Association of Venous Disorders with Leg Symptoms: Results from the Bonn Vein Study 1

The Other Side of Chronic Venous Disorder: Gaining Insights from Patients' Questions and Perspectives

Venous disorders encompass a diverse range of manifestations and diseases, impacting a significant portion of the population. While life-threatening conditions are uncommon in non-thrombotic disorders, like telangiectasias or uncomplicated varicose veins (VVs), these conditions still have a substantial impact on affected individuals. Ensuring that patients are well informed about their venous disorder is a crucial step in their treatment journey. Providing them with valuable information regarding the disease's natural progression and available therapeutic options plays a pivotal role in optimizing their care. When patients are diagnosed with venous disorders, they often have numerous questions and concerns they want to discuss with their healthcare providers. Addressing these inquiries not only improves patients' knowledge and understanding but also influences their treatment compliance and overall outcomes. Therefore, it is of utmost importance to provide comprehensive explanations that address any doubts, uncertainties, and areas of confusion that patients may have. This report aims to present a concise, practical, and informative guide to venous disorders, focusing specifically on the common questions frequently raised by patients in everyday clinical practice. By serving as a valuable resource for healthcare professionals working in the field of venous diseases, this guide equips them with the necessary tools to effectively address patients' concerns and provide optimal care. By bridging the gap between patients' inquiries and medical expertise, this guide strives to enhance therapeutic outcomes and improve the overall management of venous disorders, ultimately empowering patients in their treatment journey.

Varicose Veins and the Diagnosis of Chronic Venous Disease in the Lower Extremities

Varicose veins usually present in the superficial veins of the lower extremities and are one of the main clinical presentations of chronic venous disease (CVD). Patients' symptoms may vary according to the pathophysiology, location, and severity of CVD. The prevalence of CVD in Korea has been increasing gradually. However, due to its broad clinical spectrum and the subjective nature of its diagnosis using ultrasound, discrepancies in diagnostic and treatment quality may exist among treating physicians. There have been recent efforts to improve the quality of the diagnosis and treatment of varicose veins in Korea by standardizing the diagnostic criteria and the indications for treatment. This study is a comprehensive review of the clinical manifestations and diagnostic criteria of CVD based on the most recent international and domestic guidelines and reports.

The Effect of Superficial Venous Incompetence Treatment on Combined Segmental Deep Venous Reflux

BACKGROUND

The aim of this study was to assess the role of treatment of superficial venous reflux (SVR) in patients with combined deep segmental venous reflux as regards clinical symptoms as well as reflux improvement of the deep veins.

METHODS

We reviewed 80 patients, retrospectively selected on the inclusion criteria and having combined SVR and segmental deep venous reflux who underwent SVR ablation. The contralateral limb of 44 patients was used as a control group, asked to wear compression stockings for 3 months during day time with no surgical intervention. Duplex ultrasounds follow-up was performed at 3, 6, and 12 months postoperatively. Clinical severity of venous disease was graded from C1 to C6 according to the CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) classification. Duplex ultrasound was done in both supine and standing positions with non-weight-bearing of the examined limb. The venous reflux time, the venous flow volume and the peak venous flow velocity were registered. Removal of SVR was performed using either conventional surgery or radiofrequency ablation. The patient was required to wear compression stockings during the day time for the following weeks.

RESULTS

During the follow-up period, all patients were improved clinically as regards pain, edema, and ulcer healing. All patients included in this study had no signs of residual SVR. Corrected deep venous segment reflux was in 36 (45%). Similar data at 3, 6, and 12 months postoperatively after SVR removal. The popliteal vein reflux responded less than the femoral vein reflux did.

CONCLUSIONS

Treatment of the SVR eliminates segmental deep venous reflux in a good percentage of patients regardless of the treatment modality. Also, symptoms improvement and ulcer healing were documented, and hence, more studies are recommended to evaluate this role.

Benefit in physical function and quality of life to nonsurgical treatment of varicose veins: Pilot study

BACKGROUND

Studies on varicose veins have focused its effects on physical function; however, whether nonsurgical treatments alter muscle oxygenation or physical function remains unclear. Moreover, the differences in such functions between individuals with varicose veins and healthy individuals remain unclear.

AIM

To investigate changes in physical function and the quality of life (QOL) following nonsurgical treatment of patients with varicose veins and determine the changes in their muscle oxygenation during activity.

METHODS

We enrolled 37 participants (those with varicose veins, n = 17; healthy individuals, n = 20). We performed the following measurements pre- and post-nonsurgical treatment in the varicose vein patients and healthy individuals: Calf muscle oxygenation during the two-minute step test, open eyes one-leg stance, 30 s sit-to-stand test, visual analog scale (VAS) for pain, Pittsburgh sleep quality index, physical activity assessment, and QOL assessment.

RESULTS

Varicose veins patients and healthy individuals differ in most variables (physical function, sleep quality, and QOL). Varicose veins patients showed significant differences between pre- and post-nonsurgical treatment- results in the 30 sit-to-stand test [14.41 (2.45) to 16.35 (4.11), P = 0.018), two-minute step test [162.29 (25.98) to 170.65 (23.80), P = 0.037], VAS for pain [5.35 (1.90) to 3.88 (1.73), P = 0.004], and QOL [39.34 (19.98) to 26.69 (17.02), P = 0.005]; however, no significant difference was observed for muscle oxygenation.

CONCLUSION

Nonsurgical treatment improved lower extremity function and QOL in varicose veins patients, bringing their condition close to that of healthy individuals. Future studies should include patients with severe varicose veins requiring surgery to confirm our findings.

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

Reduction of lower-limb edema in patients with chronic venous disease by micronized purified flavonoid fraction: a systematic literature review and meta-analysis

INTRODUCTION

The prevalence of lower limb edema is high among patients with chronic venous disease (CVD). Several clinical studies with various designs have assessed the effect of micronized purified flavonoid fraction (MPFF) on edema. The aim of this work was to provide a comprehensive and accurate evaluation of the reduction in ankle and calf circumference as an indicator of lower limb edema reduction in patients with CVD treated with MPFF by combining studies that use different designs in a single group meta-analysis.

EVIDENCE ACQUISITION

We conducted a systematic literature review in April 2022 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria to identify prospective studies investigating the effect of oral MPFF treatment 1000 mg/day on ankle and calf circumference in patients with CVD. Studies with population including at least one patient with an ulcer were excluded. All prospective studies irrespectively of design (i.e., interventional and non-interventional studies, randomized controlled trials (RCTs), non-randomized studies, studies without a control or reference treatment) were eligible. The Medline, Embase and Cochrane databases were searched. Endpoints were ankle and calf circumference measurements and their overall mean change from baseline estimated with random-effects meta-analysis methods. The evaluation criterion feeling of swelling was also analyzed as a standardized mean change (SMC) with 95% confidence intervals after combination of quantitative scales.

EVIDENCE SYNTHESIS

Among 861 articles identified, eight studies (five RCTs including one placebo-controlled, three non-comparative studies) met the criteria. The overall population consisted of 1635 patients, predominantly female (89% ranging from 64% to 94%) with a mean age of 47 years ranging from 41 to 48 years. Mean reduction in ankle circumference was 6.0 mm (95%CI: 3.6 to 8.4; P<0.001) and 7.0 mm (95%CI: 0.9 to 13.1; P=0.024) after two and at least six months of treatment respectively. The results were similar when considering the study type RCTs and non-RCTs. Mean reduction in calf circumference was 5.7 mm (95%CI: 2.8 to 8.6; P<0.001) and 6.7 mm (95%CI: 5.2 to 8.1; P<0.001), at two months and at the last post-baseline evaluation respectively. Heterogeneity among studies was statistically significant (degree of consistency I2=93.5%; P<0.001 and I2=81.1%, P<0.01 for ankle and calf circumference, respectively). In the three studies reporting the effect on feeling of swelling a significant standardized mean change (SMC) reduction of 2.2 (95%CI: 0.2 to 4.2; P=0.028) on a quantitative scale was observed after two months of treatment with MPFF.

CONCLUSIONS

MPFF appeared to be effective in reducing ankle and calf circumference as well as feeling of swelling irrespective of study design. The circumference reduction is present at short and long term, suggesting that benefit occurs early and is maintained overtime. Despite the observed heterogeneity among included studies, this meta-analysis supports the significant therapeutic efficacy of MPFF in reducing lower-limb edema in patients with CVD. The complete video presentation of the work is available online at www.minervamedica.it (Supplementary Digital Material 1: Supplementary Video 1, 5 min, 192 MB).

Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery

The Brazilian Society of Angiology and Vascular Surgery has set up a committee to provide new evidence-based recommendations for patient care associated with chronic venous insufficiency. Topics were divided in five groups: 1. Classification, 2. Diagnosis, 3. Conservative or non-invasive treatment, 4. Invasive treatment and 5. Treatment of small vessels. This last series is closely related to the activities of Brazilian angiologists and vascular surgeons, who are heavily involved in the treatment of small superficial veins. These guidelines are intended to assist in clinical decision-making for attending physicians and health managers. The decision to follow a guideline recommendation should be made by the responsible physician on a case-by-case basis taking into account the patient's specific condition, as well as local resources, regulations, laws, and clinical practice recommendations.

Early-stage chronic venous disorder as a cause of leg pain overlooked for lumbar spinal disease

Leg pain can be caused by both lumbar spinal disease and chronic venous disorder (CVD) of leg veins, but their clinical differences have not been thoroughly investigated. This study aimed to determine the incidence of CVD among patients visiting a spine center for leg pain. A total of 196 cases underwent ultrasound examination with a diagnosis rate were 85.7% (168 cases). CVD-diagnosed cases were divided into two groups based on the severity of lumbar spinal disease. The Clinical grades, symptom areas, and symptom types were compared. The differences in symptom improvements with vasoactive medication were also assessed. The most common symptom area was calf then the foot in CVD, while calf then thigh in lumbar spinal disease. Tingling-paresthesia was the most common symptom type for both, with pain and cramping similarly common in CVD and pain more common than cramping in lumbar spinal disease. Considering that the majority of CVD cases (78.6%) had minor cutaneous changes and almost half of cases (41.7%) had refluxes only in tributaries, significant differences in symptom improvement in CVD-dominant group suggested that early-stage venous reflux is a symptomatic disease and a possible cause of leg pain and other symptoms.

Advanced Levels of Chronic Venous Insufficiency are Related to an Increased in Arterial Stiffness

BACKGROUND

Chronic venous insufficiency (CVI) is characterized by progressive inflammatory changes. Inflammatory damage occurs in the veins, adjacent tissues, and can lead to structural changes in the arteries. The aim of this study is to analyze whether the degree of CVI is associated with arterial stiffness.

METHODS

Cross-sectional study including patients with CVI classified by clinical, etiological, anatomical, and pathophysiological classification (CEAP) 1 to 6. We performed correlation between the degree of CVI, central and peripheral arterial pressure, and arterial stiffness measured by brachial artery oscillometry.

RESULTS

We evaluated 70 patients, 53 of whom were women with a mean age of 54.7 years. Patients with advanced degrees of venous insufficiency CEAP 4,5,6, had higher levels of systolic, diastolic, central, and peripheral arterial pressures compared to those with early stages (CEAP 1,2,3). The CEAP 4,5,6 group had higher arterial stiffness indices than the CEAP 1,2,3 group: pulse wave velocity (PWV) 9.3 m/s vs. 7.0 m/s, P < 0.001; augmentation pressure (AP) 8.0 mm Hg vs. 6.3 mm Hg; P = 0.04. There was a positive correlation between the degree of venous insufficiency measured by the venous clinical severity score, villalta score and CEAP classification, and the arterial stiffness indices (Spearman's coefficient = 0.62 for PWV and CEAP, P < 0.01). The factors influencing PWV were age, peripheral systolic arterial pressure (SAPp), and AP.

CONCLUSIONS

There is a correlation between the degree of venous disease and arterial structural changes characterized by arterial pressure and stiffness indices. Degenerative changes secondary to venous insufficiency are associated with impairment of the arterial system, which has implications for the development of cardiovascular disease.

Review of Topical Sodium Heparin 1000 IU/g Gel in Symptomatic Uncomplicated Superficial Thrombophlebitis

Heparin, a mixture of sulfated polymorphic polysaccharides (glycosaminoglycan) chains of variable lengths and weights and a natural anticoagulant, is widely used in medical practice to prevent intravascular blood coagulation. Heparin has demonstrated antithrombotic and anti-inflammatory activity, and it is mostly administered systemically (intravenously or subcutaneously) for primary or secondary prevention of venous thromboembolism after surgical interventions, or immobilized patients, or on short-term antithrombotic therapy of patients with atrial fibrillation who must undergo treatment. However, since systemic administration of heparin could be, in certain cases, linked to an increased risk of bleeding, topical heparin is widely used for the prevention and treatment of local symptoms of peripheral vascular disorders, such as venous insufficiency, varicose veins, or superficial thrombophlebitis. This review summarizes the main safety and efficacy characteristics of the topical formulation of Heparin in Gel form (1000 International Units of Heparin/g Gel) currently in use, which has demonstrated an excellent efficacy and tolerability profile in reducing signs and symptoms of peripheral vascular disease, e.g., varicose syndromes and their complications, phlebothrombosis, thrombophlebitis, superficial periphlebitis, varicose ulcers, for post-operative varicophlebitis, sequelae of saphenectomy, for traumas and contusions, local edemas and infiltrates, subcutaneous hematoma and for traumatic affections of musculotendinous and capsuloligamentous apparatuses.

Chinese expert consensus on the construction of the fluoroless cardiac electrophysiology laboratory and related techniques

Transcatheter radiofrequency ablation has been widely introduced for the treatment of tachyarrhythmias. The demand for catheter ablation continues to grow rapidly as the level of recommendation for catheter ablation. Traditional catheter ablation is performed under the guidance of X-rays. X-rays can help display the heart contour and catheter position, but the radiobiological effects caused by ionizing radiation and the occupational injuries worn caused by medical staff wearing heavy protective equipment cannot be ignored. Three-dimensional mapping system and intracardiac echocardiography can provide detailed anatomical and electrical information during cardiac electrophysiological study and ablation procedure, and can also greatly reduce or avoid the use of X-rays. In recent years, fluoroless catheter ablation technique has been well demonstrated for most arrhythmic diseases. Several centers have reported performing procedures in a purposefully designed fluoroless electrophysiology catheterization laboratory (EP Lab) without fixed digital subtraction angiography equipment. In view of the lack of relevant standardized configurations and operating procedures, this expert task force has written this consensus statement in combination with relevant research and experience from China and abroad, with the aim of providing guidance for hospitals (institutions) and physicians intending to build a fluoroless cardiac EP Lab, implement relevant technologies, promote the standardized construction of the fluoroless cardiac EP Lab.

Association between the degree of iliac venous outflow obstruction by intravascular ultrasound and lower limb venous reflux

OBJECTIVE

The present study aims to evaluate the association between the degree of iliac venous outflow obstruction (IVOO) identified by intravascular ultrasound (IVUS) and venous reflux presentation in the lower limbs on duplex ultrasound (DU).

METHODS

Patients with bilateral chronic venous insufficiency, CEAP (clinical-etiology-anatomy-pathophysiology) C3 to C6, and a visual analog scale score for pain >5 underwent DU for reflux evaluation of the deep venous system (reflux ≥1 second); superficial system, great saphenous vein, and small saphenous vein (reflux ≥0.5 second); and perforator system (reflux ≥0.35 second). All patients underwent IVUS in the iliac venous territory. The area of the impaired venous segments was categorized as obstruction <50% (category 1), 50% to 79% (category 2), and ≥80% (category 3). The venous clinical severity score and reflux multisegment score (RMS) were assessed.

RESULTS

A total of 51 patients (n = 102 limbs; age, 50.53 ± 14.5 years; 6 men) were included. The predominant clinical severity CEAP class was C3 in 54 of 102 limbs (52.9%). The mean VCSS was 14.3 ± 6.7. A severe RMS (≥3) was registered in 63.4% of the limbs. Of the 102 limbs, 51 (50%) presented with category 1, 27 (26.5%) with category 2, and 24 (23.5%) with category 3. Previous deep vein thrombosis (DVT) was associated with critical obstruction (odds ratio [OR], 3.65; 95% confidence interval [CI], 1.29-10.38; P = .015). The superficial and perforator venous systems had no association with the degree of IVOO. Deep venous reflux (DVR) had a significant association with significant IVOO (obstruction ≥50%; OR, 6.44; 95% CI, 2.19-18.93; P = .001) and critical IVOO (obstruction ≥80%; OR, 4.57; 95% CI, 1.70-12.27; P = .003) and a significant linear association with the IVOO degree and reflux in the femoral veins (P < .001) and popliteal vein (P = .008). Significant lesions were significantly more likely to develop in the left limb (OR, 5.76; 95% CI, 2.46-13.50; P < .001). After multivariate analysis, DVR remained a predictor for significant and critical obstruction (P < .003 and P < .012, respectively). Left limb and previous DVT remained as predictors for IVOO of ≥50% and ≥80% (P < .001 and P = .043, respectively).

