Secondary chronic venous disease progresses faster than primary

Safety and efficacy of endovenous ablation in patients with a history of deep vein thrombosis

OBJECTIVE

Endovenous ablation is the standard of care for patients with symptomatic superficial venous insufficiency. For patients with a history of deep vein thrombosis (DVT), concern exists for an increased risk of postprocedural complications, particularly venous thromboembolism. The objective of this study was to evaluate the safety and efficacy of endovenous thermal ablation in patients with a history of DVT.

METHODS

The national Vascular Quality Initiative Varicose Vein Registry was queried for superficial venous procedures performed from January 2014 to July 2021. Limbs treated with radiofrequency or laser ablation were compared between patients with and without a DVT history. The primary safety end point was incident DVT or endothermal heat-induced thrombosis (EHIT) II-IV in the treated limb at <3 months of follow-up. The secondary safety end points included any proximal thrombus extension (ie, EHIT I-IV), major bleeding, hematoma, pulmonary embolism, and death due to the procedure. The primary efficacy end point was technical failure (ie, recanalization at <1 week of follow-up). Secondary efficacy end points included the risk of recanalization over time and the postprocedural change in quality-of-life measures. Outcomes stratified by preoperative use of anticoagulation (AC) were also compared among those with prior DVT.

RESULTS

Among 33,892 endovenous thermal ablations performed on 23,572 individual patients aged 13 to 90 years, 1698 patients (7.2%) had a history of DVT. Patients with prior DVT were older (P < .001), had a higher body mass index (P < .001), were more likely to be male at birth (P < .001) and Black/African American (P < .001), and had greater CEAP classifications (P < .001). A history of DVT conferred a higher risk of new DVT (1.4% vs 0.8%; P = .03), proximal thrombus extension (2.3% vs 1.6%; P = .045), and bleeding (0.2% vs 0.04%; P = .03). EHIT II-IV, pulmonary embolism, and hematoma risk did not differ by DVT history (P = NS). No deaths from treatment occurred in either group. Continuing preoperative AC in patients with prior DVT did not change the risk of any complications after endovenous ablation (P = NS) but did confer an increased hematoma risk among all endovenous thermal ablations and surgeries (P = .001). Technical failure was similar between groups (2.0% vs 1.2%; P = .07), although a history of DVT conferred an increased recanalization risk over time (hazard ratio, 1.90; 95% confidence interval, 1.46, 2.46; P < .001). The groups had comparable improvements in postprocedural venous clinical severity scores and Heaviness, Aching, Swelling, Throbbing, and Itching scores (P = NS).

CONCLUSIONS

Endovenous thermal ablation for patients with a history of DVT was effective. However, appropriate patient counseling regarding a heightened DVT risk, albeit still low, is critical. The decision to continue or withhold AC preoperatively should be tailored on a case-by-case basis.

Vicious Circle With Venous Hypertension, Irregular Flow, Pathological Venous Wall Remodeling, and Valve Destruction in Chronic Venous Disease: A Review

Substantial advances occurred in phlebological practice in the last two decades. With the use of modern diagnostic equipment, the patients' venous hemodynamics can be examined in detail in everyday practice. Application of venous segments for arterial bypasses motivated studies on the effect of hemodynamic load on the venous wall. New animal models have been developed to study hemodynamic effects on the venous system. In vivo and in vitro studies revealed cellular phase transitions of venous endothelial, smooth muscle, and fibroblastic cells and changes in connective tissue composition, under hemodynamic load and at different locations of the chronically diseased venous system. This review is an attempt to integrate our knowledge from epidemiology, paleoanthropology and anthropology, clinical and experimental hemodynamic studies, histology, cell physiology, cell pathology, and molecular biology on the complex pathomechanism of this frequent disease. Our conclusion is that the disease is initiated by limited genetic adaptation of mankind not to bipedalism but to bipedalism in the unmoving standing or sitting position. In the course of the disease several pathologic vicious circles emerge, sustained venous hypertension inducing cellular phase transitions, chronic wall inflammation, apoptosis of cells, pathologic dilation, and valvular damage which, in turn, further aggravate the venous hypertension.

microRNA-301a-3p is a potential biomarker in venous ulcers vein and gets involved in endothelial cell dysfunction

