Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study

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.

Addressing the Impact of Deep Venous Stenting on the Management of Venous Ulcer

BACKGROUND

Venous ulcers are a late and severe form of chronic venous insufficiency and account for 70% of all etiologies that cause leg ulcers in the lower limb, and they account for 20% of the 2.5 million cases complaining of chronic venous disease. Our study aims to investigate the effect of venous stenting of the deep veins on the healing of the venous ulcer.

METHODS

This is a single-center, retrospective study conducted on prospectively recorded medical records of 78 patients with chronic deep venous diseases-C6 (either nonocclusive iliac venous lesion or post-thrombotic syndrome). Our lesion involved May-Thurner lesions, occlusions, insufficiencies, or stenoses owing to an affection of the venous outflow segment. All our patients underwent endovascular management, and those who did not respond successfully were transitioned to compression therapy. We then compared the outcomes of both groups in terms of ulcer healing and quality of life.

RESULTS

A total of 78 patients (78 limbs), with a mean age of 39.6 ± 8.06 (range: 22-60) years, were treated. Fifty-four patients (67.9%) were males, and 24 (32.1%) were female. The etiology was primary nonocclusive iliac venous lesion in 12 limbs (16.2%) and secondary post-thrombotic obstructions in 66 (83.7%). Follow-up of the ulcer with compliance to compression therapy and standard care of the ulcer, sustained ulcer healing (reduction in ulcer area) was achieved in 60% of limbs, and most of the nonocclusive healing occurred within the first 3 months (P < 0.01).

CONCLUSIONS

Our results show that deep venous stenting is associated with high wound healing rates. This rate reaches a statistically significant difference in 3 months, but this difference doesn't reach statistical significance at 6 months, with less recurrence and improved quality of life with a high cumulative patency rate, and compression therapy is the mainstay of the conservative management of venous ulceration.

Stasis and Inflammation in Varicose Vein Development: An Interleukin-Mediated Process from Intima to Media

INTRODUCTION

This study investigated the combination of venous stasis and inflammation in varicose vein development.

METHODS

The study included patients with primary varicose veins operated using high ligation and stripping of greater saphenous vein. All of them showed reflux at sapheno-femoral junction on preoperative Doppler ultrasound. Mesenteric veins from early or advanced gastric cancer specimens were used as control group. Inflammatory mediators expressed in the venous wall were measured via immunohistochemistry and compared between the two groups.

RESULTS

Thirty-five (59.3%) men and 24 women with a mean age of 52.8 years (range, 23-77 years) were included and 29 (49.2%) patients had edema or skin changes according to Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification and reporting standards for chronic venous disorders. The expression of interleukin 6 (IL-6) and transforming growth factor β1 (TGF-β1) in intima and those of IL-6 in media of greater saphenous veins increased, with statistically significant differences between the two groups (p < 0.001). IL-6 in media and TGF-β1 levels in intima were independent predictors of varicose veins (adjusted odds ratios 74.62 and 66.69, respectively).

CONCLUSION

Elevated venous pressure represented by reflux on Doppler ultrasound and increased expression of inflammatory cytokines including IL-6 in media and TGF-β1 in intima are associated with the development of varicose veins.

Factors associated with clinical severity in chronic venous disease: The role of functional parameters

INTRODUCTION

Chronic venous disease (CVD) is a highly prevalent disease that presents a wide spectrum of clinical expressions due to abnormalities in the venous system. Patients often have major functional changes that can limit daily activities. However, the functional factors associated with the severity of the disease remain poorly understood.

OBJECTIVE

To identify the functional factors associated with CVD severity.

METHODS

Seventy-five patients with CVD (92.0% females, 49.6 ± 13.3 years) were evaluated through clinical examination, lower limb perimetry, ankle range of motion (AROM), and lower limb muscle strength by the Heel Rise test, and Sit-to-stand test. Patients were stratified according to the disease severity as mild (telangiectasia, varicose veins, or edema in the lower limbs) or severe CVD (trophic changes or venous ulcer).

RESULTS

Patients with severe CVD (n = 13) were older (p = 0.002), predominantly male (p = 0.007), with reduced AROM in dorsiflexion (p = 0.028) and inversion (p = 0.009), reduced lower limb strength by the Heel Rise test (p = 0.040), and greater circumference of the calf (p = 0.020), ankle (p = 0.003), and plantar arch (p = 0.041) when compared to mild CVD (n = 62). Advanced age, male sex, lower ankle range of motion in dorsiflexion, and greater ankle and plantar arch circumferences were associated with CVD severity. However, the ankle circumference (OR 1.258, 95% CI: 1.008-1.570; p = 0.042), together with advanced age and male sex, was the only functional variable that remained independently associated with CVD severity.

CONCLUSION

The increased ankle circumference was a determinant of the CVD severity and may assist in risk stratification and guide treatment goals in this population.

BULBOSITIES AND INTERVORTEX VENOUS ANASTOMOSIS IN VENOUS OVERLOAD CHOROIDOPATHY MASQUERADING AS POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To describe a patient with venous overload choroidopathy in whom venous bulbosities masqueraded as polyps and intervortex venous anastomosis mimicked a branching vascular network, giving the appearance of polypoidal choroidal vasculopathy.

METHODS

The patient had complete ophthalmic examination including indocyanine green angiography and optical coherence tomography. Venous bulbosities were defined on indocyanine green angiography as focal dilations in which the diameter of the dilation is two times that of the host vessel.

RESULTS

A 75-year-old woman presented with combined subretinal and subretinal pigment epithelium hemorrhages in the right eye. During indocyanine green angiography, focal nodular hyperfluorescent lesions connected to a network of vessels were observed, which looked like polyps and branching vascular network in polypoidal choroidal vasculopathy. In both eyes, the midphase angiogram had multifocal choroidal vascular hyperpermeability. There was late-phase placoid staining nasal to the nerve in the right eye. During enhanced depth imaging-optical coherence tomography evaluation, there were no retinal pigment epithelium elevations that would be expected with polyps or branching vascular network in the right eye. A double-layer sign was seen corresponding to the placoid area of staining. Diagnosis of venous overload choroidopathy and choroidal neovascularization membrane was made. She was treated with intravitreal antivascular endothelial growth factor injections for the choroidal neovascularization membrane.

CONCLUSION

Indocyanine green angiography findings in venous overload choroidopathy may mimic polypoidal choroidal vasculopathy, but differentiation is essential because it has implications for treatment. Similar findings may have been misinterpreted in the past and may have previously contributed to conflicting clinical and histopathologic descriptions of polypoidal choroidal vasculopathy.

Exome sequencing identifies novel genetic variants associated with varicose veins

BACKGROUND

Varicose veins (VV) are one of the common human diseases, but the role of genetics in its development is not fully understood.

METHODS

We conducted an exome-wide association study of VV using whole-exome sequencing data from the UK Biobank, and focused on common and rare variants using single-variant association analysis and gene-level collapsing analysis.

FINDINGS

A total of 13,823,269 autosomal genetic variants were obtained after quality control. We identified 36 VV-related independent common variants mapping to 34 genes by single-variant analysis and three rare variant genes (PIEZO1, ECE1, FBLN7) by collapsing analysis, and most associations between genes and VV were replicated in FinnGen. PIEZO1 was the closest gene associated with VV (P = 5.05 × 10-31), and it was found to reach exome-wide significance in both single-variant and collapsing analyses. Two novel rare variant genes (ECE1 and METTL21A) associated with VV were identified, of which METTL21A was associated only with females. The pleiotropic effects of VV-related genes suggested that body size, inflammation, and pulmonary function are strongly associated with the development of VV.

CONCLUSIONS

Our findings highlight the importance of causal genes for VV and provide new directions for treatment.

Single-center clinical experience of cyanoacrylate embolization method for incompetent perforating veins in treating CEAP-6 patients

OBJECTIVE

The most severe form of chronic venous insufficiency includes venous leg ulcers in the CEAP-6 stage. The aim of this study is to evaluate the relationship between incompetent perforator veins occluding with cyanoacrylate and closure of perforator veins and healing of venous leg ulcers in patients at the CEAP-6 stage.

METHODS

A total of 187 patients who underwent cyanoacrylate application to incompetent perforator veins due to venous leg ulcers from 2018 to 2021 were retrospectively reviewed. Twelve months after the procedure, patients were evaluated for perforator vein closure, ulcer diameter, and Venous Clinical Severity Scale. Receiver operating characteristic analysis was used to estimate the probability of postoperative nonocclusion of the perforating vein based on the preoperative ulcers' diameters and the perforating veins' mean diameters. Univariate and multivariate binary logistic regression analyses were conducted to identify the risk factors associated with incomplete closure of the perforating vein.

