than 65 years, Medicare beneficiaries demonstrated the same degree of clinical improvement. Medicare should not develop coverage policy decisions that prevent access to therapies that alleviate CVD-induced symptoms.

The evidence supporting treatment of reflux and obstruction in chronic venous disease

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel convened to assess the evidence supporting treatment of chronic venous disease. Several societies addressed the questions posed to the panel. A multidisciplinary coalition, representing nine societies of venous specialists, reviewed the literature and presented a consensus opinion regarding the panel questions. The purpose of this paper is to present our coalition's consensus review of the literature and recommendations for chronic venous disease.

Report of the Society for Vascular Surgery and the American Venous Forum on the July 20, 2016 meeting of the Medicare Evidence Development and Coverage Advisory Committee panel on lower extremity chronic venous disease

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel assessed the benefits and risks of currently used lower extremity chronic venous disease (CVD) treatments and their effects on health outcome of the American adult population. The main purpose of the meeting was to advise the Centers for Medicare & Medicaid Services on coverage determination for interventions used for treatment of CVD. A systematic review of the Agency for Healthcare Research and Quality was presented, followed by lectures of invited experts and a public hearing of representatives of professional societies and the industry. After discussing critical issues, the panel voted for key questions. This report summarizes the presented evidence to support recommendations of the Society for Vascular Surgery/American Venous Forum coalition and the presentations on selected discussion topics. These included important venous disease evidence gaps that have not been sufficiently addressed, venous disease treatment disparities and how they may affect the health outcomes of Medicare beneficiaries, and mechanisms that might be supported by the Centers for Medicare & Medicaid Services to improve the evidence base to optimize the care of patients with lower extremity CVD.

A Randomised Clinical Trial Comparing N-Butyl Cyanoacrylate, Radiofrequency Ablation and Endovenous Laser Ablation for the Treatment of Superficial Venous Incompetence: Two Year Follow up Results

OBJECTIVE

To compare early and two year results for N-butyl cyanoacrylate (NBCA), radiofrequency ablation (RFA), and endovenous laser ablation (EVLA) in the treatment of varicose veins.

METHODS

This was a randomised clinical trial. Five hundred and twenty five patients were blindly randomised into NBCA, RFA, and EVLT groups (175 patients to each group; block randomisation using sealed envelopes). Four hundred and fifty six patients were monitored for 2 years (ultrasound at 2 days, and 6, 12, and 24 months). The primary endpoint was the saphenous vein occlusion rates, and the secondary endpoints were peri- and post-procedural pain, complications, and time to return to work. No simultaneous phlebectomies were performed.

RESULTS

The numbers of patients lost to follow up were NBCA seven, RFA 26, and EVLA 36. Occlusion rates were similar at 6, 12, and 24 months (6 months [NBCA 98.1%, RFA 94.1%, and EVLA 95.1%, p = .14], 1 year [NBCA 94.7%, RFA 92.5%, and EVLA 94.2%, p = .72], 2 years [NBCA 92.6%, RFA 90.9%, and EVLA 91.5%, p = .89]). Peri-procedural pain was significantly lower after NBCA (p < .001), but complication rates (DVT, bleeding, and phlebitis) were similar. Time to return to work was shortest after NBCA (NBCA 1.04 days, RFA 1.56 days and EVLA 1.31 days (p < .001) with 95% (NBCA), 50% (RFA) and 75% (EVLA) of patients returning to work on Day 1. Pre-procedural venous clinical severity scores (VCSSs) were the same in all groups. A decrease was observed in VCSS values in all groups at 6 months, and this persisted at 1 and 2 years. However, VCSS scores at 6 months and 2 years were significantly lower in the NBCA group (p < .001). Foam sclerotherapy was subsequently applied to varicose tributaries in 18 patients from all groups.

CONCLUSION

No differences were observed in occlusion rates between the three modalities, but NBCA appeared superior with respect to peri-procedural pain, return to work and decreased VCSS.

Studies on the relationship between perforating vein insufficiency and iliac compression syndrome

OBJECTIVE

To study correlation among number(n), diameter (D), and blood reflux time(t) and the left common iliac vein stenosis degree of the expansion of perforating veins, so as to guide the clinical formulation and adjust the treatment plan.

