Minimally invasive treatments for perforator vein insufficiency

Combination of Minimally Invasive Methods for the Treatment of Varicose Veins

OBJECTIVE

The aim of the study was to evaluate the efficacy and safety of the combination of minimally invasive methods for the treatment of incompetent great saphenous vein and perforating veins.

METHODS

Between December 2019 and October 2020, F-care radiofrequency ablation combined with ultrasound-guided foam sclerotherapy and residual perforator ligation and concomitant microphlebectomy were adopted for all eligible patients. The clinical symptoms scores, complications, and quality of life were recorded.

RESULTS

49 patients (64 limbs) with a mean age of 63.29 ± 10.14 years, and 60.9%4 were male. The 1-year truncal closure rate was 63/64 (98.4%).1 A significant improvement in the Venous Disability Score, the Venous Segmental Disease Score, the Venous Clinical Severity Score and Chronic Venous Disease Quality of Life Questionnaire Score, at 12 months after the combination of minimally invasive treatment, were observed in the study. One patient developed intermuscular vein thrombosis that was successfully managed with rivaroxaban.

CONCLUSIONS

The combination of minimally invasive methods is a safe and effective method for the treatment of lower extremity varicose veins. Further large-scale, prospective, multi-center studies are needed to further verify the findings of this study.

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

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

Treatment patterns and outcomes of Medicare enrolees who developed venous leg ulcers

OBJECTIVE

To retrospectively evaluate the comorbidities, treatment patterns and outcomes of Medicare enrolees who developed venous leg ulcers (VLUs).

METHOD

Medicare Limited Data Standard Analytic Hospital Inpatient and Outpatient Department Files were used to follow patients who received medical care for a VLU between 1 October 2015 and 2 October 2019. Patients diagnosed with chronic venous insufficiency (CVI) and a VLU were propensity matched into four groups based on their treatment regimen. Episode claims were used to document demographics, comorbidities and treatments of Medicare enrolees who developed VLUs, as well as important outcomes, such as time to ulcer closure, rates of complications and hospital utilisation rates. Outcomes were compared across key propensity-matched groups.

RESULTS

In total, 42% of Medicare enrolees with CVI (n=1,225,278), developed at least one VLU during the study, and 79% had their episode claim completed within one year. However, 59% of patients developed another VLU during the study period. This analysis shows that only 38.4% of VLU episodes received documented VLU conservative care treatment. Propensity-matched episodes that received an advanced treatment or high-cost skin substitutes for a wound which had not progressed by 30 days demonstrated the best outcomes when their cellular, acellular, matrix-like product (CAMP) treatment was applied weekly or biweekly (following parameters for use). Complications such as rates of infection (33%) and emergency department visits (>50%) decreased among patients who received an advanced treatment (following parameters for use).

CONCLUSION

Medicare enrolees with CVI have diverse comorbidities and many do not receive sufficient management, which contributes to high rates of VLUs and subsequent complications. Medicare patients at risk of a VLU who receive early identification and advanced CAMP treatment demonstrated improved quality of life and significantly reduced healthcare resource utilisation.

The presence of a pathologic perforator may be predictive of central venous pathology and multilevel disease in severe chronic venous insufficiency

OBJECTIVES

The treatment of a refluxing perforator is indicated in the setting of severe chronic venous insufficiency, but there are limited data on the presence of multilevel disease in these patients. This study sought to evaluate whether the presence of a pathologic perforator is predictive of the presence of central venous pathology.

METHODS

This study was a retrospective review of the institutional Vascular Quality Initiative database. Consecutive patient limbs were identified that underwent intervention of refluxing perforators. The patients who underwent imaging, including magnetic resonance imaging or computed tomography (group A), were compared with those who did not undergo imaging (group B). The treated limbs in group A were also compared with the contralateral limbs as an internal control. Anatomical findings on imaging were analyzed by two independent investigators. The primary outcome was the presence and degree of central venous stenosis as measured by an orthogonal diameter reduction of >50% by axial imaging. Secondary outcomes included demographic and clinical differences between the two groups, frequency of central venous intervention, and duration of ulcer healing. Standard statistical analysis was performed.

RESULTS

Ninety-three patient limbs underwent treatment of a pathologic perforator, with 30 in group A and 63 in group B. The following demographic and clinical variables were higher in group A compared with group B: male sex, body mass index, deep venous thrombosis history, recent or active anticoagulation use, perforator diameter, Clinical Etiology Anatomy Pathophysiology class 4, 5, or 6, and Venous Clinical Severity Score. Radiographic analysis of group A revealed concordance of a treated pathologic perforator with an ipsilateral central venous stenosis in 53.3% of patients, and a higher frequency of common iliac vein stenosis (50% vs 21.4%, P = .024) and external iliac vein stenosis (20% vs 0%, P = .012) compared with the contralateral limbs. When separated by the left or right limb, the left limbs exhibited a greater degree of common iliac vein stenosis as compared with the contralateral limbs (50.7% ± 20.9% vs 16.3% ± 16.5%, P < .001) as well as a greater frequency of >50% common iliac vein stenosis (46.7% vs 13.3%, P = .046). The right limbs exhibited a greater frequency of >50% external iliac vein stenosis as compared with the contralateral limbs (33.3% vs 0%, P = .022).