CONCLUSIONS

We found a significant linear association between the degree of IVOO and reflux in the deep venous system on DU. Limbs with DVR, a severe RMS, loss of respiratory variation on DU, and previous DVT were more likely to be affected by IVOO of ≥50%, especially with left leg involvement.

Natural History of Varicose Veins of the Legs

Objective To assess the natural history of saphenous and non-saphenous varicose veins using the results of the Bonn Vein Studies and data published in literature.

Methods We used the data of the Bonn Vein Studies (BVS) 1 and 2 to assess if preexisting non-saphenous varicose veins (NSVV) in persons who had no saphenous varicose veins (SVV) at baseline have an impact on the incidence of SVV during the follow-up of 6.6 years and vice versa. SVV where defined as tortuous or not-tortuous refluxing saphenous veins. The statistical evaluation was performed using SAS version 9.4 (SAS Institute, Cary, North Carolina). In addition, we performed a review of publications concerning the natural history of varicose veins (VV) using PubMed.

Results In the BVS the overall incidence of SVV within the follow-up time of 6.6 years was 8.0 % (n = 133 of 1661; 95 % CI: 6.8–9.4). 7.2 % (n = 107 of 1492) without VV in BVS 1 and 19.8 % (n = 26) of patients with preexisting NSVV developed SVV. The relative risk for the development of SVV in patients with preexisting NSVV was 2.44 (95% CI: 1.64–3.64) adjusted for age and sex. The overall incidence of NSVV was markedly higher with 13.3 % (n = 226 of 1661; 95 % CI: 11.8–15.1). During follow-up 148 patients (9.9 %) without VV in BVS 1 developed NSVV. 48.5 % (n = 78) of patients with preexisting SVV developed NSVV during follow-up. The relative risk for the development of NSVV in patients with preexisting SVV was 4.10 (95% CI: 3.26–5.16), adjusted for age and sex.

In published studies the development of VV is preceded by venous reflux. Initial VV may develop at any segment and the results from literature suggest that the location of VV and reflux at the time of the investigation depends on age. In younger individuals more distal location are reported with an ascending progression in the majority but also descending progression is possible.

Conclusions Based on the results of the Bonn Vein Studies 1 and 2 we could demonstrate, that preexisting SVV increase the risk of developing NSVV and preexisting NSVV increase the risk of developing SVV in a similar way. Venous reflux may initially occur in any segment of the venous system and may progress in antegrade and/or retrograde fashion. In younger adults initial VV seem to be localized more often in distal parts of the legs with an antegrade progression over time.

Relationship between iliofemoral venous stenting and femoropopliteal deep venous reflux

OBJECTIVE

Severe presentations of chronic venous insufficiency can result from reflux or obstruction at the deep venous, perforator, or superficial venous levels. Iliofemoral venous stenting can be used to address central venous obstruction; however, its effects on deep venous reflux (DVR) have remained unclear. The purpose of the present study was to evaluate the effects of iliac vein stenting on femoropopliteal DVR with the hypothesis that ultrasound evidence of DVR would remain absent or would have improved after iliac vein stenting.

METHODS

The present study was a retrospective review of patients who had undergone iliofemoral venous stenting from 2013 to 2018. The patients were divided into two cohorts according to the preprocedural presence (group A) or absence (group B) of femoropopliteal DVR. Baseline patient variables were collected, including age, gender, CEAP (clinical, etiologic, anatomic, pathophysiologic) class, presence of concomitant superficial or perforator reflux, deep vein thrombosis history, and additional venous interventions. The primary outcome evaluated was the persistent absence or resolution of DVR on the latest venous duplex ultrasound at follow-up. Other outcomes included the follow-up CEAP classification and the need for secondary deep venous interventions.

RESULTS

A total of 275 consecutive patients had undergone iliofemoral venous stenting. Of the 275 patients, 58 had presented with DVR (group A). A comparison of groups A and B revealed that group A had had a greater likelihood of prior deep vein thrombosis (P = .0001) and a higher frequency of superficial venous ablation. The remaining demographic variables did not differ significantly between the two groups. Of the 58 patients in group A, DVR had resolved at follow-up in 17 (P = .0001). When stratified by level, 7 of these 17 patients had had isolated popliteal reflux. In group B, DVR had developed at follow-up in 6 of the 217 patients. The CEAP class had improved from before intervention (C0, 1.1%; C1, 0.4%; C2, 1.8%; C3, 41.4%; C4, 24.9%; C5, 5.9%; C6, 24.5%) to the latest follow up (C0, 4.9%; C1, 1.9%; C2, 5.7%; C3, 34.2%; C4, 22.8%; C5, 17.1%; C6, 13.3%). Significant improvement had occurred in C6 disease within both groups (group A, 16 of 58 [27.6%; P = .0078]; group B, 19 of 217 [8.8%; P = .0203]).

CONCLUSIONS

For patients who undergo iliofemoral venous stenting, DVR could improve if present initially and is unlikely to develop if not present before stenting. A cohort of patients had experienced persistent DVR and warranted further evaluation. Prospective studies are required to corroborate the safety, efficacy, and durability of iliofemoral venous stenting for patients with DVR.

A randomized clinical trial of isolated ambulatory phlebectomy versus saphenous thermal ablation with concomitant phlebectomy (SAPTAP Trial)

BACKGROUND

Current treatment of patients with saphenous trunk and tributary incompetence consists of truncal ablation with concomitant, delayed or no treatment of the tributary. However, reflux of the saphenous trunk may be reversible after treatment of the incompetent tributary. The aim of this study was to determine whether single ambulatory phlebectomy with or without delayed endovenous truncal ablation (SAP) is non-inferior to thermal endovenous ablation with concomitant phlebectomy (TAP), and whether SAP is a cost-effective alternative to TAP.

METHODS

A multicentre, non-inferiority RCT was conducted in patients with an incompetent great saphenous vein or anterior accessory saphenous vein with one or more incompetent tributaries. Participants were randomized to receive SAP or TAP. After 9 months, additional truncal treatment was considered for SAP patients with remaining symptoms. The primary outcome was VEnous INsufficiency Epidemiological and Economic Study Quality of Life/Symptoms (VEINES-QOL/Sym score) after 12 months. Secondary outcomes were, among others, cost-effectiveness, perceived improvement of symptoms, and anatomical success.

RESULTS

Some 464 patients received the allocated treatment (SAP 227, TAP 237). VEINES-QOL scores were 52.7 (95 per cent c.i. 51.9 to 53.9) for SAP and 53.8 (53.3 to 55.1) for TAP; VEINES-Sym scores were 53.5 (52.6 to 54.4) and 54.2 (54.0 to 55.6) respectively. Fifty-eight patients (25.6 per cent) in the SAP group received additional truncal ablation. Treatment with SAP was less costly than treatment with TAP.

CONCLUSION

One year after treatment, participants who underwent SAP had non-inferior health-related quality of life compared with those who had TAP. Treatment with SAP was a cost-effective alternative to TAP at 12 months.

REGISTRATION NUMBER

NTR 4821 (www.trialregister.nl).

Phlebological compression bandaging competence: comparing performance of nurses before and after one-off training

OBJECTIVES

To investigate the differences in applying phlebological compression bandaging (PCB) in nurses before and after one-off training, and to compare the performance of subgroups.

METHODS

Participants received training teaching the correct application of PCB. Participants' competence was measured using the newly developed control score of compression bandaging (CCB score) before and after training, one and three months later. Subgroup analyses compared participants (work setting, wound certification, PCBs applied per week).

RESULTS

In total, 47 participants took part (mean age 40.7 years, 85.1% female, 59.6% outpatient nurses, 59.6% >10 years' working experience, 55.3% with a wound certificate). The CCB score improved after training. In all subgroups, the score differed significantly over time (p≤0.002 in all cases) except for participants applying the highest number of PCBs (p=0.241). In hospital-based participants, the CCB score three months after training was considerably, but non-significantly, higher than before training (2.84 versus 4.21, respectively; p=0.068). In participants working in outpatient settings, with and without a wound certificate, and applying a low (<5) and medium (5-10) number of PCBs per week, the CCB score remained significantly higher than before training (p≤0.011 in all cases).