METHODS

Retrospective analysis of 45 PVs patients with left common iliac vein in different degrees of compression in our hospital from 2010 to 2012 was performed. Left common iliac vein was divided into 50%-69%, 70%-99%, 30%-49% and occlusion of the stenosis to avoid the error of the left iliac vein stenosis. Pearson's correlation analysis among the number, diameter, and blood reflux time of perforating veins and left common iliac vein was performed.

RESULTS

Pearson's correlation analysis among the number, diameter, and blood back flow time of perforating veins, and the degree of stenosis was performed, and these results showed that correlation coefficients among the number, diameter, and blood return the PVs between flow time and the degree of stenosis were rp-n = 0.784, rp-d = 0.893, rp-t = 0.845 (P < .001), respectively. The two variables exist positive correlation and correlation was significant.

CONCLUSION

With the increase in left common iliac vein stenosis, the number of perforating veins and the diameter increased, and the time of blood flow were prolonged.

Pathophysiological Mechanisms of Chronic Venous Disease and Implications for Venoactive Drug Therapy

Chronic venous disease (CVD) is a common pathology, with significant physical and psychological impacts for patients and high economic costs for national healthcare systems. Throughout the last decades, several risk factors for this condition have been identified, but only recently, have the roles of inflammation and endothelial dysfunction been properly assessed. Although still incompletely understood, current knowledge of the pathophysiological mechanisms of CVD reveals several potential targets and strategies for therapeutic intervention, some of which are addressable by currently available venoactive drugs. The roles of these drugs in the clinical improvement of venous tone and contractility, reduction of edema and inflammation, as well as in improved microcirculation and venous ulcer healing have been studied extensively, with favorable results reported in the literature. Here, we aim to review these pathophysiological mechanisms and their implications regarding currently available venoactive drug therapies.

Clinical Outcomes of Radiofrequency Ablation for Unilateral and Bilateral Varicose Veins

BACKGROUND

Approximately 20% of varicose vein are bilateral. Patients prefer a simultaneous bilateral procedure instead of 2 separate unilateral procedures. There is currently little evidence comparing bilateral and unilateral varicose vein surgeries.

OBJECTIVE

To report the clinical outcomes of unilateral and bilateral radiofrequency ablation (RFA) for varicose veins.

MATERIALS AND METHODS

The authors retrospectively collected data on clinical outcomes of patients who underwent RFA. They investigated clinical, etiologic, anatomic, and pathophysiologic (CEAP) score, venous clinical severity score (VCSS), and quality of life (QoL) score.

RESULTS

Radiofrequency ablation was performed in 546 limbs in 385 patients. Women comprised 60.4% of the patients. The mean age was 52.3 ± 11.6 years (range, 19-84). The occlusion rate after 2 years was 94.5%. Clinical outcomes of CEAP score, VCSS, and QoL scores improved significantly from 2.15 ± 0.45, 2.70 ± 2.04, and 6.91 ± 6.69 at baseline to 2.10 ± 0.32, 0.63 ± 0.04, and 3.38 ± 4.74 at the study end, respectively. The preoperative and postoperative differences in CEAP score for unilateral and bilateral RFA were 0.02 ± 0.21 and 0.13 ± 0.49, respectively (p = .073). Those of VCSS for unilateral and bilateral RFA were 1.87 ± 1.50 and 4.01 ± 2.93, respectively (p < .001).

CONCLUSION

Good clinical outcomes were shown after RFA with respect to CEAP, VCSS, and QoL scores. The simultaneous bilateral RFA can be performed with effectiveness.

Leg venous ulcer healing process after application of membranous dressing with silver ions

Aim: To assess the efficiency of application of new membranous dressing with silver ions in patients with chronic venous ulceration.

Methods: 58 patients were divided randomly into two groups. In group A (n=30) mean ulcer surface area was 8.52 cm2, in group B (n=28) mean wound surface area was 8.29 cm2. In group A membranous dressings with silver ions (Textus Bioactiv® by Biocell GmbH, Germany) were used. In group B hydrocolloid dressing Unna’s boot was applied. All dressings were changed every 7 days until the wound was completely healed. Changes in wound area were calculated and the speed of healing process was measured every week with healing per day index (cm2/day).

Results: After 7 weeks ulcers healed in all patients of group A. Ulcers in group B healed after 16 weeks of treatment.

Conclusion: On the basis of this outcome the authors concluded that application of membranous dressing with silver ions speeds up the process of treating chronic lower leg ulceration.

