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Jabeen S, White Chu EF. Venous Leg Ulcers: The Need to Incorporate Age-Friendly 4M's in Management. Clin Geriatr Med 2024; 40:413-436. [PMID: 38960534 DOI: 10.1016/j.cger.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
Venous leg ulcers develop due to a complex set of conditions routed in lower extremity edema and inflammation. Even though older adults are disproportionally affected by these wounds, the guidelines discuss best practices without keeping in mind the age-friendly 4M's-what Matters Most, Mobility, Medications, and Mentation/Mood. This article reviews the management and treatment of venous leg ulcers, but with a geriatric medicine focus. Compression therapy, mobility optimization, and social isolation reduction are highlighted for our older adult population.
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Affiliation(s)
- Sarwat Jabeen
- Department of Family Medicine, Memorial Hermann Family Medicine Residency Program, 14023 Southwest Fwy, Sugar Land, TX 77478, USA.
| | - Elizabeth Foy White Chu
- Department of Geriatrics, Oregon Health & Science University, Portland VA Health Care System, 3710 SW US Veterans Hosp Road, Portland, OR 97239, USA; Department of Medicine, Oregon Health and Sciences University, Wound Healing Service, Portland VA Health Care System, Portland, Oregon, USA
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2
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Kienzl P, Deinsberger J, Weber B. Chronic Venous Disease: Pathophysiological Aspects, Risk Factors, and Diagnosis. Hamostaseologie 2024. [PMID: 38991541 DOI: 10.1055/a-2315-6206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024] Open
Abstract
Chronic venous disease (CVD) is highly prevalent in the general population and encompasses a range of pathological and hemodynamic changes in the veins of the lower extremities. These alterations give rise to a variety of symptoms, with more severe forms resulting in venous ulceration, which causes morbidity and high socioeconomic burden. The origins and underlying mechanisms of CVD are intricate and multifaceted, involving environmental factors, genetics, hormonal factors, and immunological factors that bring about structural and functional alterations in the venous system. This review offers the latest insights into the epidemiology, pathophysiology, and risk factors of CVD, aiming to provide a comprehensive overview of the current state of knowledge. Furthermore, the diagnostic approach for CVD is highlighted and current diagnostic tools are described.
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Affiliation(s)
- Philip Kienzl
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Julia Deinsberger
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Benedikt Weber
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
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3
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Jayaraj A, Rossi FH, Lurie F, Muck P. Diagnosis of chronic iliac venous obstruction. J Vasc Surg Venous Lymphat Disord 2024; 12:101744. [PMID: 38242206 DOI: 10.1016/j.jvsv.2023.101744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/05/2023] [Accepted: 12/12/2023] [Indexed: 01/21/2024]
Abstract
Stenting has become the first line of treatment for symptomatic chronic iliofemoral venous obstruction in patients with quality-of-life-impairing clinical manifestations who have failed conservative therapy. Patient selection for such intervention is, however, dependent on clear identification of relevant clinical manifestations and subsequent testing to confirm the diagnosis. In this regard, the physician engaged in management of such patients needs to be well-aware of symptoms and signs of chronic iliofemoral venous obstruction, and instruments used to grade chronic venous insufficiency and determine quality of life, in addition to diagnostic tests available and their individual roles. This review serves to provide an overview of the diagnosis of chronic iliofemoral venous obstruction and patient selection for stenting.
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Affiliation(s)
- Arjun Jayaraj
- RANE Center for Venous and Lymphatic Diseases, St Dominic Hospital, Jackson, MS.
| | - Fabio H Rossi
- Dante Pazzanese Cardiovascular Institute, Sao Paulo, Brazil
| | - Fedor Lurie
- Jobst Vascular Institute, Toledo, OH; Division of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Patrick Muck
- Division of Vascular Surgery, Department of Surgery, Good Samaritan Hospital, Cincinnati, OH
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Raju S, Thaggard D, Barry O, Peeples H, Jayaraj A. Noninvasive measurement of ambulatory venous pressure via column interruption duration in chronic venous disease. J Vasc Surg Venous Lymphat Disord 2024; 12:101861. [PMID: 38428501 DOI: 10.1016/j.jvsv.2024.101861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 01/13/2024] [Accepted: 02/11/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Column interruption duration (CID) is a noninvasive surrogate for venous refill time (VFT), a parameter used in ambulatory venous pressure measurement. CID is more accurate than invasive VFT measurement because it avoids errors involved with indirect access of the deep system through the dorsal foot vein. The aim of this retrospective single center study is to analyze the clinical usefulness of CID in assessment of chronic venous disease (CVD). METHODS A total of 1551 limbs (777 patients) were referred with CVD symptoms over a 5-year period (2018-2023); CID, air plethysmography, and duplex reflux data were analyzed. Of these limbs, 679 had supine venous pressure data as well. The pathology was categorized as obstruction if supine peripheral venous pressure was >11 mm Hg and as reflux if duplex reflux time in superficial or deep veins was >1 second. CID was measured via Doppler monitoring of flow in the great saphenous vein (GSV) and one of the paired posterior tibial (PT) veins near the ankle in the erect posture. The calf is emptied by rapid inflation cuff. CID is the time interval in seconds when cephalad venous flow in great saphenous vein and posterior tibial veins reappear after calf ejection. A CID <20 seconds in either vein is abnormal similar to the threshold used in VFT measurement. RESULTS Thirty-two percent of the limbs had obstruction, 17% had reflux, and 37% had a combination; 14% had neither. Higher clinical-etiology-anatomy-pathophysiology (CEAP) clinical classes (C4-6) were prevalent in 44% of pure reflux, significantly less (P < .0001) than in pure obstruction (73%) or obstruction plus reflux subsets (72%), partly reflecting distribution of pathology. There is a progressive increase in supine venous pressure and abnormal CID (P < .0001 and P < .0001, respectively) in successive CEAP clinical class. No such correlation between CEAP and any of the reflux severity grading methods (reflux segment score, Venous Filling Index, and Kistner axial grading) was observed. Abnormal CID (55%) was more prevalent in higher CEAP classes (>4) (P < .0001) than in lesser clinical classes (0-2) or limbs with neither obstruction nor reflux (P < .01). CONCLUSIONS Obstruction seems to be a more dominant pathology in clinical progression among CEAP clinical classes than reflux. CID is abnormal in both obstructive and refluxive pathologies and may represent a common end pathway for similar clinical manifestations (eg, ulcer). These data suggest a useful role for CID measurement in clinical assessment of limbs with CVD.
