Primary varicose veins: the sapheno-femoral junction, distribution of varicosities and patterns of incompetence

A comparison of below-knee vs above-knee endovenous ablation of varicose veins

OBJECTIVE

Varicose veins have a significant impact on quality of life and can commonly occur in the thigh and calves. However, there has been no large-scale investigation examining the relationship between anatomic distribution and outcomes after varicose vein treatment. This study sought to compare below-the-knee (BTK) and above-the-knee (ATK) varicose vein treatment outcomes.

METHODS

Employing the Vascular Quality Initiative Varicose Vein Registry, 13,731 patients undergoing varicose vein ablation for either BTK or ATK lesions were identified. Outcomes were assessed using patient-reported outcomes (PROs) and the Venous Clinical Severity Score (VCSS). Continuous variables were compared using the t-test, and categorical variables were analyzed using the χ2 test. Multivariable logistic regression was used to estimate the odds of improvement after intervention. The multivariable model controlled for age, gender, race, preoperative VCSS composite score, and history of deep vein thrombosis.

RESULTS

Patients who received below-knee treatment had a lower preoperative VCSS composite (7.0 ± 3.3 vs 7.7 ± 3.3; P < .001) and lower PROs composite scores (11.1 ± 6.4 vs 13.0 ± 6.6; P < .001) compared with those of patients receiving above-knee treatment. However, on follow-up, patients receiving below-knee intervention had a higher postoperative VCSS composite score (4.4 ± 3.3 vs 3.9 ± 3.5; P < .001) and PROs composite score (6.1 ± 4.4 vs 5.8 ± 4.5; P = .007), the latter approaching statistical significance. Patients receiving above-knee interventions also demonstrated more improvement in both composite VCSS (3.8 ± 4.0 vs 2.9 ± 3.7; P < .001) and PROs (7.1 ± 6.8 vs 4.8 ± 6.6; P < .001). Multivariable logistic regression analysis similarly revealed that patients receiving above-knee treatment had significantly higher odds of improvement in VCSS composite in both the unadjusted (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.28-1.65; P < .001 and adjusted (OR, 1.31; 95% CI, 1.14-1.50; P < .001) models. Patients receiving above-knee treatment also had a significantly higher odds of reporting improvement in PROs composite in both the unadjusted (OR, 1.85; 95% CI, 1.64-2.11; P < .001) and adjusted (OR, 1.65; 95% CI, 1.45-1.88; P < .001) models.

CONCLUSIONS

Treatment region has a significant association with PROs and VCSS composite scores after varicose vein interventions. Preoperatively, there were significant differences in the composite scores of VCSS and PROs with patients receiving BTK treatment exhibiting less severe symptoms. Yet, the association appeared to reverse postoperatively, with those receiving BTK treatments exhibiting worse PROs, worse VCSS composites scores, and less improvement in VCSS composite scores. Therefore, BTK interventions pose a unique challenge compared with ATK interventions in ensuring commensurate clinical improvement after treatment.

A Study of Valvular Incompetencies in the Lower Limb Veins Using Doppler Ultrasound Findings

INTRODUCTION

Varicose veins (VV) are one of the most common pathologies associated with the venous system of the lower limb. In the Indian population, its incidence is higher, and it is one of the most commonly encountered cases in the hospital. The study aimed to note the widely affected anatomical structure in male and female varicose patients using Doppler ultrasound (DU) examination findings.

METHODS

A total of 200 Doppler ultrasound reports of varicose patients were retrospectively analyzed and categorized based on the affected structure. The demographic data of all cases, such as age, sex, brief history, signs, symptoms, and affected side of the lower limb, was noted. Anatomical structures causing venous refluxes in the saphenous systems, junctions, and perforating venous systems were noted. Pearson's correlation coefficient was applied to find out its association.

RESULTS

Out of 200 Doppler reports studied, 133 (67%) were male and 67 (33%) were female patients. The majority, 180 (90%) cases, belonged to C1-C3 stages according to the Clinical, Etiology, Anatomy, and Pathological (CEAP) classification, while 20 (10%) were in C4-C5 stages. Male patients aged between 31 and 40 years were predominantly affected, with their left side being affected most commonly. In female patients, the older age group of 50-60 years was predominantly affected. Great saphenous reflux in the groin due to incompetent terminal valve was noted in 126 (63%) cases. In the perforator venous (PV) system, defects in the medial leg perforator (189 (95%)), posterior leg (92 (46%)), and thigh perforator (20 (10%)) were noted.

CONCLUSION

In the present study, the occurrence of varicose veins is due to the involvement of superficial, deep, and perforator veins with varying percentages. Among the structures, the medial leg perforator was predominantly involved, followed by other perforators. Since most patients were in C1-C3 stages, the involvement of deep veins was noted minimally.

Global impact and contributing factors in varicose vein disease development

Varicose veins are convoluted, expanded, and stretched subcutaneous veins of the lower leg and are the most frequently reported medical condition. This condition has a higher prevalence in Western and developed countries. Inadequacy of the valves results in reflux of blood in the veins of the lower leg. The present study aims to describe the epidemiology and contributing factors (risk factors and pathological factors) in the development of varicose veins disease. PubMed/Medline, Science Direct, Google Scholar, SciFinder, Scopus, and Web of Science databases were explored to include potential research and review articles. Finally, 65 articles were considered appropriate to include in the study. Pain, swelling, heaviness, and tingling of the lower limbs are the most common sign and symptoms caused by varicose veins while in some individuals it is asymptomatic. The Prevalence of varicose veins varies geographically. Currently, it is reported that globally about 2%–73% of the population is affected by varicose veins while the prevalence rate in Pakistan is 16%–20%. Different risk factors associated with the advancement of varicose veins are age, gender, occupation, pregnancy, family history, smoking, BMI and obesity, exercise, genetic factor, and current lifestyle. In varicose veins, some contributory elements may also play an important role in the disease development, incorporating constant venous wall aggravation, hereditary variation, and persistent venous hypertension. This condition has now turned into a curable issue that was previously viewed broadly as less important for treatment, determining the individual’s satisfaction. Moreover, the mechanisms behind the risk factors involve diet, physical work, and hormonal contribution. These are more likely to be explored.

