Chronic Venous Insufficiency

Quantitative evaluation of lower limb varicose veins using photoacoustic imaging

PURPOSE

Varicose veins in the lower extremities are dilated subcutaneous varicose veins with a diameter of  ≥ 3 mm, caused by increased venous pressure resulting from backflow of blood due to venous valve insufficiency (Gloviczki in Handbook of venous disorders: guidelines of the American venous forum, Hodder Arnold, London, 2009). When diagnosing varicose veins, the shape and thickness of the blood vessels should be accurately visualized in three dimensions. In this study, we investigated a new method for numerical evaluation of vascular morphology related to varicose veins in the lower extremities, using a photoacoustic imaging (PAI) system, which can acquire high-resolution and three-dimensional images noninvasively.

METHODS

Nine patients with varicose veins participated in the study, and their images were captured using an optical camera and PAI system. We visualized the vascular structure, created a blood presence density (BPD) heat map, and examined the correlation between BPD and location of varicose veins.

RESULTS

The obtained photoacoustic (PA) images demonstrated the ability of this method to visualize vessels ranging from as small as 0.2 mm in diameter to large, dilated vessels in three dimensions. Furthermore, the study revealed a correlation between the high-density part of the BPD heat map generated from the PAI images and the presence of varicose veins.

CONCLUSION

PAI is a promising technique for noninvasive and accurate diagnosis of varicose veins in the lower extremities. By providing valuable information on the morphology and hemodynamics of the varicose veins, PAI may facilitate their early detection and treatment.

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.

Impact of great saphenous vein ablation on healing and recurrence of venous leg ulcers in patients with post-thrombotic syndrome: A retrospective comparative study

BACKGROUND

The optimal treatment approach for patients with active venous leg ulcers (VLUs) and post-thrombotic syndrome (PTS) associated with great saphenous vein (GSV) reflux remains unclear. To address this gap, we retrospectively compared the outcomes of patients with post-thrombotic VLU with an intact GSV vs those with a stripped or ablated GSV.

METHODS

We retrospectively analyzed data from 48 patients with active VLUs and documented PTS, who were treated at a single center between January 2018 and December 2022. Clinical information, including ulcer photographs, was recorded in a prospectively maintained digital database at the initial and follow-up visits. Two patient groups-group A (with an intact GSV) and group B (with a stripped or ablated GSV)-were compared in terms of time to complete healing, proportion of ulcers achieving complete healing, and ulcer recurrence during the follow-up period.

RESULTS

There were no significant differences in age, gender, initial ulcer size, or ulcer duration between the two groups. All included patients had femoropopliteal post-thrombotic changes. Group A had significantly more completely healed ulcers (33 of 34 ulcers, 97%) compared with group B (10 of 14 ulcers, 71%) (P = .008). Group A also exhibited a significantly shorter time to complete ulcer healing (median: 42.5 days, interquartile range [IQR]: 65) compared with group B (median: 161 days, IQR: 530.5) (P = .0177), with a greater probability of ulcer healing (P = .0084). Long-term follow-up data were available for 45 of 48 patients (93.7%), with a mean duration of 39.6 months (range: 5.7-67.4 months). The proportion of ulcers that failed to heal or recurred during the follow-up period was significantly lower in group A (9 of 32 ulcers, 27%) compared with group B (11 of 13 ulcers, 85%) (P = .0009). In addition, in a subgroup analysis, patients with an intact but refluxing GSV (12 of 34) had a significantly shorter time to heal (median: 34 days, IQR: 57.25) (P = .0242), with a greater probability of ulcer healing (P = .0091) and significantly fewer recurrences (2 of 12, 16%) (P = .006) compared with group B.

CONCLUSIONS

Our findings suggest that removal of the GSV through stripping or ablation in patients with post-thrombotic deep venous systems affecting the femoropopliteal segment may result in delayed ulcer healing and increased ulcer recurrence. Patients with an intact GSV had better outcomes, even when the refluxing GSV was left untreated. These findings emphasize the potential impact of GSV treatment on the management of VLUs in individuals with PTS. Further investigation is needed to validate these results and explore alternative therapeutic strategies to optimize outcomes for this patient population.

Vein segmentation and visualization of upper and lower extremities using convolution neural network

OBJECTIVES

The study focused on developing a reliable real-time venous localization, identification, and visualization framework based upon deep learning (DL) self-parametrized Convolution Neural Network (CNN) algorithm for segmentation of the venous map for both lower and upper limb dataset acquired under unconstrained conditions using near-infrared (NIR) imaging setup, specifically to assist vascular surgeons during venipuncture, vascular surgeries, or Chronic Venous Disease (CVD) treatments.

METHODS

A portable image acquisition setup has been designed to collect venous data (upper and lower extremities) from 72 subjects. A manually annotated image dataset was used to train and compare the performance of existing well-known CNN-based architectures such as ResNet and VGGNet with self-parameterized U-Net, improving automated vein segmentation and visualization.

RESULTS

Experimental results indicated that self-parameterized U-Net performs better at segmenting the unconstrained dataset in comparison with conventional CNN feature-based learning models, with a Dice score of 0.58 and displaying 96.7 % accuracy for real-time vein visualization, making it appropriate to locate veins in real-time under unconstrained conditions.

CONCLUSIONS

Self-parameterized U-Net for vein segmentation and visualization has the potential to reduce risks associated with traditional venipuncture or CVD treatments by outperforming conventional CNN architectures, providing vascular assistance, and improving patient care and treatment outcomes.

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.

A Systematic Review of Radiological Diagnosis and Management of May-Thurner Syndrome

May-Thurner syndrome (MTS) is an anatomical condition of external luminal compression of common iliac vein due to a partial obstruction of the common iliac vein between common iliac artery and lumbar vertebra causes deep-vein thrombosis, venous hypertension, and chronic venous insufficiencies. In this article, we review present evidence of the clinical diagnosis and management of MTS. Here, we conducted a literature review of studies on MTS. We also reviewed different clinical features, presentation, diagnostic methods, and therapeutic procedure for this condition. Most studies mentioned the diagnosis of this condition is performed by color Doppler, computed tomographic angiography, venography, and problem-solving cases by intravascular ultrasound technique. Nonsurgical methods of management are first line, and vascular surgery is reserved for refractory cases. Multiple modalities are required to reach the diagnosis of MTS, and noninvasive intervention radiology methods are the first line of management. This review highlights the presentations of MTS and outlines diagnostic procedure and management.

Endovenous glue ablation for chronic venous insufficiency: A comprehensive 5-year assessment of clinical and hemodynamic outcomes

OBJECTIVES

Chronic venous insufficiency is mainly caused by reflux, obstruction, or both. Endovenous glue ablation has become one of the widely used methods for treating reflux in recent years. Duplex ultrasonography is the most commonly used method for diagnosing and evaluating treatment. However, there is important information that plethysmographic venous hemodynamics provides, which Duplex USG cannot provide. This retrospective study aimed to evaluate the 5-year clinical, anatomical, and hemodynamic results of endovenous glue ablation in the treatment of chronic venous insufficience, accompanied by the data from the plethysmographic study.

PATIENTS AND METHOD

Between January 2018 and August 2018, 133 patients with symptomatic CEAP 2-6 varicose veins with reflux of the great saphenous vein lasting longer than 0.5 seconds and a diameter of 5.5 mm in the standing great saphenous vein underwent EVGA. CEAP, VCSS, CIVIQ 20, Doppler USG, GSV diameters and insufficiency times, and hemodynamically Venous Refilling Time and Venous Half-Value Time measurements were performed before the procedure. In the same way, measurements were made at the 1st, 3rd, 6th, 12th, 24th, and 60th months of the patients who were called and came to the postoperative follow-up.

