Showing papers in "Phlebology in 2018"
TL;DR: The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is supported by this document, with 19/25 recommendations rated as Grade 1 evidence.
Abstract: Objective Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic diseases. The aim of this consensus document is to provide up-to-date recommendations and evidence grading on the indications for treatment, based on evidence accumulated during the past decade, under the auspices of the International Compression Club. Methods A systematic literature review was conducted and, using PRISMA guidelines, 51 relevant publications were selected for an evidence-based analysis of an initial 2407 unrefined results. Key search terms included: 'acute', CEAP', 'chronic', 'compression stockings', 'compression therapy', 'lymph', 'lymphatic disease', 'vein' and 'venous disease'. Evidence extracted from the publications was graded initially by the panel members individually and then refined at the consensus meeting. Results Based on the current evidence, 25 recommendations for chronic and acute venous disorders were made. Of these, 24 recommendations were graded as: Grade 1A (n = 4), 1B (n = 13), 1C (n = 2), 2B (n = 4) and 2C (n = 1). The panel members found moderately robust evidence for medical compression stockings in patients with venous symptoms and prevention and treatment of venous oedema. Robust evidence was found for prevention and treatment of venous leg ulcers. Recommendations for stocking-use after great saphenous vein interventions were limited to the first post-interventional week. No randomised clinical trials are available that document a prophylactic effect of medical compression stockings on the progression of chronic venous disease (CVD). In acute deep vein thrombosis, immediate compression is recommended to reduce pain and swelling. Despite conflicting results from a recent study to prevent post-thrombotic syndrome, medical compression stockings are still recommended. In thromboprophylaxis, the role of stockings in addition to anticoagulation is limited. For the maintenance phase of lymphoedema management, compression stockings are the most important intervention. Conclusion The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is supported by this document, with 19/25 recommendations rated as Grade 1 evidence. For recommendations rated with Grade 2 level of evidence, further studies are needed.
155 citations
TL;DR: Stent correction of iliac vein stenosis should aim to restore the lumen to the minimum recommended caliber during the initial procedure and later re-interventions.
Abstract: BackgroundIliac vein stenting has emerged as a therapeutic option in chronic venous disease. The optimal stent size is unknown but should match normal caliber at a minimum.MethodsTeleology: The ili...
83 citations
TL;DR: This is the first study assessing the real compliance in CVD patients of using compression and shows that better and repeated recommendations by the practitioner result in an increase in time the compression is used by 33% and suggests that the number of days the compression stocking is worn is a good criterion of patient compliance.
Abstract: BackgroundPatient compliance is the cornerstone of compression therapy success. However, there has been up to now no tool to assess it other than self-reporting by the patient, which is not reliable.Material and methodsForty active females classified C2S were enrolled to wear compression stockings (CS) providing a pressure of 15–20 mmHg at the ankle.A thermal probe was inserted in the stocking (Thermotrack®), recording the skin temperature every 20 min for four weeks.The patients were randomized in two groups of 20: – Group 1: Receiving minimal recommendations by their physician at the office.– Group 2: Receiving in-depth recommendations by the physician reinforced with SMS message which were repeated once a week for four weeks.The basic CEAP classification and the quality of life (QoL) were recorded before and after four weeks.ResultsThe two groups are similar for age, symptoms and type of CS.The analysis of the thermal curves showed a significant increase (+33%) in the average wearing time daily in the ...
32 citations
TL;DR: Varithena® is a promising step towards the creation of an ideal sclerosant foam and further assessment in independent randomised controlled clinical trials is required to establish the advantages of VarithenA® over and above the current best practice physician-compounded foam.
Abstract: Scope Varithena® is a recently approved commercially available drug/delivery unit that produces foam using 1% polidocanol for the management of varicose veins. The purpose of this review is to examine the benefits of foam sclerotherapy, features of the ideal foam sclerosant and the strengths and limitations of Varithena® in the context of current foam sclerotherapy practices. Method Electronic databases including PubMed, Medline (Ovid) SP as well as trial registries and product information sheets were searched using the keywords, 'Varithena', 'Varisolve', 'polidocanol endovenous microfoam', 'polidocanol' and/or 'foam sclerotherapy/sclerosant'. Articles published prior to 20 September 2016 were identified. Results Foam sclerosants have effectively replaced liquid agents due to their physiochemical properties resulting in better clinical outcomes. Medical practitioners commonly prepare sclerosant foam at the bedside by agitating liquid sclerosant with a gas such as room air, using techniques as described by Tessari or the double syringe method. Such physician-compounded foams are highly operator dependent producing inconsistent foams of different gas/liquid compositions, bubble size, foam behaviour and varied safety profiles. Varithena® overcomes the variability and inconsistencies of physician-compounded foam. However, Varithena® has limited applications due to its fixed sclerosant type and concentration, cost and lack of worldwide availability. Clinical trials of Varithena® have demonstrated efficacy and safety outcomes equivalent or better than physician-compounded foam but only in comparison to placebo alone. Conclusion Varithena® is a promising step towards the creation of an ideal sclerosant foam. Further assessment in independent randomised controlled clinical trials is required to establish the advantages of Varithena® over and above the current best practice physician-compounded foam.