RESULTS

At the 12 months, 87.1% of patients experienced incompetent perforator veins closure, leading to complete healing of venous leg ulcers. Preoperative ulcer diameter significantly decreased from 7.20 ± 3.48 cm2 to 0.28 ± 0.77 cm2 after the procedure (P < .001). On average, 3.5 ± 1.01 perforating veins were treated, with a diameter of 4.09 ± 0.41 mm. No postoperative paresthesia or deep vein thrombosis occurred. Preoperative Venous Clinical Severity Scale scores decreased significantly from 17.85 ± 3.06 to 8.03 ± 3.53 postoperatively (P < .001). Patients with nonoccluded perforating veins had larger preoperative ulcer diameters (13.77 ± 1.78 cm2) than those with occluded perforating veins (6.24 ± 2.47 cm2; P < .001). The mean perforating vein diameter was also larger in nonoccluded perforating veins patients (4.45 ± 0.41 mm) than in occluded perforating veins patients (4.04 ± 0.38 mm; P < .001). The sensitivity, specificity, and accuracy of the preoperative ulcer diameter cutoff point of 11.25 cm2 for the possibility of postoperative nonocclusion of perforating veins were 100% each. In contrast, those for the preoperative mean perforating vein diameter cutoff point of 4.15 mm were determined as 66.7%, 79.1%, and 77.5%, respectively. The presence of diabetes mellitus increased the likelihood of incompetent perforator veins, remaining open by 3.4 times (95% confidence interval: 1.11-10.44; P = .032), whereas a 1 mm larger mean perforating vein diameter increased this likelihood by 9.36 times (95% confidence interval: 3.47-25.29; P < .001).

CONCLUSIONS

This study demonstrates that occlusion of incompetent perforator veins with cyanoacrylate is effective, safe, and associated with low complication rates in CEAP-6 patients. The findings support that cyanoacrylate occlusion of perforator veins may be a valuable option in the treatment of venous leg ulcers.

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.

Vicious Circle With Venous Hypertension, Irregular Flow, Pathological Venous Wall Remodeling, and Valve Destruction in Chronic Venous Disease: A Review

Substantial advances occurred in phlebological practice in the last two decades. With the use of modern diagnostic equipment, the patients' venous hemodynamics can be examined in detail in everyday practice. Application of venous segments for arterial bypasses motivated studies on the effect of hemodynamic load on the venous wall. New animal models have been developed to study hemodynamic effects on the venous system. In vivo and in vitro studies revealed cellular phase transitions of venous endothelial, smooth muscle, and fibroblastic cells and changes in connective tissue composition, under hemodynamic load and at different locations of the chronically diseased venous system. This review is an attempt to integrate our knowledge from epidemiology, paleoanthropology and anthropology, clinical and experimental hemodynamic studies, histology, cell physiology, cell pathology, and molecular biology on the complex pathomechanism of this frequent disease. Our conclusion is that the disease is initiated by limited genetic adaptation of mankind not to bipedalism but to bipedalism in the unmoving standing or sitting position. In the course of the disease several pathologic vicious circles emerge, sustained venous hypertension inducing cellular phase transitions, chronic wall inflammation, apoptosis of cells, pathologic dilation, and valvular damage which, in turn, further aggravate the venous hypertension.

Prevalence, clinical presentation, and risk factors of chronic venous disease in Cameroon: A general population-based study

INTRODUCTION

Chronic venous disease is a global public health problem, with high morbidity and economic distress. There is scarcity of data on this disease in sub-Saharan Africa.

METHODS

We conducted the first population-based study over a period of 20 months from 1st February 2020 to 30th September 2021 in the 10 regions of Cameroon. A stratify sampling method was chose to select study site. Socio-demographic data, personal and family history, anthropometric parameters, clinical signs, illustrative images, CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification revised in 2004, VCSS (venous Clinical Severity Score) and risk factor assessment score were used to construct the survey form. Chi-squared test and Fischer exact test were used to compare the prevalence of chronic venous disease across different potential risk factors (sex, age category, previous history of deep vein thrombosis, hypertension, diabetes, smoking status, obesity). Simple and multiple logistic regression models were used to obtain crude and adjusted odds ratio for risk factors associated with chronic venous insufficiency. Statistical analyses were done with R version 4.2 for Linux and the threshold for statistical significance was 0.05.

RESULTS

A total of 6578 participants were included in the study, with a mean age of 41.09 ± 16.02 years with female predominance (54.3%). The prevalence of chronic venous disease was 21.8% (95% CI: 20.8-22.9) and the prevalence of chronic venous insufficiency (C3-C6) was 7.02% (n = 462). Night cramps (43.2%), oedema (21.7%), lower limbs pain (20.4%) mostly worsens by walking and heavy legs (16.2%) were more common symptoms. The mean total venous clinical severity score was 0.69 ± 1.76 and this score had a significant positive correlation with C classification (p < .001). In the multivariate analysis, the following factors were independently associated with CVD: Male gender (aOR: 1.27; 95%CI: 1.04-1.56; p = .021), retired people (aOR: 46.9; 95% CI: 12.6-174.5; p < .001), hypertension (aOR: 289.5; 95%CI: 169.69-493.1; p < .001), diabetes (aOR: 2.19; 95% CI: 1.21-3.96; p = .009), obesity (aOR: 10.22; 95%CI: 7.67-13.62; p < .001). Smoking appears as a protective factor (aOR: 0.18; 95%CI: 0.10-0.30; p < .001).

CONCLUSION

Chronic venous disease is frequent in Cameroon and main traditional cardiovascular risk factors are associated to this condition. Systematic screening of the CVD in these specific groups could reduce the burden of the disease and its economic impact.

Risk Factors for Contrast Media Extravasation in Intravenous Contrast-Enhanced Computed Tomography: An Observational Cohort Study

RATIONALE AND OBJECTIVES

To identify the risk factors for contrast media (CM) extravasation and provide effective guidance for reducing its incidence.

MATERIALS AND METHODS

We observed adult inpatients (n = 38 281) who underwent intravenous contrast-enhanced computed tomography between January 1, 2018, and December 31, 2022. Risk factors for CM extravasation were evaluated using univariate and multivariate logistic regression.

RESULTS

Among the 38 281 inpatients who underwent enhanced computed tomography angiography, 3885 received peripherally inserted central venous catheters (PICCs) and 34 396 received peripheral short catheters. In 3885 cases of PICCs, no CM extravasation occurred, but in five cases, ordinary PICCs that are unable to withstand high pressure were mistakenly used; three of those patients experienced catheter rupture, and eventually, all five patients underwent unplanned extubation. Among 34 396 cases of peripheral short catheters, 224 (0.65%) had CM extravasation. Female sex (odds ratio [OR]=1.541, 95% confidence interval [CI]: 1.111-2.137), diabetes (OR=2.265, 95% CI: 1.549-3.314), venous thrombosis (OR=2.157, 95% CI: 1.039-4.478), multi-site angiography (OR=9.757, CI: 6.803-13.994), and injection rate ≥ 3 mL/s (OR=6.073, 95% CI: 4.349-8.481) were independent risk factors for CM extravasation. Due to peripheral vascular protection measures in patients with malignant tumor, there was a low incidence of CM extravasation (OR=0.394, 95% CI: 0.272-0.570).

CONCLUSION

Main risk factors for CM extravasation are female, diabetes, venous thrombosis, multi-site angiography, and injection rate ≥ 3 mL/s. However, patients with malignant tumor have a low incidence of CM extravasation.

CLINICAL IMPACT

Analysis of these risk factors can help reduce the incidence of CM extravasation.

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.

Replication study identified EFEMP1 association with varicose vein predisposition among Indians

BACKGROUND

Varicose vein is a chronic condition that affects the lower extremities of the human body. Several factors have been implicated in the development of this disease, viz age, gender, weight, height and prolonged standing. Recently, genome-wide studies have identified genetic biomarkers that are associated with varicose veins in different ethnic groups. Such genetic studies are lacking in South Asians specifically in Indians where the prevalence of varicose veins is high, and it is important to replicate these variants in the stated population. The study aimed to replicate the association of genetic variants associated with varicose veins in this target population, which were found to be associated with the other ethnic groups.

METHODOLOGY

The studied cohort is of the Indian population comprising unrelated 104 varicose veins cases and 448 non-varicose vein controls. The samples were genotyped using the Illumina Global Screening Array. Using the genomic data from UK BioBank and 23andMe studied cohorts; eight genetic variants were selected to replicate in our dataset. The allelic association was performed to identify the effective allele and risk was estimated using odds ratio and p-value as level of significance. Multifactor Dimensionality Reduction was used to estimate the cumulative effect of variants in Indians.

