Mechanisms of varicose vein formation: valve dysfunction and wall dilation

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.

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.

Clinical evidence and rationale of mesoglycan to treat chronic venous disease and hemorrhoidal disease: a narrative review

Chronic venous disease (CVD) and hemorrhoidal disease (HD) are among the most common vascular diseases in the world, with CVD affecting 22-41% of the population in Europe and HD having a point prevalence of 11-39%. The burden is substantial in terms of the effect of symptoms on patients' health-related quality of life (HRQoL) and direct/indirect medical costs. Treatment begins with lifestyle changes, compression in CVD and topical therapies in HD, and escalates as needed through oral therapies first and eventually to surgery for severe disease. CVD and HD share etiological features and pathological changes affecting the structure and function of the tissue extracellular matrix. Mesoglycan, a natural glycosaminoglycan (GAG) preparation composed primarily of heparan sulfate and dermatan sulfate, has been demonstrated to positively impact the underlying causes of CVD and HD, regenerating the glycocalyx and restoring endothelial function, in addition to having antithrombotic, profibrinolytic, anti-inflammatory, antiedema and wound-healing effects. In clinical trials, oral mesoglycan reduced the severity of CVD signs and symptoms, improved HRQoL, and accelerated ulcer healing. In patients with HD, mesoglycan significantly reduced the severity of signs and symptoms and the risk of rectal bleeding. In patients undergoing excisional hemorrhoidectomy, adding mesoglycan to standard postoperative care reduced pain, improved HRQoL, reduced incidence of thrombosis, and facilitated an earlier return to normal activities/work, compared with standard postoperative care alone. The clinical effects of mesoglycan in patients with CVD or HD are consistent with the agent's known mechanisms of action.

Escin ameliorates inflammation via inhibiting mechanical stretch and chemically induced Piezo1 activation in vascular endothelial cells

Escin is an active ingredient used in the treatment of phlebitis. However, the pharmacological mechanism of escin remains largely unclear. Here, we aimed to determine the molecular basis for the therapeutic effect of escin. Human umbilical vein endothelial cells (HUVECs) were subjected to shear-stress assays with or without escin. Intracellular Ca2+ levels, inflammatory factors and the activity of NF-κB were measured in endothelial cells (ECs) after mechanical-stretch or Yoda1 activation. Isometric tensions in aortic rings were identified. In addition, murine liver endothelial cells (MLECs) isolated from Piezo1 endothelial specific knockout mice (Piezo1△ EC) were used to explore the role of Piezo1. Our results showed that escin inhibited inflammatory factors, intracellular Ca2+ levels and Yoda1-evoked relaxation of thoracic aorta rings. Cell alignment induced by shear stress was inhibited by escin in HUVECs, and Piezo1 siRNA was used to show that this effect was dependent on Piezo1 channels. Moreover, escin reduced the inflammation and inhibited the activity of NF-κB in ECs with mechanical-stretch, which were insensitive to Piezo1 deletion. SN50, an NF-κB antagonist, significantly inhibited the mechanical stretch-induced inflammatory response. In addition, escin reduced inflammation in ECs subjected to mechanical-stretch, which was insensitive after using NF-κB antagonist. Collectively, our results demonstrate that escin inhibits the mechanical stretch-induced inflammatory response via a Piezo1-mediated NF-κB pathway. This study improves our understanding of a molecular target of escin that mediates its effect on chronic vascular inflammation.

Bariatric Surgery and Femoral Vein Diameter in Morbidly Obese Patients: a Cohort Study in Iran

INTRODUCTION

Considering the importance of health, the effect of obesity on the quality of life, the person's self-image, and the effect of obesity on various organs, especially the vessels, and the absence or presence of a study in Iran that investigated the effect of gastric bariatric surgery on the diameter of the femoral vein, in the present study, we investigated the effect of bariatric surgery on femoral vein diameter in morbidly obese patients referred to Imam Hossein hospital.

MATERIALS AND METHODS

The present study was a prospective cohort study on morbidly obese patients referred to the center in 2022-2023. In this study, 31 morbidly obese patients with BMI above 30 kg/m2 who were candidates for bariatric surgery were examined. Demographic data were collected using a demographic profile checklist. BMI, the diameter of common femoral veins, and the great saphenous vein were measured and recorded before and 6 months after surgery. Ultimately, the data was collected and analyzed using SPSS V.24 software.

RESULTS

In the current study, 31 patients (62 extremities) were examined. The mean age of the patients was 34.45, with a standard deviation of 8.86. Fourteen patients (45.2%) were male, and 17 (54.8%) were female. The mean diameter of the common femoral vein in the 6 months after surgery was significantly less than before surgery (11.58 (1.64) compared to 12.95 (1.84), P = 0.0001). The mean diameter of the great saphenous vein in the 6 months after surgery was significantly less than before surgery (7.30 (1.45) compared to 7.75 (1.45), P = 0.0001).

CONCLUSION

It seems that bariatric surgery causes a significant decrease in the diameter of lower limb veins (common femoral vein and great saphenous vein) compared to before surgery. However, further studies in this field are recommended.

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.

Early Saphenous Vein Graft Aneurysm Rupture: A Not So-Late Complication. Case Report and Comprehensive Literature Review

BACKGROUND AND OBJECTIVES

Saphenous vein graft (SVG) is a cardiac surgical practice used to create a cardiac bypass in cases of coronary artery obstruction. It consists of a surgical procedure that involves the creation of an aorto-coronary communication by a venous conduit (saphenous vein) to bypass coronary stenosis and allow cardiac revascularization. This practice can be affected by early and late complications. The most feared complication is graft aneurysm or pseudoaneurysm degeneration and rupture which are considered late complications. This paper presents a rare case of SVG aneurysmal rupture that occurred 24 h after surgery and a review of the literature to provide a general look at the state of knowledge.

MATERIALS AND METHODS

The systematic review was carried out using the guidelines according to the PRISMA method.

RESULTS

Cases of aneurysmal rupture have never been described prior to one month after surgery. The male sex and subjects under 45 are the most affected by this complication. Death occurs in less than half of the cases, being more frequent in young people. Performing a CT or angio-CT examination led to the diagnosis.

CONCLUSIONS

It is impossible to estimate the implanted vessel's quality, so postoperative follow-up is fundamental. Transesophageal ultrasound can be useful, and hematochemical tests are valuable early diagnostic tools, whrease CT and angio-CT can be useful even months after surgery. Forensic analysis should always perform an autopsy and graft histological examination.

Morphological restructuring of smooth muscles elements of the wallgreat saphenous vein of a person on the lower leg during the development of varicose transformation

Introduction. Further study of the structural restructuring of the wall of the great saphenous vein throughout a person’s life with the development of chronic venous diseases is an urgent task of phlebology.

The purpose of the study. Research of the morphological restructuring of smooth muscleselements of the human great saphenous vein wall on the calf in norm, ectasia and development of varicose transformation.

Materials and methods. The study of morphological restructuring of the great saphenous vein wall on the calf was carried out in 3 comparison groups by light microscopy. In 1th group, the structure of the GSV wall was studied on autopsy material of people who died from various causes at the age of 5 to 80 years. In the 2nd and 3rd groups, fragments of GSV in the calf were taken by biopsy during the execution of the operations for varicose veins. All patients underwent ultrasound mapping before surgery to determine the presence and degree of ectasia, varicose transformation and retrograde blood flow. For histological analysis in the groups, 140 GSV fragments were removed in 1-group, 165 BPV fragments in 2-group, and 250 GSV fragments in 3-group.

Results. The general morphological analysis of histological preparations made it possible to visually identify various variants of changes in smooth muscleselements inherent in the inner, middle and outer shells of the GSV wall. The selected variants of reconstruction of the smooth muscleselements were combined into 10 morphological types.