31 citations
TL;DR: Venous rehabilitation consists of non-pharmacologic and non-surgical interventions aiming at prevention of venous disease progression and complications, reduction of symptoms and improvement of quality of life.
Abstract: BackgroundTo date, no document comprehensively focused on the complex issue of the rehabilitation of chronic venous diseases of the lower limbsMethodThis article overviews and summarizes current s
30 citations
TL;DR: Regular exercise in form of walking (≥5 days per week) was found to be a protective factor from venous ulceration in patients with varicose veins, while regular physical exercise mitigated that risk.
Abstract: Background/objectivesVenous ulcers carry psychological and high financial burden for patients, causing depression, pain, and limitation of mobility. The study aimed to identify factors associated with an increased risk of venous ulceration in patients with varicose veins in Armenia.MethodsA case-control study design was utilized enrolling 80 patients in each group, who underwent varicose treatment surgery in two specialized surgical centers in Armenia during 2013–2014 years. Cases were patients with varicose veins and venous leg ulcers. Controls included patients with varicose veins but without venous leg ulcers. Data were collected using interviewer-administered telephone interviews and medical record abstraction. Multiple logistic regression analysis was used to identify the risk factors of venous ulceration.ResultsThere were more females than males in both groups (72.5% of cases and 85.0 % of controls). Cases were on average older than controls (53.9 vs. 39.2 years old, p ≤ 0.001).After adjusting for p...
28 citations
TL;DR: Pelvic vein embolisation under local anaesthetic is safe and technically effective in a remote out-patient facility outside of a hospital.
Abstract: Objectives Pelvic vein embolisation is increasing in venous practice for the treatment of conditions associated with pelvic venous reflux. In July 2014, we introduced a local anaesthetic "walk-in walk-out" pelvic vein embolisation service situated in a vein clinic, remote from a hospital. Methods Prospective audit of all patients undergoing pelvic vein embolisation for pelvic venous reflux. All patients had serum urea and electrolytes tested before procedure. Embolisation coils used were interlock embolisation coils (Boston Scientific, USA) as they can be repositioned after deployment and before release. We noted (1) complications during or post-procedure (2) successful abolition of pelvic venous reflux on transvaginal duplex scanning (3) number of veins (territories) treated and number of coils used. Results In 24 months, 121 patients underwent pelvic vein embolisation. Three males were excluded as transvaginal duplex scanning was impossible and six females excluded due to lack of complete data. None of these nine had any complications. Of 112 females analysed, mean age 45 years (24-71), 104 were for leg varices, 48 vulval varices and 20 for pelvic congestion syndrome (some had more than one indication). There were no deaths or serious complications to 30 days. Two procedures were abandoned, one completed subsequently and one was technically successful on review. One more had transient bradycardia and one had a coil removed by snare during the procedure. The mean number of venous territories treated was 2.9 and a mean of 3.3 coils was used per territory. Conclusion Pelvic vein embolisation under local anaesthetic is safe and technically effective in a remote out-patient facility outside of a hospital.
28 citations
TL;DR: It has been determined that the increase in muscle strength affected the venous pump and this ensured improvement in venous function and range of motion of the ankle and quality of life improved after the exercise program.
Abstract: ObjectiveThe aim of this study was to observe the change of the ankle joint range of motion, the muscle strength values measured with an isokinetic dynamometer, pain scores, quality of life scale, ...
25 citations
TL;DR: This study may be considered as the first to evaluate the diagnostic performance of the clinical findings associated with pelvic congestion syndrome in a sample of the Colombian population and may be used to create a clinical score for the diagnosis of this condition.
