Clinical superiority of an innovative two-component compression system versus four-component compression system in treatment of active venous leg ulcers: A randomized trial

Objective

To evaluate the efficacy, safety and acceptability of an innovative two-component versus a well-established four-component compression systems in the management of venous leg ulcer.

Method

Multicentre randomized controlled trial in patients with active venous leg ulcer. Patients were followed-up monthly for a maximum of 16 weeks. The primary endpoint was the complete healing rate at 16 weeks.

Results

Ninety-two patients were randomized to either the two-component BIFLEX® Kit group ( n = 49) or the four-component PROFORE® group ( n = 43). In the full analysis set ( n = 88), a complete healing rate of 48.9% and 24.4% was reported in BIFLEX® Kit versus PROFORE® groups, respectively (i.e. a superiority of 24.5%, p = 0.02). Acceptability of BIFLEX® Kit was higher from both the patients’ and physicians’ perspectives.

Conclusion

The BIFLEX® Kit represents a valid alternative therapy in the management of venous leg ulcer according to its clinical efficacy, safety and acceptability with potential positive impacts on healthcare costs.

Cross-sectional study on heredity and venous disorders: the end of the dominant maternal heredity dogma?

OBJECTIVE

To evaluate the heredity factor of the chronic venous disorders and odds ratio linked to maternal or paternal heredity.

METHODS

Cross-sectional epidemiological study conducted in daily practice of medical practitioners on all patients consulting them. The practitioners described the venous status of all patients consulting them and recorded the familial past history of venous disease.

RESULTS

Among 21319 patients, 60.4% have a familial history of chronic venous disorder: unilateral paternal 7.5%, unilateral maternal 40.9% and bilateral: 12.0%. Chronic venous disorder prevalence is 58.8% in the global population, 38.2% in the absence of parental history, 67.0% for unilateral paternal, 71.3% for unilateral maternal and 79.2% for bilateral (p < 0.0001). After adjustment on age and sex, results show significant (p < 0.0001) odds ratio of 3.2 for unilateral paternal, of 3.4 for unilateral maternal and of 5.6 for a history in both parents. In the context of a history in both parents, the odds ratio increased to 5.6 for women and 8.4 for men.

CONCLUSION

This large cross-sectional study confirms the association between heredity and venous disease, but its results could call into question the maternal predominant character of the chronic venous disorder heredity.

European guidelines for sclerotherapy in chronic venous disorders

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7–10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

Importance of patient-reported outcomes in chronic venous disorders

The assessment of outcomes following treatment for chronic venous disease has been greatly improved over the last three decades. The personal opinion of the physician based on assessment of his own results has been replaced by more objective assessment based on well-defined criteria. The author describes and compares a number of different methods currently in use for this purpose.

Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program

AIM

The Vein Consult Program is an international, observational, prospective survey aiming to collect global epidemiological data on chronic venous disorders (CVD) based on the CEAP classification, and to identify CVD management worldwide. The survey was organized within the framework of ordinary consultations, with general practitioners (GPs) properly trained on the use of the CEAP classification.

METHODS

Screening for CVD was to be performed by enrolling in the survey all consecutive outpatients >18 years whatever the reason for consultation, to record patient's data and classify them according to the CEAP, from the stage C0s to C6. The program enrolled 6232 GPs 91545 subjects were analysed. Their mean age was 50.6±16.9 years, younger patients being in the Middle East and older ones in Europe, and the proportion of women was higher than that of men.

RESULTS

The worldwide prevalence of CVD was 83.6%: 63.9% of the subjects ranging C1 to C6, and 19.7% being C0s subjects. C0s patients were more frequently men whatever the age and the geographical zone. C1-C3 appeared to be more frequent among women whatever the country but the rate of severe stages (C4-C6) did not differ between men and women. GPs consider CVD subjects as patients eligible to specialist referral beginning from C2 but some geographical disparities were observed.

CONCLUSION

The VCP survey provides reliable results on CVD global epidemiology and shows that CVD affects a significant part of the populations worldwide, underlining the importance of adequate screening for CVD and training of both GPs and specialist physicians.

