The distribution and extent of reflux and obstruction in patients with active venous ulceration

Clinical outcomes after treatment of incompetent saphenous vein combined with segmental popliteal vein reflux

OBJECTIVE

This study aimed to evaluate whether differences exist in the quality of life changes and complication rates after treatment of incompetent saphenous vein (ISV) based on the presence of segmental popliteal vein reflux (SPVR).

METHODS

Patients who underwent treatment for ISV from July 2016 to July 2021 were included and divided into two groups: patients without deep venous reflux (DVR) and patients with SPVR. Patients with axial DVR, a history of deep vein thrombosis, a history of orthopedic surgery, previous venous treatment, and no postoperative follow-up were excluded from the study. Duplex ultrasound examination was performed preoperatively and at 6 and 12 months postoperatively.

RESULTS

The study included 233 patients (398 limbs), and 50 (64 limbs) had SPVR. Differences were not observed in gender, age, body mass index, distribution of clinical class according to Clinical-Etiology-Anatomy-Physiology classification, laterality, treatment method, and preoperative Venous Clinical Severity Score or Aberdeen Varicose Vein Questionnaire scores between the two groups with SPVR or without DVR. Furthermore, the Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire scores at 6 and 12 months postoperatively were improved in both groups, although without significant differences. A significant difference was not observed in the rate of postoperative complications between the groups based on the presence of SPVR (1.8% vs 1.6%: P = .896). The SPVR improvement rate after ISV treatment was 25% (16/64), and patient-reported outcomes in patients combined with SPVR improved independent of treatment modality, saphenous vein treatment section, and postoperative SPVR improvement.

CONCLUSIONS

Complication rates and clinical outcomes after ISV treatment did not differ in the presence of SPVR. In patients with SPVR, after ISV treatment, quality of life improved regardless of treatment modality, saphenous vein treatment section, and postoperative SPVR improvement.

VIEW-VLU observational study of the effect of Varithena on wound healing in the treatment of venous leg ulcers

OBJECTIVE

Chronic venous hypertension, triggered by venous reflux and/or obstruction, leads to skin changes and venous leg ulcers (VLUs). Compression therapy is the standard of care, but many wounds remain unhealed. The objectives of this study were to observe the effects of endovenous chemical ablation with commercially available 1% polidocanol injectable microfoam on VLU healing and recurrence rates.

METHODS

The VIEW VLU study was a multicenter, open-label, phase IV registry of patients with active VLUs resulting from venous insufficiency of the great saphenous vein and/or anterior accessory saphenous vein systems who underwent ablation with 1% polidocanol microfoam. Primary outcomes included wound healing rate (change in wound perimeter), wound closure at 12 weeks after treatment, and time to wound closure. Secondary outcomes included VLU recurrence, numeric pain score at the ulcer location, EuroQol five-dimension five-level questionnaire quality-of-life index, and the Venous Clinical Severity Score. Patients were followed for 12 months.

RESULTS

We enrolled 76 patients (80 ulcers) from 14 sites across the United States and Canada (mean age 63.6 ± 13.7 years, 39.5% female, mean body mass index 36.3). Of the enrollees, 96.3% presented with great saphenous vein incompetence. The mean baseline wound perimeter was 117.2 ± 107.4 mm and 26.3% of wounds (21/80) were circumferential. The mean ulcer age was 34.8 ± 51.8 weeks at first presentation and the mean compression therapy duration was 26.4 ± 35.9 weeks. The median wound perimeter decreased by 16.3% from baseline in the first 2 weeks after the procedure and by 27.0% at 12 weeks. By 12 weeks, 53.8% of wounds (43/80) were healed. The median time to ulcer closure by Kaplan-Meier analysis was 89 days (95% confidence interval, 62.0-117.0). In a Kaplan-Meier analysis of initially healed wounds, 88.9% (95% confidence interval, 76.9-94.8) remained closed at 12 weeks after closure. The mean numeric pain scores (ulcer site) improved by 41.0% and 64.1% at 12 weeks and 12 months after the procedure, respectively. The health-related quality-of-life index (scale of 0-1) improved from 0.65 ± 0.27 at baseline to 0.72 ± 0.28 at 12 weeks and 0.73 ± 0.30 at 12 months. By 12 weeks after treatment, the mean target leg Venous Clinical Severity Score had significantly decreased by 5.8 points, and by 12 months it had decreased by 10.0 points.