CONCLUSION

All subgroups benefited from training, mostly significantly, and maintained gains in competence for three months. Frequently applying these skills may improve performance. Previously published results showed that ideal pressure-related parameters are rarely achieved. Regular training should be offered, including the use of pressure-measuring devices, allowing nurses to gain experience and develop deeper understanding of correct PCB application.

The role of podiatry in the early identification and prevention of lower limb venous disease: an ethnographic study

BACKGROUND

Lower limb venous disease can cause significant pain, loss of mobility, and can be detrimental to an individual's quality of life. Manifestations of venous disease often pose a substantially negative impact on patients and place a high demand on finite healthcare resources. Whilst this problem is internationally recognised, most research and discourse has predominantly focussed on treatment of leg ulceration and prevention of recurrence. Prevention of lower limb venous disease progression to the first ulceration has received far less attention. Overall, the care of this condition appears to rest in the domain of medicine and nursing yet podiatry, a profession with responsibility for the lower limb and foot, is conspicuous by its absence from the literature.  METHODS: An ethnographic approach was used to gather data from 26 participants through observation, semi-structured interviews, and a focus group interview. Qualitative analysis was conducted using the framework approach.

RESULTS

The findings revealed an identity crisis within the podiatry profession. Evidence emerged of ritual and routine practices that did not include lower limb venous disease. External control over practice limited the professional autonomy of podiatrists determining their own activities. Inter-professional relationships with nursing, and perceptions of boundaries that venous disease was a nursing role were also found to be limiting factors.

CONCLUSIONS

This research revealed that podiatry does not occupy a substantive role in contributing to the early identification and prevention of lower limb venous disease. Policy, education, research and practice changes are all required to enhance the contribution of podiatry to reduce the burden of this disease.

Clinically Recognized Varicose Veins and Physical Function in Older Individuals: The ARIC Study

BACKGROUND

Although a few studies reported an association between varicose veins and physical function, this potentially bidirectional association has not been systematically evaluated in the general population.

METHOD

In 5 580 participants (aged 71-90 years) from the Atherosclerosis Risk in Communities study, varicose veins were identified in outpatient and inpatient administrative data prior to (prevalent cases) and after (incident cases) visit 5 (2011-2013). Physical function was evaluated by the Short Physical Performance Battery (SPPB, score ranging from 0 to 12). We evaluated (i) cross-sectional association between prevalent varicose veins and physical function, (ii) association of prevalent varicose veins with subsequent changes in physical function from visit 5 to visits 6 (2016-2017) and 7 (2018-2019), and (iii) association of physical function at visit 5 with incident varicose veins during a median follow-up of 3.6 years (105 incident varicose veins among 5 350 participants without prevalent cases at baseline).

RESULTS

At baseline, varicose veins were recognized in 230 (4.1%) participants and cross-sectionally associated with reduced physical function. Longitudinally, prevalent varicose veins were not significantly associated with a decline in SPPB over time. In contrast, a low SPPB ≤6 was associated with a greater incidence of varicose veins compared to SPPB ≥10 (adjusted hazard ratio 2.13 [95% confidence interval = 1.19, 3.81]).

CONCLUSION

In community-dwelling older adults, varicose veins and low physical function were associated cross-sectionally. Longitudinally, low physical function was a risk factor for incident varicose veins, but not vice versa. Our findings suggest an etiological contribution of low physical function to incident varicose veins.

Clinical Perspectives and Management of Edema in Chronic Venous Disease—What about Ruscus?

Background: Edema is highly prevalent in patients with cardiovascular disease and is associated with various underlying pathologic conditions, making it challenging for physicians to diagnose and manage. Methods: We report on presentations from a virtual symposium at the Annual Meeting of the European Venous Forum (25 June 2021), which examined edema classification within clinical practice, provided guidance on making differential diagnoses and reviewed evidence for the use of the treatment combination of Ruscus extract, hesperidin methyl chalcone and vitamin C. Results: The understanding of the pathophysiologic mechanisms underlying fluid build-up in chronic venous disease (CVD) is limited. Despite amendments to the classic Starling Principle, discrepancies exist between the theories proposed and real-world evidence. Given the varied disease presentations seen in edema patients, thorough clinical examinations are recommended in order to make a differential diagnosis. The recent CEAP classification update states that edema should be considered a sign of CVD. The combination of Ruscus extract, hesperidin methyl chalcone and vitamin C improves venous tone and lymph contractility and reduces macromolecule permeability and inflammation. Conclusions: Data from randomized controlled trials support guideline recommendations for the use of Ruscus extract, hesperidin methyl chalcone and vitamin C to relieve major CVD-related symptoms and edema.

Delphi case: Sharing of clinical experiences for improvement in the treatment of chronic venous disease

Chronic venous disease (CVD) is a common condition with major health consequences that is associated with poor long-term prognosis, significant socioeconomic impact, disabling symptoms, and reduced quality of life. To provide a novel evidence-based approach in the management of CVD, a consensus process (“Delphi Case”) following a first Delphi Consensus was conceived. With a real-life fashion analysis, a steering committee formed by 3 expert leaders on chronic venous disease drove a panel of 77 expert Italian angiologists/vascular surgeons along a collegial discussion, integrating data coming from the guidelines recommendations of different Vascular Scientific Societies with the consensus agreement statements gathered from the first Delphi Consensus, and with data coming from the discussion of few statements in which there was disagreement. From July 15 to October 16, 2020, demographic, anamnestic, objective, and therapeutic data coming from a total of 2,275 patients were collected by the experts panel using a predefined case report form. The results of this second consensus provided a real-life picture of CVD management in the Italian population and clearly showed that a tailored therapeutic approach together with an appropriate lifestyle (e.g., diet, physical activity, weight loss) must be considered as the milestones for the CVD-related signs and symptoms clinical improvement in daily clinical practice. An evaluation of the adherence and of the efficacy of the prescribed pharmacological and compressive treatment in a medium-long term follow-up of the study population has been planned as the last step of this course and will be object of a future final publication.

THE EFFECTS OF INSPIRATORY MUSCLE TRAINING VERSUS CALF MUSCLE TRAINING ON QUALITY OF LIFE, PAIN, VENOUS FUNCTION AND ACTIVITY IN PATIENTS WITH CHRONIC VENOUS INSUFFICIENCY

OBJECTIVE

The aim of this study was to evaluate the effect of inspiratory muscle training(IMT) and calf muscle exercise training(ETC) in addition to compression therapy(CT) on quality of life, venous refilling time, disease severity, pain, edema, range of motion, muscle strength and functionality in patients with chronic venous insufficiency (CVI) compared to compression treatment alone.

METHODS

Thirty-two participants diagnosed with CVI were randomly divided into three groups. IMT in addition to compression therapy, Group 1, exercise training for the calf muscle in addition to compression therapy, Group 2, and compression therapy alone, Group 3. All the patients were assessed with the Chronic Venous Insufficiency Quality of Life Questionnaire-20, Nottingham Health Profile, photoplethysmography, venous clinical severity score, visual analog scale, intraoral pressure measurements, dynamometer, digital goniometer, 6-minute walk test and lower extremity functional scale.

RESULTS

After treatment, Group 2 improved more than groups 1 and 3 in terms of quality of life, venous refilling time, pain, edema, range of motion, muscle strength and functionality scores; Group 1 improved more than groups 2 and 3 in terms of disease severity, inspiratory and expiratory muscle strength values(p<0.05). Only physical mobility and right leg venous refilling time increased in group 3(p<0.05).

CONCLUSIONS

IMT and ETC improve venous function in both legs in patients with CVI while CT alone improves venous function only in the right leg of patients with CVI.

Using AI and passive medical radiometry for diagnostics (MWR) of venous diseases

We studied the possibility of using artificial intelligence (AI) passive microwave radiometry (MWR) for the diagnostics of venous diseases. MWR measures non-invasive microwave emission (internal temperature) from human body 4 cm deep. The method has been used for early diagnostics in cancer, back pain, brain, COVID-19 pneumonia, and other diseases. In this paper, an AI model based on MWR data is proposed. The model was used to predict the disease state of phlebology patients. We have used MWR and infrared (skin temperature) data of the lower extremities to design a feature space and construct a classification algorithm. Our method has a sensitivity above 0.8 and a specificity above 0.7. At the same time, our method provides an advisory outcome in terms which are understandable for clinicians.