RESULTS

Procedural success was 100%, and complete occlusion was observed %93 after treatment, at the 60 month. The improvement in VCSS (from 4.4 ± 1.3 to 1.7 ± 0.9), CIVIQ20 (from 8.5 ± 3.1 to 4.7 ± 2.0), VRT (from 20.3 ± 5.0 to 131.1 ± 4.0), and TH (from 2.8 ± 0.3 to 2.4 ± 0.2) was significant (p < .001 was for all).

CONCLUSION

Endovenous glue ablation is a preferred method for the treatment of great saphenous vein insufficiency due to its ease of use and the comfort it provides to patients, as well as its effectiveness and safety. In particular, it can be considered an effective method for improving venous hemodynamics and relieving associated symptoms.

Long-Term Clinical and Imaging Findings in Patients with Lower Extremity Varicose Veins Treated with Endovenous Laser Treatment: A Follow-Up Study of up to 12 Years

Introduction

This study investigates the long-term effectiveness and safety of endovenous laser treatment (EVLT) for chronic venous insufficiency (CVI), a condition commonly caused by dysfunctional valves in the venous circulation system.

Materials and Methods

In this retrospective cohort study, patients underwent EVLT and were followed up for successive short intervals and one last time after a median duration of 9-year postprocedural. Pre- and postprocedure duplex ultrasound was used to assess changes in the great saphenous vein (GSV) diameter, reflux, and saphenofemoral junction incompetence. Quality of life was evaluated using the SF-36 and Aberdeen Varicose Vein Questionnaire (AVVQ).

Results

Sixty-eight patients with a mean age of 52.4 ± 12.4 years were enrolled in the study. The mean follow-up time was 8.9 ± 2.1 years, ranging from 5 to 12 years. The mean GSV diameter significantly decreased in all patients (whole group) across proximal (from 5.8 ± 2.3 mm to 4.2 ± 2.1 mm), middle (from 4.7 ± 1.6 mm to 2.8 ± 2.2 mm), and distal (from 4.5 ± 2.3 mm to 2.2 ± 2.2 mm) segments, with P < 0.001. A disease recurrence rate of 33.8% was noted, predominantly in male patients and those with larger middle GSV diameters (OR = 5.2 (95%CI = 1.3-20.4) and OR = 1.5 (95%CI = 1-2.1), respectively). The average follow-up time for patients without recurrence was 8.8 ± 2.1 years. Almost half of the patients without recurrence were followed up for 10 years or more (49%).

Conclusion

The efficacy of EVLT in managing varicose veins is demonstrated by its relatively low recurrence rate over a 10-year follow-up period, highlighting EVLT as a viable long-term treatment strategy.

A Narrative Review of Advancements in Understanding and Treating Varicose Veins

Chronic venous disease, with varicose veins as its archetypal manifestation, stands as a pervasive and intricate health quandary, encompassing a vast array of contributing factors. Age, genetics, obesity, pregnancy, and prolonged immobility weave a complex tapestry, underscoring the omnipresence of this ailment. Its societal and economic footprint is undeniably formidable, as diverse classifications underscore its multifaceted character. The intricate interplay of chronic venous disease with diabetes mellitus and neuropathy compounds the challenge, fostering soaring healthcare expenditures and a palpable erosion of quality of life, particularly among women harboring cardiometabolic risk factors. Despite research shedding light on heightened susceptibility within certain demographics, the enigmatic determinants orchestrating the transition from mild to severe chronic venous disease continue to elude us. Varicose veins, marked by the presence of dilated and tortuous subcutaneous vessels, precipitate both physical discomfort and cosmetic concerns, frequently necessitating meticulous clinical evaluation coupled with ultrasound studies to secure a precise diagnosis. Treatment strategies are strategically crafted to ameliorate distressing symptoms, enhance aesthetic concerns, and forestall potential complications. Nevertheless, the prognostication of chronic venous disease remains ensconced in a degree of ambiguity, hinting at the vast terrain yet to be charted in this medical domain. The quest to fathom the intricacies of this condition uncovers an ever-evolving panorama where conservative interventions play an indispensable role in managing mild cases, while interventional procedures like endovenous laser ablation and sclerotherapy step onto the stage for patients grappling with severe symptoms, thus treading the fine line between efficacy and invasiveness. Moreover, a meticulous economic analysis underscores the cost-effectiveness of various therapeutic modalities, thereby bolstering the imperative of a patient-centered approach. As we navigate the labyrinthine complexities of chronic venous disease and varicose vein management, we are inexorably drawn to the pivotal role of customized treatment approaches, as well as the dynamic interplay between scientific progress, patient preferences, and therapeutic innovations in the relentless pursuit of optimized outcomes and an enhanced quality of life.

Severity of Chronic Venous Insufficiency on Primary Total Knee Arthroplasty Outcomes

BACKGROUND

More than 700,000 people in the United States undergo total knee arthroplasty (TKA) each year. Chronic venous insufficiency (CVI) affects 5% to 30% of adults, sometimes resulting in leg ulceration. These CVI cases in TKAs have been associated with worse outcomes; however, we found no study differentiating CVI severity.

METHODS

This retrospective study analyzed TKA outcomes at one institution from 2011 to 2021 using patient-specific codes. Analyses included short-term complications (< 90 days postoperative), long-term complications (< 2 years), and CVI status (yes/no; simple/complex/unclassified). Complex CVI consisted of pain, ulceration, inflammation, and/or other complications. Revisions within 2 years and readmissions within 90 days post-TKA were assessed. Composite complications included short-term and long-term complications, revisions, and readmissions. Multivariable logistic regressions predicted complication (any/long/short) as a function of CVI status (yes/no; simple/complex) and potential confounding variables. Of 7,665 patients, 741 (9.7%) had CVI. Among CVI patients, 247 (33.3%) had simple CVI, 233 (31.4%) had complex CVI, and 261 (35.2%) had unclassified CVI.

RESULTS

There was no difference in CVI versus control in composite complications (P = .722), short-term complications (P = .786), long-term complications (P = .15), revisions (P = .964), or readmissions (P = .438) postadjustment. Composite complication rates were 14.0% without CVI, 16.7% with complex CVI, and 9.3% with simple CVI. Complication rates differed between simple and complex CVI (P = .035).

CONCLUSION

Overall, CVI did not affect postoperative complications versus control. Patients who have complex CVI are at higher risk for post-TKA complications compared to those who have simple CVI.

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.

The impact of a new intervention for venous leg ulcers: A within-patient controlled trial

A major obstacle to the development of new treatments for venous leg ulcers is the difficulty in generating evidence for their effectiveness. Randomised controlled trials using complete healing as the endpoint are seldom powered to be successful, owing to the heterogeneity of cohorts. A novel approach to the evaluation of treatments is presented, using a self-controlled trial model and two metrics of short-term healing rate as alternate endpoints: rate of wound margin advance, and percentage area reduction over 4 weeks. Two different treatment regimens are compared: multi-layer compression alone, versus multi-layer compression combined with activation of the venous leg pump by neuromuscular stimulation. With 60 patients, adding neuromuscular stimulation to multilayer compression resulted in a significant two-fold increase in the rate of wound healing over a 4-week period, both in terms of wound margin advance and in terms of percentage area reduction. The use of these short-term intermediate endpoint metrics together with a self-controlled study design offers potential for distinguishing between the relative efficacies of interventions more rapidly, with greater sensitivity, and with fewer subjects than a conventional RCT cohort model.