RESULT

Variant rs3791679 of EFEMP1 was found to be associated with varicose veins in Indians. After observing the association of the EFEMP1 with varicose veins, we further ensued to identify all genetic variants within EFEMP1 to uncover the additional variants associated with this trait. Interestingly, we identified six new variants of EFEMP1 gene that have shown association. Moreover, the cumulative effect of all associated variations was estimated and the risk was 2.7 times higher in cases than controls whereas independently their effect ranges from 0.37-1.58.

CONCLUSION

This study identifies EFEMP1 as a potential gene related to the risk of varicose veins in Indians. It also highlights that evaluating the maximum number of variants of a gene rather than focusing solely on replicating single variations offers a more comprehensive and nuanced understanding of the genetic factors contributing to a complex trait like varicose veins.

Understanding CEAP Classification: Insights from an Italian Survey on Corona Phlebectatica and Recurrent Active Venous Ulcers by Vascular Specialists

Background and Objectives: The clinical relevance of "corona phlebectatica" and the management of risk factors for recurrence of venous ulcers in patients with chronic venous disease may be variable based on vascular specialists in different geographical areas of Italy. The aim of the present survey is to evaluate the management of patients with chronic venous disease by vascular specialists in different areas of the national territory. In particular, this involves ascertaining the clinical/prognostic relevance attributed to the presence of the "corona phlebectatica" as well as to the management of risk factors related to recurrence of venous ulcers. Materials and Methods: The web-based survey aimed at vascular medicine specialists with particular interest in venous disease. A questionnaire was developed, based on 12 questions, in relation to clinical assessment, risk factor management, and therapy in patients with chronic venous disease. Results: Almost all of the specialists involved actively participated in the survey, declaring that they personally manage chronic venous disease overall. There was a strong agreement in the prognostic consideration attributed to the presence of "corona phlebectatica" and to the management of risk factors for venous ulcer recurrence, regardless of the different geographical areas of interest. Conclusions: Accordingly with the results of this self-assessment survey, the skills and experience of the specialists involved appear to be of a good standard, both in the clinical evaluation and in the management of the progression of chronic venous disease. However, the need to reach more cultural insights into the correlations between chronic venous disease and risk factors correlated with disease progression emerges. Moreover, there was the need for a greater and tighter overall clinical control of a patient with chronic venous disease, also in relation to the presence of comorbidities.

Differences in risk profile associated with varicose veins and chronic venous insufficiency - results from the Bonn Vein Study 1

Background: The aim of this publication is to demonstrate similarities and differences in the association of risk factors with the prevalence of different manifestations of chronic venous disease (CVD), like varicose veins (VV), venous oedema (C3) and severe chronic venous insufficiency (CVI) in the population-based cross-sectional Bonn Vein Study 1 (BVS). Patients and methods: In the BVS 1 between 13.11.2000 and 15.3.2002, 3.072 participants, 1350 men and 1722 women, from a simple random sample of the general population of the city of Bonn and two rural townships aged 18-79 years were included. The overall response proportion was 59%. All participants answered a standardized questionnaire including information about socio-economic data, lifestyle, physical activity, medical history, and quality of life. Venous investigations were performed clinically and by a standardized duplex examination by trained investigators. The CEAP classification in the version of 1996 was used to classify the findings. Logistic regression models were performed for the association of possible risk factors with VV, venous edema (C3) and severe CVI (C4-C6). The predictive risk (PR) describes the association of the diseases and the possible influencing factors. Results: VV, venous oedema (C3) and severe CVI (C4-C6) have common risk factors like higher age, number of pregnancies, family history of VV and overweight or obesity. Female gender is significantly associated with VV and C3 but not with severe CVI (C4-C6). High blood pressure and urban living are only associated with C3 and C4-C6 disease whereas prolonged sitting is associated with C3 and lower social class with C4-C6 exclusively. Discussion: In many epidemiological studies risk factors were associated with chronic venous disorders in general. Our data show that VV, venous edema and severe CVI may have different risk profiles. Venous edema is more often associated with arterial hypertension and sedentary lifestyle whereas lower social class seems to be a risk factor for severe CVI including venous ulcers. Conclusions: The differences in the association of risk factors to VV, venous edema and severe CVI should be considered if prevention and treatment of chronic venous diseases are planned. As examples, compression stockings could be proposed in sitting profession to prevent oedema, VV patients with risk factors like obesity might benefit from early treatment for VV and obesity. More longitudinal evaluation of risk factors is necessary to evaluate the true risk profile of CVD.

Efficacy and safety of mechanochemical ablation versus laser ablation in the treatment of primary great saphenous vein reflux: A randomized, open, parallel controlled clinical trial

OBJECTIVE

To evaluate the efficacy of a new mechanochemical ablation (MOCA) device versus endovenous laser ablation (EVLA) for primary great saphenous vein (GSV) reflux.

MATERIALS AND METHODS

Prospectively analyze the demographics, treatment detail and outcomes data of 57 primary GSV reflux patients. Patients were randomly assigned to MOCA or EVLA group with random envelope method. Primary endpoint was 6-month closure rate of GSV. Secondary endpoint including technical success rate, the venous clinical severity score (VCSS), chronic venous insufficiency questionnaire (CIVIQ-20) score and visual analogue scale (VAS) for pain.

RESULTS

The procedures were well tolerated according to the VAS score. The 6-month closure rate was 85.71% in MOCA and 96.55% in EVLA group (p = .194). Significant changes were observed in regard of VCSS and CIVIQ-20 score at 6-month follow-up. Skin paresthesia occurred in 0 in MOCA and 5 in EVLA group.

CONCLUSION

The new MOCA device is safe and effective in treating primary great saphenous vein reflux. The 6-month closure rate is non-inferior compared with EVLA. However, the long-term results need further follow-up.

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.

A novel view to varicose veins pathogenesis: Proteomic profiling suggests a pivotal role of extracellular matrix degradation

INTRODUCTION

Although morphological and anatomical studies indicate that venous wall weakening and subendothelial fibrosis characterize varicose veins (VV), the pathogenesis of VV remains poorly understood. The aim of this study is to obtain protein expression profiles in patients with VV and thereby get a step closer to understanding the pathogenesis of VV.

METHODS

Specimens were obtained from total of 10 patients, that is, from 5 patients undergoing VV surgical stripping and from 5 non-VV patients undergoing bypass surgery. Specimens were collected from the same layers of venous wall. Proteins were extracted from each specimen and analyzed by ion mobility spectrometry (IMS-MS). In total, 1387 were identified and 486 proteins were identified in all samples. From these, 15 proteins were differentially expressed between VV and non-VV samples (p < .05) and 12 of these showed a fold change >1.5.

RESULTS

Interestingly, among the differentially expressed proteins, only two proteins were significantly increased in the VV tissue, that is, GAPDH (p = .028, fold change 2.74), where several proteins involved in maintaining the homeostasis in the extracellular matrix, that is, the CXXC zinc finger protein 5 (CXXC5) and nucleoporin (SEH1) were prominently downregulated (p = .049, fold change 37.8, and p = .040, fold change 3.46). The downregulation in protein expression of CXXC5 and SEH1 as well as upregulation of GAPDH were validated by Western blotting.

CONCLUSION

The identified differentially expressed proteins suggest an altered profile of the connective tissue proteins as well as an increased proteolytic enzyme activity which both may be central in the pathophysiology of varicose veins.

The Histopathology of Leg Ulcers

Ulcerations of the lower extremities are a frequently encountered problem in clinical practice and are of significant interest in public health due to the high prevalence of underlying pathologies, including chronic venous disease, diabetes and peripheral arterial occlusive disease. However, leg ulcers can also present as signs and symptoms of various rare diseases and even as an adverse reaction to drugs. In such cases, correct diagnosis ultimately relies on histopathological examination. Apart from the macroscopic presentation, patient history and anatomic location, which are sometimes indicative, most ulcers have very distinct histopathological features. These features are found in different layers of the skin or even associated vessels. In this narrative review, we discuss and highlight the histopathological differences of several types of leg ulcers that can contribute to efficient and accurate diagnosis.

Syncope (fainting on standing from squatting) due to massive venous reflux into lower limb varicose veins - Case report

A 42-year-old man presented with very large lower limb varicose veins bilaterally and an 8-month history of fainting when standing up from a squatting position. He had been investigated for syncope by a cardiologist with no abnormality found on electrocardiogram, echocardiogram, 24-h electrocardiogram or 48-h blood pressure monitoring. Venous duplex ultrasonography showed bilaterally great saphenous vein reflux, with each vein having a diameter of 23.5 and 24.0 mm at the groin, and a similar dilation along the whole vein to ankle. These veins were successfully ablated with endovenous laser ablation, immediately following which the syncope disappeared and has not returned. We calculate that before treatment, the patient had approximately 500 ml of blood refluxing passively with gravity from his deep venous system on standing into his incompetent great saphenous veins and associated varicosities, which would account for his postural syncope.