Venous ulcer is a common contributor to chronic venous insufficiency (CVI) of lower limbs, which seriously affects the life quality of patients. In this study, we researched the expression characteristics of microRNA-301a-3p (miR-301a-3p) in patients with CVI and investigated the impact of miR-301a-3p on the dysfunction of human umbilical vein endothelial cells (HUVECs). The plasma level of miR-301a-3p in normal controls, patients with varicose great saphenous vein, and patients with the venous ulcer of lower limbs were measured. We adopted Interleukin-1β (IL-1β), H2O2, and oxygen and glucose deprivation (OGD) to induce endothelial cell injury in vitro. In this way, we evaluated the influence of miR-301a-3p on HUVEC viability, apoptosis, inflammatory response, and oxidative stress. Our data showed that miR-301a-3p was substantially overexpressed in patients with lower limb venous ulcers. The viability of HUVECs decreased, and miR-301a-3p was up-regulated after IL-1β, H2O2, and OGD treatment. miR-301a-3p inhibition greatly ameliorated the dysfunction and cell damage of HUVECs, promoted IGF1/PI3K/Akt/PPARγ, and down-regulated NF-κB/MMPs. The phosphatidylinositol 3-kinase (PI3K) inhibitor (LY294002) or the peroxisome proliferator-activated receptor-γ (PPARγ) inhibitor (GW9661) reversed the anti-inflammatory, antioxidant, and anti-apoptotic effects mediated by miR-301a-3p down-regulation. The nuclear factor-κB (NF-κB) inhibitor lessened cell injury mediated by miR-301a-3p overexpression. In terms of the mechanism, miR-301a-3p targeted the 3'UTR of Insulin-like growth factor-1 (IGF1) and repressed the profile of IGF1. Thus, miR-301a-3p mediates venous endothelial cell damage by targeting IGF1 and regulating the IGF1/PI3K/Akt/PPARγ/NF-κB/MMPs pathway.

Validity and Reliability of the Hungarian Version of Aberdeen Varicose Vein Questionnaire

Purpose: The aim of our study was to translate the Aberdeen Varicose Vein Questionnaire (AVVQ) into Hungarian, and to investigate the validity and reliability of the Hungarian AVVQ, as well as to assess the health-related quality of life in patients with varicose veins of the leg. Methods: 374 adults participated in this study who were divided into two groups (varicose vein, healthy). We analyzed internal consistency, convergent validity (using the 36-Item Short Form Survey, SF-36), repeatability, and intra-class correlation coefficient of the Hungarian AVVQ. Regarding discriminant validity, we determined the scores of the Hungarian AVVQ in both groups using the Mann-Whitney U-test. Results: The Cronbach-alpha value was 0.890, while the correlation coefficient was R = 1.000. According to the results of the convergent validation, the scores of pain and dysfunction moderately correlated with some scores of the SF-36. The score of cosmetic appearance had a relationship with many scores of the SF-36. We registered a significant relationship between the score of extent of varicosity and some scores of the SF-36. There was significant correlation between the score of complications and numerous scores of the SF-36 (physical functioning, role limitations due to physical health, pain and general health). The score of pain and dysfunction, cosmetic appearance, extent of varicosity, complications and total score of the Hungarian AVVQ showed a significant difference between both groups. Conclusions: The Hungarian AVVQ was a reliable and a valid tool to assess the health-related quality of life among patients with varicose veins and was a useful tool to justify the further treatment of the patients.

Comparative analysis of endovenous laser ablation versus ultrasound-guided foam sclerotherapy for the treatment of venous leg ulcers

BACKGROUND

Endovenous thermal and non-thermal therapeutic approaches have become standard of care for the treatment of venous insufficiency. However, comparative studies on its use in the population of venous leg ulcer patients are scarce.

METHODS

The present study aimed at a comparison of the efficacy of endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS) for the treatment of venous leg ulcers (VUs). We retrospectively analyzed patient records of 68 patients with active VUs (C6 of the CEAP-classification), who underwent EVLA (n=33) or UGFS (n=35) between January 2001 and January 2021.

RESULTS

In 68 patients, 97 venous segments (GSV: 43, SSV: 17:, NSV: 37) were treated. Ulcer surface area at initial presentation did not differ significantly between both treatment groups (EVLA: 7.7±10.7 vs. UGFS: 8.5±16.3 cm² ; p=0.73). No significant difference regarding patient characteristics was found, with the exception of age, as patients receiving UGFS treatment were significantly older (EVLA: 61±17 vs. UGFS: 70±14 years; p=0.018). The rate of ulcer resolution was not significantly different between EVLA and UGFS groups (97.0% vs. 85.7%; p=0.20). Also, the mean time to complete ulcer healing after endovenous intervention was comparable (EVLA: 59±37 vs. UGFS: 63±41 days; p=0.68). However, the relapse rate was significantly higher for UGFS than for EVLA treated patients (31.4% vs. 3.0%; p=0.002).