Abstract: Background Pelvic congestion syndrome is among the causes of pelvic pain. One of the diagnostic tools is pelvic venography using Beard's criteria, which are 91% sensitive and 80% specific for this syndrome. Objective To assess the diagnostic performance of the clinical findings in women diagnosed with pelvic congestion syndrome coming to a Level III institution. Methods Descriptive retrospective study in women with chronic pelvic pain taken to transuterine pelvic venography at the Advanced Gynecological Laparoscopy and Pelvic Pain Unit of Clinica Comfamiliar, between August 2008 and December 2011, analyzing social, demographic, and clinical variables. Results A total of 132 patients with a mean age of 33.9 years. Dysmenorrhea, ovarian points, and vulvar varices have a sensitivity greater than 80%, and the presence of leukorrhea, vaginal mass sensation, the finding of an abdominal mass, abdominal trigger points, and positive pinprick test have a specificity greater than 80% when compared with venography. Conclusion This study may be considered as the first to evaluate the diagnostic performance of the clinical findings associated with pelvic congestion syndrome in a sample of the Colombian population. In the future, these findings may be used to create a clinical score for the diagnosis of this condition.
24 citations
TL;DR: Neuromuscular electrical stimulation significantly reduces the risk of deep vein thrombosis compared to no prophylaxis and there is no evidence for its use as an adjunct to heparin.
Abstract: ObjectiveVenous thromboembolism, encompassing deep vein thrombosis and pulmonary embolism, is a significant cause of morbidity and mortality, affecting one in 1000 adults per year. Neuromuscular electrical stimulation is the transcutaneous application of electrical impulses to elicit muscle contraction, preventing venous stasis. This review aims to investigate the evidence underlying the use of neuromuscular electrical stimulation in thromboprophylaxis.MethodsThe Medline and Embase databases were systematically searched, adhering to PRISMA guidelines, for articles relating to electrical stimulation and thromboprophylaxis. Articles were screened according to a priori inclusion and exclusion criteria.ResultsThe search strategy identified 10 randomised controlled trials, which were used in three separate meta-analyses: five trials compared neuromuscular electrical stimulation to control, favouring neuromuscular electrical stimulation (odds ratio of deep vein thrombosis 0.29, 95% confidence interval 0.13–0.65...
23 citations
TL;DR: Research has shown the efficiency of class II compression shorts in the treatment of patients with isolated extension of intrapelvic venous plexuses, and Class II compression stockings do not have any impact on the clinical manifestations of pelvic congestion syndrome.
Abstract: AimTo study the influence of compression treatment on clinical manifestations and venous hemodynamics of the pelvis in patients with pelvic congestion syndrome.Materials and methodsA prospective st...
TL;DR: Rheolytic thrombectomy with or without stenting is superior to anticoagulant therapy alone in terms of both ensuring venous patency and improving clinical symptoms.
Abstract: ObjectiveTo evaluate the clinical safety and effectiveness of percutaneous rheolytic thrombectomy in patients with acute lower extremity deep venous thrombosisMethodSixty-eight consecutive patients with acute massive lower extremity deep venous thrombosis were included in this retrospective study A percutaneous rheolytic thrombectomy device (Angiojet ® Rheolytic thrombectomy catheter, Boston Scientific, Marlborough, MA, USA) was used in all patients in an angiography suite through ipsilateral popliteal vein access Thrombus clearance and complications were evaluated Furthermore, patients underwent a clinical evaluation according to a modified Villalta scale for the investigation of post thrombotic syndrome in follow-up The Venous Clinical Severity Score, Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Sym questionnaires were completed preoperatively and readministered postoperativelyResultsOverall thrombus clearance (complete recanalization was achieved in 58 patients (852%)
TL;DR: There has been a considerable increase in leg ulcer referrals and although many ulcers are multi-factorial and the mainstay of treatment remains compression, there has been an increase in SVI endovenous intervention.
