The sex prevalence of lower limb varicose vein networks.

OBJECTIVE: To determine the sex prevalence of lower limb varicose networks fed by reflux of the great saphenous vein (GSV), anterior accessory saphenous vein (AASV) and small saphenous vein (SSV) singularly or in combinations. METHODS: We scanned by the means of the same Colour Doppler Sonography (CDS) protocol 3000 lower limbs in 1500 consecutive patients, affected by symptomatic chronic venous insufficiency (CVI) during the decade 2013-2023. Limbs with normal venous function, incomplete scans or affected by post thrombotic syndrome, pelvic reflux, venous malformation, phlebolymphedema and CEAP clinical class C5-C6 were excluded from the final analysis. RESULTS: Overall, 1072 patients, 252 (23.5%) males and 820 (76.5%) females (p<0.0001), matched for age (p=0.692), were included into the study for a total of 1956 limbs affected by primary CVI, clinical class C2-C4. The main finding was the significant prevalence of varicose networks fed by reflux of the AASV alone (OR 1.96, CI 1.26-3.06, p=0.001) or combined with GSV (OR 1.84, CI 1.34-2.52, p=0.0002) in females. On the other hand, GSV insufficiency alone was significantly prevalent in males (OR 0.54, CI 0.43-0.68, p<0.0001). Moreover, we considered the presence of competent terminal valve (TV+) at the level of the sapheno-femoral junction, which resulted more significantly present in female (OR 1.57, CI 1.12-2.19, p=0.0083); to the contrary incompetent terminal valve (TV-) was more common in males (OR 0.64, CI 0.46-0.89, p=0.0083). Finally, considering reflux in the AASV territory in presence of a TV+, a strong prevalence in females was detected (OR 2.28, CI 1.48-3.52, p=0.0002), while males developed reflux along the GSV when a concomitant TV- was present (OR 0.62, CI 0.41-0.94, p =0.0244). CONCLUSIONS: The analysis of the lower limb varicose networks highlights that reflux along the AASV alone, in presence of a competent terminal valve at the junction, or coupled with GSV insufficiency, is more prevalent in females. On the other hand, GSV resulted the main trunk feeding varicose veins in males, in particular when an incompetent terminal valve was detected. Our findings suggest that females could be more prone to develop the varicose vein with an ascending mechanism, whereas in males the descending one seems more common.

Comprehensive insights into lumbar epidural varicose veins: Three clinical cases and surgical strategies.

Lumbar epidural varicose veins (LEVs) present a challenging clinical scenario with limited literature. This series addresses the scarcity of comprehensive understanding, emphasizing the need for nuanced exploration. Varied prevalence estimates and clinical oversights underscore the urgency for a standardized approach to surgical interventions. We present three diverse clinical cases: (1) segmental varicose veins causing radicular pain, (2) local varicosities leading to lower paraparesis, and (3) widespread varicose veins with prolonged symptoms. Surgical tactics involved targeted coagulation, crossing of veins, and preservation of collateral blood flow. Advanced imaging techniques guided interventions. Tailoring interventions based on varicose vein subtype, preserving collateral flow, and adopting a staged postoperative approach contribute to successful outcomes. This series provides valuable insights into LEV management, emphasizing the significance of advanced imaging in diagnosis and surgical planning.

Tomographic three-dimensional ultrasound imaging improves spatial visualization and management of varicose veins.

Tomographic three-dimensional ultrasound using handsfree electromagnetic tracking is an important adjunct to traditional two-dimensional duplex ultrasound examination. This technique allows vascular surgeons to better orientate and visualize the often complex anatomy along the entire length of the target vein. This paper reports a novel technique in preoperative and postoperative acquisition of superficial incompetent veins, thereby providing a comprehensive three-dimensional orientation of different pathological patterns of incompetence.

Atypical Antiadrenergic Effect of Refralon as a Mechanism of High Antiarrhythmic Effectiveness.