Supplement of Clinical Practice Guidelines for Endovenous Thermal Ablation for Varicose Veins: Overuse for the Inappropriate Indication

While endovenous thermal ablation (ETA) become first choice of treatment for varicose veins, overuse of ETA for the inappropriate indication is growing problem. ETA is performed not only on varicose cases without symptom but also non diseased cases with segmental reflux of saphenous veins or no reflux. Indications of ETA was demonstrated in “the Clinical Practice Guidelines for ETA for Varicose Veins 2019” by Japanese Society of Phlebology. Purpose of this supplement is description of basics of correct indication for ETA. We also demonstrate the typical case of overuse of ETA for wrong indication. (This is a translation of Jpn J Phlebol 2020; 31: 39–43.)

Assessing Post-Driving Discomfort and Its Influence on Gait Patterns

Professional drivers need constant attention during long driving periods and sometimes perform tasks outside the truck. Driving discomfort may justify inattention, but it does not explain post-driving accidents outside the vehicle. This study aims to study the discomfort developed during driving by analysing modified preferred postures, pressure applied at the interface with the seat, and changes in pre- and post-driving gait patterns. Each of the forty-four volunteers drove for two hours in a driving simulator. Based on the walking speed changes between the two gait cycles, three homogeneous study groups were identified. Two groups performed faster speeds, while one reduced it in the post-steering gait. While driving, the pressure at the interface and the area covered over the seat increased throughout the sample. Preferred driving postures differed between groups. No statistical differences were found between the groups in the angles between the segments (flexed and extended). Long-time driving develops local or whole-body discomfort, increasing interface pressure over time. While driving, drivers try to compensate by modifying their posture. After long steering periods, a change in gait patterns can be observed. These behaviours may result from the difficulties imposed on blood circulation by increasing pressure at this interface.

An evaluation of quality of life, physical activity level and symptoms in patients with early stages of chronic venous disease

BACKGROUND

Chronic venous disease (CVD) is a common, long-term disease that has a variety of symptoms, signs and decreases the patients' quality of life (QoL) of the patients. The aim of this study was to evaluate QoL, symptoms, and physical activity level of CVD patients with early stages (C₁ and C₂ classes).

METHODS

The sample of this study composed of 40 patients diagnosed with CVD. The data were collected by face-to-face interview method in the cardiovascular surgery outpatient clinic. Participants were diagnosed with duplex ultrasound (DUS). A personal information form, venous insufficiency epidemiological and economic study-quality of life/symptoms (VEINS-QOL/Sym), and international physical activity questionnaire were used to assess the participants.

RESULTS

According to DUS results, 23 participants had unilateral CVD, 17 participants had bilateral CVD. Thirty-six of these limbs were stage C₂ according to CEAP, twenty one were stage C_3. The patients with CVD had low QoL and physical activity level, also moderate pain intensity. Pain, swelling, restless leg, heavy legs, night cramps, and itching were more common symptoms. There was no statistical difference between unilateral/bilateral CVD patients in QoL scores, physical activity level, and pain intensity (p˃0.05).

CONCLUSION

There was no difference between the extent and severity of the disease and QoL, physical activity level, variety of symptoms. To increase the physical activity level and to evaluate the quality of life may be important for the management of the disease from the early stages of the disease (C₁ and C₂ classes).

Psychometric properties of the short version of the Freiburg Life Quality Assessment for chronic venous disease (FLQA-VS-10)

BACKGROUND

Chronic venous disease is a frequent vascular condition. International societies recommend the assessment of health-related quality of life (HRQoL) instruments in patients with vascular diseases. For this purpose, the 10-item questionnaire FLQA-VS-10 had previously been developed. The aim of this study was to validate this instrument in a prospective study.

METHODS

We recruited 100 patients with recurrent varicosis or (in)complete venous insufficiency undergoing interventional vein treatment (high ligation of the great or the small saphenous vein, or endovenous ablation therapy) who answered the questionnaire along with instruments assessing convergent validation criteria at four timepoints: pre- (T1) and post-surgical (T2) and twice three years later with one week in-between (T3 and T4).

RESULTS

Patients had a mean age of 56.0 years (SD 13.7), 66.0% were women. Patients presented with recurrent varicosis of the sapheno-femoral junction (28.0%), recurrent varicosis of the sapheno-popliteal junction (1.0%), (in)complete insufficiency of the great saphenous vein (69.0%), or complete insufficiency of the small saphenous vein (2.0%). The items showed few missing values. The FLQA-VS-10 global score showed no ceiling effect (patients reporting highest possible impairments in HRQoL) but a floor effect (patients reporting lowest possible impairments in HRQoL), which was highest at the post-surgical assessments. The internal consistency of the global score was high at all timepoints. Convergent validity and responsiveness analysis revealed that, the FLQA-VS-10 correlated in the expected direction with convergent instruments, including the FLQA-V (venous-disease specific HRQoL) and the EQ-5D-5L (generic HRQoL). Data from T3 and T4 revealed a high test-retest reliability (intraclass correlation = 0.92). Overall, patients stated that the FLQA-VS-10 was comprehensible, comprehensive, and easy-to-answer.

CONCLUSION

Our data suggest that the FLQA-VS-10 is a reliable, valid, responsive, and feasible HRQoL questionnaire for patients with chronic venous diseases. This questionnaire can serve as short and easy-to-use instrument to assess patient-reported outcomes in the treatment of these patients.

Assessment of venous leg symptoms in patients with hemorrhoidal disease (VEIN-HEMORRHOID study)

BACKGROUND

Coexistence of dilating venous diseases in different vascular territories has raised the idea that they have similar vascular wall abnormality in their evolutionary process. Accordingly, we aimed to evaluate venous leg symptoms in patients with hemorrhoidal disease (HD) by means of VEINES-Sym questionnaire.

MATERIALS AND METHODS

The study involved 249 consecutive patients who underwent colonoscopy and met the inclusion criteria. Presence and grading of HD were made according to Goligher's classification. All patients were examined for the existing of varicose vein and classified in respect of CEAP classification. All participants were requested to answer the VEINES-Sym questionnaire.

RESULTS

There was not statistically significant differences between the patients without HD (grade 0 or I) and with HD (Grade II or III) in respect to clinical characteristics except female predominance in hemorrhoid group (p = 0.07). Scores of heavy legs, swelling, burning sensation, restless leg, throbbing, tingling, and total VEINES score were significantly lower (ie: worse) in hemorrhoid group. Logistic regression analysis revealed that female gender and total VEINES score were independently associated with HD (OR: 2.03, 95% CI: 1.17-3.52, p = 0.01; OR: 0.96, 95% CI: 0.92-0.99, p = 0.02, respectively). Among all venous leg symptoms, severity of heavy legs, night cramps, swelling and aching were significantly correlated with the grades of HD.

CONCLUSION

We have shown significant association between the HD and venous leg symptoms reflected by total VEINES score and significant correlation between the HD grade and venous leg symptoms severity including heavy legs, swelling, night cramps and aching legs.

The effectiveness of different treatment methods in isolated telangiectasia and reticular vein treatment: A single-center prospective randomized study

BACKGROUND

There are opinions that telangiectasis and reticular veins are asymptomatic and constitute a cosmetic problem only. However, it has been proven that telangiectasis and reticular veins also affect the quality of life and are symptomatic.

METHODS

Ninety consecutive female patients who were admitted to our outpatient clinic and did not have insufficiency in deep, superficial and perforating veins were included in this study. All participants were divided into three groups as the compression group (Group 1), medical treatment group (Group 2), and sclerotherapy group (Group 3). The initial complaint severities of all patients were noted. Except for patient compliance assessment, baseline, 1st month (T1), 3rd month (T2) and 6th month (T3) evaluation records were kept in all three groups.

RESULTS

The study began with a total of 90 patients, 30 patients in each group. The mean ages of Groups 1, 2 and 3 were 39.73 ± 8.51 years, 39.30 ± 8.67 years, and 40.77 ± 9.45 years, respectively. The rates of decrease in pain, itching, restless leg, and muscle cramps were similar among the patient groups at all times (P > 0.05). The rate of reduction in swelling was similar between the groups at T1 and T2 (P > 0.05), while there was a significant difference between the groups at T3 (P = 0.009). The groups significantly differed in terms of appearance concern at all times (P = 0.002 for T1, P < 0.001 for T2 and T3).

CONCLUSION

We showed that symptoms such as swelling and heaviness in leg can be improved with medical treatment, but the patient's cosmetic satisfaction can increase with sclerotherapy.

Multicomponent compression system use in patients with chronic venous insufficiency: a real-life prospective study

OBJECTIVE

Compression therapy is the cornerstone of therapeutic management of patients with chronic venous insufficiency (CVI). This study aimed to evaluate the efficacy and safety of a multicomponent compression system in an unselected population of patients with CVI problems under real-life conditions.