Abstract: Background Leg ulcers are a common cause of morbidity and disability and result in significant health and social care expenditure. The UK National Institute for Health and Care Excellence (NICE) Clinical Guideline (CG)168, published in July 2013, sought to improve care of patients with leg ulcers, recommending that patients with a break in the skin below the knee that had not healed within two weeks be referred to a specialist vascular service for diagnosis and management. Aim Determine the impact of CG168 on referrals to a leg ulcer service. Methods Patients referred with leg ulceration during an 18-month period prior to CG168 (January 2012-June 2013) and an 18-month period commencing six months after (January 2014-June 2015) publication of CG168 were compared. Results There was a two-fold increase in referrals (181 patients, 220 legs vs. 385 patients, 453 legs) but no change in mean age, gender or median-duration of ulcer at referral (16.6 vs. 16.2 weeks). Mean-time from referral to specialist appointment increased (4.8 vs. 6 weeks, p = 0.0001), as did legs with superficial venous insufficiency (SVI) (36% vs. 44%, p = 0.05). There was a trend towards more SVI endovenous interventions (32% vs. 39%, p = 0.271) with an increase in endothermal (2 vs. 32 legs, p = 0.001) but no change in sclerotherapy (24 vs. 51 legs) treatments. In both groups, 62% legs had compression. There was a reduction in legs treated conservatively with simple dressings (26% vs. 15%, p = 0.0006). Conclusions Since CG168, there has been a considerable increase in leg ulcer referrals. However, patients are still not referred until ulceration has been present for many months. Although many ulcers are multi-factorial and the mainstay of treatment remains compression, there has been an increase in SVI endovenous intervention. Further efforts are required to persuade community practitioners to refer patients earlier, to educate patients and encourage further investment in chronically underfunded leg ulcer services.
TL;DR: Although the overall quality of these studies was poor, results suggest that compression garments might lessen intravascular coagulation, improve symptoms and appearance, diminish oedema, and protect against minor trauma.
Abstract: Introduction Low-flow vascular malformations are congenital abnormalities of the veins, capillaries or lymphatic vessels or a combination of the previous. Compressive garments are frequently used as a first-line treatment option for low-flow vascular malformations of the extremities with the purpose of relieving symptoms. Yet, the benefits and harms of compression stockings remain unclear. Methods A systematic search was performed in MEDLINE, Embase, Cochrane Central Register of Controlled Trials including a hand search for studies measuring the benefits and harms of compression garments in treating low-flow vascular malformations. Two investigators performed study selection, quality assessment and data extraction independently. Results Of the 565 studies found, eventually five (totalling 101 patients with venous malformations or Klippel-Trenaunay syndrome receiving compression therapy) observational studies were included in the systematic review. Although the overall quality of these studies was poor, results suggest that compression garments might lessen intravascular coagulation, improve symptoms and appearance, diminish oedema, and protect against minor trauma. None of the studies quantified any harms of compression therapy. Conclusion Even though compression therapy is commonly used in the treatment of low-flow vascular malformations, available literature does not provide high-quality evidence to validate its use. We therefore advocate the need for prospective comparative trials with standardised outcome measures to study the benefits and harms of this treatment option.
TL;DR: The body weight transfer manoeuvre appears to be a better method of measuring the full potential of the calf muscle pump with a 40.1% relative increase in the ejection fraction compared to a tip toe manoeuvre.
Abstract: BackgroundThe tip toe manoeuvre has been promoted as the gold standard plethysmography test for measuring calf muscle pump function The aim was to compare the tip toe manoeuvre, dorsiflexion manoeuvre and a body weight transfer manoeuvre using the ejection fraction of air-plethysmography and evaluate which has the best pumping effectMethodsSixty-six archived tracings on 22 legs were retrieved from an air-plethysmography workshop and analysed Pumping performance was measured using the calf volume reduction after each manoeuvreResultsExpressed as median [inter-quartile range], body weight transfer manoeuvres resulted in a significantly greater ejection fraction (%) than tip toe manoeuvres at 597 [535–639] versus 426 [305–526], P < 00005 (Wilcoxon) There was no significant difference in the ejection fraction between the tip toe manoeuvre versus dorsiflexion manoeuvre, P = 0615 The repeatability (confidence interval: 95%) of 66 ejection fraction tests was excellent: tip toe manoeuvre (±12), dor
TL;DR: Early results are similar to what is described so far in the mechano-chemical ablation literature but recurrences are more than expected at one year, which is disappointing but tempered by the fact that the majority of patients were asymptomatic and required no reintervention.
Abstract: ObjectivesThis study assessed the effectiveness and patient experience of ClariVein for varicose veins and chronic venous insufficiency (CVI) in a multi-ethnic Asian population from Singapore.Metho...
TL;DR: Piezoresistive sensor may represent a viable alternative to PicoPress® in interface pressure measurement and was found to be more pronounced in the higher pressure range.
Abstract: ObjectiveInterface pressure, the sine qua non for compression therapy, is rarely measured in clinical practice and scientific research. The goal of this study aimed to compare and examine the accuracy between a commercially available piezoresistive sensor and PicoPress® (Microlab, Padua, Italy) using the cylinder cuff model to measure in-vitro interface pressure.MethodTen piezoresistive sensors were calibrated using the National Institute of Standard and Technology certified manometer, and compared to PicoPress® using cylinder cuff model from 20 to 120 mmHg. Two statistical analyses were performed: (a) two-sample t-test to compare the front to back surface of the piezoresistive sensors using mean pressure value and (b) one-sample paired t-test to compare the front and back surface of the piezoresistive sensors to PicoPress® and true pressure using mean pressure value.ResultThere was no difference in interface pressure measurement between the front and back surface of the piezoresistive sensors (P > 0.05)....
