Epidemiology of chronic venous disease

The effect of distraction on pain perception during an endovenous thermal ablation procedure

OBJECTIVES

To determine whether audio and visual distraction can affect the pain perception of a patient undergoing endovenous thermal ablation under tumescent anesthesia.

METHODS

Patients underwent an endovenous thermal ablation procedure and were randomized into two groups: non-distraction (AVD-) and with distraction (AVD+). Visual analogue scale pain score and hospital anxiety depression scale scores were used to measure outcome. The recruited patients were asked to submit an anticipated visual analogue scale pain score prior to treatment as well as the actual experienced post-operative visual analogue scale pain score.

RESULTS

There was no significant difference between the AVD- and AVD+ groups post-operative pain score 2.85 (SD 1.7) versus 2.60 (SD 2.3), p = 0.68. Pain score in women with distraction (AVD+) decreased from 3.81 to 2.42. The pain score in men with distraction (AVD+) increases from 1.88 to 2.82. In the AVD- group, a significant difference was found between men and women (p = 0.014). Disregarding gender, a significant difference was found between the anticipated pain score and the actual pain score in both the AVD- group (p = 0.009) and AVD+ group (p = 0.021). There was a correlation between depression and the pain score, which was not seen between pain and anxiety score.

CONCLUSION

The results suggested that audiovisual distraction has no influence on the visual analogue scale pain score during endovenous thermal ablation under tumescent anesthesia. Despite this, patients appreciate and evaluate audio and visual distraction as pleasant to extremely pleasant when applied.

The influence of age and gender on venous symptomatology. An epidemiological survey in Belgium and Luxembourg

Aim

The aim of this study is to measure the incidence of the symptoms in patients with chronic venous disease (CVD) and to look for the influence of age on the severity of symptoms for both genders.

Materials and methods

A survey was carried out in Belgium and Luxembourg between May and September 2013. Patient recruitment was done by 406 general practitioners (GPs). Each GP screened 10–20 consecutive patients older than 18 years. Inquiries were made regarding the presence of symptoms and possible signs of CVD. Patients with diagnosed CVD filled out a questionnaire including a quality of life score (CIVIQ-14). These data were converted into a CIVIQ Global Index Score (GIS). Statistical analysis was performed in order to calculate the effect of age and gender on the number of symptoms and the estimated probabilities of having CVD.

Results

Totally 6009 patients were included in this survey. The mean age was 53.4 years. Of all, 61.3% of the patients have CVD (C1-C6). Of all, 64.7% of patients were symptomatic. Age and female gender were major risk factors for developing CVD. Most common symptoms were ‘heavy legs’ (70.4%), pain (54.0%), and sensation of swelling (52.7%). The number of symptoms increases with age ( p < 0.001). Female patients have significantly more symptoms in comparison with male patients in all age groups. In both females and males, age is negatively correlated with GIS score ( p < 0.001). The estimated probability of having CVD was significantly higher for woman compared to men and increases with age for both gender.

Conclusion

CVD is a very common progressive disease with age as a major risk factor. Increasing age results in a higher C-classification, more symptoms, and a lower GIS score (quality of life). Female gender interacts significantly with age and results in a more advanced stage of CVD.

Endovenous laser ablation is an effective treatment for great saphenous vein incompetence in teenagers

OBJECTIVES

The current knowledge of chronic venous disease in teenagers and its treatment is very limited. The aim of the study is to present our experience and the available literature data on the treatment of varicose veins in teenagers with endovenous laser ablation of the great saphenous vein.

METHODS

Five patients, aged 15-17 years, were qualified for surgery, based on typical signs and symptoms of chronic venous disease. Minimally invasive treatment with endovenous laser ablation of the great saphenous vein was applied.

RESULTS

The technical success of surgery was achieved in all patients. Over a 2-year follow-up we did not observe any case of recanalisation of the great saphenous vein, recurrence of varicose veins, or serious complications, such as deep vein thrombosis or pulmonary embolism. One patient presented with resolving of post-operative bruising, and two cases of local numbness were transient.

CONCLUSIONS

Endovenous laser ablation of the great saphenous vein in the treatment of chronic venous disease in teenagers is effective and safe. The method provides excellent cosmetic effects, very short recovery time and high levels of patient satisfaction.

Epidemiological study on chronic venous disease in Belgium and Luxembourg: prevalence, risk factors, and symptomatology

OBJECTIVE

This epidemiological study measured the prevalence of chronic venous disease (CVD) in Belgium and Luxembourg. Possible risk factors and the symptomatology were evaluated.

MATERIAL AND METHODS

A survey was carried out in Belgium and Luxembourg between May and September 2013. Patient recruitment was carried out by 406 general practitioners (GPs). Each GP screened 10-20 consecutive patients older than 18 years, and in total 6009 patients were included. Patient characteristics, prevalence of risk factors, symptomatology, and C-classification were noted. The GPs diagnosed CVD and measured the need for treatment. Patients with diagnosed CVD completed a questionnaire about their history of leg problems and a quality of life score (CIVIQ-14). These data were converted into a CIVIQ Global Index Score (GIS).

RESULTS

The mean age of the patients was 53.4 years, and they were predominantly female (67.5%). Among the 3889 symptomatic patients, heavy legs, pain, and sensation of leg swelling were the most common complaints. Among the included patients, 61.3% of patients were classified within C1-C6; however, only 45.9% of these patients were considered by the GPs to be suffering CVD. Treatment was offered to 49.5% of patients. Age and female gender correlate with a higher C-class (p < .001). Patients with a higher C-class (C3-C6) have significantly more pain, sensation of swelling and burning, night cramps, itching, and the sensation of "pins and needles" in the legs. Patients taking regular exercise and without a family history had a lower C-class. Higher BMI, age, female gender, family history, history of thrombophlebitis, and a higher C-class correlated with a lower GIS (p < .001). Of the patients with CVD, 10.4% had lost days of work because of their venous leg problems.

