Guidelines for the management of varicose veins

Management of chronic venous disease by general practitioners in Serbia: a cross-sectional study

BACKGROUND

Chronic venous disease (CVD) is one of the most prevalent medical conditions in the general population worldwide.

OBJECTIVE

To evaluate the management of CVD provided by general practitioners (GPs).

METHODS AND MATERIALS

The 2-center cross-sectional study comprised 2284 patients with CVD diagnosed and treated by GPs. Demographic and clinical data were obtained by physical examinations and standardized interviews.

RESULTS

Patients were counseled about different types of therapy; lifestyle advice was recommended to 88.8%, venoactive drugs to 90.8%, compression therapy to 44.0% of patients, anticoagulants to 16.7%, surgical treatment to 8.3%, and other types of therapy were recommended to 7.8% of patients. The most common types of treatment were dual and triple therapies recommended to 39.5% and 33.1%, respectively. The number of therapies recommended to patients increased with CVD progression. Treatment was not recommended to < 1% of patients. Only 8.4% of patients were referred to a vein specialist.

CONCLUSIONS

Although GPs had undergone special medical training about CVD before they were included in the study, some patients did not receive complete management of their condition. Continuous training of GPs and clinical guidelines for the management of CVD may help GPs to make adequate decisions.

Compression therapy versus surgery in the treatment of patients with varicose veins: A RCT

OBJECTIVE

Superficial venous reflux and varicose veins are common. The aim of this randomized controlled trial was to assess effectiveness of compression therapy compared with surgery for superficial venous reflux.

METHODS

153 patients with CEAP class C2-C3 and superficial venous reflux were randomized to receive either conservative treatment (compression stockings) (n = 77) or surgery (n = 76). Clinical examination including duplex ultrasound (DUS) was performed at entry and 1 and 2 years after randomization (compression group) or surgery (surgery group). Venous Clinical Severity Score without compression stockings (VCSS-S), Venous Segmental Disease Score (VSDS), Venous Disability Score (VDS), and health-related quality of life (HRQoL) were assessed at entry and at the follow-ups. Data were analysed on an intention-to-treat basis and according to the actual treatment performed.

RESULTS

At 2 years, 70/76 patients in the surgery group and 11/77 patients in the compression group had been operated on. VCSS-S decreased from 4.6 to 3.5 in the compression group (p < .01) and from 4.8 to 0.6 in the surgery group (p < .001). VSDS decreased from 7.7 to 7.0 in the compression group and from 8.2 to 0.9 in the surgery group (p < .0001). HRQoL did not change in the compression group, but improved significantly in the surgery group.

CONCLUSION

The surgical elimination of non-complicated superficial venous reflux is an effective treatment when compared with providing compression stockings only.

Genomics of varicose veins and chronic venous insufficiency

Recent sequencing of the human genome has opened up new areas of investigation for genetic aberrations responsible for the pathogenesis of many human diseases. To date, there have been no studies that have investigated the entire human genome for the genetic underpinnings of chronic venous insufficiency (CVI). Utilizing Gene Chip Arrays we analyzed the relative expression levels of more than 47,000 transcripts and variants and approximately 38,500 well-characterized genes from each of 20 patients (N (CVI)=10; N (Control Group)=10). Relative gene expression profiles significantly differed between patients with CVI and patients unaffected by CVI. Regulatory genes of mediators of the inflammatory reaction and collagen production were up-regulated and down-regulated, respectively in CVI patients. DNA microarray analysis also showed that relative gene expression of multiple genes which function remains to be elucidated was significantly different in CVI patients. Fundamental advancements in our knowledge of the human genome and understanding of the genetic basis of CVI represents an opportunity to develop new diagnostic, prognostic, preventive and therapeutic modalities in the management of CVI.

[Phlebology in German departments of dermatology. An analysis on behalf of the German Society of Phlebology]

BACKGROUND

Phlebologic diseases have become extremely common and have major socio-economic impact. However, the percentage of dermatologists working in phlebology appears to be decreasing according to the data of the German Society of Phlebology (DGP).

METHODS

To investigate the reasons for this development, we--on behalf of the DGP--sent a questionnaire to 120 German Departments of Dermatology in autumn 2012.