Effect of Ischemic Preconditioning on Acute Recovery in Elite Judo Athletes: A Randomized, Single-Blind, Crossover Trial

PURPOSE

The ischemic preconditioning (IPC) method has been shown to aid the recovery processes; however, no studies have been done to assess its acute recovery use in judo. This study aimed to examine IPC of lower limbs effects on recovery after a judo-specific performance in highly trained male judokas and its applicability during a competition day.

METHODS

A single-blind, placebo-randomized crossover study was carried out on a sample of 13 elite male judo athletes. They undertook measurements of body composition, judo-specific task (Special Judo Fitness Test), jump performance, handgrip strength, lactate, blood pressure, perceived exertion, and delayed-onset muscle soreness. IPC was applied on the legs and inflated 50 mm Hg above the systolic blood pressure for 5 minutes and repeated 3 times for each leg, with 5 minutes of reperfusion. Two-way analysis of variance with repeated measurements was used to determine changes between interventions and measurement times. Paired-sample t test and 1-way repeated-measures analysis of variance was used to determine the difference among measurement times. Statistical significance was set at P < .05.

RESULTS

The IPC intervention resulted in (1) decreased heart rate at 30 and 60 minutes during recovery (P = .002; P = .001), (2) better countermovement jump performance at 60 minutes (P = .05), (3) lower perceived-muscle-soreness scores (P = .006), and (4) maintained handgrip strength compared with placebo.

CONCLUSIONS

The present study revealed that IPC applied to judo athletes following judo-specific exercise resulted in better cardiovascular and neuromuscular recovery and could be a useful tool to enhance recovery during judo competition breaks between preliminaries and final block.

National trend of the treatment for chronic venous diseases in Korea between 2010 and 2020

Purpose

Limited data are available on the nationwide trend of treatments for chronic venous disease (CVD). The aim of the present study was to identify the nationwide trends of CVD treatments in Korea.

Methods

A serial, cross-sectional study was conducted with the use of time trends to analyze patients with CVD between 2010 and 2020. The trends in the number of patients and procedures were analyzed including sclerotherapy, open surgery, and endovenous thermal ablation (ETA). Health Insurance Review and Assessment Service data were used to analyze the trends. For the statistical analysis, MedCalc Statistical software was used. P < 0.05 was considered statistically significant.

Results

A total of 1,867,307 patients with CVD were managed in Korea between 2010 and 2020. The annual number of patients with CVD increased from 143,108 in 2010 to 219,319 in 2020 (risk ratio [RR], 1.53; P < 0.001). The percentage of patients with CVD who had venous ulcer gradually decreased from 3.1% in 2010 to 1.7% in 2020 (RR, 0.86; P < 0.001). The number of conventional surgeries including stripping and local resection of varicose veins decreased from 32,384 in 2010 to 21,792 in 2020 (RR, 0.67; P < 0.001). The number of ETAs performed increased, from 290 in 2011 to 12,126 procedures in 2020 (RR, 41.81; P < 0.001).

Conclusion

The total number of patients with CVD increased during the last 11 years. The number of conventional open surgery and sclerotherapy procedures decreased. On the contrary, the number of ETAs significantly increased in Korea.

A shear-wave sonoelastography investigation of calf muscle pump biomechanics in patients with chronic venous disease and healthy controls

BACKGROUND

chronic venous disease (CVD) is a common progressive disorder with incompetence of calf muscle pump due to weakness and ankle mobility abnormality is an important etiological factor in CVD, but the biomechanical properties of calf muscle pump are remain unknown.

OBJECTIVES

The purpose of the present study was to evaluate group differences between the biomechanical properties changes of the medial gastrocnemius muscle (GM) and its fascias in participants with CVD and healthy controls.

METHODS

In this case-control study, thirty patients with CVD in three equal groups (mild: C1 - C2, moderate: C3 - C4, severe: C5 - C6) and 20 healthy subjects in a control group participated. The medial GM and its fascias shear modulus (stiffness) were measured using a shear-wave sonoelastography in rest and active dorsiflexion positions of ankle joint.

RESULTS

The results of variance (ANOVA) analysis showed a significant difference in shear wave elastography (SWE) value between the groups for medial GM and its fascias at rest and active dorsiflexion of the ankle joint (P < 0.05). There was a statistically significant increase in SWE value of the medial GM and its fascias in moderate (c3-c4) and severe CVD groups (C5-C6) compared to the control and mild (C1-C2) CVD groups. A positive correlation was discovered between disease grades and the medial GM and its fascias SWE in patients with CVD ranging between r = 0.846 to 0.891; P < 0.001.

CONCLUSION

An alteration stiffness in calf myofascial pump as compared to control group indicated an impaired myofascial biomechanics. Calf myofascial SWE may be valuable information in the diagnosis and follow-up processes of patients with CVD.

Comparison of intermittent pneumatic compression device and compression stockings for workers with leg edema and pain after prolonged standing: a prospective crossover clinical trial

BACKGROUND

During prolonged standing, insufficient calf muscle pumping accompanies venous stasis and hypertension in the lower legs, resulting in valve dysfunction, venous wall problems, and sub-sequent inflammation. Compression therapy, which includes medical compression stockings (MCS) and mechanical intermittent pneumatic compression (IPC), is one of the most effective therapeutic interventions for treating chronic venous diseases. This study aimed to compare the therapeutic effect among resting, IPC and MCS alone, and IPC with MCS in long-standing workers (> 8 h daily).

METHODS

This crossover trial was conducted with 39 participants with complaints of leg edema and pain whose work involved standing for more than 8 h daily. Four treatment protocols were established for each visit as follows: protocol A (not wear MCS during work and rest without IPC after work), protocol B (wear MCS during work and rest without IPC after work), protocol C (not wear MCS during work and treat with IPC after work), and protocol D (wear MCS during work and treat with IPC after work). The primary outcome was the visual analogue scale (VAS) score for leg pain. The secondary outcomes were leg volume (mL), circumference (cm), extracellular fluid/total body fluid (ECF/TBF), and extracellular water/total body water (ECW/TBW) through bioelectrical impedance analysis. Outcomes were assessed before work (T0), after work (T1), and 60 min after intervention (T2).

RESULTS

All four protocols had significantly increased leg pain after work (T0-1) but improved 60 min after intervention (T1-2), particularly protocol C (decreased VAS by 1.9). When leg swelling was compared at T0 and T1, protocols A and C showed significant increases in leg volume and circumference, indicating significant work-induced edema, whereas protocols B and D showed no change or even a decrease. After interventions, leg volume and circumference significantly decreased in protocols A and C, although protocols B and C did not show significant improvement. The ECF/TBF and ECW/TBW of all protocols decreased after interventions.

CONCLUSIONS

Leg pain and edema after prolonged standing (T1-T2) in adults were safely and effectively improved by both IPC alone and IPC with MCS. Although the use of MCS during the workday did not show improvement in leg pain immediately after work (T0-T1), both MCS with resting and MCS with IPC decreased leg pain at T1-T2 and prevented leg edema at T0-T1.

TRIAL REGISTRATION

This trial protocol was registered at the Clinical Research Information Service (KCT0005383, the date of first registration: 08/09/2020).

The utility of hyperspectral imaging in patients with chronic venous disorders

OBJECTIVE

The underlying pathophysiology of lower limb changes in chronic venous disorders (CVD) may involve alteration in microcirculation and tissue oxygenation. Hyperspectral imaging (HSI) is a noninvasive tool that is used clinically to measure transcutaneous oxygenation in peripheral artery disease and diabetic foot disease. However, there has been little application in venous disease. The aim of this study was to determine if transcutaneous oxygenation in the lower limb, as measured by HSI, changes depending on the clinical component of the Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification in CVD.

