Post-thrombotic syndrome

Internal valvuloplasty combined with sleeve wrapping in the treatment of severe great saphenous vein insufficiency: A report of two cases

BACKGROUND

Great saphenous vein (GSV) valve incompetence is one of the most common manifestations of chronic venous insufficiency (CVI) in the lower limbs. There have been no reported attempts to repair the valve prior to the appearance of varicose morphology.

METHOD

We describe two cases. Before surgery, the male patient had obvious pigmentation in the ankle area, and the female patient had obvious pain and swelling in the lower limbs after prolonged standing. Neither patient has obvious varicose veins. After retrograde venography, both patients were found to have severe reflux of the GSV valves (Kinster IV). We performed internal valvuloplasty and sleeve wrapping in two patients.

RESULTS

After surgery, both patients had a significant improvement in symptoms and no particular complaints. Vascular ultrasound also suggested a good outcome.

CONCLUSION

This surgery is safe and feasible in the treatment of early GSV incompetence, with good short-term results; long-term results remain to be seen.

Incidence and predictors of post-thrombotic syndrome in patients with proximal DVT in a real-world setting: findings from the GARFIELD-VTE registry

Although substantial progress has been made in the pathophysiology and management of the post-thrombotic syndrome (PTS), several aspects still need clarification. Among them, the incidence and severity of PTS in the real world, the risk factors for its development, the value of patient's self-evaluation, and the ability to identify patients at risk for severe PTS. Eligible participants (n = 1107) with proximal deep-vein thrombosis (DVT) from the global GARFIELD-VTE registry underwent conventional physician's evaluation for PTS 36 months after diagnosis of their DVT using the Villalta score. In addition, 856 patients completed a Villalta questionnaire at 24 months. Variable selection was performed using stepwise algorithm, and predictors of severe PTS were incorporated into a multivariable risk model. The optimistic adjusted c-index was calculated using bootstrapping techniques. Over 36-months, 27.8% of patients developed incident PTS (mild in 18.7%, moderate in 5.7%, severe in 3.4%). Patients with incident PTS were older, had a lower prevalence of transient risk factors of DVT and a higher prevalence of persistent risk factors of DVT. Self-assessment of overall PTS at 24 months showed an agreement of 63.4% with respect to physician's evaluations at 36 months. The severe PTS multivariable model provided an optimistic adjusted c-index of 0.68 (95% CI 0.59-0.77). Approximately a quarter of DVT patients experienced PTS over 36 months after VTE diagnosis. Patient's self-assessment after 24 months provided added value for estimating incident PTS over 36 months. Multivariable risk analysis allowed good discrimination for severe PTS.

Non-coding RNAs regulating endothelial progenitor cells for venous thrombosis: promising therapy and innovation

Venous thromboembolism, which includes deep venous thrombosis (DVT) and pulmonary embolism, is the third most common vascular disease in the world and seriously threatens the lives of patients. Currently, the effect of conventional treatments on DVT is limited. Endothelial progenitor cells (EPCs) play an important role in the resolution and recanalization of DVT, but an unfavorable microenvironment reduces EPC function. Non-coding RNAs, especially long non-coding RNAs and microRNAs, play a crucial role in improving the biological function of EPCs. Non-coding RNAs have become clinical biomarkers of diseases and are expected to serve as new targets for disease intervention. A theoretical and experimental basis for the development of new methods for preventing and treating DVT in the clinic will be provided by studies on the role and molecular mechanism of non-coding RNAs regulating EPC function in the occurrence and development of DVT. To summarize, the characteristics of venous thrombosis, the regulatory role of EPCs in venous thrombosis, and the effect of non-coding RNAs regulating EPCs on venous thrombosis are reviewed. This summary serves as a useful reference and theoretical basis for research into the diagnosis, prevention, treatment, and prognosis of venous thrombosis.

Diagnostic and prognostic potential of long non-coding RNA NORAD in patients with acute deep vein thrombosis and its role in endothelial cell function

BACKGROUND

Deep venous thrombosis (DVT) is the common clinical cardiovascular disease, and easily develops into post-thrombotic syndrome (PTS). The study aimed to examine the clinical value of long non-coding RNA NORAD gene in the development of DVT and PTS. In vitro, the underlying mechanism was explored.