Prevalence of Varicose Veins and Its Risk Factors among Nurses Working at King Khalid University Hospital Riyadh, Saudi Arabia: A Cross-Sectional Study

This quantitative observational cross-sectional study assessed the prevalence and level of risk scores for varicose veins among nurses, and the association between varicose veins and sociodemographic, occupational, and lifestyle risk factors. Using simple random sampling, from August-December 2022, 250 nurses from different departments at King Khalid University Hospital completed a validated self-administered questionnaire and underwent an observational physical examination. Most nurses (191) had low-risk scores for varicose veins, 46 nurses had moderate-risk scores, and 13 nurses had high-risk scores. From the outpatient clinics, 61.5% of nurses had significant high-risk scores for varicose veins. Those with a statistically significant association had a family history of varicose veins (p < 0.001) and other chronic medical conditions (p = 0.04). Physical activity, especially race-walking/running (p = 0.006), showed a statistically significant association with the varicose veins score. The years as a staff nurse were statistically significant among the occupational risk factors (p = 0.003). The adjusted multivariable regression model showed three significant predictors: a positive family history, running/walking, and total years as a staff nurse (p < 0.001, p = 0.02, and p < 0.001, respectively). Nurses working at outpatient clinics, positive family history, years as a staff nurse, and other chronic conditions are risk factors for varicose veins, while race-walking/running is a protective factor.

Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery

The Brazilian Society of Angiology and Vascular Surgery has set up a committee to provide new evidence-based recommendations for patient care associated with chronic venous insufficiency. Topics were divided in five groups: 1. Classification, 2. Diagnosis, 3. Conservative or non-invasive treatment, 4. Invasive treatment and 5. Treatment of small vessels. This last series is closely related to the activities of Brazilian angiologists and vascular surgeons, who are heavily involved in the treatment of small superficial veins. These guidelines are intended to assist in clinical decision-making for attending physicians and health managers. The decision to follow a guideline recommendation should be made by the responsible physician on a case-by-case basis taking into account the patient's specific condition, as well as local resources, regulations, laws, and clinical practice recommendations.

Duplex ultrasound abnormalities of the lower limb veins might precede clinical venous reflux signs in post-Fontan adolescents and young adults

OBJECTIVE

After the Fontan operation (ie, direct anastomosis of the caval veins to the pulmonary arteries, constituting right ventricular bypass circulation), high central venous pressure can lead to peripheral venous stasis and venous valvar insufficiency. We hypothesized that post-Fontan patients are at a higher risk of developing lower extremity venous lesions detectable using duplex ultrasound, even if clinical signs of chronic venous disease might not be evident.

METHODS

A total of 87 transplantation-free survivors after the Fontan procedure who reached adolescence or young adulthood (current age, 15-30 years) participated in a leg vein duplex ultrasound study. The median age at the Fontan procedure, median age at the vein study, and median interval between the two were 3.65 years (interquartile range [IQR], 3.1-5.3 years), 21.7 years (IQR, 18.9-24.7 years), and 16.6 years (IQR, 14.9-19.4 years), respectively. Duplex ultrasound scanning was performed using a venous ultrasound imaging system (Logiq P7; GE Healthcare). The patients were categorized according to the presence of venous reflux (VR) in the superficial, deep, or perforating venous systems: no VR, superficial VR (SVR), deep VR (DVR), perforating VR (PVR), and a combination of multiple venous systems. Correlation of the duplex ultrasound-detected venous lesions with clinical severity using the modified CEAP (clinical, etiological, anatomical, pathophysiological) classification was analyzed using Spearman's correlation analysis.

RESULTS

Leg pain was reported by 48 of 87 patients (55.2%). The duplex ultrasound findings for the cohort were no VR in 21 patients (24.1%), SVR in 22 (25.3%), isolated PVR in 21 (24.1%), and reflux of multiple venous systems in 23 patients, including SVR and PVR in 19, DVR and PVR in 1, and SVR, PVR, and DVR in 3 patients. Although the patients with advanced venous lesions detected by duplex ultrasound tended to have a higher CEAP clinical class (P < .001), VR of any venous system on duplex ultrasound was present even in patients with a lower CEAP clinical class. The CEAP clinical class was C0 for 66 patients (76%), and VR of any venous system was present on duplex ultrasound in 66 patients (76%).

CONCLUSIONS

The prevalence of lower extremity venous lesions detected by duplex ultrasound is strikingly high in post-Fontan adolescents and young adults, and duplex ultrasound-detected venous abnormalities can precede clinical manifestations. Early detection and timely intervention for leg vein problems are mandatory for post-Fontan patients, especially for those considered to have risk factors for developing chronic lower extremity venous disease.

Prevalence and associated factors of chronic venous disease among the modern Iranian urban population

OBJECTIVES

Chronic venous disease (CVD) of the lower extremities is one of the common venous diseases in different populations, with a wide range of clinical manifestations and undetermined exact prevalence owing to different population characteristics and measurement methods. This study aimed to estimate the prevalence of CVD among the modern Iranian urban population and determine its associated risk factors.

METHODS

The Heart Assessment and Monitoring in Rajaie Hospital study, a longitudinal population-based cohort, aims to investigate the baseline prevalence and the 10-year incidence of cardiovascular diseases and associated risk factors in the adult population aged 30 to 75 years with no overt cardiovascular diseases in Tehran. Two instructed interventional cardiologists performed CVD evaluation using the Clinical-Etiology-Anatomy-Pathophysiology classification. CVD was graded as C1 to C6, and chronic venous insufficiency (CVI) as C3 to C6. A multivariable regression model was used to analyze the association between CVD and prespecified covariates of age, sex, body mass index (≥30 kg/m2), smoking, hypertension, diabetes mellitus, physical activity, dyslipidemia, and delivery method.

RESULTS

CVD prevalence among 1176 participants was 36.5% (95% confidence interval [CI], 33.8-39.3) and was higher in women than men (44.2% vs 23.5%). CVI prevalence was only 0.7% (95% CI, 0.3-1.3). Multivariable analysis showed that advanced age (odds ratio [OR], 1.06; 95% CI, 1.04-1.08), female sex (OR, 2.98; 95% CI, 2.14-4.14), and body mass index of ≥30 (OR, 1.36; 95% CI, 1.03-1.81) were independently associated with CVD. Physical activity (OR, 0.77; 95% CI, 0.58-1.02) was nearly protective, whereas other factors, including traditional cardiovascular risk factors, had no meaningful association with CVD.

CONCLUSIONS

Our findings showed that CVD was prevalent in the modern Iranian urban population. However, considering the very low prevalence of the higher stages of the disease, the benefit of mass screening is debatable, and better risk discriminators should be investigated.

Femoral nerve blockade during endovenous laser ablation of great saphenous vein decreases pain but does not affect the use of opioids during the procedure

BACKGROUND

Endovenous laser ablation (EVLA) using tumescent anesthesia for treatment of an insufficient great saphenous vein (GSV) can be painful and require intravenous pain management and, sometimes, sedation with propofol. Femoral nerve blockade (FNB) anesthetizes the femoral nerve distribution and is usually used for anterior thigh and knee procedures. It is easy to inject with ultrasound guidance because the nerve is easy to visualize in the groin. The aim of the present double-blind, randomized controlled trial was to determine whether FNB before tumescent anesthesia decreases the pain of GSV EVLA combined with local phlebectomy.

METHODS

Eighty patients who underwent GSV EVLA combined with local phlebectomy under tumescent anesthesia were randomized into two groups. The placebo group (control group; 40 patients) was given placebo FNB with 0.9% saline before tumescent injection. The FNB group (intervention group; 40 patients) received 1% lidocaine with adrenaline for FNB before tumescent injection. Only the study nurse, who performed the randomization, knew which patients were in which group. The patients and operating surgeon were unaware of the randomization group. FNB was performed under ultrasound guidance. The effectiveness of anesthesia was tested 10 minutes after injection using the pin-prick test and a numeric rating scale (NRS). The NRS was completed before and during tumescent anesthesia and during EVLA ablation and local phlebectomy. The motor function of the femoral nerve was tested at the end of the procedure and 1 hour after using the Bromage method. Patients had a follow-up visit 1 month after the procedure, and their need for pain medication and the duration of sick leave were recorded.