METHOD

A prospective, multicentre, observational study with a multicomponent two-bandage compression system (UrgoK2, Laboratoires Urgo, France) was conducted in 103 centres in Germany. Main outcomes included wound healing rate, wound healing progression, assessment of oedema and ankle mobility, local tolerability and acceptance of the compression therapy.

RESULTS

A total of 702 patients with venous leg ulcers (VLU) and/or with lower limb oedema due to CVI were treated with the evaluated system for a mean (±standard deviation) duration of 27±17 days. By the last visit, 30.9% of wounds had healed and 61.8% had improved. Limb oedema was resolved in 66.7% of patients and an improvement of ankle mobility was reported in 44.2% of patients. The skin condition under the compression therapy was also considered as improved in 73.9% of patients and a substantial reduction of pain was achieved, both in number of patients reporting pain and in pain intensity. Compression therapy with the evaluated system was 'very well' or 'well' tolerated and 'very well' or 'well' accepted by >95% of patients. These positive outcomes were in line with the general opinion of physicians on the evaluated compression bandages, which were judged 'very useful' or 'useful' for >96.6% of patients. Similar results were reported regardless of the treated condition, VLU and/or limb oedema.

CONCLUSION

Real-life data documented in this large observational study of non-selected patients receiving compression therapy in daily practice confirm the benefits and safety profile of the evaluated compression system. This study also confirms the high-level of performance and acceptability of the system, regardless of the characteristics of the wounds or patients at initiation of the treatment. The data support the use of this multicomponent compression system as one first-line intervention in patients with symptoms caused by CVI.

An algorithm combining VVSYmQ® and VCSS scores may help to predict disease severity in C2 patients

OBJECTIVES

The purpose was to assess whether combining patient reported scores (VVSymQ®) and physician reported scores (VCSS) stratifies disease severity in C2 patients.

METHODS

Consecutive patients were pooled from the VANISH-1 and VANISH-2 cohorts. VCSS and VVSymQ® were calculated for each patient. The relationship between scoring systems was evaluated using Pearson's correlation and frequency distribution analysis.

RESULTS

Two-hundred and ten C2 limbs were included. Scoring systems demonstrated: VVSymQ®: mean = 8.72; VCSS: mean = 6.32; correlation (r = 0.22, p = 0.05). Frequency distribution analysis demonstrated 61.4% of patients had low VVSymQ® and low VCSS; 31.3% had elevated VVSymQ® and increased VCSS; 7.3% were inconsistent with C2 disease. Strict concordance analysis revealed 40.5% had VVSymQ® (< 9)/VCSS (0-6), 18.6% had VVSymQ® (≥ 9)/VCSS (7-9), and 2.9% had VVSymQ® (≥9)/VCSS (≥10).

CONCLUSIONS

For combined elevated VVSymQ® and VCSS, moderate/severe disease is corroborated, and intervention may be indicated. For combined lower scores, the disease severity is mild and conservative therapy is more appropriate.

The relationship between clinical severity and outcome measures in patients with chronic venous insufficiency with or without leg ulcer

PURPOSE

To evaluate the relationship between clinical severity and functionality, sleep quality, depression, and quality of life (QoL) in patients with CVI with or without leg ulcers.

METHODS

A total of sixty patients with CVI were enrolled in the study. The patients were C2-6 according to the CEAP classification. All the patients were assessed with Venous Clinical Severity Score (VCSS) for clinical severity, Visual Analog Scale (VAS) for pain, right and left lower limb (RLL and LLL) circumference measurements for edema, 6-min-walk test (6-MWT) for functional capacity, Lower Extremity Functional Scale (LEFS) for functionality, Pittsburg Sleep Quality Index (PSQI) for sleep quality, Beck Depression Inventory version I (BDI-I) for depression, and The Quality of Life Questionnaire for Chronic Venous Diseases-20 (CIVIQ-20) for QoL.

RESULTS

The mean age of the patients was 45.83 ± 13.25 years, and the mean duration of disease was 8.30 ± 7.42 years. There was a significant association between VCSS and VAS-rest/activity, edema-RLL/LLL, PSQI, BDI-I, LEFS, and CIVIQ-20 in patients without leg ulcers. In addition, a significant association was found between VCSS and VAS-rest/activity and CIVIQ-20 in patients with leg ulcers.

CONCLUSION

The current study showed that an association has been found between clinical severity and pain at rest and during activity, edema, sleep quality, depression, lower extremity function, and QoL in patients without ulcers. However, clinical severity has been correlated with only pain at rest and during activity, and QoL in patients with leg ulcers.

Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review

PURPOSE OF REVIEW

Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease.

RECENT FINDINGS

Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.

Vulvar Varicosities in an Adolescent Girl with Morbid Obesity: A Case Report

Vulvar varicosities in nonpregnant females, either isolated or as a part of the pelvic congestion syndrome, are rare. We present a case of an adolescent girl with morbid obesity with bilateral bluish protrusions on the labia minora, as an incidental finding, that coincided with her excessive weight gain. The adolescent underwent thorough clinical examination, doppler ultrasound, contrast venography and varicography, and magnetic resonance angiography to rule out alternative diagnoses. Imaging results confirmed the presence of large venous lakes. Venous drainage to the internal iliac vein and connections with the long saphenous vein were delineated. Incompetence, dilatation, or reflux of ovarian or internal iliac veins, or their main tributaries, were not noted. Since the adolescent was asymptomatic and other pathologies, such as vascular malformations or hemangiomas were excluded, she was managed conservatively with counseling about lifestyle modification and weight reduction. This is only the third reported case of vulvar venous varicosities in adolescents. Female sex, along with obesity, are known risk factors for varicose vein formation; however, the pathogenesis is not fully understood. Additional research is needed to elucidate the role of excess adipose tissue in the pathophysiology of vulvar varicose veins and to optimize diagnostic workup and management in adolescence.

Validity of Chronic Venous Disease Diagnoses and Epidemiology Using Validated Electronic Health Records From Primary Care: A Real-World Data Analysis

PURPOSE

The aim of this study was to evaluate the validity of lower limb chronic venous disease (CVD) diagnoses entered in a large electronic health record database in primary care in Catalonia, Spain; to investigate the reliability of these data for research purposes; and to estimate the prevalence and incidence of CVD, chronic venous insufficiency (CVI), and venous leg ulcer (VLU).

DESIGN

Real-world data analysis based on a large electronic health record database in primary care in Catalonia, Spain.

METHODS

We used a primary care research database (Information System for the Development of Research in Primary Care [SIDIAP]), which contains anonymous data on some 5.8 million people from 279 primary care centers, accounting for more than 80% of the Catalonian population and 15% of the Spanish population. We evaluated the validity of the ICD-10 codes for CVD in SIDIAP for 200 adult patients through the responses of 20 primary care physicians to a questionnaire.

FINDINGS

The positive predictive value of CVD in SIDIAP was 89.95% (95% confidence interval [CI] 84.99-93.40). The prevalence rates for CVD, CVI, and VLU were 9.54% (95% CI 9.51-9.56), 3.87%, and 0.33%, respectively. The incidence rates for CVD, CVI, and VLU were 7.91/1,000 person-years (95% CI 7.82-8.00), 3.37/1,000 person-years (95% CI 3.31-3.43), and 0.23/1,000 person-years (95% CI 0.21-0.24), respectively.

CONCLUSIONS

The Catalonian SIDIAP database contains valid CVD diagnoses. The prevalence and incidence rates found using real-world data are low compared with those in the literature, possibly because CVD is an underdiagnosed entity.

CLINICAL RELEVANCE

Real-world data can inform clinicians on lower limb venous health in a population, show changes as individuals age, and reveal aspects where healthcare can be improved.

"Quality of Life after Varicose Vein Surgery in Patients with High-ligation and Stripping, External Valvuloplasty and Sapheno-femoral Redo Surgery"

BACKGROUND

High-ligation and stripping (HL/S) and external valvuloplasty (eVP) with the implantation of an external device to restore the valve's function, are surgical methods to eliminate reflux at the saphenofemoral junction. Furthermore, redo-surgery (RedoS) can be performed in terms of same side groin recurrences. It is unclear, if there is a difference in quality of life (QoL) between these 3 surgical treatment options. Therefore, it was the aim of our study to elucidate QoL in patients before and after surgical treatment at the saphenofemoral junction by comparing HL/S, eVP, and RedoS.

