Chronic Venous Insufficiency

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.

CEAP clinical classes C0S-C4: differences, similarities and role of Ruscus + HMC + vitamin C in patients with chronic venous disease

Since the publication of the CEAP classification, new research has enriched our knowledge; notably on the heritability of CVD and the genetic and environmental factors involved in this condition, as well as the symptoms apparent within the spectrum of the CEAP clinical classes and the benefits of medical treatment. Using the CEAP classification as a special theme, a symposium with the same title as the present paper was held at the annual meeting of the 2019 European Venous Forum. The lectures presented much valuable information, from which some key points can be extracted. The influence of environmental factors was demonstrated, and the fact that a large amount of information can be obtained from comprehensive history taking. There is robust evidence for heritability. Many candidate genes/loci have been identified, potentially offering new targets for treatment. More research is needed, notably using genome-wide association studies and also on microbiota, which may play a role in CVD through the inflammation pathway. Ruscus + HMC + vitamin C acts by increasing venous and lymphatic tone, protecting microcirculation, and reducing inflammation. It improves quality of life in C0S to C3 CVD patients, while a review of clinical studies and a meta-analysis have confirmed its clinical efficacy across a wide spectrum of CVD clinical classes: C0S, C1S, C2, C3 and C4. It has been awarded a Grade 1A recommendation by the international guidelines.

Hyperelastic Properties of Platinum Cured Silicones and its Applications in Active Compression

This paper presents the fundamental research of design, development, and evaluation of an active compression system consisting of silicone based inflatable mini-bladders, which could be used in applying radial pressure for the treatment of venous disease. The use of mini-bladders will nullify the effect of radius of curvature and provide a higher resolution to the pressure distribution. They are designed with two elastomeric layers and inflation is limited only to one side. The mini-bladders apply a radial force onto the treated surface when inflated, and the pressure inside mini-bladders could be measured using the concept of back pressure, which provides the flexibility to inflate mini-bladders to a predefined pressure. The 3-D deformation profile of the mini-bladders was analysed using finite element method (FEM) and FEM simulations were validated with experimental data, which showed good agreement within pressure region required for the treatment of venous disease. Finally, the pressure transmission characteristics of mini-bladders were evaluated on a biofidellic lower leg surrogate and the results have shown that the mini-bladders could apply a uniform pressure irrespective of the location on the leg with a 60%–70% of inlet pressure successfully transmitted onto the leg surface, while 40%–50% was available after the fat layers.

Correlation of Venous Clinical Severity Score and Venous Disability Score with Dermatology Life Quality Index in Chronic Venous Insufficiency

Background

Chronic venous insufficiency (CVI) is an underestimated public health problem involving the lower limbs. It exerts a significant impact on patient's quality of life (QoL). The severity of the disease was measured by venous clinical severity score (VCSS) and venous disability score (VDS).

Aims

The aim of the study was to evaluate VCSS, VDS, and dermatology life quality index (DLQI) among the patients of CVI and to evaluate the correlation among DLQI with VCSS, VDS, and leg ulcer.

Materials and Methods

In this institution-based cross-sectional study, clinically and sonographically confirmed cases of CVI were included. Clinical severity of the disease and disability were assessed by using VCSS and VDS, respectively. QoL was assessed by a validated DLQI questionnaire. Correlation between DLQI with VCSS and VDS was analyzed. The association between DLQI with different characteristics of the ulcer was also evaluated.

Results

Mean VCSS, VDS, and DLQI in the study population were 11 ± 4.96, 1.47 ± 0.67, and 6.94 ± 3.87, respectively. Both VCSS and VDS had a strong positive correlation with DLQI. The number of active ulcers, size of the ulcer, and duration of the ulcer had a strong positive correlation, whereas the age of onset of the disease had a negative correlation and duration of the disease had poor correlation with DLQI. Pain (P = 0.03) and edema (P = 0.04) had significant association with VDS.

Conclusion

VCSS and VDS are important tools for measuring severity and disability in CVI, respectively. CVI had a strong impact on patients QoL more than it was thought hitherto.

Performance changes of venous valves following tissue treatment with novel in vitro system

OBJECTIVES

The purpose of this study is to test venous valve performance and identify differences between native tissue and replacement devices developed with traditional tissue treatment methods using a new in vitro model with synchronized hemodynamic parameters and high-speed valve image acquisition.

METHODS

An in vitro model mimicking the venous circulation to test valve performance was developed using hydrostatic pressure driven flow. Fresh and glutaraldehyde-treated vein segments were placed in the setup and opening/closing of the valves was captured by a high-speed camera. Hemodynamic data were obtained using synchronized hardware and virtual instrumentation.

RESULTS

Geometric orifice area and opening/closing time of the valves was evaluated at the same hemodynamic conditions. A reduction in geometric orifice area of 27.2  ± 14.8% (p < 0.05) was observed following glutaraldehyde fixation. No significant difference in opening/closing time following chemical fixation was observed.

CONCLUSIONS

The developed in vitro model was shown to be an effective method for measuring the performance of venous valves. The observed decrease in geometric orifice area following glutaraldehyde treatment indicates a decrease in flow through the valve, demonstrating the consequences of traditional tissue treatment methods.

Weighted Gene Co-expression Network Analysis for RNA-Sequencing Data of the Varicose Veins Transcriptome

Objective

Varicose veins are a common problem worldwide and can cause significant impairments in health-related quality of life, but the etiology and pathogenesis remain not well defined. This study aims to elucidate transcriptomic regulations of varicose veins by detecting differentially expressed genes, pathways and regulator genes.

Methods

We harvested great saphenous veins (GSV) from patients who underwent coronary artery bypass grafting (CABG) and varicose veins from conventional stripping surgery. RNA-Sequencing (RNA-Seq) technique was used to obtain the complete transcriptomic data of both GSVs from CABG patients and varicose veins. Weighted Gene Co-expression network analysis (WGCNA) and further analyses were then carried out with the aim to elucidate transcriptomic regulations of varicose veins by detecting differentially expressed genes, pathways and regulator genes.