CONCLUSIONS

Treatment with 1% polidocanol microfoam was associated with promising wound healing rates and low recurrence rates for VLUs, despite a challenging patient population with recalcitrant ulcers, a large percentage of which were circumferential, in patients with high body mass indexes.

Sulodexide Develops Contraction in Human Saphenous Vein via Endothelium-Dependent Nitric Oxide Pathway

Chronic venous disease (CVD) is a proqgressive and underestimated condition related to a vicious circle established by venous reflux and endothelial inflammation, leading to vein dilation and histology distortion, including loss of media tone. Sulodexide (SDX) is a drug restoring the glycocalyx that demonstrated endothelial protection and permeability regulation, together with anti-thrombotic and anti-inflammatory roles. In the lab it also exhibited vein contractility function. The aim of the present study was to show the possible role of endothelium and nitric oxide pathway on SDX's veno-contractile effect on human saphenous veins. The remnants of great saphenous vein (GSV) segments (n = 14) were harvested during coronary artery bypass graft surgery. They were dissected as endothelium-intact (n = 8) and denuded rings (n = 6). First, a viability test was carried out in bath with Krebs-Henseleit solution to investigate a control and basal tension value. After this, cumulative doses of SDX were applied to rings and contraction values were studied in endothelium-intact phenylephrine (PheE, 6 × 10^-7 M) pre-contracted vein rings. Finally, endothelium-intact PheE pre-contacted vein rings were treated by nitric oxide synthase inhibitor Nω-nitro-L-arginine methyl ester (L-NAME, 10^-4 M) for 10 min. Contraction protocol was applied, and contraction values were measured in cumulative doses of SDX. The same protocol was applied to endothelium-denuded vein rings to investigate the effect of SDX. Saphenous vein rings showed an increase in contraction to cumulative doses of SDX. In endothel-intact rings, KCL-induced contraction from 92.6% ± 0.3 to 112.9% ± 0.4 with cumulative SDX doses. However, SDX did not show any veno-contractile effect on endothel-denuded rings. In denuded rings contraction responses measured from 94.9% ± 0.3 to 85.2% ± 0.3 with increasing doses of SDX, indicating no significant change. Nitric oxide synthase inhibitor (L-NAME) prohibited the contraction response of the sulodexide in all dosages, indicating that the contractile function of SDX was mediated by endothelial derived nitric oxide. Results of endothel-intact and denuded rings with L-NAME showed a similar incline with denuded rings with SDX only. The results confirmed SDX's veno-contractile effect in human samples, by means of nitric oxide synthase pathways involvement.

Effect of concomitant deep venous reflux on truncal endovenous ablation outcomes in the Vascular Quality Initiative

OBJECTIVE

Few studies have investigated outcomes after truncal endovenous ablation in patients with combined deep and superficial reflux and no studies have evaluated patient-reported outcomes.

METHODS

We investigated the short- and long-term clinical and patient-reported outcomes among patients with and without deep venous reflux undergoing truncal endovenous ablation from 2015 to 2019 in the Vascular Quality Initiative. Preprocedural and postprocedural comparisons were performed using the t-test, χ², or their nonparametric counterpart when appropriate. Multivariable logistic regression models were used to assess for confounding.

RESULTS

A total of 4881 patients were included, of which 2254 (46.2%) had combined deep and superficial reflux. The median follow-up was 336.5 days. Patients with deep reflux were less likely to be female (65.9% vs 69.9%; P = .003), more likely to be Caucasian (90.2% vs 86.5%; P = .003) and had no difference in BMI (30.6 ± 7.5 vs 30.6 ± 7.2; P = .904). Additionally, no difference was seen in rates of prior varicose vein treatments, number of pregnancies, or history of deep venous thrombosis; however, patients without deep reflux were more likely to be on anticoagulation at the time of the procedure (10.9% vs 8.1%; P < .001). Patients without deep reflux had slightly higher median preprocedural Venous Clinical Severity Score (VCSS) scores (8 [interquartile range (IQR), 6-10]) vs 7 [IQR, 6-10]; P = .005) as well as postprocedural VCSS scores (5 [IQR, 3-7] vs 4 [IQR, 2-6]; P < .001). The median change in VCSS from before to after the procedure was lower for patients without deep reflux (3 [IQR, 1.0-5.5] vs 3.5 [IQR, 1-6]; P = .006). Total symptom score was higher for patients without deep reflux both before (median, 14 [IQR, 10-19] vs median, 13.5 [IQR, 9.5-18]; P = .005) and postprocedurally (median, 4 [IQR, 1-9] vs median, 3.25 [IQR, 1-7]; P < .001), but no difference was seen in change in symptom score (median, 8 [IQR, 4-13] vs median, 9 [IQR, 4-13]; P = .172). Patients with deep reflux had substantially higher rates of complications (10.4% vs 3.0%; P < .001), with a particular increase in proximal thrombus extension (3.1% vs 1.1%; P < .001). After controlling for confounding, this estimate of effect size for any complication increased (odds ratio, 5.72; 95% confidence interval, 2.21-14.81; P < .001).