Conclusion. Age-related morphological changes in the smooth muscleselements in the GSV wall on the calf, over the course of a person’s life, do not have the same character as changes occurring in its wall during the development of its ectasia and varicose transformation.

Clinically Recognized Varicose Veins and Physical Function in Older Individuals: The ARIC Study

BACKGROUND

Although a few studies reported an association between varicose veins and physical function, this potentially bidirectional association has not been systematically evaluated in the general population.

METHOD

In 5 580 participants (aged 71-90 years) from the Atherosclerosis Risk in Communities study, varicose veins were identified in outpatient and inpatient administrative data prior to (prevalent cases) and after (incident cases) visit 5 (2011-2013). Physical function was evaluated by the Short Physical Performance Battery (SPPB, score ranging from 0 to 12). We evaluated (i) cross-sectional association between prevalent varicose veins and physical function, (ii) association of prevalent varicose veins with subsequent changes in physical function from visit 5 to visits 6 (2016-2017) and 7 (2018-2019), and (iii) association of physical function at visit 5 with incident varicose veins during a median follow-up of 3.6 years (105 incident varicose veins among 5 350 participants without prevalent cases at baseline).

RESULTS

At baseline, varicose veins were recognized in 230 (4.1%) participants and cross-sectionally associated with reduced physical function. Longitudinally, prevalent varicose veins were not significantly associated with a decline in SPPB over time. In contrast, a low SPPB ≤6 was associated with a greater incidence of varicose veins compared to SPPB ≥10 (adjusted hazard ratio 2.13 [95% confidence interval = 1.19, 3.81]).

CONCLUSION

In community-dwelling older adults, varicose veins and low physical function were associated cross-sectionally. Longitudinally, low physical function was a risk factor for incident varicose veins, but not vice versa. Our findings suggest an etiological contribution of low physical function to incident varicose veins.

Biomechanical stretch-induced CLOCK upregulation in venous smooth muscle cells promotes phenotypic and functional transformation

BACKGROUND

A chronic change in hemodynamic forces might activate the pathophysiological process of maladaptive venous remodeling. Biomechanical stretching stimulates venous smooth muscle cells (SMCs) in the media, and biomechanical loads exceeding physiological levels affect the intrinsic circadian rhythm and cellular phenotype. This study aimed to investigate the changes in the expression patterns of circadian clock genes under biomechanical stretching and their role in the regulation of the SMC phenotype.

METHODS

Circadian genes were detected in venous specimens and venous SMCs from patients with varicose veins (VVs) and patients with autologous vein grafts (normal veins). Molecular mechanism studies of SMC phenotypic switching under biomechanical stretching were performed in human umbilical venous SMCs (HUVSMCs).

RESULTS

CLOCK upregulation was observed in VVs. The circadian rhythm was disrupted in venous SMCs derived from VVs. In addition, CLOCK expression and cell proliferation and migration were increased in HUVSMCs exposed to biomechanical stretch. CLOCK overexpression activated NF-κB signaling and phenotypic transformation in HUVSMCs, whereas CLOCK depletion had inhibitory effects on these pathways. Further experiments revealed that the CLOCK protein regulates phenotypic and functional transformation via the RHOA/ROCK1 pathway.

CONCLUSIONS

Our results demonstrate that CLOCK is a crucial regulator of the SMC phenotype under mechanical stretch. The CLOCK/RHOA/ROCK1 pathway is important in phenotypic adaptation, and targeting RHOA/ROCK1 could potentially reverse stretch-induced phenotypic switching.

The Clinical Problem of Pelvic Venous Disorders

Pelvic venous disorders are inter-related pathologic conditions caused by reflux and obstruction in the pelvic veins. It can present a spectrum of clinical features based on the route of transmission of venous hypertension to either distal or caudal venous reservoirs. Imaging can help to visualize pelvic vascular and visceral structures to rule out other gynecologic, gastrointestinal, and urologic diseases. Endovascular treatment, owing to its low invasive nature and high success rate, has become the mainstay in the management of pelvic venous disorders. This article reviews the pathophysiology, clinical presentations, and diagnostic and therapeutic approaches to pelvic venous disorders.

Impact of retrograde anastomosis during supermicrosurgical lymphaticovenous anastomosis for cancer-related lower limb lymphedema: A retrospective cohort propensity-score-matched outcome analysis

BACKGROUND

In addition to antegrade anastomosis, retrograde anastomosis has been thought to offer further improvements after lymphaticovenous anastomosis (LVA) by bypassing the retrograde lymphatic flow. However, this concept has yet to be validated. The aim of this study was to determine the impacts on outcomes of performing both retrograde and antegrade anastomosis, as compared to antegrade-only anastomosis for treating lower limb lymphedema.

STUDY DESIGN

This was a retrospective cohort propensity score-matched study. Eighty-seven patients with gynecologic cancer-related lower limb lymphedema were enrolled, including 58 patients who had received both antegrade and retrograde anastomoses (Group I) and 29 patients who had received antegrade-only anastomoses (Group II) as the control group. LVA was the primary treatment. Patients who had previous LVA, liposuction, or excisional therapy were excluded. Patient characteristics, intraoperative findings, and functional parameters including the ratio of indocyanine green-enhanced and flow-positive lymphatic vessels were recorded. Magnetic resonance volumetry was used for outcome assessments. The primary endpoint was the volume change at 6 months after LVA.

RESULTS

After matching, a total of 26 patients have remained in each group. All parameters were matched except that Group I still had significantly more median LVA performed compared to Group II (8 [IQR: 5.3-10.0] vs. 5.5 [4.3-6.0], p = 0.001, respectively). Group II showed more post-LVA improvements at six-month and one-year follow-up compared to Group I but without statistically significant differences.

CONCLUSION

The use of supplementary retrograde anastomoses is discouraged since it may lead to inferior post-LVA outcome compared to antegrade-only anastomoses.

Genome-wide association analysis and replication in 810,625 individuals with varicose veins

Varicose veins affect one-third of Western society, with a significant subset of patients developing venous ulceration, costing $14.9 billion annually in the USA. Current management consists of either compression stockings, or surgical ablation for more advanced disease. Most varicose veins patients report a positive family history, and heritability is ~17%. We describe the largest two-stage genome-wide association study of varicose veins in 401,656 individuals from UK Biobank, and replication in 408,969 individuals from 23andMe (total 135,514 cases and 675,111 controls). Forty-nine signals at 46 susceptibility loci were discovered. We map 237 genes to these loci, several of which are biologically plausible and tractable to therapeutic targeting. Pathway analysis identified enrichment in extracellular matrix biology, inflammation, (lymph)angiogenesis, vascular smooth muscle cell migration, and apoptosis. Using a polygenic risk score (PRS) derived in an independent cohort, we demonstrate its predictive utility and correlation with varicose veins surgery.

Hypoxia and hemorheological properties in older individuals

Hypoxia is caused by insufficient oxygen availability for the organism leading to reduced oxygen delivery to tissues and cells. It has been regarded as a severe threat to human health and it is indeed implicated in pathophysiological mechanisms involved in the development and progression of many diseases. Nevertheless, the potential of controlled hypoxia interventions (i.e. hypoxia conditioning) for improving cardio-vascular health is gaining increased attention. However, blood rheology is often a forgotten factor for vascular health while aging and hypoxia exposure are both suspected to alter hemorheological properties. These changes in blood rheology may influence the benefits-risks balance of hypoxia exposure in older individuals. The benefits of hypoxia exposure for vascular health are mainly reported for healthy populations and the combined impact of aging and hypoxia on blood rheology could therefore be deleterious in older individuals. This review discusses evidence of hypoxia-related and aging-related changes in blood viscosity and its determinants. It draws upon an extensive literature search on the effects of hypoxia/altitude and aging on blood rheology. Aging increases blood viscosity mainly through a rise in plasma viscosity, red blood cell (RBC) aggregation and a decrease in RBC deformability. Hypoxia also causes an increase in RBC aggregation and plasma viscosity. In addition, hypoxia exposure may increase hematocrit and modulate RBC deformability, depending on the hypoxic dose, i.e, beneficial effect of intermittent hypoxia with moderate dose vs deleterious effect of chronic continuous or intermittent hypoxia or if the hypoxic dose is too high. Special attention is directed toward the risks vs. benefits of hemorheological changes during hypoxia exposure in older individuals, and its clinical relevance for vascular disorders.