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Affiliation(s)
- Seshadri Raju
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS.
| | - David Thaggard
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
| | - Owen Barry
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
| | - Hunter Peeples
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
| | - Arjun Jayaraj
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
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Park JK, Woo SY, Yang SS, Kim DI. Analysis of the postoperative hemodynamic changes in varicose vein surgery related with small saphenous vein reflux. Phlebology 2023; 38:516-522. [PMID: 37478564 DOI: 10.1177/02683555231186508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
PURPOSE To evaluate the postoperative hemodynamic changes in varicose vein surgery related with SSV reflux using APG. METHODS Totals of 181 limbs and 178 patients who underwent high ligation and stripping (HLS) (87 limbs), radiofrequency ablation (RFA) (43 limbs), or endovenous laser ablation (EVLA) (51 limbs) for SSV reflux from 1995 to 2022 were enrolled. We measured venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) preoperatively and at postoperative one and 6 months. RESULTS Comparing preoperative results to those at postoperative 1 month, the reduction rates of VV, VFI, and RVF were 27, 53, and 31%, while EF increased by 18% (p < 0.001). Comparing preoperative and postoperative 6 month, the reduction rates of VV, VFI, and RVF were 27, 45, and 35%, while EF increased by 27% (p < 0.001). CONCLUSIONS There were hemodynamic improvement in the lower leg after varicose vein surgery including HLS, RFA, and EVLA.
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Affiliation(s)
- Joon-Kee Park
- Samsung Medical Center Division of Vascular Surgery, Seoul, Korea
| | - Shin-Young Woo
- Samsung Medical Center Division of Vascular Surgery, Seoul, Korea
| | - Shin-Seok Yang
- Samsung Medical Center Division of Vascular Surgery, Seoul, Korea
| | - Dong-Ik Kim
- Samsung Medical Center Division of Vascular Surgery, Seoul, Korea
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Sassaki VS, Fukaya E. Varicose Veins: Approach, Assessment, and Management to the Patient with Chronic Venous Disease. Med Clin North Am 2023; 107:895-909. [PMID: 37541715 DOI: 10.1016/j.mcna.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
Varicose veins are tortuous and dilated veins commonly seen in chronic venous disease. This article will review chronic venous disease, including its differential diagnosis, workup, and treatment.
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Affiliation(s)
- Viviane Seki Sassaki
- Stanford Heart and Vascular Clinic- Vascular Laboratory, Stanford, CA 94305, USA
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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Buset CS, Gujan M, Richter C, Mosti G, Tanadini M, Hafner J. Stiffness of a Novel Two Layer Compression Stocking with 100% Donning and Doffing Success. Eur J Vasc Endovasc Surg 2023; 66:140-141. [PMID: 36967015 DOI: 10.1016/j.ejvs.2023.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/07/2023] [Accepted: 03/22/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Caroline S Buset
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Mena Gujan
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Clara Richter
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | | | - Matteo Tanadini
- Zurich Data Scientists, c/o Impact Hub Zürich AG, Zurich, Switzerland
| | - Jürg Hafner
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.
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Tauraginskii RA, Lurie F, Simakov S, Agalarov R, Borsuk D, Khramtsov P. Calf muscle pump pressure-flow cycle during ambulation. J Vasc Surg Venous Lymphat Disord 2023; 11:783-792.e7. [PMID: 37068709 DOI: 10.1016/j.jvsv.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/19/2023]
Abstract
OBJECTIVE Calf muscle pump (CMP) failure contributes to the severity and progression of chronic venous disease. Attempts to improve CMP function through resistance exercise have failed to improve chronic venous disease severity or quality of life, partially because the selection of the type of exercise was based on the assumption that the CMP ejects blood from the intramuscular venous sinuses (VSs), which has never been tested in humans. In the present study, we investigated the real-time changes in the pressure and size of the VS during the entire gait cycle of ambulation. METHODS We studied 12 lower extremities of nine healthy volunteers at rest and while walking on a treadmill at three different speeds (60, 90, and 120 steps/min). The changes in the VS cross-sectional area (CSA) and pressure were measured. Myography of the gastrocnemius muscle (GCM) and anterior tibial muscle (ATM) was used to register muscle activity. The relationship between the phases of the gait cycle and the measured parameters was analyzed using video records of all experiments. RESULTS The observed timing of events was consistent among all limbs studied. At rest, with the participants standing still, the VS pressure and CSA was 70.3 ± 4.2 mm Hg and 23.3 ± 14.6 mm2, respectively. During ambulation, at the first half of the stance, the GCM and ATM eccentrically contract, and the pressure is low (17 ± 8 mm Hg, 20 ± 12 mm Hg, and 29 ± 13 mm Hg at 1, 1.5, and 2 Hz, respectively), and the VS is collapsed. When the heel starts rising (the second half of the stance), the GCM concentrically contracts, the pressure increases, reaching its maximum value (143 ± 37, 134 ± 46, and 128 ± 41 mm Hg), and the VS opens, reaching its maximal size (1.8 ± 1.4 and 2.3 ± 2.2 mm2 at 1 and 1.5 Hz, respectively), followed by collapse of the VS. During the swing phase, the GCM relaxes, and the ATM concentrically contracts, resulting in a rapid decrease in pressure (2.6 ± 4.7, 1.1 ± 6.2, and -4.7 ± 3.2 mm Hg). The VS CSA remained negligible. CONCLUSIONS The GCM concentric contraction was associated with a simultaneous increase in VS pressure and CSA. GCM relaxation with ATM concentric contraction coincided with a decrease in VS pressure to negative values. The VSs do not fill but remain empty during the swing phase of ambulation, acting, not as a reservoir, but as a conduit, transferring blood from the network of intramuscular veins to the axial deep veins.