Results

From January 2015 to December 2016, 7 GSVs from CABG patients and 13 varicose veins were obtained. WGCNA identified 4 modules. In the brown module, gene ontology (GO) analysis showed that the biological processes were focused on response to stimulus, immune response and inflammatory response, etc. Kyoto encyclopedia of genes and genomes (KEGG) pathway analysis showed that the biological processes were focused on cytokine-cytokine receptor interaction and TNF signaling pathway, etc. In the gray module, GO analysis showed that the biological processes were skeletal myofibril assembly related. The immunohistochemistry staining showed that the expression of ASC, Caspase-1 and NLRP3 were increased in GSVs from CABG patients compared with varicose veins. Histopathological analysis showed that in the varicose veins group, the thickness of vascular wall, tunica intima, tunica media and collagen/smooth muscle ratio were significantly increased, and that the elastic fiber/internal elastic lamina ratio was decreased.

Conclusion

This study shows that there are clear differences in transcriptomic information between varicose veins and GSVs from CABG patients. Some inflammatory RNAs are down-regulated in varicose veins compared with GSVs from CABG patients. Skeletal myofibril assembly pathway may play a crucial role in the pathogenesis of varicose veins. Characterization of these RNAs may provide new targets for understanding varicose veins diagnosis, progression, and treatment.

Evaluation of hemorrhoidal disease and lower extremity venous insufficiency in primary adult varicocele: A prospective controlled study

Background

The study investigated the association between varicocele, lower extremity venous insufficiency and hemorrhoidal disease.

Methods

The study included 62 patients with varicocele and 60 voluntary subjects with no varicocele. Patients who were diagnosed as having varicocele on physical examination and Doppler ultrasonography were included in the study group. Examination of lower extremity venous insufficiency was performed by physical examination and Doppler ultrasonography. Examination of hemorrhoidal disease was performed by a general surgery specialist.

Results

The patients with varicocele had a statistically significant ( p < 0.05) higher rates of venous insufficiency of the lower extremities and had a borderline significant difference of higher hemorrhoidal disease rates ( p = 0.05). Therewithal incidences of hemorrhoidal disease and lower extremity venous insufficiency were significantly higher in body mass index > 25 and age > 30 years of varicocele patients.

Conclusion

There is a statistically significant relation between varicocele, lower extremity venous insufficiency, and hemorrhoidal disease. In particular, varicocele patients who are aged over 30 years and overweight are at higher risk.

Polydocanol foam stabilized by liposomes: Supramolecular nanoconstructs for sclerotherapy

Vascular pathology of the lower limbs is a widespread disease affecting the quality of life for more than 30% of the adult world population. Polydocanol foam is presently the main therapeutic option for treating varicosities, inflammation, and chronic disease which affect the vascular endothelium and blood vessels. Unfortunately, the commercial product contains detergents and surfactants which can provoke several side effects and decrease the efficacy of therapy. In an attempt to overcome these drawbacks, polydocanol foam was mixed with different liposomes before use. The resulting mixture was stable and generated supramolecular nanoconstructs, which may prevent the interaction of the components of the commercial polydocanol foam with the vascular endothelium. This effect depends on the presence of liposomes, which can induce polydocanol foam to change its structure from micelles to complex nanostructures, thus improving its stability. In this attempt, the physicochemical features of the resulting nanoconstructs were tested through dynamic- and multiple light scattering analyses, rheological studies and gel permeation chromatography, while the stability was tested in biological fluids. Our preliminary results showed that the nanoconstructs have some potential as therapeutic agents in sclerotherapy.

Compression therapy: Unna boot applied to venous injuries: an integrative review of the literature

OBJECTIVE

To analyze the literature related to the types of therapies for venous injuries with emphasis on use of the Unna boot, and to investigate and discuss the main aspects related to its use compared to other techniques.

METHOD

Integrative review of the literature of the last five years through searches in the following databases: VHL, LILACS, BDENF, SciELO, MEDLINE/PubMed.

RESULTS

Twenty-two publications were identified, with 15,931 cases among adult or elderly individuals, whose mean age was 60 (35-78) years or greater with no sex differences. The Unna boot presented a shorter healing time than the single and two-layer elastic bandage.

CONCLUSION

Although other compression techniques may prove to be more efficient than the Unna boot by adding more technology, the boot stands out as a traditional low-cost dressing. Multilayer bandage is a gold standard technique. This review demonstrated the best option may not be the Unna boot, because it requires a higher healing time compared to the multilayer bandage, but it meets the expectation with a high rate of treatment efficiency, also when compared to simple dressing, single or two-layer bandage.

Contemporary outcomes of elective iliocaval and infrainguinal venous intervention for post-thrombotic chronic venous occlusive disease

BACKGROUND

Patients with iliofemoral deep venous thrombosis are at risk for development of post-thrombotic syndrome. Iliac vein stenting has been shown to significantly improve clinical outcomes in patients with venous outflow obstruction, although many studies include a heterogeneous population with several different venous pathologic processes. Our objective was to evaluate the results of iliocaval and infrainguinal venous intervention for venous outflow obstruction due to post-thrombotic chronic venous occlusive disease.

METHODS

All patients treated at a single institution for symptomatic iliocaval venous occlusive lesions with and without infrainguinal extension between 2008 and 2015 were retrospectively analyzed. Nonthrombotic iliac vein lesions were excluded from analysis. All patients with symptomatic post-thrombotic occlusion of the iliac vein or inferior vena cava (IVC) and a Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) score of 3 or greater were included. Demographics of the patients, presence of IVC filters at presentation, presenting CEAP score, postintervention CEAP score, primary and secondary patency, wound healing and subjective clinical improvement outcomes, and procedural details were recorded in a database.

RESULTS

There were 105 patients with symptomatic iliocaval venous occlusive lesions identified, of which 31 patients (42 limbs) met inclusion criteria. Presenting symptoms included pain or swelling (100%); venous claudication (81%); and CEAP class 3 (76%), 4 or 5 (14%), or 6 (10%). All patients presented with either subacute (>30 days [35%]) or chronic (>90 days [65%]) iliocaval venous thrombosis. Procedural technical success with venous recanalization was achieved in 100% of cases and in 46% of IVC filter retrieval attempts. Overall clinical improvement was achieved in 84% of patients; complete clinical resolution was obtained in 42% and a decrease in CEAP score in 65%. At a mean follow-up of 14.7 months (range, 2-49 months), primary and secondary 1-year patency was 66% and 75% overall, and primary patency was equivalent between patients requiring isolated iliac venous stenting and those requiring infrainguinal stent extension (68% vs 65%, respectively; P = .74, not significant). Patients who presented with IVC filters had a higher rate of complete clinical resolution if the filter could be removed (100%) compared with those patients in whom the filter could not be removed (17%; P < .01).

