Treatment of chronic venous insufficiency

Chronic Venous Insufficiency Evaluation and Medical Management

PURPOSE OF REVIEW

This review will focus on comprehensive evaluation of chronic venous insufficiency (CVI), nuances in diagnostic testing and advances in medical therapies to provide improvement in patient specific outcomes.

RECENT FINDINGS

Chronic venous insufficiency of the lower extremities represents an often underrecognized source of morbidity. Comprehensive evaluation focuses on personal and family history of deep vein thrombosis and varicose veins. Diagnostic testing is initially with a thorough duplex ultrasound, but advanced imaging with CT scan and MRV may be indicated in selected patients who might benefit from more invasive intervention. Compression therapy, wraps and garments, remains the mainstay of conservative therapy for patients with CVI. In addition, there is renewed interest in lifestyle and nutritional supplements, most commonly micronized purified flavanoid fraction (MPFF), in relieving symptoms and preventing morbidity. A holistic approach to patients with CVI provides the best opportunity for enduring improvement in quality of life.

A prospective study on varicose veins surgery impact on systemic endothelial function evaluated by arterial brachial flow mediated dilation

OBJECTIVES

Chronic venous disease (CVD) is a prevalent pathology, and endothelial dysfunction is recognized as a core of its physiopathology. Flow-mediated dilation (FMD) is one of the most widely used tests for evaluating endothelial function. The aim of this study is to evaluate the influence of varicose vein (VV) surgery on FMD.

METHODS

A prospective study with patients with superficial CVD and saphenous incompetence on Doppler ultrasonography that were proposed for VV surgery. The FMD test was performed before and 6 months after the procedure. The operator performing the post-operative evaluation was blinded to the pre-operative result.

RESULTS

A total of 42 patients were included in the analysis. The median pre-operative percent change of FMD was 4.20% (±1.30) and the post-operative was 4.56% (±1.25) (p = 0.819).

CONCLUSIONS

Our findings do not corroborate the presence of an overall endothelial dysfunction prone to modulation by surgery. Nevertheless, further studies are needed to confirm our findings.

Flavonoids and post haemorrhoidectomy recovery: a systematic review and meta-analysis

BACKGROUND

Haemorrhoidectomy is the gold standard for definitive treatment of high-grade symptomatic haemorrhoids but is often associated with substantial pain. This systematic review aims to explore the potential of flavonoids in alleviating the postoperative symptom burden following excisional haemorrhoidectomy.

METHODS

A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD42023472711). Randomized controlled trials (RCTs) published PubMed, MEDLINE, Embase, and Scopus from inception to 1st December 2023 were retrieved. The primary outcome investigated was post-operative pain. Meta-analysis was performed using Review Manager version 5.4.1.

RESULTS

Ten articles with 775 patients were included. The meta-analysis identified statistically significant decreases in post-operative pain in favour of the flavonoid groups (Standardized Mean Difference -0.66 [95% confidence intervals (CI) -0.82, -0.52]; P < 0.00001), and bleeding (Odds Ratio 0.13 [95% CI 0.09, 0.19]; P < 0.00001).

CONCLUSION

Flavonoids show promise as a means of reducing pain associated with excisional haemorrhoidectomy. Further research is required to investigate topical routes of administration and standardize regimes.

How to Evaluate and Choose the Proper Treatments for Patients with Lower Extremity Venous Disease

With an increasing number of interventional and noninterventional treatment options available for venous disorders, it is important that patients undergo a thorough and systematic evaluation. Clinical evaluation should include a personal and family history of venous thromboembolism (VTE), varicose veins, and thrombophilia as these factors affect response and recurrence of disease. Patient should undergo diagnostic and quality of life assessment using validated tools to monitor response to treatment. Duplex ultrasound, both deep and superficial veins, documenting both obstruction and reflux is initial imaging with CT and MRI indicated to document pelvic, iliac vein, and IVC patency and pathology. Conservative therapy including compression, healthy lifestyle with diet, and exercise. New and novel interventional therapies are available for patients with venous disease with recent randomized controlled trials and multisocietal guidelines providing evidence-based recommendations for patients with superficial and deep venous disease. Since the use of anticoagulant and antiplatelet therapies post venous intervention is not well studied nor standardized, patients should routinely undergo evaluation for ongoing risk of recurrent thrombosis and stent occlusion. Finally, patients should be counseled that superficial and deep venous disease is a chronic and often progressive disease, and follow-up at least annually is recommended.

