Factors associated with clinical severity in chronic venous disease: The role of functional parameters.

INTRODUCTION: Chronic venous disease (CVD) is a highly prevalent disease that presents a wide spectrum of clinical expressions due to abnormalities in the venous system. Patients often have major functional changes that can limit daily activities. However, the functional factors associated with the severity of the disease remain poorly understood. OBJECTIVE: To identify the functional factors associated with CVD severity. METHODS: Seventy-five patients with CVD (92.0% females, 49.6 ± 13.3 years) were evaluated through clinical examination, lower limb perimetry, ankle range of motion (AROM), and lower limb muscle strength by the Heel Rise test, and Sit-to-stand test. Patients were stratified according to the disease severity as mild (telangiectasia, varicose veins, or edema in the lower limbs) or severe CVD (trophic changes or venous ulcer). RESULTS: Patients with severe CVD (n = 13) were older (p = 0.002), predominantly male (p = 0.007), with reduced AROM in dorsiflexion (p = 0.028) and inversion (p = 0.009), reduced lower limb strength by the Heel Rise test (p = 0.040), and greater circumference of the calf (p = 0.020), ankle (p = 0.003), and plantar arch (p = 0.041) when compared to mild CVD (n = 62). Advanced age, male sex, lower ankle range of motion in dorsiflexion, and greater ankle and plantar arch circumferences were associated with CVD severity. However, the ankle circumference (OR 1.258, 95% CI: 1.008-1.570; p = 0.042), together with advanced age and male sex, was the only functional variable that remained independently associated with CVD severity. CONCLUSION: The increased ankle circumference was a determinant of the CVD severity and may assist in risk stratification and guide treatment goals in this population.

Superficial Venous Disease-An Updated Review.

BACKGROUND: This review article provides an updated review of a relatively common pathology with various manifestations. Superficial venous diseases (SVDs) are a broad spectrum of venous vascular disease that predominantly affects the body's lower extremities. The most serious manifestation of this disease includes varicose veins, chronic venous insufficiency, stasis dermatitis, venous ulcers, superficial venous thrombosis, reticular veins, and spider telangiectasias. METHODS: The anatomy, pathophysiology, and risk factors of SVD were discussed during this review. The risk factors for developing SVD were related to race, age, sex, lifestyle, and certain genetic conditions as well as comorbid deep vein thrombosis. Various classification systems were listed, focusing on the most common one-the revised Clinical-Etiology-Anatomy-Pathophysiology classification. The clinical features including history and physical examination findings elicited in SVD were outlined. RESULTS: Imaging modalities utilized in SVD were highlighted. Duplex ultrasound is the first line in evaluating SVD but magnetic resonance imaging and computed tomography venography, plethysmography, and conventional venography are feasible options in the event of an ambiguous venous duplex ultrasound study. Treatment options highlighted in this review ranged from conservative treatment with compression stockings, which could be primary or adjunctive to pharmacologic topical and systemic agents such as azelaic acid, diuretics, plant extracts, medical foods, nonsteroidal anti-inflammatory drugs, anticoagulants and skin substitutes for different stages of SVD. Interventional treatment modalities include thermal ablative techniques like radiofrequency ablationss, endovenous laser ablation, endovenous steam ablation, and endovenous microwave ablation as well as nonthermal strategies such as the Varithena (polidocanol microfoam) sclerotherapy, VenaSeal (cyanoacrylate) ablation, and Endovenous mechanochemical ablation. Surgical treatments are also available and include debridement, vein ligation, stripping, and skin grafting. CONCLUSIONS: SVDs are prevalent and have varied manifestations predominantly in the lower extremities. Several studies highlight the growing clinical and financial burden of these diseases. This review provides an update on the pathophysiology, classification, clinical features, and imaging findings as well as the conservative, pharmacological, and interventional treatment options indicated for different SVD pathologies. It aims to expedite the timely deployment of therapies geared toward reducing the significant morbidity associated with SVD especially varicose veins, venous ulcers, and venous insufficiency, to improve the quality of life of these patients and prevent complications.