CONCLUSIONS

Treatment of chronic venous occlusive disease with iliocaval and infrainguinal venous stenting is associated with acceptable 1-year patency rates, healing of venous ulcers, and a significant reduction in symptoms and CEAP score. Patients who underwent successful removal of indwelling IVC filters showed improved clinical outcomes compared with those in whom the IVC filter could not be removed.

Efficacy of subcutaneous lidocaine injection in venous insufficiency: a prospective, randomized, controlled study, and new treatment protocol

[Purpose] The purpose of this study was to evaluate the efficacy of subcutaneous injection with lidocaine in patients with chronic venous insufficiency in the early stage. [Subjects and Methods] Patients (n=50) randomized to the treatment group received subcutaneous injections from a mixture of physiological saline sterile solution and lidocaine once a week to both legs below the knee for 5 sessions. Patients in the treatment group were also given ankle pumping exercises and compression stockings throughout the treatment. Patients randomized to the control group (n=50) received only ankle pumping exercises and compression stockings. Patients were evaluated using the visual analog scale (VAS) for pain and Chronic Venous Disease Quality of life Questionnaire (CIVIQ-20) for quality-of-life at months 1, 3, 6, at the end of month 12, and at the end of the injection treatment for 5 sessions. [Results] CIVIQ-20 and VAS results were significantly lower in the treatment group, than in the control group at months 1, 3 and 6. However, CIVIQ-20 and VAS results were not significantly different, compared with the pre-operative period at month 12. [Conclusion] We observed that 5-week subcutaneous lidocaine injection treatment was effective in patients who do not respond to oral medical treatment or in whom surgery is not considered.

Review of Endovenous Thermal Ablation of the Great Saphenous Vein: Endovenous Laser Therapy Versus Radiofrequency Ablation

BACKGROUND

Endovenous thermal ablation is a popular treatment for varicose veins of the greater saphenous vein. Two common techniques of thermal ablation are endovenous laser therapy (EVLT) and radiofrequency ablation (RFA).

OBJECTIVE

The authors compare EVLT and RFA in vein therapy.

METHODS

A review was conducted using PubMed. Studies comparing the treatment modalities were gathered and compared on the basis of 5 main standpoints, including: efficacy, side effects, serious complications, recurrence, and quality of life.

RESULTS

It was found that EVLT and RFA are both highly efficacious (>80%). Endovenous laser therapy seems to be slightly more efficacious than RFA in numerous studies but its significance is uncertain. Side effect profiles varied regarding postoperative pain and bruising because both were seen to be significantly less using RFA. Serious complications were found to be rare in both with no significant difference in incidence. Recanalization rate was observed to be higher using RFA with uncertainty in significance among various studies. Quality of life improved after both procedures with no significant difference among the 2.

CONCLUSION

Efficacy and recurrence rate seem to favor EVLT, whereas postoperative pain and bruising favor RFA. Further studies are needed to validate the significance of the differences found.

Peripheral vascular disease assessment in the lower limb: a review of current and emerging non-invasive diagnostic methods

BACKGROUND

Worldwide, at least 200 million people are affected by peripheral vascular diseases (PVDs), including peripheral arterial disease (PAD), chronic venous insufficiency (CVI) and deep vein thrombosis (DVT). The high prevalence and serious consequences of PVDs have led to the development of several diagnostic tools and clinical guidelines to assist timely diagnosis and patient management. Given the increasing number of diagnostic methods available, a comprehensive review of available technologies is timely in order to understand their limitations and direct future development effort.

MAIN BODY

This paper reviews the available diagnostic methods for PAD, CVI, and DVT with a focus on non-invasive modalities. Each method is critically evaluated in terms of sensitivity, specificity, accuracy, ease of use, procedure time duration, and training requirements where applicable.

CONCLUSION

This review emphasizes the limitations of existing methods, highlighting a latent need for the development of new non-invasive, efficient diagnostic methods. Some newly emerging technologies are identified, in particular wearable sensors, which demonstrate considerable potential to address the need for simple, cost-effective, accurate and timely diagnosis of PVDs.

Chronic venous insufficiency in a geriatric collective

Aim: Investigation of symptoms of chronic venous insufficiency (CVI) in geriatric patients > 65 years and their relation to activities of daily life and locomotion.

Methods: This monocenter pilot study collects data from patients of a geriatric hospital. We qualified Activities of daily live by Barthel Index, locomotion via Timed-Up-and-Go-test and clinical CEAP levels and included data from the Venous Clinical Severity Score and the patient questionnaire of the German Society of Phlebology. Additionally a duplex-sonographic screening was performed. Identified CEAP levels were correlated with results of the scores mentioned above.

Results: 42 patients with an average age of 80.5 (64–93) years were included. 76.2 % of them had a CEAP-score of ≥3. CEAP-score 5-6 correlated with limited locomotion and independence in activities of daily life. 81 % of the patients had previous venous therapies.

Conclusion: CVI is an underestimated disease in elder patients. In our collective a great part of patients showed relevant clinical symptoms of CVI which were aggravated by limitations of higher age. Early diagnostic and therapy of CVI are indicated to reduce complicated clinical courses.

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.

FTIR spectroscopy of chronic venous leg ulcer exudates: an approach to spectral healing marker identification

Chronic venous leg ulcer arises as a venous insufficiency complication and is a cause of great morbidity.

Association of Venous Leg Ulcers With Ankle Range of Motion in People Attending Chiropractic Mobile Clinics in the Dominican Republic

Objective

The goal of the study was to determine if there was an association between chronic venous disorders (CVDs), particularly venous leg ulcers, and ankle range of motion (ROM) in the Dominican Republic.

