Compression therapy after invasive treatment of superficial veins of the lower extremities: Clinical practice guidelines of the American Venous Forum, Society for Vascular Surgery, American College of Phlebology, Society for Vascular Medicine, and International Union of Phlebology

A Double-Blind Study on the Effectiveness of Polarized Light Therapy in the Treatment of Venous leg Ulcers-Pilot Study

Vein diseases are one of the most common civilization diseases. The most advanced form chronic venous insufficiency are venous leg ulcers. The study included 40 patients, 20 male (50%) and 20 female (50%) in age between 52 and 88 years (mean age: 68.00 ± 8.55 years) with venous leg ulcers lasting 12.50 ± 5.45 months. Patients were distributed randomly in a double-blind study into two equal groups including 20 patients each (group 1-polarized light therapy and group 2-sham exposure). Patients from both groups received routine pharmacological treatment, specialistic medical dressings and compression therapy. In addition, patients were exposed to a cycle of polarized light therapy procedures or to sham exposures (30 procedures performed in two series of 15 procedures). Wound surface area was evaluated by computerized planimetry and pain intensity was assessed with the use of Visual Analog Scale (VAS) before and after therapy (2.5 months). The analysis showed a statistically significant reduction of surface ulcers area between groups 1 and 2. The median (IQR) size of wounds in group 1 was 2.4 (1.95-2.9) cm2, in group 2; 2.8 (2.6-3.1) cm2 (p = 0.038). The level of pain (VAS) after treatment was assessed in group 1, median (IQR): 2 (2-3) points, in group 2 4.5 (4-5) points; and the observed difference was also statistically significant (p < 0.001). In group 1, after treatment, the area of ulcers decreased-median (IQR): 33.05 (28.7-41.48) %, in group 2 by 18.99 (15-24.4) % (p < 0.001). In group 1, the pain intensity measured using the VAS scale decreased with a median (IQR): 71.42 (61.25-71.42) %, in group 2: 37.5 (28.57-50) % (p < 0.001). Complex therapy with polarized light therapy added to standard care was more effective than standard care alone in reducing of ulcers surface area and intensity of pain ailments in patients with chronic venous leg ulcers.

Clinical Guidelines on Compression Therapy in Venous Diseases

BACKGROUND

In recent years, compression therapy has attracted gradually increasing clinical attention in lower extremity venous diseases. However, basic concepts and clear nomenclature, standard treatment methods, and consistent product standards for pressure equipment are lacking. Therefore, developing clinical guidelines for compression therapy is essential to improving the treatment of venous diseases.

METHODS

Our panel generated strong (grade I), moderate (grade IIa and IIb), and weak (grade III) recommendations based on high-quality (class A), moderate-quality (class B), and low-quality (class C) evidence, using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach and the European Society of Cardiology (ESC) grading system.

RESULTS

The panels made 30 recommendations from current evidence, focusing on 7 fields of lower extremity venous disease (venous thromboembolism, post-thrombotic syndrome (PTS), chronic venous insufficiency (CVI), varicose veins, hemangioma and vascular malformations, lymphedema, and venous ulcers) and 18 topics.

CONCLUSIONS

Of the 30 recommendations made across the 18 topics, 7 were strong (grade I) and 17 were based on high-quality (class A) evidence, highlighting the need for further research of the use of compression therapy.

Indications, contraindications, side effects, general assessment, and outlook for the future: An International Compression Club survey

BACKGROUND

The effectiveness of compression therapy (CT) and the best compression modality choice are questioned in many clinical stages of chronic venous disease (CVD). This work aims to obtain information on indications, contraindications, and the best treatment option for CT in different clinical scenarios of CVD.

METHOD

An online survey was made among members of the International Compression Club, experts in CT.

RESULTS

The experts apply CT in all clinical stages of CVD, even when evidence is missing. Regarding compression materials, experts use inelastic materials in the advanced stages of CVD and compression stockings in the early or chronic stages of CVD.

CONCLUSION

The authors highlight the gap between experts' practical use of CT and evidence-based medicine results. They also suggested that, given the cost of randomized clinical trials aimed at specifying specific indications for different devices, artificial intelligence could be used for large-scale practice surveys in the future.

Clinical efficacy of sodium aescinate administration following endovenous laser ablation for varicose veins

BACKGROUND

Endovenous interventions and minimally invasive procedures are effective in the management of varicose veins. However, they can cause postoperative discomfort.

OBJECTIVE

To evaluate the clinical efficacy of sodium aescinate (SA) in improving edema, pain, vein-specific symptoms, and quality of life in patients following endovenous laser ablation (EVLA) for varicose veins.

METHODS

In this single-center randomized controlled trial (RCT), patients were allocated into two groups: in Group A, 60 mg SA was administered twice daily for 20 days, and in Group B (control), no venoactive drug was prescribed. The Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification system for chronic venous disorders was used to assess the varicose veins. The circumferences of the calf and ankle were recorded for evaluating edema. The 10-point Visual Analog Scale (VAS), Venous Clinical Severity Score (VCSS), and Aberdeen Varicose Veins Questionnaire (AVVQ) were used to measure the pain intensity, overall varicose vein severity, and patient's quality of life, respectively.

RESULTS

The study included 87 patients (mean age, 59.9 ± 10.7 years; 54 men) with CEAP class C2-C5 varicose veins who underwent EVLA and phlebectomy or foam sclerotherapy. The calf circumference recovered quicker in Group A than in Group B by days 10, 21, and 30 (difference from baseline was 1.04 ± 0.35 vs 2.39 ± 1.15 [p < .001], 0.48 ± 0.42 vs1.73 ± 1.00 [p < .001], and 0.18 ± 0.64 vs 0.82 ± 0.96 [p < .001], respectively). The ankle circumference recovered quicker in Group A than in Group B by days 10 and 21 (the difference from baseline was 1.37 ± 0.52 vs 2.36 ± 0.93 [p < .001] and 0.58 ± 0.60 vs 1.14 ± 0.88 [p = .002], respectively). Pain relief was achieved quicker in Group A than in Group B (0.257 ± 1.097 [p = .0863] vs 0.506 ± 1.250 [p = .0168] by day 21). There were no significant differences in the VCSS and AVVQ scores between both groups. There were no drug-related adverse effects.

CONCLUSIONS

SA, in combination with compression therapy, can relieve edema and alleviate pain in patients following EVLA for varicose veins.

Recapturing the Team Approach to Vascular Care

BACKGROUND

The care of the vascular patient remains decentralized rather than coordinated.

METHODS

We reviewed the current state of practice and published competency and care documents created by vascular professional societies.

RESULTS

Vascular professional societies routinely and repeatedly endorse both a team approach and the competency of specialists from disparate training backgrounds. The care of the vascular patient does not always reflect these public endorsements.

CONCLUSIONS

Centering the vascular patient as the mode of organization of care should improve care processes, expertise brought to bear, and outcomes.

COmpressioN following endovenous TreatmenT of Incompetent varicose veins by sclerotherapy (CONFETTI)

OBJECTIVE

The evidence for post-foam sclerotherapy compression stockings for varicose veins is limited. Thus, we examined the effects of post-procedural compression stockings on varicose vein patients undergoing foam sclerotherapy.