RESULTS

In 76 returned questionnaires, the number of physicians with additional fellowship training in phlebology averaged 1.5; the average number of those who fulfill the criteria for training fellows in phlebology was 0.9. In 71.1 % of the departments there was a phlebologist. A special phlebologic outpatient clinic existed in 73.7 % of the departments. Sonography with Doppler (89.5 %) and duplex (86.8 %) was used as the most frequent diagnostic tool. For therapy, compression (94.7 %), sclerotherapy (liquid 78.9 %, foam 63.2 %, catheter 18.4 %), endoluminal thermic procedures (radio wave 28.9 %, laser 17.1 %) and surgery (especially crossectomy and stripping 67.1 %, phlebectomy of tributaries 75 %) were used. The average number of treatments was very heterogenous in the different departments.

CONCLUSIONS

Phlebology definitely plays an important role in dermatology. Most departments fulfill the formal criteria for the license to conduct advanced training in phlebology. A wide spectrum of phlebological diagnostic and therapeutic procedures is available.

Difficulty associated with donning medical compression stockings: results from a survey comparing two different compression stockings

AIM

Although medical compression stockings (MCSs) represent the cornerstone of conservative treatment for patients with chronic venous disease, high rates of noncompliance exist. This study compared comfort levels and the difficulty associated with putting on/removing two different MCSs; a conventional degressive MCS (ankle pressure: 24-28 mmHg; calf pressure: 14-18 mmHg) and a progressive MCS (ankle pressure: 8-12 mmHg; calf pressure: 21-25 mmHg).

PATIENTS & METHODS

Women wearing class III MCSs in the past 3 months were recruited from across France to complete an at-home, investigator-led questionnaire, designed to evaluate their experience with putting on/taking off MCSs. Patients were randomized to two groups (group 1: controls, degressive stocking right leg, then left leg; group 2: degressive stocking right leg, then progressive stocking left leg).

RESULTS & CONCLUSION

Patients (n = 102) in group 1 (controls) reported no differences after wearing the degressive MCS on the right leg then the left leg. By contrast, group 2 patients (n = 118) reported statistically significant improvements with the progressive MCS compared with the degressive MCS in all questionnaire parameters, including 'comfort' and 'ease of putting on/taking off' dimensions. Progressive MCSs were associated with significantly better outcomes (ease of putting on/taking off and comfort) than the conventional MCSs.

Endovenous management of venous leg ulcers

BACKGROUND

Compression is the current "standard" in the treatment of venous leg ulcers, and corrective surgery is ancillary. The emergence of safe and effective minimally invasive corrective techniques prompts a reappraisal of this paradigm.

METHODS

Among 192 consecutive limbs with venous leg ulcers, 189 were treated by (1) endovenous laser ablation (n = 30), (2) iliac vein stent placement (n = 89), or (3) both (n = 69). Residual deep reflux was not treated. No specialized wound care was used, and 38% of patients did not use stockings. Outcome measures were time to heal the ulcer and cumulative long-term healing.

RESULTS

Sixty percent of the limbs were post-thrombotic. The median reflux segment score was 3 (range, 0-7). Thirty-seven percent had deep axial reflux. Median intravascular ultrasound-detected stenosis was 70% (range, 0%-100%) in stented patients. Sensitivity of venography to iliac vein obstruction was 52%. Postprocedural mortality was 0%, and 2% had deep venous thrombosis (<30 days). By 14 weeks, 81% of the small ulcers approximately ≤1 inch in diameter had healed. Larger ulcers were slower in healing (P < .001). Post-thrombotic etiology, presence of uncorrected deep reflux, demographic factors, or stocking use had no bearing on healing time. Long-term cumulative healing at 5 years overall was 75%. Healing was better in nonthrombotic limbs compared with post-thrombotic limbs (87% vs 66% at 5 years; P < .02) but was similar among the various demographic subsets, procedures, and whether or not patients used compression. Quality-of-life measures improved significantly. Cumulative long-term healing was unaffected by residual axial reflux and was unrelated to hemodynamic severity (air plethysmography, ambulatory venous pressure). However, long-term ulcer healing was inferior in limbs with reflux segment score of ≥3 (P < .03). Post-thrombotic limbs with a reflux score of ≥3 had the lowest cumulative healing among cohorts, but even in this category, 60% of limbs had durable healing with very few recurrences.

CONCLUSIONS

Most venous leg ulcers in this consecutive series achieved long-term healing with the described minimally invasive algorithm. Uncorrected residual reflux was not an impediment to ulcer healing. Ulcers sized ≤1 inch required no specialized or prolonged wound care. Compression was not necessary to achieve or maintain healing after interventional correction.