CONCLUSION

CVD is a very common disease, which is underestimated. The prevalence increases with age, generates incapacity to work, and worsens the patients' quality of life.

Does the heel-rise test explain functional capacity in venous insufficiency?

Introduction Individuals with chronic venous insufficiency (CVI) have muscle pump dysfunction and reduced functionality. However, studies are inconsistent in proving whether a particular test can assess muscle functional capacity. Therefore, the aim of this study was to evaluate whether the heel-rise test (HRT) is able to explain functional capacity in patients with CVI. Materials and methods Subjects with CVI aged between 20 and 59 years old were selected for this study. All participants were classified by means of the Clinical Anatomy Etiology Pathophysiology Classification of Chronic Venous Disease (CEAP). The HRT and the shuttle walk test (SWT) were performed. Descriptive statistics, Spearman correlation, linear models and regression variance analysis (one-way ANOVA) were used for data analysis. Significance was set at alpha ≤ 5%. Results 79 subjects were included in the study (38.79 ± 1.34 years). The HRT was able to explain functional capacity only in individuals aged between 50-59 years (R2 = 0.60, p = 0.0001). The heel-rise test was not sensitive to detect differences between the CEAP classes analyzed (p > 0.05). Conclusion The HRT was able to explain functional capacity in individuals aged between 50-59 years, and it can be applied in clinical practice for the functional evaluation of patients with CVI with mild severity in this age range.

Prospective study of a single treatment strategy for local tumescent anesthesia in Muller phlebectomy

BACKGROUND

Ambulatory Muller phlebectomy for varicose veins can be performed under local anesthesia. However, subcutaneous injection of local tumescent anesthetics may cause discomfort because of acidity of the solution. Addition of sodium bicarbonate lowers the acidity of anesthetic solutions, which might cause less pain. The objective of this study was to study whether alkalinization of the local anesthetic solution with sodium bicarbonate 1.4% decreases perioperative pain during Muller phlebectomies.

METHODS

It is a double-blind single-center randomized controlled trial. In all, 101 patients scheduled for ambulatory Muller phlebectomy were randomized to receive either local anesthesia with alkalinized solution (lidocaine 1% and epinephrine in sodium bicarbonate 1.4%) or standard solution (lidocaine 1% and epinephrine in saline 0.9%). Primary outcome was pain during injection of local anesthetics with the use of the Visual Analogue Scale (VAS). Secondary outcomes were peroperative and postoperative pain, use of analgesics, patient satisfaction, return to function, and complications.

RESULTS

Patients receiving subcutaneous injection of local anesthetics diluted in sodium bicarbonate 1.4% experienced significantly less pain during injection compared with patients treated with standard anesthetic solution (VAS, 1.75 ± 1.8 vs. 3.55 ± 2.2, P < 0.00). Peroperative and postoperative pain, complication rates, use of analgesics, patient satisfaction, return to function, and complications did not differ between the 2 groups (P > 0.10).

CONCLUSIONS

Alkalinization of local anesthetic solution with sodium bicarbonate 1.4% significantly improves patient comfort during injection of local tumescent anesthesia.

Immunological aspects of chronic venous disease pathogenesis

Chronic venous disease (CVD) is a very common health problem concerning up to 1/3 of the society. Although venous hypertension and valvular incompetence have been long known to be crucial for development of the illness, its exact aetiology remains unclear. Recent findings indicate that inflammatory processes may be crucial for development of incompetent valves and vein wall remodelling. One of the most interesting theories describes “leucocyte trapping” as the mechanism responsible for elevated vein wall permeability and oxidative stress in the veins. At the same time, the cytokine profile of the blood in incompetent veins has not been thoroughly examined. Popular anti-inflammatory drugs relieve some symptoms but do not have much proved effects in prevention and treatment.

We intend to summarize the existing knowledge of the immunological aspects of CVD in order to emphasize its importance for understanding the aetiology of this illness. We also wish to indicate some aspects that remain to be studied in more detail.

Progression of varicose veins and chronic venous insufficiency in the general population in the Edinburgh Vein Study

OBJECTIVE

The natural history in the general population of chronic venous disease in the legs is not well understood. This has limited our ability to predict which patients will deteriorate and to assign clinical priorities. The aims of this study were to describe the progression of trunk varicose veins and chronic venous insufficiency (CVI) in the general population, to identify important lifestyle and clinical prognostic factors, and to determine the relationship between venous reflux and progression.

METHODS

The Edinburgh Vein Study is a population-based cohort study in which randomly selected adults aged 18 to 64 years had an examination at baseline. This included a questionnaire on lifestyle and clinical factors, standardized assessment and classification of venous disease in the legs, and duplex scan to detect venous reflux in eight segments of each leg. A follow-up examination 13 years later included a reclassification of venous disease to ascertain progression in the development or increase in severity of varicose veins and CVI.

RESULTS

Among 1566 adults seen at baseline, 880 had a follow-up examination, of whom 334 had trunk varicose veins or CVI at baseline and composed the study sample. The mean (standard deviation) duration of follow-up was 13.4 (0.4) years. Progression was found in 193 (57.8%), equivalent to 4.3% (95% confidence interval [CI], 3.7-4.9) annually. In 270 subjects with only varicose veins at baseline, 86 (31.9%) developed CVI, with the rate increasing consistently with age (P = .04). Almost all subjects (98%) with both varicose veins and CVI at baseline deteriorated. Progression of chronic venous disease did not differ by gender or leg, but a family history of varicose veins and history of deep venous thrombosis increased risk (odds ratio [OR], 1.85 [95% CI, 1.14-1.30] and 4.10 [95% CI, 1.07-15.71], respectively). Overweight was associated with increased risk of CVI in those with varicose veins (OR, 1.85; 95% CI, 1.10-3.12). Reflux in the superficial system increased the likelihood of progression, especially in combination with deep reflux (OR, 2.57; 95% CI, 1.55-4.25) and when located in the small saphenous vein (OR, 4.73; 95% CI, 1.37-16.39).