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Affiliation(s)
- Roman A Tauraginskii
- Research Laboratory of Venous Hemodynamics, Phlebocenter LLC, Kaliningrad, Russia.
| | - Fedor Lurie
- Department of Vascular Surgery, Jobst Vascular Institute, Toledo, OH; Division of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | | | | | - Denis Borsuk
- Clinic of Phlebology and Laser Surgery, VenoClinica, Yekaterinburg, Russia
| | - Pavel Khramtsov
- Research Laboratory of Venous Hemodynamics, Phlebocenter LLC, Kaliningrad, Russia
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Clinical tolerance of untreated reflux after iliac vein stent placement. J Vasc Surg Venous Lymphat Disord 2023; 11:294-301.e2. [PMID: 36265798 DOI: 10.1016/j.jvsv.2022.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND We have recently demonstrated in a large patient cohort that the prevalence and severity of reflux will improve in most limbs after stenting and that most limbs will not develop new-onset reflux. In the present report, we have focused on the long-term clinical outcomes associated with untreated reflux in the same patient cohort who had undergone iliofemoral venous stenting without correction of residual reflux. METHODS The clinical outcomes data from 1379 limbs treated with only iliac vein stenting without correction of superficial or deep reflux from 1997 to 2018 were analyzed (23-year follow-up period). Of the 1379 limbs, 632 (46%) had had preexisting reflux before stenting and 747 (54%) had did not. The reflux data (reflux segmental score, air plethysmography, ambulatory venous pressure) for these patients have been previously reported in detail. The subsets were compared perioperatively with each other using the following variables: grade of swelling, visual analog scale for pain score, venous clinical severity score, venous stasis dermatitis, ulceration, and quality of life measures. RESULTS Both groups demonstrated improvements in the venous clinical severity score, grade of swelling, visual analog scale score, and quality of life. No differences were found in ulcer healing (5% vs 3% for limbs with and without prestent reflux, respectively) and resolution of dermatitis (6% vs 5% for limbs with and without prestent reflux, respectively) between the two groups. Of the 632 limbs with preexisting reflux, 218 (34%) had had axial reflux and 414 had had nonaxial reflux (66%). The clinical outcomes were similar between the two groups. Using a multisegment reflux score, the limbs with prestent reflux (n = 632) were divided into two groups. A segmental score of ≥3 indicated severe reflux and a score of <3 indicated moderate reflux. Of these 632 limbs, 161 (25%) had severe reflux and 471 (75%) had moderate reflux. The two groups demonstrated similar outcomes for most clinical parameters. The post-thrombotic limbs and nonthrombotic limbs also showed similar outcomes. CONCLUSIONS The long-term follow-up of patients after iliac vein stenting showed that uncorrected reflux is well tolerated by most patients across most clinical measures.
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10
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Raju S, Lucas M, Thaggard D, Saleem T, Jayaraj A. Plethysmographic features of calf pump failure in chronic venous obstruction and reflux. J Vasc Surg Venous Lymphat Disord 2023; 11:262-269. [PMID: 36400423 DOI: 10.1016/j.jvsv.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Calf pump failure (CPF) is a common concept in chronic venous disease. Dorsal vein pressures were originally used to define the pathophysiology. More recently, an abnormal ejection fraction (EF) and residual volume fraction (RVF) with air plethysmography (APG) have been substituted for its diagnosis. The relationship between reflux and calf pump function has been studied extensively. Reflux is thought to be the main cause of CPF, although other mechanisms may play a secondary role. Data mining in our dataset revealed that CPF is frequently found in nonrefluxive limbs-an unexpected finding. We analyzed the APG features of CPF in nonrefluxive limbs of a large cohort of patients investigated for chronic venous disease in our clinic. Data from refluxive limbs (control) seen over the same period was included for comparison. Venous obstructive pathology was variably present in both subsets. Iliac vein stent outcome in CPF limbs from both subsets is included. The role of obstruction in CPF is currently unknown. METHODS Records of 13,234 limbs in 8813 patients evaluated for suspected chronic venous disease over a 22-year period were analyzed. Prestent and poststent data in 406 CPF limbs (129 nonrefluxive; 277 refluxive) that underwent iliac vein stenting to correct associated stenosis are included. This is a single-center retrospective analysis of prospectively collected data. Duplex and APG data were available for included limbs. A RVF of more than 50% was defined as CPF. A reflux time of greater than 1 second elicited with automated cuffs in the erect position was defined as reflux. RESULTS There were 7780 (59%) limbs with reflux and 5454 (41%) that were nonrefluxive. Supine venous pressure, an index of venous obstruction, was elevated in both subsets. The incidence of CPF was 25% in refluxive limbs and 16% in nonrefluxive limbs totaling 2790 limbs. Venous volume and venous filling index were significantly elevated (P = .0001) in refluxive limbs compared to nonrefluxive limbs. The EF was diminished (<50%) in all CPF limbs except in a small fraction (n = 427 [3%]). Stent correction of iliac vein stenosis corrected CPF, normalizing the RVF in both subsets. CONCLUSIONS CPF frequently occurs in nonrefluxive limbs with incidence only slightly less than in refluxive limbs. An RVF of more than 50% seems to be a practical definition of a CPF; an EF of less than 50% is associated with a RVF of greater than 50% in 97% of analyzed limbs. Prospective identification of CPF in limbs with chronic venous disease may allow more detailed investigation of its cause (preload, afterload, neuromuscular pathology or joint immobility, etc) and direct more targeted treatment than currently practiced.
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Affiliation(s)
- Seshadri Raju
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS.
| | - Michael Lucas
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
| | - David Thaggard
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
| | - Taimur Saleem
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
| | - Arjun Jayaraj
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
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Turner BRH, Jasionowska S, Machin M, Javed A, Gwozdz AM, Shalhoub J, Onida S, Davies AH. Systematic review and meta-analysis of exercise therapy for venous leg ulcer healing and recurrence. J Vasc Surg Venous Lymphat Disord 2023; 11:219-226. [PMID: 36202303 DOI: 10.1016/j.jvsv.2022.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/08/2022] [Accepted: 09/17/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE National guidelines in the United Kingdom have recommended regular exercise for individuals with venous leg ulceration. However, data on the effects of exercise on ulcer healing and recurrence are sparse. In the present study, we aimed to quantify the evidence for exercise regarding venous ulcer healing with respect to the primary outcomes of the proportion of healed ulcers and rate of ulcer recurrence. The secondary outcomes were improvement in ulcer symptoms, ulcer healing time, quality of life, compliance, and adverse events reported. METHODS The review followed PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines using a registered protocol (CRD42021220925). The MEDLINE and Embase databases and Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, European Union Clinical Trials, and International Standard Randomised Controlled Trial Number registries were searched up to April 6, 2022 and included studies comparing exercise therapy and compression vs compression alone. Data for the proportion of healed ulcers were pooled using a fixed effects meta-analysis. RESULTS After screening 1046 reports, 7 were included, with 121 participants allocated to exercise therapy and 125 to compression alone. All the reports were of randomized controlled trials and had reported ulcer healing at 12 weeks, with a pooled relative risk of ulcer healing of 1.38 for exercise vs compression (95% confidence interval, 1.11-1.71). Only one study had reported on recurrence; thus, data pooling was not performed. No differences between exercise and usual care were demonstrated. Compliance with exercise ranged from 33% to 81%. The included studies demonstrated low enrollment and a high risk of bias. Also, most of the trials had failed to demonstrate any differences in activity completed between the intervention and control arms. CONCLUSIONS A paucity of studies has examined leg ulcer recurrence after exercise programs, with no evidence to show that exercise is beneficial. Furthermore, the quality of evidence supporting exercise as an adjunct to ulcer healing is very low, and the trials demonstrated serious methodologic flaws, chiefly in recording the activity undertaken by the participants in the intervention arm. Future randomized controlled trials should implement activity monitoring and standardize the reporting of key patient, ulcer, and reflux characteristics to enable future meaningful meta-analyses to determine the role of exercise as an adjunct to venous leg ulceration healing.