What is the relationship of varicose vein pathogenesis with collagen fibers?

Aims and Background

In this study, the densities of collagen 1 and collagen 4, which are an effective vascular component in the remodelling of varicose veins, were investigated.

Materials and Methods

The study included primary varicose vein samples of 20 patients and vein samples of 20 healthy controls. Immunohistochemical staining was performed using collagen 1 and collagen 4 antibodies. Histochemical staining was performed using Masson Trichrome.

Results

In the immunohistochemical analysis of varicose samples, collagen 1 immunostaining was negative in 17 cases (85%) and positive in 3 cases (15%). In healthy venous tissue samples, collagen 1 immunostaining was negative in 12 cases (60%) and positive in 8 cases (40%). There was no statistically significant difference between both groups concerning collagen 1 immunostaining (p > 0.05). In varicose samples, collagen 4 immunostaining was negative in 4 cases (20%) and positive in 16 cases (80%). In healthy venous tissue samples, collagen 4 immunostaining was negative in 13 cases (65%) and positive in 7 cases (35%). Statistical comparison of healthy veins and varicose veins concerning collagen 4 immunostaining showed a significant difference (p = 0.03). In the histochemical analysis of varicose samples, Masson Trichrome staining was negative in 4 cases (20%) and positive in 16 cases (80%). In healthy venous tissue samples, Masson Trichrome staining was negative in 18 cases (90%) and positive in 2 cases (10%). Statistical comparison of healthy veins and varicose veins concerning collagen 4 immunostaining showed a significant difference (p = 0.01).

Conclusion

The change in the density of collagen types plays an important role in vein wall remodeling.

SARS-CoV-2 infection induces soluble platelet activation markers and PAI-1 in the early moderate stage of COVID-19

Introduction

Coagulation dysfunction and thromboembolism emerge as strong comorbidity factors in severe COVID‐19. However, it is unclear when particularly platelet activation markers and coagulation factors dysregulated during the pathogenesis of COVID‐19. Here, we sought to assess the levels of coagulation and platelet activation markers at moderate and severe stages of COVID‐19 to understand the pathogenesis.

Methods

To understand this, hospitalized COVID‐19 patients with (severe cases that required intensive care) or without pneumonia (moderate cases) were recruited. Phenotypic and molecular characterizations were performed employing basic coagulation tests including prothrombin time (PT), activated partial thromboplastin time (APTT), D‐Dimer, and tissue factor pathway inhibitor (TFPI). The flow cytometry‐based multiplex assays were performed to assess FXI, anti‐thrombin, prothrombin, fibrinogen, FXIII, P‐selectin, sCD40L, plasminogen, tissue plasminogen activator (tPA), plasminogen activator inhibitor‐1 (PAI‐1), and D‐Dimer.

Results

The investigations revealed induction of plasma P‐selectin and CD40 ligand (sCD40L) in moderate COVID‐19 cases, which were significantly abolished with the progression of COVID‐19 severity. Moreover, a profound reduction in plasma tissue factor pathway inhibitor (TFPI) and FXIII were identified particularly in the severe COVID‐19. Further analysis revealed fibrinogen induction in both moderate and severe patients. Interestingly, an elevated PAI‐1 more prominently in moderate, and tPA particularly in severe COVID‐19 cases were observed. Particularly, the levels of fibrinogen and tPA directly correlated with the severity of the disease.

Conclusions

In summary, induction of soluble P‐selectin, sCD40L, fibrinogen, and PAI‐1 suggests the activation of platelets and coagulation system at the moderate stage before COVID‐19 patients require intensive care. These findings would help in designing better thromboprophylaxis to limit the COVID‐19 severity.

Perfusion, Stance and Plantar Pressure Asymmetries on the Human Foot in the Absence of Disease—A Pilot Study

Physiological perfusion asymmetries in the lower limb are known, although poorly understood, as are asymmetries reported in plantar pressure and stance. This preliminary study aims to explore potential relationships between perfusion and pressure variables in humans. A convenience sample of eight healthy individuals (25.25 ± 5.37 years old) of both sexes, was selected. Chosen variables were perfusion, plantar pressure, and stance. Perfusion was measured in both feet by laser Doppler flowmetry (LDF) and polarized light spectroscopy (PSp), and plantar pressure and stance obtained by a pressure plate. These were measured in baseline (Phase I) in a repeated squatting (Phase II), and in recovery (Phase III). A 95% confidence interval was adopted. Intraindividual significant perfusion asymmetries between both feet were detected by LDF in Phase I. These disappeared in Phase II and returned in Phase III. PSp did not detect any asymmetries. Plantar pressure was also asymmetric and differently distributed along both feet with no statistical significance except in the hindfoot. Significant correlations were found between BMI and mean Plantar Pressure in Phase I and Phase III, and an inverse correlation between LDF perfusion and Plantar Pressure in Phase I. These results seem to suggest an interesting direction for exploration and study of these asymmetries in the absence of disease.

Review on Laser Technology in Intravascular Imaging and Treatment

Blood vessels are one of the most essential organs, which nourish all tissues in our body. Once there are intravascular plaques or vascular occlusion, other organs and circulatory systems will not work properly. Therefore, it is necessary to detect abnormal blood vessels by intravascular imaging technologies for subsequent vascular treatment. The emergence of lasers and fiber optics promotes the development of intravascular imaging and treatment. Laser imaging techniques can obtain deep vascular images owing to light scattering and absorption properties. Moreover, photothermal and photomechanical effects of laser make it possible to treat vascular diseases accurately. In this review, we present the research progress and applications of laser techniques in intravascular imaging and treatment. Firstly, we introduce intravascular optical coherent tomography and intravascular photoacoustic imaging, which can obtain various information of plaques. Multimodal intravascular imaging techniques provide more information about intravascular plaques, which have an essential influence on intravascular imaging. Secondly, two laser techniques including laser angioplasty and endovenous laser ablation are discussed for the treatment of arterial and venous diseases, respectively. Finally, the outlook of laser techniques in blood vessels, as well as the integration of laser imaging and treatment are prospected in the section of discussions.

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.

Impact of statin treatment on patients diagnosed with chronic venous disease. Morphological analysis of the venous wall and clinical implications

OBJECTIVES

The study evaluates the potential morphological changes that may occur in the venous wall in the case of the patients with chronic venous disease which associates treatment with statins for at least 2 years.

METHODS

Operated patients with chronic venous disease in the CEAP C2-C3 stage were included in the study. 215 venous fragments, collected from 50 patients within the study group and 179 venous fragments collected from 52 patients within the control group were microscopically analysed, evaluating a series of morpho-anatomical parameters.

RESULTS

In the study group, it was found that, venous reflux predominantly affects small veins, and also, a significant increase in collagen deposits in the adventitia and media tunics, proportional to the thickening of the venous wall.

CONCLUSION

Our results indicate possible effects of statins upon the venous morphology. Further studies are needed to determine the impact of these results on daily practice.