CONCLUSIONS

Nearly half of the general population with chronic venous disease deteriorated during 13 years, and almost one third with varicose veins developed skin changes of CVI, increasing their risk of ulceration. Age, family history of varicose veins, history of deep venous thrombosis, overweight, and superficial reflux, especially in the small saphenous vein and with deep reflux, might influence the risk of progression.

Heterogeneity in venous disease practice patterns amongst primary healthcare practitioners

Introduction

This study aimed to describe the practice patterns of primary healthcare practitioners who diagnose and manage venous disease to determine differences in clinical evaluation of disease, recognition of venous ulcers, and referral patterns.

Methods

A survey was distributed at the August 2011 Primary Care Medical Conference (Pri-Med) in Baltimore, Maryland. Pri-med is a medical education company that caters to the continued professional development needs of a variety of physicians.

Results

A total of 305 surveys were completed. Of the respondents, 91% were physicians and 9% were advanced level practitioners. In all, 93% prescribed compression stockings as first-line treatment. Heterogeneous referral patterns were reported with 81% referring to vascular surgery, 25% to a vein clinic, 10% to interventional radiology, and 3% to interventional cardiology. Up to 35% responded that they met resistance (did not have their referral accepted) when attempting referral to a vascular surgery colleague. There was substantial variation when asked about the treatment of deep vein thrombosis with 88% starting anticoagulation therapy, 54% prescribing compression stockings, 40% doing a thrombophilia workup, and 25% referring for lytic therapy.

Conclusion

Diagnosis and management aptitude of venous disease is highly variable. Further grassroots education is required to improve diagnosis and treatment in patients with chronic venous disease.

The impact of obesity on venous insufficiency

Association between chronic venous disease and obesity has recently been studied, with indications that it may worsen in obese patients. The aim of study was to correlate clinical classes of chronic venous disease according to Clinical Etiology Anatomy Pathophysiology (CEAP) classification and body mass index, as well as to compare the severity of chronic venous disease in obese and nonobese patients. This retrospective cross-sectional prevalence study was conducted at the Maringá State University and Belczak Vascular Center along a period of 2 years, consisting of a random sample of 482 patients with complaints compatible with chronic venous disease. Data obtained from patient’s files included gender, age, weight and height (for calculating body mass index), and clinical class (C) of chronic venous disease according to CEAP classification. Statistical analysis included Spearman’s correlation coefficient, Chi-square test (for comparing frequencies), and Student’s t-test (for comparing means). Significant positive correlation between body mass index and clinical classes was established for women (0.43), but not for men (0.07). Obesity (body mass index ≥ 30.0) was significantly more frequent in patients with chronic venous disease in clinical classes 3 (p < 0.001) and 4 (p = 0.002) and less frequent in patients with chronic venous disease in clinical class 1 (p < 0.001). This study evidenced significant correlation between body mass index and clinical classes of chronic venous disease in women, but not in men. It also corroborated the negative impact of obesity on the clinical severity of chronic venous disease.

A three-dimensional electronic report of a venous echo color Doppler of the lower limbs: MEVeC®

BACKGROUND

The reports of ultrasound evaluation of lower limb veins are difficult to understand by general practitioners (GPs) and physicians who are not specialized. We developed software for a three-dimensional (3D) electronic report of venous hemodynamic mapping (MEVeC(®)) in order to represent lower limb venous vasculature in a 3D way. The aim of the study is to compare the novel 3D report with the standard report.

METHODS

Thirty subjects (medical students and GPs) evaluated a standard report and a novel 3D report of the lower limb veins of a prespecified patient. The cases were randomly and blindly taken from an archive of 100 cases. GPs and students answered a questionnaire made up of 13 questions that were structured in order to investigate the readability and comprehension of the two reports. A score ranging from 0 to 10 (0= not understandable; 10= full comprehension) was attributed to each report for each question according to the readability of the venous scheme proposed.

RESULTS

The scores from each question of the questionnaire were compared. The 3D report (MEVeC(®)) obtained higher scores than those from the evaluation of the standard report (P<0.0001). Each question revealed the superiority of the 3D report (MEVeC(®)) as compared with the standard report of the ultrasound evaluation of lower limbs. When dividing the scores according to percentiles, the 3D report (MEVeC(®)) still continued to show more readability than the standard report in a statistically significant way (P<0.0001).

CONCLUSION

The new 3D report (MEVeC(®)) concerning ultrasound evaluation of lower limb veins is more reproducible than the standard report when evaluated by medical physicians not specialized in the evaluation of the vein tree of lower limbs.

Is vein damage the only cause of clinical signs of lower limb chronic venous insufficiency?

Background:Venous insufficiency is a very prevalent disease. Some decades ago a group of patients was identified that had symptoms of venous insufficiency, but no visible anatomic abnormalities. Studies showed that this subset had reduced venous tone, and their condition became known as hypotonic phlebopathy.Objective:To investigate prevalence, age group and variations in body mass index (BMI) among patients with hypotonic phlebopathy.Methodology:A total of 1,960 limbs were examined in 1,017 patients who had been referred for complaints compatible with venous insufficiency. Patients with BMI ≥ 30 were defined as obese. The patients were examined using color Doppler ultrasonography to detect presence or absence of reflux in veins of the lower limbs and were then distributed into two groups as follows: patients with CEAP ≤ 1 and no reflux, diagnosed with hypotonic phlebopathy; or patients with CEAP ≥ 2 and reflux.Results:The study sample comprised 89.7% women and 10.3% men with a mean age of 44.9 years. Hypotonic phlebopathy was more common among the women (p = 0.0001). Obese women were more likely than women who were not obese to have venous symptom etiology involving trunk lesions (p = 0.0017). Among the men, obesity was unrelated to etiology of symptoms (p = 0.5991). Symptomology was more likely to be related to trunk vein damage among older age groups than among younger age groups (p-valor <0.0001).Conclusions:Hypotonic phlebopathy was very prevalent, particularly among young women who were not obese.