CONCLUSION

Rates of ulcer resolution and ulcer healing time after endovenous intervention were comparable between both treatment modalities. However, a significantly higher relapse rate was observed in UGFS treated patients.

Current strategies for endovascular management of varicose veins: An updated review of superficial ablation technologies

Chronic venous insufficiency (CVI) which causes varicose veins and venous ulcers, is a major cause of morbidity and mortality in the general population. The last several years have witnessed many revolutionary developments in the realms of minimally invasive techniques (both thermal and non-thermal) to treat CVI. Moreover, multiple newer societal recommendations have been published over the past one year on the basis of the current evidence. In this article, we will briefly summarise the imaging for varicose veins and review the existing evidence in literature as well as the current guidelines and recommendations for the management of varicose veins, especially focusing on the various superficial ablation technologies.

Understanding Chronic Venous Disease: A Critical Overview of Its Pathophysiology and Medical Management

Chronic venous disease (CVD) is a multifactorial condition affecting an important percentage of the global population. It ranges from mild clinical signs, such as telangiectasias or reticular veins, to severe manifestations, such as venous ulcerations. However, varicose veins (VVs) are the most common manifestation of CVD. The explicit mechanisms of the disease are not well-understood. It seems that genetics and a plethora of environmental agents play an important role in the development and progression of CVD. The exposure to these factors leads to altered hemodynamics of the venous system, described as ambulatory venous hypertension, therefore promoting microcirculatory changes, inflammatory responses, hypoxia, venous wall remodeling, and epigenetic variations, even with important systemic implications. Thus, a proper clinical management of patients with CVD is essential to prevent potential harms of the disease, which also entails a significant loss of the quality of life in these individuals. Hence, the aim of the present review is to collect the current knowledge of CVD, including its epidemiology, etiology, and risk factors, but emphasizing the pathophysiology and medical care of these patients, including clinical manifestations, diagnosis, and treatments. Furthermore, future directions will also be covered in this work in order to provide potential fields to explore in the context of CVD.

Systematic literature review and network Meta-analysis of sulodexide and other drugs in chronic venous disease

OBJECTIVE

To assess the clinical efficacy of sulodexide, including a comparison with venoactive drugs (VAD) (micronized purified flavonoid fraction, MPFF; hydroxy-ethyl-rutosides, HR; calcium dobesilate;Ruscus extract combined with hesperidin methyl chalcone and vitamin C, Ruscus+HMC+VitC; horse chestnut seed extract, HCSE) and pentoxifylline in patients with chronic venous disease.

METHODS

We performed a literature search in MEDLINE, Embase, and Cochrane Library for randomized controlled trials (RCTs) and observational studies. Proportion of patients with complete venous ulcer healing was the primary outcome and lower leg volume, foot volume, ankle circumference and symptoms were the secondary outcomes. Bayesian network meta-analysis (NMA) was perfomed with random effects models using only RCTs. A meta-analysis of observational studies was performed for sulodexide because no RCT could be included in NMA for symptoms or signs.

RESULTS

Forty-five RCTs and eighteen observational studies were identified. Sulodexide was included only in a single NMA for the proportion of patients with complete ulcer healing and it showed to have the highest probability of being the best treatment (48%) compared with pentoxifylline (37%) and MPFF (16%). MPFF was the most effective treatment in reducing lower leg volume, CIVIQ-20 score and pain VAS scale while calcium dobesilate and Ruscus+HMC+VitC were the most effective in reducing foot volume and ankle circumference respectively.Meta-analyses of observational studies for sulodexide showed that it improves significantly the scoring of pain, feeling of swelling, heaviness and parasthesiae measured by Likert scales.

CONCLUSIONS

Sulodexide is at least as effective as pentoxifylline and more effective than MPFF in improving the rate of ulcer healing in patients with CVD. VADs are effective in improving venous symptoms and signs, as was also shown by sulodexide in the meta-analysis of observational studies. The relative effectiveness of sulodexide and VADs needs to be evaluated by an RCT in order to better inform clinical practice.