We studied the effect of Refralon on the electrophysiological properties of the supraventricular myocardium against the background of adrenergic (epinephrine) influence in the zone of the pulmonary veins, the area where 50-90% of atrial arrhythmias is triggered. The experiments were carried out on isolated tissue preparations of Wistar rats. The multichannel microelectrode array technique was used to record action potentials simultaneously in the atrium and in the ostium and distal parts of the pulmonary veins. Epinephrine application (12-50 nM) led to depolarization of the resting potential and the conduction block in the distal part of the pulmonary veins. Refralon (30 µg/kg) restored the resting potential in the distal part of the pulmonary veins. Against the background of epinephrine, Refralon did not significantly change the duration of the action potential at 90% repolarization in comparison with control. At the same time, the comparison drug E-4031 against the background of epinephrine significantly increased the duration of action potential in the atrium and in the ostium of the pulmonary veins, and sotalol increased it only in the ostium. Neither E-4031, nor sotalol restored conduction in their distal part. Refralon has a biphasic effect under conditions of adrenergic stimulation: the fast component is responsible for stabilizing the resting potential in the pulmonary vein and reduces the dispersion of action potential duration in the atrium and pulmonary vein and is also quickly washed away, and the slow component is responsible for the increase of the action potential duration and is slowly washed away.

Diagnosis and Management of Pelvic Venous Disorders in Women.

Pelvic venous reflux and obstruction can lead to chronic pelvic pain and extra-pelvic varicosities. This paper will discuss the contemporary understanding of this pathophysiology and its clinical manifestations. It will review evidence-based clinical and imaging criteria of pelvic venous disorders, data supporting benefit from venous interventions, criticisms of the available data and highlight evidence research gaps that exist. Finally, it will argue that comparative outcomes research utilizing standardized patient selection for embolization and stenting, embolization treatment strategies that eliminate the pelvic varices (at least to start), and clinically relevant outcome measures are necessary to establish the benefit of vascular treatments.

Anatomical Variants of the Renal Veins and Their Relationship with Morphofunctional Alterations of the Kidney: A Systematic Review and Meta-Analysis of Prevalence.

Background: Variations in renal veins are quite common, and most people do not experience issues due to them. However, these variations are important for healthcare professionals, especially in surgical procedures and imaging studies, as precise knowledge of vascular anatomy is essential to avoid complications during medical interventions. The purpose of this study was to expose the frequency of anatomical variations in the renal vein (RV) and detail their relationship with the retroperitoneal and renal regions. Methods: A systematic search was conducted in the Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS databases from their inception until January 2024. Two authors independently carried out the search, study selection, and data extraction and assessed methodological quality using a quality assurance tool for anatomical studies (AQUA). Ultimately, consolidated prevalence was estimated using a random effects model. Results: In total, 91 studies meeting the eligibility criteria were identified. This study included 91 investigations with a total of 46,664 subjects; the meta-analysis encompassed 64 studies. The overall prevalence of multiple renal veins was 5%, with a confidence interval (CI) of 4% to 5%. The prevalence of the renal vein trajectory was 5%, with a CI of 4% to 5%. The prevalence of renal vein branching was 3%, with a CI of 0% to 6%. Lastly, the prevalence of unusual renal vein origin was 2%, with a CI of 1% to 4%. Conclusions: The analysis of these variants is crucial for both surgical clinical management and the treatment of patients with renal transplant and hemodialysis.

Pain after 1940 nm Laser for Unilateral Incompetence of the Great Saphenous Vein.

Background: To investigate postprocedural pain after using an endovenous 1940 nm laser for great saphenous vein incompetence. Methods: A total of 72 patients were treated for symptomatic unilateral great saphenous incompetence using a 1940 nm laser device. All patients were treated using a standardized procedure under local anesthesia and investigated for postprocedural pain for 4 weeks using a visual analog scale (VAS 0-10). Results: Moderate pain was reported. A total of 17 patients reported minor scale 1 after the first day. On average, pain regressed to minor 1 after day 6. No significant complications were observed. Conclusions: Our results support the atraumatic character of this higher wavelength laser. In terms of patient comfort, higher wave lengths such as 1940 nm should be preferred for endovenous laser ablation. Using a combination of wavelengths could be the future solution to providing both safe ablation and minimum postprocedural pain.

Stasis and Inflammation in Varicose Vein Development: An Interleukin-Mediated Process from Intima to Media.