Methods

Chronic venous disorders were classified using the clinical manifestations portion (C) of the CEAP (clinical manifestations, etiology, anatomy, pathophysiology) method. The legs of participants attending mobile chiropractic clinics in rural, low-income areas in the Dominican Republic were assessed for clinical signs of CVD and venous ulcers. Ankle ROM was then measured, and photographs of the legs were taken. The 6 clinical stages of CVD were divided into 3 groups: normal legs (normal), no ulcer CVD, and ulcer CVD (healed and active). Multiple linear regression of ankle ROM against CVD grouping was used to test the association.

Results

Eight of the 837 patients for whom CVD classification was obtained had venous ulcers (healed or active) on at least 1 leg. About 30% relative reduction in ROM (ankle dorsiflexion plus plantar flexion) was observed between the ulcer group and the normal group. Regression analysis comparing legs with ulcers to healthy legs (normal), adjusted for age, gender, indicator for obesity, and previous leg trauma, revealed a significant decrease of approximately 14° (P = .0007) in ankle ROM. Age was also found to be strongly significant in the regression analysis, 1 year of aging was associated with a decrease of 0.16° (P < .0001) in ankle ROM (approximately 1.6° in 10 years).

Conclusion

A significant decrease was observed in ankle ROM for participants with active and healed leg venous ulcers compared with those without ulcers. There appeared to be an association between venous leg ulcers and ankle ROM in this sample.

Current clinical evidence on endovenous laser ablation (EVLA) from randomised trials

Background Endovenous laser ablation (EVLA) is globally counted among the most frequently administered methods to treat saphenous vein incompetence. Technical development proceeded in three particular steps: EVLA #1 – Diode lasers linearly emitting wavelengths from 810 to 980 nm through optical bare fibres; EVLA #2 – Diode or Nd:YAG lasers emitting wavelengths from 1064 to 1500 nm; EVLA #3 – Modified optical fibres warranting an optimised emission geometry by centralisation of the fibre tip (Tulip-fibre, Jacket-tip) or radial emission of the laser beam. Due to the number of different EVLA techniques their value compared with standard surgery (high ligation and stripping, HLS) and other endovascular approaches has to be questioned.

Methods Selective literature analysis based on a systematic PubMed search focussed on randomised controlled trials (RCT) comparing EVLA with HLS and other thermal or nonthermal ablation techniques – radiofrequency ablation (RFA), ultrasound guided foam sclerotherapy (UGFS), endothermal steam ablation (EStA).

Results The search terms “endovenous”, “laser”, “varicose vein” resulted in 509 publications, hereof 57 RCTs, hereof 24 randomised studies comparing EVLA with other treatment approaches: 15 studies comprise comparisons with standard surgery and further 9 studies with other endovenous techniques. 6 RCTs contain long-term followup data on EVLA #1 vs. HLS suggesting superiority of HLS in terms of same site clinical and duplex detected recurrence from the groin. 15 RCTs are reporting short-term results clearly demonstrating inferiority of EVLA #1 against EVLA #2, EVLA #3, and RFA with respect to postoperative complaints and patients’ quality of life.

Conclusions The first generation endovenous laser systems are disadvantageous or even harmful as compared with more advanced EVLA techniques and RFA in terms of patients’ complaints and side effects. Furthermore, evidence is rising that EVLA #1 is inferior to standard surgery regarding long-term treatment efficacy. Therefore, the application of EVLA #1 in the treatment of saphenous vein incompetence cannot be recommended any longer. In view of the more recently published RCTs reporting long-term superiority of standard surgery, HLS should still be implemented as control group in studies investigating endovenous treatment approaches.

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.

Cultural adaptation and validation of the Swedish VEINES-QOL/Sym in patients with venous insufficiency

Objectives

To translate and evaluate the psychometric properties of the Venous Insufficiency Epidemiological and Economic Studies (VEINES) questionnaire, divided into two subscales; symptoms (VEINES-Sym) and quality of life (VEINES-QOL), in a Swedish cohort of patients with venous disease.

Methods

The original questionnaire was translated into Swedish with forward–backward translation and administered to 112 patients who were consecutively recruited and had varying degrees of chronic venous disease. Mean age was 54.5 ± 15.2 years (range: 19–83) and 75% of the participants were female. All patients completed the RAND 36-item health survey and the VEINES-QOL/Sym.

Results

The results showed excellent internal consistency for both VEINES-QOL (Cronbach's alpha (α) = 0.93) and VEINES-Sym (α = 0.89). Both the VEINES-QOL and VEINES-Sym correlated well to all the RAND-36 domains, demonstrating good construct validity. Exploratory factor analysis confirmed both subscales of the VEINES-QOL/Sym.

Conclusions

The Swedish VEINES-QOL/Sym is a valid health-related quality of life instrument for chronic venous disease, both for research purposes and for clinical evaluation.

Analysis of the dynamics of venous blood flow in the context of lower limb temperature distribution and tissue composition in the elderly

OBJECTIVE

The elderly are particularly vulnerable to degenerative diseases, such as circulatory and respiratory system and vascular system diseases. The objective of this study was therefore to evaluate the distribution of temperature and the dynamics of venous blood flow in the lower limbs (LLs) and to assess the interdependence of these parameters in terms of the somatic components in males and females participating in activities at the University of the Third Age.

MATERIALS AND METHODS

The study included 60 females (mean age 67.4 years) and 40 males (mean age 67.5 years). A body composition assessment was performed using the bioimpedance technique - Tanita BC-418MA. The following parameters were examined: fat%, fat mass, fat-free mass, and total body water. The minimal, maximal, and mean temperature values and their distributions were examined using infrared thermographic camera VarioCAM Head. Measurements of the venous refilling time and the work of the LL venous pump were examined using a Rheo Dopplex II PPG.

RESULTS

In males, the mean value of the right LL temperature was 30.58 and the mean value of the left LL was 30.28; the P-value was 0.805769. In females, the mean value of the right LL temperature was 29.58 and the mean value of the left limb was 29.52; the P-value was 0.864773. In males, the right limb blood flow was 34.17 and the left limb blood flow was 34.67; the P-value was 0.359137. In females, the right limb blood flow was 26.89 and the left limb blood flow was 26.09; the P-value was 0.796348.

CONCLUSION

Research results showed that the temperature distribution and the dynamics of blood flow are not significantly different between the right and left extremities in both males and females. However, significant temperature differences were found between the gender groups. Significantly higher temperature values in both the right and left extremities were recorded in males than in females.

