The 2022 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 I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology

Predicting lack of clinical improvement following varicose vein ablation using machine learning

OBJECTIVE

Varicose vein ablation is generally indicated in patients with active/healed venous ulcers. However, patient selection for intervention in individuals without venous ulcers is less clear. Tools that predict lack of clinical improvement (LCI) after vein ablation may help guide clinical decision-making but remain limited. We developed machine learning (ML) algorithms that predict 1-year LCI after varicose vein ablation.

METHODS

The Vascular Quality Initiative database was used to identify patients who underwent endovenous or surgical varicose vein treatment for Clinical-Etiological-Anatomical-Pathophysiological (CEAP) C2 to C4 disease between 2014 and 2024. We identified 226 predictive features (111 preoperative [demographic/clinical], 100 intraoperative [procedural], and 15 postoperative [immediate postoperative course/complications]). The primary outcome was 1-year LCI, defined as a preoperative VCSS, Venous Clinical Severity Score (VCSS) minus postoperative VCSS of ≤0, indicating no clinical improvement after vein ablation. The data were divided into training (70%) and test (30%) sets. Six ML models were trained using preoperative features with 10-fold cross-validation (Extreme Gradient Boosting [XGBoost], random forest, Naïve Bayes classifier, support vector machine, artificial neural network, and logistic regression). The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). The algorithm with the best performance was further trained using intraoperative and postoperative features. The focus was on preoperative features, whereas intraoperative and postoperative features were of secondary importance, because preoperative predictions offer the most potential to mitigate risk, such as deciding whether to proceed with intervention. Model calibration was assessed using calibration plots, and the accuracy of probabilistic predictions was evaluated with Brier scores. Performance was evaluated across subgroups based on age, sex, race, ethnicity, rurality, median Area Deprivation Index, prior ipsilateral varicose vein ablation, location of primary vein treated, and treatment type.

RESULTS

Overall, 33,924 patients underwent varicose vein treatment (30,602 endovenous [90.2%] and surgical 3322 [9.8%]) during the study period and 5619 (16.6%) experienced 1-year LCI. Patients who developed the primary outcome were older, more likely to be socioeconomically disadvantaged, and less likely to use compression therapy routinely. They also had less severe disease as characterized by lower preoperative VCSS, Varicose Vein Symptom Questionnaire scores, and CEAP classifications. The best preoperative prediction model was XGBoost, achieving an AUROC of 0.94 (95% confidence interval [CI], 0.93-0.95). In comparison, logistic regression had an AUROC of 0.71 (95% CI, 0.70-0.73). The XGBoost model had marginally improved performance at the intraoperative and postoperative stages, both achieving an AUROC of 0.97 (95% CI, 0.96-0.98). Calibration plots showed good agreement between predicted and observed event probabilities with Brier scores of 0.12 (preoperative), 0.11 (intraoperative), and 0.10 (postoperative). Of the top 10 predictors, 7 were preoperative features including VCSS, Varicose Vein Symptom Questionnaire score, CEAP classification, prior varicose vein ablation, thrombus in the greater saphenous vein, and reflux in the deep veins. Model performance remained robust across all subgroups.

CONCLUSIONS

We developed ML models that can accurately predict outcomes after endovenous and surgical varicose vein treatment for CEAP C2 to C4 disease, performing better than logistic regression. These algorithms have potential for important utility in guiding patient counseling and perioperative risk mitigation strategies to prevent LCI after varicose vein ablation.

Ultrasound-guided foam sclerotherapy using physician-compounded foam: Position statement from the American vein and lymphatic society

Background: Chronic venous disease has a major impact on the quality of life of millions of patients. Large randomized controlled trials have established ultrasound-guided foam sclerotherapy (UGFS) as a safe and effective treatment option for both saphenous vein insufficiency and tributary disease. Ultrasound guidance is a critical component of sclerotherapy of non-visible veins.Method: An expert panel of the American Vein and Lymphatic Society (AVLS) was convened to review the literature and write a Position Statement with recommendations for the use of UGFS with physician-compounded foam for patients with venous insufficiency.Result: Consensus recommendations from the expert panel highlight the advantages and safety of high-quality physician-compounded foam. These recommendations were reviewed, edited and approved by the Guidelines Committee of the AVLS.Conclusion: UGFS with in-office, physician-compounded foam is a safe primary treatment option for varicose, tributary, and truncal veins of the lower extremities and is an important adjunct therapy for tributary disease following or concomitant to endovenous ablation procedures.

Early experience managing intravascular coagulum using polidocanol endovenous microfoam: Risk factor analysis

OBJECTIVE

A single-center retrospective cohort study was conducted to identify potential risk factors that lead to increased incidence of intravascular coagulum (IC) observed in clinical practice using polidocanol endovenous microfoam (PEM 1%, VarithenaTM [polidocanol injectable microfoam], Boston Scientific, Marlborough, Mass).

METHODS

Patients (n = 119) who received polidocanol endovenous microfoam (PEM) treatment for chronic venous insufficiency between December 2021 and January 2024 at a private outpatient vascular surgery clinic were observed to identify potential risk factors in the development of IC. The patients were stratified into two groups: IC (n = 16) versus non-IC (n = 103). Patients who returned with increased pain and irritation at the treatment site in the early post ablation period within 2-6 weeks of treatment and had coagulum aspirated at the subsequent follow-up visit met the study criteria and were included in the IC group. In addition, patient demographics, comorbidities, and duplex ultrasound reports were analyzed using deidentified chart records.

RESULTS

There were 119 patients treated in the study period with a mean age of 62 years. Females were the most common sex 66% (n = 78) and Latinos represented the largest ethnicity 60% (n = 71). Overall, 13% (n = 16) of the patients developed an intravascular coagulum. The mean time to onset of IC was 45 days (range: 7-106 days) post-ablation. There was no difference between the groups (IC vs non-IC) for age, sex, ethnicity, or index VCSS scores. On univariate analysis, patients who developed IC had lower PEM injection volumes when compared to non-IC patients (4.1 vs 6.3 mL, p = .04). High reflux at the GSV (>1800 ms) and Latino ethnicity were also found to be significant risk factors. When these factors were evaluated in multivariate analysis, lower PEM injection volumes was the only factor that remained significant for the development of IC (p = .006).

CONCLUSION

Lower polidocanol endovenous microfoam injection volumes is a risk factor for developing intravascular coagulum. Further studies are needed to identify the ideal injection volume per segment of vein treated.

Venous Insufficiency: Wound Management

PURPOSE OF REVIEW

Venous leg ulcers (VLUs) are one of the most common forms of chronic wounds and with nearly half the people having recurrent episodes, this significantly impacts a patient's quality of life. As such, VLU is a chronic disease that requires lifelong maintenance and awareness. A correct diagnosis of VLU is essential for management.

RECENT FINDINGS

VLUs can be of mixed etiology and treatment should be aimed at optimizing the underlying venous hypertension based on its cause. If there is an anatomical venous reflux contributing to the non-healing of the VLU, early treatment of incompetent veins can improve healing rates. All aspects contributing to the patient's ongoing venous hypertension should be addressed to provide appropriate treatment. This can include venous interventions but also through conservative measures. Patient education and their engagement in their own care is essential for good outcomes.