Correlation of Clinical Class with Duplex Ultrasound Findings in Lower Limb Chronic Venous Disease

Background

This study investigated the distribution of valve incompetence in patients with chronic venous disease (CVD) and its correlation with the clinical category of the clinical, etiological, anatomical, and pathophysiological (CEAP) classification.

Methods

In total, 1,386 limbs with clinically suspected CVD were categorized according to the CEAP classification and consecutively underwent duplex ultrasonography between April 2017 and December 2020.

Results

There were 362 limbs in male patients and 1,024 limbs in female patients. The limbs were classified as C0s–C1 (608 limbs, 43.8%), C2 (727 limbs, 52.5%), or C3–C6 (51 limbs, 3.7%). The prevalence of saphenous vein incompetence in CEAP C0s–C1 limbs was 43.6%. The saphenofemoral junction (SFJ) was competent in 37% of CEAP C2–C6 limbs. The CEAP C3–C6 category was not correlated with reflux patterns of the saphenous vein system (Cramer’s V=0.07), incompetent SFJ (Cramer’s V=0.07), deep vein reflux (Cramer’s V=0.03), or the distribution of incompetent segments in the great saphenous vein (GSV) (Cramer’s V=0.11).

Conclusion

Duplex ultrasonography is necessary to formulate a proper treatment plan for limbs categorized as CEAP C0s–C1. The SFJ was competent in more than one-third of CEAP C2–C6 limbs with GSV reflux; as such, flush ligation of the GSV may be unnecessary in these patients. The CEAP C3–C6 category showed no correlations with reflux patterns of the saphenous vein system, SFJ reflux, deep vein reflux, or the distribution of incompetent segments in the GSV.

A systematic review on the treatment of nonhealing venous ulcers following successful elimination of superficial venous reflux

OBJECTIVE

Nonhealing leg ulcers are frequently associated with the saphenous vein reflux. Despite the success of endovascular ablations, there are patients who either fail to heal or develop recurrent ulcers. This systematic review aims to summarize the available evidence on how to treat these patients after successful elimination of superficial reflux.

METHODS

A systematic review was performed following the PRISMA guidelines. The MEDLINE and Embase databases were searched for full text articles in English from 1946 to July 31, 2020. All articles that did not specifically mention the treatment of persistent venous ulcers or superficial venous reflux associated with healed or active venous ulcers were eliminated. The remaining abstracts were read for mention of either recurrent or persistent venous ulcers and, if mentioned, the full article was reviewed. All study designs were included. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers.

RESULTS

Four eligible studies including a total of 161 patients (177 limbs) with C6 disease were included in the review after the screening of 546 identified articles. A total of 62 patients were treated for persistent or recurrent venous ulcers after treatment of superficial reflux. Treatments included four-layer compression dressings, repeat ablations of superficial veins, and endovenous ablation of incompetent perforator veins. Overall, successful healing was noted in 50% of patients undergoing repeat ablative procedures, 100% of patients treated solely with four-layer compression dressings, and 90% of patients treated with compression and successful ablation of incompetent perforator veins. Across all studies the presence of deep vein reflux was 31% (50 of 164 limbs), post-thrombotic (secondary) ulcers 13.7% (16 of 117), and proximal obstruction was present in a single patient. Superficial venous reflux was treated using endovenous ablation (either radiofrequency ablation or laser), foam sclerotherapy, and endovenous radiofrequency ablation with or without microphlebectomy procedures. The frequency of persistent ulcers after elimination of superficial reflux ranged from 2.3% at 2 years after the intervention to 21.1% at 1 year with follow-up ranging from 6 to 52 months.

CONCLUSIONS

Although further studies are warranted to improve the quality of evidence, it seems that additional ablative procedures to address incompetent perforating veins and persistent superficial reflux in combination with ongoing compression therapy is effective in healing persistent or recurrent venous ulcers after the elimination of superficial venous reflux.

Flow cytometric characterization of the saphenous veins endothelial cells in patients with chronic venous disease and in patients undergoing bypass surgery: an exploratory study

Recent findings have suggested that the primary factors for development of chronic venous disease (CVD), which commonly manifests as varicose veins (VV), are due to structural and biochemical modifications of the vessel wall. The aim of this exploratory study was to characterize by flow cytometry the endothelial cells (EC) mechanically extracted from the varicose saphenous veins (VSV) segments of patients submitted to VV surgery, and to compare the expression of cell surface molecules in these EC with that observed in the EC from the graft SV (GSV) of patients undergoing bypass surgery. EC were isolated from distal- (varicose trunk) and from proximal- (nearly normal) VSV segments of 30 patients submitted to VV surgery, and from proximal GSV segments of 20 patients submitted to bypass surgery (control group), using a mechanical method, and their immunophenotype was characterized by flow cytometry. EC were identified as being CD45^negCD146^brightCD31^bright, and analyzed for expression of activation-related (CD54, CD62E, CD106), procoagulant (CD142), and cell junction (CD31, CD146) molecules, and for the scavenger receptor, CD36. The EC harvested from the SV segments of CVD patients had lower expression of all the molecules evaluated, in comparison to controls; these differences were more evident for the EC isolated from the distal-VSV. The EC extracted from the proximal- and distal-VSV segments of the CVD patients also differ from each other, the first having lower levels of CD62E, CD106, CD142 and CD36. Groups did not match for gender and controls were heterogeneous concerning the underlying pathologies, which may have a confounding effect. Our study revealed that the EC isolated from varicose (distal) and nearly normal (proximal) VSV segments of the CVD patients differ phenotypically from each other, and from the EC of the control group. The VSV segments more affected by the CVD have the lowest expression of the studied markers. We hypothesize that CVD is associated with a decrease on the EC surface molecules, causing EC dysfunctionality. Further studies with a large number of gender-matched participants are needed, to confirm the results obtained in this exploratory study.