METHODS

A total of 303 participants (156 HL/S, 81eVP, 64 RedoS) were recruited during the daily clinical routine. QoL was measured at admission and 6 weeks after the surgical procedure by means of SF-12 (12 item short form health survey) and Aberdeen Varicose Vein Questionnaire.

RESULTS

The mean value of Aberdeen Varicose Vein Questionnaire was 14.5 (SD 2.1) preoperatively and 4.9 (SD 3.3) postoperatively in the HL/S group, 16.4 (SD 1.4) preoperatively and 6.8 (SD 2.5) postoperatively in the eVP group and 15.5 (2.2) preoperatively and 5.8 (SD 4.2) postoperatively in the RedoS group, which was statistically significant (P< 0.05) in all groups. Postoperatively, the mean values were statistically significant within the groups. Concerning physical aspects of the SF-12 we found a significant improvement in the RedoS group, while mental aspects were significantly better in the HL/S and eVP group postoperatively. Nevertheless, the clinical relevance of these SF-12 differences is questionable under consideration of the minimal important difference.

CONCLUSIONS

Varicose vein surgery leads to a significant improvement of QoL in all groups. The implantation of an external patch could have a negative influence in QoL.

Defining the human and health care costs of chronic venous insufficiency

Chronic venous insufficiency (CVI) affects more than 25 million adults in the United States alone, and more 6 million with advanced stages of venous disease. The high incidence of CVI and the increasing costs of care, place a heavy financial burden on the US health care system. Recent studies estimate the total cost of care at more than $3 billion per year. These staggering numbers highlight the importance of timely diagnosis, treatment, and prevention of CVI. In this article, we review the epidemiology and prevalence of CVI, and its financial impact on national health care budget. Racial disparities in CVI and the impact of socioeconomic status on access to care are also discussed. Finally, we discuss CVI-related screening programs and the importance of preventative measures in venous disease.

Venous leg symptoms, ecchymosis, and coldness in patients with peripheral varicose vein: A multicenter assessment and validation study (VEIN-VIOLET study)

OBJECTIVES

We aimed to evaluate peripheral varicose vein symptoms including ecchymosis and coldness by using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms (VEINES-QoL/Sym) questionnaire.

METHODS

A total of 1120 patients were enrolled to the analysis after the exclusion of 199 patients who did not match the inclusion criteria. Patients were asked to answer the VEINES-Sym questionnaire and questions about ecchymosis and coldness. Scores of ecchymosis and coldness were calculated similar to VEINES-Sym questionnaire. Classifications of peripheral varicose vein were made according to the clinical part of clinical, etiological, anatomical, and pathophysiological classification system and patients with grade 2 or higher were considered as positive for peripheral varicose vein.

RESULTS

Frequency of symptoms present in the VEINES-Sym instrument, ecchymosis and coldness were significantly higher in patients with peripheral varicose vein. Mean score of each symptom was significantly lower in peripheral varicose vein patients including scores of ecchymosis and coldness. Logistic regression analysis revealed that presence of hemorrhoids and all symptoms in VEINES-Sym questionnaire except restless leg were significantly and independently associated with peripheral varicose vein. Besides, ecchymosis (odds ratio: 2.04, 95% confidence interval: 1.34-3.08, p = 0.008) but not coldness was significantly and independently associated with peripheral varicose vein. There was also significant correlation of VEINES-Sym score with ecchymosis (r = 0.43, p < 0.001) and coldness (r = 0.47, p < 0.001).

CONCLUSIONS

Venous leg symptoms present in VEINES-Sym questionnaire except restless legs, presence of hemorrhoids and ecchymosis are significantly and independently associated with peripheral varicose vein. Not only ecchymosis but also coldness has shown an independent association with total VEINES-Sym score.

Accuracy of contralateral Villalta score to assess for pre-existing chronic venous insufficiency in patients with unilateral deep vein thrombosis

BACKGROUND

International guidelines recommend using the Villalta score (VS) to diagnose the postthrombotic syndrome (PTS). However, a high proportion of PTS detected with VS could just reflect the presence of preexisting primary venous insufficiency (PVI). Furthermore, it is unclear whether the contralateral VS (cl-VS) can be used to assess for preexisting PVI.

OBJECTIVES

To estimate whether cl-VS can be used to assess for preexisting PVI, and to assess the proportion of PTS that could be attributable to preexisting PVI.

METHODS

Subanalysis of the SOX multicenter randomized trial focusing on patients with a first unilateral proximal deep vein thrombosis (DVT) followed for up to 2 years. PVI was defined as a baseline cl-VS > 4, and PTS as VS > 4 in the leg ipsilateral to DVT starting 6 months after DVT.

RESULTS

Among 680 patients, mean cl-VS remained stable over time: 1.23 (standard deviation [SD] ±2.49) at baseline and 1.17 (±2.20), 1.59 (±2.81), 1.54 (±2.50), 1.65 (±2.82), and 1.55 (±2.63) at the 1-, 6-, 12-, 18-, and 24-month visits, respectively. Baseline cl-VS and ipsilateral VS measured during follow-up were mildly correlated (Pearson correlation = 0.13-0.25). This association disappeared after subtracting the cl-VS measured at the same visit from the ipsilateral VS. Overall, 48.8% of patients developed PTS of whom 12.8% had baseline cl-VS > 4.

CONCLUSION

In our study of patients with a first unilateral proximal DVT, the proportion of patients with PTS who had a cl-VS > 4 is modest. However, cl-VS appears to be stable over time. Its assessment could constitute a simple way of documenting preexisting PVI and help to classify patients as having PTS.

Peripheral Vascular Disease

Peripheral vascular disease (PVD) is a leading health concern in the United States, with an estimated prevalence of 8.5 million. The incidence of PVD is growing due to increasing rates of obesity and diabetes, as well as an aging population. Peripheral vascular disease is categorized as either venous, arterial, or mixed. A differential assessment is essential to identify the type of PVD and to plan management strategies to prevent further vascular dysfunction. This article describes assessment of patients with PVD, risk factors, treatments, and patient education.

Validation of the 3D SYM VEIN Symptom Assessment Tool

OBJECTIVE

The aim was to validate the SYM VEIN consensus 3D scoring tool in chronic venous disease (CVD).

METHODS

This was a prospective cohort study with a total of 35 consecutive patients with CVD. Patients with CVD undergoing saphenectomy were assessed with the revised Venous Clinical Severity Score (r-VCSS), the CIVIQ-20 quality of life score questionnaire, and the SYM VEIN consensus statement 3D system, pre-operatively and four weeks post-operatively. The total 3D score was tested for reliability, construct validity, and responsiveness.

RESULTS

The total 3D score demonstrated good reliability and internal consistency (Cronbach's alpha 0.85). Principal component analysis identified three groups of symptoms (paraesthesia, burning pain, and pruritus, vs. heaviness, sensation of swelling and aching/pain, vs. restless leg and throbbing pain) demonstrating a high intragroup correlation and likely to share similar pathophysiology, indicative of adequate construct validity. The total 3D score showed a significant correlation with r-VCSS and CIVIQ-20 score (rho .46, p = .005 and rho .65, p < .001, respectively) indicative of adequate convergent validity. After saphenectomy, significant reductions (p < .001) of the total 3D, and 3D scores for all but two individual venous symptoms were observed, indicative of excellent responsiveness. Median total 3D score was reduced from 31 to 6 (83.8% decrease, p < .001), median r-VCSS was reduced from 6 to 0 (100% decrease, p < .001), and median CIVIQ-20 score was reduced from 24 to 14 (40% decrease, p < .001). The difference of median percentage change between r-VCSS and CIVIQ-20 score vs. total 3D score was significant (p = .005 and p < .001, respectively).

CONCLUSION

The total SYM VEIN 3D score has good reliability, construct validity and excellent responsiveness, although less prone to change after saphenectomy compared with r-VCSS.