Treatment of varicose great saphenous vein with endovenous laser alone or combined with eco-guided foam sclerotherapy: A randomized controlled trial

Objectives: This study compares Endovenous Laser Ablation (EVLA) alone versus combined with ultrasound-guided foam sclerotherapy (UGFS) for Great Saphenous Vein (GSV) insufficiency. Methods: Sixty patients were randomly allocated to EVLA or EVLA-UGFS groups which focused on GSV occlusion rates, complications, additional treatments, and quality of life (QoL) changes. Results: Among 55 participants, the EVLA group had higher 12-month occlusion rates (92.3% vs. 75.8%, p = 0.11). Nervous injury (NI) was rarer in EVLA-UGFS (3.4% vs. 23.1%, p = 0.04). No significant difference in other complication rates (p > 0.05). QoL improved in both groups (p < 0.001). EVLA-UGFS required more subsequent procedures (24.1% vs. 7.7%, p = 0.03). Conclusions: EVLA and EVLA-UGFS effectively treat GSV insufficiency, enhancing QoL. The combined method reduces NI risk but may require more follow-up procedures.

The role of the giacomini vein in preoperative mapping of lower limb varicose veins

Background

The Giacomini vein (GV) can transfer reflux from perineal veins, tributary veins, and perforators of the thigh to the small saphenous vein (SSV). Vascular ultrasound with Doppler (VUD) is the preferred method for detecting reflux in specific veins such as the GV.

Objective

To identify GV depth and diameter, reflux in the GV, and presence of reflux in the SSV caused by the GV.

Methods

A cross-sectional, retrospective study was conducted in women undergoing lower limb venous mapping for varicose vein surgery. The following parameters were analyzed in GVs in which reflux was detected: segmental or diffuse reflux pattern; GV diameter and depth; and reflux in the SSV caused by the GV.

Results

340 of the 2368 women evaluated were included in the study because they had a GV, totaling 511 veins analyzed, 150 (29.4%) of which had reflux. The diameters of the 150 GVs with reflux ranged from 1.5 to 7.8 mm and their depth varied from 4 to 25 mm. Most GVs with reflux (91.3%) had a segmental reflux pattern. The majority (66%) of refluxing GVs drained reflux into the popliteal vein through the saphenopopliteal junction, while reflux was transferred to the SSV in 34 veins (22.7%), and was drained by a tributary vein in the thigh in 15 veins (11.3%).

Conclusions

Approximately one-third of the studied GVs had reflux, mostly segmental, mean caliber was 2.7 mm, and mean depth was 11 mm. Reflux in the SSV originating from the GV was detected in 22% of the evaluated veins.

Reporting and Methodological Quality of Systematic Reviews Underpinning Clinical Practice Guidelines for Vascular Surgery: A Systematic Review

OBJECTIVE

Clinical practice guideline recommendations are often informed by systematic reviews. This review aimed to appraise the reporting and methodological quality of systematic reviews informing clinical practice recommendations relevant to vascular surgery.

DATA SOURCES

MEDLINE and Embase.

METHODS

MEDLINE and Embase were searched from 1 January 2021 to 5 May 2023 for clinical practice guidelines relevant to vascular surgery. Guidelines were then screened for systematic reviews informing recommendations. The reporting and methodological quality of these systematic reviews were assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement and Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) 2017 tool. Pearson correlation and multiple regression analyses were performed to determine associations between these scores and extracted study characteristics.

RESULTS

Eleven clinical practice guidelines were obtained, containing 1 783 references informing guideline recommendations. From these, 215 systematic reviews were included for synthesis. PRISMA item completeness ranged 14 - 100%, with a mean of 63% across reviews. AMSTAR 2 item completeness ranged 2 - 95%, with a mean of 50%. Pearson correlation highlighted a statistically significant association between a review's PRISMA and AMSTAR 2 score (r = 0.85, p < .001). A more recent publication year was associated with a statistically significant increase in both scores (PRISMA coefficient 1.28, p < .001; and AMSTAR 2 coefficient 1.31, p < .001). Similarly, the presence of funding in a systematic review was shown to be statistically significantly associated with an increase in both PRISMA and AMSTAR 2 scores (coefficient 4.93, p = .024; and coefficient 6.07, p = .019, respectively).

CONCLUSION

Systematic reviews informing clinical practice guidelines relevant to vascular surgery were of moderate quality at best. Organisations producing clinical practice guidelines should consider funding systematic reviews to improve the quality of their recommendations.

Comparative study on the effectiveness and safety of simultaneous and staged bilateral saphenous vein radiofrequency ablation

OBJECTIVE

Chronic venous insufficiency (CVI) is a common condition affecting more than one-half of the general population, with approximately 20% of cases being bilateral. The high prevalence, diagnosis, and treatment costs, along with the negative impact on patients' quality of life, underscore its significance. This study evaluates the clinical outcomes, quality-of-life effects, and postoperative complications of simultaneous and staged bilateral radiofrequency ablation (RFA) in patients with bilateral CVI in the great saphenous vein at Clinical, Etiological, Anatomical, Pathophysiological stages 2 to 4.

METHODS

This retrospective study included 433 patients with bilateral CVI in the great saphenous vein at Clinical, Etiological, Anatomical, Pathophysiological stages 2 to 4, treated with RFA between January 2018 and December 2022. Patients were classified into two groups: group 1 (n = 257) underwent simultaneous bilateral RFA, and group 2 (n = 176) underwent staged bilateral RFA. Clinical outcomes and quality of life effects were evaluated using Venous Clinical Severity Score, Aberdeen Varicose Vein Questionnaire, and visual analog scale scores. Demographic data, type of anesthesia, surgery durations, and postoperative complications were analyzed.

RESULTS

Both groups showed significant improvements in Aberdeen Varicose Vein Questionnaire and Venous Clinical Severity Score scores at 12 months postoperatively, with no significant differences between the groups in preoperative and postoperative scores. No significant difference was found in postoperative visual analog scale scores. Postoperative complication rates were low and comparable. No pulmonary embolism was observed. Symptomatic deep vein thrombosis was detected in one patient from each group and treated successfully.

CONCLUSIONS

Simultaneous bilateral RFA is as effective and safe as staged bilateral RFA for treating CVI, providing similar clinical outcomes and low complication rates. The simultaneous approach offers the advantage of a single treatment session, potentially improving patient satisfaction and operational efficiency. This study supports simultaneous bilateral RFA as a viable and effective option for treating bilateral CVI.

Chronic Venous Insufficiency Evaluation and Medical Management

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Clinical outcomes after treatment of incompetent saphenous vein combined with segmental popliteal vein reflux

OBJECTIVE

This study aimed to evaluate whether differences exist in the quality of life changes and complication rates after treatment of incompetent saphenous vein (ISV) based on the presence of segmental popliteal vein reflux (SPVR).

METHODS

Patients who underwent treatment for ISV from July 2016 to July 2021 were included and divided into two groups: patients without deep venous reflux (DVR) and patients with SPVR. Patients with axial DVR, a history of deep vein thrombosis, a history of orthopedic surgery, previous venous treatment, and no postoperative follow-up were excluded from the study. Duplex ultrasound examination was performed preoperatively and at 6 and 12 months postoperatively.

RESULTS

The study included 233 patients (398 limbs), and 50 (64 limbs) had SPVR. Differences were not observed in gender, age, body mass index, distribution of clinical class according to Clinical-Etiology-Anatomy-Physiology classification, laterality, treatment method, and preoperative Venous Clinical Severity Score or Aberdeen Varicose Vein Questionnaire scores between the two groups with SPVR or without DVR. Furthermore, the Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire scores at 6 and 12 months postoperatively were improved in both groups, although without significant differences. A significant difference was not observed in the rate of postoperative complications between the groups based on the presence of SPVR (1.8% vs 1.6%: P = .896). The SPVR improvement rate after ISV treatment was 25% (16/64), and patient-reported outcomes in patients combined with SPVR improved independent of treatment modality, saphenous vein treatment section, and postoperative SPVR improvement.