The sonographic features of lymph node venous networks and flow patterns in patients with primary chronic venous disease.

BACKGROUND: Our study aims to enhance the understanding of lymph node venous networks (LNVNs) by summarising their anatomical, sonographic features, and reflux patterns. METHOD: We examined 241 legs from 141 patients with primary chronic venous disease (CVD) using duplex ultrasound. RESULTS: The findings indicated variations in the shape, size, vascularity, and echogenicity of LNVN. The superficial inguinal lymph node with reflux appeared slightly larger, exhibiting higher velocities in the hilar artery. Regarding connections, venous flow within LNVN was predominantly drained through the saphenofemoral junction (SFJ), anterior accessory great saphenous vein (AAGSV), and great saphenous vein (GSV). A significant number of LNVNs were observed to be associated with anterolateral thigh tributaries. The study also identified valve cusps within LNVN. CONCLUSION: This study revealed a 12% prevalence of primary LNVN. Understanding the anatomical and haemodynamic features of LNVN informs treatment strategies and potentially helps prevent the recurrence of varicose veins.

Risk factors for recanalization of truncal veins following endoluminal ablation.

BACKGROUND: Recanalization of target veins after treatment of superficial venous incompetence has clinical implications and may depend on the type of intervention. The aim of this study was to evaluate patient and procedural factors associated with truncal vein recanalization in a large study cohort using the Vascular Quality Initiative (VQI) Varicose Vein Registry. METHODS: We performed a retrospective review using the VQI Varicose Vein Registry from 2014 to 2018. We evaluated all procedures performed for truncal venous insufficiency. Demographic data and information about treatment modality were collected. Patients were separated into recanalization and nonrecanalization groups based on the status of the treated vein at follow-up ultrasound examination. The vein was only considered recanalized if the VQI noted complete recanalization of the target vein. Univariate and multivariate comparisons were performed as appropriate. RESULTS: A total of 10,604 procedures were performed in 7403 patients. The average age was 55.9 years and 70.3% of the patients were female. Patients with recanalization were more likely to have a history of phlebitis (P < .001) and had a higher mean body mass index (30.5 vs 32., kg/m2 ; P = .006) compared with those without recanalization. There was no difference in the use of compression therapy, anticoagulation, deep venous reflux, number of pregnancies, prior deep vein thrombosis, Venous Clinical Severity Score, and clinical-etiology-anatomy-pathophysiology between patients with and without recanalization. The number of truncal veins treated per procedure was higher in the recanalization group compared with the nonrecanalization group (2.36 vs 1.88; P = .001). After multivariate logistic regression, laser ablation was associated with higher rate of recanalization compared with radiofrequency ablation (P = .017). CONCLUSIONS: This study is the first to use VQI based data to describe risk factors for recanalization following treatment of truncal venous reflux. The use of laser ablation for truncal veins is associated with a higher risk for recanalization compared with radiofrequency ablation. Obesity, prior phlebitis, and number of veins treated were independently associated with increased rate of recanalization.

Factors associated with lack of clinical improvement after vein ablation in the vascular quality initiative.