Systematic review and meta-analysis of the anatomic variants of the saphenofemoral junction

BACKGROUND

The aim of this systematic review was to provide comprehensive data on the prevalence of variations of the saphenofemoral junction (SFJ) to prevent misidentification of the SFJ or the incomplete ligation of the tributaries of the great saphenous vein.

METHODS

A systematic review was conducted using the PubMed, Embase, and Cochrane Library databases through September 14, 2017. To be included in the meta-analysis, a study had to report prevalence data on the morphology of the SFJ or the presence of venous tributaries.

RESULTS

A total of 16 studies (7433 legs) were included. The majority of studies were performed during varicose vein surgery (74.14%), with fewer studies by means of computed tomography venography and cadaveric dissection. The pooled prevalence estimate (PPE) for a duplication of the SFJ with a bifid junction was 9.6% (P = .001). The PPE for a duplication of the SFJ with two separate junctions was 1.7%. The PPE for ectasia of the SFJ was 2.3% in type 1, 1.2% in type 2, and 1.7% in type 3. The distribution of the PPE for the number of venous SFJ tributaries was approximately normal with a slight right skew; a higher rate was observed in the group with four venous tributaries to the SFJ.

CONCLUSIONS

This analysis found high heterogeneity in the prevalence of SFJ anatomic variants and the number of venous SFJ tributaries. For this reason, it is highly recommended that a preoperative Doppler ultrasound assessment of the SFJ and great saphenous vein be performed.

An Epidemiological Survey of Venous Disease Among General Practitioner Attendees in Different Geographical Regions on the Globe: The Final Results of the Vein Consult Program

This study measured the prevalence of chronic venous disease (CVD, C1-C6), chronic venous insufficiency (C3-C6) in 23 countries. The possible influence of risk factors was assessed. Patient recruitment was carried out by general practitioners. Patient characteristics, prevalence of risk factors, and C-classification were recorded. We assessed differences in prevalence and risk factors between Asia (A), Eastern Europe (EE), Latin America (LA), and Western Europe (WE). A total of 99 359 patients were included. The prevalence of CVD (51.9% A, 70.18% EE, 68.11% LA, and 61.65% WE) was significantly ( P < .001) lower in A. Risk factors such as age, obesity, smoking, having regular exercise, use of birth control pills, prolonged standing and sitting, and having a positive family history differ significantly between regions. After model-based probabilities corrected for risk factors, significant differences in the probability of having CVD were only found in the older age-group (>65 years). The lowest prevalence was noted in A. Chronic venous disease is very common and the prevalence varies between different geographical areas. After correcting for risk factors, these differences diminished.

The endovenous ASVAL method: principles and preliminary results

PURPOSE

We aimed to investigate the feasibility and safety of the endovenous ambulatory selective varicose vein ablation under local anesthesia (eASVAL) method in a selected group of pa-tients with varicose disease and present the short-term results of one-year ultrasonographic follow-up.

METHODS

Three hundred and ninety-five consecutive patients with varicose veins who had been treated with endovenous laser ablation (EVLA) were retrospectively reviewed over a period of two years. From this group, 41 patients who were treated using the eASVAL technique and had the great saphenous vein (GSV) preserved were included in the study. These patients had only limited segmental GSV reflux accompanied by a competent terminal valve. The eASVAL technique can be defined as EVLA of the proximal straight segments of the major tributaries connecting the symptomatic varicose veins with the GSV, followed by ultrasound-guided foam sclerotherapy of the superficial varicose veins themselves. The patients were assessed before and after the treatment by duplex scan findings and clinical assessment scores.

RESULTS

The GSVs were successfully preserved in all 41 cases, and all patients showed significant clinical improvement using the eASVAL approach (P < 0.001). Segmental reflux was no longer present in 75.3% of patients. The mean diameters of the GSVs were significantly reduced at one-year follow-up (8.5 mm vs. 7.5 mm, P < 0.001).

CONCLUSION

eASVAL is a feasible and safe procedure in selected patients, with promising results at one-year ultrasonographic follow-up. However, prospective studies are required, comparing this approach with the standard techniques.

The influence of age and gender on venous symptomatology. An epidemiological survey in Belgium and Luxembourg

Aim

The aim of this study is to measure the incidence of the symptoms in patients with chronic venous disease (CVD) and to look for the influence of age on the severity of symptoms for both genders.

Materials and methods

A survey was carried out in Belgium and Luxembourg between May and September 2013. Patient recruitment was done by 406 general practitioners (GPs). Each GP screened 10–20 consecutive patients older than 18 years. Inquiries were made regarding the presence of symptoms and possible signs of CVD. Patients with diagnosed CVD filled out a questionnaire including a quality of life score (CIVIQ-14). These data were converted into a CIVIQ Global Index Score (GIS). Statistical analysis was performed in order to calculate the effect of age and gender on the number of symptoms and the estimated probabilities of having CVD.

Results

Totally 6009 patients were included in this survey. The mean age was 53.4 years. Of all, 61.3% of the patients have CVD (C1-C6). Of all, 64.7% of patients were symptomatic. Age and female gender were major risk factors for developing CVD. Most common symptoms were ‘heavy legs’ (70.4%), pain (54.0%), and sensation of swelling (52.7%). The number of symptoms increases with age ( p < 0.001). Female patients have significantly more symptoms in comparison with male patients in all age groups. In both females and males, age is negatively correlated with GIS score ( p < 0.001). The estimated probability of having CVD was significantly higher for woman compared to men and increases with age for both gender.

Conclusion

CVD is a very common progressive disease with age as a major risk factor. Increasing age results in a higher C-classification, more symptoms, and a lower GIS score (quality of life). Female gender interacts significantly with age and results in a more advanced stage of CVD.