TL;DR: Cyanoacrylate adhesive embolization and sclerotherapy for the treatment of primary varicose veins is efficacious and can be performed as an outpatient procedure, but has a guarded safety profile due to its propensity to cause deep venous occlusion if not handled carefully.
Abstract: Various treatment methods are available for the treatment of varicose veins, and there has been a recent surge in the usage of cyanoacrylate glue for treating varicose veins.PurposeTo investigate the technical possibility, efficiency and safety of cyanoacrylate adhesive embolization and sclerotherapy using commonly available n-butyl cyanoacrylate glue for the treatment of primary varicose veins due to great saphenous vein reflux with or without incompetent perforators.Materials and MethodsOne hundred forty-five limbs of 124 patients with varicose veins due to great saphenous vein reflux were subjected to cyanoacrylate adhesive embolization and sclerotherapy – adhesive embolization of great saphenous vein in the thigh and perforators using cyanoacrylate followed by sclerotherapy of any residual varicose veins in the leg. Procedural success, venous closure rates and clinical improvement were assessed. Follow-up for 1, 3, 6, 9 and 12 months was obtained.ResultsTechnical success rate was 100%. Saphenous vein ...
TL;DR: It is suggested that pelvic vein reflux should probably be investigated and pelvic vein embolisation considered in patients with bilateral lower limb varicose veins, as well as lower limb venous insufficiency in some males with leg varicOSE veins.
Abstract: Objectives To report on a male cohort with pelvic vein reflux and associated primary and recurrent lower limb varicose veins. Methods Full lower limb duplex ultrasonography revealed significant pelvic contribution in eight males presenting with bilateral lower limb varicose veins. Testicular and internal iliac veins were examined with either one or a combination of computed tomography, magnetic resonance venography, testicular, transabdominal or transrectal duplex ultrasonography. Subsequently, all patients received pelvic vein embolisation, prior to leg varicose vein treatment. Results Pelvic vein reflux was found in 23 of the 32 truncal pelvic veins and these were treated by pelvic vein embolisation. Four patients have since completed their leg varicose vein treatment and four are undergoing leg varicose vein treatments currently. Conclusion Pelvic vein reflux contributes towards lower limb venous insufficiency in some males with leg varicose veins. Despite the challenges, we suggest that pelvic vein reflux should probably be investigated and pelvic vein embolisation considered in such patients.
TL;DR: Stenting through the femoral confluence into a single inflow vessel is a feasible bailout option if primary hybrid intervention fails with relative high patency rates and clinical improvement.
Abstract: BackgroundVenous stenting with an endophlebectomy and arteriovenous fistula can be performed in patients with extensive post-thrombotic changes. However, these hybrid procedures can induce restenosis, sometimes requiring stent extension, into a single inflow vessel. This study investigates the effectiveness of stenting into a single inflow vessel.MethodsAll evaluated patients had temporary balloon occlusion of the arteriovenous fistula to evaluate venous flow into the stents. When stent inflow was deemed insufficient, AVF closure was postponed and additional stenting was performed. Patency rates and clinical outcomes were evaluated.ResultsTwenty-four (38%) of 64 patients had additional stenting. The primary, assisted primary and secondary patency were 60 %, 70% and 70% respectively. Villalta score reduced by 6.1 points (p < 0.001), and venous clinical severity score by 2.7 points (p = 0.034).ConclusionStenting through the femoral confluence into a single inflow vessel is a feasible bailout option if prima...
TL;DR: Using a previously reported optimised, low power/slow pullback radiofrequency-induced thermotherapy protocol, it is possible to achieve a 100% ablation at one year, which compares favourably with results reported at oneyear post-procedure using the high power/fast pullback protocols that are currently recommended for this device.
Abstract: BackgroundIn previous in vitro and ex vivo studies, we have shown increased thermal spread can be achieved with radiofrequency-induced thermotherapy when using a low power and slower, discontinuous...
TL;DR: The present investigation points out the association among iliac-femoral vein tract incompetence and sapheno- femoral junction recurrences after high ligation, which is similar to that found in patients diagnosed with varicose veins recurrence despite many technical diagnostic and therapeutic refinements.