CONCLUSIONS

Complication rates and clinical outcomes after ISV treatment did not differ in the presence of SPVR. In patients with SPVR, after ISV treatment, quality of life improved regardless of treatment modality, saphenous vein treatment section, and postoperative SPVR improvement.

The sex prevalence of lower limb varicose vein networks

OBJECTIVE

To determine the sex prevalence of lower limb varicose networks fed by reflux of the great saphenous vein (GSV), anterior accessory saphenous vein (AASV), and small saphenous vein singularly or in combination.

METHODS

We scanned by the means of the same color Doppler ultrasound protocol 3000 lower limbs in 1500 consecutive patients, affected by symptomatic chronic venous insufficiency from 2013 to 2023. Limbs with normal venous function, incomplete scans, or that were affected by post-thrombotic syndrome, pelvic reflux, isolated perforator reflux, venous malformation, phlebolymphedema and Clinical, Etiological, Anatomical, Pathophysiological clinical class C5 and C6 were excluded from the final analysis.

RESULTS

Overall, 1072 patients-252 (23.5%) males and 820 (76.5%) females (P < .0001) matched for age (P = .692)-were included in the study for a total of 1956 limbs affected by primary chronic venous insufficiency, clinical class C2 to C4. The main finding was the significant prevalence of varicose networks fed by reflux of the AASV alone (odds ratio [OR], 1.96; 95% confidence interval [CI], 1.26-3.06; P = .001) or combined with GSV (OR, 1.84; 95% CI, 1.34-2.52; P = .0002) in females. In contrast, GSV insufficiency alone was significantly prevalent in males (OR, 0.54; 95% CI, 0.43-0.68; P < .0001). No significant sex differences regarding SSV reflux were detected. Moreover, we considered the presence of competent terminal valve (TV+) at the level of the saphenofemoral junction, which resulted more significantly present in female (OR, 1.57; 95% CI, 1.12-2.19; P = .0083); to the contrary incompetent terminal valve (TV-) was more common in males (OR, 0.64; 95% CI, 0.46-0.89; P = .0083). Finally, considering reflux in the AASV territory in the presence of a TV+, a strong prevalence in females was detected (OR, 2.28; 95% CI, 1.48-3.52; P = .0002), whereas males developed reflux along the GSV when a concomitant TV- was present (OR, 0.62; 95% CI, 0.41-0.94; P = .0244).

CONCLUSIONS

The analysis of the lower limb varicose networks highlights that reflux along the AASV alone, in presence of a TV+ at the junction or coupled with GSV insufficiency, is more prevalent in females. In contrast, GSV resulted the main trunk feeding varicose veins in males, in particular when a TV- was detected. Our findings suggest that females could be more prone to developing varicose veins with an ascending mechanism, whereas in males the descending one seems to be more common.

Analysis of computed tomography venography for the diagnosis and endovascular treatment of iliac venous compression syndrome with venous leg ulcers: a retrospective study

Iliac vein compression syndrome (IVCS) is a clinical condition defined as obstruction of the iliac vein caused by chronic compression imposed by various causes. Currently, the clinical role of computed tomography venography (CTV) in the diagnosis of IVCS is unclear. Accurately diagnosing IVCS using CTV may enhance the understanding of the pathological anatomy of iliac veins, which may lead to better treatment outcomes, especially for recalcitrant venous leg ulcers (VLU). We aimed to investigate diagnostic criteria, contributing clinical factors, and stenting for IVCS with VLU in this study. CTV, digital subtraction angiography (DSV), and Doppler ultrasound (DUS) data were obtained from the medical and imaging records of 62 patients. Additionally, contributing factors and stenting for IVCS were analysed. Patients (100%) had clinical, aetiological, anatomic, or pathological C6 disease. CTV reduced the procedure time and contrast medium dose and provided more information than DSV. Risk factors for IVCS with VLU included female sex (P = 0.036) and advanced age (P = 0.014). The rate of ulcer healing was lower in the IVCS group without stent implantation (P = 0.020). Significant improvements were noted in venous clinical severity scores (P < 0.001) and chronic venous insufficiency questionnaire-20 scores (P < 0.001) after stenting for IVCS with C6 ulcers. CTV provides a more accurate diagnosis than DUS and DSV and allows detection of possible causes of IVCS. Female sex and advanced age were potential contributing factors for IVCS. Satisfactory outcomes were observed with stenting in the treatment of IVCS with C6 ulcers.

Safety and efficacy of endovenous microwave ablation for treatment of varicose veins of the lower limbs in China: A prospective registered clinical trial

OBJECTIVE

This study aimed to investigate the safety and efficacy of a new Chinese device using microwave ablation for treating symptomatic great saphenous vein (GSV) varicose veins (VVs).

METHODS

This prospective, single-arm, single-center, cohort study investigated the safety and efficacy of endovenous microwave ablation for the treatment of symptomatic VVs. A total of 50 patients with lower limb varicose veins were enrolled from the Hospital of Chengdu University of Traditional Chinese Medicine. The clinical outcomes and complications were assessed at 1, 6, and 12 months after the procedure. The primary outcome was the occlusion rate of GSV immediately and at 1, 6, and 12 months after the treatment. The secondary outcomes included the venous clinical severity score (VCSS), the chronic venous insufficiency questionnaire 14 items (CIVIQ-14) score, the Aberdeen varicose vein questionnaire (AVVQ) score, and the pain visual analog scale (VAS) score. This study protocol was registered at ClinicalTrials.gov (ID: NCT04645771).

RESULTS

In total, 50 limbs from 50 patients (26 female; mean age: 53.45 ± 9.78 years) were treated. A technical success rate of 100% was achieved and no serious adverse events were recorded. During the follow-up period, the occlusion rate of the major/minor saphenous vein trunk remained 100% at 1, 6, and 12 months after surgery except one patient fell off. The median 24-h VAS value was 2 (2,3). The VCSS score, CIVIQ-14 score, and AVVQ score (p < .05) at 1, 6, and 12 months improved significantly compared with the value preoperative (p < .05).

CONCLUSION

EMA was safe and effective for treating varicose veins in the lower limbs, with a high rate of venous trunk occlusion and few complications, thus improving patients' postoperative quality of life.

Mechanochemical chemically assisted ablation of varicose veins for venous insufficiency: American vein and lymphatic society position statement

Background: Mechanical occlusion chemically assisted ablation (MOCA) of incompetent saphenous veins has been utilized since its FDA approval in 2008. However, only recently have longer-term three and 5 year clinical follow up data become available. This updated information necessitates a societal update to guide treatment and ensure optimal patient outcomes. Method: The American Vein and Lymphatic Society convened an expert panel to write a Position Statement with explanations and recommendations for the appropriate use of MOCA for patients with venous insufficiency. Result: This Position Statement was produced by the expert panel with recommendations for appropriate use, treatment technique, outcomes review, and potential adverse events. These recommendations were reviewed, edited, and approved by the Guidelines Committee of the Society. Conclusions: MOCA is effective in alleviating symptoms and a safe treatment option for venous insufficiency. It obviates the need for tumescent anesthesia, has less procedural discomfort and lower risk of thermal nerve or skin injury. It may be used in both the below knee distal GSV as well as the SSV. However, it is associated with significantly lower rates of vessel closure and higher recanalization rates compared to both RFA and EVLA and is less cost effective than thermal techniques. It is an available option for those in whom thermal ablation is not suitable.