CONCLUSIONS

No significant difference is seen in total symptom improvement when patients undergo truncal endovenous ablation with concomitant deep venous reflux, although a greater improvement was seen in VCSS score in these patients. Patients with deep venous reflux had a significantly increased rate of complications, independent of confounding variables, and should be counseled appropriately before the decision for treatment.

The need for a timely diagnostic workup for patients with venous leg ulcers

OBJECTIVE

To explore the need for an extended diagnostic workup in patients with venous leg ulcers (VLUs) and to establish the prevalence of the underlying causes of VLU.

METHOD

This retrospective cohort study analysed data from patients with VLU. The visual analogue scale (VAS) was used for pain assessment. The ankle-brachial index (ABI) was measured to exclude patients with arterial pathology. A duplex was performed. All patients received a wound treatment plan and ambulatory compression therapy. Continuous variables were presented as mean±standard deviation (SD) or median and interquartile range (IQR). Mann-Whitney U test and Kruskal-Wallis were used. When normally distributed, an independent sample t-test was used.

RESULTS

A total of 70 patients were recruited. Of these, 18 (25.7%) experienced a VLU once and 52 (74.3%) had a recurrent VLU. Treatment of the underlying lesions was performed in almost 30% of patients. Patients who were treated showed almost two times slower healing rates compared with those who were not treated for an underlying pathology. The mean time in patient referral exceeded two years, and patients who did not see their GP were treated by nurses who did not provide regular feedback the GP; as a result, compression therapy was not always adequate.

CONCLUSION

Patients with a VLU showing no signs of healing after 2 months should be referred to a dedicated wound care centre to avoid delays.

Do All Abdominal Neuroendocrine Tumors Require Extended Postoperative VTE Prophylaxis? A NSQIP Analysis

BACKGROUND

Venous thromboembolism (VTE) occurs at high incidence in abdominal cancer surgery; therefore, a 4-week postoperative VTE prophylaxis is advocated. However, most patients with neuroendocrine tumors (NETs) have more favorable prognoses. This study aimed to determine the incidence of VTE in patients with abdominal NETs, compare these rates to other abdominal malignancies, and identify VTE risk factors.

METHODS

The ACS-NSQIP database was queried to identify patients with abdominal NETs and other abdominal malignancies who underwent surgery from 2008 to 2015. A 30-day postoperative VTE incidence for each group was compared. Univariable and multivariable analyses were used to identify VTE risk factors.

RESULTS

Of the 7226 operations for patients with benign (2154) and malignant (5072) abdominal NETs, 144 patients experienced a VTE without significant differences between groups. Subgroup analysis revealed a spectrum of VTE rates. Compared to VTE rates of other abdominal malignancies, patients with benign (1.1% vs. 2.4%, p < 0.001) or malignant (1.7% vs. 2.4%, p < 0.001) non-pancreatic abdominal NETs had significantly lower rates, malignant pancreatic NETs (PNETs) (3.4% vs. 2.4%, p = 0.03) had significantly higher rates, and benign PNETs (3.2% vs. 2.4%, p = 0.21) had comparable rates. Multivariable analysis identified pre-operative albumin (p < 0.001), bleeding disorders (p < 0.001), operative time (p < 0.001), and having a PNET (p = 0.04) as risk factors for VTE in abdominal NET patients.

CONCLUSION

Routine extended VTE prophylaxis after surgery may be necessary in PNETs, but probably unnecessary in other abdominal NETs. However, clinicians should use risk factors identified in this study when considering to forego extended VTE prophylaxis in NET patients.