Initiation of reticular and spider veins, incompetent perforantes and varicose veins in the saphenous vein network of the rat

In an attempt to induce experimental varicosity, reverse perforant vein development was initiated in the rat leg by applying a chronic (14 and 32 weeks) partial stricture on the main branch of the deep femoral vein. At surfacing of the incompetent perforantes, typical reticular vein plaques and spider veins were identified by video-microscopy and quantitative histology. Deep vein blood was channeled by them into the saphenous vein system, the extra flow deforming these vessels, causing local dilations and broken course, even undulations of larger branches.

Sulodexide for the Symptoms and Signs of Chronic Venous Disease: A Systematic Review and Meta-analysis

INTRODUCTION

Chronic venous disease (CVD) is a common condition associated with valvular dysfunction, venous hypertension and endothelial inflammation. Sulodexide facilitates the healing of venous ulcers and is frequently used in patients with CVD without ulcer. This review assessed the efficacy and safety of sulodexide for treatment of signs and symptoms of lower extremity CVD.

METHODS

We searched MEDLINE, EMBASE, CINAHL and AMED as well as the Cochrane Central Register of Controlled Trials and the World Health Organisation (WHO) International Clinical Trials Registry Platform Search Portal. We also manually searched potentially relevant journals, conference proceedings and journal supplements. Any study monitoring any effect of sulodexide in patients with CVD at any stage of the disease, classified or non-classified, was considered. Treatment effects were estimated using standardised mean differences (SMDs), mean differences (MDs) and risk ratios (RRs), as appropriate. We calculated 95% confidence intervals (CIs) and heterogeneity (Q, tau and I²).

RESULTS

The search found 64 studies, but only 23 provided data on 7153 participants (mean age 55 years; 68% female). The 13 studies providing extractable quantitative information included 1901 participants (mean age 55.2 years; 65% female). Sulodexide decreased the intensity of pain, cramps, heaviness, oedema and total symptom score and reduced inflammatory mediators in patients with CVD. The risk of adverse events (AEs) was not different between sulodexide and placebo or heparan sulphate (RR 1.31, 95% CI 0.74-2.32; I² = 0%; 270 participants). The overall risk of AEs with sulodexide was low: 3% (95% CI 1-4%) estimated from 3656 participants.

CONCLUSION

Sulodexide was found to have a beneficial venoactive effect on the major signs and symptoms of CVD such as pain, cramps, heaviness and oedema without increasing the risk of AEs. It is also likely to exert a systemic effect on the course of CVD by interfering with inflammatory chemokines.

How Does Chronic Venous Disease Progress from the First Symptoms to the Advanced Stages? A Review

Risk factors for the development of progression chronic venous disease (CVD) and varicose veins are widespread and include advanced age, excess body weight, sedentary lifestyles and occupations, family history, and pregnancy. Varicose veins and CVD are associated with venous hypertension, venous reflux, dysfunctional venous valves, and vein wall inflammation, though the precise etiologies are unclear. Once venous pathology develops, it can progress through a vicious cycle of inflammation and leukocyte recruitment that leads to further deterioration of vein walls and valves, increased hypertension, and release of additional proinflammatory mediators. Early treatment of symptomatic varicose veins and CVD as well as lifestyle changes can help break the inflammatory cycle and alleviate symptoms. Physicians and patients should be aware of the risk factors for CVD, the treatments and measures available to slow disease progression, and the serious consequences of allowing the disease to progress unchecked.

Funding: Servier (France).

LivRelief varicose veins cream in the treatment of chronic venous insufficiency of the lower limbs: A 6-week single arm pilot study

BACKGROUND

Chronic Venous Disease is characterized by morphological abnormalities of the venous system. Affected limbs are classified in increasing clinical severity with the Clinical Etiological Anatomical and Pathological system from C0 to C6. Limbs assessed at C3 through C6 meet the criteria of Chronic Venous Insufficiency. Chronic Venous Insufficiency of the Lower Limbs is a very common pathology affecting approximately ~40% of the world's population. This study observes the use of the LivRelief Varicose Vein Cream, a Natural Health Product that is licensed for sale by Health Canada, for use in the treatment of varicose veins.

METHODS

An open label, single arm interventional, pilot study was conducted to determine the feasibility of recruitment and data collection in this population. To accomplish this, the cream was provided to all enrolled subjects. Subsequently, objective and subjective measures were performed at baseline and after 6 weeks of at-home use. Recruitment and data collection targets of at least 70% were established and the data collected at both timepoints were compared and analyzed using a paired t-test. Results were also reported as proportions where appropriate.