Varicose veins in hairdressers and associated risk factors: a cross-sectional study

BACKGROUND

Varicose veins (VV) cause not only cosmetic problems but also clinical symptoms such as pain of the affected limbs. Whereas an occupation associated with orthostasis has been recognized as a risk factor of VV, epidemiological studies on working populations are limited. We conducted a study to identify the risk factors of lower limb VV among hairdressers in Taiwan and evaluate their effects, with a focus on long-term standing at work.

METHODS

We recruited participants from members of a hairdressers union in southern Taiwan and conducted a questionnaire survey. Data on demographic characteristics, body weight and height, work history, medical history, and other potential related factors were collected from each participant.

RESULTS

A total of 182 hairdressers participated in the survey, and 44 (24.2%) had lower limb VV. Uni-variate analyses showed that hairdressers with lower limb VV tended to be older (49.3 vs. 44.7 years, p = 0.032), have a family history of VV (25.6% vs. 9.9%, p = 0.011), doing housework in standing position (86.4% vs. 71.0% , p = 0.042), have a longer work history (30.5 vs. 24.0 years, p = 0.005), and stand longer at work (213.9 vs. 176.0 hour/month, p = 0.008). In multivariate analysis, in hairdressers ≤ 45 years old, the only significant risk factor was a family history of VV (odds ratio [OR] = 11.9, 95% confidence interval [95% CI] = 1.1-133.5). In hairdressers > 45 years old, the risk factors included standing working for > 260 hours per month (OR = 31.8, 95% CI = 1.8-566.5) and working as a hairdresser for > 30 years (for 31-42 years, OR = 10.9, 95% CI = 1.6-73.8; for ≥ 43 years, OR = 12.0, 95% CI = 1.6-88.5).

CONCLUSIONS

In hairdressers ≤ 45 years old, family history of VV is a major risk factor for developing lower limb VV, while in those who are > 45 years old, the effects of occupational risk factors are more prominent.

Burden of venous leg ulcers in the United States

OBJECTIVE

To estimate the annual incremental per-patient and overall payer burden (2012USD) of venous leg ulcers (VLU) in the US.

METHODS

Beneficiaries with and without VLU were identified using two de-identified insurance claims databases: aged 65+ from a 5% random sample of Medicare beneficiaries (2007-2010: n ∼ 2.3 million); and aged 18-64 from a privately-insured population (2007-2011: n ∼ 8.4 million). The index date was selected as the date of a VLU claim with no other VLU diagnoses in the preceding 12 months for the VLU cohort and as the date of a random medical claim for the non-VLU patients. These groups were matched using propensity scores to account for differences in demographics, comorbidities, resource utilization, and costs in the 12 month pre-index period. Medical resource use and costs incurred during the 12 month follow-up period were calculated for both payers. Drug costs and indirect work-loss due to disability and medically-related absenteeism were estimated for the privately-insured sample only. Annual VLU incidence rates were also estimated for both payers.

RESULTS

Data for 58,672 matched VLU/non-VLU pairs of Medicare and 22,476 matched pairs of privately-insured patients were analyzed. Relative to matched non-VLU patients, VLU patients used more medical resources and incurred annual incremental medical costs of $6391 in Medicare ($18,986 vs $12,595), and $7030 ($13,653 vs $6623) in private insurance ($7086 including drug costs). Compared with non-VLU patients, privately-insured VLU patients had more days missed from work (14.0 vs 10.0), resulting in 29% higher work-loss costs (comparisons significant at p < 0.0001). The average annual incidence rate of VLU was 2.2% in Medicare and 0.5% in private insurance.

LIMITATIONS

Findings did not account for out-of-pocket payments or other indirect costs (e.g., lost productivity), and relied on accuracy of diagnosis and procedure codes contained in claims data.

CONCLUSION

These findings suggest an annual US payer burden of $14.9 billion.

Mechanochemical endovenous Ablation versus RADiOfrequeNcy Ablation in the treatment of primary great saphenous vein incompetence (MARADONA): study protocol for a randomized controlled trial

Background

Radiofrequency ablation (RFA) is associated with an excellent outcome in the treatment of great saphenous vein (GSV) incompetence. The use of thermal energy as a treatment source requires the instillation of tumescence anesthesia. Mechanochemical endovenous ablation (MOCA) combines mechanical endothelial damage, using a rotating wire, with the infusion of a liquid sclerosant. Tumescence anesthesia is not required. Preliminary experiences with MOCA showed good results and low post-procedural pain.

Methods/Design

The MARADONA (Mechanochemical endovenous Ablation versus RADiOfrequeNcy Ablation) trial is a multicenter randomized controlled trial in which 460 patients will be randomly allocated to MOCA or RFA. All patients with primary GSV incompetence who meet the eligibility criteria will be invited to participate in this trial. The primary endpoints are anatomic and clinical success at a one-year follow-up, and post-procedural pain. The secondary endpoints are technical success, complications, operation time, procedural pain, disease-specific quality of life, time taken to return to daily activities and/or work, and cost-efficiency analyses after RFA or MOCA. Both groups will be evaluated on an intention to treat base.

Discussion

The MARADONA trial is designed to show equal results in anatomic and clinical success after one year, comparing MOCA with RFA. In our hypothesis MOCA has an equal anatomic and clinical success compared with RFA, with less post-procedural pain.