METHODS

The CONFETTI study was a prospective, single-center, randomized controlled trial. Patients with foam sclerotherapy-suitable varicose veins were randomly assigned to the compression group (CG) or the no compression stockings group (NCG) for 7 days. The primary outcome was post-procedural pain measured on a 100-mm visual analog scale for 10 days. Secondary outcomes included clinical severity, generic and disease-specific quality of life scores, return to normal activities and/or work, occlusion rates, degree of ecchymosis, CG compliance, and complications. Patients were reviewed at 2 weeks and 6 months.

RESULTS

A total of 139 patients were consented to and randomly assigned. The intention-to-treat analysis included 15 patients who did not receive the allocated intervention. Both groups had similar baseline characteristics. Of the patients, 63.3% and 55.4% returned for follow-up at 2 weeks and 6 months, respectively. Most of the veins treated were tributaries. The CG experienced significantly lower pain scores than the NCG, with median scores of 7 mm and 19 mm, respectively (Mann-Whitney U-test; P = .001). At 2 weeks, no differences were observed in ecchymosis or the time to return to normal activities or work. Both groups showed improvements in clinical severity and quality of life, and occlusion rates were comparable. The NCG experienced one deep venous thrombosis and superficial thrombophlebitis, whereas the CG experienced two superficial thrombophlebitis.

CONCLUSIONS

The CONFETTI study suggests that short-term post-procedural compression stockings are beneficial for reducing post-procedure pain.

Black holes in compression therapy: A quest for data

OBJECTIVE

Although compression therapy (CT) is considered a crucial conservative treatment in chronic venous disease, strong evidence is missing for many clinical indications. This literature review aims to point out what strong evidence we have for CT and all the clinical scenarios where strong evidence still needs to be included.

METHODS

The research was conducted on MEDLINE with PubMed, Scopus and Web of Science. The time range was set between January 1980 and October 2022. Only articles in English were included.

RESULTS

The main problem with CT is the low scientific quality of many studies on compression. Consequently, we have robust data on the effectiveness of CT only for advanced venous insufficiency (C3-C6), deep vein thrombosis and lymphedema. We have data on the efficacy of compression for venous symptoms control and in sports recovery, but the low quality of studies cannot result in a strong recommendation. For compression in postvenous procedures, superficial venous thrombosis, thromboprophylaxis, post-thrombotic syndrome prevention and treatment, and sports performance, we have either no data or very debated data not allowing any recommendation.

CONCLUSIONS

We need high-level scientific studies to assess if CT can be effective or definitely ineffective in the clinical indications where we still have a paucity of or contrasting data.

Comparative Efficacy of Postoperative Compression Methods After EVLT for Great Saphenous Vein Insufficiency

Introduction: The preference for endovascular techniques in treating varicose veins, particularly in the great saphenous vein (GSV), has increased due to their minimally invasive nature and reduced complications. Post-operative care, especially involving compression therapy, remains crucial to improve outcomes, prevent varicose vein recurrence, and enhance overall recovery. This study aimed to evaluate the efficacy of eccentric compression therapy compared to alternative post-operative care methods following endovenous laser treatment (EVLT) for GSV insufficiency. Methods: This prospective randomized clinical trial encompassed 88 EVLT procedures for GSV insufficiency. The participants were divided into two groups, each receiving different postoperative compression methods, and were evaluated over a specified period. The primary outcome was the pain scale after EVLT; meanwhile, the secondary outcome measured in the present study was the rate of GSV occlusion after EVLT. Results: Both groups underwent all EVLT procedures successfully without any complications. At the one-month duplex ultrasound (DUS) follow-up, the sapheno-femoral junction occlusion rates were 97% (43 out of 44) for group A (eccentric compression plus gradual compression stocking) and 95% (42 out of 44) for group B (only gradual compression stocking). Ecchymosis was observed in only 12 patients across both groups, accounting for an overall occurrence of 13.6%. Group A patients reported significantly lower analgesic usage (10%) compared to group B (18%), although this difference did not reach statistical significance. Analysis of postoperative pain data utilizing the visual analog scale (VAS) showed a median value of 5.5 in group B patients, which decreased to 3.1 with the application of eccentric compression. Moreover, there was less ecchymosis in group A observed by one week. Conclusion: This study contributes to the ongoing discourse on the efficacy of postoperative compression in varicose vein treatment. It underscores the necessity for more comprehensive, well-designed studies to yield clearer conclusions and provide better guidance for post-procedure care.

Foam sclerotherapy of great saphenous vein: The need for further improvement and ill-defined issues

Foam sclerotherapy is considered an acceptable method to treat great saphenous vein (GSV) insufficiency, promoting occlusion of its trunk and eradicating reflux. Yet, certain technical points have not been standardized while issues regarding the ultrasonographic appearance of successful or acceptable GSV obliteration or the end-points of the method are not clearly defined. This article comments on the aforementioned using examples based on personal experience.

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

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

The impact of class I compression stockings on the peripheral microperfusion of the lower limb: A prospective pilot study

OBJECTIVE

The use of medical compression stockings (MCS) in patients with peripheral arterial disease (PAD) and diabetes is the subject of an ongoing critical debate. While reducing leg edema of various origins by improving venous back flow, there is a concern about additional arterial flow obstruction when compression therapy is applied in pre-existing PAD. The aim of this study is to obtain further information on the use of class I MCS in patients with advanced PAD and to evaluate the framework conditions for a safe application.

METHODS

The total collective (n = 55) of this prospective, clinical cohort study consisted of 24 patients with PAD Fontaine stage IIb and higher studied before revascularization, of whom 16 patients were examined again after revascularization, and 15 healthy participants included for reference. The microperfusion of the lower extremity of all participants was examined in a supine, elevated, and sitting position using the oxygen to see (O2C) method.

RESULTS

The results indicate that leg positioning had the strongest influence on microcirculation (SO2 and flow: p = 0.0001), whereas MCS had no significant effect on the perfusion parameters (SO2: p = 0.9936; flow: p = 0.4967) and did not lead to a deterioration of values into critical ranges.

CONCLUSION

Mild medical compression therapy appears to be feasible even in patients with advanced PAD. Larger studies are warranted to observe any long-term effects, in particular for the treatment of reperfusion edema after revascularization.

The role of compression therapy after endovenous laser ablation (EVLA) - review

<b><br>Introduction:</b> Chronic venous disease (CVD) is a rising problem in western countries. There are several stages of CVD that can be treated with different ways. One of the methods of treating varicosity, C2 stage of CVD, is still developing endovenous laser ablation (EVLA). This method is popular due to its short operation time, less bleeding, quick recovery and no surgical scars. The compression therapy in form of compression stockings has been widely used as a conservative treatment of early stage CVD and it's also used after EVLA. However there are no strong recommendations towards using compression therapy after this kind of surgery.</br> <b><br>Aim and Method:</b> This paper is aimed to review existing knowledge about compression therapy benefits and its recommended time period after EVLA. Search engines used in review: Pubmed and Cochrane.</br> <b><br>Results:</b> Studies focusing on the compression therapy after EVLA of varicose veins have questioned the prolonged use of compression therapy as it brings no additional benefits and might be difficult for patients to adhere. The existing studies recommended the time period no greater than 1-2 weeks. There are no significant changes in reoccurrence rate and return to normal activities between compression and non-compression group. It is proven that compression therapy significantly reduces the postoperative pain and consumption of analgesics.</br> <b><br>Discussion:</b> Compression therapy seems as a safe option for low pain management. There is a need for further research involving the impact of the compression therapy after EVLA, especially in group of low energy delivered settings as the results of treatment are promising.</br>.