Abstract: BackgroundRecurrent varicose veins occur up to 80% of procedures. The sapheno-femoral junction can be involved in more than 50% of cases. A detailed pathophysiological explanation of the phenomenon...
TL;DR: It is suggested that incompetent great saphenous veins that need treatment can always be treated with endovenous laser ablation, and open surgery should never be recommended on vein diameter alone.
Abstract: AimsTo report on great saphenous vein diameter distribution of patients undergoing endovenous laser ablation for lower limb varicose veins and the ablation technique for large diameter veinsMethodsWe collected retrospective data of 1929 (943 left leg and 986 right leg) clinically incompetent great saphenous vein diameters treated with endovenous laser ablation over five years and six months The technical success of procedure, complications and occlusion rate at short-term follow-up are reported Upon compression, larger diameter veins may constrict asymmetrically rather than concentrically around the laser fibre (the ‘smile sign’), requiring multiple passes of the laser into each dilated segment to achieve complete ablationResultsOf 1929 great saphenous veins, 334 (1731%) had a diameter equal to or over 15 mm, which has been recommended as the upper limit for endovenous laser ablation by some clinicians All were successfully treated and occluded upon short-term follow-upConclusionWe suggest that inc
TL;DR: Recanalization of obstructed iliac veins and/or the inferior vena cava combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation is a safe and feasible treatment option in the post-thrombotic syndrome.
Abstract: IntroductionVenous recanalization of obstructed femoral and iliac veins is associated with good results regarding the feasibility and patency rate. If the common femoral vein with its inflow vessels is involved, open surgical desobliteration or endophlebectomy has been described as a crucial part of the intervention. However, when performing the hybrid procedure, a number of specific complications have been described. We present our results after venous recanalization including an endophlebectomy, focussing on wound complications and its impact on outcome.Material and methodsA retrospective analysis of prospective recorded data of all patients who underwent a hybrid procedure for chronic obstruction of iliofemoral veins between 2010 and 2015 was performed. The patients were treated by recanalization of the affected veins combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation. Data assessment focussed on complications and patency rates.ResultsThis study includes 96 ...
TL;DR: The VDI was significantly lower in the post-thrombotic obstructed patients with duplex evidence of groin collaterals versus controls with a cut-off point of 10.8mL/s, and improved significantly as a result of stenting.
Abstract: Ever since they were published in 1908 by the pathologist McMurrich, non-thrombotic iliac vein lesions (NIVLs) are increasingly recognised as a cause of venous obstruction. Treatment with a stent is successful in the majority of patients with relief of symptoms and improvement of skin changes. However, many patients have no clinical benefit despite the successful deployment of a stent of adequate calibre. Interestingly, iliac vein compression on computerised tomography (CT) of >50% occurs in 25% of the normal population. This casts doubt whether the finding is a true pathological entity or just an indentation of a collapsible tube by an overlying artery. Furthermore, intrinsic lesions occur often within a normal calibre lumen and may be revealed using intra-venous ultrasound, which is invasive. Valsalva manoeuvres add a dynamic component to these investigations and may help to evaluate a true obstructing lesion, in some cases. The limitations of imaging in assessing flow impairments are also apparent when there are several lesions, collaterals which may (or may not) be of haemodynamic benefit, and tortuosity. Furthermore, chronic venous insufficiency (CVI) is multi-factorial in haemodynamic pathophysiology. Since leg drainage, contrary to most other drainage systems is upward, the remaining four components of drainage insufficiency are: reflux encouraging downward flow, poor pump function of the heart and calf hampering upward flow, poor venous tone facilitating pooling, and physiological inactivity like prolonged standing or sitting promoting dependency. Correcting only the obstructive component of the insufficiency may have less impact if the other four components of insufficient drainage are not also corrected. Air-plethysmography (APG) is a non-invasive test which may quantify venous obstruction. The concept is simple. The air sensor-cuff wrapped around the calf records merely a change in calf volume. This is reported as a volume change in mL or a rate of volume reduction in mL/s. It is intuitive that when a dependent leg is elevated suddenly the veins collapse, the venous blood drains and the calf reduces in volume. The amount and rate of this reduction may be related to the degree of obstruction. It is noticeable in daily practice that rapid venous guttering on elevation of the leg is a feature of a healthy unobstructed leg. This was known by the observations of Trendelenburg using his elevation drainage manoeuvre. The function of APG is to support these clinical observations with a numerical value, termed the venous drainage index (VDI) in mL/s. In health, the drainage tracing is a straight line down at a constant rate. This can be likened to a falling column of fluid unimpeded by external forces, without a pressure– volume relationship and with zero resistance. In short, a ‘‘waterfall’’ drainage. The original paper describing the use of elevation drainage with APG on a tilt-table was published in 1964 by Allan. He noted that the volume of the leg decreased with elevation but the rate of this decrease was not quantified. His work was largely forgotten until recently with the introduction of the VDI as a measurement of obstruction. This technique has now been validated in three different ways. First, using a proximal thigh-cuff to simulate known obstruction pressures in healthy volunteers. In this study, the VDI decreased significantly with higher inflation pressures confirming its responsiveness to obstruction. Second, using rapid Trendelenburg tilting on a tilt-table. Here, the VDI was significantly lower in the post-thrombotic obstructed patients with duplex evidence of groin collaterals versus controls with a cut-off point of 10.8mL/s. Finally, in a small study comparing a heterogeneous group of NIVL patients before and after stent deployment. Here, the VDI improved significantly as a result of stenting.