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Affiliation(s)
- Benedict R H Turner
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, United Kingdom
| | - Sara Jasionowska
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, United Kingdom
| | - Matthew Machin
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, United Kingdom
| | - Azfar Javed
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, United Kingdom
| | - Adam M Gwozdz
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, United Kingdom
| | - Joseph Shalhoub
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, United Kingdom
| | - Sarah Onida
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, United Kingdom
| | - Alun H Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, United Kingdom.
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Menegatti E, Mandini S, Pagani A, Mandini B, Zerbini V, Piva T, Raisi A, Fabbri M, Fogli M, Mazzoni G, Zamboni P, Gianesini S. The Effect of Active Stretching Training in Patients with Chronic Venous Insufficiency Monitored by Raster-Stereography. SENSORS (BASEL, SWITZERLAND) 2022; 22:8509. [PMID: 36366206 PMCID: PMC9657419 DOI: 10.3390/s22218509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 06/16/2023]
Abstract
(1) Background: Musculoskeletal disorders can be associated with advanced clinical stages of chronic venous insufficiency (CVI). The aim of the study is to investigate the effect of active stretching (AS) training on lower limb venous function and quality of life in patients affected by CVI. (2) Methods: A prospective two-armed pilot randomized controlled was conducted. Twenty (20) CVI patients were randomly assigned to an AS training or to a control group (C) who did not receive any exercise indication. At baseline and after three months all the participants were tested for leg volumetry (LV), air plethysmography (APG), and quality of life (QoL) measured by a disease specific validated questionnaire (VVSymQ), ankle range of motion (ROM), and postural deformities using an optoelectronic body posture machine. (3) Results: At the end of the training in the AS group a significant leg volume reduction was detected (from 2340 ± 239 mL to 2239 ± 237 mL (4.3%); p < 0.0001), whereas in the C group no significant volume changes were found. The ejection fraction rate (EF%) increased significantly from 49.3 ± 9.3 to 61.1 ± 14.5, p < 0.005. A moderate-strong linear correlation with EF% and ankle ROM variation was found (R2 = 0.6790; p < 0.0034). Several postural outcomes such as pelvic tilt, pelvic torsion, and lordotic angle significantly improved in the AS group (p < 0.01, p < 0.04, p < 0.01 respectively). (4) Conclusion: The AS training impacts on the APG parameters related to the musculoskeletal pump efficiency, opening a further possibility in the management of CVI patients by means of an appropriate adapted physical exercise program.
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Affiliation(s)
- Erica Menegatti
- Department of Environmental and Prevention Sciences, University of Ferrara, 44123 Ferrara, Italy
| | - Simona Mandini
- Center for Exercise Science and Sport, Department of Neuroscience and Rehabilitation, University of Ferrara, 44123 Ferrara, Italy
| | - Anselmo Pagani
- Vascular Diseases Center, Department of Translational Medicine, University of Ferrara, 44124 Ferrara, Italy
| | - Beatrice Mandini
- Center for Exercise Science and Sport, Department of Neuroscience and Rehabilitation, University of Ferrara, 44123 Ferrara, Italy
| | - Valentina Zerbini
- Center for Exercise Science and Sport, Department of Neuroscience and Rehabilitation, University of Ferrara, 44123 Ferrara, Italy
| | - Tommaso Piva
- Center for Exercise Science and Sport, Department of Neuroscience and Rehabilitation, University of Ferrara, 44123 Ferrara, Italy
| | - Andrea Raisi
- Center for Exercise Science and Sport, Department of Neuroscience and Rehabilitation, University of Ferrara, 44123 Ferrara, Italy
| | - Marinella Fabbri
- Center for Exercise Science and Sport, Department of Neuroscience and Rehabilitation, University of Ferrara, 44123 Ferrara, Italy
| | - Marco Fogli
- Center for Exercise Science and Sport, Department of Neuroscience and Rehabilitation, University of Ferrara, 44123 Ferrara, Italy
| | - Gianni Mazzoni
- Center for Exercise Science and Sport, Department of Neuroscience and Rehabilitation, University of Ferrara, 44123 Ferrara, Italy
| | - Paolo Zamboni
- Vascular Diseases Center, Department of Translational Medicine, University of Ferrara, 44124 Ferrara, Italy
| | - Sergio Gianesini
- Vascular Diseases Center, Department of Translational Medicine, University of Ferrara, 44124 Ferrara, Italy
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Dong Z, Zhao Y, Zhao X, Chen X, Ta S, Zhao J, Liu L, Chi YW. Summary of diagnostic and characteristic parameters of C 0 to C 2 patients based on the CEAP2020 classification. J Vasc Surg Venous Lymphat Disord 2022; 10:1201-1207.e2. [PMID: 35810993 DOI: 10.1016/j.jvsv.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/11/2022] [Accepted: 05/25/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Hemodynamic changes in C0 to C2 according to the clinical/etiological/anatomical/pathophysiological classification have not been analyzed extensively. We intend to investigate the characteristics of early stage venous disease using venous clinical severity score (VCSS), heaviness/ache/swelling/throbbing/itching (HASTI) score and duplex ultrasound (DUS) derived parameters. METHODS From Aug. 2020 to Jul. 2021, consecutive patients were categorized according to the clinical/etiological/anatomical/pathophysiological 2020 classification. The vein diameter (mm), reflux time (s), cross-sectional area (cm2), peak and mean reflux velocity (cm/s), and total reflux volume (mL) were documented in the superficial system and deep system. VCSS and HASTI scores were assessed and DUS parameters were analyzed. A P value of less than .05 was considered statistically significant. RESULTS We studied 257 consecutive patients (142 female) with 371 limbs. The mean age was 50.96 ± 13.27 years (range, 20-81 years; median, 53 years) with an average body mass index of 24.03 ± 2.96 kg/m2 (range, 17.00-33.06 kg/m2; median, 23.67 kg/m2). The proportion of clinical (C) category was as followed: 47 C0S (12.67%), 45 C1 (12.13%), and 279 C2 (75.20%). There were 42.6% of C0 and 62.2% of C1 associated with some form of venous reflux, Pr (pathology [P]-reflux). Reflux of the great saphenous vein above the knee (GSVa) was the most commonly affected vein segment from C0-2. C1 differed from C0 only by age and severity scores with a cut-off value of 1 for both VCSS and HASTI. Larger saphenous veins diameter (GSV and small saphenous vein) were seen in Pr (P-reflux) than Pn (P-none) of C0 cases. Larger deep vein diameters (common femoral vein, femoral vein, and popliteal vein) were evident in Pr versus Pn of C1 cases. In C2, the popliteal vein, saphenofemoral junction, and GSVa were dilated in Pr cases. CONCLUSIONS Both HASTI and VCSS were discriminative from C0 to C2. C0 differed from C1 by age and severity scores as DUS characteristics were not significantly different between the two groups. Vessel diameter played a discriminative role in distinguishing Pn versus Pr cases in each C0-2 category. GSVa was the most frequent reflux segment irrespective of reflux types.