Epidemiology, Pathophysiology, Stratification, and Natural History of Pulmonary Embolism

Pulmonary embolism (PE) is a common and potentially fatal form of venous thromboembolism that can be challenging to diagnose and manage. PE occurs when there is obstruction of the pulmonary vasculature and is a common cause of morbidity and mortality in the United States. A combination of acquired and inherited factors may contribute to the development of this disease and should be considered, since they have implications for both susceptibility to PE and treatment. Patients with suspected PE should be evaluated efficiently to diagnose and administer therapy as soon as possible, but the presentation of PE is variable and nonspecific so diagnosis is challenging. PE can range from small, asymptomatic blood clots to large emboli that can occlude the pulmonary arteries causing sudden cardiovascular collapse and death. Thus, risk stratification is critical to both the prognosis and management of acute PE. In this review, we discuss the epidemiology, risk factors, pathophysiology, and natural history of PE and deep vein thrombosis.

Total Ankle Replacement in the Presence of Talar Varus or Valgus Deformities

Patients presenting with end-stage ankle arthritis with coronal plane talar deformities have a variety of complex multidirectional deformities that require careful preoperative assessment and a clear understanding of the pathophysiology. Surgeons managing these patients with total ankle arthroplasty need to be familiar with extra-articular and intra-articular surgical methods to correct pes planus and pes cavus deformities, including bony procedures and soft tissue procedures. Performing these procedures in 1 or 2 stages depends on surgeon preference and the severity of the deformities. This article recommends a two-staged reconstruction for more severely deformed feet.

Clinical correlation with failure of endovenous therapy for leg swelling

Background The development and use of minimally invasive procedures provide improved options for the management of symptoms of chronic venous insufficiency. While many patients with iliac venous occlusive disease and superficial venous insufficiency improve with combined iliac venous stenting and correction of superficial venous reflux, some patients have symptoms which persist. The goal of this study was to identify clinical factors related to persistent symptoms in patients with leg swelling after treatment of both iliac vein stenting and thermal ablation. Methods This observational study analyzed data for patients who underwent both iliac vein stent placement as well as endovenous ablation (either RFA or EVLT) as a management for chronic venous insufficiency between February 2012 and February 2014. Follow-up was performed after completion of both procedures and inquiring for improvement of swelling. Statistical analysis performed using Chi-square and student's t-test. Results Of the total 173 patients who underwent both endovenous closure and iliac vein stent placements, 55 (31.8%) patients were men; 29 (16%) patients stated they had no improvement after these procedures. The average age of patients who did not improve was 68.8 (±16.7 SD) years and 66.2 (±13.3 SD) years for patients who improved. Over all, the classification of the presenting symptoms by CEAP classification demonstrated 25.4%, 53.2%, 5.8%, and 15.6%, for C3-C6, respectively. There was no correlation with failure to improve the swelling with: age ( P = .44), gender ( P = .33), presenting symptom ( P = .67), use of calcium channel blockers ( P = .85), nitroglycerin ( P = .86), Plavix ( P = .07), aspirin ( P = .55), Synthyroid ( P = .55), Coumadin ( P = .14), angiotensin receptor blocker ( P = .81), β Blockers ( P = .61), angiotensin converting enzyme inhibitors ( P = .88), furosemide 40 mg ( P = .74), hydrochlorothiazide 12.5 mg ( P = .07), hydrochlorothiazide 25 mg ( P = .48), and EVLT vs. RFA ( P = .91). The use of furosemide (20 mg) was associated with continued swelling ( P = .01). The use of dual diuretics (furosemide and hydrochlorothiazide) was associated with persistent swelling even after these combined endovenous procedures P = .03). Conclusion These preliminary data suggest that the treatment with diuretics may be associated with failure to relieve lower extremity swelling despite combined endovascular therapy for chronic venous insufficiency.

Identificação pela ultrassonografia vascular dos diâmetros das veias safenas magnas sem refluxo em mulheres

Contexto

A ultrassonografia vascular (UV) é o exame de escolha para estudar o sistema venoso superficial dos membros inferiores e mensurar o diâmetro das veias safenas, podendo ser utilizada como parâmetro para o planejamento cirúrgico.

Objetivos

Identificar pela UV os diâmetros de veias safenas magnas sem refluxo em mulheres e sua relação com a idade, altura, Classificação Clínica, Etiologia, Anatomia e Fisiopatologia (CEAP) e índice de massa corporal (IMC).

Métodos

Estudo transversal em mulheres com sintomas de IVC primária (C0, 1 ou 2), sem cirurgia prévia de varizes e sem refluxo detectado pela UV, nas quais foram mensurados os diâmetros da veia safena magna (VSM) na crossa, coxa e perna, que foram comparados com a idade, altura, classe clínica CEAP e IMC.

Resultados

Foram avaliadas 353 mulheres, das quais 146 foram incluídas no estudo sendo 88 avaliadas unilateralmente e 58 bilateralmente. Os diâmetros encontrados para a VSM sem refluxo foram de aproximadamente 6,5 mm na crossa, 4,0 mm na coxa proximal, 3.0 mm na coxa médio-distal e joelho e 2,5 mm na perna. Em todos os segmentos mensurados houve diferença estatisticamente significativa (p < 0,05) na correlação dos diâmetros com IMC. Não houve diferença estatística na correlação da medida dos diâmetros com classe CEAP, altura e idade das pacientes.

Conclusões

Observou-se que os diâmetros de veias safenas magnas sem refluxo independem da classe clínica CEAP 0 ou 1 e 2; da idade e da altura das pacientes. Entretanto, os diâmetros da VSM se relacionam significativamente com o IMC das pacientes.

Size of Sclerosing Foams Prepared by Ultrasound, Mechanical Agitation, and the Handmade Tessari Method for Treatment of Varicose Veins

OBJECTIVES

Sclerotherapy is a therapeutic method used in the treatment of varicose veins and works by occluding damaged blood vessels with a chemical solution. Foam sclerotherapy is an attractive treatment because the results are more effective than those obtained by using liquid sclerosants. However, serious neurologic complications, which are likely related to air embolism, have been reported after treatment with foams generated by the handmade method (Tessari technique) most often used clinically. We present an alternative ultrasonic technique for preparation of sclerosing foams to treat varicose veins.