Cardiometabolic, Lifestyle, and Nutritional Factors in Relation to Varicose Veins: A Mendelian Randomization Study

Background We conducted a 2-sample Mendelian randomization study to assess the associations of cardiometabolic, lifestyle, and nutritional factors with varicose veins. Methods and Results Independent single-nucleotide polymorphisms associated with height (positive control), body mass index, type 2 diabetes, diastolic and systolic blood pressure, smoking, alcohol and coffee consumption, 7 circulating vitamins (A, B6, B9, B12, C, 25-hydroxyvitamin D, and E), and 5 circulating minerals (calcium, iron, magnesium, selenium, and zinc) at the genome-wide significance level were used as instrumental variables. Summary-level data for the genetic associations with varicose veins were obtained from the UK Biobank (8763 cases and 352 431 noncases) and the FinnGen consortium (13 928 cases and 153 951 noncases). Genetically predicted higher height, body mass index, smoking, and circulating iron levels were associated with an increased risk of varicose veins. The odds ratios (ORs) per 1-SD increase in the exposure were 1.34 (95% CI, 1.25-1.43) for height, 1.39 (95% CI, 1.27-1.52) for body mass index, 1.12 (95% CI, 1.04-1.22) for the prevalence of smoking initiation, and 1.24 (95% CI, 1.16-1.33) for iron. Higher genetically predicted systolic blood pressure and circulating calcium and zinc levels were associated with a reduced risk of varicose veins, whereas the association for systolic blood pressure did not persist after adjustment for genetically predicted height. The OR was 0.75 (95% CI, 0.62-0.92) per 1-SD increase in calcium levels and 0.97 (95% CI, 0.95-0.98) for zinc. Conclusions This study identified several modifiable risk factors for varicose veins.

Clinical and Pathological Correlations in Chronic Venous Disease

BACKGROUND

Chronic Venous Disease (CVD) has a high prevalence in the western world. Varicose veins (VVs) are the main signs of this disease that is characterized by important pathological vessel wall changes. The aim of this study is to correlate the main histopathological abnormalities with related clinical issues of CVD.

METHODS

A cohort of patients with VVs scheduled for open surgical treatment namely stab avulsion of VVs was recruited. Subsequently, venous tissue from stab avulsion was collected in order to evaluate the following biomarkers: Vascular-Endothelial Growth Factor (VEGF), Protein Gene Product 9.5 (PGP 9.5), Fibronectin (FN), and Matrix Metalloproteinase-9 (MMP-9). The Clinical-Etiology-Anatomy-Pathophysiology (CEAP) criteria were used to classify CVD.

RESULTS

Fourteen tissue fragments were processed for histological and immunohistochemical studies. Of these, 43% were from CEAP C2 patients, 36% from CEAP C3 patients, and 21% from CEAP C4 patients. CEAP Class C2 had few to moderate structures positive to VEGF; occasional structures positive to Fibronectin, numerous structures positive to MMP9, few to moderate structures positive to PGP 9.5. CEAP Class C3 had moderate structures positive to VEGF; few to moderate structures positive to Fibronectin; many structures positive to MMP9; few to moderate structures positive to PGP 9.5. CEAP Class C4 had numerous structures positive to VEGF; numerous structures positive to Fibronectin; abundant structures positive to MMP-9; few structures positive to PGP 9.5.

CONCLUSIONS

In this study, positive VEGF, FN, and MMP-9 structures were found with increasing trends in relation to the disease staging. VEGF and FN are associated with a progressive increase from C2 to C4. The MMP-9 marker has an important positivity even at early stage of the disease, being higher in CEAP C4 patients. PGP 9.5 decreases in CEAP C4 patients and this is concordant to decreased vein wall innervation.

A Comprehensive Review on Varicose Veins: Preventive Measures and Different Treatments

The purpose of this article was to review the different preventive measures and treatments for varicose veins disease. Varicose veins are tortuous, enlarged veins that are usually found in the lower extremities damages blood vessels leading to its painful swelling cause's blood clots, affecting people over increasing prevalence with age and affects the proficiency, productivity, and life quality of a person. Prolonged standing and obesity are the major reason for varicose vein disease. The mechanisms, prevention, risk factors, complications, and treatment of varicose veins are explained in this review. Various types of treatments such as endovascular, surgical, and herbal treatments improve quality of life and reduce the secondary complications of varicose veins. Besides these methods of treatments, varicose vein disease can be prevented by doing regular yoga/exercise and consumption of several fruits and vegetables such as Grapes, blackberries, avocados, ginger, and rosemary. Typically, varicose veins can be a benign process with several problems that can influence the life quality of an individual that can lead to potentially life-threatening complications. However, there are numerous surgical, endovascular, and chemical treatments that improve quality of life and decrease secondary complications of varicose veins. Patients with varicose veins should take an antioxidant medicament from the flavonoid groups to reduce the arterial blood pressure value, risk of atherosclerosis development, prevent thrombotic incidents.Key teaching pointsChronic venous disease is a pathological state of vein circulatory systems of the lower limbsProlonged standing and obesity are the major reason for varicose vein diseaseEndovascular, surgical, and herbal treatments improve quality of life and reduce the secondary complications of varicose veinsVenoactive drugs such as flavonoids, saponins, and others have a therapeutic effect on chronic venous disordersPhlebotropic drugs are semi-synthetic substances widely used in different states of chronic venous insufficiencyFood rich in phytoconstituents are more effective in varicose veins.

Epidemiology and Genetics of Venous Thromboembolism and Chronic Venous Disease

Venous disease is a term that broadly covers both venous thromboembolic disease and chronic venous disease. The basic pathophysiology of venous thromboembolism and chronic venous disease differ as venous thromboembolism results from an imbalance of hemostasis and thrombosis while chronic venous disease occurs in the setting of tissue damage because of prolonged venous hypertension. Both diseases are common and account for significant mortality and morbidity, respectively, and collectively make up a large health care burden. Despite both diseases having well-characterized environmental components, it has been known for decades that family history is an important risk factor, implicating a genetic element to a patient's risk. Our understanding of the pathogenesis of these diseases has greatly benefited from an expansion of population genetic studies from pioneering familial studies to large genome-wide association studies; we now have multiple risk loci for each venous disease. In this review, we will highlight the current state of knowledge on the epidemiology and genetics of venous thromboembolism and chronic venous disease and directions for future research.

Mechanisms of Lower Extremity Vein Dysfunction in Chronic Venous Disease and Implications in Management of Varicose Veins

Chronic venous disease (CVD) is a common venous disorder of the lower extremities. CVD can be manifested as varicose veins (VVs), with dilated and tortuous veins, dysfunctional valves and venous reflux. If not adequately treated, VVs could progress to chronic venous insufficiency (CVI) and lead to venous leg ulcer (VLU). Predisposing familial and genetic factors have been implicated in CVD. Additional environmental, behavioral and dietary factors including sedentary lifestyle and obesity may also contribute to CVD. Alterations in the mRNA expression, protein levels and proteolytic activity of matrix metalloproteinases (MMPs) have been detected in VVs and VLU. MMP expression/activity can be modulated by venous hydrostatic pressure, hypoxia, tissue metabolites, and inflammation. MMPs in turn increase proteolysis of different protein substrates in the extracellular matrix particularly collagen and elastin, leading to weakening of the vein wall. MMPs could also promote venous dilation by increasing the release of endothelium-derived vasodilators and activating potassium channels, leading to smooth muscle hyperpolarization and relaxation. Depending on VVs severity, management usually includes compression stockings, sclerotherapy and surgical removal. Venotonics have also been promoted to decrease the progression of VVs. Sulodexide has also shown benefits in VLU and CVI, and recent data suggest that it could improve venous smooth muscle contraction. Other lines of treatment including induction of endogenous tissue inhibitors of metalloproteinases (TIMPs) and administration of exogenous synthetic inhibitors of MMPs are being explored, and could provide alternative strategies in the treatment of CVD.