INTRODUCTION: This study investigated the combination of venous stasis and inflammation in varicose vein development. METHODS: The study included patients with primary varicose veins operated using high ligation and stripping of greater saphenous vein. All of them showed reflux at sapheno-femoral junction on preoperative Doppler ultrasound. Mesenteric veins from early or advanced gastric cancer specimens were used as control group. Inflammatory mediators expressed in the venous wall were measured via immunohistochemistry and compared between the two groups. RESULTS: Thirty-five (59.3%) men and 24 women with a mean age of 52.8 years (range, 23-77 years) were included and 29 (49.2%) patients had edema or skin changes according to Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification and reporting standards for chronic venous disorders. The expression of interleukin 6 (IL-6) and transforming growth factor ß1 (TGF-ß1) in intima and those of IL-6 in media of greater saphenous veins increased, with statistically significant differences between the two groups (p < 0.001). IL-6 in media and TGF-ß1 levels in intima were independent predictors of varicose veins (adjusted odds ratios 74.62 and 66.69, respectively). CONCLUSION: Elevated venous pressure represented by reflux on Doppler ultrasound and increased expression of inflammatory cytokines including IL-6 in media and TGF-ß1 in intima are associated with the development of varicose veins.

Modified histological staining for the identification of arterial and venous segments of brain microvessels.

BACKGROUND: This study aimed to develop a modified histochemical staining technique to successfully identify arterial and venous segments of brain microvessels. NEW METHOD: Gelatin/red ink-alkaline phosphatase-oil red O (GIAO) staining was developed from the traditional gelatin-ink perfusion method. Oil red Chinese ink for brush writing and painting mixed with gelatin was used to label cerebral vascular lumens. Subsequently, alkaline phosphatase staining was used to label endothelial cells on the arterial segments of cerebral microvessels. Thereafter, the red ink color in vessel lumens was highlighted with oil red O staining. RESULTS: The arterial segments of the brain microvessels exhibited red lumens surrounded by dark blue walls, while the venous segments were bright red following GIAO staining. Meanwhile, the nerve fiber bundles were stained brownish-yellow, and the nuclei appeared light green under light microscope. After cerebral infarction, we used GIAO staining to determine angiogenesis features and detected notable vein proliferation inside the infarct core. Moreover, GIAO staining in conjunction with hematoxylin staining was performed to assess the infiltration of foamy macrophages. COMPARISON WITH EXISTING METHOD: Red Chinese ink enabled subsequent multiple color staining on brain section. Oil red O was introduced to improved the resolution and contrast between arterial and venous segments of microvessels. CONCLUSION: With excellent resolution, GIAO staining effectively distinguished arterial and venous segments of microvessels in both normal and ischemic brain tissue. GIAO staining, as described in the present study, will be useful for histological investigations of microvascular bed alterations in a variety of brain disorders.

Vitis vinifera seed extract versus micronized purified flavonoid fraction for patients with chronic venous disease: a randomized, non-inferiority trial.

BACKGROUND: Venoactive drugs (VADs) based on Vitis vinifera extract are widely used in Korea. However, studies on the clinical effects and head-to-head comparisons with other groups of VADs are limited. This trial aimed to evaluate whether Vitis vinifera seed extract was non-inferior to the micronized purified flavonoid fraction (MPFF) in relieving venous symptoms and improving quality of life in patients with chronic venous disease (CVD). METHODS: In this double-blind prospective randomized trial, patients from 13 hospitals, who were diagnosed with venous incompetence by duplex ultrasound and classified as clinical class 1, 2, or 3 in the Clinical, Etiological, Anatomical, and Pathophysiological classifications were enrolled. The primary outcome was the change in the Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-20) score at 8 weeks from baseline. Secondary outcomes included changes in the Aberdeen Varicose Vein Questionnaire (AVVQ), visual analog scale (VAS), and Venous Clinical Severity Score (VCSS) at 4- and 8 weeks from baseline. Moreover, the change in leg circumferences was measured at 8 weeks and compared to baseline. RESULTS: In total, 303 patients were enrolled and randomly assigned to receive either Vitis vinifera seed extract (n = 154) or MPFF (n = 149). The CIVIQ-20 scores at 8 weeks were significantly reduced compared to those at baseline in both groups. No significant inter-group difference in the change of CIVIQ-20 at 8 weeks from baseline was observed (-8.31 ± 14.63 vs. -10.35 ± 14.38, P = 0.29, 95% confidence interval [CI] -1.65 to 5.72). The lower limit of the 95% CI was within the predefined noninferiority margin of 6.9. Furthermore, the AVVQ, VAS, and VCSS scores significantly decreased at 4- and 8 weeks after randomization compared with baseline in both groups. No significant differences were observed in the reduction of each score between groups. The calf circumference measured at 8 weeks was significantly reduced compared to that at baseline in patients receiving Vitis vinifera seed extract. CONCLUSIONS: Vitis vinifera seed extract was non-inferior to MPFF in relieving venous symptoms and improving the quality of life in patients with CVD.