Trial registration

Clinicaltrials NCT01936168

Modulation of circulating cytokine-chemokine profile in patients affected by chronic venous insufficiency undergoing surgical hemodynamic correction

The expression of proinflammatory cytokines/chemokines has been reported in in vitro/ex vivo settings of chronic venous insufficiency (CVI), but the identification of circulating mediators that might be associated with altered hemodynamic forces or might represent innovative biomarkers is still missing. In this study, the circulating levels of 31 cytokines/chemokines involved in inflammatory/angiogenic processes were analysed in (i) CVI patients at baseline before surgical hemody namic correction, (ii) healthy subjects, and (iii) CVI patients after surgery. In a subgroup of CVI patients, in whom the baseline levels of cytokines/chemokines were analyzed in paired blood samples obtained from varicose vein and forearm vein, EGF, PDGF, and RANTES were increased at the varicose vein site as compared to the general circulation. Moreover, while at baseline, CVI patients showed increased levels of 14 cytokines/chemokines as compared to healthy subjects, 6 months after surgery, 11 cytokines/chemokines levels were significantly reduced in the treated CVI patients as compared to the CVI patients before surgery. Of note, a patient who exhibited recurrence of the disease 6 months after surgery, showed higher levels of EGF, PDGF, and RANTES compared to nonrecurrent patients, highlighting the potential role of the EGF/PDGF/RANTES triad as sensitive biomarkers in the context of CVI.

Forkhead box C2 promoter variant c.-512C>T is associated with increased susceptibility to chronic venous diseases

Chronic venous disease (CVD) is one of the most prevalent yet underrated disorders worldwide. High heritability estimates of CVD indicate prominent genetic components in its etiology and pathology. Mutations in human forkhead box C2 (FoxC2) gene are strongly associated with valve failure in saphenous and deep veins of lower extremities. We explored the association of genetic variants of FoxC2 as well as FoxC2 mRNA and protein expression levels with CVD of lower limbs. We systematically sequenced the single coding exon, 5' and 3' flanking regions of FoxC2 gene in 754 study subjects which includes 382 patients with CVD and 372 healthy subjects. Four novel and three reported polymorphisms were identified in our cohort. Three variants in 5' flanking region and one in 3' flanking region of FoxC2 gene were significantly associated with CVD risk. FoxC2 mRNA in vein tissues from 22 patients was 4±1.42 fold increased compared to saphenous veins from 20 normal subjects (p<0.01). FoxC2 protein was also significantly upregulated in varicose veins compared to control samples. The c.-512C>T (rs34221221: C>T) variant which is located in the FoxC2 putative promoter region was further analyzed. Functional analysis of c.-512C>T revealed increased mRNA and protein expression in patients with homozygous TT genotype compared to heterozygous CT and wild CC genotypes. Luciferase assay indicated higher transcriptional activity of mutant compared to wild genotype of this variant. These findings suggested that c.-512C>T variant of FoxC2 was strongly associated with susceptibility to CVD and also that this variant resulted in FoxC2 overexpression. To obtain a mechanistic insight into the role of upregulated FoxC2 in varicosities, we overexpressed FoxC2 in venous endothelial cells and observed elevated expression of arterial markers Dll4 and Hey2 and downregulation of venous marker COUP-TFII. Our study indicates altered FoxC2-Notch signaling in saphenous vein wall remodeling in patients with varicose veins.

Extracellular matrix assessment of infected chronic venous leg ulcers: role of metalloproteinases and inflammatory cytokines

Chronic venous ulcer (CVU) represents a dreaded complication of chronic venous disease (CVD). The onset of infection may further delay the already precarious healing process in such lesions. Some evidences have shown that matrix metalloproteinases (MMPs) are involved and play a central role in both CVUs and infectious diseases. Two groups of patients were enrolled to evaluate the expression of MMPs in infected ulcers and the levels of inflammatory cytokines as well as their prevalence. Group I comprised 63 patients (36 females and 27 males with a median age of 68·7 years) with infected CVUs, and group II (control group) comprised 66 patients (38 females and 28 males with a median age of 61·2 years) with non-infected venous ulcers. MMP evaluation and dosage of inflammatory cytokines in plasma and wound fluid was performed by means of enzyme-linked immunosorbent assay test; protein extraction and immunoblot analysis were performed on biopsied wounds. The first three most common agents involved in CVUs were Staphylococcus aureus (38·09%), Corynebacterium striatum (19·05%) and Pseudomonas aeruginosa (12·7%). In this study, we documented overall higher levels of MMP-1 and MMP-8 in patients with infected ulcers compared to those with uninfected ulcers that showed higher levels of MMP-2 and MMP-9. We also documented higher levels of interleukin (IL)-1, IL-6, IL-8, vascular endothelial growth factor and tumour necrosis factor-alpha in patients with infected ulcers with respect to those with uninfected ulcers, documenting a possible association between infection, MMP activation, cytokine secretions and symptoms. The present results could represent the basis for further studies on drug use that mimic the action of tissue inhibitors of metalloproteinases in order to make infected CVU more manageable.

Thinking Outside the Heart: Use of Engineered Cardiac Tissue for the Treatment of Chronic Deep Venous Insufficiency

This article considers the use of autologous stem cell-derived cardiomyocytes as a novel means to aid venous return. The approach consists of creating external cuffs of engineered heart tissue around vein segments with incompetent or poorly competent valves. The engineered heart tissue cuff prevents distention of the impaired vein segments and aids unidirectional flow by its rhythmic contractions. There appear to be no fundamental limitations to this approach as feasibility of all of the individual components has already been shown. Here, we underline the clinical need for novel ways to treat chronic deep venous insufficiency, review previous research that enabled this approach, consider potential designs of engineered heart tissue cuffs, and outline its advantages and future challenges.

