Occlusion of the Great and Small Saphenous Vein Using Copolymeric Glue Based on N-Butyl Cyanoacrylate and Methacryloxy Sulfolane.

We present the preliminary results of a longitudinal observational study aimed at evaluating the effectiveness and safety at different short- and long-term follow-ups of vascular occlusion of the great saphenous vein (GSV) and small saphenous vein (SSV) affected by severe pathological reflux, using an innovative modified cyanoacrylate surgical glue composed of N-butyl cyanoacrylate and methacryloxy sulfolane (NBCA+MS). Ninety patients, prospectively recruited for 1 year, underwent the study with EcoColor-Doppler (ECD) to evaluate the maximum diameters of the GSV and SSV in the orthostatic position and the reflux time (RT). An RT greater than 0.5 s was considered pathologic. Clinical, etiology, anatomy, and pathophysiology (CEAP) assessment was used for the complete evaluation of each patient in the study. All the patients were treated by NBCA+MS glue to obtain vein occlusion and observed before treatment (baseline; T0), within 6 h after treatment (T1), 1 month after treatment (T2), 3 months after treatment (T3), 6 months after treatment (T4), and 1 year after treatment (T5). Chi-square (χ) analysis was performed to evaluate the effectiveness and safety of the treatment. All the patients participated in the entire duration of the study. Complete occlusion was maintained in 100% of patients at T1, 98.9% at T2 and T3, and 97.8% at T4 and T5 (p < 0.001). None of the patients suffered from post-surgical thrombosis. No blue hyperpigmentation, or paresthesia was observed during the entire observation period. Immediately after treatment, 7.7% of patients needed painkillers; 1 week after treatment, 100% of patients returned to normal life. Vascular occlusion of the great or small saphenous vein using NBCA+MS glue is a safe procedure with persistent benefits after a 1 year follow-up. This procedure can be performed with local anesthesia, allowing a quick return to normal life. Thanks to its low invasiveness, the treatment is not painful.

Complete Resection of Pancreatoblastoma With Portal Vein Obstruction After High-dose Chemotherapy: A Case Report.

BACKGROUND: As no standard chemotherapy exists for pancreatoblastoma (PB), surgical resection is the most effective way of achieving complete remission. CASE REPORT: A 3-year-old girl with PB causing portal vein obstruction was referred to our hospital. Because of the portal vein involvement, she initially received 5 cycles of preoperative chemotherapy after biopsy, consisting of cyclophosphamide, vincristine, pirarubicin, and cisplatin. After chemotherapy, she underwent distal pancreatectomy, and the tumor was resected completely. She has been disease free for 4 years since the operation. CONCLUSIONS: Even in cases of advanced PB, complete surgical resection with appropriate chemotherapy can lead to complete remission.

Testing a fall risk model for injection drug users.

BACKGROUND: Fall risk is a critical component of clinical assessment and has not been examined for persons who have injected illicit drugs and are aging. OBJECTIVES: The aim of this study was to test and develop the Fall Risk Model for Injection Drug Users by examining the relationships among injection drug use, chronic venous insufficiency, lower extremity impairments (i.e., decreased ankle range of motion, reduced calf muscle endurance, and leg pain), age and other covariates, and the Tinetti balance and gait total score as a measure of fall risk. METHODS: A cross-sectional comparative design was used with four crossed factors. Standardized instruments were used to assess the variables. Moderated multiple regression with linear and quadratic trends in age was used to examine the nature of the relationship between the Tinetti balance and gait total and age and the potential moderating role of injection drug use. A prespecified series of models was tested. RESULTS: Participants (n = 713) were men (46.9%) and women with a mean age of 46.26 years and primarily African American (61.7%) in methadone treatment centers. The fall risk of a 48-year-old leg injector was comparable with the fall risk of a 69-year-old who had not injected drugs. Variables were added to the model sequentially, resulting in some lost significance of some when they were explained by subsequent variables. Final significant variables in the model were employment status, number of comorbidities, ankle range of motion, leg pain, and calf muscle endurance. DISCUSSION: Fall risk was associated with route of drug use. Lower extremity impairments accounted for the effects of injection drug use and chronic venous insufficiency on risk for falls. Further understanding of fall risk in injection users is necessary as they age, attempt to work, and participate in activities.

