Medicine and Phlebolymphology: Time to Change?

The Other Side of Chronic Venous Disorder: Gaining Insights from Patients' Questions and Perspectives

Venous disorders encompass a diverse range of manifestations and diseases, impacting a significant portion of the population. While life-threatening conditions are uncommon in non-thrombotic disorders, like telangiectasias or uncomplicated varicose veins (VVs), these conditions still have a substantial impact on affected individuals. Ensuring that patients are well informed about their venous disorder is a crucial step in their treatment journey. Providing them with valuable information regarding the disease's natural progression and available therapeutic options plays a pivotal role in optimizing their care. When patients are diagnosed with venous disorders, they often have numerous questions and concerns they want to discuss with their healthcare providers. Addressing these inquiries not only improves patients' knowledge and understanding but also influences their treatment compliance and overall outcomes. Therefore, it is of utmost importance to provide comprehensive explanations that address any doubts, uncertainties, and areas of confusion that patients may have. This report aims to present a concise, practical, and informative guide to venous disorders, focusing specifically on the common questions frequently raised by patients in everyday clinical practice. By serving as a valuable resource for healthcare professionals working in the field of venous diseases, this guide equips them with the necessary tools to effectively address patients' concerns and provide optimal care. By bridging the gap between patients' inquiries and medical expertise, this guide strives to enhance therapeutic outcomes and improve the overall management of venous disorders, ultimately empowering patients in their treatment journey.

Venous ulcers: look at the patient, not at the ulcer! Risk factors and comorbid conditions in venous ulcers of lower limbs

BACKGROUND

In venous leg ulcers (VLU), risk factors and comorbidities may affect prognosis and recurrence. Aim of this paper was to assess risk factors and most frequent medical conditions in venous ulcers.

METHODS

This a single center retrospective study from January 2017 to December 2020 on 172 patients with VLU admitted at our Center for Ulcer therapy in San Filippo Neri Hospital in Rome; data about medical history, Duplex scanning results and lifestyle questionnaire were collected in an Excel database and evaluated with Fisher test. Patients with lower limbs arterial insufficiency were excluded.

RESULTS

Incidence of VLU in patients over 65 was twice that in patients under 65 and woman were affected by VLU more than men (59.3% vs. 40.7%; P<0.001); more significant comorbidities were arterial hypertension in 44.19% (P=0.06), heart disease in 35.47% (P<0.001), chronic obstructive pulmonary disease (COPD) in 16.28% (P=0.008). In 33 patients (19% of cases) a trauma caused the ulcer. Diabetes, obesity, chronic renal insufficiency and orthopedic disease do not seem to have a direct influence on VLU.

CONCLUSIONS

Age, female sex, arterial hypertension, heart disease and COPD were significant risk factors. Thinking "globally" to the patient rather than only taking the ulcer into account is the key for a long-lasting therapeutic result; comorbidities are interconnected so weight loss, an exercise program for calf pump and compression must all be part of the VLU therapy, not only to heal the existing ulcer but also to prevent recurrences.

Comprehensive overview of the venous disorder known as pelvic congestion syndrome

Pelvic venous disorders (PeVD) also known as Pelvic Congestion Syndrome (PCS) affect a great number of women worldwide and often remain undiagnosed. Gynecological symptoms caused by vascular background demand a holistic approach for appropriate diagnosis. This is a relevant cause of chronic pelvic pain and atypical varicose veins. The diagnosis is based on imaging studies and their correlation with clinical presentation. Although the aetiology of PCS still remains unclear, it may result from a combination of factors including genetic predisposition, anatomical abnormalities, hormonal factors, damage to the vein wall, valve dysfunction, reverse blood flow, hypertension and dilatation. The following paper describes an in-depth overview of anatomy, pathophysiology, symptoms, diagnosis and treatment of PCS. In recent years, minimally invasive interventions have become the method of first choice for the treatment of this condition. The efficacy of a percutaneous approach is high and it is rarely associated with serious complications.Key MessagesPelvic venous disorders demand a holistic approach for appropriate diagnosis.This article takes an in-depth look at existing therapies of Pelvic Congestion Syndrome and pathophysiology of this condition.Embolisation is an effective and safe treatment option.