Comparison of one-year outcomes and quality of life between radiofrequency ablation and microwave ablation in the treatment of lower extremity varicose veins: A retrospective cohort study

OBJECTIVE

This study compared the outcomes of radiofrequency ablation (RFA) and microwave ablation (EMA) for treating lower limb varicose veins.

METHODS

Patients who underwent RFA (n = 240) or EMA (n = 209) at our institute from December 2020 to August 2022 were included in this retrospective investigation. Follow-up outcomes included active vein occlusion rate, Venous Clinical Severity Score (VCSS), the Aberdeen Varicose Vein Questionnaire (AVVQ), and Chronic Insufficiency Venous Quality of Life questionnaire-14 (CIVIQ-14)score.

RESULTS

There was no significant difference in the active vein occlusion rate between the two groups after the operation (p > .05). Compared to pre-surgery scores, both groups showed substantial improvement in VCSS, AVVQ, and CIVIQ-14 scores(p < .05), there was no significant difference in these scores in either group (p > .05).

CONCLUSION

Intravenous radiofrequency and microwave ablation effectively improve the quality of life for patients with lower limb varicose veins, with low post-operative complication and recurrence rates.

Superficial Venous Disease-An Updated Review

BACKGROUND

This review article provides an updated review of a relatively common pathology with various manifestations. Superficial venous diseases (SVDs) are a broad spectrum of venous vascular disease that predominantly affects the body's lower extremities. The most serious manifestation of this disease includes varicose veins, chronic venous insufficiency, stasis dermatitis, venous ulcers, superficial venous thrombosis, reticular veins, and spider telangiectasias.

METHODS

The anatomy, pathophysiology, and risk factors of SVD were discussed during this review. The risk factors for developing SVD were related to race, age, sex, lifestyle, and certain genetic conditions as well as comorbid deep vein thrombosis. Various classification systems were listed, focusing on the most common one-the revised Clinical-Etiology-Anatomy-Pathophysiology classification. The clinical features including history and physical examination findings elicited in SVD were outlined.

RESULTS

Imaging modalities utilized in SVD were highlighted. Duplex ultrasound is the first line in evaluating SVD but magnetic resonance imaging and computed tomography venography, plethysmography, and conventional venography are feasible options in the event of an ambiguous venous duplex ultrasound study. Treatment options highlighted in this review ranged from conservative treatment with compression stockings, which could be primary or adjunctive to pharmacologic topical and systemic agents such as azelaic acid, diuretics, plant extracts, medical foods, nonsteroidal anti-inflammatory drugs, anticoagulants and skin substitutes for different stages of SVD. Interventional treatment modalities include thermal ablative techniques like radiofrequency ablationss, endovenous laser ablation, endovenous steam ablation, and endovenous microwave ablation as well as nonthermal strategies such as the Varithena (polidocanol microfoam) sclerotherapy, VenaSeal (cyanoacrylate) ablation, and Endovenous mechanochemical ablation. Surgical treatments are also available and include debridement, vein ligation, stripping, and skin grafting.

CONCLUSIONS

SVDs are prevalent and have varied manifestations predominantly in the lower extremities. Several studies highlight the growing clinical and financial burden of these diseases. This review provides an update on the pathophysiology, classification, clinical features, and imaging findings as well as the conservative, pharmacological, and interventional treatment options indicated for different SVD pathologies. It aims to expedite the timely deployment of therapies geared toward reducing the significant morbidity associated with SVD especially varicose veins, venous ulcers, and venous insufficiency, to improve the quality of life of these patients and prevent complications.

Risk factors for recanalization of truncal veins following endoluminal ablation

BACKGROUND

Recanalization of target veins after treatment of superficial venous incompetence has clinical implications and may depend on the type of intervention. The aim of this study was to evaluate patient and procedural factors associated with truncal vein recanalization in a large study cohort using the Vascular Quality Initiative (VQI) Varicose Vein Registry.

METHODS

We performed a retrospective review using the VQI Varicose Vein Registry from 2014 to 2018. We evaluated all procedures performed for truncal venous insufficiency. Demographic data and information about treatment modality were collected. Patients were separated into recanalization and nonrecanalization groups based on the status of the treated vein at follow-up ultrasound examination. The vein was only considered recanalized if the VQI noted complete recanalization of the target vein. Univariate and multivariate comparisons were performed as appropriate.

RESULTS

A total of 10,604 procedures were performed in 7403 patients. The average age was 55.9 years and 70.3% of the patients were female. Patients with recanalization were more likely to have a history of phlebitis (P < .001) and had a higher mean body mass index (30.5 vs 32., kg/m2 ; P = .006) compared with those without recanalization. There was no difference in the use of compression therapy, anticoagulation, deep venous reflux, number of pregnancies, prior deep vein thrombosis, Venous Clinical Severity Score, and clinical-etiology-anatomy-pathophysiology between patients with and without recanalization. The number of truncal veins treated per procedure was higher in the recanalization group compared with the nonrecanalization group (2.36 vs 1.88; P = .001). After multivariate logistic regression, laser ablation was associated with higher rate of recanalization compared with radiofrequency ablation (P = .017).

CONCLUSIONS

This study is the first to use VQI based data to describe risk factors for recanalization following treatment of truncal venous reflux. The use of laser ablation for truncal veins is associated with a higher risk for recanalization compared with radiofrequency ablation. Obesity, prior phlebitis, and number of veins treated were independently associated with increased rate of recanalization.

Strategies to reduce rates of severe endothermal heat-induced thrombosis following radiofrequency ablation

OBJECTIVE

Endothermal heat-induced thrombosis (EHIT) is a potential complication of radiofrequency ablation (RFA). Data on effective prophylaxis of EHIT are limited. In 2018, a high-volume, single institution implemented strategies to decrease the incidence of EHIT, including a single periprocedural prophylactic dose of low-molecular-weight heparin to patients with a great saphenous vein (GSV) diameter of ≥8 mm or saphenofemoral junction (SFJ) diameter of ≥10 mm and limiting treatment to one vein per procedure. The size threshold was derived from existing literature. The study objective was to evaluate the effects of these institutional changes on thrombotic complication rates after RFA.

METHODS

A retrospective cohort control study was conducted using the Vascular Quality Initiative database. Data were collected for patients who underwent RFA with a GSV diameter of ≥8 mm or SFJ diameter of ≥10 mm from January 2015 to July 2022. The clinical end points were thrombotic complications (ie, thrombophlebitis, EHIT, deep vein thrombosis) and bleeding complications. Patient demographic and procedural variables were included in the analysis, and significant variables after univariable logistic regression were included in a multivariable logistic regression.

RESULTS

After the policy change, the overall vein center EHIT rate decreased from 2.6% to 1.5%, with a trend toward significance (P = .096). The inclusion criterion of a GSV diameter of ≥8 mm or an SFJ diameter of ≥10 mm yielded 845 patients, of whom 298 were treated before the policy change and 547 after. There was a significant reduction in the rate of EHIT classified as class ≥III (2.34 vs 0.366; P = .020) after the institutional changes. Treatment of two or more veins and an increased vein diameter were associated with an increased risk of EHIT (P = .049 and P < .001, respectively). No significant association was found between periprocedural anticoagulation and all-cause thrombotic complications or EHIT (P = .563 and P = .885, respectively).