Stocking-only versus additional eccentric compression after below-the-knee truncal vein sclerotherapy: A SOVAECS prospective randomized within-person trial

OBJECTIVE

After foam sclerotherapy in the truncal saphenous vein, the clinical effects of additional eccentric compression has not yet been explored.

METHODS

Between April 2020 and February 2021, we enrolled 42 patients (84 limbs) who underwent bilateral endovenous combined therapy for great saphenous vein (GSV) reflux. Each patient received the same type of endovenous ablation in both above-the-knee GSVs (laser, radiofrequency, cyanoacrylate glue), and combined foam sclerotherapy was performed on both below-the-knee GSVs. Subsequently, we conducted a prospective randomized, single-blind, within-person study in which each patient's bilateral truncal saphenous vein of the calves underwent two different compression therapies: wearing of a regular class II compression stocking on one side (RC group) and additional eccentric compression on the other side (AC group). The primary end point was the occlusion range (score, 0-10) of the below-the-knee truncal GSV after foam sclerotherapy. The secondary outcomes were the pain score (visual analog scale score range, 0-10) of the paired limb, the required number of additional foam sclerotherapy sessions, compliance with compression therapy, and procedure-related complications.

RESULTS

For the above-the-knee GSV, endovenous laser treatment (n = 44), endovenous radiofrequency ablation (n = 14), and endovenous cyanoacrylate glue ablation (n = 26) were performed. The mean subcompression pressure of the medial calf in the supine and standing positions were 16.7 ± 2.34 mm Hg and 24.5 ± 6.6 mm Hg in the RC group and 38.5 ± 5.5 mm Hg and 45.3 ± 8.2 mm Hg in the AC group, respectively (P = .000). The secondary outcomes of pain score, number of additional foam sclerotherapy sessions, and pigmentation were not significantly different statistically between the two groups. The patient-reported satisfaction scores (range, 0-10) on compression at 24 hours postoperatively were 8.03 ± 1.9 for the AC group and 7.98 ± 1.9 for the RC group (P = .317; Wilcoxon signed ranks test). In both groups, the closure rate of the above-the-knee GSV at 1 month postoperatively was 100%. No procedure-related complications were identified within 1 month postoperatively, including no deep vein thrombosis, numbness, or skin necrosis requiring additional medical attention.

CONCLUSIONS

The 24 hours of additional eccentric compression on the truncal GSV compared with the use of a conventional knee-level stocking only did not yield any clinical advantages in terms of the occlusion range, postoperative pain, need for additional sclerotherapy, or skin pigmentation after foam sclerotherapy. The decision on which type of compression therapy to perform after foam sclerotherapy in the truncal vein should be comprehensively determined.

ACR Appropriateness Criteria® Lower Extremity Chronic Venous Disease

Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Effect of short-term compression therapy after thermal ablation for varicose veins: study protocol for a prospective, multicenter, non-inferiority, randomized controlled trial

BACKGROUND

For patients with varicose veins, the goal is to relieve pain and swelling, reduce the severity of edema, improve skin changes, and heal ulcers associated with venous disease. Compression therapy is the cornerstone of their management. Several studies have shown that wearing an elastic bandage for the first 24 h and then a compression stocking for a week can effectively reduce the pain after thermal ablation. However, in clinical practice, patient compliance with this treatment could be better, considering difficulties in pulling up and removing the compression stocking, tightness, and skin irritation because these must be worn for a prolonged period. A potential solution to battling these barriers is short-term compression therapy. Besides, the effect and necessity of wearing compression stockings after thermal ablation have been questioned. Based on current clinical experience and limited evidence, although some scholars have suggested that compression therapy may be an unnecessary adjunctive therapy after thermal ablation, there is still a great deal of uncertainty in the absence of compression therapy after thermal ablation compared to compression therapy. Therefore, we advocate further research to evaluate the clinical effect of short-term postoperative compression therapy. Furthermore, well-designed randomized controlled trials are needed.

METHODS

A prospective, multicenter, non-inferiority randomized controlled trial is designed to evaluate the non-inferiority of target vein occlusion rate at 3 months. Three hundred and sixty patients will be randomly assigned in a 1:1 ratio to one of the following treatments: (A) 3 M™ Coban™ elastic bandage for 48 h or (B) 3 M™ Coban™ elastic bandage for the first 24 h and then a class II compression full-length stocking (23-32 mm Hg) for 1 week. The two groups will be compared on several variables, including target vein occlusion rate at 3 months (primary outcome indicator), pain, quality of life, clinical severity of varicose veins, postoperative complications, time to return to regular work, and compliance.

DISCUSSION

Suppose the effect of the 3 M™ Coban™ elastic bandage for 48 h proves to be non-inferior to long-term compression therapy. In that case, this short-term treatment may contribute to a future update of clinical guidelines for compression therapy after thermal ablation of varicose veins, resulting in higher patient compliance and better postoperative quality of life.

TRIAL REGISTRATION

Clinical Trials NCT05840991 . Registered on May 2023.

Daily Duration of Compression Treatment in Chronic Venous Disease Patients: A Systematic Review

Background: There are no data on the daily regimen of compression therapy in patients with chronic venous disease. This systematic review aimed to establish the optimal daily duration of compression treatment. Methods: A systematic search of CENTRAL and MEDLINE was performed to identify RCTs, non-RCTs, reviews, systematic reviews, meta-analyses, and guidelines evaluating the use of compression regimens in the treatment of varicose veins. Results: Thirty-two RCTs, three non-RCTs, four observational studies, and two crossover trials reporting the duration and regimes of compression treatment fulfilled the inclusion criteria. The daily duration of compression was reported in patients after invasive treatment, for venous ulcer treatment, in patients with venous symptoms. The quality of the studies varied. We could not conduct a meta-analysis due to the heterogeneity of the research data and their quality. Twenty-three studies reported results of compression usage after invasive procedures. Eight studies reported daily duration regimens in patients with venous ulcers. Nine studies reported the impact of compression on venous symptoms and/or edema or limb volume change. One study was conducted to assess if compression improves QoL in venous patients. While there was a clear difference found in the daily duration depending on the clinical scenario, no data in support of exact regimens were found. Conclusions: There are no reliable data supporting exact daily regimens of compression treatment in various cohorts of CVD patients.

Influence of compression therapy following varicose vein surgery: a prospective randomized study

Background

The use of compression dressings after phlebectomy is based solely on clinical experience due to the lack of a unified set of definitive recommendations, which makes clinical practice extremely heterogeneous.

Objectives

To evaluate compression therapy with elastic stockings for 7 days after phlebectomy.

