[Adjuvant phlebotrophic therapy and its effect on anti-inflammatory response after sclerotherapy]

The study was aimed at evaluating the degree of the systemic and local inflammatory reaction after sclerotherapy, as well as the effect of micronized purified flavonoid fraction (Detralex) thereupon. The study comprised a total of 60 female patients presenting with reticular veins and telangiectasias (clinical class C1 according to the CEAP classification). The patients were subdivided into two groups, each comprising 30 women. The Study Group patients two weeks prior to the forthcoming sclerotherapy had been taking Detralex prescribed at a daily dose of 1,000 mg whose administration was prolonged by not less than 2 months after the procedure. The Control Group patients received no drug. We determined the systemic and local levels of inflammatory markers, anti-inflammatory cytokines and growth factors: C-reactive protein in a highly sensitive range, histamine, interleukin-1, tumour necrosis factor alpha and vascular endothelial growth factor. Patients in the Study and Control Groups on day 10 after sclerotherapy demonstrated a considerable increase in the levels of anti-inflammatory cytokines and inflammatory markers. At the same time, excess of the baseline levels of the parameters in patients taking Detralex was statistically significantly lower as compared with the Control Group patients: C-reactive protein - 6.0±0.9 mg/l vs 8.3±1.0 mg/l; histamine - 87.0±9.8 µg/l vs 156.9±33.9 µg/l; interleukin-1 - 5.9±0.4 pg/ml vs7.6±0.6 pg/ml; tumour necrosis factor alpha - 5.9±0.9 pg/ml vs 7.5±0.4 pg/ml; vascular endothelial growth factor - 252.3±26.0 pg/ml vs 325.1±47.7 pg/ml. A conclusion was made that microsclerotherapy with the use of low-concentration detergent drugs was accompanied by a local vein-specific inflammatory reaction whose degree may be diminished by means of prescribing micronized purified flavonoid fraction (Detralex) two weeks prior to and during the whole subsequent period of phlebosclerosing treatment in a standard daily dose of 1,000 mg.

[Effect of angioprotective therapy with bioflavonoids on endothelial dysfunction in patients with acute venous thromboses]

The study was aimed at evaluating a possibility of correcting endothelial dysfunction by means of angioprotective therapy with natural-origin bioflavonoids in patients presenting with acute venous thromboses. Ours was an open comparative prospective study including a total of thirty 34-to-60-year-old patients suffering from lower limb deep vein thrombosis. The patients were subdivided into two groups. The Study Group was composed of 15 patients receiving on the background of anticoagulant therapy with direct thrombin inhibitors (dabigatran etexilate at a daily dose of 300 mg) natural-origin angioprotectors (red grape leaf extract). The Control Group also consisted of 15 patients undergoing anticoagulant therapy with direct thrombin inhibitors alone. Blood sampling for laboratory monitoring [the quantitative level of von Willebrand factor (vWF) in blood plasma, integral assessment of the links of blood coagulation and fibrinolysis by means of thromboelastography] and ultrasonographic angioscanning of lower extremities were carried out in both Group twice: at the beginning of the study and 3 months after the beginning of therapy. The absolute majority of patients demonstrated a quantitative increase in vWF (the median in the Study Group amounted to 208.3%, being 190.0% in the Control Group, with the cut-off level equaling 140.8%). Assessing dynamics of the vWF level after 3 months on the background of using natural-origin flavonoids (the Study Group) showed a more pronounced decrease in the vWF level in the Study Group patients as compared with the Control Group patients (98.4%). Comparing the dynamic composite indices of the thromboelastogram revealed that with similar parameters in patients from the Study and Control Groups at admission, in dynamics there was observed greater growth of the level of indices of the process of dissolution of the fibrin clot (lysis) in the Study Group as compared to the Control Group. Also noted was more pronounced recanalization of the venous bed in patients taking the natural-origin bioflavonoid. A conclusion was drawn that including angioprotectors (red vine leaf extract) into the comprehensive therapy in order to correct endothelial dysfunction may improve the immediate results and terms of treatment of patients with acute venous thrombosis.