Quality of life improvement in Latin American patients suffering from chronic venous disorder using a combination of Ruscus aculeatus and hesperidin methyl-chalcone and ascorbic acid (quality study)

AIM

The present study assessed the effect of Ruscus aculeatus, hesperidin methyl-chalcone and ascorbic acid (HMC-AA), in the treatment of chronic venous disorders (CVD) in Latin American patients.

METHODS

This study is an observational, single arm, multicentric and prospective trial. Patients suffering from CVD and belonging to C0s-C3 Clinical Etiological Anatomical and Physiopathological (CEAP) classes were included. Patient profiles, risk factors, clinical symptomatology and quality of life (QoL) assessed by SF-12 and CIVIQ questionnaires were evaluated at inclusion and after 12-week treatment.

RESULTS

The main factors influencing the previous management of patients were age, gender, body mass index (BMI), familial history, physical activity, exposure to heat, heavy loads lifting, profession and clinical characteristics. All clinical symptoms significantly improved with treatment and, as BMI and CEAP classes increased. Ankle circumferences decreased over time, correlating with BMI and CEAP classes. The physical and psychological dimensions of the SF-12 score significantly increased over time and improved within each CEAP class. The CIVIQ score significantly improved over time, correlating with age and CEAP classes.

CONCLUSION

A 12-week treatment with Ruscus aculeatus HMC-AA showed a significant decrease in the clinical symptoms and a significant improvement in the QoL of patients with CVD.

Pathophysiology of visual disturbances occurring after foam sclerotherapy

Background

Visual disturbances (VDs) are reported with an average rate of 1.4% after foam sclerotherapy (FS). Some clinical clues indicate that they could correspond to migraine with aura (MA).

Aims

To validate the hypothesis that VDs occurring after FS correspond to MA and are not transient ischaemic cerebro-vascular events.

Method

A prospective multicentre study was carried out by the French Society of Phlebology in collaboration with the Neurology Department of the Marseille University Hospital (France). We included prospectively and consecutively all patients who experienced VDs after FS using air to make the foam. The patients were assessed (1) clinically with a specific form describing procedures of FS and recording neurological symptoms, later analysed by a neurologist specialized in migraine; and (2) by a brain diffusion-weighted magnetic resonance imaging (MRI) (T1, T2, T2*, diffusion) carried out within two weeks and analysed by a neuroradiologist.

Results

Twenty patients, 16 women and four men, were included in 11 phlebology clinics. All kinds of veins were treated. VDs occurred in average seven minutes after FS. Clinical assessment showed that VDs presented characteristics of MA in all patients, with headache in 10 and without in 10. Paresthesia was observed in five patients and dysphasic speech disturbance in one. Fifteen patients (75%) had a personal history of migraine. Fifteen MRIs were performed within two weeks (mean: 8 days) and three were late (26 days). All of them were normal. MRI was not performed in two patients.

Conclusion

These results show that VDs occurring after FS correspond to MA and are not transient ischaemic cerebro-vascular events. We suggest a pathophysiological hypothesis resting on the release of endothelin that would reach the cerebral cortex through a paten foramen ovale.

Assessment of quality of life in Mexican patients suffering from chronic venous disorder – impact of oral Ruscus aculeatus-hesperidin–methyl-chalcone–ascorbic acid treatment – ‘QUALITY Study’

Objectives

The present study assessed the effect of Ruscus aculeatus-hesperidin-methyl-chalcone–ascorbic acid (HMC–AA) on the quality of life (QoL) of patients suffering from chronic venous disorders (CVDs).

Methods

An observational, multicentre and prospective study was performed with 917 Mexican patients suffering from CVD. Patients were treated with R. aculeatus–HMC–AA. After 12 weeks of treatment, the physicians then assessed the patients' symptoms and QoL using Short Form (SF-12) and Chronic Venous Insufficiency (CIVIQ) auto-questionnaires.

Results

Patients were mainly women (86.7%), overweight or obese (72.7%) or C2 (39.3%)–C3 (27.6%). All symptoms and ankle circumferences significantly improved over time, with increasing clinical, aetiological, anatomical and pathophysiological (CEAP) classes and body mass index (BMI) ( P < 0.001). Concerning QoL, all dimensions of the SF-12 score significantly improved over time ( P < 0.001). Moreover, the CIVIQ scores significantly improved ( P < 0.001) with increasing BMI ( P < 0.002) and CEAP classes ( P < 0.05).