BACKGROUND: Insurance companies have adopted variable and inconsistent approval criteria for chronic venous disease (CVD) treatment. Although vein ablation (VA) is accepted as the standard of care for venous ulcers, the treatment criteria for patients with milder forms of CVD remain controversial. This study aims to identify factors associated with a lack of clinical improvement (LCI) in patients with less severe CVD without ulceration undergoing VA to improve patient selection for treatment. METHODS: We performed a retrospective analysis of patients undergoing VA for CEAP C2 to C4 disease in the Vascular Quality Initiative varicose veins database from 2014 to 2023. Patients who required intervention in multiple veins, had undergone prior interventions, or presented with CEAP C5 to C6 disease were excluded. The difference (Δ) in venous clinical severity score (VCSS; VCSS before minus after the procedure) was used to categorize the patients. Patients with a ΔVCSS of ≤0 were defined as having LCI after VA, and patients with ≥1 point decrease in the VCSS after VA (ΔVCSS ≥1) as having some benefit from the procedure and, therefore, "clinical improvement." The characteristics of both groups were compared, and multivariable regression analysis was performed to identify factors independently associated with LCI. A second analysis was performed based on the VVSymQ instrument, which measures patient-reported outcomes using five specific symptoms (ie, heaviness, achiness, swelling, throbbing pain, and itching). Patients with LCI showed no improvement in any of the five symptoms, and those with clinical improvement had a decrease in severity of at least one symptom. RESULTS: A total of 3544 patients underwent initial treatment of CVD with a single VA. Of the 3544 patients, 2607 had VCSSs available before and after VA, and 420 (16.1%) had LCI based on the ΔVCSS. Patients with LCI were more likely to be significantly older and African American and have CEAP C2 disease compared with patients with clinical improvement. Patients with clinical improvement were more likely to have reported using compression stockings before treatment. The vein diameters were not different between the two groups. The incidence of complications was overall low, with minor differences between the two groups. However, the patients with LCI were significantly more likely to have symptoms after intervention than those with improvement. Patients with LCI were more likely to have technical failure, defined as vein recanalization. On multivariable regression, age (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00-1.02) and obesity (OR, 1.47; 95% CI, 1.09-2.00) were independently associated with LCI, as was treatment of less severe disease (CEAP C2; OR, 1.82; 95% CI, 1.30-2.56) compared with more advanced disease (C4). The lack of compression therapy before intervention was also associated with LCI (OR, 6.05; 95% CI, 4.30-8.56). The analysis based on the VVSymQ showed similar results. CONCLUSIONS: LCI after VA is associated with treating patients with a lower CEAP class (C2 vs C4) and a lack of compression therapy before intervention. Importantly, no significant association between vein size and clinical improvement was observed.

Ultrasound-assisted varicose vein surgery and endovenous laser ablation using 1470-nm laser for treatment of great saphenous vein incompetence has similar outcomes at 1 year in a single-center prospective randomized study.

BACKGROUND: Technical errors are the most common preventable cause of recurrence after high ligation and stripping procedures for the treatment of great saphenous vein incompetence. Ultrasound-assisted varicose vein surgery (UAVS) uses intraoperative ultrasound during high ligation and stripping to minimize such failures, although no data have been reported regarding its use during open surgery. The present study compared the short-term outcomes of UAVS and endovenous laser ablation (EVLA) with a 1470-nm laser. METHODS: The present prospective randomized study was conducted from January 2019 to December 2019. We compared 40 patients who had undergone UAVS under regional anesthesia with an equal number of patients who had undergone EVLA under tumescent anesthesia. Both groups received 1 week of standardized postoperative analgesia. The improvements in the pain score, venous clinical severity score, and recurrence at 6 months and 1 year were studied. RESULTS: No significant differences were found in either clinical or radiologic great saphenous vein recurrence after UAVS compared with EVLA at 1 year. The mean pain score at 8 hours after the procedure was higher in the UAVS group (3.7 ± 1.2 vs 2.9 ± 1.0; P = .03). At 1 week, the score was higher in the EVLA group (1.8 ± 0.7 vs 1.4 ± 0.5; P = .01). At 6 months, the venous clinical severity score had improved from 9.2 ± 3.7 to 2.4 ± 1.4 in the UAVS group and from 9.3 ± 3.2 to 2.1 ± 0.8 in the EVLA group (P = .64). At 1 year, the corresponding scores were 1.3 ± 0.7 and 1.4 ± 0.6 (P = .21). CONCLUSIONS: UAVS has high technical success, making it a suitable alternative to EVLA using a 1470-nm laser.

A multicenter randomized controlled trial of cyanoacrylate closure and surgical stripping for incompetent great saphenous veins.

