Clinical Perspectives and Management of Edema in Chronic Venous Disease-What about Ruscus?

Background: Edema is highly prevalent in patients with cardiovascular disease and is associated with various underlying pathologic conditions, making it challenging for physicians to diagnose and manage. Methods: We report on presentations from a virtual symposium at the Annual Meeting of the European Venous Forum (25 June 2021), which examined edema classification within clinical practice, provided guidance on making differential diagnoses and reviewed evidence for the use of the treatment combination of Ruscus extract, hesperidin methyl chalcone and vitamin C. Results: The understanding of the pathophysiologic mechanisms underlying fluid build-up in chronic venous disease (CVD) is limited. Despite amendments to the classic Starling Principle, discrepancies exist between the theories proposed and real-world evidence. Given the varied disease presentations seen in edema patients, thorough clinical examinations are recommended in order to make a differential diagnosis. The recent CEAP classification update states that edema should be considered a sign of CVD. The combination of Ruscus extract, hesperidin methyl chalcone and vitamin C improves venous tone and lymph contractility and reduces macromolecule permeability and inflammation. Conclusions: Data from randomized controlled trials support guideline recommendations for the use of Ruscus extract, hesperidin methyl chalcone and vitamin C to relieve major CVD-related symptoms and edema.

The Effects of Below-Knee Medical Compression Stockings on Pulse Wave Velocity of Young Healthy Volunteers.

ABSTRACT: Szolnoky, G, Gavallér, H, Gönczy, A, Bihari, I, Kemény, L, Forster, T, and Nemes, A. The effects of below-knee medical compression stockings on pulse wave velocity of young healthy volunteers. J Strength Cond Res 35(1): 275-279, 2021-The effects of graduated medical compression stockings (MCS) on cardiovascular responses are poorly investigated. A simple study was undertaken to investigate whether the application of below-knee leg MCSs with different pressures could influence aortic pulse wave velocity (PWV) as the gold standard for aortic stiffness measurement evaluated by arteriography. Ten volunteers underwent PWV measurement at baseline, then in below-knee compression class (ccl) 1 (18-21 mm Hg), 2 (23-32 mm Hg) and 3 (34-46 mm Hg) MCSs in a consecutive manner. Baseline PWV (mean value: 7.86 ± 1.70 m·s-1) was significantly reduced by ccl 1 MCSs (mean value: 6.55 ± 0.88 m·s-1, p = 0.04). ccl 2 and ccl 3 stockings also notably decreased baseline PWV (mean values: 6.63 ± 0.65 m·s-1, p = 0.058 and 6.62 ± 1.00 m·s-1, p = 0.067; respectively). The application of low compression MCSs (ccl 1) leads to a significant decrease in PWV indicating a beneficial cardiovascular influence.

[A turning point in the invasive treatment of lower limb varicosity]. / Megújulás az alsó végtagi varicositas mutéti kezelésében.

During the 20th century, continuous development of classic varicose vein surgery was carried out. From the beginning of the 21st century, however, new endovascular interventions were introduced. Compared to classic surgery, their main benefit is that no incision and dissection is necessary. Only catheters are used to scar the saphenous stems, which are introduced via punctures. Before and during the intervention, ultrasound is used. Laser surgery is the most popular option, and its outcomes have improved a lot with the introduction of laser crossectomy. Radiofrequency surgery is another intervention which is widely performed. A further heat ablation method is the steam operation. One newer technique is the cyanoacrylate tissue adhesive operation. The well-known practice of sclerotherapy has developed by turning the liquid sclerosant into foam, and by causing mechanical damage to the intimal layer of the vein. The new methods have fewer complications because these avoid incisions and dissections during the interventions. Orv Hetil. 2018; 159(52): 2195-2201.

[Laser surgery on varicose veins]. / Visszérmutét lézerrel.

INTRODUCTION: With the development of medicine, technical inventions have been intoduced into the therapy of varicose veins, such as ultrasound examination and laser treatment. PATIENTS AND METHODS: Over 11 years 1729 laser surgery were performed on varicose veins. Junctions of saphenous veins, saphenous stems and perforator veins were treated with lasers, but reticular and spider veins were treated with other methods. The most important elements of laser surgery are the introduction of the laser fibre into the lumen of the vein and delivering the laser energy. All of this is performed without incisions under ultrasound guidance. Laser crossectomy is an innovation in our technique. This procedure is performed under a combination of local and intravenous anaesthesia. RESULTS: After 1 year 58% of operated legs (998) were checked (mean 3.3 years) and recurrent varicosity was found in 114 legs (11.4%). Recurrences were found mainly in those cases which would have been excluded from other studies, but in everyday practice they occur in a high percentage, such as being overweight, after delivery and previously operated cases. In selected cases, the recurrence rate is only 6.0%. Complications after laser surgery are less frequent than following classic varicose vein surgery. CONCLUSIONS: According to international guidelines and this study, endovascular interventions can be recommended instead of classic varicose vein surgery because they are less demanding, and cause fewer complications. Using laser crossectomy, the number of early recurrences decreases. All stem varicosities are suitable for laser surgery.

[5-year experience with varicose vein laser surgery]. / Lézeres visszérmutéttel szerzett ötéves tapasztalatok.