CONCLUSIONS

The institutional policy changes have led to lower rates of EHIT, with a reduction in severe EHIT rates in patients with an ≥8-mm diameter GSV or a ≥10-mm diameter SFJ treated with RFA. Of the changes implemented, restricting treatment to one vein was associated with a reduction in severe EHIT. No association was found with periprocedural low-molecular-weight heparin, although a type 2 error might have occurred. Alternative strategies to prevent thrombotic complications should be explored, such as increasing the dosage and duration of periprocedural anticoagulation, antiplatelet use, and nonpharmacologic strategies.

Factors associated with lack of clinical improvement after vein ablation in the vascular quality initiative

BACKGROUND

Insurance companies have adopted variable and inconsistent approval criteria for chronic venous disease (CVD) treatment. Although vein ablation (VA) is accepted as the standard of care for venous ulcers, the treatment criteria for patients with milder forms of CVD remain controversial. This study aims to identify factors associated with a lack of clinical improvement (LCI) in patients with less severe CVD without ulceration undergoing VA to improve patient selection for treatment.

METHODS

We performed a retrospective analysis of patients undergoing VA for CEAP C2 to C4 disease in the Vascular Quality Initiative varicose veins database from 2014 to 2023. Patients who required intervention in multiple veins, had undergone prior interventions, or presented with CEAP C5 to C6 disease were excluded. The difference (Δ) in venous clinical severity score (VCSS; VCSS before minus after the procedure) was used to categorize the patients. Patients with a ΔVCSS of ≤0 were defined as having LCI after VA, and patients with ≥1 point decrease in the VCSS after VA (ΔVCSS ≥1) as having some benefit from the procedure and, therefore, "clinical improvement." The characteristics of both groups were compared, and multivariable regression analysis was performed to identify factors independently associated with LCI. A second analysis was performed based on the VVSymQ instrument, which measures patient-reported outcomes using five specific symptoms (ie, heaviness, achiness, swelling, throbbing pain, and itching). Patients with LCI showed no improvement in any of the five symptoms, and those with clinical improvement had a decrease in severity of at least one symptom.

RESULTS

A total of 3544 patients underwent initial treatment of CVD with a single VA. Of the 3544 patients, 2607 had VCSSs available before and after VA, and 420 (16.1%) had LCI based on the ΔVCSS. Patients with LCI were more likely to be significantly older and African American and have CEAP C2 disease compared with patients with clinical improvement. Patients with clinical improvement were more likely to have reported using compression stockings before treatment. The vein diameters were not different between the two groups. The incidence of complications was overall low, with minor differences between the two groups. However, the patients with LCI were significantly more likely to have symptoms after intervention than those with improvement. Patients with LCI were more likely to have technical failure, defined as vein recanalization. On multivariable regression, age (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00-1.02) and obesity (OR, 1.47; 95% CI, 1.09-2.00) were independently associated with LCI, as was treatment of less severe disease (CEAP C2; OR, 1.82; 95% CI, 1.30-2.56) compared with more advanced disease (C4). The lack of compression therapy before intervention was also associated with LCI (OR, 6.05; 95% CI, 4.30-8.56). The analysis based on the VVSymQ showed similar results.

CONCLUSIONS

LCI after VA is associated with treating patients with a lower CEAP class (C2 vs C4) and a lack of compression therapy before intervention. Importantly, no significant association between vein size and clinical improvement was observed.

Application of the ankle pump method in a sitting position to evaluate calf perforating veins by color Doppler ultrasound

OBJECTIVE

We investigated the feasibility and efficacy of assessing calf perforating veins (PVs) using the ankle pump in a sitting position (AP-sit) method by color Doppler ultrasound.

METHODS

We performed a multicenter prospective clinical trial between November 2022 and October 2023. Eligible patients with chronic venous disease and healthy controls were enrolled. The calf PVs were assessed using three different methods: manual compression in a standing position, manual compression in a sitting position, and AP-sit method. The reflux durations and detection rate of incompetent PVs (IPVs) were compared among the three methods. The number and diameter of calf PVs and distribution of IPVs were analyzed.

RESULTS

A total of 50 patients with chronic venous disease and 50 healthy controls were included. There were 173 calves analyzed, including 97 healthy calves and 76 calves with chronic venous disease. The number of PVs per calf was higher in the diseased calves (median, 7.0; interquartile range [IQR], 6.0-8.0) than in the healthy calves (median, 5.0; IQR, 3.0-6.0; P < .001). The diameter of IPVs (median, 2.3 mm; IQR, 2.0-3.1 mm) was larger than that of competent PVs (median, 1.4 mm; IQR, 1.2-1.7 mm). Most of the IPVs (78.8%) were located in the medial and posterior middle of the calf. The reflux duration induced by the AP-sit method was greater than that induced by the manual compression methods (P < .001). Although the AP-sit method had a higher detection rate (92.0%) of IPVs than the manual compression methods (71.7% and 74.3% for standing and sitting, respectively; P < .001), especially in the distal lower leg, the manual compression methods found IPVs not found using the AP-sit method.

CONCLUSIONS

Diseased calves with chronic venous disease have more PVs than do healthy calves. IPVs are commonly larger than competent PVs, with most IPVs located in the medial and posterior middle of the calf. Most importantly, the AP-sit method provides a convenient and effective approach for assessing the calf PVs, especially those located in the distal calf, as an alternative or complementary method to traditional manual compression, which is valuable in the daily practice of sonographers.

Venous ablation procedures by provider type, including advanced practice providers

OBJECTIVE

The necessary training and certification of providers performing venous ablation has become a topic of debate in recent years. As venous interventions have shifted away from the hospital, the diversity of provider backgrounds has increased. We aimed to characterize superficial venous ablation practice patterns associated with different provider types.

METHODS

We analyzed Medicare Fee-For-Service data from 2010 through 2018. Procedures were identified by their Current Procedural Terminology code and included radiofrequency ablation, endovenous laser ablation, chemical adhesive ablation (ie, VenaSeal; Medtronic, Inc), and mechanochemical ablation. These procedures were correlated with the practitioner type to identify provider-specific trends.

RESULTS

Between 2010 and 2018, the number of ablation procedures increased by 107% from 114,197 to 236,558 per year (P < .001). Most procedures were performed by surgeons without vascular board certification (28.7%; 95% confidence interval [CI], 28.7%-28.8%), followed by vascular surgeons (27.1%; 95% CI, 27.0%-27.2%). Traditionally noninterventional specialties, which exclude surgeons, cardiologists, and interventional radiologists, accounted for 14.1% (95% CI, 14.1%-14.2%), and APPs accounted for 3.5% (95% CI, 3.4%-3.5%) of all ablation procedures during the study period. The total number of ablations increased by 9.7% annually (95% CI, 9.7%-9.8%), whereas procedures performed by APPs increased by 62.0% annually (95% CI, 61.6%-62.4%). There were significant differences between specialties in the use of nonthermal ablation modalities: APPs had the highest affinity for nonthermal ablation (odds ratio [OR], 2.60; 95% CI, 2.51-2.69). Cardiologists were also more likely to use nonthermal ablation (OR, 1.62; 95% CI, 1.59-1.66). Similarly, the uptake of new nonthermal technology (ie, chemical adhesives) was greatest among APPs (OR, 3.57; 95% CI, 3.43-3.70) and cardiologists (OR, 1.86; 95% CI, 1.81-1.91). Vascular surgeons were less likely to use nonthermal modalities (OR, 0.95; 95% CI, 0.92-0.97), including new nonthermal technology in the first year of availability (OR, 0.93; 95% CI, 0.90-0.95).