Impact of weight loss due to sleeve gastrectomy on shear stress of the femoral vein in morbid obesity

Background

Studies have shown that obesity is associated with venous flow disturbances that lead to changes of the biomechanical forces on the venous wall known as shear stress. We hypothesized that weight loss due to bariatric surgery affects the venous hemodynamics and biomechanical forces on the venous wall. The aim of this study was to evaluate the effects of laparoscopic sleeve gastrectomy (LSG) on the wall shear stress (WSS) and the venous hemodynamics of the femoral vein.

Methods

We studied ten morbidly obese patients who underwent LSG. We investigated venous hemodynamics before, 6 and 12 months after LSG. The femoral vein diameter, cross-sectional area, peak (PeakV) and maximum (TA_max) velocities, WSS, and shear rate (SR) were assessed.

Results

PeakV and TA_max were significantly lower in the obese patients compared with the control group. WSS and SR were significantly lower in the obese patients compared with the control subjects. Venous hemodynamic parameters increased in the postoperative period at baseline compared with 12 months after surgery: PeakV increased from 17.53 (14.25–20.01) cm/s to 25.1 (20.9–30.1) cm/s (P = 0.04) and the TA_max from 12.97 (11.51–14.6) cm/s to 18.46 (13.24–24.13) cm/s (P = 0.057). WSS significantly increased from 0.21 (0.19–0.23) Pa at baseline to 0.31 (0.23–0.52) Pa 12 months after surgery (P = 0.031). SR also significantly increased from 47.92 (43.93–58.55) s⁻¹ at baseline to 76.81 (54.04–109.5) s⁻¹ 12 months after surgery (P = 0.02).

Conclusions

This study showed that weight loss due to LSG significantly changes the biomechanical forces on the femoral vein generated by blood flow.

Endovenous laser ablation under general anesthesia for day surgery: feasibility and outcomes of the 300 patients

PURPOSE

Endovenous laser ablation (EVLA) for superficial venous insufficiency is traditionally performed under tumescent local anesthesia as day case surgery. The aim of this study is to evaluate the feasibility of general anesthesia in addition to tumescent anesthesia in patients undergoing EVLA.

METHODS

The anesthesia and clinical registration records of 341 extremities of 300 adult patients were reviewed and analyzed retrospectively. Demographic and clinical data, preoperative anesthetic evaluation data (ASA physical status, preoperative airway assessment, Mallampati score), type of supraglottic device, duration of anesthesia and surgery, any surgical and/or anesthetic complication, timing of mobilization and discharge, and postoperative course were evaluated.

RESULTS

Mean duration of operation and anesthesia was 28 (12-55) and 40 (20-65) minutes, respectively. Mobilization and discharge timing was 25 (11-45) and 139 (110-200) minutes, respectively. All patients were discharged the same day of surgery.

CONCLUSION

The combination technique of administering general anesthesia with supraglottic device and tumescent anesthesia is a safe and effective method to reduce the patients' pain and discomfort during the EVLT procedure within the scope of day case surgery.

[Treatment of varicose veins and limb lymphedema]

Two questions arise when considering the treatment of varicose veins and the development of lymphedema: can the treatment cause lymphedema? Can it worsen it? Primary lymphedema is rarely associated with varicose veins except in the lymphedema-distichiasis syndrome. Data available in the literature is essentially based on surgical treatment. Stripping on a normal limb may induce chronic lymphedema in almost 0.1% of cases. The risk of lymphedema after stripping in patients with previous pelvic surgery including lymph node excision and/or radiotherapy remains unknown. In patients with lower limb lymphedema wearing strong elastic compression stockings, stripping provides little clinical improvement and can worsen volume. The main objective is also to avoid venous complications. Lymphatic lesions related to stripping can be evaluated by lymphography or lymphoscintigraphy. New techniques for treating varicose veins (sclerotherapy, endovenous laser treatment, radiofrequency ablation) seem to induce fewer lymphatic complications. Further studies are required to confirm these results. Indications for treatment should be unquestionable and patients must be alerted to the potential risk of lymphedema or its worsening.

Compression stockings for the initial treatment of varicose veins in patients without venous ulceration

BACKGROUND

Compression hosiery or stockings are often the first line of treatment for varicose veins in people without either healed or active venous ulceration. Evidence is required to determine whether the use of compression stockings can effectively manage and treat varicose veins in the early stages. This is an update of a review first published in 2011.

OBJECTIVES

To assess the effectiveness of compression stockings for the only and initial treatment of varicose veins in patients without healed or active venous ulceration.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched August 2013) and CENTRAL (2013, Issue 5).

SELECTION CRITERIA

Randomised controlled trials (RCTs) were included if they involved participants diagnosed with primary trunk varicose veins without healed or active venous ulceration (Clinical, Etiology, Anatomy, Pathophysiology (CEAP) classification C2 to C4). Included trials assessed compression stockings versus no treatment, compression versus placebo stockings, or compression stockings plus drug intervention versus drug intervention alone. Trials comparing different lengths and pressures of stockings were also included. Trials involving other types of treatment for varicose veins (either as a comparator to stockings or as an initial non-randomised treatment), including sclerotherapy and surgery, were excluded.

DATA COLLECTION AND ANALYSIS

Two authors assessed the trials for inclusion and quality (SS and LR). SS extracted the data, which were checked by LR. Attempts were made to contact trial authors where missing or unclear data were present.

MAIN RESULTS

Seven studies involving 356 participants with varicose veins without healed or active venous ulceration were included. Different levels of pressure were exerted by the stockings in the studies, ranging from 10 to 50 mmHg. One study assessed compression hosiery versus no compression hosiery. The other six compared different types or pressures of stockings. The methodological quality of all included trials was unclear, mainly because of inadequate reporting.The symptoms subjectively improved with the wearing of stockings across trials that assessed this outcome, but these assessments were not made by comparing one randomised arm of a trial with a control arm and are therefore subject to bias.Meta-analyses were not undertaken due to inadequate reporting and actual or suspected high levels of heterogeneity.