[On possible role of endothelial dysfunction in development of acute venous thrombosis]

The study included a total of 18 patients (12 women and 6 men, aged from 22 to 51 years, mean age 34 years) with newly onset unilateral acute thrombosis of deep veins in the system of inferior vena cava, confirmed by the findings of ultrasound duplex scanning. The patients had no apparent risk factors for venous thromboembolic complications, they had not used antiplatelet drugs during the last month and were characterized by a low level of risk for cardiovascular complications. Along with general clinical examination the patients were subjected to measuring the quantitative level of the von Willebrand factor (vWF), resistance to activated C-protein conditioned by V factor mutation, D-dimer, qualitative assessment of the level of C-reactive protein by a highly sensitive method, as well as integral assessment of the links of blood coagulation and fibrinolysis by means of thromboelastography. Eighteen (100%) patients had the vWF level above the norm, four (22.2%) patients were found to have resistance to activated C protein conditioned by factor V mutation, these patients had non-O (I) blood group. In twelve (66.7%) patients the quantitative level of D-dimer remained within the normal limits, and in 6 patients the D-dimer level was above the norm. The findings of thromboelastography demonstrated decreased activity of blood platelets. Fibrinolysis (LY30 and LY60) in the absolute majority of the examined patients was lowered. Six (33.3%) patients when comparing the LY30 and LY60 levels had no significant elevation of the index (<1%), four (22.2%) patients when comparing LY30 and LY60 showed an elevation of the index (>3.8%). The mean level of C-reactive protein (4.93 mg/l) exceeded the median of the reference values (2.5 mg/l) and in five (27.8%) out of 18 patients the value was two times higher than the reference ones. The obtained experimental data suggest that acute venous thrombosis is accompanied by alterations in the work of the coagulation and fibrinolytic systems, associated with endothelial dysfunction.

Electrical muscle stimulation with Veinoplus® device in the treatment of venous ulcers

AIM

The aim of the study was to analyze the results of the electrical muscle stimulation (EMS) usage in patients with venous ulcers developed on top of a post-thrombotic syndrome (PTS).

METHODS

Sixty patients (60 legs) with active venous ulcer (C6EsAsdpPr according to CEAP classification) were divided into two groups. In addition to the background therapy consisting of a standardized compression with ULCER X and intake of micronized purified flavonoid fraction (MPFF 1000 mg daily), all the patients in the main group underwent EMS with Veinoplus® V.I. for at least 3 times a day. Follow-up examinations were performed on days 30, 60 and 90. These included pain severity assessment with 100-mm Visual Analogue Scale (VAS), disease severity measurement with VCSS (Venous Clinical Severity Score) and ankle circumference above malleolus, as well as recording number of healed venous ulcers.

RESULTS

At day 90 pain severity was reduced in both main and control groups. However, according to VAS pain reduction rates were significantly higher in patients of the main group (from 8.7 ± 0.6 to 1.9 ± 0.3 in the main group and 8.4 ± 0.6 to 3.9 ± 0.5 in the control group). At the end of the study, ankle circumference decreased from 270.9 ± 4.6 mm to 257.1 ± 4.2 mm in the main and from 269.7 ± 5.3 mm to 263.4 ± 5.2 in the control group. VCSS before treatment was 7.3 ± 0.6 in the main group and 6.8 ± 0.5 in the control group. By day 90 VCSS significantly decreased to 2.3 ± 0.4 and 4.6 ± 0.5 in the main and control groups respectively. Healing rates were significantly higher in the main group. On day 90, the number of open venous ulcers in the main group was 3 times lower than in the control group (4 vs. 12).

CONCLUSION

EMS demonstrated high efficacy and good tolerability and provided significant reduction in pain severity, VCSS score and ankle edema, as well as a 3-fold increase in the number of healed venous ulcers.

[Peculiarities of treatment of chronic venous diseases in Russia. Preliminary results of the "VEIN ACT Program"]

Presented herein are the results of the Russian part of the International Research Program "VEIN ACT" aimed at studying the structure of variants of conservative treatment for chronic venous diseases in the Russian Federation, assessing its efficacy and safety, as well as monitoring of patient compliance. The obtained findings demonstrated high popularity, among both physicians and patients, of phlebotrophic drugs, determining high patient's adherence thereto. Recommendations on correction of the lifestyle were complied with by more than 80% of patients, however frequently not in the full scale. Noted was sufficiently low compliance to compression therapy, manifesting itself as a decrease in the class of compression and irregular use thereof in more than 30% of patients. Usefulness of conservative therapy was objectively proved, consisting in satisfaction with treatment and a statistically significant decrease in severity of symptoms of chronic venous diseases in the overwhelming majority of patients.

Electromuscular stimulation with VEINOPLUS® for the treatment of chronic venous edema

AIM

Electromuscular stimulation (EMS) with VEINOPLUS® has recently emerged as a new technique to activate the calf muscle pump, improving the symptoms of venous disease. The aim of the study was to evaluate efficacy of EMS and its impact on evening edema, venous pain, venous outflow and patients quality of life.