CONCLUSIONS

The use of venous procedures has increased rapidly during the past decade, particularly as endovenous ablations have been performed by a wider practitioner base, including APPs and noninterventionalists. Practice patterns differ by provider type, with APPs and cardiologists skewing more toward nonthermal modalities, including more rapid uptake of new nonthermal technology. Provider-specific biases for specific ablation modalities might reflect differences in training, skill set, the need for capital equipment, clinical privileges, or reimbursement. These data could help to inform training paradigms, the allocation of resources, and evaluation of appropriateness in a real-world setting.

The anterior saphenous vein. Part 4. Clinical and technical considerations in treatment. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology

BACKGROUND

The decision to treat a refluxing anterior saphenous vein (ASV) should be a clinical decision based on the assessment on the ASV's contribution to patient's signs and symptoms. Once the decision to treat has been made, there are anatomic, clinical, and technical considerations in treatment planning.

METHODS

Clinical scenarios were discussed by a panel of experts and common anatomic, clinical, and technical considerations were identified.

RESULTS

There are unique clinical considerations such as whether both the great saphenous vein (GSV) and ASV should be concomitantly treated, if a normal ASV should be treated when treating a refluxing GSV and when and how to treat the associated tributary varicose tributaries. Being aware of the anatomic, clinical, and technical considerations allows development of a treatment plan that optimizes long-term outcomes in patients with ASV reflux.

CONCLUSION

Ultimately the treatment plan should be tailored to address these types of variables in a patient-centered discussion.

The anterior saphenous vein. Part 4. Clinical and technical considerations in treatment. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology

BACKGROUND

The decision to treat a refluxing anterior saphenous vein (ASV) should be a clinical decision based on the assessment on the ASV's contribution to patient's signs and symptoms. Once the decision to treat has been made, there are anatomic, clinical, and technical considerations in treatment planning.

METHODS

Clinical scenarios were discussed by a panel of experts and common anatomic, clinical, and technical considerations were identified.

RESULTS

There are unique clinical considerations such as whether both the great saphenous vein (GSV) and ASV should be concomitantly treated, if a normal ASV should be treated when treating a refluxing GSV and when and how to treat the associated tributary varicose tributaries. Being aware of the anatomic, clinical, and technical considerations allows development of a treatment plan that optimizes long-term outcomes in patients with ASV reflux.

CONCLUSIONS

Ultimately the treatment plan should be tailored to address these types of variables in a patient-centered discussion.

Current practice of cyanoacrylate endovenous ablation: American vein and lymphatic society position statement

BACKGROUND

Cyanoacrylate endovenous ablation and closure of incompetent saphenous veins have become increasingly utilized since its approval for use in the United States in 2015. This increase in usage necessitates a societal update to guide treatment and ensure optimal and consistent patient outcomes.

METHOD

The American Vein and Lymphatic Society convened an expert panel to write an updated Position Statement with explanations and recommendations for the appropriate use of cyanoacrylate endovenous ablation for patients with venous insufficiency.

RESULT

A Position Statement was produced by the expert panel with recommendations for appropriate use, treatment technique, outcomes review, and potential adverse events. Their recommendations were reviewed, edited, and approved by the Guidelines Committee of the Society.

CONCLUSION

This societal Position Statement provides a useful document for reference for physicians and venous specialists to assist in the appropriate use of cyanoacrylate endovenous ablation in the treatment of patients with venous insufficiency.

Editor's Choice - Short Term Cost Effectiveness of Radiofrequency Ablation and High Ligation and Stripping for Great Saphenous Vein Incompetence

OBJECTIVE

Superficial venous incompetence (SVI) is a common disease that causes significant quality of life (QoL) impairment. There is a need for more health economic evaluations of SVI treatment. The aim of this study was to perform a cost effectiveness analysis in patients with great saphenous vein (GSV) incompetence comparing radiofrequency ablation (RFA), high ligation and stripping (HL/S), and no treatment or conservative treatment with one year follow up.

METHODS

Randomised controlled trial economic analysis from an ongoing trial; 143 patients (156 limbs) with GSV incompetence (CEAP clinical class 2 - 6) were included. Treatment was performed with RFA or HL/S. Follow up was performed up to one year using duplex ultrasound, revised venous clinical severity score (r-VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ), and EuroQol-5D-3L (EQ-5D-3L).

RESULTS

Seventy-eight limbs were treated with RFA and HL/S respectively. No treatment or conservative treatment was assumed to have zero in treatment cost and no treatment benefit. In the RFA group, one limb had reflux in the GSV after one month and three limbs after one year. In HL/S, two limbs had remaining reflux in the treated area at one month and one year. Both disease severity (r-VCSS, p = .004) and QoL (AVVQ, p = .021 and EQ-5D-3L, p = .028) were significantly improved over time. The QALY gain was 0.21 for RFA and 0.17 for HL/S. The cost per patient was calculated as €1 292 for RFA and €2 303 for HL/S. The cost per QALY (compared with no treatment or conservative treatment) was €6 155 for RFA and €13 549 for HL/S. With added cost for days absent from work the cost per QALY was €7 358 for RFA and €24 197 for HL/S. The cost per QALY for both methods was well below the threshold suggested by Swedish National Board of Health.

CONCLUSION

RFA is more cost effective than HL/S and no treatment or conservative treatment at one year follow up.

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.

A prognostic nomogram for recurrence survival in post-surgical patients with varicose veins of the lower extremities

Varicose veins of the lower extremities (VVLEs) are prevalent globally. This study aims to identify prognostic factors and develop a prediction model for recurrence survival (RS) in VVLEs patients after surgery. A retrospective analysis of VVLEs patients from the Third Hospital of Nanchang was conducted between April 2017 and March 2022. A LASSO (Least Absolute Shrinkage and Selection Operator) regression model pinpointed significant recurrence predictors, culminating in a prognostic nomogram. The model's performance was evaluated by C-index, receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). The LASSO regression identified seven predictors for the nomogram predicting 1-, 2-, and 5-year RS. These predictors were age, body mass index (BMI), hypertension, diabetes, the Clinical Etiological Anatomical Pathophysiological (CEAP) grade, iliac vein compression syndrome (IVCS), and postoperative compression stocking duration (PCSD). The nomogram's C-index was 0.716, with AUCs (Area Under the Curve scores) of 0.705, 0.725, and 0.758 for 1-, 2-, and 5-year RS, respectively. Calibration and decision curve analyses validated the model's predictive accuracy and clinical utility. Kaplan-Meier analysis distinguished between low and high-risk groups with significant prognostic differences (P < 0.05). This study has successfully developed and validated a nomogram for predicting RS in patients with VVLEs after surgery, enhancing personalized care and informing clinical decision-making.