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Affiliation(s)
- Zilong Dong
- Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Yongfeng Zhao
- Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Xiaoyu Zhao
- Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Xi Chen
- Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Shengjun Ta
- Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Junfeng Zhao
- Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Liwen Liu
- Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Yung-Wei Chi
- University of California, Davis, Vascular Center, Sacramento, CA.
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14
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Bihari I, Guex JJ, Jawien A, Szolnoky G. Clinical Perspectives and Management of Edema in Chronic Venous Disease—What about Ruscus? MEDICINES 2022; 9:medicines9080041. [PMID: 35893088 PMCID: PMC9331752 DOI: 10.3390/medicines9080041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Imre Bihari
- Vascular Surgery Department, St Rokus Clinical Block, Semmelweis University, 1085 Budapest, Hungary
- Correspondence:
| | | | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, University Hospital No. 1, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, 85-094 Tourn, Poland;
| | - Gyozo Szolnoky
- Department of Dermatology and Allergology, Albert Szent-Györgyi Medical School, University of Szeged, 6720 Szeged, Hungary;
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15
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De Maeseneer MG, Kakkos SK, Aherne T, Baekgaard N, Black S, Blomgren L, Giannoukas A, Gohel M, de Graaf R, Hamel-Desnos C, Jawien A, Jaworucka-Kaczorowska A, Lattimer CR, Mosti G, Noppeney T, van Rijn MJ, Stansby G, Esvs Guidelines Committee, Kolh P, Bastos Goncalves F, Chakfé N, Coscas R, de Borst GJ, Dias NV, Hinchliffe RJ, Koncar IB, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, Björck M, Labropoulos N, Lurie F, Mansilha A, Nyamekye IK, Ramirez Ortega M, Ulloa JH, Urbanek T, van Rij AM, Vuylsteke ME. Editor's Choice - European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg 2022; 63:184-267. [PMID: 35027279 DOI: 10.1016/j.ejvs.2021.12.024] [Citation(s) in RCA: 224] [Impact Index Per Article: 112.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 01/12/2023]
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16
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Raju S, Lucas M, Luke C, Peeples H, Saleem T, Jayaraj A. Long Term Improvement Of Limb Reflux Prevalence and Severity after Iliac Vein Stent Placement. J Vasc Surg Venous Lymphat Disord 2022; 10:640-645.e1. [DOI: 10.1016/j.jvsv.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 01/21/2022] [Indexed: 10/19/2022]
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17
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Chen ZH, Huang Y, Wang LP, Peng MY, Li C, Huang W. Preliminary study of hemodynamics of iliac venous compression syndrome using magnetic resonance imaging. J Vasc Surg Venous Lymphat Disord 2021; 10:131-138.e3. [PMID: 34634518 DOI: 10.1016/j.jvsv.2021.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/30/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE In clinical practice, the degree of iliac vein stenosis has often been inconsistent with the symptoms of chronic venous disease (CVD). To the best of our knowledge, no clinical studies have evaluated the hemodynamic changes associated with iliac vein stenosis. Magnetic resonance imaging (MRI) can noninvasively provide hemodynamic information. In the present study, we assessed the degree of stenosis associated with iliac venous compression syndrome and the relationships between iliac venous compression syndrome-induced, MRI-determined hemodynamic changes and lower limb symptoms. METHODS Stenosis severity, the presence of collateral vessels, and flow rate (FR) differences between the common and external iliac veins secondary to iliac vein stenosis were measured using MRI in 69 patients with CVD. Villalta scores were used as a measure of symptom severity for all patients, and the percentage of change in the Villalta score was used as a measure of symptom improvement for the patients who had received iliac vein stents. Symptom severity for all patients, a subgroup of patients with iliac vein compression (affected limbs), and a group of patients with unilateral iliac vein compression treated with stents was correlated with stenosis, differences in the external and common iliac vein FRs (<0-mL/s group, indicating stenosis-induced decreased common iliac vein flow, and ≥0-mL/s group), and stenosis-induced collateral vessel formation. RESULTS Iliac vein stenosis severity and FR differences in all affected limbs were correlated with the Villalta scores of the affected limbs (stenosis: r = 0.38, P < .001, n = 95; FR difference: r = -0.44, P < .001). In the unilateral compression subgroup, stenosis severity, FR differences, and the presence of collateral vessels were not associated with significant changes in contralateral symptoms. In the endovascular treatment subgroup, both lower limbs exhibited significant improvement after stent implantation (affected limb symptom remission, 64.6% ± 18.2%, n = 15; contralateral limb symptom remission, 49.1% ± 29.1%, n = 11). The rate of symptom remission was greater for patients with decreased iliac vein flow in the affected limbs (<0-mL/s group: 74.6% ± 16.4%, n = 7; ≥0-mL/s group: 52.2% ± 16.6%, n = 6; P = .032). CONCLUSIONS Iliac vein stenosis, the presence of collateral vessels, and decreased FRs due to stenosis correlated significantly with lower limb symptom severity. Endovascular treatment yielded good outcomes in patients with stenosis >50%. A decreased iliac venous FR could indicate a better response to stent implantation and could be used in the diagnosis and guiding decisions to treat iliac venous compression.