Role of mechanosignaling on pathology of varicose vein

Varicose veins are the most common vascular disease in humans. Veins have valves that help the blood return gradually to the heart without leaking blood. When these valves become weak, blood and fluid collect and pool by pressing against the walls of the veins, causing varicose veins. In the cardiovascular system, mechanical forces are important determinants of vascular homeostasis and pathological processes. Blood vessels are constantly exposed to a variety of hemodynamic forces, including shear stress and environmental strains caused by the blood flow. In varicose veins within the leg, venous blood pressure rises in the vein of the lower extremities due to prolonged standing, creating a peripheral tension in the vessel wall thereby causing mechanical stimulation of endothelial cells and vascular smooth muscle. Studies have shown that long-term increased exposure to vascular wall tension is associated with the overexpression of HIF-1α and HIF-2α and increased levels of MMP-2 and MMP-9, thereby reducing venous contraction and progressive venous dilatation, which is involved in the development of varicose veins. Following the expression of metalloproteinase, the expression of type 1 collagen increases, and the amount of type 3 collagen decreases. Therefore, collagen imbalance will cause the varicose veins to not stretch. Loss of structural proteins (type 3 collagen and elastin) in the vessel wall causes the loss of the biophysical properties of the varicose vein wall. This review article tries to elaborate on the effect of mechanical forces and sensors of these forces on the vascular wall in creating the mechanism of mechanosignaling, as well as the role of the onset of molecular signaling cascades in the pathology of varicose veins.

Prospective evaluation of the association between varicocele and benign prostatic hyperplasia in men over 40 years of age

We investigated the association between varicocele and benign prostatic hyperplasia in men over the age of 40 years. A total of 296 outpatients were evaluated. Prostate volume was measured with transrectal ultrasound. Varicocele was diagnosed by physical examination and ultrasound. Prostatic hyperplasia was defined as prostate volume greater than or equal to 40 ml. Two groups were compared: patients with prostate volume less than 40 ml and patients with prostate volume greater than or equal to 40 ml. There was a statistically significant difference between the groups in terms of mean age, post-void residual, International Prostate Symptom Score and PSA. The percentage of patients with clinical varicocele in the group with a volume less than 40 ml and the group with a volume equal to or greater than 40 ml was 38.2% and 47.7% respectively (p = .12). There were no differences between the two groups in the percentage of patients with clinical or subclinical varicocele (43.2% vs. 52.2%, respectively, p = .12). No differences were found in the percentage of patients with varicocele when comparing men with prostates smaller than 40 ml and greater than or equal to 40 ml.

Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment

Venous leg ulcers (VLUs) are one of the most common ulcers of the lower extremity. VLU affects many individuals worldwide, could pose a significant socioeconomic burden to the healthcare system, and has major psychological and physical impacts on the affected individual. VLU often occurs in association with post-thrombotic syndrome, advanced chronic venous disease, varicose veins, and venous hypertension. Several demographic, genetic, and environmental factors could trigger chronic venous disease with venous dilation, incompetent valves, venous reflux, and venous hypertension. Endothelial cell injury and changes in the glycocalyx, venous shear-stress, and adhesion molecules could be initiating events in VLU. Increased endothelial cell permeability and leukocyte infiltration, and increases in inflammatory cytokines, matrix metalloproteinases (MMPs), reactive oxygen and nitrogen species, iron deposition, and tissue metabolites also contribute to the pathogenesis of VLU. Treatment of VLU includes compression therapy and endovenous ablation to occlude the axial reflux. Other interventional approaches such as subfascial endoscopic perforator surgery and iliac venous stent have shown mixed results. With good wound care and compression therapy, VLU usually heals within 6 months. VLU healing involves orchestrated processes including hemostasis, inflammation, proliferation, and remodeling and the contribution of different cells including leukocytes, platelets, fibroblasts, vascular smooth muscle cells, endothelial cells, and keratinocytes as well as the release of various biomolecules including transforming growth factor-β, cytokines, chemokines, MMPs, tissue inhibitors of MMPs (TIMPs), elastase, urokinase plasminogen activator, fibrin, collagen, and albumin. Alterations in any of these physiological wound closure processes could delay VLU healing. Also, these histological and soluble biomarkers can be used for VLU diagnosis and assessment of its progression, responsiveness to healing, and prognosis. If not treated adequately, VLU could progress to non-healed or granulating VLU, causing physical immobility, reduced quality of life, cellulitis, severe infections, osteomyelitis, and neoplastic transformation. Recalcitrant VLU shows prolonged healing time with advanced age, obesity, nutritional deficiencies, colder temperature, preexisting venous disease, deep venous thrombosis, and larger wound area. VLU also has a high, 50-70% recurrence rate, likely due to noncompliance with compression therapy, failure of surgical procedures, incorrect ulcer diagnosis, progression of venous disease, and poorly understood pathophysiology. Understanding the molecular pathways underlying VLU has led to new lines of therapy with significant promise including biologics such as bilayer living skin construct, fibroblast derivatives, and extracellular matrices and non-biologic products such as poly-N-acetyl glucosamine, human placental membranes amnion/chorion allografts, ACT1 peptide inhibitor of connexin 43, sulodexide, growth factors, silver dressings, MMP inhibitors, and modulators of reactive oxygen and nitrogen species, the immune response and tissue metabolites. Preventive measures including compression therapy and venotonics could also reduce the risk of progression to chronic venous insufficiency and VLU in susceptible individuals.

Noninvasive measurement of venous wall deformation induced by changes in transmural pressure shows altered viscoelasticity in patients with chronic venous disease

OBJECTIVE

The noninvasive measurement of venous wall deformation induced by changes in transmural pressure could allow for the assessment of viscoelasticity and differentiating normal from diseased veins.

METHODS

In 57 patients with limbs in the C1s (telangiectasia or reticular veins and symptoms), C3 (edema), or C5 (healed venous ulcer) CEAP (clinical, etiologic, anatomic, pathophysiologic) category of chronic venous disease and 54 matched healthy controls, we measured the changes in the cross-sectional area of the small saphenous vein and a deep calf vein in the supine and standing positions and under compression with an ultrasound probe using ultrasonography.

RESULTS

The small saphenous vein, but not the deep calf vein, cross-sectional area was smaller in the limbs of the controls than in the limbs with C3 or C5 disease but was not different from that in C1s limbs. When changing from the supine to the standing position, a greater force was required to collapse the leg veins. Their cross-sectional area increased in most subjects but decreased in 31.5% of them as for the small saphenous veins and 40.5% for the deep calf vein. The small saphenous vein area vs compression force function followed a hysteresis loop, demonstrating viscoelastic features. Its area, which represents the viscosity component, was greater (P < .001) in the pooled C3 and C5 limbs (median, 2.40 N⋅mm²; lower quartile [Q1] to upper quartile [Q3], 1.65-3.88 N⋅mm²) than in the controls (median, 1.24 N⋅mm²; Q1-Q3, 0.64-2.14 N⋅mm²) and C1s limbs (median, 1.15 N⋅mm²; Q1-Q3, 0.71-2.97 N⋅mm²). The area increased (P < .0001) in the standing position in all groups.

CONCLUSIONS

Postural changes in the cross-sectional area of the leg veins were highly diverse among patients with chronic venous disease and among healthy subjects and appear unsuitable for pathophysiologic characterization. In contrast, small saphenous vein viscoelasticity increased consistently in the standing position and the viscosity was greater in limbs with C3 and C5 CEAP disease than in controls.

Compression stockings attenuate the expression of proteins associated with vascular damage in human varicose veins

OBJECTIVE

The objective of this study was to analyze whether compression stocking therapy in the human varicose vein wall may change the levels of biomarkers associated with vein insufficiency.