Methods

We randomly allocated 104 lower limbs with disease classified as C1 and C2 to 1 of 2 groups: an intervention group (64 limbs) - wearing elastic compression stockings for the first 7 days after phlebectomy; or a control group (40 limbs) - given conventional bandaging for 24 hours postoperatively. We compared clinical response by analyzing the evolution of symptoms, hematoma formation, and preoperative vs. postoperative limb volume.

Results

Pain (median 1.0 vs. 1.5, p=0.0320) and limb volume (mean 43.7 vs. 99.8, p=0.0071) were significantly improved in patients wearing elastic compression stockings for 7 days after phlebectomy compared with controls.

Conclusions

Use of elastic compression therapy for 7 days after phlebectomy was effective for improving pain and lower limb volume.

May thermal imaging be useful in early diagnosis of lower extremities chronic venous disease?

Introduction: World statistics confirmed that about 40-50% of men and 50-55% of women suffer from chronic venous disease. Currently, the Duplex ultrasound is the leading diagnostic method for chronic venous disease (CVD), but it has some limitations. Therefore, it is important to find a new diagnostic technique that will provide additional parameters, describing not only structural but also early metabolic and functional changes.

Materials and Methods: This study aimed to demonstrate the usefulness of the thermal imaging technique in the diagnosis of chronic venous disease. Results were obtained for two groups: 61 patients suffering from the primary chronic venous disease (CVD group) and 30 healthy people (control group). The obtained results compared the thermal imaging parameters to data obtained from the ultrasound examination. Parameters such as the reflux duration and extent of the CEAP classification were correlated with the mean temperature of the limb, the mean temperature of the lesion (determined using two methods), and the thermal range. Based on data obtained during the study, correlation coefficients were calculated for individual parameters.

Results: The results obtained show that the mean limb temperature, and especially the mean temperature of a proposed isothermal area, is significantly correlated with the range of reflux. The conducted tests showed the correlation between some thermal and ultrasonic parameters determined by Spearman's coefficient is 0.4 (p < 0.05).

Conclusions: Thus, parameters such as the isothermal area and the thermal range may be used as a preliminary quantitative diagnosis, similarly to those derived from the Duplex ultrasound.

Venous leg ulcers and prevalence of surgically correctable reflux disease in a national registry

BACKGROUND

Chronic venous disorders are common, with varicose veins occurring in ∼40% of the population. Venous leg ulcers affect 1% to 2% of the population, with the prevalence increasing ≤4% for those aged >65 years. Both conditions are expensive and together are responsible for ≤2% of the annual healthcare budget expenditure of Western societies. The ESCHAR (effect of surgery and compression on healing and recurrence) and EVRA (early venous reflux ablation) trials demonstrated that surgical correction of superficial venous reflux reduced ulcer recurrence, resulted in faster healing times (EVRA), and was proved cost-effective. Largescale data regarding patients with chronic venous leg ulcers presenting to venous centers with treatable superficial venous insufficiency has not been previously reported. Our study was designed to evaluate the percentage of patients with leg ulcers presenting to dedicated vein centers who were found to have surgically correctable superficial venous insufficiency.

METHODS

The American Vein & Lymphatic Society Patient Reported Outcome Venous Registry began collecting data in 2014 and is one of two national registries focused on chronic venous disorders. The database was queried first for the presence of an ulcer using the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification (C6 status). These de-identified data were further correlated by crossing the number of ulcers for the same limb using the revised venous clinical severity score (rVCSS). The demographics, index duplex ultrasound details, and rVCSS features for ulcer duration and compression use were analyzed. Once the presence of an ulcer had been validated by CEAP and rVCSS, the population was divided into groups according to the ultrasound-reported anatomic pathology (eg, normal, reflux, obstruction, reflux plus obstruction). The query was directed toward all patients seeking a venous evaluation at participating centers from January 2018 through January 2022.

RESULTS

More than 270,000 unique patient records were reviewed. Of the 270,000 records, 163,027 (60%) had had duplex ultrasound scans available, for 1794 unique patients (1879 limbs), representing 1.1% with a leg wound. Of these patients, 55.4% were men and 44.6% were women. Group S included patients with isolated superficial pathology (n = 1291; 68.7%). Group M included patients with mixed superficial and deep pathology (n = 238; 12.7%). Group D included patients with isolated deep vein pathology (n = 58; 3.1%). Finally, group N included patients with leg wounds but no venous pathology (n = 292; 15.5%). The rVCSSs for groups S and M were significantly higher than those for group N. In group S, the dominant patterns involved the great saphenous vein (GSV) above the knee (54.8%), the small saphenous vein (30.7%), and the anterior accessory GSV (14.4%). The frequency of single, double, and triple axial vein reflux identified 1.45 vessels eligible for ablation treatment per limb. In group M, the dominant patterns involved the GSV above the knee (61.7%), the small saphenous vein (26.2%), and the anterior accessory GSV (12.1%), for 1.52 axial segments per limb. Of the 84.4% of venous ulcer patients, duplex ultrasound analysis revealed that 97% of this large subset had had surgically correctable disease.

CONCLUSIONS

The American Vein & Lymphatic Society Patient Reported Outcome Venous Registry demonstrated that 85% of the leg wounds in the present study were venous in origin and 97% possessed surgically correctable disease. Our findings support early referral to dedicated vein centers with appropriate venous reflux management as a part of the multidisciplinary team caring for patients with venous leg ulcers.

Measuring patient compliance with wearing graduated compression stockings

BACKGROUND

Patient compliance is an essential precondition for assessing the effectiveness of graduated compression stockings (GCS). However, patient compliance with use of GCS has not received sufficient attention. Only a few clinical studies have explicitly evaluated patients' adherence to GCS therapy, and the instruments used to measure patient compliance have either not been well adapted to daily use or lacked scientific development techniques. Most instruments have focused on "wear or not wear" or "how long did you wear" questions, which do not consider all the perspectives on patient compliance. In the present study, we used scale development and validation steps to create a self-reported questionnaire to measure patients' compliance with wearing GCS.

METHODS

We designed a questionnaire to measure compliance with wearing GCS among patients who had undergone invasive treatment of superficial varicose veins of the lower extremities. The initial questions were determined after a literature review and interviews with experts and patients. Reliability was evaluated using the Delphi method with expert judges, pretesting, Cronbach's alpha, and test-retest reliability. Exploratory and confirmatory factor analyses were used to test the questionnaire's validity.

RESULTS

The developed questionnaire had 11 questions with the responses rated from 1 to 4 and included three factors: compliance with correct GCS wearing methods, compliance with GCS wearing cautions, and compliance with seeking advice. The Cronbach alpha for the overall questionnaire was 0.853 (factor 1, 0.934; factor 2, 0.803; factor 3, 0.789), its content validity was good, and the factor structure fitted the data well.

CONCLUSIONS

We have presented our initial version of the questionnaire for patients who have undergone invasive treatment of superficial varicose veins of the lower extremities. The questionnaire can be used to evaluate patient compliance with wearing GCS thoroughly and effectively. However, further work is still required to maximize its reliability and validity for its use in daily practice in the future.