Conclusion

R. aculeatus–HMC-AA significantly improved the symptoms and QoL of CVD patients.

Construction and validation of a patient-reported outcome dedicated to chronic venous disorders: SQOR-V (specific quality of life and outcome response - venous)

BACKGROUND

Chronic venous disorders (CVD) have an impact on quality of life (QoL), both physically and psychologically. As of now, several vein specific QoL scales exist, but no patient-reported outcome (PRO) is available which takes into account altogether symptoms, impairment of activities, appearance of the legs and concerns regarding health risk. Since clinical severity and disability are mostly evaluated in severe patients, where the main outcome - namely skin changes - is obvious but rare, the authors considered that a reproducible and clinically relevant survey that could account for specific patients' complaints was needed, particularly for CEAP C0s-C3 patients.

OBJECTIVES

The objective of this study was to build a specific autoquestionnaire and to establish its statistical validity and clinical relevance.

METHODS

A review of existing questionnaires and an analysis of relevant literature were carried out by a committee of experts. The committee then developed a questionnaire of 46 items, with special attention to relevance for venous disorders and patients' main complaints. After construction, the French version was field-tested and results statistically analyzed. In the specific QoL & Outcome Response - Venous (SQOR-V), each item is given a value by the patient and items are grouped in five dimensions. Each dimension is weighed to a maximum value of 20, yielding an overall maximum score of 100.

RESULTS

Two hundred and two questionnaires were analyzed for the initial evaluation and 152 at a second (test-retest). Determination of the Cronbach's alpha coefficient (0.96) and structural analysis demonstrated an excellent internal and structural coherence. Test-retest comparisons confirmed good reproducibility. Comparison with SF-12 and CED-D questionnaires and with CEAP classification groups verified both structural and clinical validity.

CONCLUSIONS

This study demonstrates QoL impairment in patients suffering from chronic venous disorders (CVD). It also verifies the statistical validity of the SQOR-V questionnaire. More studies are needed to demonstrate the improvement in specificity and accuracy this questionnaire provides compared to existing vein-specific QoL scales, and to determine its ability to assess efficacy of any kind of treatment at any stage of the disease. Provided adequate acknowledgment of its authors, the use of SQOR-V is free. An English version is available, currently pending validation.

Chronic venous disease: health status of a population and care impact on this health status through quality of life questionnaires

AIM

There is growing interest for patient-reported outcomes (PROs) in clinical research. Application of quality of life (QoL) questionnaires to patients suffering from chronic venous disease (CVD) is thought to be an important improvement in the assessment of results in these complex disorders. The aims of the study were to describe the health status of female patients suffering from CVD, and to assess the care impact through QoL questionnaires.

METHODS

Symptomatic female patients suffering from CVD (all CEAP clinical classes), aged over 18, newly treated by their general practitioner with a phlebotropic drug were enrolled in the study. Every patient had to complete a self-questionnaire including the SF-12, the CES-D, the Epworth and the CIVIQ scales at day 0 (D0), day 3 (D3) and day 7 (D7). The CIVIQ scale assesses pain and the psychological, physical and social consequences of CVD. The SF-12 is a generic measure of health status. The CES-D scale studies presence of depressive symptoms (DS) in the general population. The Epworth scale measures daytime sleepiness.