Persistent incompetent truncal veins should not be treated immediately

Background

The traditional attitude for the treatment of chronic venous disorder is to systematically treat incompetent truncal veins. We wanted to evaluate the outcomes of not treating all incompetent truncal veins with regard to our experience of focusing the treatment to the varicose tributaries.

Methods

Retrospective study on all procedures of surgical treatment consecutively performed for varicose veins by single phlebectomy with preservation of a refluxing great saphenous vein (GSV), according to the principles of the ambulatory selective varices ablation under local anesthesia (ASVAL) during four years of practice. The clinical and hemodynamic outcomes have been evaluated at eight days, one year, and once a year.

Results

We have included 1212 lower limbs (LLs) that underwent consecutive ASVAL procedures in 816 patients (611 women and 205 men) aged between 19 and 93 years (mean age 53.7 years). The CEAP Class C classification was C0–C1 = 0%; C2 = 85.6%; C3 = 5.4%; C4 = 7.8%; C5 = 0.7%; C6 = 0.7%. Symptoms were present in 854 cases (70.5%). A thrombosis of the GSV was diagnosed at eight days postoperative in 13 cases (1.1%). A total of 1010 LLs were followed after the first postoperative year (mean follow-up of 44.5 months). A secondary major procedure was done in 30 cases during the follow-up: a striping of the GSV in nine cases and a redo phlebectomy in 21 cases. The cumulative incidence of a persistent or recurrent GSV reflux, of a varicose recurrence, and of secondary major procedure at five years after life table analysis was 33.8%, 13%, and 4.5%, respectively. A GSV reflux extended above plus below the knee and multiple connections of the varicose tributaries to the GSV at the calf were associated with a varicose recurrence (respectively 66.7% versus 55.3% p < 0.05 and 46.7% versus 12.8% p < 0.05).

Conclusion

A treatment limited to the varicose tributaries by phlebectomy is safe and efficient at midterm with preservation of the main veins of the superficial venous system. It can be performed in a large group of patients thanks to a proper exclusion of cases with advanced chronic venous disorder. Therefore, the systematic treatment of an incompetent truncal vein is not relevant in the majority of the cases.

A study to evaluate patterns of superficial venous reflux in patients with primary chronic venous disease

Objective

This study assessed patterns of superficial reflux in patients with primary chronic venous disease.

Methods

Retrospective review of all patient venous duplex ultrasonography reports at one institution between 2000 and 2009. Legs with secondary, deep or no superficial reflux were excluded.

Results

In total, 8654 limbs were scanned; 2559 legs from 2053 patients (mean age 52.3 years) were included for analysis. Great saphenous vein reflux predominated (68%), followed by combined great saphenous vein/small saphenous vein reflux (20%) and small saphenous vein reflux (7%). The majority of legs with competent saphenofemoral junction had below-knee great saphenous vein reflux (53%); incompetent saphenofemoral junction was associated with combined above and below-knee great saphenous vein reflux (72%). Isolated small saphenous vein reflux was associated with saphenopopliteal junction incompetence (61%), although the majority of all small saphenous vein reflux limbs had a competent saphenopopliteal junction (57%).

Conclusion

Superficial venous reflux does not necessarily originate from a saphenous junction. Large prospective studies with interval duplex ultrasonography are required to unravel the natural history of primary chronic venous disease.

Does extracellular matrix of the varicose vein wall change according to clinical stage?

OBJECTIVE

The etiology and pathophysiology of chronic venous disease is not fully understood. This study aimed to determine the variation of the extracellular matrix proteins in varicose vein wall according to clinical stage.

MATERIAL AND METHODS

Forty varicose and 10 control veins were sampled from the saphenofemoral junction. The Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification was used in patients with varicose veins. Samples were stained with hematoxylin-eosin, Masson's trichrome, EVG (Elastica-van Gieson) stain and with laminin, fibronectin, tenascin antibodies. Stained samples were examined immuno-histochemically. Changes in extracellular matrix were determined semi-quantitatively using light microscopy.

RESULTS

It was observed that in the early stages (C2-C3) of chronic venous disease, fibrosis is increased in the intima and media layers, with fragmentation in lamina elastica interna, and increased tenascin expression in the intima layer. In advanced stages (C4-C6), the accumulation of tenascin in the intima continued along with fibrosis in the media layer, the thickness of the media layer increased and fibronectin deposition was observed.

CONCLUSION

This study showed that changes first occur in the intima during the early stages of the disease with addition of alterations in the media layer at later stages.

Inequalities of health insurance guidelines for the treatment of symptomatic varicose veins

OBJECTIVES

The emerging model of US health-care delivery is aimed at reducing costs, standardizing care, and improving outcomes. Although it is necessary for health-care providers and insurance carriers to work together to achieve those goals, insurers have the added duty of assuring physicians and patients that they comprehend the medical evidence and, based on that understanding, construct policies. Are US insurers meeting that responsibility or are they simply creating policies to serve their own needs?

METHODS

The medical policies of several US health insurers were analysed. The goal was to see whether it could readily be determined if these carriers used evidence-based medicine consistently to create uniform policies for the treatment of patients with symptomatic varicose veins. The literature was also reviewed to determine whether increased insurance documentation requirements have affected cost reduction, standardization of care and/or improvement of outcomes related to chronic vein disease management.

RESULTS

There is a dramatic lack of uniformity among the insurance policies reviewed. Insurers appear to not choose important papers to create policy but use carefully chosen articles to reinforce what they want their policies to say. In so doing, conflicting policy criteria are being created. Complicating this inconsistency, rules for medical necessity are modified frequently, raising frustration levels among vein providers and their patients. What is clear is that costs are not being lowered, care is not being standardized and little is being done to prevent potential complications resulting from chronic vein disease.