Compression therapy, autonomic nervous system, and heart rate variability: A narrative review and our preliminary personal experience

Aims

To highlight the relationship among compression therapy (CT), the autonomic nervous system (ANS) (parasympathetic and sympathetic system), and the heart rate variability (HRV) analysis.

Background

Beyond the typical analgesic and anti-inflammatory effects of CT in patients affected by venous and/or lymphatic diseases, some literature about CT influence on wellbeing has been published as well. More specifically, CT influence on the ANS has been elucidated mostly through HRV application, providing useful quali-quantitative data for scientific and clinical purposes.

Material and Methods

A literature search was performed through several web-based search engines to investigate the available evidence concerning the possible influence of CT on the ANS and on psychoneuroendocrineimmunology. Moreover, we examined literature data regarding HRV use in the assessment of CT. Lastly, a preliminary cross-over study was performed on 10 patients affected by phlebolymphedema of the lower limbs, undergoing CT with 18–21 mmHg stockings for 10 h and investigated by means of HRV.

Results

A CT-based increase of the anti-inflammatory activity of the parasympathetic (vagal) system has been elucidated in most scientific literature. Similarly, CT application has generally resulted in an improvement of HRV, which indicates a beneficial influence on the ANS. In our preliminary experience with compression stockings and HRV, two parasympathetic-based parameters improved by 22.8% and 68.0% after 10 h, whereas they decreased in the same subjects without stockings by 2.7% and 8.2%, during normal breathing. The remaining HRV parameters did not show relevant variations, especially during diaphragmatic breathing.

Conclusions

From literature data and based on our very preliminary experience, it is possible to deduce that CT exerts different effects on the psychobiological parameters of the individual, overall improving HRV and parasympathetic activity. Incorporating both HRV/ANS assessment in phlebolymphology and the beneficial neural action of CT in health care may represent viable options in the future biomedical science.

COVID-19, Cation Dysmetabolism, Sialic Acid, CD147, ACE2, Viroporins, Hepcidin and Ferroptosis: A Possible Unifying Hypothesis

Background: iron and calcium dysmetabolism, with hyperferritinemia, hypoferremia, hypocalcemia and anemia have been documented in the majority of COVID-19 patients at later/worse stages. Furthermore, complementary to ACE2, both sialic acid (SA) molecules and CD147 proved relevant host receptors for SARS-CoV-2 entry, which explains the viral attack to multiple types of cells, including erythrocytes, endothelium and neural tissue. Several authors advocated that cell ferroptosis may be the core and final cell degenerative mechanism.

Methods: a literature research was performed in several scientific search engines, such as PubMed Central, Cochrane Library, Chemical Abstract Service. More than 500 articles were retrieved until mid-December 2021, to highlight the available evidence about the investigated issues.

Results: based on COVID-19 literature data, we have highlighted a few pathophysiological mechanisms, associated with virus-based cation dysmetabolism, multi-organ attack, mitochondria degeneration and ferroptosis. Our suggested elucidated pathological sequence is: a) spike protein subunit S1 docking with sialylated membrane glycoproteins/receptors (ACE2, CD147), and S2 subunit fusion with the lipid layer; b) cell membrane morpho-functional changes due to the consequent electro-chemical variations and viroporin action, which induce an altered ion channel function and intracellular cation accumulation; c) additional intracellular iron concentration due to a deregulated hepcidin-ferroportin axis, with higher hepcidin levels. Viral invasion may also affect erythrocytes/erythroid precursors, endothelial cells and macrophages, through SA and CD147 receptors, with relative hemoglobin and iron/calcium dysmetabolism. AB0 blood group, hemochromatosis, or environmental elements may represent possible factors which affect individual susceptibility to COVID-19.    