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Affiliation(s)
- Zi-Hui Chen
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing City, China
| | - Yang Huang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing City, China
| | - Liang-Peng Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing City, China
| | - Ming-Yong Peng
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing City, China
| | - Chao Li
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing City, China
| | - Wen Huang
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing City, China.
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18
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Maleti O, Nicolaides A, Guerzoni S, Bergamo G, Lugli M. Residual volume fraction during walking using wireless air plethysmography in patients with chronic deep venous disease. J Vasc Surg Venous Lymphat Disord 2021; 10:423-429.e2. [PMID: 34450356 DOI: 10.1016/j.jvsv.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/13/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Traditional air plethysmography (APG) provides a quantitative measure of the residual volume fraction (RVF) after 10 tiptoe movements. The recent development of a wireless Bluetooth (Bluetooth SIG, Inc, Kirkland, Wash) APG device, the PicoFlow (Microlab Elettronica, Padua, Italy), enabled us to measure RVF during normal walking. The aim of our study was to compare the RVF obtained during tiptoeing with RVF obtained during normal walking in patients with deep venous pathology (ie, reflux and/or obstruction). METHODS A total of 61 consecutive symptomatic patients (27 women and 34 men; median age, 46 years; range, 18-79 years) with chronic venous disease due to deep venous pathology (venous reflux or obstruction, or both) before treatment or persisting after intervention were included in the present study. Of the 122 total limbs examined, 79 were affected by deep chronic venous disease and 43 contralateral limbs were normal with normal deep veins and acted as controls. The APG examination was performed using the PicoFlow device using the standard examination technique. The RVF was calculated from the residual volume at the end of 10 tiptoe movements and also during normal walking. RESULTS At the end of the 10 tiptoe movements, the mean ± standard deviation RVF was 27.0% ± 13.2% in the limbs with normal deep veins and 38.8% ± 16.9% in the limbs with deep chronic venous disease (P < .001). During walking, when a steady state in volume was reached, the RVF was 26.3% ± 17.8% in the limbs with normal deep veins and 43.1% ± 18.6% in limbs with deep venous disease (P < 0.001). A significant difference was found between limbs with normal deep veins and limbs with deep venous reflux, irrespective of which exercise was performed. However, the mean RVF between the limbs with normal deep veins and those with outflow obstruction in the absence of reflux was significant during walking (P = .012) but not during tiptoeing (P = .212). The mean RVF was higher in the C3 to C6 limbs than in the C0 to C2 limbs with tiptoeing (29.9% ± 14.5% vs 38.3% ± 17.0%; P < .006). Similar results were obtained with walking (29.2% ± 18.0% vs 42.4% ± 18.8%; P < .004). CONCLUSIONS In limbs with normal deep veins and deep veins with reflux, the RVF measured during walking with wireless APG was similar to the RVF obtained during tiptoeing. However, in the limbs with outflow obstruction in the absence of reflux, the RVF during walking was higher than the RVF after tiptoeing. Our results have shown that the evaluation of RVF during walking is feasible and practical.
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Affiliation(s)
- Oscar Maleti
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Hesperia Hospital, Modena, Italy.
| | - Andrew Nicolaides
- Department of Surgery, Medical School, University of Nicosia, Nicosia, Cyprus
| | - Sara Guerzoni
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Hesperia Hospital, Modena, Italy
| | | | - Marzia Lugli
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Hesperia Hospital, Modena, Italy
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Ortega MA, Fraile-Martínez O, García-Montero C, Álvarez-Mon MA, Chaowen C, Ruiz-Grande F, Pekarek L, Monserrat J, Asúnsolo A, García-Honduvilla N, Álvarez-Mon M, Bujan J. Understanding Chronic Venous Disease: A Critical Overview of Its Pathophysiology and Medical Management. J Clin Med 2021; 10:3239. [PMID: 34362022 PMCID: PMC8348673 DOI: 10.3390/jcm10153239] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Miguel A. Ortega
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
- Cancer Registry and Pathology Department, Hospital Universitario Principe de Asturias, 28806 Alcalá de Henares, Spain
| | - Oscar Fraile-Martínez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Cielo García-Montero
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Miguel A. Álvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Chen Chaowen
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
| | - Fernando Ruiz-Grande
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain;
- Department of Vascular Surgery, Príncipe de Asturias Hospital, 28801 Alcalá de Henares, Spain
| | - Leonel Pekarek
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Jorge Monserrat
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Angel Asúnsolo
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain;
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, The City University of New York, New York, NY 10027, USA
| | - Natalio García-Honduvilla
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Melchor Álvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
- Immune System Diseases—Rheumatology and Internal Medicine Service, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcalá de Henares, Spain
| | - Julia Bujan
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
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Marcelli E, Cercenelli L, Bortolani B, Marini S, Arfilli L, Capucci A, Plicchi G. A Novel Non-Invasive Device for the Assessment of Central Venous Pressure in Hospital, Office and Home. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:141-154. [PMID: 34012302 PMCID: PMC8128499 DOI: 10.2147/mder.s307775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/14/2021] [Indexed: 12/27/2022] Open
Abstract
Background Venous congestion can be quantified by central venous pressure (CVP) and its monitoring is crucial to understand and follow the hemodynamic status of patients with cardio-respiratory diseases. The standard technique for CVP measurement is invasive, requiring the insertion of a catheter into a jugular vein, with potential complications. On the other hand, the current non-invasive methods, mainly based on ultrasounds, remain operator-dependent and are unsuitable for use in the home environment. In this paper, we will introduce a novel, non-invasive device for the hospital, office and home assessment of CVP. Methods After describing the measurement concept, we will report a preliminary experimental study enrolling 5 voluntary healthy subjects to evaluate the VenCoM measurements’ repeatability, and the system’s capability in measuring small elicited venous pressure variations (2 mmHg), as well as an induced venous hypertension within a pathological range (12÷20 mmHg). Results The experimental measurements showed a repeatability of ±1mmHg. The VenCoM device was able to reliably detect the elicited venous pressure variations and the simulated congestive status. Discussion and Conclusion The proposed non-invasive VenCoM device is able to provide a fast and repeatable CVP estimate, having a wide spectrum of potential clinical applications, including the monitoring of venous congestion in heart failure patients and in subjects with renal and hepatic dysfunction, as well as pulmonary hypertension (PH) that can be extended to pneumonia COVID-19 patients even after recovery. The device needs to be tested further on a large sample size of both healthy and pathological subjects, to systematically validate its reliability and impact in clinical setting.