RESULTS

A total of 32 subjects were enrolled. The pre-defined feasibility objectives for recruitment and data collection were met with the enrolment of 97% of all screened patients and the collection of 94% of all scheduled data. The most significant therapeutic improvement was seen in the results of the Venous Clinical Severity Score where 66% of the treated legs experienced a decrease in severity after 6 weeks of treatment. P values were <0.0001 and 0.0003 for the left and right leg, respectively.

CONCLUSION

It is feasible to recruit and collect data with the chosen outcome assessments within this population. Preliminary results suggest that the product could improve some of the clinical symptoms associated with the presence varicose veins. These results warrant further exploration in a longer, randomized and placebo-controlled study.

TRIAL REGISTRATION

Clinicaltrial.gov: NCT03653793.

Report of the Society for Vascular Surgery and the American Venous Forum on the July 20, 2016 meeting of the Medicare Evidence Development and Coverage Advisory Committee panel on lower extremity chronic venous disease

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel assessed the benefits and risks of currently used lower extremity chronic venous disease (CVD) treatments and their effects on health outcome of the American adult population. The main purpose of the meeting was to advise the Centers for Medicare & Medicaid Services on coverage determination for interventions used for treatment of CVD. A systematic review of the Agency for Healthcare Research and Quality was presented, followed by lectures of invited experts and a public hearing of representatives of professional societies and the industry. After discussing critical issues, the panel voted for key questions. This report summarizes the presented evidence to support recommendations of the Society for Vascular Surgery/American Venous Forum coalition and the presentations on selected discussion topics. These included important venous disease evidence gaps that have not been sufficiently addressed, venous disease treatment disparities and how they may affect the health outcomes of Medicare beneficiaries, and mechanisms that might be supported by the Centers for Medicare & Medicaid Services to improve the evidence base to optimize the care of patients with lower extremity CVD.

Present and future options for treatment of infrainguinal deep vein disease

OBJECTIVE

Management of chronic deep vein disease focuses on the alleviation of reflux and obstruction. For the suprainguinal veins, the main underlying pathologic process is obstruction, which has been recognized as a significant contributor to chronic venous insufficiency. This is currently being addressed with venous stenting and the development of dedicated stents designed for this segment of the venous system. Treatment of the femoropopliteal vein (FPV) is far more challenging because of the idiosyncratic anatomy, the hemodynamic physiology, and the technical aspects of size mismatch and valve flow dynamics in managing deep venous reflux. This review article discusses traditional and emerging technologies to treat infrainguinal disease.

METHODS

Previous and current articles addressing this issue were reviewed. Emphasis was placed on emerging techniques and technologies.

RESULTS

Significant bench work, in vitro and in vivo studies, have been conducted over the last 40 years addressing the issue of infrainguinal reflux and obstruction. Historically, open procedures to address FPV reflux and obstruction have had variable success in a few centers around the world. The significant increase of emerging endovascular therapies may allow more appropriate, reproducible, widespread treatment of infrainguinal deep venous disease.

CONCLUSIONS

Adequate and durable therapies for infrainguinal venous disease represent one of the greatest challenges for a vein specialist. Recently, a cluster of interest and techniques/technologies have been developed. The endovascular management of arterial disease is mature. The endovenous management of infrainguinal disease is on the cusp of meaningful innovation. The purpose of this evidence summary is to describe the options for the management of chronic FPV disease, with emphasis on emerging technologies and techniques.

Diagnosis of stenosis within the popliteal-femoral venous segment upon clinical presentation with a venous ulcer and subsequent successful treatment with venoplasty

This case study reports the diagnosis and treatment of a lower limb venous ulcer with abnormal underlying venous pathology. One male patient presented with bilateral varicose veins and a right lower limb ulcer. Upon investigation, full-leg duplex ultrasonography revealed total incompetence of the great saphenous vein in the left leg. In the right leg, duplex ultrasonography showed proximal incompetence of the small saphenous vein, and dilation of the anterior accessory saphenous vein, which remained competent. Incidentally, two venous collaterals connected onto the distal region of both these segments, emerging from a scarred, atrophic popliteal–femoral segment. An interventional radiologist performed venoplasty to this popliteal–femoral venous segment. Intervention was successful and 10 weeks post procedure ulceration healed. Popliteal–femoral venous stenosis may be associated with venous ulceration in some cases and may be successfully treated with balloon venoplasty intervention.