Compression Therapy to Prevent Recurrent Cellulitis of the Leg

BACKGROUND

Chronic edema of the leg is a risk factor for cellulitis. Daily use of compression garments on the leg has been recommended to prevent the recurrence of cellulitis, but there is limited evidence from trials regarding its effectiveness.

METHODS

In this single-center, randomized, nonblinded trial, we assigned participants with chronic edema of the leg and recurrent cellulitis, in a 1:1 ratio, to receive leg compression therapy plus education on cellulitis prevention (compression group) or education alone (control group). Follow-up occurred every 6 months for up to 3 years or until 45 episodes of cellulitis had occurred in the trial. The primary outcome was the recurrence of cellulitis. Participants in the control group who had an episode of cellulitis crossed over to the compression group. Secondary outcomes included cellulitis-related hospital admission and quality-of-life assessments.

RESULTS

A total of 183 patients were screened, and 84 were enrolled; 41 participants were assigned to the compression group, and 43 to the control group. At the time of a planned interim analysis, when 23 episodes of cellulitis had occurred, 6 participants (15%) in the compression group and 17 (40%) in the control group had had an episode of cellulitis (hazard ratio, 0.23; 95% confidence interval [CI], 0.09 to 0.59; P = 0.002; relative risk [post hoc analysis], 0.37; 95% CI, 0.16 to 0.84; P = 0.02), and the trial was stopped for efficacy. A total of 3 participants (7%) in the compression group and 6 (14%) in the control group were hospitalized for cellulitis (hazard ratio, 0.38; 95% CI, 0.09 to 1.59). Most quality-of-life outcomes did not differ between the two groups. No adverse events occurred during the trial.

CONCLUSIONS

In this small, single-center, nonblinded trial involving patients with chronic edema of the leg and cellulitis, compression therapy resulted in a lower incidence of recurrence of cellulitis than conservative treatment. (Funded by Calvary Public Hospital Bruce; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000412336.).

The validity of heart failure diagnoses in the Finnish Hospital Discharge Register

Background: Contemporary validation studies of register-based heart failure diagnoses based on current guidelines and complete clinical data are lacking in Finland and internationally. Our objective was to assess the positive and negative predictive values of heart failure diagnoses in a nationwide hospital discharge register. Methods: Using Finnish Hospital Discharge Register data from 2013-2015, we obtained the medical records for 120 patients with a register-based diagnosis for heart failure (cases) and for 120 patients with a predisposing condition for heart failure, but without a heart failure diagnosis (controls). The medical records of all patients were assessed by a physician who categorized each individual as having heart failure (with reduced or preserved ejection fraction) or no heart failure, based on the definition of current European Society of Cardiology heart failure guidelines. Unclear cases were assessed by a panel of three physicians. This classification was considered as the clinical gold standard, against which the registers were assessed. Results: Register-based heart failure diagnoses had a positive predictive value of 0.85 (95% CI 0.77-0.91) and a negative predictive value of 0.83 (95% CI 0.75-0.90). The positive predictive value decreased when we classified patients with transient heart failure (duration <6 months), dialysis/lung disease or heart failure with preserved ejection fraction as not having heart failure. Conclusions: Heart failure diagnoses of the Finnish Hospital Discharge Register have good positive predictive value and negative predictive value, even when patients with pre-existing heart conditions are used as healthy controls. Our results suggest that heart failure diagnoses based on register data can be reliably used for research purposes.

Clinical correlation of the area of inferior vena cava, iliac and femoral veins for stent use

Objective

The purpose of the study is to evaluate normal anatomical areas of infrarenal inferior vena cava, common iliac, external iliac and common femoral veins by intravascular ultrasound with the goal of assisting the development of venous-specific stents in the treatment of iliac vein stenosis.

Method

From February 2012 to December 2013, 656 office-based venograms were performed in our facility. Among them, 576 were stented and 80 were not. The measurements of veins were done intraoperatively using an intravascular ultrasound catheter to record areas of the inferior vena cava, proximal, middle and distal segments of common iliac vein, external iliac vein and common femoral vein. The data were compared between non-diseased segments of patients who were stented and those not stented. The stented diseased segments were excluded.