METHODS

Dilated collateral varicose vein samples were obtained from patients showing chronic venous disease (class 2 of the Clinical, Etiology, Anatomy, and Pathophysiology classification). Before elective surgery, 12 patients underwent compression stocking therapy (for 1 month) and 9 patients did not (control group). Expression levels of biomarkers associated with endothelial functionality (nitric oxide synthase 3), inflammation (interleukin-6, interleukin-10), oxidative stress (Gp91^phox subunit of NADPH oxidase), and coagulation (factor Xa) were determined. P-selectin, an inflammatory and thrombosis-related biomarker, was also measured.

RESULTS

Compression stockings increased the content of nitric oxide synthase 3 (control, 16.48 [16.04-17.40] AU; compression, 83.71 [67.70-91.85] AU; P < .001) in the varicose vein wall that was accompanied by reduction of both interleukin-6 levels (control, 38.72 [33.48-48.52] pg/μg protein; compression, 14.49 [11.05-17.41] pg/μg protein; P = .001) and the expression of Gp91^phox subunit of NADPH oxidase (control, 63.24 [53.79-77.03] AU; compression, 36.85 [35.66-52.27] AU; P < .010). P-selectin (control, 77.37 [61.86-85.00] AU; compression, 54.31 [49.60-67.50] AU; P = .017) and factor Xa (control, 90.78 [75.02-100.00] AU; compression, 14.50 [13.77-36.20] AU; P < .001) were also reduced in the varicose vein wall of compression stocking-treated patients. However, P-selectin lost its statistical significance after adjustment by dyslipidemia.

CONCLUSIONS

In the varicose vein wall, compression stocking therapy improved the content levels of biomarkers associated with endothelial functionality, inflammation, oxidative stress, and coagulation.

Intense remodeling of extracellular matrix within the varicose vein: the role of gelatinases and vascular endothelial growth factor

BACKGROUND

Increased blood pressure in the varicose veins (VV) can contribute to the overexpression of matrix metalloproteinases (MMPs), affecting the endothelium, smooth muscle, and extracellular matrix of the vein wall. Gelatinases (MMP-2 and MMP-9), hypoxia, and inflammation occurring in the VV wall contribute to the increased expression of vascular endothelial growth factor (VEGF).

AIMS

Our objective was to analyze the concentration of gelatinases and VEGF in the great saphenous VV wall and plasma of patients.

METHODS

In total, 65 patients (2nd degree according to clinical state classification, etiology, anatomy, and pathophysiology-CEAP classification) aged 22 to 70 were enrolled. Control veins (n = 10) were collected from the patients who underwent coronary artery bypass graft surgery. Control plasma (n = 20) was obtained from healthy individuals. Gelatinases and VEGF levels were measured with the usage of ELISA method.

RESULTS

A significant increase in MMP-9 (11.2 vs. 9.98 ng/mg of protein) and VEGF (41.06 vs. 26 ng/g of protein) concentration in VV wall compared with control veins was observed. A positive correlation between VEGF versus MMP-2 (p = 0.03, r = 0.27) was found in the VV wall. However, no correlation was found between the concentration of VEGF and MMP-9 (p = 0.4, r = 0.11) in the VV wall. In addition, no statistical differences between MMP-9, MMP-2, and VEGF levels in plasma of VV patients compared with controls were noticed.

CONCLUSIONS

The results of the present study confirm that VV's patients have altered expression of MMPs and VEGF. Overexpression of MMP-9 and VEGF in the VV wall may contribute to the spreading of inflammatory process and suggests the intense remodeling of extracellular tissue within the VV wall.

Study of association of varicose veins and inflammation by inflammatory markers

OBJECTIVE

In varicose veins, increased levels of inflammatory markers are indicators of endothelial damage and increased procoagulant activity. These findings support the assumption that the constitution of blood in varicose veins differs from that of systemic blood. The purpose of the study was a correlative study of blood constituents in varicose veins and peripheral veins (normal vein) in same individual with varicose vein which was done by comparing the level of concentration of interleukin-6, fibrinogen, haemoglobin from blood of varicose veins and normal peripheral vein (antecubital vein).

METHOD

Using citrated plasma samples withdrawn from arms and legs of same patient and plasma obtained by centrifugation of citrated venous blood at 5000 r/min for 10 min was used for correlation. Serum concentration of interleukin-6 and fibrinogen were determined by human enzyme-linked immunosorbent assay Kit for both interleukin-6 and fibrinogen, which is based on the standard sandwich enzyme-linked immunosorbent assay technology. This assay employs a monoclonal antibody specific for human interleukin-6 coated on a 96-well plate.

RESULT

Expressed as median (interquartile range) in pg/mL, leg samples from patient having varicose vein has significantly increased interleukin-6 in cases as compared to controls (p value of <0.001). Leg samples from patient having varicose vein has significantly increased fibrinogen concentration than their arm samples (p value of <0.001). Concentration of haemoglobin significantly increased in leg samples as compared to blood withdrawn from arms (p value of 0.012).

CONCLUSION

Blood withdrawn from the site of varicose vein appears to have significantly increased concentration of interleukin-6, fibrinogen and haemoglobin when compared to same patient's antecubital blood sample supporting the hypothesis that inflammation is increased in tissues drained by varicose vein.

The role of oxygen transport in atherosclerosis and vascular disease

Atherosclerosis and vascular disease of larger arteries are often associated with hypoxia within the layers of the vascular wall. In this review, we begin with a brief overview of the molecular changes in vascular cells associated with hypoxia and then emphasize the transport mechanisms that bring oxygen to cells within the vascular wall. We focus on fluid mechanical factors that control oxygen transport from lumenal blood flow to the intima and inner media layers of the artery, and solid mechanical factors that influence oxygen transport to the adventitia and outer media via the wall's microvascular system-the vasa vasorum (VV). Many cardiovascular risk factors are associated with VV compression that reduces VV perfusion and oxygenation. Dysfunctional VV neovascularization in response to hypoxia contributes to plaque inflammation and growth. Disturbed blood flow in vascular bifurcations and curvatures leads to reduced oxygen transport from blood to the inner layers of the wall and contributes to the development of atherosclerotic plaques in these regions. Recent studies have shown that hypoxia-inducible factor-1α (HIF-1α), a critical transcription factor associated with hypoxia, is also activated in disturbed flow by a mechanism that is independent of hypoxia. A final section of the review emphasizes hypoxia in vascular stenting that is used to enlarge vessels occluded by plaques. Stenting can compress the VV leading to hypoxia and associated intimal hyperplasia. To enhance oxygen transport during stenting, new stent designs with helical centrelines have been developed to increase blood phase oxygen transport rates and reduce intimal hyperplasia. Further study of the mechanisms controlling hypoxia in the artery wall may contribute to the development of therapeutic strategies for vascular diseases.

Effect of a Peptide Construct on Differentiated Macrophage MMP-2 and MMP-9 Levels of Varicose Patients

BACKGROUND

The Matrix Metalloproteinase (MMPs) secreted from macrophages can affect the extracellular matrix remodeling process and improve varicose veins.

AIM

The aim of this study was to investigate the MMP-2 and MMP-9 gene expression and activity levels in the differentiated macrophages M2 of subjects with varicose veins, and to evaluate a peptide construct on their catalytic functions.

METHODS

The macrophages were differentiated from the monocytes using M-CSF. The MMP-2 and MMP-9 gene expression and activity levels were measured by RT-qPCR and Zymography techniques, respectively. A peptide construct (ESLCG) was predicted with bioinformatics tools, and was prepared for the study of enzyme functions as compared to Batimastat. Furthermore, the docking studies were obtained for the evaluation of interactions between peptide construct, Batimastat and enzyme 3D structures.