Reflection on the cause and avoidance of recurrent venous leg ulcers: An interpretive descriptive approach

AIMS AND OBJECTIVES

To gain insight into the experience of recurrent venous leg ulcers from the individual's perspective and provide knowledge on potential risks of recurrence not previously investigated.

BACKGROUND

Venous leg ulcers are a consequence of chronic venous disease and frequently recur. They are costly and can impact on physical and psychological health. Despite research suggesting the risk can be reduced through compression and lifestyle changes, recurrence rates are often high. This study provides an insight into individual's perceptions of the cause of their ulcers and how they try to avoid them.

DESIGN

A qualitative design guided by the Chronic Illness Trajectory Model and Social Cognitive Theory.

METHOD

A purposive sample of three males and four females were recruited from a community nursing clinic. Participants were ulcer free, had experienced at least two previous venous leg ulcers and could speak and comprehend English. An interpretive descriptive approach was taken using semi-structured interviews and thematic analysis.

RESULTS

Three themes each containing three categories emerged: The Increasing Influence of the Recurring Wound on Mind and Body, Reflection on Past Experiences and Optimism in the Face of Adversity. Most participants reported traumatic injury and lower leg surgery triggered ulcer recurrence. Failure to replace compression stockings was also deemed a cause. Compression was reported essential, but some participants were unaware of the level they were wearing and how often it should be replaced. Other preventive activities included avoiding injury and securing immediate assistance if wounding occurred.

CONCLUSION

Clinicians need to be aware that lower leg surgery may trigger recurrent venous ulceration and that individuals require ongoing emotional, physical and financial support throughout the trajectory of venous disease. The continued use of old compression stockings should be avoided and recurrence prevented by adoption of evidence-based practice rather than reflection on past experiences.

RELEVANCE TO CLINICAL PRACTICE

This research raises the awareness of factors from the individual's perspective which can influence the recurrence of venous leg ulcers.

Venous leg ulceration pathophysiology and evidence based treatment

Venous leg ulceration (VLU) is one of the most predominate medical disorders worldwide and in the western hemisphere it affects around 1.5% of the general population and up to 5% of the elderly population. Unfortunately, this trend will only increase given the growth of an aging population worldwide. Understanding its pathophysiology that begins with venous hemodynamic abnormalities and leads to inflammatory alterations with microcirculatory changes is critical to delivering effective curative therapy. As such, the main component to treatment is reversing the underlying venous hypertension and pro-inflammatory milieu using compression treatment along with various adjuvant therapies. Given its impact, a comprehensive multi-pronged approach to care, treatment and prevention is required to reverse the increasing trend that is observed worldwide.

Progression in venous pathology

Aim

To review epidemiologic data on progression of venous pathology in varicose veins and from varicose veins towards chronic venous insufficiency.

Methods

We searched Medline and PubMed for epidemiologic studies concerning progression of venous pathology.

Results

The data suggest that reflux progression may develop from segmental to multisegmental superficial reflux. In younger age, reflux in tributaries and non-saphenous veins is more frequent. In older age, more saphenous reflux develops and more proximal sites seem to be affected. A high proportion of uncomplicated varicose vein (C2) develops skin changes and chronic venous insufficiency (C3–C6). Significant risk factors for the progression of varicose vein towards venous leg ulcers are skin changes, corona phlebectatica, higher body mass index and popliteal vein reflux. During a 13.4-year follow-up period, 57.8% (4.3%/year) of all chronic venous disease patients showed progression of the disease.

Summary

Studies on the progression of venous pathology show a high progression rate of chronic venous disease. More follow-up studies are still needed to get better information about the risk of varicose vein patients for progression to venous leg ulcers and to answer the question which patients may benefit from early varicose vein interventions.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Measurement of calf muscle oxygenation during light-intensity exercise in patients with post-thrombotic syndrome

BACKGROUND

Near-infrared spectroscopy (NIRS) provides continuous noninvasive monitoring of changes in the levels of oxygenated hemoglobin (O2Hb) and deoxygenated hemoglobin (HHb) in tissues. The purpose of this study was to investigate changes in calf muscle O2Hb and HHb levels during standing and exercise in the follow-up of deep venous thrombosis (DVT).