Results

The mean patient age was 67.33 years (range 22–96, SD ±13.99). Our data included 218 males, 438 females and 324 right lower extremities and 332 left lower extremities. The presenting symptoms of these patients based on CEAP were C1(0), C2 (185), C3(233), C4(107), C5(89) and C6(42). No correlation was found between area of veins and age, gender, laterality and CEAP score (P > .13). Comparison of the areas of non-diseased iliac vein segments between patients not stented and patients who underwent stenting showed a significant difference, with larger areas in non-stented patients in the distal common iliac vein (P = .039) and inferior vena cava (P = .012). Younger age (P = .03) and male gender (P < .0001) were associated with increased area of iliac vein segments.

Conclusion

Utilizing the intravascular ultrasound-guided technique, we were able to define normal anatomical areas of non-diseased inferior vena cava, iliac and femoral veins, which could be employed to guide the development of appropriate-sized stents and other tools needed for the treatment of venous insufficiency. There is specific variability in areas of normal vein segments with age and gender with/without stents.

Tissue Engineering of Vein Valves Based on Decellularized Natural Matrices

Valvular repair or transplantation, designed to restore the venous valve function of the legs, has been proposed as treatment in chronic venous insufficiency. Available grafts or surgeries have provided limited durability so far. Generating venous valve substitutes by means of tissue engineering could be a solution. We generated decellularized jugular ovine vein conduits containing valves (oVVC) after reseeding with ovine endothelial cells differentiated from peripheral blood-derived endothelial cells (oPBEC), cultivated in vitro corresponding to the circulatory situation in the lower leg at rest and under exertion. oVVC were decellularized by detergent treatment. GFP-labeled oPBEC were seeded onto the luminal side of the decellularized oVVC and cultivated under static-rotational conditions for 6 h (group I) and 12 h (group II), respectively. Reseeded matrices of group I were exposed to continuous low flow conditions (“leg at rest”). The tissues of group II were exposed to a gradually increasing flow (“leg under effort”). After 5 days, the grafts of group I revealed a uniform luminal endothelial cell coverage of the examined areas of the venous walls and adjacent venous valve leaflets. In group II, the cell coverage on luminal areas of the venous wall parts was found to be nearly complete. The endothelial cell coverage of adjacent venous valve leaflets was revealed to be less dense and confluent. Endothelial cells cultured on acellular vein tissues of both groups were distinctly orientated uniformly in the flow direction, clearly creating a stable and flow-orientated layer. Thus, an endothelium could successfully be reestablished on the luminal surface of a decellularized venous valve by seeding peripheral blood endothelial cells and culturing under different conditions.

Medical Treatment for Postthrombotic Syndrome

Deep vein thrombosis (DVT) is a prevalent disease. About 20 to 30% of patients with DVT will develop postthrombotic syndrome (PTS) within months after the initial diagnosis of DVT. There is no gold standard for diagnosis of PTS, but clinical signs include pitting edema, hyperpigmentation, phlebectatic crown, venous eczema, and varicose veins. Several scoring systems have been developed for diagnostic evaluation. Conservative treatment includes compression therapy, medications, lifestyle modification, and exercise. Compression therapy, the mainstay and most proven noninvasive therapy for patients with PTS, can be prescribed as compression stockings, bandaging, adjustable compression wrap devices, and intermittent pneumatic compression. Medications may be used to both prevent and treat PTS and include anticoagulation, anti-inflammatories, vasoactive drugs, antibiotics, and diuretics. Exercise, weight loss, smoking cessation, and leg elevation are also recommended. Areas of further research include the duration, compliance, and strength of compression stockings in the prevention of PTS after DVT; the use of intermittent compression devices; the optimal medical anticoagulant regimen after endovascular therapy; and the role of newer anticoagulants as anti-inflammatory agents.

Management of venous ulcers: State of the art

Venous ulceration is a complex and serious problem that affects 1-2% of the global elderly population (>65 years), and its incidence is constantly increasing. The population group with higher risk of development of venous ulceration is the elderly. These lesions have a significant negative impact on patients' quality of life. Our aim was to analyze the state of the art, starting with the medical literature review. The evidence supports that managing chronic wounds with a multidisciplinary wound care team significantly increases wound healing and reduces the severity of wound-associated pain and the required daily wound treatments compared with persons who are not managed by such a team.

Exploring the usefulness of botanicals as an adjunctive treatment for lymphedema: a systematic search and review

OBJECTIVES

To provide a critical analysis of the current published research regarding the use, risks, and benefits of botanicals in the treatment of lymphedema and to provide health professionals with current knowledge of safe, appropriate use of botanicals for treatment of lymphedema. TYPE: This systematic search and review addresses the use of botanicals in the treatment of lymphedema in order to develop a best evidence synthesis of the research.