TL;DR: It was showed that higher compression pressure leads to higher proportions of venous leg ulcers healed, independent of age and could be safely preferred in older patients.
Abstract: ObjectivesThe aim of the study is to compare proportions of venous leg ulcers healed in patients treated with two different sub-bandage pressure values in relation to age.MethodsThe study included 102 outpatients with venous leg ulcers, one group with moderate compression pressure of 35–40 mmHg and the second with high pressure >45 mmHg. Each group was divided into two subgroups according to the age (≥65 vs. <65 years). Computerized planimetry was used to measure the size of the ulcers at 6, 12, 18 and 24 weeks.ResultsKaplan–Maier analysis showed high pressure leads to higher proportion of healed venous leg ulcers, compared to moderate pressure, in patients aged ≥65 years (57.6% vs. 28%) and in patients <65 years (53.8% vs. 36%) (p < 0.05).ConclusionThe study showed that higher compression pressure leads to higher proportions of venous leg ulcers healed, independent of age and could be safely preferred in older patients.
TL;DR: Considerable consensus was reached within a group of experts but also some gaps in available research were highlighted.
Abstract: Objective To obtain consensus on management criteria for symptomatic patients with chronic venous disease (CVD; C2-C6) and superficial venous reflux. Method We used a Delphi method by means of 36 statements sent by email to experts in the field of phlebology across the world over the course of three rounds. The statements addressed criteria for different venous treatments in patients with different characteristics (e.g. extensive comorbidities, morbid obesity and peripheral arterial disease). If at least 70% of the ratings for a specific statement were between 6 and 9 (agreement) or between 1 and 3 (disagreement), experts' consensus was reached. Results Twenty-five experts were invited to participate, of whom 24 accepted and completed all three rounds. Consensus was reached in 25/32 statements (78%). However, several statements addressing UGFS, single phlebectomies, patients with extensive comorbidities and morbid obesity remained equivocal. Conclusion Considerable consensus was reached within a group of experts but also some gaps in available research were highlighted.
TL;DR: The procedures were at least equally efficient in treating patients with varicose vein disease in terms of quality of life assessment tools at 12 and 24 months compared to surgical ligation and vein stripping.
Abstract: Purpose Lower limb varicose veins have a significant effect upon the quality of life and a considerable socioeconomic impact despite their relatively benign nature. The aim of this study is to compare the effects of various therapeutic strategies among patients with varicose veins to surgical ligation and vein stripping on the basis of quality of life. Methods PubMed/Medline and Scopus databases were systemically searched from 1 January 2000 until 23 December 2015 for studies reporting outcome on the quality of life of different treatment techniques for varicose veins. We used Cohen's d to make the outcomes of the reported scales comparable. Heterogeneity was calculated with the use of the Q statistic and the I2. Results A total of 1047 participants were randomized across all analyzed trials. The number of participants in a single trial ranged from 30 to 308. The majority of participants in any trial were C2 on the CEAP scores. Overall, the quality of evidence was low. For the meta-analysis performed at 12 months postintervention (seven studies, n = 1047 patients) and after random effects meta-analyses due to high heterogeneity, no differences are observed between intervention and surgical ligation and vein stripping. The pooled estimate is -0.001 and the 95% confidence interval is -0.069 to 0.067 with a p = 0.98. In the case of the 24 months, postintervention analysis (six studies, n = 840 patients) the inference is almost identical. The effect of various interventional modes of treatment compared to surgical ligation and vein stripping is negligible in terms of clinical outcomes and quality of life so that surgical ligation and vein stripping versus the other interventional procedures were equally effective approaches to treat great saphenous vein incompetence in terms of quality of life measurements. Conclusion The procedures were at least equally efficient in treating patients with varicose vein disease in terms of quality of life assessment tools at 12 and 24 months compared to surgical ligation and vein stripping.