OBJECTIVE: The treatment of varicose veins has shifted from conventional surgical stripping (SS) to minimally invasive endovenous modalities. Cyanoacrylate closure (CAC) with the VenaSeal system (Medtronic, Dublin, Ireland) has increased in popularity owing to its nonthermal and nontumescent technique. The purpose of the present study was to compare the clinical outcomes of CAC and SS for the treatment of incompetent great saphenous veins. METHODS: An open-label, multicenter, prospective, randomized controlled trial was conducted. The subjects were randomized to either the CAC or SS procedure. The primary endpoint of the present study was to evaluate complete closure of the target vein at 3 months. Target vein occlusion was assessed on the third day and 1, 3, 6, and 12 months postoperatively using duplex ultrasound. The pain and ecchymosis grades were also assessed. Additionally, the clinical outcomes, such as the venous clinical severity score and Aberdeen Varicose Vein Questionnaire score, were assessed. RESULTS: Three-month follow-up data were obtained for all 126 enrolled and randomized subjects (63 with CAC and 63 with SS). At 3 months, complete target vein closure was observed in both groups. The postoperative pain score was significantly better in the CAC group than in the SS group (0.3 ± 0.6 in the CAC group and 1.1 ± 1.5 in the SS group; P < .001). In addition, the mean ecchymosis grade was 0.3 ± 0.5 in the CAC group and 1.1 ± 1.1 in the SS group (P < .001). The venous clinical severity score and quality of life had improved equally in both groups. The adverse events after both procedures were mostly minor complications (9 events in CAC group and 20 events in SS group). Major complications occurred in one patient who had undergone the SS procedure. CONCLUSIONS: The CAC and SS procedures were both associated with complete occlusion of the target vein at 3 months. The postoperative pain and ecchymosis grades were significantly lower in the CAC group. Other differences between the two groups included the frequency and nature of the complications. The results showed that CAC has high success with few complications.

Endovenous microfoam ablation of below knee superficial truncal veins is safe and effective in patients with prior saphenous treatment across a wide range of CEAP classes.

OBJECTIVE: Patients requiring thermal or chemical ablation of below knee (BK) truncal veins often have their proximal saphenous veins treated initially and comprise a study population with multilevel, refractory chronic venous insufficiency. The study objective was to assess the outcomes after microfoam ablation of BK truncal and tributary veins in patients with a history of proximal great saphenous vein (GSV) ablation or stripping. METHODS: A retrospective review of a prospectively maintained database was performed. All the patients who had undergone endovenous chemical ablation with commercially manufactured polidocanol microfoam for symptomatic BK truncal vein reflux after a previous saphenous ablation or stripping were identified. The patients had undergone duplex ultrasound scanning 48 to 72 hours after the procedure; those who had not adhered to the recommended follow-up protocol were excluded. The demographic data, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, venous clinical severity score (VCSS), procedure details, adverse thrombotic events, and follow-up data were abstracted. RESULTS: Between April 2018 and April 2021, 201 limbs were treated for symptomatic superficial truncal vein reflux with microfoam ablation. Of the 201 limbs, 68 in 49 patients met the inclusion criteria for the present study. The veins treated included the BK GSV (n = 45) and small saphenous vein (n = 23). The median follow-up was 97 days (range, 33-457 days) for the entire cohort. Most patients (63%) had a preoperative CEAP classification of C4 to C6. The median preoperative VCSS was 12.5. All the limbs that had undergone microfoam ablation in this cohort had a previously treated proximal ipsilateral GSV, with either thermal ablation or stripping. The median postoperative VCSS after BK treatment decreased to 10 (P < .001). The closure rate at the last follow-up was 96%. The overall symptomatic relief was 78% at the last follow-up. The absolute ulcer healing rate during the study period was 64% (16 of 25 ulcers had healed). One patient had developed thrombus extension into the popliteal vein, which resolved with anticoagulation therapy. One asymptomatic patient had developed nonocclusive thrombus in a gastrocnemius vein after small saphenous vein ablation. Because she was asymptomatic, anticoagulation therapy was not prescribed. Postoperative pain, phlebitis, and swelling were reported in 12%, 12%, and 2% of patients, respectively, and all had resolved at the last follow-up visit. Three limbs treated with chronic oral anticoagulant agents had had recanalized truncal veins during the study period after initial closure. No pulmonary emboli or neurologic adverse events were reported. No symptoms of saphenous or sural nerve injury had occurred. CONCLUSIONS: Endovenous chemical ablation with commercially manufactured polidocanol microfoam of BK truncal veins is a safe and effective treatment for patients with severe, refractory chronic venous insufficiency and prior saphenous interventions. This technique results in excellent overall closure rates and symptomatic relief with low adverse venous thrombotic events, across a wide range of CEAP classes.