Chronic Venous Disease of the Lower Extremities: A State-of-the Art Review

Chronic venous disease is a common disease, the prevalence of which increases with age, and can cause debilitating symptoms that adversely affect the quality of life. The risk factors include family history, female sex, obesity, pregnancy, parity, and history of deep vein thrombosis. Moreover, it is associated with venous obstruction, reflux, or both, which, in turn, leads to ambulatory venous hypertension. Chronic venous disease is the leading cause of leg ulcers, which place a significant cost burden on the health care system. Compression therapy remains the cornerstone of treatment, particularly for more advanced disease. Superficial saphenous vein reflux can be associated with significant symptoms. Catheter techniques, both thermal and nonthermal, have demonstrated efficacy and safety in successful closure and symptom improvement. Deep vein obstruction can be broadly divided into thrombotic and nonthrombotic and can lead to symptomatic chronic venous disease. Recanalization using balloons and stents has been increasingly used and studied in such patients. It is critical to develop training opportunities and guidelines to improve evidence-based and appropriate care for cardiologists treating chronic venous disease.

Sclerotherapy in Aesthetic Medicine: Myths and Realities

BACKGROUND

Sclerotherapy is commonly performed for elimination of reticular and telangiectatic leg veins. There are several variations in practice, from the preparation to post-therapy directives.

OBJECTIVE

To critically examine the misconceptions of sclerotherapy for aesthetic indications.

MATERIALS AND METHODS

This review assesses evidence for and against each of the most common myths regarding sclerotherapy for aesthetic indications.

RESULTS

Sclerotherapy can be safely used to treat veins in areas other than the lower extremities, with the exception of the face. Laser therapy is not superior to sclerotherapy for the treatment of small telangiectatic veins on the lower extremities. The type of syringe used to produce foam sclerotherapy is an important procedural consideration. After sclerotherapy, graduated compression stocking usage is a vital part of the procedure. Detergent sclerotherapy agents are similar, but not equivalent. Touch-up treatments after sclerotherapy should not be performed for 2 months post-treatment. Foam sclerotherapy does not have a high risk for air emboli. It is not advisable to treat the leg veins in "sections." Finally, one cannot reliably treat the telangiectatic veins without treating the feeding reticular veins for a satisfactory result.

CONCLUSION

Many aspects of sclerotherapy have existing evidence to dictate best clinical practice.

Cryostripping-A Safe and Efficient Alternative Procedure in Chronic Venous Disease Treatment

Objective: The presentation of cryostripping as an alternative procedure useful in venous insufficiency treatment. Methods: This retrospective study presents the results of 1087 operated patients, including follow-ups. Cryostripping was practised in all mentioned cases. Patient follow-up was performed at one week, one month, and six months postoperatively by clinical examination, Doppler ultrasonography, CIVIQ-20 and r-VCSS questionnaires. Outcomes, complications, surgery and hospitalisation period, and benefits of the method were analysed. Results: Generally, good functional and aesthetic outcomes defined by clinical symptom remission, absence of insufficient veins on Doppler ultrasonography, QoL and r-VCSS improvement (p < 0.001) were obtained. Complications included bruising ⌀ < 2 cm (32.38%), haematoma (8.92%), saphenous nerve injury (3.49%), deep vein thrombosis (0.18%). Recurrence was noted in 2.94% cases. Mean duration of procedure was 42 ± 12.5 min, mean duration of hospitalisation was 1.05 ± 0.36 days. Compared to high ligation and conventional stripping, the postoperative complications were reduced; compared to other minimally invasive procedures, the costs were reduced. Conclusions: Cryostripping seems to combine the radicality and efficacy of the stripping technique with the cosmetic advantage of the endothermal procedures, being an effective therapeutic method perfectly adapted to the economic conditions of middle-income countries health system. It is also suitable as day-case surgery.

Compression versus no compression after endovenous radiofrequency ablation: A meta-analysis of randomized controlled trials

OBJECTIVES

The aim of this meta-analysis was to compare compression with no-compression, after radiofrequency endothermal ablation of a truncal varicose vein.

METHODS

Databases, such as PubMed, Embase, Cochran Library, and Web of Science, were independently searched by two researchers for relevant literature, preliminary screening was performed, and the full text was read to select studies that met the inclusion criteria. The quality of the included literature was evaluated using the Cochrane Risk of Bias tool, and meta-analysis was performed using Review Manager 5.4.

RESULTS

A total of four randomized controlled trials were included and a total of 552 patients were involved. Among them, 273 patients were in the compression group and 279 in the no-compression group. Meta-analysis results showed that the pain using the 100 mm Visual Analogue Scale was lower in the compression group than the pain in the no-compression group (MD = -4.22, 95% CI = -7.95 - -0.49, p = 0.03). No significant differences in terms of occlusion rate (RR = 0.99, 95% CI = 0.96-1.02, p = 0.55), Aberdeen Varicose Vein Questionnaire (MD = 0.46, 95% CI = -0.80-1.73, p = 0.47), and complications (OR = 1.33, 95% CI = 0.61-2.94, p = 0.47) were observed between groups.

CONCLUSIONS

This meta-analysis suggests that compression therapy reduced post-operative pain compared to the no-compression group. However, no additional advantages were observed in terms of occlusion rates, quality of life scores and complications.

Recovery and patient satisfaction following radiofrequency ablation and concomitant foam sclerotherapy of varicose veins with and without compression: A randomized controlled non-inferiority trial

Background

The benefits of postoperative compression are not well established following radiofrequency ablation of the truncal vein and concomitant foam sclerotherapy.

Methods

A total of 104 patients were randomized: Postoperatively, 54 patients received no compression and 50 patients received class II thigh-high compression. The primary outcome for this study was the difference between means on postoperative pain scores over the first 10 days follow-up measured on a visual analog scale (VAS) from 0 to 100 mm (prespecified delta 10 mm).

Results

The difference between means in no compression and compression group on postoperative pain scores over the 10 days follow-up was 2.1 mm (95% confidence interval −5.1–9.3 mm; p = 0.28) indicating non-inferiority. Patients in the no compression group were more satisfied with the visual appearance of the treated leg at 1 month ( p = 0.003).

Conclusion

Over the first 10 postoperative days, no compression was non-inferior to compression on pain scores.

Combined Treatment of the Anterior Accessory Saphenous Vein and the Great Saphenous Vein

The anterior accessory saphenous vein (AASV) is a common source of primary and recurrent lower extremity varicose veins. Reflux in the AASV can occur independently or simultaneously with great saphenous vein (GSV) reflux. A number of published reports describe recommendations and treatment of symptomatic refluxing AASVs, but descriptions of combined treatment are sparse. Treatment options for ablation of the AASV include both thermal and non-thermal techniques, and results are equivalent to ablation of the great and small saphenous veins. Although not commonly performed, concomitant ablation of the AASV and the GSV is effective and safe, and can be accomplished with minimal additional time. Concomitant treatment is an appropriate option that should be discussed with the patient.