METHODS

This was an observational study of patients with CVD recruited from a vascular specialist clinic at a tertiary hospital from January 2020 to January 2021. Participants were allocated to eight groups according to the clinical component of CEAP classification of CVD. Baseline demographic and risk factor information were collected. Transcutaneous oxygenation was measured using HSI at seven sites around the foot and gaiter area in the supine and standing position. Participants rested supine for 15 minutes before the supine measurements and then stood for 15 minutes before the standing measurements. Tissue oxygenation was analyzed over a fixed circular surface area of 79 mm² at the target location. Calculations of oxyhemoglobin level (artificial unit [AU]), deoxyhemoglobin level (AU), oxygen saturation (%), and temperature (°C) were obtained. The Northern Ethics Committee (18/NTA/78) approved this conduct of the study and participants signed written consent forms.

RESULTS

There were 94 participants (164 lower limbs) included in the study. The median age was 59 years and 59 participants (63%) were women. At all sites except the heel, deoxyhemoglobin measurements increased in the standing position compared with the supine position (P < .001). In the gaiter region, there was nearly a doubling in deoxyhemoglobin level at 5 cm above the medial malleolus (supine 43.88 AU vs standing 80.46 AU; P < .001) and 5 cm above the lateral malleolus (supine 46.33 AU vs standing 87.72 AU; P < .001). When measurements were stratified by clinical class of the CEAP classification, there was a greater increase in deoxyhemoglobin levels with increasing clinical class in the standing position (P < .001). This finding was not observed in the supine measurements.

CONCLUSIONS

In CVD, HSI shows an increase in deoxyhemoglobin in the standing compared with supine position, particularly in the gaiter region. Furthermore, standing deoxyhemoglobin increases as the CEAP clinical class increases. Thus, this noninvasive tool may respond to venous physiology and may supplement the clinical class of the CEAP classification system.

Clinical value of deep vein thrombosis density on pre-contrast and post-contrast lower-extremity CT for prediction of pulmonary thromboembolism

Background

There was a lack of studies assessing the relationship between deep vein thrombosis (DVT) Hounsfield unit (HU) density and pulmonary thromboembolism (PTE).

Purpose

To evaluate the clinical value of DVT density measured on pre- and post-contrast lower-extremity computed tomography (CT) for the prediction of PTE.

Material and Methods

From 2017 to 2021, patients who underwent pulmonary CT angiography within one week after diagnosis of DVT on lower-extremity CT were included in this retrospective study. Then, the patients without PTE were included in “DVT group” and those with both DVT and PTE were included in the “DVT-PTE group.” The DVT HU density was measured by drawing free-hand region of interests (ROIs) within the thrombus at the most proximal filling defect level. A receiver operating characteristic (ROC) analysis was used to evaluate the predictive value of DVT density for the risk of PTE.

Results

This study included a total of 94 patients (DVT group: n=56; DVT-PTE group: m=38). DVT density was significantly higher in the DVT-PTE group than the DVT group in both pre-contrast (53.5 ± 6.2 HU vs. 44.1 ± 7.9 HU; P < 0.001) and post-contrast CT (67.0 ± 8.6 HU vs. 57.1 ± 10.6 HU; P < 0.001). ROC analysis revealed that the area under curve, sensitivity, and specificity for predicting the risk of PTE were 0.739, 71.1%, and 64.2%, respectively, at a DVT density cutoff of 48.2 HU on pre-contrast CT and were 0.779, 73.7%, and 69.6% at a DVT density cutoff of 61.8 HU on post-contrast CT.

Conclusion

The DVT density on both pre- and post-contrast CT could be a predictive factor of PTE.

Biohybrid elastin-like venous valve with potential for in situ tissue engineering

Chronic venous insufficiency (CVI) is a leading vascular disease whose clinical manifestations include varicose veins, edemas, venous ulcers, and venous hypertension, among others. Therapies targeting this medical issue are scarce, and so far, no single venous valve prosthesis is clinically available. Herein, we have designed a bi-leaflet transcatheter venous valve that consists of (i) elastin-like recombinamers, (ii) a textile mesh reinforcement, and (iii) a bioabsorbable magnesium stent structure. Mechanical characterization of the resulting biohybrid elastin-like venous valves (EVV) showed an anisotropic behavior equivalent to the native bovine saphenous vein valves and mechanical strength suitable for vascular implantation. The EVV also featured minimal hemolysis and platelet adhesion, besides actively supporting endothelialization in vitro, thus setting the basis for its application as an in situ tissue engineering implant. In addition, the hydrodynamic testing in a pulsatile bioreactor demonstrated excellent hemodynamic valve performance, with minimal regurgitation (<10%) and pressure drop (<5 mmHg). No stagnation points were detected and an in vitro simulated transcatheter delivery showed the ability of the venous valve to withstand the implantation procedure. These results present a promising concept of a biohybrid transcatheter venous valve as an off-the-shelf implant, with great potential to provide clinical solutions for CVI treatment.

Acute and chronic wound infections: microbiological, immunological, clinical and therapeutic distinctions

Wound infection is a complex pathology that may manifest either as a rapid onset acute condition, or as a prolonged chronic condition. Although systemic antibiotic therapy is often appropriate and necessary for acute wound infections, it is often used inappropriately, excessively and unsuccessfully in chronic wound infections. Overuse of antibiotics in chronic (hard-to-heal) wound management contributes to antibiotic resistance. This literature review confirms that acute and chronic wound infections are significantly differentiated by their cause (microbial phenotype), the subsequent host immune response and by the resulting clinical manifestations. Consequently, recognition of the type of wound infection followed by appropriate and timely therapy is required to improve wound healing outcomes while encouraging more judicious and responsible use of antibiotics.

Glutaraldehyde fixation of venous valve tissue: A benchmark for alternative fixation methods

Objective

Bioprosthetic venous valves have yet to achieve long-term patency due to issues with calcification following implantation that is influenced by current xenograft fixation methods, most notably glutaraldehyde. The goal of this study was to investigate the effects of glutaraldehyde fixation on the functional properties of venous tissue to establish a benchmark for the evaluation of alternative fixation methods.

Methods

The degree of crosslinking was evaluated by determining shrink temperature and the stability of tissue with pronase and collagenase digestion.

Results

Glutaraldehyde fixation of venous tissue was confirmed by a significant difference in the shrink temperature between fresh and glutaraldehyde treated samples. Significant differences in the amount of tissue remaining following digestion were observed for venous versus cardiac tissue.

Conclusions

This study demonstrates the importance of tissue-specific evaluation in the development of alternative xenograft fixation methods to improve outcomes with bioprosthetic venous valves.

The effects of gravity and compression on interstitial fluid transport in the lower limb

Edema in the limbs can arise from pathologies such as elevated capillary pressures due to failure of venous valves, elevated capillary permeability from local inflammation, and insufficient fluid clearance by the lymphatic system. The most common treatments include elevation of the limb, compression wraps and manual lymphatic drainage therapy. To better understand these clinical situations, we have developed a comprehensive model of the solid and fluid mechanics of a lower limb that includes the effects of gravity. The local fluid balance in the interstitial space includes a source from the capillaries, a sink due to lymphatic clearance, and movement through the interstitial space due to both gravity and gradients in interstitial fluid pressure (IFP). From dimensional analysis and numerical solutions of the governing equations we have identified several parameter groups that determine the essential length and time scales involved. We find that gravity can have dramatic effects on the fluid balance in the limb with the possibility that a positive feedback loop can develop that facilitates chronic edema. This process involves localized tissue swelling which increases the hydraulic conductivity, thus allowing the movement of interstitial fluid vertically throughout the limb due to gravity and causing further swelling. The presence of a compression wrap can interrupt this feedback loop. We find that only by modeling the complex interplay between the solid and fluid mechanics can we adequately investigate edema development and treatment in a gravity dependent limb.

