Superficial Venous Disease

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.

Diameter-reflux relationship of the saphenous vein in the C0–C3 patients of chronic venous disease

Objective

To evaluate the relationship between the saphenous vein’s diameter and reflux and determine the cut point of the saphenous vein’s diameter that indicates lack of reflux.

Material and methods

A retrospective cohort study conducted in 807 limbs underwent the venous ultrasound for 36 months. The saphenous vein’s diameter in the reflux and non-reflux groups was evaluated. The receiver operating characteristics (ROC) curve was constructed to determine the saphenous vein’s diameter that maximizes the summation of sensitivity and specificity for saphenous vein reflux in C0–C3 patients.

Results

The reflux group had a significantly greater diameter than a non-reflux group at four great saphenous vein (GSV) levels and two small saphenous vein (SSV) levels ( p-value < 0.001). The venous reflux correlated significantly with GSV diameter at all four GSV levels and two SSV levels ( p-value <0.001). The ROC area of the diameter at four GSV levels ranges from 0.59 to 0.69. The optimal cut-off diameter for GSV reflux is 3.8 mm at the proximal thigh, 2.8 mm at the distal thigh, 3.2 mm at the proximal calf, and 2.5 mm at the distal calf. The ROC area of the diameter at two SSV levels ranges from 0.66 to 0.67. The optimal cut-off diameter for SSV reflux is 2.5 mm at the proximal calf and 2.3 mm at the distal calf.

Conclusion

The saphenous vein’s diameter has been proved to be significantly correlated with the presence of reflux in duplex ultrasound in all lower limbs’ levels. Unfortunately, the study’s cut point diameter is considered poor accuracy and is not an accurate measurement to use as the screening test for the presence of reflux.

Symptoms in Dilating Venous Disease

Lower extremity venous diseases or insufficiency include clinically deteriorating conditions with morphological and functional alterations of the venous system, including venous hypertension, vascular wall structural abnormality, and venous valvar incompetency in association with an inflammatory process. In fact, the same pathophysiological processes are the main underlying mechanisms of other venous insufficiencies in different vascular territories such as Peripheral Varicose Vein (PVV), varicocele, Pelvic Varicosities or Congestion Syndrome (PCS) and Hemorrhoidal Disease (HD). Regarding the anatomical continuity of lower extremity venous system, urogenital system (pampiniform plexus in male and broad ligament and ovarian veins in female) and anorectal venous system, it is reasonable to expect common symptoms such as pain, burning sensation, pruritis, swelling, which arise directly from the involved tissue itself. High coexistence rate of PVV, varicocele/PCS and HD between each other underlines not only the same vascular wall abnormality as an underlying etiology but also the existence of common symptoms originating from the involved tissue in dilating venous disease. Accordingly, it might be reasonable to query the common symptoms of venous dilating disease in other venous vascular regions in patients with complaints of any particular venous territory.

Evaluation of quality of life after minimally invasive varicose vein treatment

BACKGROUND

This cross-sectional study aims to evaluate the changes in quality of life after minimally invasive procedures in patients with varicose veins.

METHODS

The study included 150 patients (58 males, 92 females; mean age 47.1±12.0; range, 19 to 80 years) with varicose veins who were treated using minimally invasive techniques. Data were collected using patient information forms and the Venous Insufficiency Epidemiological and Economic Study-Quality of life/Symptoms questionnaire. Before the minimally invasive procedures, patients were informed about varicose veins and medical approaches for relief. They were also provided information about the use of compression stockings. Varicose vein symptoms and quality of life were evaluated before the minimally invasive procedures and four weeks following the last operation.

RESULTS

Females, individuals aged between 51-60 years, those with Body Mass Index >30, or having had a pregnancy had higher prevalence of variceal disease and lower quality of life. Clinical severity of the disease decreased and the quality of life improved in patients treated with minimally invasive procedures. After treatment, 45.33% of patients put on compression stockings regularly for one month.

CONCLUSION

After minimally invasive treatment, severe disease symptoms decreased and quality of life increased in patients with varicose veins. Lifestyle modifications, use of compression stockings, and roles of nurses and healthcare workers are significant in maintaining healthy veins.