CONCLUSIONS

Patients and physicians are increasingly ill-served by, and frustrated with, the clear lack of consistency in the medical policy criteria being created by US insurance carriers in covering the treatment of patients with symptomatic varicose veins. The contradictory coverage requirements, seemingly based on no understanding of evidence-based medicine guidelines, and total variability in reimbursement for various types of treatment options is particularly worrisome. Collaboration between venous treatment providers and insurance carriers, to create evidence-based standards of care, would be timely and beneficial in creating guidelines for optimal patient care.

Patterns of reflux in the great saphenous vein system

Objective:

To report the patterns of reflux in the great saphenous vein as well as to investigate the correlations between patterns of reflux, the demographics and the clinical findings in the population studied.

Methods:

A total of 1882 limbs were assessed by duplex ultrasound examination in 1449 patients (348 men and 1101 women). Ages ranged from 21 to 94 years (mean 51.8). The presence of symptoms of venous disease (aching, heaviness, night cramps, swelling, itching, burning, tingling and throbbing) and clinical signs were recorded.

Results:

Varicose veins without saphenous reflux occurred at a younger age (43 versus 55.6 years P < 0.05). The presence of incompetence at the saphenofemoral junction occurred in older patients (58.5 versus 54.1 years P < 0.05). Venous reflux to the ankle also occurred in older patients (mean 64.0 years P < 0.05). Saphenous vein reflux without clinical varices was associated with more advanced signs (C4–C6: 20.3% P < 0.05). A younger age was associated with less advanced signs (C0–C2:49.4 versus C4–C6: 60.1 years P < 0.05). Presence of symptoms was associated with advancing patient age (51.1 versus 49.1 years P < 0.05).

Conclusions:

A significant correlation between the extent of great saphenous vein reflux and the patient age and the clinical stage of SVI has been observed in this study. The authors hypothesize that these findings support the concept of early treatment of venous insufficiency before symptomatic and physiological deterioration occurs.

Patterns of short saphenous vein incompetence

The significance of short saphenous vein (SSV) reflux is an under-explored territory in chronic venous disease (CVD). We have examined the origin and significance of SSV reflux in primary and secondary CVD. While the natural history of SSV incompetence remains uncertain, its prevalence has been shown to approximate 3.5%, rising with progressing clinical venous insufficiency, and bears an association with lateral malleolar venous ulceration. The most common pattern of reflux extends throughout the SSV Patterns of incompetence in recurrent disease are highly variable, but SSV reflux may itself pose a risk for recurrence, in part due to the complex anatomy of the saphenopopliteal system. Further studies are required to delineate the impact of SSV reflux in secondary venous disease and deep venous incompetence.

Patient-reported symptoms are independent of disease severity in patients with primary varicose veins

The objective of this paper is to explore patterns of incompetence and disease distribution in patients with chronic venous disorders and to correlate this with CEAP (Clinical, Etiologic, Anatomic and Pathologic) classification and presenting symptoms to determine which features of chronic venous disorder (CVD) could be used to guide a patient pathway for referral and treatment. Consecutive patients attending a one-stop venous clinic at a university teaching hospital were recruited over a 12-month period. Patients were clinically assessed, assigned CEAP scores, duplex-scanned and categorized. Data were analyzed to identify associations between symptomatology and disease. Four hundred twenty-four limbs were divided into groups A (C2–3) (339) and B (C4–6) (85). The number of men, mean patient age, varicose vein diameter and quality-of-life score (Aberdeen Varicose Vein Questionnaire – AVVS) were significantly higher in group B ( P < 0.01). Ache occurred more commonly in group A and in women ( P < 0.01). Ache and pain were seen more frequently with saphenofemoral junction reflux ( P < 0.05). Group A women were more likely to be offered surgical intervention while men were managed conservatively ( P < 0.05). In conclusion, CVD symptoms are independent of disease severity assessed by CEAP score. Advanced disease is associated with larger venous diameters, older age and corresponds to a poorer quality of life. Objective markers such as CEAP, Venous Clinical Severity Score and AVVS should be used in determining a patient pathway for referral and treatment of CVD.

Preservação da veia safena magna na cirurgia de varizes dos membros inferiores

A veia safena magna autóloga é o melhor substituto arterial nas revascularizações dos membros inferiores, importante na revascularização do miocárdio e pode ser utilizada nas cirurgias do sistema venoso e nos traumas das extremidades. A fleboextração aumenta os riscos de lesões linfáticas e neurológicas. Assim, no tratamento das varizes primárias dos membros inferiores por meio da cirurgia ou de outras técnicas, a preservação da safena é recomendável se ela for normal ou apresentar alterações que ainda permitam sua preservação pela correção da causa desencadeante. Tal correção pode ser feita por técnicas cirúrgicas. Entre elas, a cura hemodinâmica da insuficiência venosa em ambulatório (CHIVA) tem mostrado bons resultados. Recentemente, um ensaio clínico randomizado e controlado foi publicado comprovando sua eficácia. Outra técnica bastante utilizada é a da ligadura rasante da junção safenofemoral + crossectomia + ligadura das tributárias de crossa, com a qual se tem obtido resultados contraditórios. Finalmente, as técnicas que corrigem a insuficiência da safena reparando as valvas ostial e pré-ostial (valvoplastia externa) são mais fisiológicas. Um ensaio clínico internacional multicêntrico, randomizado e controlado, testando um novo dispositivo, está sendo realizado, com resultados iniciais favoráveis. Este estudo pretende fazer uma revisão sobre as técnicas utilizadas na preservação da safena magna.

Interventions for uncomplicated varicose veins

Objective

To review the evidence regarding interventions (compression, sclerotherapy, surgery and endoluminal) for uncomplicated venous disease.

Method

A literature search of MEDLINE and EMBASE was performed. In addition, bibliographies of published data and the Cochrane Peripheral Vascular Review Group Specialist Register were examined. Publications describing an intervention for uncomplicated venous disease or trials comparing one intervention against another were considered.