Chronic venous insufficiency: Part 1 Pathophysiology and Clinical features

Chronic venous disease (CVD) is a commonly encountered disease in dermatology out-patient department and if untreated, may progress to chronic leg ulcer causing serious morbidity to the patient. Also, it affects the quality of life of the affected patient and contributes to the loss of work productivity. The range of clinical manifestations is myriad, ranging from asymptomatic varicose veins and pigmentation to ulceration and scarring. The awareness of spectrum of clinical presentations is required to identify, diagnose and manage CVD. Long standing cases may develop ankle joint stiffness, significant fibrosis causing fixed flexion deformity, periostitis and even, Marjolin's ulcer. Increased venous hypertension, thought to result from incompetent valve and failure of calf muscle pump, is central to the pathophysiology of the development of CVD. Tissue edema, hypoxia and subsequent fibrosis are major immediate contributing factors responsible for the clinical manifestations of CVD. Localized, chronic inflammation is now increasingly being recognized as a key player, directly responsible for stasis dermatitis and hypercoagulable state. The complete ramifications of persistent inflammation in CVD is yet to be understood and serious systemic morbidities like arterial and cardiac disease are increasingly been recognized in association with CVD.

Shear Stress Alterations Activate BMP4/pSMAD5 Signaling and Induce Endothelial Mesenchymal Transition in Varicose Veins

Chronic venous diseases, including varicose veins, are characterized by hemodynamic disturbances due to valve defects, venous insufficiency, and orthostatism. Veins are physiologically low shear stress systems, and how altered hemodynamics drives focal endothelial dysfunction and causes venous remodeling is unknown. Here we demonstrate the occurrence of endothelial to mesenchymal transition (EndMT) in human varicose veins. Moreover, the BMP4-pSMAD5 pathway was robustly upregulated in varicose veins. In vitro flow-based assays using human vein, endothelial cells cultured in microfluidic chambers show that even minimal disturbances in shear stress as may occur in early stages of venous insufficiency induce BMP4-pSMAD5-based phenotype switching. Furthermore, low shear stress at uniform laminar pattern does not induce EndMT in venous endothelial cells. Targeting the BMP4-pSMAD5 pathway with small molecule inhibitor LDN193189 reduced SNAI1/2 expression in venous endothelial cells exposed to disturbed flow. TGFβ inhibitor SB505124 was less efficient in inhibiting EndMT in venous endothelial cells exposed to disturbed flow. We conclude that disturbed shear stress, even in the absence of any oscillatory flow, induces EndMT in varicose veins via activation of BMP4/pSMAD5-SNAI1/2 signaling. The present findings serve as a rationale for the possible use of small molecular mechanotherapeutics in the management of varicose veins.

May-Thurner syndrome

May-Thurner syndrome (MTS) is a venous compression syndrome in which the left common iliac vein (LCIV) is compressed between the lower lumbar spine and the right common iliac artery (RCIA). Variations are known where in the right lower limb can be affected. While most of the cases are asymptomatic, it can cause severe morbidity in symptomatic individuals, most commonly deep vein thrombosis and post thrombotic sequelae. In this article, we review the key clinical features, multimodality imaging findings and treatment options of this disorder. Our goal is to raise awareness of this under-diagnosed condition among clinicians in order to promote early detection and recognition to enhance positive and expedited outcomes.

Chronic venous disorders - common and yet unknown - a study of public awareness and primary symptoms in a selected group of patients

Introduction

Chronic venous disorder (CVD) is thoroughly spread across the globe. It affects about 40% of the Polish population. European guidelines underline that there are no data on the percentage of people who have first symptoms of chronic venous insufficiency.

Aim

To determine the frequency and pattern of first symptoms and examine public knowledge on CVD in a selected group of patients.

Material and methods

Our study group consists of 175 patients who took part in preventive assessment of nevi. To determine public knowledge on CVD, we constructed a questionnaire, which consisted of two sections: one part to be completed by the patient and the other by the doctor.

Results

The median age was 41 years. From 175 patients, about 40% claimed that they do not recognize CVD. Only about half of them knew how to diagnose and treat it. Most of them associate telangiectasia and varicose veins as primary signs and symptoms of CVD.

Conclusions

Despite the fact that the disease itself is common, the level of public awareness is astonishingly low. Majority of patients tested could not associate first signs and symptoms, even though most of them had primary symptoms of the disease. In order to avoid high-cost treatment of ulcers and varicose veins, we should spread the knowledge on CVD.

The association between chronic venous disease and measures of physical performance in older people: a population-based study

BACKGROUND

Muscle pump dysfunction is an essential component of chronic venous disease (CVD) pathology. Aging reduces muscle strength which further weakens the venous return. However, the epidemiology of CVD and its relationship with the physical performance in older persons is poorly studied. We studied the prevalence of CVD in subjects aged over 70 years and its association primarily with the Short Physical Performance Battery (SPPB) and 10 m walk test.

METHODS

An accurate clinical leg examination was performed and the Clinical-Etiological-Anatomical-Pathophysiological-classification (CEAP, clinical classification of chronic venous disorders, C1-C6) determined by dermatologists in 552 subjects aged between 70 and 93 years belonging to the Northern Finland Birth Cohort 1966 - Parents' Study (NFBC-PS). Linear regression analyses were used to examine the association between CVD and functional tests and anthropometric measurements.

RESULTS

The prevalence of CVD (C1-C6) was 54.3%. C1 was diagnosed in 22.1% (n=84), C2 in 15.2% (n=45), C3 in 8.2% (n=45), C4 in 7.8% (43), C5 in 0.4% (n=2) and C6 in 0.5% (n=3). The prevalence and severity of CVD increased with increasing age (p<0.05). Males presented more with severe stages of CVD (C4-C6) (p<0.001). Subjects with CVD had significantly lower total SPPB scores and longer times in the 10 m walk test (p<0.001). The association between CVD severity and SPPB remained statistically significant in females after adjusting for age, body mass index (BMI) and number of children. The 10 m walk test times were associated with CVD when adjusted for sex and age but not after adjusting for BMI.

CONCLUSIONS

It is recommended that detailed skin examination of legs should be performed by physicians treating older subjects in order to improve early diagnosis of CVD. We highlight the importance of physical activity in older persons - lower limb activation of older persons with CVD may improve venous return and therefore prevent progression of CVD. We found an association between CVD and gait speed, however, there may exist bidirectional relationship.

Internal Perivenous Compression for venous insufficiency at the Saphenofemoral Junction: Early and Midterm Results and Operative Pain

OBJECTIVES

To assess the postoperative pain and midterm results of patients undergoing internal perivenous compression with internal compression therapy (ICT) for venous insufficiency at the saphenofemoral junction (SFJ).

MATERIALS AND METHODS

Patients managed with ICT between April and October 2019 for grade 4 venous reflux at the SFJ were retrospectively evaluated. The venous clinical severity score (VCSS) was calculated preoperatively and 1, 3, and 6 months postoperatively. Postoperative pain was assessed with the visual analog scale (VAS). Control Doppler ultrasound imaging was performed 6 months postoperatively.