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

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

Early versus deferred endovenous sclerotherapy of superficial venous reflux in patients with venous ulceration

This study aimed to compare early endovenous sclerotherapy with superficial venous reflux combined with compression therapy and deferred intervention in patients with venous leg ulcers (VLUs). A total of 80 patients with 80 VLUs treated at the Department of General Surgery, Shangjin Nanfu Hospital, Chengdu, China, between February 2022 and January 2023 were included in the study. The primary outcome was the time to ulcer healing from the date of compression therapy or endovenous sclerotherapy. Secondary outcome measures were the rate of ulcer healing at 6 months, the rate of ulcer recurrence at 6 months, and patient-reported health-related quality of life. A total of 54 patients received early intervention and 26 received deferred intervention. The patient and clinical characteristics at baseline were similar between the two treatment groups. The median time to ulcer healing was 1.5 months (95% confidence interval [CI], 1.3-1.7 months) in the early-intervention group and 3.5 months (95% CI, 2.9-4.1 months) in the deferred-intervention group. The time to ulcer healing was shorter in the early-intervention group than in the deferred-intervention group (p < 0.001). The rate of ulcer healing at 6 months was 94% in the early-intervention group and 92% in the deferred-intervention group. The rate of ulcer recurrence before the end of the 6-month follow-up period was 2% in the early-intervention group and 4% in the deferred-intervention group. In conclusion, early endovenous sclerotherapy for superficial venous reflux resulted in faster healing of VLUs than deferred endovenous sclerotherapy.

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.

Radiofrequency venous ablation for symptomatic relief in postural orthostatic tachycardia syndrome: a case series

Background

Hypovolemic postural orthostatic tachycardia syndrome (POTS) is thought to be caused by dysregulated circulating blood volume. Management is mainly limited to symptom-targeted lifestyle changes. Radiofrequency venous ablation (RFA) represents a minimally invasive method of increasing circulating blood volume. The following case series describes a novel application of RFA to successfully target POTS symptoms in patients demonstrating venous insufficiency. The use of RFA in alleviating POTS symptoms has not previously been reported.

Case summary

We describe four patients with either a well-established historical POTS diagnosis or dysautonomia symptoms refractory to both medical management and lifestyle modifications. They all demonstrated venous reflux on lower extremity venous ultrasound testing. Upon vascular surgery referral, all underwent great and small saphenous vein RFA. They each subsequently reported subjective improvement in their dysautonomia symptoms and quality-of-life. Two with symptom recurrence years later were found to have new-onset pelvic venous congestion and are being evaluated for pelvic venous insufficiency interventions.

Discussion

Lower extremity venous pooling can exacerbate dysautonomia symptoms in POTS patients. Patients refractory to conventional treatment strategies should undergo venous insufficiency workup, and if positive, should be referred for venous pooling intervention evaluation. The success of RFA at treating refractory POTS symptoms in these four patients with lower extremity venous reflux, including no surgical intervention and no adverse effects, are compelling grounds to further explore this therapy and to quantify and standardize symptom improvement assessment in a larger patient population. Future directions include a demonstration of quality-of-life improvement in randomized clinical trials.

Safety and Efficacy of Combining Saphenous Endovenous Laser Ablation and Varicose Veins Foam Sclerotherapy: An Analysis on 5500 Procedures in Patients With Advance Chronic Venous Disease (C3-C6)

BACKGROUND

endovenous laser ablation (EVLA) represents the gold standard in treating both great and small saphenous veins (GSV and SSV) incompetence. To achieve a "no-scalpel" procedure in patients with chronic venous insufficiency (CVI, CEAP C3-C6), concomitant phlebectomies could be replaced by ultrasound-guided foam sclerotherapy (UGFS) into varicose tributaries. The aim of this study is to present a single-centre experience on EVLA + UGFS for patients with CVI secondary to varicose veins and saphenous trunk incompetence, analysing ling-term outcomes.

METHODS

all consecutive patients with CVI and treated by EVLA + UGFS from 2010 to 2022 were included in the analysis. EVLA was performed using a 1470-nm diode laser (LASEmaR® 1500, Eufoton, Trieste, Italy), adapting the linear endovenous energy density (LEED) depending on saphenous trunk diameter. Tessari method was used for UGFS. Patients were evaluated clinically and by duplex scanning at 1, 3 and 6 months, and annually up to 4 years, to assess treatment efficacy and adverse reactions.

RESULTS

5500 procedures in 4895 patients (3818 women, 1077 men) with a mean age of 51.4 years were analysed during the study period. A total of 3950 GSVs and 1550 SSVs were treated with EVLA + UGFS (C3 59%, C4 23%, C5 17% and C6 1%). Neither deep vein thrombosis nor pulmonary embolism were detected during follow-up, as well as superficial burns. Ecchymoses (7%), transitory paraesthesia (2%), palpable vein induration/superficial vein thrombosis (15%) and transient dyschromia (1%) were registered. Saphenous and tributaries closure rate at 30 days, 1 and 4 years were 99.1%, 98.3% and 97.9%, respectively.

CONCLUSIONS

EVLA + UGFS for an extremely minimally invasive procedure appears to be a safe technique, with only minor effects and acceptable long-term outcomes, in patients with CVI. Further prospective randomized studies are needed to confirm the role of this combined therapy in such patients.

Variations and inconsistencies in venous ablation coverage policies between single-state and multistate carriers in the United States

BACKGROUND

Vein ablation is a common and effective treatment for patients with chronic venous insufficiency. The overuse of vein ablation despite the existence of evidence-based guidelines has resulted in insurance companies developing restrictive policies for coverage that create barriers to appropriate care. This study compares the insurance coverage by single-state carriers (SSCs) and multistate carriers (MSCs), highlighting the variations and inconsistencies in the various policies.

METHODS

The American Venous Forum Venous Policy Navigator was reviewed for the various policies available in the United States. The policies were divided into SSCs and MSCs. The characteristics of the policies, including the anatomic and hemodynamic criteria for specific veins, duration of conservative treatment, disease severity, symptoms, and types of procedures covered, were compared between the two groups. SAS, version 9.4 (SAS Institute Inc) was used for statistical analysis.

RESULTS

A total of 122 policies were analyzed and divided between SSCs (n = 85; 69.7%) and MSCs (n = 37; 30.3%). A significant variation was found in the size requirement for great saphenous vein ablation. Although 48% of the policies did not specify a size criterion, the remaining policies indicated a minimal size, ranging from 3 to 5.5 mm. However, no significant differences were found between SSCs and MSCs. Similar findings were encountered for the small and anterior accessory saphenous veins. MSCs were more likely to define a saphenous reflux time >500 ms compared with SSCs (81.1% vs 58.8%; P = .04). A significant difference was found between the SSCs and MSCs in the criteria for perforator ablation in terms of size and reflux time. MSCs were significantly more likely to provide coverage for mechanochemical ablation than were SSCs (24.3% vs 8.2%; P = .03). SSCs were more likely to require ≥12 weeks of compression stocking therapy than were MSCs (76.5% vs 48.7%; P = .01). No significant differences were found in the clinical indications between the two groups; however, MSCs were more likely to mention major hemorrhage than were SSCs.

CONCLUSIONS

The results of this study highlight the variations in policies for venous ablation, in particular, the striking inconsistencies in size criteria. MSCs were more likely to cover mechanochemical ablation and require a shorter duration of conservative therapy before intervention compared with SSCs. Evidence-based guidance is needed to develop more coherent policies for venous ablation coverage.

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.

Clinical Efficacy of a Modified Surgical Procedure in the Treatment of Incompetent Great Saphenous Veins

Background

The aim of this study was to evaluate the clinical efficacy of a modified surgical procedure for the treatment of varicose veins.

Methods

This retrospective analysis was conducted on lower extremities with symptomatic great saphenous vein (GSV) incompetence that underwent stripping from the groin to the knee, with preservation of the superficial epigastric vein (SEV), between January 2015 and April 2022. Follow-up assessments were performed using Doppler ultrasound, Venous Clinical Severity Score (VCSS), and the Aberdeen Varicose Vein Questionnaire (AVVQ) at 6 and 12 months after surgery.