RESULTS

No differences were found in the gender distribution, age, or GSV dimensions at baseline. The mean length of the treated GSV segment was 28 cm and 30 cm and the mean energy used was 1911 J and 2059 J in the placebo and FNB groups, respectively. The median NRS score for pain during tumescent injection around the GSV was 2 (interquartile range [IQR], 1-4) in the placebo group compared with 1 (IQR, 1-3) in the FNB group. Very little pain was experienced during laser ablation. The median NRS score was 0 (IQR, 0-0) and 0 (IQR, 0-0.75) in the placebo and FNB groups, respectively. The most painful stage was injection of tumescence to the local phlebectomy sites in both groups. The median NRS score was 4 (IQR, 3-7) in the placebo group and 2 (IQR, 1-4) in the FNB group (P = .01). During local phlebectomy, the NRS score was 2 (IQR, 0-4) vs 1 (IQR, 0-3) in the placebo and FNB groups, respectively. Only the difference in pain during injection of tumescence before local phlebectomy was significant.

CONCLUSIONS

FNB seems to decrease pain during EVLA combined with local phlebectomy. Patients experienced the highest pain when tumescence was injected before local phlebectomy, and those in the FNB group experienced significantly less pain than the placebo group. No indication for routine use of FNB is indicated. However, it could be used to decrease the pain for patients who experience strong pain during varicose vein surgery, especially if extensive local phlebectomies are required.

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

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

An Individualized Machine Learning Approach for Human Body Weight Estimation Using Smart Shoe Insoles

Rapid significant weight fluctuations can indicate severe health conditions such as edema due to congestive heart failure or severe dehydration that could require prompt intervention. Daily body weighing does not accurately represent the patient's body weight fluctuations occurring within a day. The patient's lack of compliance with tracking their weight measurements is also a predominant issue. Using shoe insole sensors embedded into footwear could achieve accurate real-time monitoring systems for estimating continuous body weight changes. Here, the machine learning models' predictive capabilities for continuous real-time weight estimation using the insole data are presented. The lack of availability of public datasets to feed these models is also addressed by introducing two novel datasets. The proposed framework is designed to adapt to the patient, considering several unique factors such as shoe type, posture, foot shape, and gait pattern. The proposed framework estimates the mean absolute percentage error of 0.61% and 0.74% and the MAE of 1.009 lbs. and 1.154 lbs. for the less controlled and more controlled experimental settings, respectively. This will help researchers utilize machine learning techniques for more accurate real-time continuous weight estimation using sensor data and enable more reliable aging-in-place monitoring and telehealth.

Health Economic Analysis of Two-Layer Bandage System for Treatment of Chronic Venous Insufficiency

Background: Compression therapy is the gold standard for the treatment of chronic venous insufficiency (CVI). Two-layer bandage (2LB) systems have been shown to be a safe and effective treatment option. Objective: To estimate the total cost per response (CPR) for the resolution of edema and wounds in patients with CVI treated with a 2LB system as part of their overall wound healing regimen. Methods: A probabilistic decision tree model was developed to estimate the incremental CPR for a 2LB system. The model simulated 10 000 patients to estimate the CPR for the resolution of edema and wound healing. The analysis was performed using clinical data from a published single-arm, multicenter prospective study of CVI indicated for compression therapy. The response outcomes of interest were resolution of edema and rate of wound healing. The follow-up time was a maximum of 6 weeks, and the perspective of the study was a US outpatient treatment center. Economic data for compression therapy were based on the public prices of a 2LB system. Dressing changes occurred per manufacturer instructions for use. Results: The study comprised 702 patients (56% female), with a total of 414 wounds. The median duration of the wounds was 42 days, and the median size at the initial visit was 3.5 cm2. The average pain reduction fell by 67% using a visual analog score. Bandages were typically changed once or twice a week (51.7%). Wound healing occurred in 128 of the 414 wounds (30.9%). The expected incremental CPR of a 2LB system for the resolution of edema was $65.67 (range, $16.67-$124.32). The expected incremental CPR of a 2LB system for the healing of a wound was $138.71 (range, $35.71-$273.53). Conclusion: This economic evaluation complements previous clinical effectiveness and safety studies of 2LB systems for the treatment of CVI. The results demonstrate that the costs of incorporating 2LB into standard wound-healing protocols are negligible compared with overall treatment costs. Two-layer bandages may be considered a cost-effective first-line system for the treatment of wounds caused by CVI.

The influence of different sub-bandage pressure values in the prevention of recurrence of venous ulceration-A ten year follow-up

OBJECTIVE

The aim of this study was to establish the efficacy of three different strengths of compression systems in the prevention of venous leg ulcer (VLU) recurrences during a 10-year follow up period.

METHODS

An open, prospective, randomized, single-center study included 477 patients (240 men, 237 women; mean age 59 years). Patients were randomized into three groups: Group A) 149 patients (allocated to wear elastic stocking 18-25 mmHg). Group B) 167 patients (wearing compression device exerting 25-35 mmHg), and Group C) 161 patients (treated with multilayer compression system exerting 35-50 mmHg).

RESULTS

Overall, 65% (234/360) of patients had recurrent VLU within 10 years. Recurrence occurred in 120 (96%) of 125 in group A, in 89 (66.9%) of 133 patients in group B and in 25 (24.5%) of 102 patients in group C (p < 0.05).

CONCLUSION

Compression systems with the higher compression class provide lower recurrence rate.

A review of the current literature of ethnic, gender, and socioeconomic disparities in venous disease

Venous disease is prevalent, undertreated, and frequently unrecognized. During the past two decades, new treatment modalities have changed how venous disease is approached. Some of these treatment modalities are only available in certain centers or locations and access to care could be inequitable. Although venous disease affects millions in the United States, we have little understanding of the gender, socioeconomic, and ethnic disparities in both superficial and deep venous disease presentation. In an effort to better understand the treatment of male and female patients from different gender, ethnic, and socioeconomic backgrounds, literature searches were conducted to investigate how these patients were evaluated and treated. PubMed was used to search literature using the terms "venous insufficiency," "superficial venous disease," "venous thromboembolism," "deep vein thrombosis," "DVT," "May-Thurner," and "pulmonary embolism," with gender, sex, racial, and socioeconomic disparities and differences within the keywords. In addition, once articles were discovered, the "similar articles" function was used to expand the search. The included studies were restricted to those reported from 1995 to the present. Given the paucity of data, no study was excluded. It is readily apparent that there is not enough data to make decisions that would modify treatment to affect the outcomes of patients with differing backgrounds and gender. Studies currently are limited to evaluating patients by sex assigned at birth without interrogation of their identified gender. It is imperative that consideration is given to evaluating gender and ethnic differences, because treatment options might need to be tailored accordingly. Outreach and education for underserved patient populations with improvement in access to care must also be incorporated into the healthcare system. Additional work in this area is required. Further data collection and research related to demographic disparities among patients with venous disease is necessary to better understand the differences that could change treatment algorithms tailored to specific groups.

Varicose Vein Education and Informed coNsent (VVEIN) study: a randomised controlled pilot feasibility study

INTRODUCTION

Doctors have a legal requirement and duty of care to ensure patients are enabled to make an informed decision about their treatment, including discussion of the benefits, risks and alternatives to a procedure. A patient-centred approach to consent has been firmly established in Ireland, and fundamental to this is the ability to engage in a dialogue that offers comprehensible information to patients. Telemedicine has revolutionised the way we can deliver care to patients in the modern era of computers, tablets, and smartphones, and its use has been rapidly expanded. Novel digital strategies to improve the informed consent process for surgical procedures have been increasingly under investigation over the last 10-15 years and may offer a low cost, accessible and tailored solution to consent for surgical interventions. Within vascular surgery, superficial venous interventions have been associated with a high number medicolegal claims and also represents an area within the specialty with rapidly evolving technology and techniques. The ability to communicate comprehensible information to patients has never been greater. Thus, the author's aim is to explore whether it is feasible and acceptable to deliver a digital health education intervention to patients undergoing endovenous thermal ablation (EVTA) to supplement the consent process.

METHODS

This is a prospective, single centre, randomised controlled, feasibility trial recruiting patients with chronic venous disease deemed suitable to undergo EVTA. Patients will be randomised to receive either standard consent (SC) or a newly developed digital health education tool (dHET). The primary outcome is feasibility; assessing the recruitment and retention rate of participants and assessing acceptability of the intervention. Secondary outcomes include knowledge retention, anxiety and satisfaction. This feasibility trial is designed to recruit 40 patients, which will allow for a moderate dropout rate. This pilot study will inform the authors of the appropriateness of an adequately powered multicentre trial.

DISCUSSION

To examine the role of a digital consent solution for EVTA. This may improve and standardise the consent dialogue with patients and may have the potential to reduce claims related to poor consent processes and disclosure of risks.

ETHICAL COMMITTEE REFERENCE

Ethical approval has been sought and received from both the Bon Secours Hospital and RCSI (202109017), on 14 May 2021 and 10 October 2021, respectively.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05261412 , registered on 1 March 2022.

Physical exercise for the treatment of non-ulcerated chronic venous insufficiency

BACKGROUND

Chronic venous insufficiency (CVI) is a condition related to chronic venous disease that may progress to venous leg ulceration and impair quality of life of those affected. Treatments such as physical exercise may be useful to reduce CVI symptoms. This is an update of an earlier Cochrane Review.