Results

Uncomplicated but symptomatic varicose veins are associated with a significant reduction in quality of life (QoL). Evaluation must include a detailed history and examination supported by non-invasive imaging. Although HHD is useful, its utility is limited in the popliteal fossa. It can not provide morphological/anatomical detail when considering an endoluminal treatment option. Regardless of intervention, all treatments considered are associated with a significant improvement in QoL at acceptable cost.

Conclusion

Uncomplicated symptomatic varicose veins lead to a reduced QoL, which can be significantly improved by all interventions considered.

Classification of saphenous refluxes: implications for treatment

Objective

To determine the possible correlations of patient age, symptoms and signs with findings of Doppler duplex examination in limbs with varicose veins.

Methods

A total of 2275 ultrasound examinations were done on 2275 limbs of 1751 patients (421 men and 1330 women). Ages ranged from 21 to 94 years (mean 50). Symptoms of aching, heaviness, burning pain (venous neuropathy) were recorded, and signs of ankle hyperpigmentation, scars of healed ulcers and presence of open venous ulcers were noted.

Results

Presence of symptoms was associated with advancing patient age (50.7 vs. 48.8 years). Varicose veins without great saphenous reflux correlated with younger age (43 vs. 53.5 years). Presence of saphenofemoral junctional incompetence correlated with an older age (54.7 vs. 49.8 years), and reflux to the ankle (Hach stage IV) also correlated with older age (mean 63.7 years). A younger age was associated with less advanced signs (C0–C2: 49.1 vs. C4–C6: 60.1 years). Saphenous vein reflux without clinical varices was associated with more advanced signs (C4–C6: 21.3%).

Conclusions

Ageing is associated with advancing clinical symptoms, signs and increasing multifocal reflux in limbs with venous insufficiency. These facts support the concept of early treatment of venous insufficiency before predictable deterioration occurs.

Probabilidade de refluxo nas veias safenas de mulheres com diferentes graus de insuficiência venosa crônica

CONTEXTO: A presença de refluxo nas junções safeno-femoral e safeno-poplítea é um dado importante para programação da cirurgia de varizes. Estudos mostraram que, na maioria dos pacientes com insuficiência venosa crônica, as junções estão competentes, e o refluxo está presente ao longo do trajeto das veias safenas. OBJETIVOS: Identificar probabilidade de diferentes padrões de refluxo nas veias safenas de mulheres com vários graus de insuficiência venosa crônica e avaliar se o comprometimento das junções das safenas está associado com gravidade da insuficiência venosa. MÉTODOS: Um total de 1.184 membros inferiores de 672 mulheres foram estudados pela ultra-sonografia vascular com Doppler colorido e avaliados pela classificação clínica, etiológica, anatômica e patológica (CEAP). As extremidades foram agrupadas de acordo com a gravidade da insuficiência venosa em graus leve (CEAP C1-C2), moderado (CEAP C3) e grave (CEAP C4-C6). Para avaliar a classificação clínica CEAP na predição do padrão de refluxo, utilizou-se o Teorema de Bayers. Para avaliar associação entre classificação clínica CEAP e padrões de refluxo com ou sem comprometimento das junções das safenas, utilizou-se o teste qui-quadrado (p < 0,05). RESULTADOS: Das 1.184 extremidades avaliadas, 50,2% apresentavam varizes sem edema (CEAP C2). O padrão de refluxo segmentar foi o mais freqüente nas veias safenas magna (35,14%) e parva (8%), independente da gravidade da insuficiência venosa. As junções safeno-femoral e safeno-poplítea foram fontes de refluxo em 12 e 6% das extremidades, respectivamente. Considerando a associação entre classificação clínica CEAP e insuficiência das junções das safenas, foi observada diferença significativa entre presença de refluxo nas junções safeno-femoral (p = 0,0009) e safeno-poplítea (p = 0,0006) na doença avançada. CONCLUSÕES: O refluxo inicia-se predominantemente em segmentos no trajeto das veias safenas. As junções das safenas não são as principais fontes causadoras do refluxo no sistema venoso superficial. À medida que piora a apresentação clínica da insuficiência venosa, aumenta a probabilidade de refluxo nas junções das safenas.

Cardiovascular evaluation of young patients with varicocele

OBJECTIVE

To evaluate cardiovascular risk factors and demographic parameters in patients with varicocele.

DESIGN

Although some pathophysiologic hypotheses have been suggested to explain the etiology of varicocele, the exact mechanism underlying varicocele is not yet known. The coexistence of arterial and venous system pathologic conditions has been reported recently, including varicosities of the coronary venous system and leg veins. Cardiovascular risk factors have not been evaluated previously in patients with varicocele. In addition to the presence of cardiovascular risk factors and demographic parameters, we assessed the prevalence of peripheral varicose veins in patients with and without varicocele.

PATIENT(S)

Study groups consisted of 52 patients with varicocele and 100 patients without varicocele younger than 50 years old.

RESULT(S)

There were no statistically significant differences between the two groups with respect to presence of hypertension, diabetes mellitus, hyperlipidemia, family history of coronary artery disease, body mass index, age, and height. The weight and presence of peripheral varicose veins in the patients with varicocele were significantly higher than in those without varicocele. It was found that presence of peripheral varicose veins was independently and positively associated with varicocele.

CONCLUSION(S)

We have demonstrated that varicocele is not associated with cardiovascular risk factors or demographic parameters. However, the presence of peripheral varicose veins is positively associated with varicocele, suggesting a possible common pathologic step.

Age-related variations of varicose veins anatomy

BACKGROUND

Primary varicose veins are commonly considered a progressive disease starting from the saphenous junctions and extending to tributaries in a retrograde fashion along the saphenous trunks. This theory has been criticized by studies indicating different patterns of development and progression of varicose veins. To contribute to the understanding of the pathogenesis of the disease, the anatomy of the venous bed was comparatively evaluated by duplex sonography in patients with varicose veins with a marked difference in age.