The presence of a pathologic perforator may be predictive of central venous pathology and multilevel disease in severe chronic venous insufficiency.

OBJECTIVES: The treatment of a refluxing perforator is indicated in the setting of severe chronic venous insufficiency, but there are limited data on the presence of multilevel disease in these patients. This study sought to evaluate whether the presence of a pathologic perforator is predictive of the presence of central venous pathology. METHODS: This study was a retrospective review of the institutional Vascular Quality Initiative database. Consecutive patient limbs were identified that underwent intervention of refluxing perforators. The patients who underwent imaging, including magnetic resonance imaging or computed tomography (group A), were compared with those who did not undergo imaging (group B). The treated limbs in group A were also compared with the contralateral limbs as an internal control. Anatomical findings on imaging were analyzed by two independent investigators. The primary outcome was the presence and degree of central venous stenosis as measured by an orthogonal diameter reduction of >50% by axial imaging. Secondary outcomes included demographic and clinical differences between the two groups, frequency of central venous intervention, and duration of ulcer healing. Standard statistical analysis was performed. RESULTS: Ninety-three patient limbs underwent treatment of a pathologic perforator, with 30 in group A and 63 in group B. The following demographic and clinical variables were higher in group A compared with group B: male sex, body mass index, deep venous thrombosis history, recent or active anticoagulation use, perforator diameter, Clinical Etiology Anatomy Pathophysiology class 4, 5, or 6, and Venous Clinical Severity Score. Radiographic analysis of group A revealed concordance of a treated pathologic perforator with an ipsilateral central venous stenosis in 53.3% of patients, and a higher frequency of common iliac vein stenosis (50% vs 21.4%, P = .024) and external iliac vein stenosis (20% vs 0%, P = .012) compared with the contralateral limbs. When separated by the left or right limb, the left limbs exhibited a greater degree of common iliac vein stenosis as compared with the contralateral limbs (50.7% ± 20.9% vs 16.3% ± 16.5%, P < .001) as well as a greater frequency of >50% common iliac vein stenosis (46.7% vs 13.3%, P = .046). The right limbs exhibited a greater frequency of >50% external iliac vein stenosis as compared with the contralateral limbs (33.3% vs 0%, P = .022). CONCLUSIONS: This study suggests that patients with severe chronic venous insufficiency who undergo treatment for a pathologic perforator may have additional ipsilateral central venous pathology, supporting the presence of multilevel disease. Additional axial imaging might unmask central venous pathology and provide another option for treatment.

Radiofrequency Ablation for Axial Reflux Associated with Foam Sclerotherapy for Varicosities in One-Step Approach: A Prospective Cohort Study Comprising Large Diameters Saphenous Veins.