Results

The study included 179 limbs from 120 patients (47 men and 73 women). The mean patient age was 56.5 years (range, 20-78 years), and the distribution of preoperative Clinical-Etiology-Anatomy-Pathophysiology clinical classes was 8% C0-C1, 88% C2, and 4% C3-C6. The preoperative diameter of the saphenofemoral confluence averaged 6.9 mm (range, 2.7-15.8 mm). After a mean postoperative follow-up period of 24 months, evidence of neovascularization around the stump of the saphenofemoral junction (SFJ) was observed in 2 limbs (1.1%). Additionally, varicose vein recurrence was found in 1 limb (0.6%) and was associated with an incompetent thigh perforator. At postoperative follow- up, both VCSS and AVVQ scores were significantly lower than the preoperative scores.

Conclusion

Modified surgical treatment of GSV incompetence, involving preservation of the SEV and stripping of a short segment up to the knee, demonstrated favorable clinical results in terms of postoperative complication rate, neovascularization rate around the SFJ stump, varicose vein recurrence rate, and improvement in lower extremity symptoms.

Exploring the perception of venous disease within vascular surgery

BACKGROUND

Biases and gender disparities influence career pathways within medicine, and vascular surgery is no exception. Venous disease comprises an estimated 1% to 3% of total health care expenditures. However, its value among vascular surgeons is poorly understood. This study aims to investigate the factors that influence vascular surgeons' current perceptions of superficial and deep venous disease treatments.

METHODS

An anonymous survey was distributed electronically to practicing vascular surgeons in December 2021. The respondents were stratified by gender and practice breakdown. A venous-heavy practice was defined as a practice with venous work comprising ≥25% of the total volume. Changes in practice patterns over the respondent's career were also explored. Descriptive, univariate, and multivariate analyses were performed using STATA (StataCorp).

RESULTS

A total of 315 practicing vascular surgeons responded, with 81.5% from the United States. Their mean age was 46.6 ± 9.6 years, and most identified as men (63.3%). The race and ethnicity breakdown was as follows: White (non-Hispanic), 63.0%; Asian or Asian Indian, 17.1%; Hispanic, Latinx, or Spanish, 8.4%; Black, 1.6%; and unknown, 9.9%. The practice settings were academic for 47.0%, private practice for 26.5%, hospital employed for 23.3%, and other for 3.2%. The female respondents were significantly younger (P < .0001), with fewer years in practice (P < .0001) and were more likely to perceive a gender bias within a career encompassing venous disease compared with the male respondents (P = .02). Of the 315 participants, 143 (45.4%) had a venous-heavy practice. No differences were found in age or gender between the venous-heavy and venous-light practices. Those with a venous-heavy practice had significantly more years in practice statistically (P = .02), had sought more venous training after graduation (P < .0001), were more likely to be in private practice (P < .0001), and were more likely to desire a practice change (P = .001) compared with those with a venous-light practice. Overall, 74.3% of respondents indicated that venous work might be less "valued" than arterial work in the field of vascular surgery. On multivariable regression, the predictors for the perception of venous work being less valued were female gender (odds ratio, 2.01; 95% confidence interval, 1.14-4.03) and completion of a vascular surgery fellowship (odds ratio, 2.0; 95% confidence interval, 1.15-3.57).

CONCLUSIONS

Vascular surgeons overwhelmingly perceived the management of venous disease to be of less value than that of arterial disease, particularly by women and fellowship-trained vascular surgeons. The prevalence of venous disease, as measured by its proportion of the U.S. healthcare budget, cannot be overstated. Thus, efforts to elevate the importance of chronic venous disease within the scope of vascular surgery practices are essential to ensure patients are provided with appropriate specialty care.

Race, sex, and socioeconomic disparities affect the clinical stage of patients presenting for treatment of superficial venous disease

OBJECTIVE

Superficial venous disease has a U.S. prevalence of nearly 30%, with advanced disease contributing to a significant healthcare burden. Although the risk factors for venous disease are well known, the correlation between race, sex, socioeconomic status, and disease severity on presentation is not well established. The area deprivation index (ADI) is a validated metric with respect to regional geography, social determinants of health, and degree of socioeconomic disadvantage. In the present study, we aimed to identify the disparities and the effect that the ADI, in addition to race and sex, has among patients associated with an advanced venous disease presentation.

METHODS

A retrospective review between 2012 and 2022 was performed at four tertiary U.S. institutions to identify patients who underwent endovenous closure of their saphenous veins. Patient demographics, state ADI, comorbidities, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, and periprocedural outcomes were included. Pearson's correlation was performed between the CEAP classification and ADI. Poisson regression analysis was performed to identify factors predicting for an increasing CEAP classification at presentation. Variables with P < .05 were deemed significant.

RESULTS

A total of 2346 patients underwent endovenous saphenous vein closure during the study period, of whom 7 were excluded because of a lack of follow-up data. The mean age was 60.4 ± 14.9 years, 65.9% were women, and 55.4% were White. Of the 2339 patients, 73.3% presented with an advanced CEAP class (≥3). The mean state ADI for the entire cohort was 4.9 ± 3.1. The percent change in the CEAP classification is an increase of 2% and 1% for every level increase in the state ADI for unadjusted (incidence rate ratio [IRR] = 1.02; P < .001) and adjusted (IRR = 1.01; P < .001) models, respectively. Black race has a 12% increased risk of a higher CEAP class on presentation compared with White race (IRR = 1.12; P = .005). Female sex had a 16% lower risk of a higher CEAP presentation compared with male sex (IRR = 0.84; P < .01).

CONCLUSIONS

Low socioeconomic status, Black race, and male sex are predictive of an advanced CEAP classification on initial presentation. These findings highlight the opportunity for improved mechanisms for identification of venous disease and at-risk patients before advanced disease progression in known disadvantaged patient populations.

Vascular Imaging for the Primary Care Provider: Venous and Arterial Disease

The vascular laboratory provides important contributions to the diagnosis, workup, and treatment of known or suspected vascular disease. Knowing what tests to order (and when to order them) allows for the best utilization of these resources. This article will focus on the appropriate use of the vascular lab for the primary care clinician regarding a variety of vascular presentations, including swollen leg, suspected peripheral artery disease, vasospastic disease, carotid artery stenosis, and abdominal aortic aneurysms. Patients with known vascular disease often require serial surveillance imaging to document the stability or progression of disease, and consensus guidelines regarding these strategies will be reviewed.

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

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

Measuring the Quality of Life in Patients with Chronic Venous Disease before and Short Term after Surgical Treatment-A Comparison between Different Open Surgical Procedures

Chronic venous disease (CVD) is a common pathology that significantly affects the quality of life (QoL) of patients. Methods: QoL was assessed in 317 patients diagnosed with CVD who underwent surgeries, including cryostripping (n = 113), high ligation and stripping (HL&S, n = 96), and phlebectomies (n = 108). CVD symptoms and QoL were assessed before surgery and 2 weeks after surgery using the following questionnaires: CIVIQ-20, VAS, Eq-5D, PHQ-9 and GAD-9. Results. The results reveal a significant correlation (p < 0.05) between CEAP score and QoL questionnaires performed preoperatively and postoperatively in all three surgical technique groups, with a statistical improvement postoperatively. Phlebectomy had the best postoperative QoL score (r = 0.495) compared to the other two types of procedures. Conclusions: Analyzing patients’ subjective perception following conventional surgery for CVD treatment, an improved QoL is observed both in functional and psychosocial aspects, even early postoperatively. Classical surgical procedures remain an effective and feasible option in CVD treatment.