TL;DR: Abnormal embryologic development may cause variable pelvic venous anatomy and knowledge of this will enable interventional radiologists to successfully treat patients with pelvic vein embolisation, as well as provide therapeutic challenges.
Abstract: BackgroundPelvic venous reflux is often treated with pelvic vein embolisation; however, atypical pelvic venous anatomy may provide therapeutic challenges.MethodsWe retrospectively reviewed seven pa...
TL;DR: Evidence indicates that subjects at low to medium risk of VTE have a 0–2% risk of developing thrombosis associated with long-haul air travel; this increases to 5% for individuals at high risk, such as those with a history of DVT or hypercoagulable states including factor V Leiden mutation and obesity.
Abstract: Travel is a booming business thanks to globalisation, the rise of commercial aviation and significant reductions in fare prices. In 2015, 3.5 billion passengers were carried on scheduled flights, a 6.8% increase on the previous year. However, increased travel mobility is not entirely without risk. Venous thromboembolism (VTE), first linked to travel in the 1950s, is of particular concern. Growing public and media interest in this preventable and potentially fatal condition has prompted airlines, healthcare professionals and advisory bodies to offer advice on ‘traveller’s thrombosis’. The National Institute for Health and Care Excellence (NICE) advises compression stockings for all moderate or high-risk long-haul travellers, and consideration of low-molecular weight heparin (LMWH) in high-risk travellers. ‘General measures’ such as leg exercises and avoiding dehydration or excessive alcohol intake feature amongst advice given by patient websites and airline carriers. However, is this guidance evidence based? This is debatable. Several issues exist regarding VTE, travel and available evidence, raising questions including: ‘What travel-related factors determine an increased VTE risk?’, ‘Who is most likely to be affected by this risk?’ and ‘How should the risk be mitigated?’ At a more fundamental level, ‘How long is long-haul?’ Studies addressing these questions are heterogeneous and therefore difficult to compare and draw conclusions from. One area of consensus is that a travellers’ background VTE risk plays an important role in determining their travel-related risk. A 2008 international consensus statement grouped subjects into low, medium and high risk for traveller’s thrombosis; highrisk subjects included those with a personal history of VTE, malignant disease or recent major surgery. Evidence indicates that subjects at low to medium risk of VTE have a 0–2% risk of developing thrombosis associated with long-haul air travel; this increases to 5% for individuals at high risk, such as those with a history of DVT or hypercoagulable states including factor V Leiden mutation and obesity. Unfortunately, the inter-study consensus largely ends there. Studies employ various definitions of longhaul travel, ranging from journeys longer than 4 h to 7 h, up to 10–12 h. Furthermore, VTE assessment differs both in modality and timing. Two of the largest studies employed very different assessments. Researchers in the LONFLIT study performed systematic duplex ultrasound scanning (DUS) for all participants within 24 h of their flight. Conversely, the New Zealand Air Traveller’s Thrombosis Study considered subjects at risk for three months after travel and performed DUS only if they became D-dimer positive or symptomatic during this period. This may have led to an underestimation of DVT, as, although this assay is sensitive in suspected DVT, it may be less reliable in prediction of travel-related VTE. This is illustrated in the LONFLIT studies where there was no significant difference in the D-dimer level of those with ultrasound-detected VTE and those without. Lastly, many studies have significant dropout rates and insufficient subjects to accurately calculate risk. Due to the low incidence of DVT in the general population, studies require large numbers of travellers to confirm a significantly increased risk above controls. Evidence exists that VTE risk is not confined to air travel. Results from a large case-control study revealed a 2-fold increased VTE risk for all modes of travel including train, bus, car and plane, suggesting that immobility is an important contributing factor. However, in specific individuals, air travel increases VTE risk above simple immobility. One study compared participant’s blood results after an 8-h flight, an 8-h movie marathon and 8 h of normal activity. Markers of coagulation activation, specifically thrombin–antithrombin complexes, were raised in individuals after air travel but not in the other situations, particularly if using oral contraceptives or factor V Leiden mutation positive. This provides further evidence that specific patient risk factors convey an increased risk in travel.