Sulodexide in venous disease

Sulodexide is a glycosaminoglycan extracted from porcine intestinal mucosa. The purpose of this review is to discuss sulodexide's complex pharmacological profile and its clinical applications for venous disease. Sulodexide has wide-ranging biological effects on the vascular system, including antithrombotic, profibrinolytic, anti-inflammatory, endothelial protective and vasoregulatory effects. Sulodexide has emerged as a potential therapeutic option for the management of chronic venous insufficiency, including venous ulceration, and the prevention of recurrent venous thromboembolism, with a low rate of major bleeding complications. Sulodexide's pleiotropic vascular effects may facilitate the management of common venous disorders.

Risk Factors for Venous Thromboembolism following Thoracolumbar Surgery: Analysis of 43,777 Patients from the American College of Surgeons National Surgical Quality Improvement Program 2005 to 2012

Study Design Retrospective clinical study of a prospectively collected, national database. Objective Determine the 30-day incidence, timing, and risk factors for venous thromboembolism (VTE) following thoracolumbar spine surgery. Methods The American College of Surgeons National Surgical Quality Improvement Program Participant Use File identified 43,777 patients who underwent thoracolumbar surgery from 2005 to 2012. Multiple patient characteristics were identified. The incidence and timing (in days) of deep vein thrombosis (DVT) and pulmonary embolus (PE) were determined. Multivariable regression analysis was performed to identify significant risk factors. Results Of the 43,777 patients identified as having had thoracolumbar surgery, 202 cases of PE (0.5%) and 311 cases of DVT (0.7%) were identified. VTE rates were highest in patients undergoing corpectomy, with a 1.7% PE rate and a 3.8% DVT rate. Independent risk factors for VTE included length of stay (LOS) ≥ 6 days (odds ratio [OR] 4.07), disseminated cancer (OR 1.77), white blood cell count > 12 (OR 1.76), paraplegia (OR 1.75), albumin < 3 (OR 1.73), American Society of Anesthesiologists class 4 or greater (OR 1.54), body mass index > 40 (OR 1.49), and operative time > 193 minutes (OR 1.43). LOS < 3 days was protective (OR 0.427). Conclusions We report an overall 30-day PE rate of 0.5% and DVT rate of 0.7% following thoracolumbar spine surgery. Patients undergoing corpectomy were at highest risk for VTE. Multiple VTE risk factors were identified. Further studies are needed to develop algorithms to stratify VTE risk and direct prophylaxis accordingly.

Thromboembolic Disease after Cervical Spine Surgery: A Review of 5,405 Surgical Procedures and Matched Cohort Analysis

STUDY DESIGN

Retrospective matched cohort analysis.

OBJECTIVE

The majority of the literature on venous thromboembolism (VTE) after spine surgery is limited to studies of thoracolumbar surgery. Less is known regarding the incidence of VTE and associated risk factors following cervical spine surgery.

METHODS

A total of 5,405 patients at our institution underwent cervical diskectomy, laminectomy, corpectomy, laminoplasty, or fusion between 1995 and 2012; 85 of the 5,405 patients (1.57%) suffered either a DVT (55) or pulmonary embolus (51) within 30 days postoperatively. The cases were matched 1:2 to controls based on age, sex, and date of surgery. Data regarding multiple perioperative factors, demographics, and comorbidities was collected.

RESULTS

Several risk factors were identified for VTE. Significant medical comorbidities included chronic venous insufficiency (odds ratio [OR] = 3.40), atrial fibrillation (OR = 2.69), obesity (OR = 2.67), and ischemic heart disease (OR = 2.18). Staged surgery (OR = 28.0), paralysis (OR = 19.0), combined approach (OR = 7.46), surgery for infection (OR = 18.5), surgery for trauma (OR = 11.1), comorbid traumatic injuries (OR > 10), oncologic procedures (OR = 5.2), use of iliac crest autograft (OR = 4.16), two or more surgical levels (OR = 3.48), blood loss > 300 mL (OR = 1.66), and length of stay 5 days or greater (OR = 3.47) were all found to be risk factors for VTE (p < 0.05) in univariate analysis. Multivariate analysis found staged surgery (OR = 35.7), paralysis (OR = 7.86), and nonelective surgery (OR = 6.29) to be independent risk factors for VTE.

CONCLUSIONS

Although the incidence of VTE following cervical spine surgery is low, we identified several risk factors that may be predictive. More aggressive approaches to prophylaxis and surveillance in certain patient populations may be warranted.