A Systematic Review of Anatomical Reflux Patterns in Primary Chronic Venous Disease.

OBJECTIVE: Patients with chronic venous disease can present with different underlying haemodynamic abnormalities affecting the deep, superficial and perforator veins. This review explores the relationship between reflux patterns, extent of venous reflux and clinical manifestations of chronic venous disease. METHODS: The Medline and EMBASE databases were systematically searched from 1946 to 1st April 2024. References of shortlisted papers were searched for relevant articles. Studies were included if they were in English language, included participants ≥16 years of age, documented reflux patterns in ≥2 of the following: deep, superficial and/or perforator systems, and related patterns to presentation or severity. Exclusion criteria included patients with isolated deep venous thrombosis, post-thrombotic syndrome or stenotic or obstructive disease. RESULTS: 18 studies were identified (11,177 participants, range 55 to 3016). Meta-analysis showed significant odds ratios (OR) for C4-6 disease being associated with deep reflux (OR 2.41, 95% confidence interval (CI) 1.53-3.78) and perforator reflux (OR 3.37, 95% CI 2.16-5.27), but not superficial reflux (OR 2.11, 95% CI 0.87-5.14), versus C0-3 disease. Severe chronic venous disease (C4-6) was significantly associated with isolated deep, combined deep/superficial and combined superficial/perforator reflux. The highest risk of CVD progression (defined as de novo development of varicose veins and progression to greater CVD severity) was shown by two studies to be related to combined deep/superficial reflux. CONCLUSIONS: While limited by the heterogenous nature of the studies, this review confirms that reflux pattern is a significant predictor of clinical class, and higher CEAP stages are associated with higher prevalence of superficial, deep and perforator reflux. Isolated deep and combined reflux also appear to predict the onset of leg ulceration. Future studies should relate reflux patterns to treatment outcomes, including recurrence risk. This could help inform health policies and management guidelines so that reflux patterns, in conjunction with other demographic and haemodynamic parameters, could be used to risk stratify patients and identify individuals that may benefit from earlier treatment.

Treatment of varicose veins using the Cryo laser after foam technique.

Sclerotherapy is the treatment of choice for telangiectasias and reticular veins. The most common side effects of this procedure are hyperpigmentation and matting, which are feared owing to their aesthetic damage and difficulty of treatment. Combined treatments with laser and hypertonic glucose sclerotherapy have been described with excellent results, but limited to treatment of veins of ≤2 mm in diameter. Cryo laser after foam sclerotherapy is a procedure to treat reticular veins in the lower extremities that utilizes first foam sclerotherapy with polidocanol than immediately followed by transdermal Nd:YAG 1064 laser treatment and we can treat veins ≤5 mm. This report presents a successful case of varicose vein treatment using combined transdermal laser and sclerotherapy with foam sclerotherapy with polidocanol to treat veins >2.5 mm in diameter.

Epicardium and Coronary Vessels.

Congenital anomalies and acquired diseases of the coronary blood vessels are of great clinical relevance. The early diagnosis of these conditions remains, however, challenging. In order to improve our knowledge of these ailments, progress has to be achieved in the research of the molecular and cellular mechanisms that control development of the coronary vascular bed. The aim of this chapter is to provide a succint account of the key elements of coronary blood vessel development, especially in the context of the role played by the epicardium and epicardial cellular derivatives. We will discuss the importance of the epicardium in coronary blood vessel morphogenesis, from the contribution of the epicardially derived mesenchyme to these blood vessels to its role as an instructive signaling center, attempting to relate these concepts to the origin of coronary disease.