METHODS

Serum levels of lncRNA NORAD gene in 85 DVT cases and 85 healthy individuals were tested. The role of lncRNA NORAD gene in human umbilical vein endothelial cells (HUVECs) proliferation, migration and inflammation was examined. The candidate downstream target gene was predicted via bioinformatic analysis. Gene ontology (GO) analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis were done for the function annotation and pathway enrichment.

RESULTS

LncRNA NORAD gene was at high expression in the serum of DVT patients, it can distinguish DVT patients from healthy controls with the area under the curve of 0.919. Elevated expression of lncRNA NORAD gene in PTS patients was detected, DVT cases with high expression of lncRNA NORAD gene were more susceptible to PTS. LncRNA NORAD gene knockdown promoted HUVECs' proliferation, migration while suppressing cell apoptosis and inflammation. MiR-93-5p served as a target of lncRNA NORAD gene, and its overexpression reversed the role of lncRNA NORAD gene in the biological function of HUVECs. The target genes of miR-93-5p were enriched in HIF-1 signaling, TGF-beta signaling and PI3K-Akt signaling, protein-protein interaction (PPI) network indicated STAT3, MAPK1 to be the key targets.

CONCLUSIONS

Upregulation of expression of lncRNA NORAD gene was a potential diagnostic biomarker for DVT and related to the development of PTS. LncRNA NORAD/miR-93-5p axis was involved in the progress of DVT through regulating endothelial cell function.

Identifying venous clinical severity score thresholds for Clinical-Etiology-Anatomy-Pathophysiology classifications of venous edema and higher

OBJECTIVE

Venous Clinical Severity Score (VCSS) is a widely used standard for assessing and grading the severity of chronic venous disease (CVD). Prior research highlighted its high validity in detecting and quantifying venous disease. However, there is little, if any, known about the precise thresholds at which VCSS discriminates important stages of deep venous disease. This study sought to elucidate the diagnostic accuracy, thresholds, and correlation at which VCSS detects salient CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classes in deep venous disease progression.

METHODS

A registry of 840 patients who presented with chronic proximal venous outflow obstruction (PVOO) secondary to non-thrombotic iliac vein lesions from August 2011 to June 2021 was retrospectively analyzed. VCSS and CEAP classifications were used to evaluate preoperative symptoms. VCSS was compared to CEAP classes to determine the precise VCSS composite values at which the instrument was able to detect CEAP C3 and higher, C4 and higher, and C5 and higher. Receiver operative characteristic (ROC) curve and area under the curve (AUC) were used to evaluate VCSS for its ability to discriminate disease at these stages of CEAP classification. Spearman's rank coefficient was used to determine the correlation between CEAP VCSS composite as well as individual VCSS components (pain, varicose vein, edema, pigmentation, inflammation, induration, ulcer number, ulcer size, ulcer duration, compression).

RESULTS

VCSS composite was able to detect venous edema (C3) and higher at a sensitivity of 68.9% and a specificity of 54.8% at an optimized threshold of 8.5 (AUC = 0.648; 95% C.I. = 0.575-0.721). To detect changes in skin and subcutaneous tissue from CVD (C4) and higher, an optimal threshold of 11.5 was found with a sensitivity of 51.7% and specificity of 76.5% (AUC = 0.694; 95% C.I. = 0.656-0.731). Healed venous ulcer (C4) and higher was detectable at an optimized threshold of 13.5 at a sensitivity of 67.7% and a specificity of 88.9% (AUC = 0.819; 95% C.I. = 0.766-0.873). The correlation between VCSS composites and CEAP was weak (ρ = 0.372; p < .001). Attributes of VCSS that reflect more severe venous disease correlated more closely with CEAP classes, namely pigmentation (ρ = 0.444; p < .001), inflammation (ρ = 0.348; p < .001), induration (ρ = 0.352; p < .001), number of active ulcers (ρ = 0.497; p < .001), active ulcer size (ρ = 0.485; p < .001), and ulcer duration (ρ = 0.497; p < .001). The correlation between CEAP class and the other four components of VCSS were not statistically significant.