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Affiliation(s)
- Emanuela Marcelli
- eDIMES Lab-Laboratory of Bioengineering, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Laura Cercenelli
- eDIMES Lab-Laboratory of Bioengineering, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Barbara Bortolani
- eDIMES Lab-Laboratory of Bioengineering, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Saverio Marini
- Ars Medica: Associazione Medico-Chirurgica Della Gallura, Olbia, Italy
| | - Luca Arfilli
- Villa Laura Ospedale Privato Accreditato, Bologna, Italy
| | | | - Gianni Plicchi
- TRE ESSE Progettazione Biomedica S.r.l., Bologna, 40138, Italy
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21
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Raju S, Walker W, Noel C, Kuykendall R, Powell T, Jayaraj A. Dimensional disparity between duplex and intravascular ultrasound in the assessment of iliac vein stenosis. Vasc Med 2021; 26:549-555. [PMID: 33840321 DOI: 10.1177/1358863x211003663] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Minimum iliac vein caliber necessary to maintain normal peripheral venous pressure can be derived by the Poiseuille equation. Duplex was compared to intravascular ultrasound (IVUS) in the assessment of iliac vein stenosis in this single center retrospective study. Parallel IVUS and duplex caliber data for common iliac vein (CIV) and external iliac vein (EIV) in 382 limbs were separately compared. One or both segments were stenotic by IVUS criteria in 213 limbs. Neither segment was stenotic by IVUS in 22 limbs. Bland-Altman analyses and Passing-Bablok linear regressions were used. Duplex calibers were dimensionally smaller than corresponding IVUS images of CIV and EIV segments in Bland-Altman comparison by a mean of 54 mm2 and 34 mm2, respectively. Passing-Bablok regression suggested the difference was due to a systematic bias and not proportional. Duplex yields a smaller cross-sectional image of CIV and EIV compared to IVUS. Duplex is not a reliable diagnostic test for iliac vein stenosis.
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Raffetto JD, Ligi D, Maniscalco R, Khalil RA, Mannello F. Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment. J Clin Med 2020; 10:jcm10010029. [PMID: 33374372 PMCID: PMC7795034 DOI: 10.3390/jcm10010029] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022] Open
Abstract
Venous leg ulcers (VLUs) are one of the most common ulcers of the lower extremity. VLU affects many individuals worldwide, could pose a significant socioeconomic burden to the healthcare system, and has major psychological and physical impacts on the affected individual. VLU often occurs in association with post-thrombotic syndrome, advanced chronic venous disease, varicose veins, and venous hypertension. Several demographic, genetic, and environmental factors could trigger chronic venous disease with venous dilation, incompetent valves, venous reflux, and venous hypertension. Endothelial cell injury and changes in the glycocalyx, venous shear-stress, and adhesion molecules could be initiating events in VLU. Increased endothelial cell permeability and leukocyte infiltration, and increases in inflammatory cytokines, matrix metalloproteinases (MMPs), reactive oxygen and nitrogen species, iron deposition, and tissue metabolites also contribute to the pathogenesis of VLU. Treatment of VLU includes compression therapy and endovenous ablation to occlude the axial reflux. Other interventional approaches such as subfascial endoscopic perforator surgery and iliac venous stent have shown mixed results. With good wound care and compression therapy, VLU usually heals within 6 months. VLU healing involves orchestrated processes including hemostasis, inflammation, proliferation, and remodeling and the contribution of different cells including leukocytes, platelets, fibroblasts, vascular smooth muscle cells, endothelial cells, and keratinocytes as well as the release of various biomolecules including transforming growth factor-β, cytokines, chemokines, MMPs, tissue inhibitors of MMPs (TIMPs), elastase, urokinase plasminogen activator, fibrin, collagen, and albumin. Alterations in any of these physiological wound closure processes could delay VLU healing. Also, these histological and soluble biomarkers can be used for VLU diagnosis and assessment of its progression, responsiveness to healing, and prognosis. If not treated adequately, VLU could progress to non-healed or granulating VLU, causing physical immobility, reduced quality of life, cellulitis, severe infections, osteomyelitis, and neoplastic transformation. Recalcitrant VLU shows prolonged healing time with advanced age, obesity, nutritional deficiencies, colder temperature, preexisting venous disease, deep venous thrombosis, and larger wound area. VLU also has a high, 50-70% recurrence rate, likely due to noncompliance with compression therapy, failure of surgical procedures, incorrect ulcer diagnosis, progression of venous disease, and poorly understood pathophysiology. Understanding the molecular pathways underlying VLU has led to new lines of therapy with significant promise including biologics such as bilayer living skin construct, fibroblast derivatives, and extracellular matrices and non-biologic products such as poly-N-acetyl glucosamine, human placental membranes amnion/chorion allografts, ACT1 peptide inhibitor of connexin 43, sulodexide, growth factors, silver dressings, MMP inhibitors, and modulators of reactive oxygen and nitrogen species, the immune response and tissue metabolites. Preventive measures including compression therapy and venotonics could also reduce the risk of progression to chronic venous insufficiency and VLU in susceptible individuals.
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Affiliation(s)
- Joseph D. Raffetto
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Correspondence: (J.D.R.); (F.M.)
| | - Daniela Ligi
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
| | - Rosanna Maniscalco
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
| | - Raouf A. Khalil
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Ferdinando Mannello
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
- Correspondence: (J.D.R.); (F.M.)