CONCLUSIONS

This study suggests that patients with severe chronic venous insufficiency who undergo treatment for a pathologic perforator may have additional ipsilateral central venous pathology, supporting the presence of multilevel disease. Additional axial imaging might unmask central venous pathology and provide another option for treatment.

Physical Examination and Ultrasound Evaluation of Patients with Superficial Venous Disease

Systematic and standardized evaluation of superficial venous disease, guided by knowledge of the various clinical presentations, venous anatomy, and pathophysiology of reflux, is essential for appropriate diagnosis and optimal treatment. Duplex ultrasonography is the standard for delineating venous anatomy, detecting anatomic variants, and identifying the origin of venous insufficiency. This article reviews tools and techniques essential for physical examination and ultrasound assessment of patients with superficial venous disease.

Ultrasound-guided cyanoacrylate injection for the treatment of incompetent perforator veins

Objective

The use of cyanoacrylate products (CA) in incompetent perforator vein (IPV) treatment has not been thoroughly examined. The primary objective of this study is to describe the technique of ultra sound guided direct injection of IPV with CA, and secondarily to determine early closure rates and safety of this technique.

Methods

A retrospective analysis of patients undergoing IPV injection at two centres between 2015-2018 was conducted. Demographics, CEAP classification and IPV location were collected. Outcomes were assessed at two follow-up appointments.

Results

A total of 83 perforator vein injections were completed. CEAP classifications include C2 – C6 classes. Location of perforators were posteromedial (6%), femoral canal (9%), paratibial (14%), and posterior-tibial (71%). IPV closure rates were 96.3% at initial follow-up (16 ± 2 days). Closure rates decreased to 86.5% at second follow-up (72 ± 9 days). There were no deep vein thromboses during follow-up. One patient developed septic thrombophlebitis that was successfully managed with antibiotics.

Conclusion

Ultrasound-guided CA glue injection is a simple and low risk procedure that effectively closes incompetent perforator veins.

Venography and Selective Ablation for Recurrent Varices after Surgery Using Radiofrequency Ablation Catheter

Recurrent varices after surgery (REVAS) is a common problem with no established treatment. Ultrasonography is a hard method to identify the source of veins that cause REVAS, especially in obese patients with thick thighs. Here, we report the case of a 64-year-old obese patient who previously underwent endothermal venous ablation for her right great saphenous vein. The patient presented with right leg swelling and venous ulceration due to REVAS. Although the source of REVAS was unclear because the patient had thick thighs on ultrasonography assessment, venography revealed that the source of REVAS was the incompetent perforator vein (IPV). Selective ablation for the IPV with radiofrequency ablation catheter was performed. We could ablate the target veins selectively so as not to ablate within the deep vein. The patient remains asymptomatic for 2 years after the procedure, and there has been no recurrence of her varicose veins. Venography allows better visualization of the source of REVAS than ultrasonography. With selective ablation, it is especially effective procedure in obese patients, in whom it is difficult to identify and access the source of REVAS with ultrasonography.

Evaluation of perforating venous insufficiency with shear wave elastography: a preliminary study

PURPOSE

The aim of this study was to investigate the efficacy of shear wave elastography (SWE) in the diagnosis of perforating vein insufficiency, and to determine the applicability of these measurements.

METHODS

A total of 140 symptomatic patients with a total of 280 lower extremities were investigated. All patients presented with venous insufficiency (VI) symptoms, and received Doppler ultrasound assessment to determine VI and SWE measurements. The SWE values were measured in the adjacent perivenous tissue of the largest Cockett's perforating vein (PV) of both lower extremities, at the level where they pass the fascia. The Cockett's PV diameter and the presence of reflux in Cockett's PV and the great saphenous vein were compared with SWE values in perivenous tissue of PVs.

RESULTS

The SWE values of the perforating vein insufficiency group were significantly higher than those of the normal PV without insufficiency group (P < 0.001). A significant and positive relation was seen between increased PV diameter and SWE values (P < 0.001) and there was a significant relationship between the presence of perforating vein insufficiency and increase in PV diameter. A statistically significant increase was detected in SWE values for the PV for those with reflux in the great saphenous vein (P < 0.001). The best cut-off values that can be used to detect perforating vein insufficiency were found 34.600 for kPa and 3.375 for m/s.