Compression Therapy Following Endovenous Thermal Ablation of Varicose Veins: A Systematic Review and Meta-Analysis

OBJECTIVE

A systematic review and meta-analysis were performed to evaluate the necessity for compression therapy with elastic stockings following endovenous thermal ablation (EVTA) for chronic venous insufficiency.

METHODS

MedLine, ScienceDirect and the Cochrane Library were searched for the relevant literature according to the inclusion and exclusion criteria. Two researchers independently extracted data and assessed the quality of the literature. Randomized controlled trials comparing the use of elastic stockings for compression therapy versus no compression therapy following RFA or EVLA for varicose veins were included in this study. The primary outcome of postoperative pain was assessed using the visual analogue pain scale. Secondary outcomes included the bruising score, quality of life, venous clinical severity score, time to return to normal activities, complications, and the rate of saphenous vein occlusion. The mixed effect model or random effect model was used to calculate relative risk (RR), mean difference (MD) or standardized mean difference following the heterogeneity test. Sensitivity analysis was performed for outcomes with high heterogeneity (I² >50%). Outcomes were described qualitatively for studies that could not be pooled.

RESULTS

Six RCTs with 1,045 subjects were included. Overall, postoperative compression therapy significantly reduced the mean pain in the first 10 days post-EVTA (MD = - 4.98,95% CI: -8.71 to -1.24), and the time to return to normal activities (MD = -1.01, 95% CI: -1.97 to -0.06). In terms of the bruising score, the venous clinical severity score, complications (RR = 1.05,95% CI: 0.55-2.00), quality of life at 2 weeks (MD = -0.71,95% CI: -2.09 to 0.67) and 6 months (MD = 0.26,95% CI: -1.22 to 1.74), and the saphenous vein occlusion rate (RR=1.00,95% CI: 0.95-1.04), there were no significant differences between the compression and control groups.

CONCLUSION

Our study recommends the routine use of compression therapy with elastic stockings following EVTA of varicose veins to reduce postoperative pain and the time to return to normal activities. However, further multi-center and high-quality randomized clinical trials are needed for the unified treatment for varicose veins, the target population as well as the duration of compression therapy on whether elastic stockings is beneficial following EVTA.

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.

Utility of compression immediately after venous closure: Does it matter?

BACKGROUND

Leg compression after venous closures for 24-48 hours or longer is commonplace and controversial.

OBJECTIVE

The goal of our study was to evaluate compression immediately post-venous closures and its associated costs.

METHODS

Records were retrospectively reviewed after consecutive therapies of sclerotherapy, mechanochemical ablation (MOCA) & radiofrequency ablation (RFA) from 1 clinic with 2 cohorts: 7/2/13-10/15/15 were immediately ACE-wrapped for 3-5 days (AW, N = 52) and 10/20/15-1/5/16 were non ACE-wrapped (NAW, N = 49). All procedures were performed in an outpatient office setting of one surgeon (P.L.). Follow-up was within 1 week and 3 months with ultrasounds. Financial data of ACE wraps and ABD pads were assessed.

RESULTS

Closures consisted of consecutive therapies of sclerotherapy (4 patients); MOCA (44 patients) and RFA (53 patients). No statistical difference existed in age (p = 0.61), sex (p = 0.2063); race (0.3689), CAD (p = 0.1442), ESRD (p = 0.2914), diabetes mellitus (p = 0.8943), hypertension (p = 0.681), COPD (p = 0.38), or smoking (p = 0.3628). NAW group had higher rate of hyperlipidemia (p = 0.0225), obesity (p = 0.0283), MOCA and sclerotherapy (p = 0.0005). No difference existed in pain (p = 0.8897); wound complications were too small to perform analysis; and swelling was greater in AW group compared to NAW group (p = 0.0132, OR 3.3951, CI 1.269; 9.0834). Closure rates were 98% and 100% in AW and NAW groups, respectively. NAW were only a total cost savings of $1.58 per leg per procedure.

CONCLUSION

AW for compression after vein closures confers no benefit in postoperative period with no effect on closure rates; may be associated with increased swelling, discomfort, and wound complications while increasing unnecessary and negligible monetary costs. Larger sample size is needed to validate these conclusions.

Ultrasound-guided foam sclerotherapy is safe and effective in the management of superficial venous insufficiency of the lower extremity

BACKGROUND

Superficial venous disease of the lower extremity has a significant impact on quality of life. Both truncal and tributary vein reflux contribute to this disease process. Endovenous foam sclerotherapy is a widely used technique throughout the world for the management of superficial venous reflux and ultrasound guidance improves its safety and efficacy.

METHODS

A PubMed search for ultrasound-guided foam sclerotherapy (UGFS) was conducted and all abstracts were reviewed to identify clinical trials and systematic reviews for a full-text analysis. Additional articles were also identified through searching the references of the selected studies.

RESULTS

The production of foam for sclerotherapy in a 1:3 or 1:4 ratio of air to sclerosant is optimal in a low silicone, low-volume syringe system. Physiologic gas may decrease any side effects, with the trade-off of decreased foam stability. Proper technique with appropriate sterility and cleansing protocols are paramount for safe and effective treatment. The technical success of UGFS for great saphenous vein disease is inferior to endothermal and surgical modalities and retreatment is more common. However, the clinical improvement in patient-reported quality of life is similar between these three modalities. When used for tributary veins in combination with endothermal approaches of the truncal veins, UGFS has high rates of success with excellent patient satisfaction. UGFS has demonstrated an excellent safety profile comparable with or superior to other modalities.

CONCLUSIONS

With proper technique, UGFS is safe and effective for the management of superficial venous disease.

Optimal Duration of Compression Stocking Therapy after Endovenous Laser Ablation Using a 1470-nm Diode Dual-Ring Radial Laser Fiber for Great Saphenous Vein Insufficiency

Objective: To investigate the optimal duration of compression therapy after endovenous laser ablation (EVLA) using a 1470-nm diode dual-ring radial laser fiber for great saphenous vein (GSV) insufficiency.

Methods: Patients undergoing EVLA of GSV for varicose vein disease were divided into two groups based on the duration of subsequent compression after the procedure: short duration group (S group; 0–2 days) and long duration group (L group; 1–4 weeks). Patient-reported outcomes (pain and quality of life [QOL]) were set as the primary outcomes, and objective findings (venous clinical severity score [VCSS], leg circumference, and duplex ultrasound [DUS] findings) were set as the secondary outcomes. A follow-up examination was performed at 1 week and 1 and 6 months. Each variable between the groups was compared after a propensity score matching using the age, sex, Clinical–Etiological–Anatomical–Pathophysiological (CEAP) clinical class, job type, and target variable as covariates. A per-protocol analysis was performed.

Results: The S and L groups included 98 and 99 patients, respectively. A propensity score matching analysis showed no significant differences between the groups in any outcomes at any follow-up intervals.

Conclusion: Long-term compression showed little benefit; therefore, the prescription of compression stocking beyond 2 days after EVLA is unnecessary.

A randomized trial of class II compression sleeves for full legs versus stockings after thermal ablation with phlebectomy

OBJECTIVE

Compression stockings and bandages are widely used after invasive treatment of varicose veins. The goals of compression after venous interventions are to reduce pain, bruising, and ecchymosis. Nevertheless, patients often report discomfort with the compression. To make postprocedural compression more tolerable, foot-sparing bandages were tested in a randomized clinical trial of noninferiority.