RESULTS

Forty-five patients [14 (31%) males and 31 (69%) females; mean age, 47 ± 13 years] were included. The median preoperative VCSS was 7 (5-8.5). The median VCSS at 1, 3, and 6 months postoperatively was 6 (4-7.5), 4 (3-5.5), and 3 (2-4), respectively, and these values were significantly lower than the preoperative score (p = 0,001, p < 0.001, and p < 0.001, respectively). The postoperative VAS score was 0 in 6 patients (13%), 1 in 17 patients (38%), 2 in 6 patients (13%), 3 in 15 patients (33%), and 4 in 1 patient (2%). At 6 months, reflux was absent in 9 (20%), grade 1 in 20 (44%), and grade 2 in 16 (36%) patients. A vena saphena magna diameter of >6.7 mm predicted grade >1 reflux at 6 months [87.5%, with an area under the curve of 0.78 (p < 0.001)]. No complications occurred.

CONCLUSION

ICT alleviated symptoms and reduced reflux grade in patients with venous insufficiency at the SFJ. This therapy can be applied with satisfactory patient comfort.

Health professionals' perceptions of maggot debridement therapy

BACKGROUND

Maggot debridement therapy (MDT), or the use of maggots in dead tissue removal, has been shown to be beneficial in wound healing. Yet MDT in the US is often only used once conventional debridement methods have failed.

METHOD

In this study, nine health professionals, experienced in MDT, were interviewed in order to identify and analyse the perceived societal barriers to MDT acceptance and usage in the US.

RESULTS

Through qualitative analysis, using the grounded theory framework, this study found that among those interviewed, insurance reimbursement restrictions and stigmatisation of medicinal maggots were the factors driving resistance to MDT use.

CONCLUSION

Specifically, the 'yuck' factor and the perception of MDT as an 'ancient' modality contributed towards MDT stigma; in addition, lack of outpatient insurance coverage deterred MDT use. These findings provide useful information regarding the perceptual and systemic barriers that prevent greater acceptance of MDT. Ultimately, these barriers must be understood if we are to facilitate MDT implementation and improve MDT usage in the future.

Transcutaneous Partial Pressure of Oxygen Measurement in Advanced Chronic Venous Insufficiency as a Marker of Tissue Oxygenation

Purpose

Determination of oxygen concentration in tissues affected by chronic venous insufficiency (CVI) has shown inconsistent results over the years and has confounded the pathophysiology of venous diseases. This study measured transcutaneous partial oxygen pressure (TcPO₂) levels in patients with CVI to assess oxygenation and variation in oxygenation according to CVI stage.

Methods

Materials and A prospective study was performed on consecutive patients with unilateral CVI. TcPO₂ of diseased and unaffected limbs was measured in the supine and dependent positions. A single TcPO₂ value was measured at the site of greatest skin change or at the edge of the ulcer. The TcPO₂ values were analyzed and compared according to stage.

Results

A total of 96 patients were included in the study with C4 (24.0%), C5 (19.8%), and C6 (56.3%) disease. The mean age was 44.7 years, and 85 (88.5%) were male. There was a statistically significant (P<0.01) difference in mean TcPO₂ levels between the unaffected limb (supine, 32.1 mmHg; dependent, 50.7 mmHg), C5 diseased limb (supine, 16.6 mmHg; dependent, 35.5 mmHg), and C6 diseased limb (supine, 24.2 mmHg; dependent, 40.4 mmHg). In the supine and dependent positions, the mean TcPO₂ in the affected limb was significantly lower (P<0.01) than that in the unaffected limb.

Conclusion

TcPO₂ in advanced CVI can be used as a marker of oxygenation status. This is the first study in an Indian population looking at the relevance of TcPO₂ in the prognostication of advanced CVI.

Early Results of Popliteal Vein External Banding for Treatment of Chronic Venous Insufficiency

BACKGROUND

Chronic venous insufficiency (CVI) encompasses a myriad of clinical manifestations including lower extremity swelling and pain, ulcerations and chronic skin changes such as stasis dermatitis, and lipodermatosclerosis. CVI effects greater than 25 million Americans and has a significant socioeconomic and psychosocial impact. Treatment of CVI varies depending on the etiology. For those patients with deep venous reflux, restoration of the deep venous valvular system is critical. Popliteal vein external banding is a novel technique to treat deep venous reflux. Our study aims to retrospectively review the early outcomes for the largest U.S. series of patients undergoing popliteal vein external banding.

METHODS

Patients with C4, C5, and C6 disease with underlying deep venous reflux were treated with external banding of the popliteal vein. Basic demographic, ultrasound, and procedural data were collected. Patients were seen in clinic and underwent post procedure duplex. Procedure-specific complications were also assessed. The primary outcome was improvement of symptoms or wound healing.

RESULTS

Twelve patients were identified. Seventy-five percent of patients had a history of DVT on the ipsilateral extremity and 66.7% (n = 6) of those patients had previous common or external iliac vein stenting for post-phlebitic syndrome. 58.3% of patients had active ulcerations (C6) at the time of popliteal vein banding and the mean VCSS score was 12.7, consistent with advanced venous disease. Patients were followed for a mean 8.62 months. Of the 8 patients that had active ulcers (C6), 75% completely healed with a mean time to healing of 3.3 months. 91.6% of patients reported clinical improvement in their symptoms (i.e., reduction in edema/swelling, pain or improvement in size of ulcer). Three patients had post-operative wound complications and 1 required oral antibiotic for associated cellulitis.

CONCLUSION

Popliteal vein external banding represents a viable treatment modality for patients with venous insufficiency secondary to deep venous reflux. It is technically easier than most deep venous reconstructive options and may have an important role in the multimodal treatment of patients with advanced CVI.

Utility of high-frequency ultrasound in assessing cutaneous edema in venous ulcer patients

BACKGROUND

High-frequency ultrasound (HFUS) using a 20 MHz probe is a non-invasive assessment tool. Its utility in dermatology for diagnosis of disease or for monitoring of treatment response in various dermatological conditions is still being explored. Edema secondary to venous hypertension is the main pathogenic factor in the development of venous leg ulcers. However, there is no objective method for assessment of degree of edema. In this study, we explore the utility of high-frequency ultrasound in assessing cutaneous edema and for monitoring its improvement with compression therapy among patients with venous ulcer.

MATERIALS AND METHODS

Twenty patients with venous ulcer were enrolled in the study. Measurement of cutaneous edema was done at baseline and after 2 weeks of compression therapy in all patients. The 3 levels of measurement were dorsum of foot (low site, L1), 4 cm proximal to the medial malleolus (middle site, L2), and the medial aspect of the calf between the medial malleolus and the knee (upper site, L3).

RESULTS

Baseline subepidermal low echogenic band (SLEB) measurements were 2.46 ± 0.69 mm, 2.94 ± 0.65 mm, and 2.66 ± 0.64 mm at L1, L2, and L3, respectively. There was a significant reduction in SLEB measurement after compression therapy ( p values 0.008, 0.002, and 0.003 at L1, L2, and L3, respectively). The mean percentage reduction in SLEB at level of medial malleolus (mid level - 29.61 ± 12.24) was higher than the other 2 sites (L1-22.45 ± 15.83 and L3 were 27.57 ± 12.34).

CONCLUSION

Cutaneous ultrasound aids in accurate assessment of level and severity of edema. Hence, it can be utilized in trials to objectively assess the adequacy of treatment for patients with venous insufficiency.

Prevalence of Varicose Veins Among Nurses at Different Departments in a Single Tertiary Care Center in Riyadh

Background

Varicose veins (VV) is a chronic venous disease that affects the lower extremities. It is the dilation of subcutaneous veins, three to four millimeters in diameter. VV can be attributed to several risk factors such as age, obesity, multiple parities, heavy lifting, and long-standing hours. Direct and indirect complications can occur due to VV. Several studies were conducted to estimate the prevalence of VV.

Methods

A self-administered questionnaire was used to estimate the prevalence of VV among nurses from different departments in the National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia. The questionnaire included questions on weight, height, work history, lifestyle, and multiple diseases. The chi-square test and Fisher’s exact test were used for testing the association between the various predictors and the diagnosis of VV.