Conclusions: our literature analysis confirms the combined role of SA molecules, ACE2, CD147, viroporins and hepcidin in determining the cation dysmetabolism and final ferroptosis in the cells infected by SARS-CoV-2. The altered ion channels and electrochemical gradients of the cell membrane have a pivotal role in the virus entry and cell dysmetabolism, with subsequent multi-organ immune-inflammatory degeneration and erythrocyte/hemoglobin alterations.

Chronic venous insufficiency: Part 2 Diagnosis and treatment

Chronic venous insufficiency (CVI) is a common medical condition that results from venous hypertension of the extremities, leading to significant morbidity. The diagnosis of CVI is quite straightforward from patient history and obvious clinical manifestations. In the recent past, availability of various invasive and non-invasive modalities have assisted in evaluation of such cases. Although compression therapy is the mainstay of management, newer surgical and other interventional techniques are now being considered for patients who do not respond to conventional medical management. This review article will outline a diagnostic approach in cases of CVI and discuss the management principles encompassing conservative, pharmacological, and interventional options.

Physical fitness changes induced by thermal aquatic standardized exercise in chronic venous disease patients

BACKGROUND

Lack of physical activity represents a risk factor for both cardiovascular and chronic venous diseases (CVD), nevertheless a specific exercise protocol for CVD patient is still missing. This investigation was aimed to assess the impact of a standardized exercise protocol in a thermal water environment on physical fitness and quality-of-life (QoL) in CVD patients.

METHODS

Sixteen (16) CVD patients performed 5 standardized exercise sessions in a thermal water pool. Before starting the exercise protocol, the cohort filled International Physical Activity Questionnaire (IPAQ) to determine their physical activity level. At baseline and at the end of the exercise program, leg volume, QoL, musculoskeletal and cardiovascular physical fitness were assessed by means of water plethysmography, validated questionnaire and functional test, blood pressure and heart rate at rest were also reported.

RESULTS

All the patients were categorized as physically inactive: average activity time 235.6 (155.2) MET-minutes per week. At the end of the study, a significant leg volume reduction was found (-16%; p < .002). Significant improvement in lower limb strength (p < .0001), endurance (p < .006), rapidity and balance (p < .05) together with decrease in resting heart rate (-1.8%, p < .0001) and systolic blood pressure (-1.1%, p < .04) were reported, significant improvement in bodily pain (p < .0005) and social function (p < .002) QoL items were observed.

CONCLUSIONS

The proposed exercise protocol in thermal aquatic environment demonstrated to be an effective treatment modality improving both cardiovascular and musculoskeletal outcomes and QoL in sedentary CVD patients. Aquatic environment investigations require proper analysis of the various factors involved, in a standardized and reproducible way. The herein report can be a reference for further studies on different health related conditions.

Understanding Chronic Venous Disease: A Critical Overview of Its Pathophysiology and Medical Management

Chronic venous disease (CVD) is a multifactorial condition affecting an important percentage of the global population. It ranges from mild clinical signs, such as telangiectasias or reticular veins, to severe manifestations, such as venous ulcerations. However, varicose veins (VVs) are the most common manifestation of CVD. The explicit mechanisms of the disease are not well-understood. It seems that genetics and a plethora of environmental agents play an important role in the development and progression of CVD. The exposure to these factors leads to altered hemodynamics of the venous system, described as ambulatory venous hypertension, therefore promoting microcirculatory changes, inflammatory responses, hypoxia, venous wall remodeling, and epigenetic variations, even with important systemic implications. Thus, a proper clinical management of patients with CVD is essential to prevent potential harms of the disease, which also entails a significant loss of the quality of life in these individuals. Hence, the aim of the present review is to collect the current knowledge of CVD, including its epidemiology, etiology, and risk factors, but emphasizing the pathophysiology and medical care of these patients, including clinical manifestations, diagnosis, and treatments. Furthermore, future directions will also be covered in this work in order to provide potential fields to explore in the context of CVD.