METHODS

Forty-three patients with a first episode of unilateral proximal DVT were included. Final clinical manifestations were evaluated at a mean follow-up point of 53 months after diagnosis of DVT, and post-thrombotic syndrome (PTS) was considered to be present if the Villalta score was >5. Moreover, to assess the severity of PTS, the revised Venous Clinical Severity Score (VCSS) was employed. NIRS was used to measure changes in the levels of O2Hb and HHb in calf muscle. On standing, increases in O2Hb and HHb were calculated by subtracting the baseline value from the maximum value (ΔO2Hbst and ΔHHbst). The times taken for the O2Hb and HHb concentrations to become maximal (TO2Hbst, and THHbst) were also measured. During 10 tiptoe movements, the relative change in O2Hb was calculated by subtracting the value measured at the end of exercise from the value measured at the beginning of exercise (ΔO2Hbex). On the other hand, 10 tiptoe movements produced venous expulsion (ΔHHbEex) and a subsequent retention (ΔHHbRex). The oxygenation index (HbD; HbD = O2Hb - HHb) was also calculated at the end of standing and at the end of 10 tiptoe movements (ΔHbDst and ΔHbDex).

RESULTS

Among the 43 limbs evaluated, 21 had PTS. On standing, the ΔHbDst was significantly decreased in patients with PTS relative to the patients without PTS (12 ± 8, 22 ± 11 μmol/L; P = .001). The TO2Hbst was also significantly reduced in patients with PTS relative to those without (43 ± 41, 107 ± 58 seconds; P = .001). During 10 tiptoe movements, the ΔHHbEex was significantly reduced in patients with PTS relative to those without (-2 ± 1, -3 ± 3 μmol/L; P = .016). Similarly, the ΔHHbRex was significantly increased in patients with PTS relative to those without (8 ± 7, 3 ± 2 μmol/L; P = .001). Furthermore, falls in ΔHbDex were more pronounced in patients with PTS (-10 ± 16, 10 ± 10 μmol/L; P < .001). NIRS-derived TO2Hbst (r = -0.568; P < .001) and ΔHbDex (r = -0.645; P < .001) showed strong inverse correlations with VCSS. Similarly, NIRS-derived ΔHHbEex (r = 0.409; P < .01) and ΔHHbRex (r = 0.476; P < .01) showed moderate positive correlations and ΔHbDst (r = -0.422; P < .01) had a moderate inverse correlation with VCSS.

CONCLUSIONS

Changes in O2Hb and HHb concentrations differ between patients with and without PTS. The reduced TO2Hbst may indicate impairment of the venoarteriolar reflex in patients who have PTS. Furthermore, severe falls in HbD in patients with PTS might reflect the pain of venous claudication. These findings may have implications for investigations of the microcirculation in the context of post-thrombotic sequelae.

Recanalization rates after acute deep vein thrombosis: a single-center experience using a newly proposed vein diameter variation index

BACKGROUND

Duplex ultrasound scanning (DUS) is the method of choice for diagnosis of deep vein thrombosis (DVT). However, only a few studies have performed prospective serial DUS after an acute episode of DVT to assess its evolution. This study aimed to report our experience using DUS combined with a thrombosis score (TS) and a newly proposed vein diameter variation index (VDVI) to evaluate the rate of resolution of DVT by assessing and quantifying the early stages of vein recanalization in proximal vein segments within 6 months after an episode of acute lower extremity DVT.

METHODS

Twelve patients with first episode of acute lower extremity DVT confirmed by DUS as occurring in ≤10 days after the onset of venous thrombosis symptoms were followed up prospectively for 6 months. TS and VDVI were calculated at 1, 3, and 6 months to assess vein recanalization. Intra-thrombus arteriovenous fistula formation was also investigated and related to the recanalization process.

RESULTS

Seven (58%) women were included, with a total cohort median age of 53.5 ± 19 years. The left lower extremity was affected in 7 (58%) patients. DVT was diagnosed in 55 proximal vein segments. All patients had proximal DVT, with involvement of the external iliac, femoral, and popliteal veins. After 6 months, there was a significant decrease in TS and increase in VDVI (P < 0.001) in all proximal vein segments assessed, indicating thrombus regression. The more distal the DVT was, the faster was the VDVI increase, with most popliteal veins being recanalized at 3 months (P < 0.001). Intra-thrombus arteriovenous fistula was identified in 50% of patients at 1 month while on anticoagulation.