RESULTS

A total of 765 physicians took part in the survey from April to August 2003. The results of the study concern 1 045 patients. Analyses are realized on the 399 patients who filled out all 3 questionnaires. Mean age was 45 years (SD=11), patients average height was 164.39 cm (SD=5.99) for an average weight of 65.2 kg (SD=12.5). Concerning change in QoL between inclusion and Day 7, the mean CIVIQ total scores at inclusion were 26.7 in the CEAP class 0-2 group and 36.3 in the CEAP class 3-6 group. The mean CIVIQ total scores at D7 were 18.5 in the CEAP class 0-2 group and 27.3 in the CEAP class 3-6 group. The mean CIVIQ total scores demonstrated that QoL is more impaired for patients in the CEAP class 3-6 group. In both groups, an improvement in patients' QoL was observed following patient management (P<0.001). At inclusion time, MCS-12 and PCS-12 were respectively 44.7 (SD=10.6) and 46.4 (SD=8.4): at day 3 and day 7, these dimensions were respectively: D3: 46.5 (SD=10.2) and 46.2 (SD=8) D7: 48 (SD=10.3) and 46.2 (SD=7.8). For the mental dimension, the difference was statistically significant (P=0.0001). In our study a possible DS (score ?17) was reported for 36.3%, 32.3% and 29% respectively at day 0, D3 and D7 (P<0.01, n=328). Concerning daytime sleepiness the Epworth mean total score showed a decrease in daytime sleepiness for patients with severe CVD (C3-C6) between day 0 and D 7 (P=0.02).

CONCLUSIONS

Our study demonstrates the high impact of CVD on health status and the validity of QoL questionnaires in this pathology. They show a significant improvement of the QoL after one week of medical management.

Edema and leg volume: methods of assessment

Various techniques may be used to assess leg edema. The value of these investigations has been discussed in depth in the consensus statement made in Vaux de Cernay in 1997 and supported by Servier Research Group. These techniques can be classified into three groups: The most simple is leg circumference measurement, which can be assessed by a tape measure, or more rigorously with a Leg-O-Meter. This device is a cheap and reproducible method that has been validated and that takes into account the height at which the circumference has been measured. However, circumference measurement is not always correlated with leg (including foot) volume measurement. The second group of techniques assess leg volume. The most simple method is water displacement volumetry, which has been validated in terms of reproducibility. Several other devices have been used: optoelectronic methods, computed tomography, magnetic resonance imaging (high resolution), dual X-ray absorptiometry. These methods are expensive and not all of them have been validated, but these might be the future investigations of choice. Some other investigations assess immediate variations in volume such as water displacement using dynamic foot volumetry, rheoplethysmography, strain gauge plethysmography, and air plethysmography. The assessment made by these methods (using postural, dynamic, or compressive maneuvers) is more an assessment of the venomuscular pump and/or venous outflow than volume assessment. In conclusion, edema, an early and frequent sign of chronic venous insufficiency (CVI), can be precisely measured by several methods. This measurement can be considered one of the most objective ways of assessing treatment efficacy in CVI-associated edema.

Thrombotic complications of varicose veins. A literature review of the role of superficial venous thrombosis

BACKGROUND

Some recent publications have emphasized the risk (up to 25%) of deep venous thrombosis (DVT) coexisting with a clinical evidence of superficial venous thrombosis (SVT). However, most papers on this topic are old and do not consider the use of the duplex scanning.

OBJECTIVE

To determine what the spontaneous risk is of venous thrombosis and emboli in varicose patients, in the superficial veins, and in the deep veins; what the risk is of extension or coexistence between superficial and deep thrombosis; and whether the treatments of varicose disease are responsible for thrombosis?

METHODS

Review of the literature.

RESULTS

The frequency of venous thrombosis appears to be increased in patients with varicose disease.

CONCLUSIONS

In all cases of clinical SVT a duplex scan examination of both deep and superficial veins is necessary in order to provide a complete diagnosis. The treatment of SVTs depends on the situation and the size of the thrombi. In case of associated DVT, the most important treatment is of the DVT. The interest of heparin or low molecular weight heparin (therapeutic doses) is proved for patients with coexisting DVT, and thought so for ascending SVT. Interest and doses have not been stated in other cases. SVT must be considered as a risk factor of DVT and treated from this point of view. Biological analysis and a complete check-up are mandatory in cases of varicose thrombosis in young patients and in cases of recurrence.

Indications for the sclerosing agent polidocanol (aetoxisclerol dexo, aethoxisklerol kreussler)

BACKGROUND

Polidocanol is a widely used sclerosing agent that was first developed as a local anesthetic. In France it is used in varicose veins as well as in telangiectases.

OBJECTIVE

To improve the knowledge of the effects of polidocanol and provide recommendations for better use.

METHODS

Based on 12 years of experience in treating nearly 11,000 patients with polidocanol, the author reviews his observations. A theoretical model of dilution of sclerosing agents in injected veins is provided.