Results

A total of 366 nurses participated in the study. There were 40 (39 females and one male) cases of VV accounting for 11.0%. Variables that have a statistically significant association with VV were social status and lifting heavy objects (p=0.02), a family history of VV (p-value=<0.001), and the number of childbirths (p=0.04). The observation of each department was not statistically significant with VV (p=0.35).

Conclusion

Among nurses, positive family history, age, marital status, long-standing hours, and heavy object lifting were significant risk factors for the development of VV. However, the prevalence of VV in the four departments was low.

Endovascular management of the deep venous thrombosis: A new challenging role for the endovascular specialist in 2020

Over the last years, the endovascular approach to the management of the acute and chronic deep vein thrombosis (DVT) has gained more and more attention from the scientific community. DVT is the third most common cardiovascular disease after coronary heart disease and stroke, with classic treatment based on anticoagulation. Recent evidences have highlighted the risk of postthrombotic syndrome as high as 30%-50% in proximal ilio-femoral lesions, with irreversible clinical symptoms and impact on the quality of life of the population. Since 2000s, the new concept of thrombus removal in the acute phase has been supported by the introduction of different techniques based on the endovascular ablation of the clot by in-situ fibrinolysis and, more recently, fragmentation and aspiration. In the chronic phase, recanalization of the thrombosed segment is recommended by stent placement to remove the obstruction and eventually reduce the congestion. Immediate technical success of these procedures is widely satisfying, whereas the long-term clinical benefits are still debated. This paper presents an overview of the modern management of the DVT by endovascular approach with regard to the clinical contexts, interventional strategies and clinical outcomes. Endovascular specialist needs to be aware of this incoming challenge, as local expertise is demanded for the modern management of these patients in multidisciplinary theaters.

Calf muscle pump function as a predictor of all-cause mortality

Calf muscle pump (CMP) promotes venous return from the lower extremity and contributes to preload and cardiac output. Impaired CMP function may reflect a measure of frailty or cumulative disease burden or may impede cardiac function. The study objective was to test the hypothesis that impaired CMP negatively impacts survival. Consecutive adult patients who underwent venous strain gauge plethysmography at the Mayo Clinic Gonda Vascular Laboratory (January 1, 1998 - December 31, 2011) were assessed for overall survival. Patients with venous incompetence, venous obstruction or unilateral calf pump dysfunction were excluded. Risk of mortality was assessed with Cox proportional hazard ratios and after adjusting for Charlson Comorbidity Index variables. Over the study period, 2728 patients were included in the analysis. Compared to patients with normal CMP, those with impaired CMP were older (p < 0.001), predominantly female (p = 0.01) and had higher mean Charlson scores (p < 0.001). Patients with impaired CMP had a higher mortality rate at 5 (8.9% vs 2.4%), 10 (17.5% vs 5.9%), and 15 years (22.8% vs 8.3%) compared to those with normal CMP (p < 0.001 for each comparison). Of patients with heart failure, those with impaired CMP had worse survival at each 5-year increment compared to those with normal CMP (p < 0.05 at each increment). In conclusion, impaired CMP appears to be an independent predictor of poor outcomes after adjusting for variables within the Charlson Comorbidity Index. The association between impaired CMP, heart failure, and mortality may represent a negative impact on circulatory function or a surrogate measure of frailty.

Association between deep vein thrombosis and stent patency in symptomatic iliac vein compression syndrome: Systematic review and meta-analysis

BACKGROUND

The study intended to evaluate stent primary patency rates for patients with iliac vein obstruction related with iliac vein compression syndrome according to clinic presentation.

METHODS

A systematic review and meta-analysis was conducted of studies that compared: unexposed patients with nonthrombotic iliac vein lesion (NIVL, group 1) vs exposed patients with iliac acute deep vein thrombosis (DVT, group 2); and NIVL (group 1) vs exposed patients with iliac vein obstruction and post-thrombotic syndrome (PTS, group 3). The following databases were searched: EMBASE, PubMed, Web of Science, Scopus, SciELO, and LILACS. Two reviewers independently selected the potential studies and extracted data. The pooled odds ratio (OR) and 95% confidence interval (95% CI) are shown for each outcome.

RESULTS

Five studies with a total of 1050 participants and 1169 lower limbs were included. Five hundred eighty-eight lower limbs presented NIVL (50.3%), 91 lower limbs presented acute DVT (7.7%), and 490 lower limbs presented PTS (42%). The endovascular technical success rate of stenting did not differ in any of the groups: 99.6% in NIVL, 94.5% in acute DVT, and 96.5% in PTS (P = .0632). The primary stent patency rates in the 6-month follow-up were 98.3% in NIVL vs 90.9% in PTS, with a statistical difference showing reduced stent patency rates in PTS (OR, 0.17; 95% CI, 0.06-0.48; P = .0008; I² = 0%), and 100% in the NIVL group vs 91.6% in acute DVT, with no statistical difference (OR, 0.30; 95% CI, 0.06-2.32; P = .30; I² = 0%). The primary stent patency rates in the 12-month follow-up were 94.6% in NIVL vs 84.1% in PTS, with a statistical difference showing decreases stent patency rates in the PTS group (OR, 0.29; 95% CI, 0.14-0.63; P = .0008; I² = 0%), and 91.1% in NIVL vs 90.9% in acute DVT, with no statistical difference (OR, 1.03; 95% CI, 0.26-4.07; P = .96; I² = 0%).

CONCLUSIONS

There is no statistical difference for the stent primary patency rates when the treatment is conducted in NIVL as compared with acute DVT lower limbs (at 6 and 12 months); therefore, other criteria must be considered for the indication of this treatment in NIVL patients. However, because there were better results of stent primary patency rates for NIVL vs PTS patients, this finding favors the treatment of acute DVT instead of PTS in lower limbs, once PTS renders smaller stent patency rates at 6 and 12 months.

Extracellular Fluid Content in the Legs of Patients with Chronic Venous Disease

BACKGROUND

This study aimed to determine the factors that affect the extracellular fluid (ECF) content in the legs of patients with chronic venous disease (CVD).

METHODS

Bioimpedance analysis and air plethysmography (APG) were performed in 79 patients with CVD who visited our clinic between September 2016 and March 2019. The normal right legs (N) of 14 healthy volunteers were also reviewed for comparison. The ratio of ECF resistance (Re) of the leg to that of the arm (ReL/ReA) was used to express the ECF content in the tested leg. The severity of CVD was expressed using the clinical, etiological, anatomical, and pathophysiological (CEAP) classification.

RESULTS

The ReL/ReA decreased as the CEAP class increased (N: median; 0.81 [range 0.66-0.95], C0-1: 0.79 [0.60-0.98], C2: 0.77 [0.56-1.08], C3: 0.67 [0.57-0.85], C4: 0.64 [0.44-0.89]). Older age, female sex, and CEAP class affected the ReL/ReA, but body mass index did not. The ReL/ReA did not correlate with the parameters that were derived from APG, including the venous filling index.

CONCLUSIONS

We found that the ECF content in legs of patients with CVD might be primarily affected by patient-related factors and CEAP class, as opposed to venous hemodynamics.