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23
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Ravikumar R, Lane TR, Babber A, Onida S, Davies AH. A randomised controlled trial of neuromuscular stimulation in non-operative venous disease improves clinical and symptomatic status. Phlebology 2020; 36:290-302. [PMID: 33176593 PMCID: PMC8044600 DOI: 10.1177/0268355520968640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND This randomised controlled trial investigates the dosing effect of neuromuscular electrical stimulation (NMES) in patients with chronic venous disease (CVD). METHODS Seventy-six patients with CEAP C3-C5 were randomised to Group A (no NMES), B (30 minutes of NMES daily) or C (60 minutes of NMES daily). Primary outcome was percentage change in Femoral Vein Time Averaged Mean Velocity (TAMV) at 6 weeks. Clinical severity scores, disease-specific and generic quality of life (QoL) were assessed. RESULTS Seventy-six patients were recruited - mean age 60.8 (SD14.4) and 47:29 male. Six patients lost to follow-up. Percentage change in TAMV (p<0.001) was significantly increased in Groups B and C. Aberdeen Varicose Veins Questionnaire Score (-6.9, p=0.029) and Venous Clinical Severity Score (-4, p-0.003) improved in Group C, and worsened in Group A (+1, p=0.025). CONCLUSIONS Daily NMES usage increases flow parameters, with twice daily usage improving QoL and clinical severity at 6 weeks in CVD patients.
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Affiliation(s)
- Raveena Ravikumar
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Tristan Ra Lane
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust, Addenbrookes Hospital, Cambridge, UK
| | - Adarsh Babber
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sarah Onida
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London, UK
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Suehiro K, Morikage N, Harada T, Samura M, Nagase T, Takeuchi Y, Mizoguchi T, Nakamura K, Hamano K. Extracellular Fluid Content in the Legs of Patients with Chronic Venous Disease. Ann Vasc Surg 2020; 71:215-219. [PMID: 32768548 DOI: 10.1016/j.avsg.2020.07.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/11/2020] [Accepted: 07/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND This study aimed to determine the factors that affect the extracellular fluid (ECF) content in the legs of patients with chronic venous disease (CVD). METHODS Bioimpedance analysis and air plethysmography (APG) were performed in 79 patients with CVD who visited our clinic between September 2016 and March 2019. The normal right legs (N) of 14 healthy volunteers were also reviewed for comparison. The ratio of ECF resistance (Re) of the leg to that of the arm (ReL/ReA) was used to express the ECF content in the tested leg. The severity of CVD was expressed using the clinical, etiological, anatomical, and pathophysiological (CEAP) classification. RESULTS The ReL/ReA decreased as the CEAP class increased (N: median; 0.81 [range 0.66-0.95], C0-1: 0.79 [0.60-0.98], C2: 0.77 [0.56-1.08], C3: 0.67 [0.57-0.85], C4: 0.64 [0.44-0.89]). Older age, female sex, and CEAP class affected the ReL/ReA, but body mass index did not. The ReL/ReA did not correlate with the parameters that were derived from APG, including the venous filling index. CONCLUSIONS We found that the ECF content in legs of patients with CVD might be primarily affected by patient-related factors and CEAP class, as opposed to venous hemodynamics.
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Affiliation(s)
- Kotaro Suehiro
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan.
| | - Noriyasu Morikage
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Takasuke Harada
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Makoto Samura
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Takashi Nagase
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Yuriko Takeuchi
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Takahiro Mizoguchi
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Kaori Nakamura
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Kimikazu Hamano
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
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Raju S, Walker W, May C. Measurement of ambulatory venous pressure and column interruption duration in normal volunteers. J Vasc Surg Venous Lymphat Disord 2020; 8:127-136. [DOI: 10.1016/j.jvsv.2019.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022]
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26
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Raju S, Knight A, Lamanilao L, Pace N, Jones T. Peripheral venous hypertension in chronic venous disease. J Vasc Surg Venous Lymphat Disord 2019; 7:706-714. [PMID: 31196767 DOI: 10.1016/j.jvsv.2019.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 03/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Microvascular venous hypertension has emerged as a central feature of chronic venous disease (CVD). Yet, the incidence and severity of peripheral venous hypertension in the clinical setting have not been reported. This is an observational study of venous hypertension in the lower limb of a large cohort of patients with suspected CVD referred to a single referral center during a 16-year period. METHODS Clinical and venous laboratory test data for 8868 limbs of 5792 patients with CVD symptoms seen from 1999 to 2015 were analyzed. Subset A limbs had a mix of obstruction/reflux or neither (n = 4132). These are limbs in which duplex ultrasound reflux (yes/no) status is known. The incidence and severity of obstruction in these limbs are unknown as tests of obstruction were not routinely performed. Subset B limbs had central obstruction (n = 159). These are limbs with intravascular ultrasound-proven stenosis in the iliac veins that was corrected by stent placement. Reflux was assessed by duplex ultrasound and air plethysmography (venous filling index [VFI90]). Pressure measurements included supine venous pressure, erect venous pressure, and ambulatory venous pressure (AMVP). Pressure measurements are categorized according to Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class, reflux and obstruction with Venn distributions of prevalence. RESULTS All pressures (supine, erect, and ambulatory) trended worse in higher CEAP clinical classes. Supine foot venous pressures were elevated in 70% and 76% of subsets A and B, respectively. A positive association between elevated supine pressures and reflux could not be shown in this study. Supine foot venous pressure did not worsen with increasing reflux in the two subsets, but erect foot venous pressure did. Elevated supine pressures were associated with obstruction in subset B. AMVP worsened in most higher reflux categories. Ambulatory venous hypertension was dominantly associated (Venn distribution) with reflux, less commonly with obstruction. CONCLUSIONS Supine venous hypertension is associated with obstruction and does not worsen with reflux. In contrast, erect foot venous pressure worsens in severe reflux categories. Ambulatory venous hypertension worsens in higher CEAP clinical classes. It worsens with increasing reflux. AMVP is dominantly associated (Venn distribution) with reflux, not obstruction.
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Affiliation(s)
- Seshadri Raju
- The RANE Center, St. Dominic's Memorial Hospital, Jackson, Miss.
| | | | - Lara Lamanilao
- The RANE Center, St. Dominic's Memorial Hospital, Jackson, Miss
| | - Nicholas Pace
- The RANE Center, St. Dominic's Memorial Hospital, Jackson, Miss
| | - Tamekia Jones
- The RANE Center, St. Dominic's Memorial Hospital, Jackson, Miss
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