OBJECTIVE: This study assessed the outcomes and impact on the quality of life following one-step outpatient radiofrequency ablation (RFA) and ultrasound guided foam sclerotherapy (USGFS) for large reflux with varicosities in the great saphenous vein (GSV). DESIGN: Prospective, single-centre, analytical cohort. MATERIALS AND METHODS: Thirty symptomatic patients having reflux in the GSV and varicosities (CEAP C3 to C6) were treated with RFA and USGFS simultaneously, in a single-step procedure, from March 2016 to December 2016. They were followed up at 1 week, 6 months, 1 and 3 years. Clinical outcomes, changes in the Quality of Life (QOL) questionnaires SF-36™, VCSS and AVVQ, evolutive vein occlusion rates were assessed by duplex ultrasound, and ulcer closure was checked. RESULTS: The sample was divided into two groups: (Group 1) GSV diameter ≥13.0 mm (median 19.0 [14-24]), 17 subjects, and (Group 2) GSV diameter ≤12.9 mm (median 10.3 [10-12]), 16 subjects. No major adverse event was observed, and the postoperative minor adverse event rates were similar between the two groups. A significant improvement was observed in VCSS and AVVQ from the preoperative levels to the sixth month and the third-year follow-up. Twelve of 13 ulcers had healed at 1 year and remained closed until 3 years. The entire sample had a significant increase in all short form 36 domains, except for mental health in the Group 2 (GSV ≥ 13.0 mm). Overall first week occlusion rate for the whole sample was 90.9% and 69.7% at the 3-year follow-up. No difference in occlusion rate was observed between the two groups at any time. CONCLUSION: Exclusively outpatient combined techniques were safe and feasible in this study with no major adverse events, despite the large diameters of the GSV or ulcer presence. Within 3 years, both diameter groups showed equivalent improvement in all QOL parameters, satisfactory axial occlusion, and maintained ulcer closure.

Imaging of Pelvic Venous Disorders (PeVD); Should Every Patient Get an MRI?

Pelvic venous disease (PeVD) is part of the broad differential diagnosis of chronic pelvic pain with a challenging diagnosis and clinical workup to identify those patients that are most likely to benefit from intervention. Ultrasound, MRI, CT, venography, and intravascular ultrasound can all provide information to aid in the diagnostic algorithm. The purpose of this article is to review imaging as a component of the outpatient workup of patients with chronic pelvic pain to guide appropriate understanding and use of imaging modalities to accurately identify patients suffering from PeVD. A favored approach is to begin with transabdominal sonography with selective use of MRI/MRV in specific patient populations.

Clinical Presentation and Evaluation of Pelvic Venous Disorders in Women.

The term pelvic venous disorders (PeVD) describes a group of related clinical entities with overlapping clinical presentations that were previously characterized by separate imprecise syndromic terminology. The clinical manifestations of PeVD may variously include chronic pelvic pain; pelvic origin extrapelvic lower extremity and genital varices; lower extremity pain and swelling; and left flank pain and hematuria. This manuscript focuses on the primary manifestations of PeVD in women - chronic pelvic pain and pelvic origin lower extremity and vulvar varices - and will review the underlying pathophysiology and related complicating factors (such as maladaptive pain responses) to explain the variety of clinical presentations.

Ovarian Vein Embolization: How and When Should It Be Done?

Pelvic Venous Disease (PeVD) is characterized by pelvic varicosities and chronic pelvic pain, defined as noncyclic pelvic pain that persists for more than 6 months. Pain and discomfort related to PeVD typically worsen with upright positioning and occur more frequently in multiparous and premenopausal women. The most common cause of PeVD is pelvic venous insufficiency (PVI) due to incompetent valves. Noninvasive imaging modalities such as ultrasound, computed tomography, or magnetic resonance imaging, and invasive catheter-based venography can help characterize varicosities and venous insufficiency, supporting the diagnosis of PeVD. In patients with PeVD, ovarian and/or internal iliac vein embolization demonstrate excellent technical and clinical success rates with relatively low complication rates and should be considered as standard management, in conjunction with medical therapy. Appropriate diagnostic work-up and patient selection are important prior to any intervention for achieving therapeutic success, as multiparous women have a higher success rate compared to patients with dyspareunia after embolization therapy. Post-procedure follow-up is critical for assessing symptom improvement and need for repeat intervention. However, further research is needed to identify additional predictors of successful outcomes after embolization therapy. This article aims to provide an overview of patient selection, interventional technique, challenges, and outcomes of ovarian vein embolization.

Patients with chronic venous insufficiency in the times of COVID-19 and the risk of thrombus formation - suggestions on conservative treatment of such patients based on the principles of pathophysiology.