TGF-β1 in Vascular Wall Pathology: Unraveling Chronic Venous Insufficiency Pathophysiology

Chronic venous insufficiency and varicose veins occur commonly in affluent countries and are a socioeconomic burden. However, there remains a relative lack of knowledge about venous pathophysiology. Various theories have been suggested, yet the molecular sequence of events is poorly understood. Transforming growth factor-beta one (TGF-β1) is a highly complex polypeptide with multifunctional properties that has an active role during embryonic development, in adult organ physiology and in the pathophysiology of major diseases, including cancer and various autoimmune, fibrotic and cardiovascular diseases. Therefore, an emphasis on understanding its signaling pathways (and possible disruptions) will be an essential requirement for a better comprehension and management of specific diseases. This review aims at shedding more light on venous pathophysiology by describing the TGF-β1 structure, function, activation and signaling, and providing an overview of how this growth factor and disturbances in its signaling pathway may contribute to specific pathological processes concerning the vessel wall which, in turn, may have a role in chronic venous insufficiency.

Upregulation of epidermal gap junctional proteins in patients with venous disease

Background

Leg ulceration is a feared complication of venous insufficiency. It is not known whether varicose veins predispose skin to poor wound healing. The expression pattern of gap junctional protein connexin, a known marker of poor wound healing, was investigated across various stages of venous disease.

Methods

Patients undergoing intervention for varicose veins were assessed according to the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification of varicose veins. Paired 4-mm punch biopsies were taken from above the ankle (pathological) and above the knee (control). Tissues were stained with haematoxylin and eosin, and for connexin 43, connexin 30 and connexin 26.

Results

Forty-eight paired biopsies were taken (12 each for CEAP class C0, C2, C4 and C6). The pathological skin showed progressive epithelial hyperthickening, an increase in the number and depth of rete ridges, increased inflammation and loss of dermal architecture with disease progression from C4 onwards. The overall absolute connexin expression and mean connexin expression per cell in the pathological skin similarly increased across the CEAP classes from as early as C2. Increasing levels of connexin in control skin were also noted, indicating progression of the disease proximally. Connexin 43 expression showed the strongest positive correlation between pathological and control skin.

Conclusion

Connexins were overexpressed in patients with simple varicose veins, with a stepwise increased expression through venous eczema to ulceration. Connexin 43 is a potential biomarker for venous disease. This finding suggests that varicose veins predispose skin to poor wound healing. Surgical relevanceThe overexpression of connexins, a family of gap junctional proteins, is known to cause poor healing in venous leg ulceration. It is not known whether there is any association with superficial venous disease. Here, connexin proteins were overexpressed in patients with uncomplicated varicose veins, before histological skin changes. Connexin could be a biomarker of venous disease progression.

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.

[Health related quality of life in chronic venous disease: Systematic literature review]

OBJECTIVE

Excepting life-threatening situations, improvement of health-related quality-of-life is the main therapeutic goal in chronic disease. The purpose of this review was to study the different ways of assessing Quality-of-Life (QoL) in patients with chronic venous disease (CVD) (CEAP classes C3 to C6).

METHODS

A literature search was conducted with three databases: MEDLINE, WEB OF SCIENCE and COCHRANE LIBRARY in order to identify articles with the PRISMA reporting guidelines. Then we compared psychometric performance of general and specific QoL questionnaires for a French population with CVD.

RESULTS

A total of 481 articles were identified, from which 25 were selected and analyzed. CIVIQ 20, CIVIQ 14 and VEINES Qol/sym are the specific health related QoL scales validated for a French population with CVD. VEINES Qol/sym was specifically validated in patients with leg ulcer or post-thrombotic syndrome (PTS). CIVIQ 14 is a CIVIQ 20 optimized to be used more widely in international studies and validated in milder forms of the CVD spectrum (C0 à C4). The general health related QoL scales are SF-36, SF-12 and EQ-5D. EQ-5D is simple and provides health state utility values.

CONCLUSION

CIVIQ 14 is a simple specific health-related QoL scale for less severe CVD. VEINES Qol/sym was developed for severe CVD and PTS but clinically relevant point scales remain to be assessed. EQ-5D is a generic scale to be preferred to assess economic impact based on a cost-utility analysis.