Treatment-refractory vulvodynia from nutcracker syndrome: A case report

BACKGROUND

Pelvic venous disorders are often undiagnosed due to the symptom variability and similarity to other disease presentations. 'Pelvic congestion syndrome' is a term often used as a diagnosis of exclusion, since there is currently no standardized diagnostic approach for pelvic venous disorders, which further delays treatment.

CASE

A 25-year-old woman with treatment-refractory vulvodynia presented with symptoms that included left-sided vaginal wall pain, pruritis, dysmenorrhea, dyspareunia, muscle tension, and a chronic vaginal ulceration. Abnormal pelvic varices were discovered, and she was referred to vascular surgery for treatment of nutcracker syndrome causing ovarian vein reflux and abnormal engorgement of pelvic varices.

CONCLUSION

Patients presenting with signs of pelvic venous insufficiency such as vaginal pruritis, irritation, pain, recurrent vaginitis, or chronic ulcerations should be examined for pelvic venous disorders.

The Histological Changes of the Great Saphenous Vein at 2 Years after Cryosclerosis

Cryosclerosis was developed at the end of the last decade. It is the endovenous cryoablation of the great saphenous vein and has been forgotten before the era of the endovenous ablation techniques began. The caused histomorphological changes of the vein weren’t described before, especially, years after the procedure. A 31-year-old female patient underwent cryosclerosis 2 years ago. Because of the recanalization of the great saphenous vein and recurrent varicosity, high ligation, cryostripping and phlebectomy of varices were performed. During surgery, a saphenous vein piece was harvested to investigate the histomorphological effect of cryosclerosis. Histological findings verified that recanalization had occurred, the vein wall had undergone remodeling, and the picro-sirius red stain showed collagen deposition in the whole vein wall. Cryosclerosis seems to result in the remodeling of the vein wall.

Interventions on the Superficial Venous System for Chronic Venous Insufficiency by Surgeons in the Modern Era

Objective:

To evaluate patient characteristics, practice patterns, and outcomes for patients treated for chronic venous insufficiency (CVI).

Background:

Chronic venous insufficiency is a common problem treated using open or endovascular methods by physicians from a number of surgical and nonsurgical specialties.

Methods:

Patients treated for CVI in the American College of Surgeons National Surgical Quality Improvement Program data set (2005-2011) were identified. Analyses were based on open surgical treatment (open surgery of varicose vein [OSVV]) versus endovenous ablation (EVA), specialty of treating surgeon, and by the presence of venous ulceration (VU). Preoperative patient characteristics and intraoperative measures were examined, and multivariate logistic regression analyses were performed for the postoperative outcomes of superficial surgical site infection (sSSI) and deep venous thrombosis (DVT).

Results:

A total of 4366 patients were identified. Patients undergoing EVA were older (53.3 vs 51.8 years; P < .001), had higher body mass index (BMI; 29.9 vs 29.0; P < .001), and more commonly presented with VU (20.9% vs 13.3%; P < .001). Vascular surgeons were more likely than general surgeons to treat patients with VU (17.0% vs 13.4%; P = .017). Patients with VU had higher BMI (32.2 vs 28.8; P < .001), were older (57.9 vs 51.4 years; P < .001), and more likely to be diabetic (9.0% vs 4.7%; P < .001). Factors associated with sSSI were OSVV (adjusted odds ratio [AOR] 2.56; 95% confidence interval [CI] 1.19-5.50; P = .016), obesity (AOR 2.16; 95% CI 1.10-4.24; P = .025), and VU (AOR 2.56; 95% CI 1.19-5.50; P = .016). Patients undergoing OSVV had significantly lower odds of DVT when compared to EVA (AOR 0.52; 95% CI 0.28-0.97; P = .040).

Conclusions:

The OSVV, obesity, and VU increase the odds of sSSI after procedures treating CVI. Patients in these categories should be monitored closely for signs of infection in the perioperative period. Patients undergoing EVA have higher odds of postoperative DVT, suggesting that routine screening after EVA for DVT may be justified.