INTRODUCTION: The incidence of varicose veins in the lower limb is relatively frequent in Europe including Hungary. AIM: Authors report their 5-year experience in varicose vein laser surgery focusing with regards to recurrence and complication rates. PATIENTS AND METHODS: Surgery was performed on 647 lower limbs in 546 patients with an age between 17 and 80 years. They were overweight in 4.6 % of cases. The diameter of treated saphenous veins was between 4 and 31 mm. Indications for surgery were recurrence in 9.1% of cases and crural ulcer in 4.0% of cases. Laser fibre was introduced into the varicose saphenous stems and then 980 nm, later 1470 nm wavelength laser was delivered while the fibre was step-by-step pulled-out. Following the learning period laser energy was raised from a mean of 28 J/cm to 164 J/cm because of high recurrence rate. RESULTS: During the learning period the recurrence rate was 13.8% while it was 1.9% thereafter. Pulmonary embolism occurred in two cases, which could have been avoidable. Further minor complications were also noted. CONCLUSIONS: Varicose vein laser surgery can be recommended because the recurrence rate is very low, major complications can be avoided and minor complications are temporary.

Efficacy and tolerability of liposomal heparin spraygel as an add-on treatment in the management of superficial venous thrombosis.

Superficial venous thrombosis usually resolves spontaneously in a few weeks. In most cases, treatment includes peroral analgesics or nonsteroidal anti-inflammatory drugs accompanied by the recommendation to wear elastic stockings and perform regular mild ambulation. In contrast to this "standard treatment," a recent ACCP guideline has recommended that patients affected by spontaneous superficial thrombophlebitis be treated with intermediate doses of unfractionated or low-molecular-weight heparin. This study was designed to assess the efficacy of topically applied heparin spraygel in terms of reduction of local symptoms and signs of superficial venous thrombosis.

[Injection sclerotherapy for varicosities of the lower limb: 25 years of experience with 115000 injections]. / Az alsó végtagi varicositas injekciós sclerotherapiája: 25 év és 115000 injekció tapasztalata.

INTRODUCTION: The author began to deal with injection sclerotherapy 25 years ago, which is still being practised by him to this day. PATIENTS: Experience is drawn from 115 000 injections given to 4025 limbs of 3107 patients. The mean age is 41.7 years, 80.3% of patients were women. METHOD: For decades, medicines necessary for sclerotherapy (polidocanol, tetradecylsulphate) have been available in Hungary. At the same time diagnosis and method have developed both abroad and in Hungary. Instead of the previously used standard standing position, the patient is either sitting or lying during the puncture. The diameter of the needle used is smaller than earlier. Previously at the injection the patient was lying and her leg was raised, but now usually she is in the same position as during the puncture. The amount of given medicine at one session was 1 x 0.2 ml, later 4 and 6 x 0.5 ml, but now the allowed maximal dosage is 28 ml 0.5%. RESULTS: Treatments were successful in every case and there were not any serious complications. This method has an outstanding importance in the treatment of intracutaneous venectases and reticular varicosis but side branches and perforators can be cured as well. As is well known, varicosity is a progressive disease and the sclerotherapy can be repeated unrestricted. It is therefore suitable for its treatment in the long run. Strong reactions and complications: The most common strong reactions are fainting, suffusion, phlebitis and pigmentation at the site of the injection. COMPLICATIONS: Very rarely blistering, allergic reaction and deep venous thrombosis. The latter is highly focused, therefore the patient's thrombophilic history is revealed. The authors' results and the survey in Hungary showed 1.5% complication in treated patients including one non serious deep venous thrombosis. The recently introduced ultrasound-guided foam sclerotherapy of the leg is suitable for the injection of stem varicosities. Successful treatments were carried out not only in the lower leg but also in upper limb varicosities, vascular malformations, venous lake of the lip and hemorrhoidal nodes. The sclerotherapy and operation rather supplement each other than compete. CONCLUSION: Sclerotherapy has proved to be suitable for the therapy of lower limb varicosity and some other venous dilatations.

Laser-doppler examination shows high flow in some common telangiectasias of the lower limb.

BACKGROUND: The accepted pathophysiology of telangiectasias is reflux from superficial or deep veins. There are physical signs and scientific findings that do not fit this theory but support the possibility of arteriovenous (AV) shunt origin. OBJECTIVE: If there is a higher flow in spider veins than in the surrounding skin, it means that AV shunts participate in the circulation of the telangiectasia. On the other hand, slow flow indicates reflux as the etiologic factor. METHOD: Telangiectasias and the surrounding skin of 22 legs of 19 patients were examined with laser-Doppler equipment. RESULTS: The probe over the spider vein found a higher flow value (average 28.2 perfusion units [PU]) than in the surrounding skin (15.6 PU) in 13 limbs, but it was significantly higher only in 5 cases. In 9 limbs, the flow was slower. CONCLUSION: We interpret the higher flow values as a consequence of open AV shunts. This means that AV shunt pathophysiology was present in some of our cases.

Importance of subfascial collaterals in deep-vein malformations.

BACKGROUND: The removal of varicose veins in patients with absent or hypoplastic deep veins is contraindicated. OBJECTIVE: To determine a reliable examination for detection of the function of subfascial collaterals. METHODS: Five crural ulcer limbs with deep-vein aplasia and hypoplasia were operated on. In all cases, a segmental or total deep-vein aplasia (four cases) or hypoplasia (one case) was found in the affected limb by venography. Patients were selected for surgery using a new modification of the Perthes test. Radical varicectomy was performed in every case using stripper and open varicectomy. RESULTS: There was no circulatory complication during or after the operation. Crural ulcers healed. CONCLUSION: The agenesia or hypoplasia of a shorter or longer segment of deep veins is not a contraindication to radical varicectomy in every patient.