METHODS

A total of 187 patients were randomized to use class II foot-sparing compression sleeves for the full leg or class II stockings after radiofrequency ablation with concomitant phlebectomy. The primary endpoint was the quality of life, measured using the Chronic Venous Disease Quality of Life Questionnaire 20-item scale 30 days after intervention. The secondary endpoints were pain in the leg and discomfort related to the compression garment, which were assessed using the visual analog scale (VAS) at 2, 7, 14, and 30 days.

RESULTS

The global index score of the questionnaire was 66.1 and 70.6 and 83.8 and 87.7 for the sleeve and stocking groups before and 30 days after intervention, respectively (P = .542 and P = .150, respectively). The VAS for pain score in the operated leg was slightly higher in the sleeve group the day after the intervention (score, 2.1 vs 1.6; P = .03). At 7, 14, and 30 days, the VAS for pain scores did not differ significantly (score, 0.7 vs 0.5; 0.5 vs 0.3; and 0.1 vs 0.1, respectively; P = NS for all). The VAS for discomfort score was not significantly different statistically in the study group at 2 days (sleeve, 1.9; vs stocking, 1.4; P = .08) but was higher after 7 days (sleeve, 0.9; vs stocking, 0.6; P = .008). No difference in discomfort was found between the study and control groups at 14 or 30 days (sleeve, 0.6; vs stocking, 0.4; and sleeve, 0.4; vs stocking, 0.4, respectively; P = NS for both).

CONCLUSIONS

Quality of life after thermal ablation with phlebectomy improved equivalently in patients who had used class II compression sleeves for full legs and those who had used class II compression stockings. Pain and discomfort were slightly higher in the sleeve group.

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

PURPOSE

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

DESIGN

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Randomized Controlled Trial of Compression After Endovenous Thermal Ablation of Varicose Veins (COMETA Trial)

BACKGROUND

The 21st century has witnessed a rise in the use of endovenous thermal ablation. Being highly clinically and cost-effective and improving the quality of life of patients, they are now considered to be the "gold-standard" treatment for varicose veins. Post-intervention management, especially in terms of postoperative compression, however, remains unclear. As a result, a randomized study was undertaken to investigate the effects of wearing compression stockings after varicose vein treatment.

METHOD

Patients with saphenous vein reflux undergoing treatment with endothermal ablation (with or without concurrent phlebectomies) were randomized to receive either 7 days of compression stockings or no stockings. The primary outcome measure for this study was the pain score over the first 10 postoperative days. The pain scores, clinical score, time to return to normal activities, and ecchymosis were assessed. Patients were followed-up at 2 weeks and 6 months post-ablation.

RESULTS

In total, 206 patients were randomized, 49% of them to the compression group. The mean age was 49.7 (±16) years and approximately 51% of the population was male. The median pain score in the compression group using a visual analog scale was significantly lower on days 2-5, compared to the no compression group. Those having concurrent phlebectomies and compression stockings also had significantly better pain scores on days 1-3, day 5, and day 7. Improvement in the median venous clinical severity score was noted at 6-month follow-up, but this was not significant. No difference in the generic- or disease-specific quality of life was observed and the time to return to activities was similar. There were no differences in the degree of ecchymosis between the 2 groups and both groups had similar occlusion rates.

CONCLUSIONS

These results indicate that wearing compression stockings after endothermal ablation is advantageous in the first few days after treatment and is especially beneficial for those having concurrent phlebectomies.

Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment

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.

Thromboprophylaxis practice after outpatient endovenous thermal ablation

OBJECTIVE

The use of endovenous thermal ablation (ETA) for the treatment of truncal varicose veins has been increasing worldwide; however, uncertainty remains regarding the need for thromboprophylaxis and follow-up of patients undergoing this minimally invasive procedure. A nationwide survey of among physicians performing ETA was conducted to assess the thromboprophylaxis practice and follow-up protocols after ETA in Switzerland.

METHODS

A questionnaire was sent to all ETA-certified physicians (n = 193) in Switzerland. The survey covered procedure type, thromboprophylaxis (including pharmacologic and compression therapy), duplex ultrasound follow-up examinations, and the management of endovenous heat-induced thrombosis (EHIT).

RESULTS

Overall, 121 responses were received, for a response rate of 62.7%. Of the 121 respondents, 71 were vascular medicine specialists (58.7%) and 46 were general or vascular surgeons (38.0%), representing the two largest groups of specialists, followed by 2 dermatologists (1.7%) and 2 interventional radiologists (1.7%). Pharmacologic thromboprophylaxis after ETA was always used by 86 physicians (71.1%), nearly always by 8 (6.6%), frequently used by 5 (4.1%), rarely used by 21 (17.4%), and never by 1 physician (0.8%). A direct oral anticoagulant drug was the preferred type of thromboprophylaxis used by 92 physicians (77.3%). The first dose of thromboprophylaxis was mostly administered immediately after intervention by 53 physicians (53.7%). The duration of postablation thromboprophylaxis ranged from 1 to 21 days, with 7 to 10 days used by 57 physicians. Compression therapy was used by all physicians, with large variation in duration ranging from 1 to 42 days after a single ETA session and after ETA with concomitant phlebectomy. Postablation duplex ultrasonography was performed routinely by 120 respondents (99.2%), and 84 respondents (69.4%) performed two to three duplex ultrasound scans. Management of EHIT depended on the EHIT class and differed widely among the physicians.

CONCLUSIONS

Our nationwide survey on thromboprophylaxis practices after ETA of truncal varicose veins in Switzerland showed that most physicians use pharmacologic thromboprophylaxis, with a direct oral anticoagulant drug the preferred agent. However, the timing of the first dose and the duration of thromboprophylaxis varied widely among the respondents, reflecting the uncertainty in this domain owing to the absence of high-quality evidence-based guidelines.

Postsclerotherapy compression: A systematic review

BACKGROUND

Compression after sclerotherapy is commonly used, although the evidence base for this practice is unclear. This study aims to summarize and assess the evidence for compression therapy after sclerotherapy to inform clinical practice.

METHODS

A systematic review was performed according to PRISMA guidelines via Medline and EMBASE databases (1946 to December 31, 2019) by two reviewers. Full-text, English-language studies comparing compression type and/or duration in adult chronic venous disease patients undergoing liquid or foam sclerotherapy were included.

RESULTS

Nine studies were identified: five using liquid sclerotherapy, three foam sclerotherapy and one using both. Studies had short follow-up periods (6-24 weeks) and reported on clinical outcomes, quality of life, side effects and complications. In C1 patients undergoing liquid sclerotherapy, any duration of stocking use significantly decreased telangiectasia and reticular vein number and size compared with no compression. No significant difference in clinical symptoms or quality of life was seen when comparing compression duration after liquid or foam sclerotherapy in tributary or truncal veins in C2 to C6 patients. Greater superficial vein resolution was seen with stockings compared with bandages in C2 patients undergoing liquid sclerotherapy to tributary veins. A comparison of stockings vs bandaging revealed differing thrombophlebitis rates but no significant difference in pigmentation. In C2 to C6 patients undergoing foam sclerotherapy, use of 35 mm Hg stockings significantly improved post-treatment symptoms compared with 23 mm Hg stockings. This review was limited by heterogeneity of outcome measurements and the variety of comparisons between compression types and durations.