OBJECTIVES

To evaluate the benefits and harms of physical exercise programmes for the treatment of individuals with non-ulcerated CVI.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 28 March 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing exercise programmes with no exercise in people with non-ulcerated CVI.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were intensity of disease signs and symptoms, ejection fraction, venous refilling time, and incidence of venous leg ulcer. Our secondary outcomes were quality of life, exercise capacity, muscle strength, incidence of surgical intervention, and ankle joint mobility. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included five RCTs involving 146 participants. The studies compared a physical exercise group with a control group that did not perform a structured exercise programme. The exercise protocols differed between studies. We assessed three studies to be at an overall unclear risk of bias, one study at overall high risk of bias, and one study at overall low risk of bias. We were not able to combine data in meta-analysis as studies did not report all outcomes, and different methods were used to measure and report outcomes. Two studies reported intensity of CVI disease signs and symptoms using a validated scale. There was no clear difference in signs and symptoms between groups in baseline to six months after treatment (Venous Clinical Severity Score mean difference (MD) -0.38, 95% confidence interval (CI) -3.02 to 2.26; 28 participants, 1 study; very low-certainty evidence), and we are uncertain if exercise alters the intensity of signs and symptoms eight weeks after treatment (MD -4.07, 95% CI -6.53 to -1.61; 21 participants, 1 study; very low-certainty evidence). There was no clear difference in ejection fraction between groups from baseline to six months follow-up (MD 4.88, 95% CI -1.82 to 11.58; 28 participants, 1 study; very low-certainty evidence). Three studies reported on venous refilling time. We are uncertain if there is an improvement in venous refilling time between groups for baseline to six-month changes (MD 10.70 seconds, 95% CI 8.86 to 12.54; 23 participants, 1 study; very low-certainty evidence) or baseline to eight-week change (MD 9.15 seconds, 95% CI 5.53 to 12.77 for right side; MD 7.25 seconds, 95% CI 5.23 to 9.27 for left side; 21 participants, 1 study; very low-certainty evidence). There was no clear difference in venous refilling index for baseline to six-month changes (MD 0.57 mL/min, 95% CI -0.96 to 2.10; 28 participants, 1 study; very low-certainty evidence). No included studies reported the incidence of venous leg ulcers. One study reported health-related quality of life using validated instruments (Venous Insufficiency Epidemiological and Economic Study (VEINES) and 36-item Short Form Health Survey (SF-36), physical component score (PCS) and mental component score (MCS)). We are uncertain if exercise alters baseline to six-month changes in health-related quality of life between groups (VEINES-QOL: MD 4.60, 95% CI 0.78 to 8.42; SF-36 PCS: MD 5.40, 95% CI 0.63 to 10.17; SF-36 MCS: MD 0.40, 95% CI -3.85 to 4.65; 40 participants, 1 study; all very low-certainty evidence). Another study used the Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-20), and we are uncertain if exercise alters baseline to eight-week changes in health-related quality of life between groups (MD 39.36, 95% CI 30.18 to 48.54; 21 participants, 1 study; very low-certainty evidence). One study reported no differences between groups without presenting data. There was no clear difference between groups in exercise capacity measured as time on treadmill (baseline to six-month changes) (MD -0.53 minutes, 95% CI -5.25 to 4.19; 35 participants, 1 study; very low-certainty evidence). We are uncertain if exercise improves exercise capacity as assessed by the 6-minute walking test (MD 77.74 metres, 95% CI 58.93 to 96.55; 21 participants, 1 study; very low-certainty evidence). Muscle strength was measured using dynamometry or using heel lifts counts. We are uncertain if exercise increases peak torque/body weight (120 revolutions per minute) (changes from baseline to six months MD 3.10 ft-lb, 95% CI 0.98 to 5.22; 29 participants, 1 study; very low-certainty evidence). There was no clear difference between groups in baseline to eight-week change in strength measured by a hand dynamometer (MD 12.24 lb, 95% CI -7.61 to 32.09 for the right side; MD 11.25, 95% CI -14.10 to 36.60 for the left side; 21 participants, 1 study; very low-certainty evidence). We are uncertain if there is an increase in heel lifts (n) (baseline to six-month changes) between groups (MD 7.70, 95% CI 0.94 to 14.46; 39 participants, 1 study; very low-certainty evidence). There was no clear difference between groups in ankle mobility measured during dynamometry (baseline to six-month change MD -1.40 degrees, 95% CI -4.77 to 1.97; 29 participants, 1 study; very low-certainty evidence). We are uncertain if exercise increases plantar flexion measured by a goniometer (baseline to eight-week change MD 12.13 degrees, 95% CI 8.28 to 15.98 for right leg; MD 10.95 degrees, 95% CI 7.93 to 13.97 for left leg; 21 participants, 1 study; very low-certainty evidence). In all cases, we downgraded the certainty of evidence due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to assess the benefits and harms of physical exercise in people with chronic venous disease. Future research into the effect of physical exercise should consider types of exercise protocols (intensity, frequency, and time), sample size, blinding, and homogeneity according to the severity of disease.

Multidisciplinary Approach to Venous Disease: Enhancing Patient Care and Trainee Education Through Collaboration

The full spectrum of venous disease poses a significant burden on individuals and health-care systems globally. Venous disease can lead to a wide range of symptoms based on the level of disease and underlying pathology. In general, underlying pathologies are due to nonthrombotic (reflux/obstructive) and thrombotic causes. Most conditions are a sequela of the long-term effects of chronic venous insufficiency, deep vein thrombosis (DVT), or nonthrombotic deep vein obstruction. The prevalence of venous disease is substantial, impacting the quality of life of a considerable proportion of the adult population. Untreated and progressive lower extremity venous disease can lead to venous ulceration and other complications. Additionally, poorly recognized and poorly understood venous conditions of the abdomen and pelvis leave many patients "orphaned" in health-care systems that lack expertise in complex venous conditions. Addressing the burden and breadth of venous disease requires comprehensive management approaches, early diagnosis, appropriate treatment interventions, and provider and patient education. Multidisciplinary collaborations and further research are essential to enhance our understanding, develop innovative therapies, and improve patient outcomes in the field of venous disease. In this paper, we highlight the importance of multidisciplinary collaboration and our journey to building an institutional venous team, as well as lessons learned.

Chronic Venous Insufficiency With Emphasis on the Geriatric Population

The underpinning of Chronic Venous Insufficiency (CVI) is valvular dysfunction, which manifests on a spectrum depending on the severity of insufficiency and duration of the disease. The mainstay of treatment relies on compression therapy of a proper type and intensity. In older adults, special consideration must be taken during the patient encounter to account for age-related factors. This review discusses the clinical presentation, diagnosis, and mimicking of CVI, focusing mainly on older adults. The epidemiology, risk factors, disease burden, and grave complications -- such as thrombosis and ulceration, are reviewed. The physiological impacts of CVI are described, providing the background for treatment strategies, including non-invasive, medical, and surgical therapies. The findings show advanced age to be an important risk factor contributing to CVI and that other age-related factors add to the risk of severe complications. Clinical assessments combined with objective measurements that assess localized skin water using tissue dielectric constant values or whole limb assessments may aid in the differential diagnosis. Furthermore, understanding the mechanism of action of compression therapy, the mainstay of CVI treatment, and its physiological impacts, allows for its informed use in geriatric patients with increased risks of potential compression-related side effects.

Natural History of Varicose Veins of the Legs

Objective To assess the natural history of saphenous and non-saphenous varicose veins using the results of the Bonn Vein Studies and data published in literature.

Methods We used the data of the Bonn Vein Studies (BVS) 1 and 2 to assess if preexisting non-saphenous varicose veins (NSVV) in persons who had no saphenous varicose veins (SVV) at baseline have an impact on the incidence of SVV during the follow-up of 6.6 years and vice versa. SVV where defined as tortuous or not-tortuous refluxing saphenous veins. The statistical evaluation was performed using SAS version 9.4 (SAS Institute, Cary, North Carolina). In addition, we performed a review of publications concerning the natural history of varicose veins (VV) using PubMed.

Results In the BVS the overall incidence of SVV within the follow-up time of 6.6 years was 8.0 % (n = 133 of 1661; 95 % CI: 6.8–9.4). 7.2 % (n = 107 of 1492) without VV in BVS 1 and 19.8 % (n = 26) of patients with preexisting NSVV developed SVV. The relative risk for the development of SVV in patients with preexisting NSVV was 2.44 (95% CI: 1.64–3.64) adjusted for age and sex. The overall incidence of NSVV was markedly higher with 13.3 % (n = 226 of 1661; 95 % CI: 11.8–15.1). During follow-up 148 patients (9.9 %) without VV in BVS 1 developed NSVV. 48.5 % (n = 78) of patients with preexisting SVV developed NSVV during follow-up. The relative risk for the development of NSVV in patients with preexisting SVV was 4.10 (95% CI: 3.26–5.16), adjusted for age and sex.