Assessment of the intraday variability of anthropometric measurements in the work environment: a pilot study

Sitting for long periods of time, both during work and leisure times, is the typical behavior of the modern society. Especially at work, where there is not much flexibility, adopting the sitting posture for the entire day can cause some short-term and long-term effects. As workers' productivity and well-being relies on working conditions, evaluating the effects caused by work postures assumes a very important role. The purpose of this article was to evaluate the variation of some anthropometric measurements during one typical workday to understand whether the known long-term effects can also be seen and quantified in an 8-h period. Twenty participants were measured before and after work, using traditional anthropometry equipment. The data from the two repetitions were compared using statistical tests. The results showed a slight variation in the anthropometric measurements, some with a tendency to increase over time and others with a tendency to decrease.

Prophylactic GSV surgery in elderly candidates for hip or knee arthroplasty

Aging is one of the major risk factors for varicose veins. The same is for Knee and Hip Osteoarthritis. Most of the patients undergoing to Hip (THA) or Knee (TKA) arthroplasty are over sixteen. Varicose veins, excluding thrombophilia, are the most significant risk factors for VTE after THA and TKA. This study investigates on the usefulness of prophylactic treatment of GSV insufficiency in elderly patients undergoing to orthopedic surgery. A retrospective study enrolling 44 over-sixty five patients, undergoing to TKA or THA. 24 patients underwent to traditional surgery and 20 to EVLA. The presence of evident varicosities and/or a saphenic reflux lasting > 500 ms has been considered as operability criterion. Both in surgery and EVLA group has been performed the ablation of visible varicosities and only saphenic refluxing traits.

RESULTS

1 case of symptomatic DVT was recorded after arthroplasty. A statistically significant difference (p = 0.006) of recovery time between surgery and EVLA groups has been detected. There is not a statistically significant difference in long-term recurrence rate between surgery and EVLA.

CONCLUSIONS

It is useful to program GSV surgery, before treat hip or knee. This study showed a 50% decrease in the incidence of postoperative DVT.

Recommendations for the medical management of chronic venous disease: The role of Micronized Purified Flavanoid Fraction (MPFF)

Scope A systematic review of the clinical literature concerning medical management of chronic venous disease with the venoactive therapy Micronized Purified Flavonoid Fraction was conducted in addition to an investigation of the hemodynamics and mechanism of chronic venous disease. Methods The systematic review of the literature focused on the use of Micronized Purified Flavonoid Fraction (diosmin) which has recently become available in the US, in the management of chronic venous disease. The primary goal was to assess the level of evidence of the role of Micronized Purified Flavonoid Fraction in the healing of ulcers, and secondarily on the improvement of the symptoms of chronic venous disease such as edema. An initial search of Medline, Cochrane Database for Systematic Reviews and Google Scholar databases was conducted. The references of articles obtained in the primary search, including a Cochrane review of phlebotonics for venous insufficiency, were reviewed for additional studies. Studies were included if patients had a diagnosis of chronic venous disease documented with Doppler and Impedance Plethysmography. Studies excluded were those that had patients with arterial insufficiency (Ankle Brachial Index < .6), comorbidity of diabetes, obesity, rheumatological diseases, or if other causes of edema were present (congestive heart failure, renal, hepatic or lymphatic cause), or if the patient population had recent surgery or deep vein thrombosis, or had been using diuretics (in studies of edema). Other elements of the study design were to note specifically the type of compression therapy used in conjunction with Micronized Purified Flavonoid Fraction. Results The literature review yielded 250 abstracts, 65 of which met criteria for further review and 10 papers were selected for consideration in the systematic review. Conclusion In summary, the general level of evidence supports the recommendation that the use of medical therapy with Micronized Purified Flavonoid Fraction has beneficial outcomes without serious adverse events. In the United States, diosmiplex is the only available prescription formulation of Micronized Purified Flavonoid Fraction. It is derived from the rinds of oranges and is categorized as a medical food and not as a drug; and may be a particularly attractive therapy for many chronic venous disease patients because of its favorable safety profile. The Working Group for chronic venous disease concurs with previous guidance by the International European Society for Vascular Surgery in 2015 which recommended the use of Micronized Purified Flavonoid Fraction for the healing of venous ulcers, alone and adjunctive to compression therapy, and for the reduction in symptoms of chronic venous disease such as edema.