METHODS

Three methods of foam generation were compared: ultrasound, mechanical agitation, and Tessari techniques.

RESULTS

Optical microscopic analyses showed that low-frequency ultrasound can generate foams with smaller bubble distributions compared to those produced by handmade and mechanical agitation methods: 98% of the bubble population was less than 55 ± 10 μm for sonicated foams (mean ± SD, 19 ± 1.8 μm; maximum bubble size, <138.3 ± 32.5 μm), 196.7 ± 38.2 μm for mechanically agitated foams (mean, 37.1 ± 10.6 μm; maximum bubble size, <350 ± 70.9 μm), and 211.7 ± 20.8 μm for handmade foams (mean, 30.8 ± 3.8 μm; maximum bubble size, <445 ± 32.8 μm).

CONCLUSIONS

Low-frequency ultrasonic foam generation yields smaller bubbles and more uniform size distributions than other investigated methods. These properties may reduce serious adverse events reported for sclerotherapy of varicose veins, increasing the safety of foam treatment.

The value of near-infrared spectroscopy for the assessment of calf muscle function in venous patients

OBJECTIVE

Near-infrared spectroscopy (NIRS) is a noninvasive technique with the potential to determine the degree of tissue oxygenation. The aim of the current study was to investigate the use of NIRS as a reliable method of detecting calf muscle pump dysfunction in groups of patients with venous disease.

METHODS

Patients with superficial venous insufficiency (SVI) or history of deep venous thrombosis (DVT) were classified according to the comprehensive classification system for chronic venous disorders (clinical class, etiology, anatomy, and pathophysiology) and compared with controls (GROUP variable). A 10-stage evaluation of ambulatory venous function was performed, and corresponding values of calf regional oxygen saturation (crSaO₂, %) at each phase were recorded (TIME variable). Thereafter, the percentage changes of crSaO₂ values (Δ scores, %) between a given phase and the reference phase were estimated. Differences among groups and phases were evaluated using analysis of variance. Subgroup analysis between C0-C2 and C3-C6 patients was performed. The receiver operating characteristic curve analysis was used to detect the best predictive capability for SVI and DVT.

RESULTS

A total of 30 patients with SVI, 31 patients with DVT, and 34 controls were included in the study. A statistically significant effect of TIME (F = 382.4; P < .001) and TIME × GROUP interaction (F = 6.3; P < .001) was recorded. Concerning prediction, we found a statistically significant area under the curve (AUC) for SVI (AUC = 0.72; 95% confidence interval, 0.58-0.83; P = .003) and for DVT (AUC = 0.83; 95% confidence interval, 0.71-0.92; P < .0001) patients.

CONCLUSIONS

The measurement of crSaO₂ using NIRS detected alterations in calf muscle pump oxygenation during exercise and differences in tissue oxygenation among SVI patients, DVT patients, and controls. NIRS may represent a reliable noninvasive tool for the study of calf muscle dysfunction in venous disease and a useful vehicle for generating testable hypotheses in the laboratory setting.

Efficacy of bacterial cellulose membrane for the treatment of lower limbs chronic varicose ulcers: a randomized and controlled trial

ABSTRACT Objective: to evaluate the efficacy of Bacterial Cellulose (BC) membrane dressings in the treatment of lower limb venous ulcers. Methods: we carried out a prospective, randomized, controlled study of 25 patients with chronic venous ulcer disease in the lower limbs from the Angiology and Vascular Surgery Service of the Federal University of Pernambuco Hospital and from the Salgado Polyclinic of the County Health Department, Caruaru, Pernambuco. We randomly assigned patients to two groups: control group, receiving dressings with triglyceride oil (11 patients) and experimental group, treated with BC membrane (14 patients). We followed the patients for a period of 120 days. Results: There was a reduction in the wound area in both groups. There were no infections or reactions to the product in any of the groups. Patients in the BC group showed decreased pain and earlier discontinuation of analgesic use. Conclusion: BC membrane can be used as a dressing for the treatment of varicose ulcers of the lower limbs.

Effect of socio-demographic characteristics and clinical findings on the quality of life of patients with chronic venous insufficiency

Objective

This study was planned and implemented to evaluate the effect of socio-demographic characteristics and clinical findings on the quality of life of patients with chronic venous insufficiency.

Methods

The sample of this cross-sectional study consisted of 163 patients that presented with the diagnosis of chronic venous insufficiency to the cardiovascular surgery clinic of an education and research hospital in the west of Turkey. The data were collected during face-to-face interviews using a personal information form, clinical, etiology, anatomy, pathophysiology classification, venous insufficiency epidemiological and economic study-quality of life/symptoms scales and the Short Form-36. Descriptive statistics as well as univariate and multivariate analyses were used to analyze the data.

Results

The chronic venous insufficiency patients were found to have a low quality of life. Advanced age, higher body mass index, longer working times, being on regular medication, hypertension and presence of pigmentation according to the clinical, etiology, anatomy, pathophysiology classification were found to be associated with a reduced physical score in SF-36. Furthermore, longer weekly working hours and presence of pigmentation reduced the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms scores. Undertaking physical exercise at twice and more than twice a week increased the overall physical scores in SF-36.

Conclusions

The results of the study showed that the quality of life of chronic venous insufficiency patients are affected by not only physical characteristics, working hours and physical activity but also presence of edema and pigmentation.

Advantages and disadvantages of graduated and inverse graduated compression hosiery in patients with chronic venous insufficiency and healthy volunteers: A prospective, mono-centric, blinded, open randomised, controlled and cross-over trial

Background The therapeutic effectiveness of compression therapy depends on the selection of compression hosiery. Objectives To assess efficacy and tolerability of graduated elastic compression stockings (GECS) and inverse graduated elastic compression stockings (PECS). Methods Thirty-two healthy volunteers and thirty-two patients with chronic venous insufficiency were analysed; wear period: one week for each stocking type (randomised, blinded).

PRIMARY OUTCOME

volume reduction of 'Lower leg' (Image3D®) and 'Distal leg and foot' (water plethysmography).