CONCLUSIONS

The combined use of two different DUS-based assessment tools, TS and the proposed VDVI, provided an effective method to prospectively assess vein recanalization rates after an episode of acute lower extremity DVT in this series of patients and may allow a correct evaluation of DVT and its resolution or progression.

Avaliação do segmento venoso femoropoplíteo pela ultrassonografia Doppler em pacientes com úlcera varicosa

CONTEXTO: Como a úlcera é uma grave complicação da insuficiência venosa crônica, é necessário o conhecimento amplo de sua fisiopatologia. A ultrassonografia Doppler venosa é o exame complementar mais adequado, que possibilita o estudo do sistema venoso superficial e profundo, sua anatomia e fisiologia. Trabalhos recentes valorizam o refluxo em Veia Poplítea como importante fator para o desenvolvimento deste quadro clínico. OBJETIVOS: Avaliar o refluxo em segmento venoso femoropoplíteo em pacientes com úlcera varicosa. TIPO DE ESTUDO: Estudo de prevalência. MÉTODOS: Cento e quatro pacientes apresentando 118 membros inferiores com úlcera varicosa. Procedimentos: exame de ultrassonografia Doppler venosa do membro acometido, observado o refluxo no segmento venoso femoropoplíteo e diâmetro da Veia Poplítea. Variáveis: Primária: refluxo no segmento venoso femoropoplíteo. Secundária: diâmetro da Veia Poplítea. RESULTADOS: A presença de refluxo no segmento venoso femoropoplíteo foi observada em 56 (47,45%) dos 118 membros com úlcera varicosa, examinados em 104 pacientes. O diâmetro médio da Veia Poplítea foi de 1,14 cm, sendo o diâmetro médio normal da população 0,6 cm. CONCLUSÃO: O refluxo venoso no segmento venoso femoropoplíteo é um importante fator na avaliação do prognóstico destes pacientes, o aumento de diâmetro da Veia Poplítea reflete a magnitude da insuficiência venosa.

The relevance of the natural history of varicose veins and refunded care

Chronic venous disease (CVD) is one of the most common diseases in our population. Aside from venous symptoms like heaviness and pain, which are present in about 50% of the general population, signs of CVD include varicose veins (VVs), oedema, eczema, venous eczema, hyperpigmentation, white atrophy, lipodermatosclerosis and venous ulcers. The aim of this paper is to review current literature for the relevance of natural history of VVs in refunded care. Available papers on VVs, progression of the disease and complications were reviewed. Prevalence of VVs is high with more than 20% in the general population. Information on progression of uncomplicated VV to chronic venous insufficiency (CVI) is rare. However, most venous ulcers have a primary venous origin. The progression rate of VV to higher clinical stages reaches 4% per year. Among the risk factors are obesity and higher age. Quality of life (QOL) is also reduced in uncomplicated VV in C2 patients. In conclusion, there is evidence from the literature that a high proportion of patients with uncomplicated VVs in the clinical, aetiological, anatomical and pathophysiological classification (CEAP Clinical Class 2) will progress to CVI if untreated. VVs have a negative impact on QOL and clinical symptoms. VV patients with CVI (C3-C6) as well as those C2 patients with severe clinical symptoms and impaired QOL due to CVD should be treated with ablation of the VVs in a refunded care system.

The Effect of Aging on Venous Valves

Objective— Age is the strongest risk factor for venous thrombosis. Vessel wall changes such as thickening of venous valves may be one of the contributing mechanisms. We determined thickness and function of venous valves in the popliteal vein with ultrasound in 77 healthy individuals.

Methods and Results— The study included 6 age groups ranging from 20 to 80 years old. Thickness of the valves was compared between age groups. Valve closure time was assessed as an indicator for valve function. In 69 of 77 participants, valve parameters could be measured. We found an increasing thickness of the valves with age, with a mean thickness of 0.35 mm (range, 0.25 to 0.44 mm) in the group of 20 to 30 years and 0.59 mm (range, 0.30 to 1.21 mm) in the group of 71 to 80 years. The increase in valve thickness per year (linear regression coefficient) was 0.004 mm (95% CI, 0 to 0.009). Valve function was not directly associated with age. Valve thickness, however, was inversely associated with valve function.

Conclusion— Our results show that deep venous valves change with age, with thicker valves in older individuals. The increase of valve thickness with age may be part of the explanation for the age gradient seen in the incidence of venous thrombosis.