Compression therapy for leg oedema in patients with heart failure

The presence of chronic heart failure (CHF) results in a significant risk of leg oedema. Medical compression (MC) treatment is one of the basic methods of leg oedema elimination in patients with chronic venous disease and lymphedema, but it is not routinely considered in subjects with CHF‐related swelling. In the study, an overview of the current knowledge related to the benefits and risk of using MC in the supportive treatment of leg oedema in CHF patients is presented. The available studies dedicated the comprehensive management of leg swelling using MC in CHF patients published in the English language literature till December 2019 were evaluated in term of the treatment efficacy and safety. In studies performed on CHF populations, manual lymphatic drainage, MC stocking, multilayer bandaged, as well as intermittent pneumatic compression or electric calf stimulations were used. The current evidence is based on non‐randomized studies, small study cohorts, as well as very heterogenous populations. The use of the intermittent pneumatic compression in CHF patients significantly increases the right auricular pressure and mean pulmonary artery pressures as well as decreases systemic vascular resistance in most patients without the clinical worsening. The transient and rapid increase in the human atrial natriuretic peptide, after an application of the MC stocking in New York Heart Association (NYHA) class II patients was observed without clinical exacerbation. An application of the multilayer bandages in NYHA classes III and IV patients lead a significant increase in the right arterial pressure and lead to transient deterioration of the right and the left ventricular functions. In the manual lymphatic drainage study, aside from expected leg circumference reduction, no clinical worsening was observed. In a pilot study performed in a small cohort of CHF patients, electrical calf stimulation use resulted in a reduction in the lean mass of the legs without cardiac function worsening. The use of local leg compression can be considered stable CHF patients without decompensated heart function for both CHF‐related oedema treatment and for treatment of the concomitant diseases leading to leg swelling occurrence. The use of MC in more severe classes of CHF (NYHA III and IV) should be the subject of future clinical studies to select the safest and most efficient compression method as well as to select the patients who benefit most from this kind of treatment.

Randomised controlled study to compare radiofrequency ablation with minimally invasive ultrasound-guided non-flush ligation and stripping of great saphenous vein in the treatment of varicose veins

INTRODUCTION

Flush ligation at the saphenofemoral junction and stripping of the great saphenous vein is being increasingly replaced by endovenous methods such as radiofrequency or endovenous laser ablation for the treatment of varicose veins. These modalities are expensive and not widely available. A minimally invasive ultrasound-guided surgery with non-flush ligation and stripping under local anaesthesia is a cost-effective alternative with similar postoperative outcomes.

MATERIALS AND METHODS

A total of 62 limbs (58 patients) with saphenofemoral junction incompetence underwent clinical evaluation including the CEAP clinical score, the venous clinical severity score, the venous disability score and venous doppler. Patients were randomly assigned to either group A (radiofrequency ablation) or group B (ultrasound-guided non-flush ligation and stripping of the great saphenous vein) for procedures under tumescent anaesthesia and ultrasound guidance. Patients were followed-up on days 7, 30 and 90 to assess primary (obliteration rates) and secondary (venous clinical severity score and venous disability score) outcomes.

RESULTS

Both the groups showed 100% obliteration of the great saphenous vein at day 90. The venous clinical severity and venous disability scores significantly improved from day 0 to day 90 in both groups (p = 0.0001). There were no major complications. Group A showed significantly lower minor complications (p = 0.001). None required conversation to general anaesthesia.

CONCLUSIONS

The ultrasound-guided non-flush ligation and stripping of the great saphenous vein are as efficacious as radio frequency ablation, with similar obliteration rates, improvement in disability scores and complication profile at a lower cost. It has the potential for wider availability in the community as most surgeons are conversant with the surgical procedure.

Ecchymosis and Coldness in Peripheral Varicose Vein Patients: Observations From VEIN-TURKEY Study

The purpose of this subgroup analysis is to investigate and analyze the venous leg symptoms including sense of coldness and sign of ecchymosis in patients with or without peripheral varicose veins (PVVs) from VEIN-TURKEY study population. A total of 600 patients, who were enrolled to VEIN-TURKEY study recently, were included in this subgroup analysis. Patients were examined clinically for the presence and severity of PVV and varicocele. Patients were asked to answer the VEINES-Sym questionnaire consisting of 10 parts and questions about ecchymosis and coldness in their legs. Frequency of symptoms present in the VEINES-Sym instrument, coldness (16.6%, 6.5%, P = .002, respectively), and ecchymosis (16.6%, 2.7%, P < .001, respectively) were significantly higher in patients with PVV compared to patients without PVV. Mean score of each symptom was significantly lower in PVV (+) patients including scores of ecchymosis and coldness. Total VEINES-Sym score was also correlated with the scores of ecchymosis ( r = 0.18, P < .001) and coldness ( r = 0.35, P < .001). Logistic regression analysis revealed that heavy legs, aching legs, night cramps, and ecchymosis are significantly and independently associated with PVV. In conclusion, sign of ecchymosis and coldness are significantly higher in patients with PVV compared to patients without PVV in a population recruited from the urology clinics. In clinical evaluation, presence or sign of ecchymosis and coldness in legs should be considered to be compatible with PVV in the absence of trauma, hematologic pathologies including antiplatelet treatment, and arterial stenosis or obstruction.

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

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

Effect of obesity on chronic venous insufficiency treatment outcomes

BACKGROUND

Obesity is a known risk factor for the development and progression of chronic venous disorders (CVDs). It is currently unknown whether the treatment outcomes, after an intervention for CVDs, are affected by obesity. The purpose of the present investigation was to assess the effectiveness of various CVD treatments in obese patients and determine what level of obesity is associated with poor outcomes.

METHODS

Data were prospectively collected in the Center for Vein Restoration electronic medical record system (NexGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. The patients and limbs were categorized by the following body mass index (BMI) categories: <25, 26 to 30, 31 to 35, 36 to 40, 41 to 45, and >46 kg/m². The changes in the revised venous clinical severity score and Chronic Venous Insufficiency Quality of Life Questionnaire 20-item (CIVIQ-20) quality of life survey were used to determine the CVD treatment effectiveness for patients who had undergone endovenous thermal ablation (TA), phlebectomy, or ultrasound-guided foam sclerotherapy (USGFS).

RESULTS

From January 2015 to December 2017, 65,329 patients (77% female; 23% male) had undergone a venous procedure. Of these patients, 25,592 (39,919 limbs) had undergone ablation alone, ablation with phlebectomy, or ablation with phlebectomy and USGFS. The number of procedures performed was as follows: TA, n = 37,781; USGFS, n = 22,964; and phlebectomy, n = 17,467. The degree of improvement at 6 months after the procedure was progressively less with an increasing BMI for the patients who had undergone TA, and the decrease was more significant for those patients with a BMI >35 kg/m² (P ≤ .001). The outcomes improved ∼12% with the addition of phlebectomy to TA. The patients who had undergone a combination of TA, phlebectomy, and USGFS demonstrated no additional improvement. Significantly inferior outcomes were noted in patients with a BMI ≥35 kg/m², with the poorest outcomes observed in patients with a BMI ≥46 kg/m² (P ≤ .001). The average number of TAs per patient increased with an increasing BMI and was significantly different compared with the number for those with a BMI <30 kg/m² (P ≤ .001). All pre- and post-CIVIQ-20 quality of life scores, within a BMI category, at 6 months were significantly different (P ≤ .01). No differences in the degree of improvement were observed in patients with a BMI ≥31 kg/m². Finally, multivariate logistic regression analysis indicated that when controlling for BMI, diabetes, a history of cancer, female gender, and black and Hispanic race were independently associated with poorer outcomes.

CONCLUSIONS

Progressive increases in BMI negatively affected CVD-related treatment outcomes as measured using the revised venous clinical severity score and CIVIQ-20. The outcomes progressively worsened with a BMI >35 kg/m² for patients undergoing CVD treatment. The treatment outcomes for patients with a BMI ≥46 kg/m² were so poor that weight loss management should be considered before offering CVD treatment.

Red vine leaf extract (AS 195) can improve some signs and symptoms of chronic venous insufficiency, a systematic review

AIM

Chronic venous insufficiency (CVI) is common in adults. Some complications include skin changes, edema, heavy legs, muscle cramps, pain, and varicose veins. In traditional medicine, red vine leaf extract (AS 195) has been used to cure the symptoms of CVI. This systematic review was aimed to assess the effects of AS 195 in patients with CVI.

MATERIAL AND METHODS

A systematic literature search was performed to identify trials that reported the impact of red vine leaf extract on CVI. The primary outcomes investigated were Leg (limb) volume, calf circumference, ankle circumference, tired and heavy legs, a sensation of tension, tingling sensation, and pain.

RESULTS

From the 56 studies, 5 trials were selected according to our inclusion criteria. Red vine leaf extract significantly improved numbers of outcomes (lower leg volume, calf and ankle circumference, tired, heavy legs, tingling sensation, pain, the sensation of tension in the legs, cutaneous microcirculation, and transcutaneous oxygen pressure) in only some trials. The tolerability for red vine leaf extract was reported good or satisfactory.

CONCLUSIONS

Red vine leaf extract had a beneficial therapeutic role in patients with CVI. Further high-quality trials are required to be carried out to provide strong evidence.