SECONDARY OUTCOMES

clinical symptoms of chronic venous insufficiency assessed by the Venous Clinical Severity Score, side effects and wear comfort in both groups. Results Volume of 'Lower leg': significant reduction in healthy volunteers (mean GECS: -37.5 mL, mean PECS: -37.2 mL) and in patients (mean GECS: -55.6 mL, mean PECS: -41.6 mL). Volume of 'Distal lower leg and foot': significant reduction in healthy volunteers (mean GECS: -27 mL, mean PECS: -16.7 mL), significant reduction in patients by GECS (mean: -43.4 mL), but non-significant reduction by PECS (mean: -22.6 mL). Clinical symptoms of chronic venous insufficiency were improved significantly better with GECS than with PECS, p < 0.001. GECS led to more painful constrictions, p = 0.047, PECS slipped down more often, p < 0.001. Conclusion GECS and PECS reduce volume of the segment 'Lower leg' in patients and healthy volunteers. Patients' volume of the 'Distal lower leg and foot', however, were diminished significantly only by GECS ( p = 0.0001). Patients' complaints were improved by both GECS and PECS, and GECS were superior to PECS.

Physical exercise for the treatment of non-ulcerated chronic venous insufficiency

BACKGROUND

Chronic venous insufficiency (CVI) is a common disease that causes discomfort and impairs the quality of life of affected persons. Treatments such as physical exercise that aim to increase the movement of the ankle joint and strengthen the muscle pump in the calf of the leg may be useful to reduce the symptoms of CVI.

OBJECTIVES

To assess and summarise the existing clinical evidence on the efficacy and safety of physical exercise programmes for the treatment of individuals with non-ulcerated CVI.

SEARCH METHODS

The Cochrane Vascular Information Specialist (CIS) searched the Cochrane Vascular Specialised Register (May 2016). In addition, the CIS searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4) and trial databases for details of ongoing or unpublished studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing exercise with no exercise programmes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the search results and selected eligible studies. We resolved disagreements by discussion. We summarised and double-checked details from included studies. We attempted to contact trial authors for missing data, but obtained no further information.

MAIN RESULTS

We included two trials involving 54 participants with CVI. Many of our review outcomes were not reported or reported by only one of the two studies. The intensity of disease signs and symptoms was measured in both studies but using different scales; we were therefore unable to pool the data. One study reported no difference between the exercise and control groups whereas the second reported a reduction in symptoms in the exercise group. In one study, increases in change in ejection fraction compared with baseline (mean difference (MD) 4.88%, 95% confidence interval (CI) 3.16 to 6.60; 30 participants; P < 0.00001), half venous refilling time (MD 4.20 seconds, 95% CI 3.28 to 5.12; 23 participants; P < 0.00001) and total venous refilling time (MD 9.40 seconds, 95% CI 7.77 to 11.03; 23 participants; P < 0.00001) were observed in the exercise group compared with the control group. One study reported no difference between the exercise and control groups with regard to quality of life or ankle range of motion. Although muscle strength assessed by dynamometry at slow speed did not differ between the two groups in this study, variable peak torque at fast speed was lower in the control group than in the exercise group (2.8 ± 0.9 compared with -0.3 ± 0.6, P < 0.03). The incidence of venous leg ulcers, incidence of surgical intervention to treat symptoms related to CVI and exercise capacity were not assessed or reported in either of the included trials. We rated both included studies as at high risk of bias; hence, these data should be interpreted carefully. Due to the small number of studies and small sample size, we were not able to verify indirectness and publication bias. Therefore, we judged the overall quality of evidence as very low according to the GRADE approach.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence available to assess the efficacy of physical exercise in people with CVI. Future research into the effect of physical exercise should consider types of exercise protocols (intensity, frequency and time), sample size, blinding and homogeneity according to the severity of disease.

Magnetic Resonance Venous Volume Measurements in Peripheral Artery Disease (from ELIMIT)

The relation between the arterial and venous systems in patients with impaired lower extremity blood flow remains poorly described. The objective of this secondary analysis of the Effectiveness of Intensive Lipid Modification Medication in Preventing the Progression on Peripheral Artery Disease Trial was to determine the association between femoral vein (FV) volumes and measurements of peripheral artery disease. FV wall, lumen, and total volumes were quantified with fast spin-echo proton density-weighted magnetic resonance imaging scans in 79 patients with peripheral artery disease over 2 years. Reproducibility was excellent for FV total vessel (intraclass correlation coefficient 0.924, confidence interval 0.910 to 0.935) and lumen volumes (intraclass correlation coefficient 0.893, confidence interval 0.873 to 0.910). Baseline superficial femoral artery volumes were directly associated with FV wall (r = 0.46, p <0.0001), lumen (r = 0.42, p = 0.0001), and total volumes (r = 0.46, p <0.0001). The 2-year change in maximum walking time was inversely associated with the 24-month change in FV total volume (r = -0.45, p = 0.03). In conclusion, FV volumes can be measured reliably with fast spin-echo proton density-weighted magnetic resonance imaging, and baseline superficial femoral artery plaque burden is positively associated with FV volumes, whereas the 2-year change in FV volumes and leg function show an inverse relation.

Aetiology, comorbidities and cofactors of chronic leg ulcers: retrospective evaluation of 1 000 patients from 10 specialised dermatological wound care centers in Germany

Numerous comorbidities and cofactors have been known to influence wound healing processes. In this multicentre study, clinical data of 1 000 patients with chronic leg ulcers from ten specialised dermatological wound care centers were analysed. The patient cohort comprised 567 females and 433 males with an average age of 69·9 years. The wounds persisted on average for 40·8 months and had a mean size of 43·7 cm(2) . Venous leg ulcers represented the most common entity accounting for 51·3% of all chronic wounds, followed by mixed-type ulcers in 12·9% and arterial ulcerations in 11·0% of the patients. Vasculitis was diagnosed in 4·5%, trauma in 3·2%, pyoderma gangrenosum in 2·8%, lymphoedema in 1·7%, neoplasia in 1·0% and delayed post-surgical wound healing in 0·6% of the included patients. In total, 70·5% of patients suffered from arterial hypertension, 45·2% were obese, 27·2% had non-insulin dependent diabetes, and 24·4% dyslipidaemia. Altogether 18·4% suffered from metabolic syndrome. Cofactors and comorbidities of patients with chronic leg ulcers have previously been studied but not in detail. Here, we were able to demonstrate the existence of several potentially relevant cofactors, comorbidities of their associations and geographical distributions, which should be routinely examined in patients with chronic leg ulcers and - if possible - treated.