The current limitations of surgical treatment, as well as restrictions on professional and sport activities related to COVID-19 pandemic require seeking therapeutic solutions for the vast population of patients with chronic venous insufficiency (CVI, chronic venous insufficiency). To understand the principles of pharmacotherapy of this disease, the authors used data related to epidemiology and pathophysiology of CVI. They provided the latest data on venoactive drugs and recommendations that should be followed and summarized the literature based on the EBM. The article should provide the answer to the question of how to deal with patients with varicose veins or, more broadly, chronic venous insufficiency during the pandemic.

Efficiency of Prophylactic Ablation of the Tributary Venous Pathways Draining Around the Saphenofemoral Junction to Decrease the Rate of Future Varicose Vein and Symptoms Occurence.

BACKGROUND: There are various other collaterals draining into the venous system around the saphenofemoral junction in addition to the great saphenous vein. We aimed to determine the efficiency of prophylactic ablation of tributary veins in long term varicose vein and symptom recurrence. METHODS: Two hundred and sixty-three consecutive patients whom underwent radiofrequency ablation therapy for the treatment of superficial venous reflux disease were investigated. There were 129 patients who received isolated great saphenous vein ablation (Group A) where as 134 patients underwent ablation of the other tributary veins in addition to the great saphenous vein (Group B) between June 2015 and January 2017. The tributary superficial veins; refluxing and/or not refluxing, draining into the saphenofemoral junction were selectively catheterized and ablated in Group B. Patients are followed at least 1 year after the procedures regulary and researched for recurrence of varciose veins and symptoms. RESULTS: Gender, mean age, body mass index, diameter of the great saphenous veins, small saphenous vein disease, and grade of deep venous insufficiency did not differ significantly between the two groups. The mean number of tributary veins were similar in both groups (n: 1.9 ± 0.4 in Group A vs. n: 1.8 ± 0.7 in Group B) which were detected preoperatively as well as during the procedure. The mean number of ablated tributary venous pathways could be 1.4 ± 0.6 in Group B. During the follow up period symptoms related with varicose veins recurred in 19 patients in Group A where as in 7 patients in Group B (P < 0.05). Three of these symptomatic patients in Group B were the ones in whom the tributary pathways could not be catheterized ablated where as 14 patients in Group A were diagnosed with newly refluxing tributary pathways. All the symptomatic patients in both groups were managed medically and/or with additional interventions. CONCLUSION: The absence of any fascial unsheathing and the parietal weakness are suggestive of a lower resistance of the tributary veins wall, so collapse and size of veins make it more complex to catheterization regarding to great saphenous vein. Ablation of the tributary superficial venous pathways during the treatment of great saphenous vein reflux disease decreased the rate of recurrence of superficial venous reflux disease and patients symtoms in our modest cohort.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders.

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology ("SVP") classification for PeVD, includes three domains-Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVPA,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

[Anatomy of foot perforator veins in surgery of varicose veins]. / Anatomiya perforantnykh ven stopy v khirurgii varikoznoi bolezni.

OBJECTIVE: To clarify the role of clinical anatomy of foot and ankle perforator veins (PV) in surgical treatment of varicose vein disease. MATERIAL AND METHODS: Anatomy of foot and ankle PV was assessed in 50 amputated lower extremities by anatomical dissection. RESULTS: There were 4-6 PVs at the medial surface of the foot. These veins connected medial marginal vein and vv. plantaris medialis (VPM). There were 2-3 PVs at the lateral surface of the foot. These veins connected lateral marginal vein and vv. plantaris lateralis (VPL). All PVs on the lateral surface of the foot constitute the neurovascular bundles. PVs flowing into vv. dorsalis pedis are localized on the medial surface of the medial marginal vein at the level of the ankle base. In most cases, we found an arterial branch nearby at the subfascial level. In anterior part of the plantar surface of the foot, we distinguished 4-5 small PVs (~1 mm) flowing into vv. digitales plantares through the commissural orifices of the aponeurosis. There were 6-9 vessels (~1 mm) along the fascial aponeurotic septa. These vessels connected superficial plantar venous network and plantar veins. Small arterial branch was found almost in all cases near these veins. Noteworthy is the area where the plantar veins lie on the quadratus plantae and are covered by a leaf of deep plantar fascia. This anatomy is similar to topography of posterior tibial veins. CONCLUSION: Foot perforator veins constitute the neurovascular bundles as a rule. Plantar vein topography and their relationship with PV confirm an existence of muscular-venous pump of the foot.