RESULTS

The author observed: seven cases of minor urticaria, occurrence of grey veil when used under the air-block technique, one case of cutaneous necrosis (5 cm3), and some small epidermic necrosis (1-mm diameter) and neither shock nor severe adverse reaction.

CONCLUSION

Polidocanol is characterized by its spasmogenic action on veins, excellent local tolerance, and a very low incidence of general reactions. Low concentrations (0.3 to 0.6%) can be used for the treatment of quite large varicose veins if an adequate volume is injected.

Microsclerotherapy

The full text of the course given at the European School of Phlebology (Paris, France, November 27, 1990), presenting all the aspects of pathology and microsclerosing treatment is offered. Practical technique, material, and hints are presented to help young (or new) practitioners. These protocols are widely used in France and they are based on the works of the Ecole Française de Phlébologie founded by Raymond Tournay. Some differences may appear between our methods and other methods proposed in Europe and the United States but the results are, in fact, proven to be very good with very little postsclerotherapic matting and pigmentation. For instance, we do not recommend compression in these cases because it does not improve the results. In this article, the sclerosing agents we discuss are different from those available in the United States but our reflections remain valid and we hope these products will soon be approved for use outside of France.

[Phlebologic management of seropositive patients]

There appears to be an increase in the number of HIV-positive patients seeking treatment for varicose veins. This is due to the increase of the incidence of the disease in the population, its spread amongst non-marginalized people and because the patients known that although their long-term prognosis is poor, they do have a latency period during which they can live a normal life. Should HIV-positive varicose patients be considered in the same way as other varicose patients or should they be refused treatment unless this is really indispensable? This is the main pratical question, because many patients are refused treatment, whereas the authors make no distinction in principle. The authors ask what impact will this attitude have on the work of the consultation service and try to give some guidelines.

[What can a neurophysiologic examination contribute to phlebologists?]

After a theoretical summary and account of current techniques, the authors describe the 'electric symptomatology' of the lower limbs and suggest the pathologies in which the anomalies are to be located. The analysis of some personal clinical cases enables them, finally, to draw some practical conclusions: an NP check-up can easily be requested, is not traumatic, and should be considered (except in cases where a primary neurological pathology is suspected) when the clinical and paraclinical symptoms on the one hand, and functional disorders on the other, are dissociated. Emphasis should be placed on reduction of speed of conduction, provided that the examination is carried out by a trained specialist, preferably always the same one. Finally we think that metabolic disorders engendered by venous stasis are likely to be accompanied by neuritic-type degenerations which then develop on their own account; this will be the subject of a further study.

[Complicated lymphatic lesions following extensive venous surgery. Various questions apropos of 2 cases]

In reference to two rather representative cases, the author describes an clinical picture consisting of repeated attacks evoking a masked erysipelas this type of attack, in a context of repeated or extensive venous surgery with incisions in the areas of projection of the lymph collectors must be the indication lymphography showing partial lesions of the lymphatic network. This implies that the etiology is the persistence of streptococci, in dead-end collectors and their occasional awakening. The treatment proposed, justified by frequent recurrences, their progressive aggravation and the possible risks for the general condition, must be, as in chronic streptococcal infections, penicillin V therapy in prolonged but continuous doses (500,000/day) associated with a thorough hygiene of the feet and a regularly worn elastic contention.

[Ambulatory dermo-epidermal patch graft. Its advantages to the phlebologist in his office]

By way of analysing the leg ulcers treated at his consulting rooms during six months, the author introduces the dermo-epidermal graft, simplified in a way that makes it practicable in the framework of an ambulatory treatment, with maximum ease for both practitioner and patient. The results, altogether satisfactory, prompt him to suggest that this technique be used in the context of routine treatment of leg ulcers of all aetiologies and sizes. The time gain is considerably more significant than the simplicity of the technique would lead one to suppose. The incidence of the method is quite high as it has been used in 15% of cases, but this frequency could easily be increased further with more daring. To all accounts there are no significant accidents to be feared and the author, describing the technique, urges those of his colleagues who have not yet tried the ambulatory dermo-epidermal patch graft to familiarize themselves with it.