The effect of pathologic venous valve on neighboring valves: fluid-structure interactions modeling

Understanding the hemodynamics surrounding the venous valve environment is of a great importance for prosthetic valves design. The present study aims to evaluate the effect of leaflets' stiffening process on the venous valve hemodynamics, valve's failure on the next proximal valve hemodynamics and valve's failure in a secondary daughter vein on the healthy valve hemodynamics in the main vein when both of these valves are distal to a venous junction. Fully coupled, two-way fluid-structure interaction computational models were developed and employed. The sinus pocket region experiences the lowest fluid shear stress, and the base region of the sinus side of the leaflet experiences the highest tissue stress. The leaflets' stiffening increases the tissue stress the valve is experiencing in a very low fluid shear region. A similar effect occurs with the proximal healthy valve as a consequence of the distal valve's failure and with the mother vein valve as a consequence of daughter vein valve's failure. Understanding the described mechanisms may be helpful for elucidating the venous valve stiffness-function relationship in nature, the reasons for a retrograde development of reflux and the relationship between venous valves located near venous junctions, and for designing better prosthetic valves and for improving their positioning.

Global sensitivity analysis of a model for venous valve dynamics

Chronic venous disease is defined as dysfunction of the venous system caused by incompetent venous valves with or without a proximal venous obstruction. Assessing the severity of the disease is challenging, since venous function is determined by various interacting hemodynamic factors. Mathematical models can relate these factors using physical laws and can thereby aid understanding of venous (patho-)physiology. To eventually use a mathematical model to support clinical decision making, first the model sensitivity needs to be determined. Therefore, the aim of this study is to assess the sensitivity of the venous valve model outputs to the relevant input parameters. Using a 1D pulse wave propagation model of the tibial vein including a venous valve, valve dynamics under head up tilt are simulated. A variance-based sensitivity analysis is performed based on generalized polynomial chaos expansion. Taking a global approach, individual parameter importance on the valve dynamics as well as importance of their interactions is determined. For the output related to opening state of the valve, the opening/closing pressure drop (dp_valve,0) is found to be the most important parameter. The venous radius (r_vein,0) is related to venous filling volume and is consequently most important for the output describing venous filling time. Finally, it is concluded that improved assessment of r_vein,0 and dp_valve,0 is most rewarding when simulating valve dynamics, as this results in the largest reduction in output uncertainty. In practice, this could be achieved using ultrasound imaging of the veins and fluid structure interaction simulations to characterize detailed valve dynamics, respectively.

Progressive compression versus graduated compression for the management of venous insufficiency

Venous leg ulceration (VLU) is a chronic condition associated with chronic venous insufficiency (CVI), where the most frequent complication is recurrence of ulceration after healing. Traditionally, graduated compression therapy has been shown to increase healing rates and also to reduce recurrence of VLU. Graduated compression occurs because the circumference of the limb is narrower at the ankle, thereby producing a higher pressure than at the calf, which is wider, creating a lower pressure. This phenomenon is explained by the principle known as Laplace's Law. Recently, the view that compression therapy must provide a graduated pressure gradient has been challenged. However, few studies so far have focused on the potential benefits of progressive compression where the pressure profile is inverted. This article will examine the contemporary concept that progressive compression may be as effective as traditional graduated compression therapy for the management of CVI.

Prolonged Mechanical Circumferential Stretch Induces Metabolic Changes in Rat Inferior Vena Cava

OBJECTIVE/BACKGROUND

Circumferential stretch on the vein wall has been suggested as a potential etiological factor in the development of varicose veins. However, the influence of vein wall stretch on vein metabolism has not yet been explored. The aim of this study was to investigate the effect of short and prolonged mechanical stretch on vein wall metabolism.

METHODS

Circular segments of inferior vena cava from male Sprague-Dawley rats were exposed to normal 0.5-g (nonstretched) or high 2-g (stretched) tension for short (4 h) or prolonged (18 h) duration (five vein segments per group). Contraction response to phenylephrine (10^-5 M) and KCl (96 mM) was elicited to observe the effect of circumferential stretch on vein function. The polar and organic metabolites in vein tissue were extracted using a bilayer extraction method. Aqueous and organic extracts were analyzed using nuclear magnetic resonance spectroscopy and ultra performance liquid chromatography coupled to mass spectrometry, respectively. Data acquired from both analytical platforms were analyzed using mathematical modeling.

RESULTS

Increased concentrations of valine (p = .02) and choline (p = .03) metabolites and triglyceride moieties (p = .03) were observed in veins stretched for 18 h compared with the nonstretched/18 h group.

DISCUSSION

Increased concentrations of branched chain amino acid valine and cell membrane constituent choline indicate increased muscle breakdown and increased metabolism of membrane phospholipids under stretch in an ex-vivo model. Increased intensities of triglyceride moieties in stretched vein segments for 18 h suggest that high pressure may induce an inflammatory response.

CONCLUSION

This study has shown that prolonged mechanical circumferential stretch (18 h) alters the metabolic profile of rat inferior vena cava.

Pathogenesis of Varicose Veins and Implications for Clinical Management

Varicose veins (VVs) classically result from venous hypertension owing to incompetence of the major communications between the superficial and deep veins of the lower extremity. In a significant number of patients, there is no demonstrable truncal saphenous reflux and varicosities are the result of isolated perforating and nonsaphenous vein incompetence. The clinical and histologic features of VVs are the result of disruption of the normal architectural structure of the venous wall as a consequence of remodeling of the extracellular matrix (ECM) in response to increased venous distention and altered hemodynamic shear stress. Although a number of genes, growth factors, proteases, and their inhibitors known to modulate the ECM have been implicated in the pathogenesis of VVs, their etiology remains unknown. The complex variations in venous anatomy in patients with VVs require detailed vein mapping to determine the source and drainage locations of reflux if the rates of residual and recurrent varicosities are to be reduced. The distinct pathogenic mechanisms involved in the development of VVs have important implications for the management of VVs that include a wide spectrum of treatment modalities ranging from reassurance, alternative medicines, conservative management or compression therapy, and surgical or endovascular therapy.