In published studies the development of VV is preceded by venous reflux. Initial VV may develop at any segment and the results from literature suggest that the location of VV and reflux at the time of the investigation depends on age. In younger individuals more distal location are reported with an ascending progression in the majority but also descending progression is possible.

Conclusions Based on the results of the Bonn Vein Studies 1 and 2 we could demonstrate, that preexisting SVV increase the risk of developing NSVV and preexisting NSVV increase the risk of developing SVV in a similar way. Venous reflux may initially occur in any segment of the venous system and may progress in antegrade and/or retrograde fashion. In younger adults initial VV seem to be localized more often in distal parts of the legs with an antegrade progression over time.

Clinical validation of a smartphone application for automated wound measurement in patients with venous leg ulcers

Chronic wounds are associated with significant clinical, economic and quality-of-life burden. Despite the variety of wound imaging systems available in the market for wound assessment and surveillance, few are clinically validated among patients of Asian ethnicity. We aimed to clinically validate the accuracy of a smartphone wound application (Tissue Analytics [TA], Net Health Systems Inc, Florida, USA), versus conventional wound measurements (visual approximation and paper rulers), in patients of Asian ethnicity with venous leg ulcers (VLU). A prospective cohort study of patients presenting with VLU to a specialist wound nurse clinic over a 5-week duration was conducted. Each patient received seven wound measurements: one by a trained wound nurse clinician, and three separate wound measurements using TA on each of the iOS and Android operating systems. Inter-rater and intra-rater reliability between clinical and TA-based measurements were analysed using intra-class correlation statistics, with values of <0.5, 0.5 to 0.75, 0.75 to 0.9, and >0.9 indicating poor, moderate, good and excellent reliability, respectively. 82 patients (51% males), with a mean age at 65.8 years, completed the 5-week study duration. 25 (30%) had underlying diabetes mellitus. Chinese, Malay and Indian ethnicity comprised 68%, 12% and 11%, respectively. The VLU healed in 26 (32%) of patients within the study period. In total, 358 wound episodes with 2334 wound images were analysed. Inter-rater reliability for length, width and area between wound nurse measurements and TA application measurements was good (range 0.799-0.919, P < 0.001). Separate measurements of intra-rater reliability for length, width and area within the iOS or Android systems were excellent (range 0.967-0.985 and range 0.977-0.984 respectively, P < 0.001). Inter-rater reliability between TA used on the iOS and Android systems was also excellent (0.987-0.989, P < 0.001). Tissue Analytics, a smartphone wound application, is a useful adjunct for wound assessment and surveillance in VLU patients of Asian ethnicity.

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

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

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

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

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

A randomized clinical trial of isolated ambulatory phlebectomy versus saphenous thermal ablation with concomitant phlebectomy (SAPTAP Trial)

BACKGROUND

Current treatment of patients with saphenous trunk and tributary incompetence consists of truncal ablation with concomitant, delayed or no treatment of the tributary. However, reflux of the saphenous trunk may be reversible after treatment of the incompetent tributary. The aim of this study was to determine whether single ambulatory phlebectomy with or without delayed endovenous truncal ablation (SAP) is non-inferior to thermal endovenous ablation with concomitant phlebectomy (TAP), and whether SAP is a cost-effective alternative to TAP.

METHODS

A multicentre, non-inferiority RCT was conducted in patients with an incompetent great saphenous vein or anterior accessory saphenous vein with one or more incompetent tributaries. Participants were randomized to receive SAP or TAP. After 9 months, additional truncal treatment was considered for SAP patients with remaining symptoms. The primary outcome was VEnous INsufficiency Epidemiological and Economic Study Quality of Life/Symptoms (VEINES-QOL/Sym score) after 12 months. Secondary outcomes were, among others, cost-effectiveness, perceived improvement of symptoms, and anatomical success.

RESULTS

Some 464 patients received the allocated treatment (SAP 227, TAP 237). VEINES-QOL scores were 52.7 (95 per cent c.i. 51.9 to 53.9) for SAP and 53.8 (53.3 to 55.1) for TAP; VEINES-Sym scores were 53.5 (52.6 to 54.4) and 54.2 (54.0 to 55.6) respectively. Fifty-eight patients (25.6 per cent) in the SAP group received additional truncal ablation. Treatment with SAP was less costly than treatment with TAP.

CONCLUSION

One year after treatment, participants who underwent SAP had non-inferior health-related quality of life compared with those who had TAP. Treatment with SAP was a cost-effective alternative to TAP at 12 months.

REGISTRATION NUMBER

NTR 4821 (www.trialregister.nl).

The risk of harm whilst waiting for varicose veins procedure

INTRODUCTION

Varicose veins (VV) negatively impact quality of life (QoL) and have risks of major complications including bleeding, ulceration and phlebitis. During the COVID-19 pandemic, the VSGBI (Vascular Society of Great Britain and Ireland) and GIRFT (Get It Right First Time) classified VVs as lowest priority for intervention.

OBJECTIVE

This study aims to determine harm caused and the impact on the QoL on patients waiting for their VVs procedures for more than 1 year.

METHODS

This was a prospective study conducted at the Norfolk and Norwich University Hospital (NNUH). Patients with VVs awaiting intervention for >1 year were included in the study. Patients with CEAP C6 disease were considered to be too high risk to be invited for treatment during the Covid-19 pandemic. Patients were sent QoL questionnaires and underwent a telephone consultation to assess harm. Both generic (EQ-VAS and EQ-5D) and disease-specific (AVVQ and CIVIQ-14) instruments were utilised. There were no control groups available for comparison.

RESULTS

275 patients were identified (37.1% male) with median time on waiting list of 60 weeks (IQR 56-65). 19 patients (6.9%) came to major harm, including phlebitis (3.6%), bleeding (1.8%) and ulceration (1.8%). Fifty-two patients (18.9%) had minor harm, including worsening pain (12.7%) and swelling (6.2%). 6.9% reported psychological harm. Rising CEAP stage was also associated with worsening level of harm in patients with C5-6 disease (p < 0.0001). Only 8.7% stated they would decline surgery during the pandemic. 104 QoL questionnaires were returned. Median EQ-VAS and EQ-5D was 75 (IQR: 60-85) and 0.685 (0.566-0.761), respectively. Median AVVQ score was 23.2 (14.9-31.0) and CIVIQ-14 score was 33 (21-44).ConclusionsThis study highlights the impact of delaying VVs surgery during a pandemic. A significant rate of both major and minor as well as psychological harm was reported. In addition, VVs had a significant detriment to quality of life.

Concentrations of selected acute phase proteins in patients with chronic venous insufficiency treated with Sulodexide. Part 1

Introduction

Chronic venous insufficiency (CVI) is a widespread and serious social problem. The pathogenesis of the disease is multifactorial and one of the important factors in its development is inflammation.

Aim

Assessment of the concentration of selected acute phase proteins: C-reactive protein (CRP) and α1 antitrypsin (AAT) in the blood serum of patients with CVI before and after treatment with Sulodexide.

Material and methods

The study was carried out in 88 people, including 39 clinically healthy subjects as the reference group and 49 patients with CVI at various stages of the disease. The concentrations of CRP and AAT were determined.

Results

The concentration of CRP in patients before the use of Sulodexide, compared to the results in the reference group, was statistically significantly higher. The concentration decreased significantly after the applied treatment. AAT concentration was significantly (p < 0.05) higher in the group of patients compared to the reference group. After treatment with Sulodexide, AAT concentration decreased in all study groups, which was statistically significant compared to the reference group.

Conclusions

Elevated levels of acute phase proteins: CRP and AAT in patients indicate the participation of the inflammatory component in the pathogenesis of CVI. Monitoring levels of acute phase protein, especially AAT, may be useful in tracking the course of the disease, the body's response to treatment, and in making prognosis. Sulodexide, which acts mainly as an anticoagulant and profibrinolytic, also has an anti-inflammatory effect, which may contribute to the inhibition of the development of subsequent stages of CVI.