RESULTS

The results showed significant increases in MMP2 and MMP9 gene expression levels (P<0.001 and P<0.004, respectively) and gelatinolytic activities (P<0.001 and P<0.0001, respectively) in the macrophages. In agreement with the inhibitory effects of Batimastat, the peptide construct inhibited the MMP-2 and MMP-9 gelatinolytic activities up to 6.8 and 6.5 folds in the concentration of 150 µM. The docking analyses showed that the Lys187, Arg98, Leu49, Gly189, Leu190, Met97, Tyr53 and Phe57 residues of MMP-2 and the Leu187, His190, Glu402, His401, His405 and His411 residues of MMP-9 are interacted with the atoms of Batimastat and ESLCG peptide.

CONCLUSION

The ESLCG peptide may be applied as an inhibitor of MMP-2 and MMP-9 enzymes in the subjects with varicose veins.

Expression profile of tRNA‑derived fragments and their potential roles in human varicose veins

Varicose veins (VVs) is a common disease presenting with chronic venous insufficiency. tRNA-derived fragments (tRFs) are associated with a variety of pathological conditions. However, the functions of tRFs in VVs have not been elucidated to date. The present study aimed to identify the key tRFs and investigate their potential roles in VVs. Small RNA sequencing (RNA-seq) was performed to investigate the expression of tRFs in tissues of patients with VVs and their matched adjacent normal veins tissues (ANVs). Reverse transcription-quantitative PCR (RT-qPCR) was used to confirm the differential expression of tRFs. A total of 13,789 tRFs were identified by small RNA-seq, including 45 differentially expressed tRFs (DETs), which comprised 14 upregulated and 31 downregulated tRFs in VV tissues compared with ANVs. In addition, DETs were mainly involved in the function of epidermal growth factor receptor and vascular endothelial growth factor receptor signaling pathways in VVs. Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis revealed that the target genes of DETs were predominantly involved in Wnt and mitogen-activated protein kinase (MAPK) signaling pathways, as well as calcium signaling. Additionally, two upregulated tRFs (tRF-36-F900BY4D84KRIME and tRF-23-87R8WP9IY) and one downregulated tRF (tRF-40-86J8WPMN1E8Y7Z2R) were further validated by RT-qPCR, and a signaling pathway regulation network of their target genes confirmed their involvement in the calcium, Wnt and MAPK signaling pathways. The results of the present study identified three DETs (tRF-36-F900BY4D84KRIME, tRF-23-87R8WP9IY and tRF-40-86J8WPMN1E8Y7Z2R), which may have crucial roles in the occurrence and progression of VVs by regulating Wnt and MAPK signaling, as well as calcium signaling. The present results may provide a basis for further investigation of the functional roles of tRFs in VVs.

Refining diagnosis and management of chronic venous disease: Outcomes of a modified Delphi consensus process

Chronic venous disease (CVD) is a common condition with major health consequences that is associated with poor long-term prognosis, significant socioeconomic impact, disabling symptoms and reduced quality of life. To provide practical guidance for diagnosis and management of CVD, a Delphi panel of 5 experts in steering committee and 28 angiologists/vascular surgeons met with the major aim of providing a supplement for established national and international guidelines. A total of 24 statements were voted upon in two rounds, of which consensus was reached on 22 statements, indicating a high level of overall agreement. Consensus was reached on 7 of 8 statements relative to diagnosis (CEAP classification, diagnostic tools, QoL assessment, diagnostic imaging) and on 15 of 16 statements on management (conservative treatments, compressive therapy, pharmacological therapy, surgical treatment). The results of the consensus reached are discussed herein from which it is clear that diagnostic and management approaches utilising personalised therapies tailored to the individual patient should be favoured. While it is clear that additional studies are needed on many aspects of diagnosis and management of CVD, the present Delphi survey provides some key recommendations for clinicians treating CVD that may be useful in daily practice.

Combined effect of chronic partial occlusion and orthostatic load on the saphenous vein network: A varicosity model in the rat

Objectives

We tested the combined effects of chronic flow obstacle and gravitation on the saphenous vein network of rats.

Methods

A narrowing clip (500 µm, partial occlusion) was administered on the saphenous vein main branch for 4, 8 and 12 weeks, either separately or in combination with chronic orthostatic load (tilted tube-cages for four weeks). Resulting network changes were studied on plastic casts, by video-microscopy, histochemistry–immunohistochemistry and image analysis.

Results

A rich collateral venous network developed containing newly formed masses of retrograde conducting small veins. Their walls had less dense elastica, less contractile protein, increased cell division activity and macrophage invasion, and were more sensitive to chronic gravitational load.

Conclusions

Hemodynamic disturbance induces remodeling of the saphenous vein network. Walls of veins being in the process of flow-induced morphological remodeling are weak and more sensitive to gravitational load. Reticular vein conglomerates, veins with local dilations, and convoluted courses were observed.

[Drug-Based Therapy of Varicose Veins from the Perspective of Experimental Models]

Drug-Based Therapy of Varicose Veins from the Perspective of Experimental Models Abstract. Varicose remodeling of the venous wall primarily occurs in the lower extremities and is often associated with venous insufficiency. Although a large part of the western population shows various degrees of varicosis, little is known about the mechanisms driving their formation. In recent years, experimental animal models have spurred the identificatoin of target molecules and cellular mechanisms that control varicose remodeling processes. Thus, the chronic increase in venous wall tension appears to be a crucial determinant to stimulate signal cascades, culminating in increased proteolytic and proliferative activity of venous wall cells. The pharmacological inhibition of key molecules in these processes may provide a way to influence the course and severity of varicosis. This review article gives a brief insight into this topic.

Endovenous Photocoagulation Using a Diode Laser for Complicated Varicose Veins Related to Stasis Ulcers

BACKGROUND

The objective of this study was to assess the efficacy and safety of endovenous laser photocoagulation (EVLP) at a wavelength of 810 nm for treating complicated venous insufficiency associated with venous ulcers.

MATERIALS AND METHODS

A retrospective review of 110 patients with 180 legs having chronic venous insufficiencies associated with varicose veins treated over an 8-year period was conducted. Patients ranged from 16 to 80 years of age and included 85 women and 25 men. Of the 110 patients, 32 (29.10%) patients with 40 legs having varicose veins were defined as having complicated varicose veins associated with venous ulcers. All 32 patients received EVLP treatment using a diode laser. Complications were evaluated at 3 weeks (early), 6 weeks (late), and 6 months (final) after EVLP treatment. The primary efficacy and final outcome measurement were determined through quantitative assessment using Hach's and clinical, etiological, anatomical, and pathophysiological classification. Safety was evaluated for each treatment group by monitoring adverse effects.

RESULTS

Early complications were swelling, local paresthesia, pigmentation, minor superficial thermal injury, superficial phlebitis, and localized hematomas. All complications and ulcerations resolved completely within 2 weeks. No recurrence occurred after the study's 6-month follow-up period. Based on paired t test analysis, clinically significant differences in severity scores were discovered, which were based on Hach's classification before and after EVLP treatment at a wavelength of 810 nm. All patients achieved improvement from clinical, etiological, anatomical, and pathophysiological class C6 to C5. Permanent adverse effects were not observed.

CONCLUSIONS

Endovenous laser photocoagulation at the wavelength of 810 nm permitted the use of appropriate light doses for treating complicated varicose veins associated with venous ulcers and resulted in significant improvement in lesions.