Clinical Presentation and Therapy of Total Anomalous Pulmonary Venous Return.

Total anomalous pulmonary venous return (TAPVR) is rare (accounting for about 1% of all CHD) and can occur as a single lesion or in combination with other types of CHD (such as heterotaxy or HLHS). TAPVR is defined as an abnormal connection where all pulmonary veins do not drain into the left atrium but into the right atrium either directly or through a vein that is connected to the right atrium. TAPVR can be divided into four anatomic groups (Fig. 32.1): (1) supracardiac (about 55%), (2) cardiac (about 30%), (3) infracardiac (about 13%), and (4) mixed (very rare). In addition, it can be divided into two physiological types: nonobstructed and obstructed. Embryologically, all pulmonary veins usually connect to a pulmonary venous confluence that connects to the left atrium. If this connection does not occur, the pulmonary venous confluence connects to a systemic vein instead.

Treatment of varicose great saphenous vein with endovenous laser alone or combined with eco-guided foam sclerotherapy: A randomized controlled trial.

Objectives: This study compares Endovenous Laser Ablation (EVLA) alone versus combined with ultrasound-guided foam sclerotherapy (UGFS) for Great Saphenous Vein (GSV) insufficiency. Methods: Sixty patients were randomly allocated to EVLA or EVLA-UGFS groups which focused on GSV occlusion rates, complications, additional treatments, and quality of life (QoL) changes. Results: Among 55 participants, the EVLA group had higher 12-month occlusion rates (92.3% vs. 75.8%, p = 0.11). Nervous injury (NI) was rarer in EVLA-UGFS (3.4% vs. 23.1%, p = 0.04). No significant difference in other complication rates (p > 0.05). QoL improved in both groups (p < 0.001). EVLA-UGFS required more subsequent procedures (24.1% vs. 7.7%, p = 0.03). Conclusions: EVLA and EVLA-UGFS effectively treat GSV insufficiency, enhancing QoL. The combined method reduces NI risk but may require more follow-up procedures.

Pulmonary Vein Morphology in Patients Undergoing Catheter Ablation of Atrial Fibrillation.

PURPOSE: Variations in the anatomy of pulmonary veins can influence selection of approaches of atrial fibrillation catheter ablation. Therefore, preprocedural evaluation and knowledge of pulmonary veins anatomy is crucial for proper mapping and the successful ablation of atrial fibrillation. The aim of this observational study was to assess CT angiography scans and perform detailed analysis of pulmonary veins morphology in patients scheduled for catheter ablation of atrial fibrillation. METHODS: CT angiography was performed in 771 individuals (223 females, 548 males, mean age 58.4 ± 10.7 years). Pulmonary veins anatomy was evaluated using 3D models. The patterns used for evaluation included typical anatomy with four separate pulmonary veins, a common left ostium, and various types of accessory veins either alone or in combination with common left ostia. RESULTS: An anatomical variant with common left ostium was observed as the most prevalent anatomy (44%). The typical variant was observed in 34.8% of patients. Accessory pulmonary veins were observed predominantly on the right side. The prevalence of anatomical variants did not differ between sexes with the exception of the unclassifiable category U (4.4% vs. 9%, p < 0.05). CONCLUSIONS: Our study shows that a considerable number of atypical anatomies is present in patients undergoing AF catheter ablation. This knowledge may influence the choice of instrumentation. The data could be possibly helpful also in development of new ablation techniques.

Systemic venous anomalies in a child with a vein of Galen.

We describe our findings in a child with a vein of Galen malformation, in whom the right superior caval and the azygos veins drained into the roof of the morphologically left atrium. A persistent left superior caval vein drained into the morphologically right atrium through the coronary sinus. The additional presence of dual brachiocephalic veins permitted the deployment of a multifunctional ventricular septal defect occluder device to occlude the right superior caval vein, correcting the right-to-left shunt. This also prevented azygos venous drainage into the left atrium.

Suprastin (Chloropyramine) Causes Proarrhythmic Deterioration of Excitation Conduction, Depolarization and Potentiates Adrenergic Automaticity in the Pulmonary Veins Myocardium.