METHODS

The study included 100 varicose limbs in 82 patients aged < 30 years and 238 limbs in 183 patients aged > 60 years. Veins were designated as saphenous veins (SVs), tributaries of the SVs (STVs), and veins not connected with the SVs (NSVs). Four main anatomic patterns were comparatively evaluated: (1) varicose changes only along SVs, (2) varicose changes along SVs and STVs, (3) varicose changes only in STVs, and (4) varicose changes only in NSVs.

RESULTS

SVs were normal in 44% of varicose limbs. In most limbs from young subjects, varicose changes afflicted only SVTs (25%) and NSVs (36%). Varicose SVs were more frequent in the older group (62%) than in younger one (39%) owing to a higher prevalence of limbs with combined SV and STV varicosities (respectively, 59% and 37%). In the older group, varicosities in the STVs were more frequently observed in association with incompetence of the SV trunks.

CONCLUSION

The frequent occurrence of normal SVs in varicose limbs of all patients does not support the crucial role commonly credited to SVs in the pathogenesis of primary varicosities. Moreover, the SV trunks were normal in most varicose limbs from young patients. These findings suggest that varicose disease may progressively extend in an antegrade fashion, spreading from the STVs to the SVs. This hypothesis suggests that the saphenous trunks could be spared in the treatment of a relevant number of varicose legs. Prospective longitudinal studies with serial duplex evaluations of large series of extremities are necessary to confirm this hypothesis.

Dysregulated apoptosis in primary varicose veins

OBJECTIVE

Programmed cell death plays a critical role in various physiological processes. To investigate its possible pathogenic role in primary varicose veins we studied histological changes in surgical specimens from human varicose veins. In varicose and healthy veins, we also determined the number of cells in apoptosis, and investigated mediators regulating the intrinsic apoptotic mitochondrial pathway (Bax and caspase 9).

METHODS

A total 23 varicose veins were obtained from 18 patients undergoing lower-extremity varicose vein surgery for primary varicose disorders. We used nine healthy veins obtained from nine patients undergoing distal arterial bypass grafting surgery as controls. The venous segment analysed was the distal part of the greater saphenous vein. Specimens for histological examination were stained with hematoxylin and eosin, trichromic and Victoria blue. Cell apoptoses and mediators of the mitochondrial pathway were detected in the media by immunohistochemistry using antibodies to peroxidase in situ apoptosis, Bax and caspase 9. Results were expressed as indexes for the three antibodies tested. The Mann-Whitney test was used to compare the results obtained in the two groups.

RESULTS

Varicose vein specimens exhibited a more disorganised architecture than healthy veins and showed an increased number of collagen fibres and a decrease in the density and size of elastic fibres. All anti-apoptotic antibodies tested detected significantly fewer immunoreactive cells in tissue sections from the media of varicose veins than of healthy veins (peroxidase in situ, varicose veins (VV) median 2.4% (inter-quartile range 1.6-3.9) versus control (C) 14% (IQR 8.8-19); Bax, VV 1.4% (IQR 0.36-2.4) versus C 11% (IQR 7.6-15); and caspase 9, VV 1.7% (IQR 0.06-3.4) versus C 10% (IQR 9.1-12), P=0.0001 (Mann-Whitney test).

CONCLUSION

Apoptosis is down regulated in the medial layer of varicose veins. This dysregulation of the cellular mechanism that maintains normal tissue integrity is mediated through the intrinsic apoptotic pathway and may be among the causes of primary varicose veins.

Randomized clinical trial of routine preoperative duplex imaging before varicose vein surgery

Background

Duplex imaging is used increasingly for preoperative evaluation of varicose veins, but its value in terms of the long-term results of surgery is not clear.

Methods

Patients with primary varicose veins were randomized to operation with or without preoperative duplex imaging. Reoperation rates, clinical and duplex findings were compared at 2 months and 2 years after surgery.

Results

Two hundred and ninety-three patients (343 legs) had varicose vein surgery after duplex imaging (group 1; 166 legs) or no imaging (group 2; 177 legs). In 44 legs (26·5 per cent), duplex examination suggested a different surgical procedure than had been considered on clinical grounds; the procedure was changed accordingly for 29 legs. At 2 months, incompetence was detected at the saphenofemoral or saphenopopliteal junction (or both) in 14 legs (8·8 per cent) in group 1 and in 44 legs (26·5 per cent) in group 2 (P &lt; 0·001). At 2 years, two legs (1·4 per cent) had undergone or were awaiting reoperation in group 1, and 14 legs (9·5 per cent) in group 2 (P = 0·002). In the remainder, major incompetence was found in 19 legs (15·0 per cent) in group 1 and in 53 (41·1 per cent) in group 2 (P &lt; 0·001).

Conclusion

Routine preoperative duplex examination led to an improvement in results 2 years after surgery for patients with primary varicose veins.

Patterns of saphenous reflux in women with primary varicose veins

OBJECTIVE

Varicose veins have been linked to great saphenous vein (GSV) reflux and in particular, with reflux at the saphenofemoral junction (SFJ). Early stages of disease, however, may be associated with limited, localized reflux in segments of the GSV and/or small saphenous vein (SSV). Ultrasound mapping of saphenous veins was performed to determine patterns of GSV and SSV reflux in women with simple, primary varicose veins.

METHODS

Ultrasound mapping was performed prospectively in 590 extremities of 326 women with varicose veins (CEAP C 2 class) but without edema, skin changes, or ulcers (C 3 to C 6 ). Average age was 42 +/- 13 (SD) years (range, 8 to 87). Patterns of GSV and SSV reflux, obtained in the upright position, were classified as I: perijunctional, originating from the SFJ or saphenopopliteal junction (SPJ) tributaries into the GSV or SSV; II: proximal, from the SFJ or SPJ to a tributary or perforating vein above the level of the malleoli; III: distal, from a tributary or perforating vein to the paramalleolar GSV or SSV; IV: segmental, from a tributary or perforating vein to another tributary or perforating vein above the malleoli; V; multisegmental, if two or more distinct refluxing segments were detected; and VI: diffused, involving the entire GSV or SSV from the SFJ or SPJ to the malleoli.