CONCLUSION

VCSS composite thresholds of 8.5, 11.5, and 13.5 are threshold values for detecting CEAP classification C3 and higher, C4 and higher, and C5 and higher, respectively. Consistent with prior work, VCSS appears to have a better ability to discriminate CVD at more severe CEAP classifications. In this registry, the correlation between VCSS and CEAP was found to be weak while components of VCSS that suggest more advanced disease exhibited the strongest correlation with CEAP.

Impact of concomitant popliteal vein thrombosis in patients with acute iliofemoral deep vein thrombosis treated with endovascular early thrombus removal

Summary: Background: Catheter-based thrombus removal (CBTR) reduces the risk of moderate to severe post-thrombotic syndrome (PTS) in patients with acute iliofemoral deep vein thrombosis (IF-DVT). However, the impact of concomitant popliteal DVT on clinical and duplex sonographic outcomes is unknown. Patients and methods: In this post-hoc analysis including the entire cohort of the randomized controlled BERNUTIFUL trial (48 patients), we compared clinical (incidence/severity of PTS assessed by Villalta score and revised venous clinical severity scores, rVCSS), disease-specific quality-of-life (QOL, CIVIQ-20 survey) and duplex sonographic outcomes (patency, reflux, post-thrombotic lesions) at 12 months follow-up between patients with IF-DVT with and without concomitant popliteal DVT treated by CBTR. Results: Overall, 48 IF-DVT patients were included (48% men, median age of 50 years), of whom 17 (35%) presented with popliteal DVT. At baseline, patients with popliteal DVT were older, had a higher body mass index and more important leg swelling. At 12 months, freedom from PTS (93% vs 87%, P=0.17), median total Villalta score (1 vs 1.5; P=0.46), rVCSS (2 vs 1.5, P=0.5) and disease-specific QOL (24 points vs 24 points, P=0.72) were similar between patient with and without popliteal DVT, respectively. Duplex sonographic outcomes were similar, except for more frequent popliteal post-thrombotic lesions and reflux (P=0.02) in patients with popliteal DVT. Conclusions: Relevant clinical outcomes 1 year after successful CBTR were favorable, regardless of the presence or absence of concomitant popliteal DVT. However, post-thrombotic popliteal vein lesions and reflux are more frequent in IF-DVT patients with popliteal involvement. Their impact on long-term outcomes remains to be investigated.

A novel management strategy for treatment of pelvic venous disorders utilizing a clinical screening score and non-invasive imaging

Summary: Background: Treatment of pelvic venous disorders (PVD) including pelvic congestion syndrome (PCS) are often delayed due to its varying clinical manifestations. Patients and methods: Patient referral was based on a literature- and personal experience-derived clinical “PCS screening score” (higher score points indicate greater likelihood with a maximum score of 10 points). We studied consecutive women who were (i) referred for vascular assessment and treatment to the University Hospital Zurich (2017–2021), (ii) had a PCS score ≥3 points, (iii) had evidence of obstructive or non-obstructive PVD by duplex sonography or cross-sectional imaging, and (iv) underwent endovascular therapy. The primary outcome was change in symptom severity after endovascular therapy: (i) freedom from symptoms, (ii) improvement with residual symptoms, (iii) no improvement. Results: We included 43 women (mean age 36 years): 81% had previous pregnancy, 19% endometriosis. The median PCS score was 7 (IQR 5–9) points. Chronic lower-abdominal pain was the leading symptom in 86% patients, followed by recurrent leg (9%) and vulvar (5%) varicosities. The main PVD pathologies were ovarian vein insufficiency (61%), internal iliac vein insufficiency (9%), or a combination of both (30%), whereas 42% had a deep venous obstruction of the inferior vena cava, common iliac or left renal veins. Endovascular therapy included ovarian vein embolization (86%), internal iliac vein embolization (9%), and venous stent placement (35%). After a median of 4 (IQR 1–8) months from endovascular treatment, 40 (93%) patients reported improvement of the leading symptom, and 14 (33%) were symptom-free. Complications included re-intervention for stent stenosis (13%, all post-thrombotic), coil-migration into the left renal vein (7%, all retrieved), and transient pelvic sclerotherapy-induced thrombophlebitis (2%). Conclusions: Endovascular therapy following a diagnostic approach, which included a PCS screening tool and non-invasive imaging, appeared to be highly effective and was associated with a low rate of complications.