Increase and Redistribution of Sex Hormone Receptors in Premenopausal Women Are Associated with Varicose Vein Remodelling

In chronic venous insufficiency of the lower limbs, data show that the clinical manifestation is varicose veins (VVs), and VV epidemiology suggests that sex hormones directly influence disease development through intracellular receptors. This study aimed to determine the presence and localization of oestrogen receptors (ERs), progesterone receptors (PRs), and androgen receptors (ARs) in both healthy and VV wall cells and their relationship with gender. In this study, samples from patients without a history of venous disease (CV) (n = 18) and with VV (n = 40) were used. The samples were divided by gender: CV women (CVw) = 6, CV men (CVm) = 12, VV women (VVw) = 25, and VV men (VVm) = 15. RT-qPCR and immunohistochemical techniques were performed, and increased ER and PR protein expression was found in VVw in all tunica layers. ARs were localized to the adventitial layer in the CV and were found in the neointima in VVs. mRNA expression was increased for ER and PR in VVw. AR gene expression was significantly decreased in VVm. The increase in the number of these receptors and their redistribution through the wall reinforces the role of sex hormones in varicose vein development.

Report of the Society for Vascular Surgery and the American Venous Forum on the July 20, 2016 meeting of the Medicare Evidence Development and Coverage Advisory Committee panel on lower extremity chronic venous disease

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel assessed the benefits and risks of currently used lower extremity chronic venous disease (CVD) treatments and their effects on health outcome of the American adult population. The main purpose of the meeting was to advise the Centers for Medicare & Medicaid Services on coverage determination for interventions used for treatment of CVD. A systematic review of the Agency for Healthcare Research and Quality was presented, followed by lectures of invited experts and a public hearing of representatives of professional societies and the industry. After discussing critical issues, the panel voted for key questions. This report summarizes the presented evidence to support recommendations of the Society for Vascular Surgery/American Venous Forum coalition and the presentations on selected discussion topics. These included important venous disease evidence gaps that have not been sufficiently addressed, venous disease treatment disparities and how they may affect the health outcomes of Medicare beneficiaries, and mechanisms that might be supported by the Centers for Medicare & Medicaid Services to improve the evidence base to optimize the care of patients with lower extremity CVD.

Biomechanical properties of veins cultured in vitro under elevated internal pressure

BACKGROUND

The venous response to elevated blood pressure (BP) is of major importance because it is closely related to the etiology of venous diseases and the competency of vein grafts. In vitro culture experiments may provide useful information on the function of vein grafts because it is easier to separate mechanical and hemodynamic effects from other systemic influences compared to in vivo experiments.

OBJECTIVE

To study the effects of BP elevation on wall dimensions and mechanical properties of in vitro cultured veins.

METHODS

Rabbit femoral veins were cultured in vitro under internal pressures of 1 to 50 mmHg for 1 week, and their wall dimensions, biomechanical properties, and histology were determined.

RESULTS

No significant differences were observed in internal vein diameter and wall thickness among vessels cultured at 10-50 mmHg compared to non-cultured control vessels. For an internal pressure of 10 mmHg applied to vessels during culture (equivalent to in vivo working BP), wall circumferential stress was maintained within control levels. There were no significant effects of pressure on basal tone and contractility of vascular smooth muscle and vascular compliance.

CONCLUSIONS

The in vitro results were essentially similar to those obtained from previous in vivo animal experiments, indicating that in vitro tissue culture techniques are applicable to studies of venous remodeling.

Effect of spatial light distribution on the thermal response of vascular tissue

The aim of the current study is to investigate the effect of radial and cylindrical light distributions on the response of vascular tissue during 1470-nm irradiation in ex vivo models. Due to a low irradiance (5.3 W/cm²) and wide light distribution, cylindrically diffusing irradiation yielded uniform thermal coagulation while radial irradiation accompanied delamination of layers in leporine veins. Bovine foot model testing verified that the diffusing irradiation was associated with the steady maximum temperature and no tissue attachment, compared with the radial irradiation. The proposed cylindrical light application can be a feasible way to treat varicose veins in an effective manner.

Lower limb blood flow and mean arterial pressure during standing and seated work: Implications for workplace posture recommendations

Sit-stand workstations are a popular workplace intervention. Organizations often require a medical professional's guidance for implementation. Therefore, it is important to understand potential negative outcomes associated with standing work, such as lower limb discomfort and peripheral vascular issues. The objective of this study was to compare changes in lower limb discomfort, blood pressure and blood flow accumulation during a light-load repetitive upper limb work task accomplished from seated and standing postures. At the Jewish Rehabilitation Hospital (Laval, Quebec, Canada), 16 participants were outfitted with Laser Doppler Flow (LDF) electrodes to measure blood flow in the lower limb, and a sphygmomanometer to measure lower limb mean arterial blood pressure (MAP). Participants completed simulated work over 34 min in standing and seated conditions. Repeated measures ANOVAs (Posture x Time) were used to assess the differences. There were significant effects for both Posture (p = 0.003) and Time (p = 0.007) for LDF-measured of blood flow accumulation in the soleus and the foot, with a mean increase of 77% blood flow over time in the standing posture, when compared to seated work. There was a significant 'Posture × Time' (p = 0.0034) interaction effect and a significant Posture (p = 0.0001) effect for MAP, with higher values in the standing posture by a mean of 37.2 mmHg. Posture had a significant effect (p < 0.001) on lower limb discomfort, with standing posture reporting higher levels. These results suggest that recommendations for using static standing work postures should be tempered, and physicians' guidance on workstation changes should consider the impacts on the lower limb.

The haemodynamic causes of skin changes in limbs with primary varicose veins

OBJECTIVES

To investigate the haemodynamic causes of skin changes in limbs with primary varicose veins, which were assessed with air plethysmography.

METHODS

Five hundred seventeen consecutive patients with axial reflux in the great saphenous vein (varicose vein group) and 248 normal subjects (normal group) were investigated. Varicose vein group patients were divided into two groups according to whether they did (C4-6) or did not (C2-3) have skin changes. Several parameters obtained using air plethysmography were compared among the normal group, C2-3 and C4-6 patients.

RESULTS

Although there was no significant difference in the regurgitation index to quantify venous reflux in C2-3 and C4-6 patients, the maximum arterial inflow rate increased (normal group < C2-3 < C4-6), even in limbs with a small amount of venous reflux.

CONCLUSIONS

This study suggests that it is not essential to increase the venous reflux rate in skin change development; rather, it is based on various pathophysiological conditions that increase the arterial inflow rate.

Clinical Outcomes of Radiofrequency Ablation for Unilateral and Bilateral Varicose Veins

BACKGROUND

Approximately 20% of varicose vein are bilateral. Patients prefer a simultaneous bilateral procedure instead of 2 separate unilateral procedures. There is currently little evidence comparing bilateral and unilateral varicose vein surgeries.

OBJECTIVE

To report the clinical outcomes of unilateral and bilateral radiofrequency ablation (RFA) for varicose veins.

MATERIALS AND METHODS

The authors retrospectively collected data on clinical outcomes of patients who underwent RFA. They investigated clinical, etiologic, anatomic, and pathophysiologic (CEAP) score, venous clinical severity score (VCSS), and quality of life (QoL) score.

RESULTS

Radiofrequency ablation was performed in 546 limbs in 385 patients. Women comprised 60.4% of the patients. The mean age was 52.3 ± 11.6 years (range, 19-84). The occlusion rate after 2 years was 94.5%. Clinical outcomes of CEAP score, VCSS, and QoL scores improved significantly from 2.15 ± 0.45, 2.70 ± 2.04, and 6.91 ± 6.69 at baseline to 2.10 ± 0.32, 0.63 ± 0.04, and 3.38 ± 4.74 at the study end, respectively. The preoperative and postoperative differences in CEAP score for unilateral and bilateral RFA were 0.02 ± 0.21 and 0.13 ± 0.49, respectively (p = .073). Those of VCSS for unilateral and bilateral RFA were 1.87 ± 1.50 and 4.01 ± 2.93, respectively (p < .001).

CONCLUSION

Good clinical outcomes were shown after RFA with respect to CEAP, VCSS, and QoL scores. The simultaneous bilateral RFA can be performed with effectiveness.