Comparison of the Hemodynamic Performance of Two Neuromuscular Electrical Stimulation Devices Applied to the Lower Limb

Currently, 1% of the population of the Western world suffers from venous leg ulcers as a result of chronic venous insufficiency. Current treatment involves the use of moist wound healing, compression bandages, and intermittent pneumatic compression. Neuromuscular electrical stimulation is a novel potential new therapeutic method for the promotion of increased lower limb hemodynamics. The aim of this study was to measure the hemodynamic changes in the lower limb with the use of two neuromuscular electrical stimulation devices. Twelve healthy volunteers received two neuromuscular stimulation device interventions. The Geko^TM and National University of Ireland (NUI) Galway neuromuscular electrical stimulation devices were randomized between dominant and non-dominant legs. Hemodynamic measurements of peak venous velocity (cm/s), the time average mean velocity (TAMEAN) (cm/s), and ejected volume (mL) of blood were recorded. Peak venous velocity was significantly increased by the Geko^TM and the NUI Galway device compared to baseline blood flow (p < 0.0001), while only the voluntary contraction produced significant increases in TAMEAN and ejected volume (both p < 0.05). Neuromuscular muscular electrical stimulation can produce adequate increases in lower limb hemodynamics sufficient to prevent venous stasis. Greater use of neuromuscular stimulation devices could be considered in the treatment of conditions related to chronic venous insufficiency but requires further research.

Effects of Kinesio Taping and compression stockings on pain, edema, functional capacity and quality of life in patients with chronic venous disease: a randomized controlled trial

OBJECTIVE

The aim of this study was to compare the effects of Kinesio Taping and compression stockings on pain, edema, functional capacity and quality of life in patients with chronic venous disease (CVD).

DESIGN

This is a prospective, randomized, controlled, single-blind clinical trial.

SETTING

The study was conducted in a physiotherapy and rehabilitation unit of a university hospital.

SUBJECTS

A total of 62 patients with early-stage CVD were allocated to either an experimental group or a control group.

INTERVENTIONS

Experimental group (n = 29) received Kinesio Taping intervention once a week for four weeks, while control group (n = 29) received compression stockings for four weeks. All patients additionally undertook an exercise training programme including calf muscle pump exercises, flexibility exercises and diaphragmatic breathing.

MAIN MEASURES

Visual analogue scale, lower limb circumference measurements, 6-minute walk test and Short Form 36 questionnaire were applied before and after four weeks of treatment.

RESULTS

Control group showed statistically significant improvements in pain (P < 0.001), ankle circumferences (right, P = 0.002; left, P = 0.037), calf circumferences (right, P = 0.020; left, P = 0.022), knee circumference (left, P = 0.039) and thigh circumferences (right, P = 0.029; left, P = 0.002) compared with experimental group. There were no significant differences between groups with respect to functional capacity and quality of life (P > 0.05). Both groups significantly improved 6-minute walk distance (P < 0.001) and Short Form 36 physical component summary (experimental group, P = 0.002; control group, P = 0.006).

CONCLUSION

This study demonstrated that Kinesio Taping and compression stockings revealed similar improvements of functional capacity and quality of life in patients with CVD. The symptoms of pain and edema caused by CVD can be decreased more efficiently with compression stockings than Kinesio Taping intervention.

A multi-centre, prospective, randomised controlled feasibility study of plantar resistance exercise therapy for venous leg ulcers – Results of the PREVUE study

Objectives

To evaluate the feasibility of an interventional study involving a seated plantar resistance exercise programme, using a StepIt pedal, aimed at promotion of venous leg ulcer healing.

Methods

Thirty-two venous leg ulcer patients, recruited from community, GP and hospital settings, were randomised to either a standard care or adjuvant StepIt exercise programme arm for up to 12 weeks. The exercise involved a twice daily routine of 10 times 1 min of exercise, i.e. 2 s push and 2 s lift repetitions (equating to 300 daily ‘steps’).

Results

Complete healing of the venous leg ulcers was observed in 10 out of 15 (67%; StepIt cohort) and 7 out of 17 (41%; control cohort), respectively (p-value 0.18, Fisher’s exact test). Baseline differences between the two cohorts were longer wound chronicity, less venous leg ulcer-related pain and better venous leg ulcer-related quality of life in the StepIt cohort. One adverse event, involving increased wound exudate and slough production, was observed in a participant using StepIt, and no study withdrawals were recorded in either arm. StepIt users whose wound had completely healed by week 12 were more likely to be compliant with the exercise programme (self-reported) and more positive about the trial experience; however, all would recommend the device to others.

Conclusions

Seated plantar resistance exercise shows promise and may accelerate venous leg ulcer wound healing. The StepIt pedal is well-received by patients, and its efficacy may depend on the degree of patient compliance with the exercise programme. Further larger scale studies are indicated to allow more concrete inferences to be made on the clinical and potential health economics impact that this device may have.

The risk factors of lower limb cellulitis: A case-control study in a tertiary centre

INTRODUCTION

Lower limb cellulitis is a common superficial skin infection that leads to morbidity and mortality. Cellulitis risk factors have been well studied in many countries, but to date, not in Malaysia. Geographical and climate variables may affect risk factors. Early identification of the preventable risk factors is vital to prevent cellulitis and improve holistic patient care.

OBJECTIVE

To determine the risk factors of lower limb cellulitis amongst hospitalized patients at a tertiary center.

METHODS

A prospective case-control study of hospitalized patients with a clinical diagnosis of lower limb cellulitis was conducted at UKM Medical Centre, January-August 2015. Each patient was compared to two age and gender-matched control patients. All patients were interviewed and examined for risk factors of cellulitis.

RESULTS

A total of 96 cellulitis patients and 192 controls participated in this study. The cellulitis patients included 61 males and 35 females with a mean age of 62.07±15.43 years. The majority of patients were experiencing their first episode of cellulitis. Multivariate analysis showed a previous history of cellulitis (OR 25.53; 95% CI 4.73-137.79), sole anomalies (OR 16.32; 95% CI 6.65-40.06), ulceration (OR 14.86; 95% CI 1.00-219.39), venous insufficiency (OR 10.46 95% CI 1.98-55.22), interdigital intertrigo (OR 8.86; 95% CI 3.33-23.56), eczema (OR 5.74; 95% CI 0.96.-34.21), and limb edema (OR 3.95; 95% CI 1.82-8.59) were the significant risk factors for lower limb cellulitis.

CONCLUSION

Previous cellulitis and factors causing skin barrier disruption such as sole anomalies, ulceration, venous insufficiency, eczema, intertrigo, and limb edema were the risk factors for lower limb cellulitis. Physician awareness, early detection, and treatment of these factors at the primary care level may prevent hospital admission and morbidity associated with cellulitis.

Prevalence and Mortality of Venous Leg Diseases of the Deep Veins: An Observational Cohort Study Based on German Health Claims Data

This study estimates the prevalence and mortality of diseases of the deep veins of the legs such as deep vein thrombosis (DVT), postthrombotic syndrome (PTS), and venous leg ulceration (VLU). We used a random sample of 250 000 patients at age 50+ years of the register of the Allgemeine Ortskrankenkasse from 2004 to 2015. Selected manifestations of venous diseases assumed as risk factors for mortality were analyzed using Cox models while adjusting for various basic demographic and health characteristics. The prevalence in 2004 was 0.05% for DVT of the femoral veins, 0.50% for DVT of any deep veins, 0.86% for PTS, and 0.91% for VLU. The mortality rate in 2004 to 2015 was 20.40 deaths/100 person-years for DVT of the femoral veins, 10.69 for DVT of any deep veins, 4.34 for PTS, and 7.02 for VLU. The model revealed a 35% higher risk (p < .001) in patients with any DVT, an 88% higher mortality (p < .001) for femoral DVT, a 23% higher risk (p < .001) for VLU, and no health disadvantage in persons with PTS. Our study revealed an increased mortality for patients with VLU and DVT. Even after adjustment for embolic events and infections of the venous ulcers mortality remained significantly higher.