A number of pharmacological drugs have side effects that contribute to the occurrence of atrial fibrillation, the most common type of cardiac rhythm disorders. The clinical use of antihistamines is widespread; however, information regarding their anti- and/or proarrhythmic effects is contradictory. In this work, we studied the effects and mechanisms of the potential proarrhythmic action of the first-generation antihistamine chloropyramine (Suprastin) in the atrial myocardium and pulmonary vein (PV) myocardial tissue. In PV, chloropyramine caused depolarization of the resting potential and led to reduction of excitation wave conduction. These effects are likely due to suppression of the inward rectifier potassium current (IK1). In presence of epinephrine, chloropyramine induced spontaneous automaticity in the PV and could not be suppressed by atrial pacing. Chloropyramine change functional characteristics of PV and contribute to occurrence of atrial fibrillation. It should be noted that chloropyramine does not provoke atrial tachyarrhythmias, but create conditions for their occurrence during physical exercise and sympathetic stimulation.

Key Regulators of Angiogenesis and Inflammation Are Dysregulated in Patients with Varicose Veins.

Varicose veins (VVs) are the most common manifestation of chronic venous disease (CVD) and appear as abnormally enlarged and tortuous superficial veins. VVs result from functional abnormalities in the venous circulation of the lower extremities, such as venous hypertension, venous valve incompetence, and venous reflux. Previous studies indicate that enhanced angiogenesis and inflammation contribute to the progression and onset of VVs; however, dysregulations in signaling pathways associated with these processes in VVs patients are poorly understood. Therefore, in our study, we aimed to identify key regulators of angiogenesis and inflammation that are dysregulated in patients with VVs. Expression levels of 18 genes were analyzed in peripheral blood mononuclear cells (PBMC) using real-time PCR, as well as plasma levels of 6 proteins were investigated using ELISA. Higher levels of CCL5, PDGFA, VEGFC, TGF-alpha, TGF-beta 1, and VEGF-A, as well as lower levels of VEGFB and VEGF-C, were found to be statistically significant in the VV group compared to the control subjects without VVs. None of the analyzed factors was associated with the venous localization of the varicosities. The presented study identified dysregulations in key angiogenesis- and inflammation-related factors in PBMC and plasma from VVs patients, providing new insight into molecular mechanisms that could contribute to the development of VVs and point out promising candidates for circulatory biomarkers of this disease.

Deep vein thrombosis after sclerotherapy and endovenous laser ablation of varicose veins - an observational study.

Background: The risk of developing deep vein thrombosis (DVT) after endovenous ablation of varicose veins varies in the literature. Little is known about the characteristics of this complication and associated factors. This study aimed: 1) to study the occurrence of DVT after ultrasound-guided foam sclerotherapy (UGFS) alone or combined with endovenous laser ablation (EVLA) for lower-limb varicose veins; 2) to identify factors associated with DVT. Patients and methods: The study included all outpatients aged 18 years or older who underwent UGFS and EVLA or UGFS alone at the University Hospital of Zurich between 2011 and 2015. Data were extracted from the hospital electronic medical record. Patients were surveyed about their level of pain after the procedure and their level of satisfaction with the procedure. Duplex ultrasound was used to assess the deep venous system 7-10 days and 6-8 months after the procedure. Regression analysis was used to examine the association of patient and procedure characteristics with the development of DVT. Results: A total of 334 patients (561 procedures performed in 393 different sessions) were included: 73% of the patients underwent combined UGFS and EVLA and 27% underwent UGFS alone. DVT occurred in 24 (7.2%) patients, of whom 88% underwent combined procedures and 17% underwent interventions involving both the great and small saphenous veins on the same session. DVT occurred in 8.2% of patients receiving thromboprophylaxis and in 9.5% of patients not receiving thromboprophylaxis. DVT occurred in 5.2% of women and 11.9% of men. No factors associated with a diagnosis of DVT after intervention were identified. Pain and satisfaction levels did not differ between patients with and without DVT. Conclusions: This study adds to the knowledge of the risk of DVT following UGFS alone or combined with EVLA. Further studies are needed to revise thromboprophylaxis.