RESULTS

Reflux was detected in 472 extremities (80%): 100 (17%) had reflux in both the GSV and SSV, 353 (60%) had GSV reflux only, and 19 (3%) had SSV reflux only, for a total prevalence of 77% at the GSV and 20% at the SSV. The most common pattern of GSV reflux was segmental (types IV and V) in 342 (58%) of 590; either one segment in 213 (36%) or more than one segment with competent SFJ in 99 (17%), or incompetent SFJ in 30 (5%), followed by distal GSV reflux (type III) in 65 (11%), proximal GSV reflux (type II) in 32 (5%), diffused throughout the entire GSV (type VI) in 10 (2%), and perijunctional (type I) in 4 (<1%). GSV refluxing segments were noted in the SFJ in 72 (12%) and in the thigh in 220 (37%), and leg (or both) in 345 (58%).

CONCLUSIONS

The high prevalence of reflux justifies ultrasound mapping of the saphenous veins in women with primary varicose veins. Correction of SFJ reflux, however, may be needed in <or=12% of the extremities, and only about one third CEAP C2 limbs may require treatment of a refluxing GSV in the thigh.

The Epidemiology of Chronic Venous Insufficiency and Varicose Veins

Chronic venous disease is a common condition presenting to physicians in Western Europe and the United States. This article provides a comprehensive review of the published literature in the English language, from 1942 to the present, and focuses on the prevalence of chronic venous insufficiency and varicose veins, as well as the involved risk factors. Prevalence estimates vary widely by geographic location, with the highest reported rates in Western countries. Reports of prevalence of chronic venous insufficiency vary from < 1% to 40% in females and from < 1% to 17% in males. Prevalence estimates for varicose veins are higher, <1% to 73% in females and 2% to 56% in males. The reported ranges in prevalence estimations presumably reflect differences in the population distribution of risk factors, accuracy in application of diagnostic criteria, and the quality and availability of medical diagnostic and treatment resources. Established risk factors include older age, female gender, pregnancy, family history of venous disease, obesity, and occupations associated with orthostasis. Yet, there are several factors that are not well documented, such as diet, physical activity and exogenous hormone use, which may be important in the development of chronic venous disease and its clinical manifestations.

Smooth Muscle Cell Apoptosis in Primary Varicose Veins

OBJECTIVES

One of the important factors responsible for vessel wall remodelling is programmed cell death. In the paper the role of smooth muscle cell (SMC) apoptosis in primary varicose veins (PVV) is investigated.

MATERIAL AND METHODS

Vein specimens were obtained from 40 patients with PVV. In each case proximal and distal (upper crural) great saphenous veins (GSV) were harvested. Morphometric computer assessed quantitative evaluation of SMCs, collagen and elastin content was carried out. Apoptotic cells were detected by TUNEL assay. The levels of p53, BAX, BCLl-2 and p21 mRNA expression were assessed by real time RT-QPCR and the presence of respective proteins in the vessel wall was confirmed by immunohistochemistry.

RESULTS

In the proximal GSV segments a significant increase of p53, p21 and BCL-2 mRNA levels was found in PVV patients. In the distal segments BAX and BCL-2 expression levels were higher. Taking into account the patient age, elevated p53 mRNA expression level was noticed in the distal incompetent GSVs of young PVV patients. In this group a statistically significant increase in the apoptotic index (APIx) within the vein media was found which correlated positively with p53 mRNA expression level. There was no increase of the apoptotic activity in elderly patients that led to the structural changes increase. In proximal GSV segments, despite SMC amount reduction or presence of structural changes in perivalvular wall region, no increase of the APIx with was noticed.

CONCLUSIONS

P53-related apoptosis is one of the regulatory mechanisms of vein wall homeostasis maintenance. During varicose vein development its activation is related to the early stages of the disease. In the further course, the down-regulation of the SMC apoptosis within the vein media leads to the structural changes increase. The reduction of the SMC population corresponding to an increase of p21 expression in proximal saphenous vein segments suggests that the cell cycle disturbances may lead to the 'weakness' of the proximal GSV wall. Valve injury is not the only factor leading to the varicose veins occurrence.

Primary Varicose Veins: Altered Transcription of VEGF and its Receptors (KDR, flt-1, Soluble flt-1) with Sapheno-femoral Junction Incompetence

OBJECTIVE

Loss of regulation of vascular endothelial growth factor (VEGF) production and action disturbs vascular homeostasis leading to pathology. Primary varicose veins (VVs) demonstrate aberrant production/release of VEGF. Our aim was to examine transcription of genes for VEGF (VEGF(121)/VEGF(165)) and its receptors (KDR, flt-1, s.flt-1) in VVs, in relation to underlying venous incompetence.

MATERIALS AND METHODS

Samples of varicose (n=83, 18 patients) or normal (n=14, five subjects) great saphenous vein were divided into segments, determined by anatomical position from the sapheno-femoral junction (SFJ). SFJ and segmental incompetence were determined from duplex scans. Gene transcripts were amplified by RT-PCR, analysed by scanning densitometry, and the levels of transcription determined by ratio to control gene GADPH-3 (GAP-3).

RESULTS

VEGF(121)/(165), KDR and flt-1 transcription was elevated in VVs overall (p<0.001), and in VVs with an incompetent SFJ (p<0.001), but not when the SFJ was functional; s.flt-1 was unaltered. Notably, gene transcription was unaffected by segmental position, or incompetence. Position below the SFJ correlated with increased transcription of s.flt-1 when the SFJ was incompetent (p<0.04), and s.flt-1 and VEGF(121) when the segment was incompetent (p<0.03).

CONCLUSIONS

SFJ incompetence is associated with altered transcription of VEGF and its receptors reflecting an aetiological mechanism or later stage of disease development. Altered VEGF(121) and s.flt-1 transcription may be an early event in varicogenesis.