LITERATURE SURVEY

Articles were identified from 11 major medical indices published from 2004-2012 using search terms for lymphedema and management. Eighty-five articles met the inclusion criteria of evidence-based lymphedema therapies for the category "complementary and alternative methods for lymphedema therapy."

METHODOLOGY

Two clinical lymphedema experts reviewed the studies according to level of evidence guidelines established by the Oncology Nursing Society, Putting Evidence into Practice, and subdivided the methods into subcategories that included Botanical, Pharmaceutical, Physical Agent Modalities, and Modalities of Contemporary Value. The pharmaceutical articles were excluded (5) because they fell outside the inclusion criteria. Twenty-two articles were used in a separate review of physical agent modalities and modalities of contemporary value for lymphedema. Botanicals generated substantial research (11) and warranted its own independent review.

SYNTHESIS

The levels of evidence are weak, because research conclusions were limited by size, dose, and study design. A limited number of randomized controlled trials have been performed, and reliability is not always evident, particularly in the context of large systematic reviews where evidence was bundled.

CONCLUSIONS

Evidence supporting the use of botanicals for the treatment of lymphedema is insufficient. Some evidence suggests benefits for the treatment of chronic venous insufficiency. Development of specific and sensitive measurement methods may change how botanicals are studied and establish a body of evidence for their use.

Venous endothelial injury in central nervous system diseases

The role of the venous system in the pathogenesis of inflammatory neurological/neurodegenerative diseases remains largely unknown and underinvestigated. Aside from cerebral venous infarcts, thromboembolic events, and cerebrovascular bleeding, several inflammatory central nervous system (CNS) diseases, such as multiple sclerosis (MS), acute disseminated encephalomyelitis (ADEM), and optic neuritis, appear to be associated with venous vascular dysfunction, and the neuropathologic hallmark of these diseases is a perivenous, rather than arterial, lesion. Such findings raise fundamental questions about the nature of these diseases, such as the reasons why their pathognomonic lesions do not develop around the arteries and what exactly are the roles of cerebral venous inflammation in their pathogenesis. Apart from this inflammatory-based view, a new hypothesis with more focus on the hemodynamic features of the cerebral and extracerebral venous system suggests that MS pathophysiology might be associated with the venous system that drains the CNS. Such a hypothesis, if proven correct, opens new therapeutic windows in MS and other neuroinflammatory diseases. Here, we present a comprehensive review of the pathophysiology of MS, ADEM, pseudotumor cerebri, and optic neuritis, with an emphasis on the roles of venous vascular system programming and dysfunction in their pathogenesis. We consider the fundamental differences between arterial and venous endothelium, their dissimilar responses to inflammation, and the potential theoretical contributions of venous insufficiency in the pathogenesis of neurovascular diseases.

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.

Investigation of an on-line detection method combining near infrared spectroscopy with local partial least squares regression for the elution process of sodium aescinate

An on-line detection method combining near infrared (NIR) spectroscopy with local partial least squares regression (PLSR) was investigated for the elution process of sodium aescinate. A 2 mm pathlength flow cell which transmitted NIR radiation through two fiber optic probes was placed in bypass of the macroporous resin column to collect real-time spectra of the sodium aescinate eluate. To compare the predictive accuracy, both local and global PLSR were employed to build mathematical models between NIR spectra and reference values. Meanwhile, Mahalanobis distance was introduced to select the appropriate local model for the prediction of unknown samples. Experimental results demonstrated that local PLSR was superior to global PLSR in both calibration performance and predictive accuracy. Moreover, the on-line detection method was proven to be feasible in real application and thereby would be of great value for monitoring the elution process of sodium aescinate in real time as well as determining the start and end points of eluate collection.

Evaluation of in vivo antioxidant and immunity enhancing activities of sodium aescinate injection liquid