CONCLUSIONS

Postsclerotherapy compression may have beneficial clinical outcomes at short-term follow-up; however, evidence is lacking regarding its type, class, length, and duration. Further trials are required to guide the optimal management of postsclerotherapy patients.

Clinical outcome of short-term compression after sclerotherapy for telangiectatic varicose veins

BACKGROUND

Sclerotherapy is considered to be the method of choice for the treatment of telangiectatic varicose veins (C1 veins). Whereas the use of compression stockings after sclerotherapy is recommended, little is known about the impact of compression on the outcome of sclerotherapy. The aim of this study was to assess the influence of compression on the outcome of injection sclerotherapy of C1 varicose veins.

METHODS

There were 100 legs of 50 consecutive patients with chronic venous insufficiency (C1) included. After randomization per patient, both legs were treated with sclerotherapy in a predefined area of the thigh (measuring 100 cm²), followed by eccentric compression for 24 hours. Group A received no further compression, whereas group B was additionally equipped with compression stockings of 18 to 20 mm Hg above the ankle and continued wearing these for 1 week. Photodocumentation was performed before, 1 week after, and 4 weeks after sclerotherapy, and the clinical outcome was assessed at these postprocedure follow-up dates. The photographs were reviewed by an internal unblinded rater and an independent blinded external rater.

RESULTS

There was no discernible difference between the groups in terms of clinical outcome or side effects after 4 weeks. Whereas inter-rater reliability was high, there was no correlation between the raters and patients in terms of outcome. In 55% of the treated legs, the patients deemed the result of the treatment to be good; in 27% of the treated legs, fair; and in 18%, poor. Postprocedure hyperpigmentation occurred in 13% of patients and was comparable in both groups. Compression therapy was found to be comfortable by the majority (58%) of patients.

CONCLUSIONS

One week of postinterventional compression therapy had no clinical benefit compared with no compression.

Results of polidocanol endovenous microfoam in clinical practice

BACKGROUND

Initial phase III clinical studies with polidocanol endovenous microfoam (PEM) demonstrated its safety and efficacy in the treatment of superficial venous reflux. In those studies, the primary outcome requirement was to assess the improvement in symptoms related to superficial venous disease. The goal of the present study was to evaluate the efficacy of PEM technology in routine clinical practice-specifically, the closure rates after treatment.

METHODS

We performed an observational study during which data were prospectively collected from 2 vein centers using an electronic database. Patients with CEAP (clinical, etiologic, anatomic, pathophysiologic) class ≥2 and symptomatic superficial axial reflux (great saphenous vein, anterior accessory saphenous vein, and small saphenous vein) were included and followed up prospectively. PEM was used to treat the saphenous vein and varicosities. The CEAP classification was used to classify chronic venous disease, and the venous clinical severity score (VCSS) was applied to measure the disease severity. Pain and discomfort were assessed using a visual analog scale, and the residual veins were assessed by physical examination.

RESULTS

PEM was used to treat superficial reflux in 60 patients. The CEAP classification was C2 for 32 patients, C3 for 14, C4 for 10, and C5 for 4 patients. The average pretreatment VCSS was 7.3. The saphenous vein diameter was 6.5 mm, and the average length was 31 cm. The average volume of PEM used to treat the saphenous veins was 9.3 mL. The closure rate at 3 and 6 months was 93% (54 of 58) and 93% (51 of 55), respectively. The VCSS had improved from 7.3 to 1.4. Complications included 1 case of deep vein thrombosis (1.7%), 5 patients (8.3%) with thrombophlebitis, and 4 patients (6.6%) with skin pigmentation.

CONCLUSIONS

PEM is safe and effective for the treatment of saphenous reflux and varicosities. The early closure rates using PEM were maintained at 6 months and are comparable to the results reported with nonthermal, nontumescent technologies and thermal tumescent technologies.

[Evidence of compression therapy with special consideration of medical adaptive compression systems]

For several decades, compression therapy, which is associated with few side effects, has been a basis for the conservative treatment of patients with phlebological and lymphological diseases. For the practical implementation of compression therapy, many different materials are available, some with system-specific advantages and disadvantages. Medical adaptive compression systems (MAK) are still a relatively new treatment option in Germany. Apart from the very good practical experience in clinical everyday life, the compilation of the scientific evidence of compression therapy also shows that the scientific data situation is significantly better than for many other medical areas, especially for the treatment of patients with venous diseases. It is important to note that compression therapy must reliably guarantee adequate compression pressure. If these conditions are met, it can be assumed on the basis of the currently available data that the clinical effectiveness of the different compression systems is comparably good. These aspects have now also been well tested for MAK, so that these analogies can be drawn. Therapists today can therefore choose between different, very effective therapy options and take individual factors, patient wishes and economic aspects into account when making their selection.

Post-procedural Compression vs. No Compression After Radiofrequency Ablation and Concomitant Foam Sclerotherapy of Varicose Veins: A Randomised Controlled Non-inferiority Trial

OBJECTIVE

To compare post-operative compression with no compression, after radiofrequency endothermal ablation (RFA) of a truncal varicose vein and concomitant foam sclerotherapy of the tributaries.

METHODS

This prospective randomised controlled, non-inferiority trial recruited patients from two centres in Northern Ostrobothnia, Finland. Patients with clinical class C2-C4 chronic venous disease were randomised to receive no compression after the operation, or to receive compression stockings continuously for two days, and then, during the daytime for five days. In follow up visits, additional foam sclerotherapy was performed for symptoms of distal incompetence. Patients were followed up for six months. The primary outcome was occlusion of the RFA treated truncal vein at six months. Secondary outcomes were return to full activity within 14 days, Aberdeen Varicose Vein Questionnaire (AVVQ) score, post-operative pain, need for painkillers, and postprocedural complications.

RESULTS

Of 177 included patients, 90 were allocated to post-operative compression and 87 to no compression. At six months, both groups showed 100% occlusion rates in RFA treated truncal veins (95% confidence interval -0.043-0.042). Within 14 days of treatment, full physical activity was achieved by 87% of the compression group and 81% of the no compression group, (p = .29). At six months, the AVVQ scores were comparable and significantly improved in both groups, compared with baseline. Pain scores were comparable between groups, in day to day analyses, and they were significantly lower in both groups on day 10, compared with pre-operative pain caused by varicose veins. On average, post-operative pain medication was used for 2.3 days and for 2.8 days in the compression and no compression groups, respectively (p = .28). Complications throughout the six month follow up were comparable between groups, although skin rash/blisters occurred more often in the compression group (p = .01).

CONCLUSION

After treating C2-C4 varicose veins with RFA and concomitant foam sclerotherapy, no post-operative compression was non-inferior to post-operative compression, in terms of safety and efficacy. ClinicalTrials.gov Identifier: NCT02890563.

Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019

Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.