Venous leg symptoms, ecchymosis, and coldness in patients with peripheral varicose vein: A multicenter assessment and validation study (VEIN-VIOLET study).

OBJECTIVES: We aimed to evaluate peripheral varicose vein symptoms including ecchymosis and coldness by using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms (VEINES-QoL/Sym) questionnaire. METHODS: A total of 1120 patients were enrolled to the analysis after the exclusion of 199 patients who did not match the inclusion criteria. Patients were asked to answer the VEINES-Sym questionnaire and questions about ecchymosis and coldness. Scores of ecchymosis and coldness were calculated similar to VEINES-Sym questionnaire. Classifications of peripheral varicose vein were made according to the clinical part of clinical, etiological, anatomical, and pathophysiological classification system and patients with grade 2 or higher were considered as positive for peripheral varicose vein. RESULTS: Frequency of symptoms present in the VEINES-Sym instrument, ecchymosis and coldness were significantly higher in patients with peripheral varicose vein. Mean score of each symptom was significantly lower in peripheral varicose vein patients including scores of ecchymosis and coldness. Logistic regression analysis revealed that presence of hemorrhoids and all symptoms in VEINES-Sym questionnaire except restless leg were significantly and independently associated with peripheral varicose vein. Besides, ecchymosis (odds ratio: 2.04, 95% confidence interval: 1.34-3.08, p = 0.008) but not coldness was significantly and independently associated with peripheral varicose vein. There was also significant correlation of VEINES-Sym score with ecchymosis (r = 0.43, p < 0.001) and coldness (r = 0.47, p < 0.001). CONCLUSIONS: Venous leg symptoms present in VEINES-Sym questionnaire except restless legs, presence of hemorrhoids and ecchymosis are significantly and independently associated with peripheral varicose vein. Not only ecchymosis but also coldness has shown an independent association with total VEINES-Sym score.

Randomized clinical trial of radiofrequency-induced thermotherapy combined with transilluminated powered phlebectomy versus high ligation and stripping for the treatment of lower limb varicose veins.

OBJECTIVE: The objective of this study was to evaluate the efficacy and safety of radiofrequency-induced thermotherapy (RFiTT) combined with transilluminated powered phlebectomy (TIPP) in the treatment of lower limb varicose veins (VVs) in comparison with high ligation and stripping (HLS) combined with TIPP. METHODS: The patients with lower limb VVs were randomly assigned to RFiTT combined with TIPP or HLS combined with TIPP. The primary end point was total closure rate of the great saphenous vein at 12 months. Secondary end points included Venous Clinical Severity Score and 14-item Chronic Venous Insufficiency Questionnaire score changes at 12 months and perioperative complications. RESULTS: The total closure rate of the great saphenous vein at 12 months was slightly lower in the RFiTT group (90.9% [90/99]) than in the HLS group (97.0% [98/101]) but not statistically significant (χ2 = 0.068; P = .08). Operation time, intraoperative blood loss, duration in hospital, duration in bed, and resumption of activities were statistically significantly better with RFiTT than with HLS. There were no significant differences between the groups in deep venous thrombosis, phlebitis, hematomas, pain, and infection. However, skin pigmentation and paresthesia were statistically significantly better with RFiTT than with HLS. At 12 months, both groups showed similar improvement from baseline in Venous Clinical Severity Score (1.28 ± 0.57 in the RFiTT group vs 1.33 ± 0.61 in the HLS group) and 14-item Chronic Venous Insufficiency Questionnaire score (67.32 ± 1.29 in the RFiTT group vs 67.45 ± 1.32 in the HLS group); however, neither group was superior to the other. CONCLUSIONS: RFiTT combined with TIPP is an effective treatment method for lower limb VVs and had a more satisfactory clinical outcome in surgical data, skin pigmentation, and paresthesia than HLS at the 12-month follow-up.