AUTHORS' CONCLUSIONS

There is insufficient, high quality evidence to determine whether or not compression stockings are effective as the sole and initial treatment of varicose veins in people without healed or active venous ulceration, or whether any type of stocking is superior to any other type. Future research should consist of a large RCT of participants with trunk varices either wearing or not wearing compression stockings to assess the efficacy of this intervention. If compression stockings are found to be beneficial, further studies assessing which length and pressure is the most efficacious could then take place.

Lymph drainage in pregnant women

Aim. The aim of this study was to evaluate the efficacy of lymph drainage to reduce edema of pregnant women. Method. Pregnant women (30 limbs) from the Obstetrics Outpatient Clinic of the Medical School of Santa Casa in São Paulo in the period December 2009 to May 2010 were enrolled in this quantitative, prospective study. The patients, in the 5th to 8th months of gestation, were submitted to one hour of manual lymph drainage of the legs. The volume of the legs was measured by water displacement volumetry before and after one hour of drainage using the Godoy & Godoy manual lymph drainage technique. The paired t-test was used for statistical analysis with an alpha error of 5% being considered significant. Results. Manual lymph drainage significantly reduced swelling of the legs of pregnant women during the day (P = 0.04). Conclusion. Manual lymph drainage helps to reduce limb size during the day of pregnant women.

Role of matrix metalloproteinases in non-healing venous ulcers

Chronic venous ulceration (CVU) of the lower limbs is a common condition affecting 1% of the adult population in Western countries, which is burdened with a high complication rate and a marked reduction in the quality of life often due to prolonged healing time. Several metalloproteinases (MMPs) such as MMP-9 together with neutrophil gelatinase-associated lipocalin (NGAL) appear to be involved in the onset and healing phases of venous ulcer, but it is still unclear how many biochemical components are responsible for prolonged healing time in those ulcers. In this study, we evaluate the role of MMP-1 and MMP-8 in long lasting and refractory venous ulcers. In a 2-year period we enroled 45 patients (28 female and 17 male, median age 65) with CVU. The enroled population was divided into two groups: group I were patients with non-healing ulcers (ulcers that had failed to heal for more than 2 months despite appropriate treatments) and group II were patients with healing ulcers (ulcers in healing phases). MMP-1 and MMP-8 were measured in fluids and tissues of healing and non-healing ulcers by means of enzyme-linked immunosorbent assay (ELISA) and Western blot analysis, respectively. In particular the patterns of the collagenases MMP-1 and MMP-8 in healing wounds were distinct, with MMP-8 appearing in significantly greater amounts especially in the non-healing group. Our findings suggest that MMP-1, and MMP-8 are overexpressed in long lasting CVU. Therefore, this dysregulation may represent the main cause of the pathogenesis of non-healing CVU.

Endovenous laser ablation of the great saphenous vein versus high ligation: long-term results

Endovenous laser therapy (EVLT) for greater saphenous vein (GSV) insufficiency is a relatively new method of treatment only recently made available in Iran. This is the first long-term randomized trial comparing EVLT with high ligation of saphenous vein (HLS) in the Iranian population. Sixty-five patients met the inclusion criteria and were divided into homogenous treatment groups of EVLT (n = 30) or HLS (n = 35). Clinical severity, etiology, anatomy, pathophysiology (CEAP) classification and Aberdeen Varicose Vein Symptom Severity Scores (AVSS) were used to determine disease severity and symptoms before and after the procedure in both groups. Outcome was measured by the rate of recurrence as shown in Doppler ultrasonography evaluation. Follow-up was conducted 1 week and 3, 6, 12, and 18 months after the intervention. The occlusion rate of GSV was similar in both groups (93.6% for EVLT, 88.3 for HLS) at 18 months of follow-up. The median CEAP score showed a dramatic decrease in both groups after 1 week which was sustained for the rest of the study. The Aberdeen Varicose Vein Symptom Severity score was significantly lower in the EVLT group at 12 and 18 months of follow-up. There was no significant difference in patient satisfaction in both groups. Our findings show that EVLT may offer a better long-term relief of symptoms. This, alongside its better cosmetic outcome, and less invasive anesthesia requirements may make it the favorable choice for treatment of GSV insufficiency.

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.

Phlebotonic and compression stocking therapy in venous edema management: an overview of recent advances with a focus on Cyclo 3 Fort® and progressive compression stockings

Venous edema of the limb presents several challenges to clinicians, particularly with regard to its definition, pathophysiology and measurement, as well as those relating to its management. Compression therapy forms the cornerstone of standard care for thromboprophylaxis and management of lower limb venous and lymphatic disorders. Venoactive drugs, of plant or synthetic origin, have also been shown to be effective and safe in the management of venous edema and/or chronic venous disease-related symptoms. This article, based on a symposium held at the XXV World Congress of the International Union of Angiology on 2-5 July 2012 (Prague, Czech Republic), provides an overview of some of the recent developments in the use of phlebotonic and compression therapy in the management of patients with lower limb venous edema, with a focus on Cyclo 3 Fort(®) and progressive compression stockings.

The pernicious cycle of VLUs in Brazil: epidemiology, pathogeny and auxiliary healing methods

Venous leg ulcers (VLUs) represent the most advanced stage of chronic venous insufficiency. Despite the large body of knowledge available regarding the risk factors and aetiopathogeny of the condition, patients referred to public health care systems in developing countries often do not receive adequate diagnosis or early treatment, leading to clinical evolution and disease recurrence. This review collates updated information about the epidemiology, risk factors, aetiopathogeny, diagnosis, ulcer healing methods and determinant factors of the pernicious cycle of VLUs in developing countries, with a focus on the Brazilian setting.