Update in the management of lipedema

Lipedema is a chronic feminine disease that causes abnormal fat deposition in lower limbs and occasionally upper limbs. Easy bruising and pain are common. Lipedema patients suffer from both physical and psychological disability. Despite the relatively high prevalence and the impact on the quality of life, little is known about the disease. The majority of patients are misdiagnosed as lymphedema or obesity. The objective was to perform a non-systematic review on lipedema literature, related to diagnosis and therapy. Regarding pathophysiology, alterations are not exclusively confined to adipose tissue. Lymphatic dysfunction, cardiovascular variations, blood capillary fragility and increased permeability are common. Patients often present with neurological alterations and hormonal malfunction. Elevated cutaneous sodium has been documented. Due to the absence of a defined etiology, evidence-based research is difficult in the management of lipedema. The setting of realistic expectations is important for both patient and medical care provider. The major aims of the management are multimodal for improvements in the quality of life; reduction in heaviness and pain, reshaping the affected limbs, weight control, improvements in mobility. Compression garments, physical therapy, exercise regimens, diet and psychological counseling are necessities. For selected patients, surgical treatment is an added option.

Editorial

Not required.

Two-Year Follow-Up after Endovenous Closure with Short-Chain Cyanoacrylate versus Laser Ablation in Venous Insufficiency

Background: The current treatment of venous disease is focused on the minimally invasive exclusion of the affected vein. Besides widely used thermal ablation, chemical ablation with cyanoacrylate, reported as safe and highly effective, has been gaining increasing interest. Patients and methods: In the current report, we present data from a two-year observation in 89 patients (61 female/28 male, mean age 44.3 ± 13.5) suffering from venous insufficiency (C2–C4), treated either using short-chain cyanoacrylate, the VenaBlock system (n = 43) or laser thermoablation with ELVeS 1470 (n = 46). The assessment comprised the occurrence of venous disease-related symptoms and the ultrasound examination of the leg venous system. Results: The frequency of recanalization after 2 years from the VenaBlock procedure was significantly higher than after laser treatment (37.2 vs. 8.7%). Apart from recanalization, in some individuals from both groups, the symptoms of recurrence and/or disease progression, including the development of insufficiency in other veins of treated or contralateral legs (9.3 vs. 15.2% and 9.3 vs. 17.4%, respectively), were observed. Unexpectedly, the general prevalence of the disease progression did not differ significantly between the VenaBlock and ELVeS groups (44.2 vs. 34.8%, respectively). Conclusions: Despite the higher recanalization rate of VenaBlock compared to ELVeS, the overall effectiveness of cyanoacrylate and laser thermoablation after two years was similar. Therefore, both methods similarly failed to prevent recurrence and disease progression, which seem to be method-independent.

The Analysis of Selected Morphological and Hemodynamic Parameters of the Venous System and Their Presumable Impact on the Risk of Recurrence after Varicose Vein Treatment

INTRODUCTION

The current treatment of venous disease is focused on reflux elimination in main venous trunks, especially in the saphenous vein. However, a high recurrence rate, independent of the method of treatment, suggests that the reason of low effectiveness may be due to a strategy focused on symptoms, without considering their origin.

METHOD

The aim of study was the comparison of retrospective data from 535 women with venous disease, either after treatment (n = 183) or not treated before (n = 352). The analysis concerned clinical symptoms and the results of the extended diagnostics, including the examination of the lower limb, pelvic and abdominal veins either using duplex-doppler ultrasound as well as venography with computed tomography or magnetic resonance.

RESULTS

The comparison of selected venous system parameters revealed more advanced disease progression in previously treated patients, compared to non-treated individuals (e.g., ipsi- or bilateral incompetence of sapheno-phemoral junction-29.5% vs. 20.4%, at P < 0.05 and 13.6% vs. 7.7% at P < 0.05, respectively). This difference could be explained by post-treatment alterations in the venous system, an older age and the higher number of pregnancies in the recurrence group. However, both groups did not differ in regards to the symptoms of pelvic venous insufficiency or the frequency of relevant variants/abnormalities in venous system.

CONCLUSIONS

Based on the aforementioned findings, we postulate the revision of treatment strategy, which should consider abdominal and pelvic veins as the source of reflux in many female subjects.