CONCLUSION

SWE may be used effectively in addition to conventional Doppler ultrasound examination in diagnosing and following perforating vein insufficiency.

Protocol for a systematic review and meta-analysis of interventions for pathologic perforator veins in chronic venous disease

INTRODUCTION

Perforator veins (PVs) play an important role in the development of chronic venous insufficiency and ulceration. Procedures to eliminate incompetence and reflux in PV may include open surgery, subfascial endoscopic surgery, intravenous ablation techniques and sclerotherapy. With the aim of filling the evidence gap, this is a protocol for a systematic review that will assess the effects of any form of intervention for the treatment of pathologic PVs of the lower limbs in patients with chronic venous disease.

METHODS AND ANALYSIS

Systematic searches will be carried out in MEDLINE, EMBASE, Cochrane CENTRAL, IBECS and LILACS databases at a minimum without date or language restrictions for relevant randomised controlled trials (RCTs) and quasi-RCTs (trials in which the method of allocation is not truly random). In addition, a search will also be carried out in the WHO International Clinical Trials Registry Platform, in the clinical trial registries of ClinicalTrials.gov and in the grey literature source OpenGrey.eu. The RCT and quasi-RCT comparison techniques isolated or in combination for treating PVs will be considered. Three review authors will independently perform data extraction and quality assessments of data from included studies, and any disagreements will be resolved by discussion. The primary outcomes will be wound healing and pain. Secondary outcomes will include oedema, adverse events, recurrence or recanalisation, quality of life and economic aspects. The Cochrane handbook will be used for guidance. If the results are not appropriate for a meta-analysis in RevManV.5 software (eg, if the data have considerable heterogeneity and are drawn from different comparisons), a descriptive analysis will be performed.

ETHICS AND DISSEMINATION

Ethics committee approval is not necessary. We intend to update the public registry used in this review, report any important protocol amendments and publish the results in a widely accessible journal.

PROSPERO REGISTRATION NUMBER

CRD42018092974.

Frequency and Significance of Perforating Venous Insufficiency in Patients with Chronic Venous Insufficiency of Lower Extremity

OBJECTIVE

The aim of this study was to reveal the frequency and impact of perforating venous insufficiency (PVI) in chronic venous insufficiency (CVI) of lower extremity (LE).

MATERIALS AND METHODS

Between 2012 and 2017, a total of 1154 patients [781 females (67.68%) and 373 males (32.32%), 228 (19.76%) unilateral and 926 (80.24%) bilateral LE] were examined using Doppler ultrasound (US). A total of 2080 venous systems of LEs [31.4% male (n=653) and 68.6% female (n=1427); 1056 left LEs (50.77%) and 1024 right LEs (49.23%)] were examined. All patients had symptoms of venous insufficiency (VI).

RESULTS

PVI was revealed in 27.5% (n=571) of LEs. Varicose veins (VVs) related with perforating vein (PV) were revealed in 44.7% of LEs (n=929). PVI was observed in 50.91% of patients with chronic deep venous thrombosis (DVT), 64.41% with deep venous insufficiency (DVI), 59.81% with great saphenous vein (GSV) insufficiency, 68.49% with small saphenous vein (SSV) insufficiency, 58.65% with accessory GSV insufficiency, and 58.77% with PV associated with VVs. There was a statistically significant relationship between PVI and chronic DVT, DVI, GSV, SSV, and accessory GSV insufficiency (p<0.001). A significant relationship was observed between the increase in PV diameter and the presence of PVI (p<0.001).

CONCLUSION

PVI is quite common in combined VI, and PV evaluation should be a part of LE venous system examination.

Episodes of extreme lower leg pain caused by intraosseous varicose veins

We present a case of a 67-year-old man with episodes of extreme pain of the right lower extremity that prevented him from walking and sleeping. The patient had a history of varices in both legs. Physical examination showed a pretibial varix of the right leg inferiorly from a painful spot. X-ray of the right lower leg showed a cortex disruption at this spot. MRIs confirmed the disruption of the cortex of the right tibia and demonstrated an intraosseous vessel. The diagnosis intraosseous varices was made and the vein was surgically resected. Follow-up took place after 3 years and the patient was free from any symptoms related to the intraosseous varicose vein. The pathophysiology causing the pain symptoms is hard to understand, partly due to the limited cases presented with such anomalies. We demonstrate our case in the hope to generate more knowledge about this disorder.

Perforator Vein Access for Venous Pharmacomechanical Thrombolysis

A 28-year-old Hispanic female with a history of deep vein thrombosis (DVT) presented to the emergency room with left lower extremity swelling and pain. On duplex venous examination, an extensive left lower extremity DVT extending to her left common iliac vein was identified. A perforator vein measuring 2.6 mm located in the midcalf area was used to access and perform mechanical and chemical thrombolysis. Complete resolution of symptoms was observed.