Genome-wide association study of varicose veins identifies a protective missense variant in GJD3 enriched in the Finnish population

Varicose veins is the most common manifestation of chronic venous disease that displays female-biased incidence. To identify protein-inactivating variants that could guide identification of drug target genes for varicose veins and genetic evidence for the disease prevalence difference between the sexes, we conducted a genome-wide association study of varicose veins in Finns using the FinnGen dataset with 17,027 cases and 190,028 controls. We identified 50 associated genetic loci (P < 5.0 × 10-8) of which 29 were novel including one near ERG with female-specificity (rs2836405-G, OR[95% CI] = 1.09[1.05-1.13], P = 3.1 × 10-8). These also include two X-chromosomal (ARHGAP6 and SRPX) and two autosomal novel loci (TGFB2 and GJD3) with protein-coding lead variants enriched above 56-fold in Finns over non-Finnish non-Estonian Europeans. A low-frequency missense variant in GJD3 (p.Pro59Thr) is exclusively associated with a lower risk for varicose veins (OR = 0.62 [0.55-0.70], P = 1.0 × 10-14) in a phenome-wide scan of the FinnGen data. The absence of observed pleiotropy and its membership of the connexin gene family underlines GJD3 as a potential connexin-modulating therapeutic strategy for varicose veins. Our results provide insights into varicose veins etiopathology and highlight the power of isolated populations, including Finns, to discover genetic variants that inform therapeutic development.

Molecular Determinants of Chronic Venous Disease: A Comprehensive Review

Chronic Venous Disease (CVD) refers to several pathological and hemodynamic alterations of the veins of lower limbs causing a wide range of symptoms and signs with a high prevalence in the general population and with disabling consequences in the most severe forms. The etiology and pathophysiology of CVD is complex and multifactorial, involving genetic, proteomic, and cellular mechanisms that result in changes to the venous structure and functions. Expressions of several genes associated with angiogenesis, vascular development, and the regulation of veins are responsible for the susceptibility to CVD. Current evidence shows that several extracellular matrix alterations (ECM) could be identified and in some cases pharmacologically targeted. This review shows the most up to date information on molecular determinants of CVD in order to provide a complete overview of the current knowledge on this topic. In particular, the article explores the genetic influence, the hormonal influence, ECM imbalance, and histopathology of CVD and the role of endothelial dysfunction in CVD.

Stasis Dermatitis: An Overview of Its Clinical Presentation, Pathogenesis, and Management

Stasis dermatitis is a chronic inflammatory skin disease of the lower extremities. It typically occurs in older individuals and is the cutaneous manifestation of venous hypertension caused by venous reflux. Such retrograde venous blood flow is the result of incompetent venous valves, valve destruction, or venous obstruction. Stasis dermatitis is eczematous. The associated impairment of venous valves may cause swelling of the legs, leading to serious conditions including venous ulcerations. Diagnosis can be challenging because of its clinical resemblance to other skin conditions and poor clinical recognition by physicians. The cornerstones of stasis dermatitis treatment are compression therapy to ameliorate pain and swelling, topical treatments to alleviate secondary skin changes, and interventional treatment options to correct the underlying causes of venous reflux. Given the central role of inflammation of the lower extremities in driving the cutaneous changes characteristic of stasis dermatitis, new therapeutic approaches that target the inflammation are under clinical evaluation in patients with stasis dermatitis.

The role of podiatry in the early identification and prevention of lower limb venous disease: an ethnographic study

BACKGROUND

Lower limb venous disease can cause significant pain, loss of mobility, and can be detrimental to an individual's quality of life. Manifestations of venous disease often pose a substantially negative impact on patients and place a high demand on finite healthcare resources. Whilst this problem is internationally recognised, most research and discourse has predominantly focussed on treatment of leg ulceration and prevention of recurrence. Prevention of lower limb venous disease progression to the first ulceration has received far less attention. Overall, the care of this condition appears to rest in the domain of medicine and nursing yet podiatry, a profession with responsibility for the lower limb and foot, is conspicuous by its absence from the literature.  METHODS: An ethnographic approach was used to gather data from 26 participants through observation, semi-structured interviews, and a focus group interview. Qualitative analysis was conducted using the framework approach.

RESULTS

The findings revealed an identity crisis within the podiatry profession. Evidence emerged of ritual and routine practices that did not include lower limb venous disease. External control over practice limited the professional autonomy of podiatrists determining their own activities. Inter-professional relationships with nursing, and perceptions of boundaries that venous disease was a nursing role were also found to be limiting factors.

CONCLUSIONS

This research revealed that podiatry does not occupy a substantive role in contributing to the early identification and prevention of lower limb venous disease. Policy, education, research and practice changes are all required to enhance the contribution of podiatry to reduce the burden of this disease.

Pilot study on the effect of grape seed proanthocyanidin extract on inferior vene cava blood flow in patients with chronic venous insufficiency using 4D flow MRI

BACKGROUND

Four-dimensional (4D) flow magnetic resonance imaging (MRI) was used to objectively assess changes in blood flow velocity in patients with chronic venous insufficiency (CVI) who underwent stocking treatment alone and stocking combined with Grape seed proanthocyanidin extract (GSPE) treatment.

METHODS

Patients diagnosed with CVI were recruited from August 31, 2018 to December 31, 2020. A total of 23 participants were selected, with 10 and 13 patients in the stocking treatment and stocking + GSPE treatment groups, respectively. The blood flow velocity (Th-plane peak and average velocities) was calculated using 4D flow MRI. A paired t test was used to evaluate the differences in blood flow velocity before and after treatment.

RESULTS

In the stocking treatment group, The Th-Plane peak velocity increased by 2.48 ± 5.05 cm/s after treatment (P = .16). In the stocking + GSPE treatment group, the Th-Plane peak velocity increased by 4.85 ± 5.57 cm/s after treatment (P < .001).

CONCLUSION

The blood flow velocity on 4D flow MRI was significantly increased in participants who underwent GSPE, highlighting the potential of GSPE for CVI treatment.

Women benefit from endovenous ablation with fewer complications: Analysis of the Vascular Quality Initiative Varicose Vein Registry

OBJECTIVE

To evaluate the association between gender and long-term clinician-reported and patient-reported outcomes after endovenous ablation procedures.

METHODS

This retrospective cohort study of prospectively collected data from the Vascular Quality Initiative's Varicose Vein Registry included patients undergoing endovenous ablation procedures on truncal veins with or without treatment of perforating veins between 2015 and 2019. A univariate analysis included comparisons of preprocedural, postprocedural, and periprocedural change in Venous Clinical Severity Score (VCSS) and total symptom score by gender. Rates of complications including deep vein thrombosis, endovenous heat-induced thrombosis, leg pigmentation, blistering, paresthesia, incisional infection, and any postprocedural complications were reported by gender. Multivariable analysis leveraged linear regression to examine how gender affected the relationships between patient characteristics, complication rates, and periprocedural change in VCSS score and total symptom score.

RESULTS

Of 9743 patients who met the inclusion criteria, 3090 (31.7%) were men and 6653 (68.2%) were women. The perioperative change in VCSS score was greater for men than women (average -4.46 for men vs -4.13 for women; P < .0001). Perioperative change in total symptom score was greater for women than for men (average -10.64 for women vs -9.64 for men; P < .0001). Women had lower incidence of any leg complication (6.1% vs 8.6%; P = .001) endovenous heat-induced thrombosis (1.1% vs 2.2%; P = .002), and infection (0.4% vs 0.7%; P = .001). In multivariable analysis, among patients with a body mass index of more than 40, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2, women had a greater periprocedural change in VCSS score than men.

CONCLUSIONS

Women benefited from endovenous ablation similarly as men, with a lower incidence of postprocedural complications. Gender may be useful for patient selection and counseling for endovenous ablation, with particular usefulness among patients with a high body mass index, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2.

Thermal Ablation, Nonthermal Ablation And Surgical Striping Applications: 1-Year Single Center Early Results

ABSTRACT: Objectives : Starting from the 1900's minimally invasive methods such as endovenous laser ablation (EVLA), radiofrequency ablation (RFA), and ultrasound-guided foam sclerotherapy (UGFS) developed. Methods: This study includes a total of 136 patients (81 women/55 men), of whom 22 (10 women/12 men) were treated with classic surgical stripping, 54 (32 women/22 men) with thermal ablation and 60 (39 women/55 men) with non-thermal ablation. Results: Twenty-two patients (10 women/12 men) were treated with surgical stripping. In one female patient a hematoma arose in the medial crural region postoperatively. A radiofrequency catheter (ThermoBLOCK TM) was used in the thermal ablation procedures in 54 patients (32 female/22 male). It is believed that permanent paresthesia occured in one female patient after the procedure. In 3 male patients temporary paresthesia occured postoperatively. Non- thermal ablation was performed in 60 patients(39 female/55 male). Even through a severe burning sensation was present in 6 patients (5 female/1 male) during the procedure, this symptom was only transient. In one of the patients, deep venous thrombosis (DVT) occured at the level of the popliteal vein postoperatively at the sixth day. Conclusion: Even if thermal and non-thermal ablation and surgical procedures have the same pain decreasing rates, hematomas and a longer hospital stay are more frequent in surgical procedures.

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.