METHODS

Thirty patients (32 legs) aged 19-50 (mean 45.2±1.3) classified CEAP C3 with chronic evening venous edema took part in the study (22 limbs: C3, S, Ep, Asp, Pr and 10 limbs: C3, S, Es, Aspd, Pr). All patients were treated with CE-registered VEINOPLUS® neuromuscular stimulator for 30 days. 3 sessions per day (each session lasted for 20 minutes) for the first 10 days, the next 10 days 2 sessions per day and one session per day for the last 10 days. The main evaluated criteria for venous edema was the circumference of the supramaleoal shin segment, measured twice with a tape measure; in the evening the day before and then 5 days after the treatment. All measurements were taken during the interval between 6 and 8 o'clock P.M. All the patients were asked to evaluate venous pain using the Visual Analog Scale, and to fill in a CIVIQ questionnaire (validated for Russian patients) for the Quality Of Life (QOL) measurement. Also venous refilling time (RT) was measured by digital PPG. That was also made twice - before the treatment and in 35 days after the treatment. No other treatments were used.

RESULTS

The EMS treatment was well tolerated by patients. There were no drop outs and patients had no need to change their lifestyles. After the treatment, total or partial reduction of evening edema was shown in 93.8% of limbs, the circumference of the lower leg diminished by 20.3mm (P<0.001), the number of painful legs reduced from 28 to 12 and the severity score of venous pain was cut from 8.3 ±1.1 to 3.8 points ±0.9 (P<0.001), QOL improved significantly as the score dropped from 34.5 ±7.8 to 17.2 points ±4.6 (P<0.001) and RT increased from 17.3 ±0.9 to 21.5 seconds ±1.1 (P<0.001). Three months after VEINOPLUS® treatment, total remission of symptoms was observed in 50% of legs, despite there being no other treatments.

CONCLUSION

VEINOPLUS® stimulation is an effective and well-tolerated therapeutic method for the treatment of chronic venous disease. The introduced scheme of EMS application was shown to be useful for treatment of chronic edema, for reducing pain and improving quality of life. It can be used as an additional mean in treatment and to prevent symptoms of CVI. This study also reveals that stimulation of calf muscles with VEINOPLUS® can improve venous outflow and symptoms of CVI. This finding should be investigated and confirmed in further studies.

Surgical correction of varicose vein disease under micronized diosmin protection (results of the Russian multicenter controlled trial DEFANS)

The paper presents the results of DEFANS trial (Detralex - assessment of efficacy and safety for combined phlebectomy). The study enrolled 245 patients with varicose vein disease, who underwent unilateral combined phlebectomy. The main group (n=200) received micronized diosmin (Detralex, 1000 mg/day) for 2 weeks before and 30 days after the procedure; control group (n=45) did not receive Detralex in pre- and postoperative period. Pain severity by 10-point visual analog scale (VAS), an area of subcutaneous hemorrhage in the zone of femoral great saphenous vein resection (by original 12-point scale) and subjective feelings of limb heaviness and fatigability were evaluated 7, 14 and 30 days after the procedure. Subjective symptoms and the area of subcutaneous hemorrhage were significantly lower in the main group, then in control: 7 days after the procedure VAS score was 2.9 and 3.5, respectively; hemorrhage area - 3.4 and 4.6 points, respectively. The same trend was observed for limb heaviness and fatigability, evidencing the better exercise and orthostatic tolerance among patients of the main group in early postoperative period. Quality of life assessment by CIVIQ failed to reveal statistically significant difference between main and control groups in 4-weeks postoperative follow-up. Micronized diosmin in pre- and postoperative period after plebectomy helps to attenuate pain syndrome, to decrease postoperative haematomas and accelerate their resorption, to increase exercise tolerance in early postoperative period.

[Elimination of major trunk reflux as a basis for surgical management of lower limb varicosity]

The article reviews the available literature data related to the problem of eliminating the blood reflux along the trunks of saphenous veins in lower limb varicosity. The authors have herein classified the literature-proposed interventions depending on the underlying principle, to have also carried out a detailed analysis of the data contained in the available Russian and foreign publications, as well as having considered technical peculiarities concerning different methods of removing veins, i. e., phlebectomy according to the Babcock technique, inversion venectomy, and cryophlebectomy. The article also deals with comparing therapeutic outcomes and a wide variety of postoperative complications involved. The role of the trunk catheter sclerosing therapy in comprehensive management of varicose disease is also discussed herein. Special attention is paid to the present-day techniques aimed at removing the trunk reflux, i. e., with the help of radio-frequency and laser-mediated obliteration. The currently available information about both advantages and disadvantages of these methods necessitates further studies aimed at searching for an optimal method (or a combination of methods) of removing one of the most important links of pathogenesis of varicosity.