Oxidative stress is involved in the development and progression of disease. Because sodium aescinate has been reported to have immunity enhancing and antioxidative effects, we investigated its activity by employing a hepatocellular carcinoma (HCC) mouse model. Sixty BALB/c mice were randomly divided into four groups, including a 1.4 mg/kg treated group (n = 15), a 2.8 mg/kg treated group (n = 15), an untreated hepatocellular carcinoma control group (n = 15) and a normal control group (n = 15). After H22 cells were cultured for one week, we collected 2 × 10⁶ cells and injected them subcutaneously as 0.2 mL cell suspensions in sterile saline into the right shoulder region of every mouse. The animals were monitored for changes in activity, physical condition and body weight during the experiment. The next day after injection of H22 cells, animals in these test groups received one intraperitoneal injection of drug or physiological saline for 13 days. Results showed that in the sodium aescinate injection liquid (SAIL)-treated HCC mice, serum interleukin-1 beta (IL-1β), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), interferon-gamma (IFN-γ), Gamma-glutamyltransferase (γ-GT), alanine transaminase (ALT), aspartate transaminase (AST) and alkaline phosphatase (ALP) levels were significantly decreased compared with normal control mice. In addition, treatment with sodium aescinate injection liquid significantly decreased blood and liver malondialdehyde (MDA) levels, increased glutathione (GSH) levels, and antioxidant enzyme [superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GSH-Px)] activities in a dose-dependent manner. We conclude that sodium aescinate injection liquid can decrease oxidative injury and enhance immunity functions in HCC mice.

Venous leg ulcerations: a treatment update

OPINION STATEMENT

Selecting the appropriate treatment for venous leg ulcerations is essential for optimal wound healing and patient quality of life. Compression therapy remains the mainstay of treatment for these wounds. Compression methods should be carefully selected and tailored for compatibility with patients' daily life. Pain management should not be neglected. When response to compression therapy is limited, adjuvant therapy such as medication, débridement, or surgical procedures should be considered on an individual basis.

Alternative prevention and treatment of cardiovascular disease, part 2

This article discusses alternative therapies for secondary prevention and treatment of major cardiac disorders: congestive heart failure, hypertension, dyslipidemias, and peripheral vascular disease. The role of various therapies (eg, herbal and botanic preparations, supplements, mind/body interventions, other alternative modalities of care) are addressed relative to each disease state and will hopefully give the practitioner or student a readily accessible suite of integrative therapies for common cardiac illnesses.

Introducing knowledge of wearing compression stockings on the skin blood flow by using microHematron device

The aim of this preliminary study was to review the actual state of knowledge concerning the mechanisms underlying compression medical stockings action on the skin blood flow (SBF) in capillaries. SBF was assessed by measuring the thermal conductivity of living-tissues using microHematron ambulatory device. The investigation was performed for different postures using three standard French classes (10-15 mmHg, 15-20 mmHg and 20-36 mmHg) of Medical compression stockings (MCS) on six healthy subjects without chronic venous insufficiency. The experiment was divided into four stages (supine, sitting, standing and walking) and was repeated for each class of compression stockings and without MCS. The results showed a significant improvement of SBF depending on the class of MCS used. Best results were obtained for the Class III, which exerts to the highest level of pressure exerted around the ankle. Due to the low number of subjects, which therefore reduces the statistical relevance of results, a non-significant difference in SBF due to the subject's posture was observed. Nonetheless, a positive action by all the classes of MCS on SBF was measured for the supine position. This is a very important result; with patients with chronic venous insufficiency have often some mobility reduction, MCS may enhance their microcirculation even at rest.

Dual effects of sodium aescinate on vascular tension in rat thoracic aorta

OBJECTIVE

Sodium aescinate (SA) is used as a vasoactive drug in clinical treatment. This study was designed to investigate the effects of SA on rat isolated thoracic aorta and the possible mechanisms.

METHODS

Isometric tension was recorded in response to drugs in organ bath.

RESULTS

The effects of SA obeyed an all-or-nothing response. SA in relatively low dose (> or = 50 microg/ml) had an endothelium-independent contractile effect in rat aorta (P<0.01), which depended on extracellular Ca(2+) influx via L-type Ca(2+) channel (P<0.05). SA in relatively high dose (> or = 100 microg/ml) also induced vasoconstriction in Ca(2+)-free medium (P<0.01), which was independent of the activity of inositol-1,4,5-trisphosphate receptor (IP(3)R), ryanodine receptor (RYR), and protein kinase C (PKC). SA in relatively high dose (> or = 100 microg/ml) dilated both endothelium-intact and endothelium-denuded aortic rings precontracted by phenylephrine (PE) or KCl (each P<0.01). SA inhibited extracellular Ca(2+) influx induced by PE or KCl (each P<0.01) and had no activation effect on K(+) channels on vascular smooth muscle. The relaxant effect of SA partly depended on the activity of NO synthase but not on the activity of cyclooxygenase.

CONCLUSIONS

Taken together, this study indicated that SA had dual effects on vascular tension in rat isolated thoracic aorta.