Prevalence and presentation of chronic venous disease in Pakistan: a multicentre study

Our objective was to study the prevalence and clinical pattern of chronic venous disease (CVD) in the Pakistani population. This was a multicentre cross-sectional study in which 100 primary care physicians examined 3000 subjects. The study population was aged 18–95 years (mean ± SD = 39 ± 13.2) comprised 47.4% women and 52.6% men. The prevalence of CVD was 34.8%, being significantly higher ( P < 0.04) among men (36.4%) than women (33.0%). The maximum prevalence was of C3 (36.7%), followed by C2 (15.8%). The most frequent symptom was pain in the legs (59.2%) followed by heavy legs (42.7%) and night cramps (34.4%). The prevalence of symptoms increased with age but was similarly distributed between men and women. Family history of CVD, blood clots in veins and lack of exercise were significant risk factors. The roles of age or gender as risk factors could not be established. In conclusion, the prevalence and presentation of CVD in Pakistan is similar to most other countries.

Impact of radiofrequency ablation for patients with varicose veins on the budget of the German statutory health insurance system

OBJECTIVES

In contrast to other countries, surgery still represents the common invasive treatment for varicose veins in Germany. However, radiofrequency ablation, e.g. ClosureFast, becomes more and more popular in other countries due to potential better results and reduced side effects. This treatment option may cause less follow-up costs and is a more convenient procedure for patients, which could justify an introduction in the statutory benefits catalogue. Therefore, we aim at calculating the budget impact of a general reimbursement of ClosureFast in Germany.

METHODS

To assess the budget impact of including ClosureFast in the German statutory benefits catalogue, we developed a multi-cohort Markov model and compared the costs of a "World with ClosureFast" with a "World without ClosureFast" over a time horizon of five years. To address the uncertainty of input parameters, we conducted three different types of sensitivity analysis (one-way, scenario, probabilistic).

RESULTS

In the Base Case scenario, the introduction of the ClosureFast system for the treatment of varicose veins saves costs of about 19.1 Mio. € over a time horizon of five years in Germany. However, the results scatter in the sensitivity analyses due to limited evidence of some key input parameters.

CONCLUSIONS

Results of the budget impact analysis indicate that a general reimbursement of ClosureFast has the potential to be cost-saving in the German Statutory Health Insurance.

Patterns of short saphenous vein incompetence

The significance of short saphenous vein (SSV) reflux is an under-explored territory in chronic venous disease (CVD). We have examined the origin and significance of SSV reflux in primary and secondary CVD. While the natural history of SSV incompetence remains uncertain, its prevalence has been shown to approximate 3.5%, rising with progressing clinical venous insufficiency, and bears an association with lateral malleolar venous ulceration. The most common pattern of reflux extends throughout the SSV Patterns of incompetence in recurrent disease are highly variable, but SSV reflux may itself pose a risk for recurrence, in part due to the complex anatomy of the saphenopopliteal system. Further studies are required to delineate the impact of SSV reflux in secondary venous disease and deep venous incompetence.

Body mass index and primary chronic venous disease--a cross-sectional study

OBJECTIVES

This study aims to investigate whether overweight and obesity are related to the clinical (C) category of clinical, etiologic, anatomic and pathophysiologic (CEAP) classification of chronic venous disease (CVD).

DESIGN

A cross-sectional study.

MATERIALS AND METHODS

The study was conducted in Serbia, in the year 2011. Men and women aged >18 years, consecutively coming to venous specialists because of venous problems in the legs, were included in the study. Patients demographic, anthropometric and clinical data were collected. For the analysis, univariate and multivariate logistic regressions were used.

RESULTS

The study comprised 1116 subjects with primary CVD, 384 (34.4%) men and 732 (65.6%) women. Among them 464 (41.6%) were normal-weight patients (body mass index (BMI) < 25.0 kg m(-2)), 476 (42.7%) were overweight (BMI = 25.0-29.9 kg m(-2)) and 176 (15.8%) were obese (BMI ≥ 30.0 kg m(-2)). According to multivariate analysis, the CEAP C category of CVD was significantly more advanced in overweight and obese patients, the association being more pronounced in obese. Compared groups did not differ in the presence of venous reflux. In univariate analysis, venous obstruction was related to overweight and obesity but this association did not substantially affect the relationship between obesity and CEAP C categories of CVD.

CONCLUSION

The CEAP C categories of CVD were significantly related to overweight and obesity, and this association was independent of age, sex and some other postulated risk factors.

A plasma oxidative stress global index in early stages of chronic venous insufficiency

BACKGROUND

Chronic venous insufficiency (CVI) represents a social and health care problem because it affects working age populations, particularly in jobs requiring orthostasis, has no effective pharmacologic treatment, and requires surgery. Oxidative stress is present in varicose veins, but whether this is reflected in the plasma is controversial. We aimed to quantify plasma oxidative stress biomarkers in the early stages of CVI and calculate a global index of oxidative stress representative of the disease.

METHODS

Plasma was obtained from blood samples of nine patients with CEAP C2 stage CVI and 10 healthy controls. Biomarkers related to antioxidant defense systems (total thiols, reduced glutathione, uric acid, total antioxidant capacity, catalase), oxidative damage (malondialdehyde-bound protein, protein carbonyls, advanced oxidation products, and 3-nitrotyrosine), and activity of enzymes producing key free radicals (xanthine oxidase and myeloperoxidase) were assessed.

RESULTS

Compared with the controls, CVI patients exhibited decreased catalase activity and thiol levels and increased malondialdehyde-bound protein and protein carbonyls. These parameters were used to calculate the global index of oxidative stress in CVI, which was significantly different between groups.

CONCLUSIONS

It is possible to detect significant changes in plasma oxidative stress biomarkers in early stages of CVI and to calculate a global index representative of the oxidative status in an individual. This index, with the appropriate validation in a larger population, could be used for early detection or progression of CVI.