A case-control study of risk factors of chronic venous ulceration in patients with varicose veins

Background/objectives

Venous ulcers carry psychological and high financial burden for patients, causing depression, pain, and limitation of mobility. The study aimed to identify factors associated with an increased risk of venous ulceration in patients with varicose veins in Armenia.

Methods

A case-control study design was utilized enrolling 80 patients in each group, who underwent varicose treatment surgery in two specialized surgical centers in Armenia during 2013–2014 years. Cases were patients with varicose veins and venous leg ulcers. Controls included patients with varicose veins but without venous leg ulcers. Data were collected using interviewer-administered telephone interviews and medical record abstraction. Multiple logistic regression analysis was used to identify the risk factors of venous ulceration.

Results

There were more females than males in both groups (72.5% of cases and 85.0 % of controls). Cases were on average older than controls (53.9 vs. 39.2 years old, p ≤ 0.001). After adjusting for potential confounders, the estimated odds of developing venous ulcer was higher in patients with history of post thrombotic syndrome (odds ratio = 14.90; 95% confidence interval: 3.95–56.19; p = 0.001), with higher average sitting time (odds ratio = 1.32 per hour of sitting time; 95% confidence interval: 1.08–1.61; p = 0.006), those with reflux in deep veins (odds ratio = 3.58; 95% confidence interval: 1.23–10.31; p = 0.019) and history of leg injury (odds ratio = 3.12; 95% confidence interval: 1.18–8.23; p = 0.022). Regular exercise in form of walking (≥5 days per week) was found to be a protective factor from venous ulceration (odds ratio = 0.26; 95% confidence interval: 0.08–0.90; p = 0.034).

Conclusion

We found that reflux in deep veins, history of leg injury, history of post thrombotic syndrome, and physical inactivity were significant risk factors for venous ulceration in patients with varicose veins, while regular physical exercise mitigated that risk. Future studies should investigate the relationships between the duration and type of regular exercise and the risk of venous ulceration to make more specific recommendations on preventing ulcer development.

Treatment of Primary Varicose Veins in Japan: Japanese Vein Study XVII

Purpose: This study aimed at clarifying the changes in treatments for primary varicose veins in Japan. Methods: A questionnaire was mailed to the members of the Japanese Society of Phlebology. The contents of the survey covered the treatment and treatment strategy of varicose vein cases in 2013. The results were examined and compared with the results of previous surveys conducted by the aforesaid society in 1998, 2004 and 2009. Results: Of 36078 patients, 43958 limbs were reported from 201 institutions. Saphenous type was the most common type of varicose veins that developed in patients aged 70-79 years. The C4-6 cases according to the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification occurred significantly more in males than in females (p <0.01). For the treatments of saphenous type and of segment type (dilatation of peripheral branch), endovenous laser ablation (EVLA) was performed most frequently (51%), while the frequency of stripping and of high ligation decreased. EVLA was performed with tumescent local anesthesia, which required one day of hospitalization. Conclusion: In our study, the number of patients with varicose veins increased especially in the elderly. Surgical treatments were selected for a number of patients, and EVLA was the most commonly adopted method of treatment in Japan. (This article is a translation of Jpn J Phlebol 2016: 27; 249-57.).

Risk Factors in Patients with Venous Stasis-Related Skin Lesions without Major Abnormalities on Duplex Ultrasonography

Purpose: To clarify the risk factors for venous stasis-related skin lesions in the legs in patients without major abnormalities on duplex ultrasonography (DUS). Methods: Fifty patients (nine males and 41 females, age 27-93 years) with symptoms of C4 or greater according to the Clinical, Etiological, Anatomical, Pathological (CEAP) classification, but having no abnormalities on DUS were reviewed for known risk factors for chronic venous insufficiency (CVI) such as older age (>70 years), obesity (body mass index [BMI] >30 kg/m²), short walking distance (<200 m/day), reduced ankle range of motion (<20°), and occupation requiring prolonged standing (>8h per day). Results: The risk factor was different between male and female patients; although all patients had at least one of the above risk factors, the most commonly found risk factor in male patients was occupation requiring prolonged standing (63%), while advanced age (78%) and limited walking distance (83%) were risk factors in female patients. Conclusions: Although male and female patients had different risk factors, insufficient walking seemed to be closely related to the development of venous stasis-related skin lesions.