[The effect of oral contraceptives on the orthostatic diameter of lower limb major veins and its correction].

UNLABELLED: The study assessed the effect of combined oral contraceptives (COCs) on the lower limb major vein diameter during orthostasis and the possibility of its medical correction in 214 women aged 17-42 with chronic venous insufficiency (CVI), including 37 women with CEAP class C0, 76 - with class C1 and 101 - with class C2. Venous diameter was measured by duplex scanning; its increment between evening and morning measurements was calculated in 3 groups. In the first group (n=68) venous diameter was measured before COC indication and after 2 months of COC use. In this group the second assessment revealed significant increase in venous diameter among women with CVI classes C1 and C1. The second group (n=69) received COCs for at least 6 months; then COC was withdrawn and Flebodia 600 was indicated. In this group venous scanning was fulfilled during COC use and after 2 months of its withdrawal and Flebodia 600 indication. Statistically significant decrease of orthostatic venous diameter was demonstrated for all scanned veins, evidencing diosmine-induced enhanced venous tone. The third group (n=77) did not interrupted COC intake and received Flebodia 600 concurrently. In this group venous measurements were fulfilled before and after 2 months of Flebodia 600 intake. Significant, though not ubiquitous decrease of venous diameter was registered in this group. CONCLUSION: Phlebopathic effect of COCs was demonstrated in women with CVI, CEAP classes 0-1-2, as well as safety and efficiency of Flebodia 600. The results prove the feasibility of Flebodia 600 indication for this population in case of COC intake.

[Phlebopathies: aetiology and therapeutic management].

Phlebopathy is an ambiguously interpreted term. In the Russian literature, it implies functional disorders of the venous system, albeit not seriously jeopardizing, however substantially decreasing quality of life. Phlebopathies may be induced by different causes, not infrequently common with the risk factors of chronic venous insufficiency. The present work deals with the classification, pathogenesis and epidemiology of phlebopathies, as well as the results of the original studies on management of hormone-induces phlebopathy. Hormone-induced phlebopathy - symptoms of phlebopathy or chronic venous insufficiency induced by long-term intake of combined oral contraceptives (COCs). To optimize treatment of the pathology concerned, we examined three groups of female patients (112 women) suffering from hormone-induced phlebopathy of the lower limbs. In Group One patients, COCs were discontinued with no administration of venotonic agents. Group Two patients along with withdrawal of COCs were given Antistax, as well as elastic compression. Group Three patients continued receiving COCs accompanied by simultaneous treatment with Antistax. During the study, we determined the malleolar volume, also assessing the degree of subjective symptoms, and quality of life. It was shown that withdrawal of COCs alone was not sufficient to stop symptoms of phlebopathy. Antistax efficiently stops the majority of these clinical manifestations, even on the background of intake of contraceptives. The maximal effect was observed in discontinuation of the COCs, intake of Antistax and prescription of elastic compression.

[Heavy legs, venous insufficiency of the legs and hormone substitution therapy]. / Jambes lourdes, insuffisance veineuse des membres inférieurs et hormonothérapie substitutive.

The effects of estrogens and gestagens on veins and circulation have been studied since prescription of these hormones as oral contraception and description of related thromboembolic events. The identification of different receptors and the description of these receptors in venous walls have helped to understand some hormonal effects. However, the actual knowledge remains insufficient to explain the complexity of the actions of hormones on venous function. The distribution, the density and the receptor types vary with age, gender, hormonal status and vascular bed. Gestagens mainly reduce the tone of venous walls, whereas estrogens have various effects. Between 25% and 50% of European adults and even 80% or more in some risk groups complain about heavy legs, with or without chronic venous insufficiency. The number of women to whom hormonal substitution is or could be prescribed increases along with aging of populations and the better understanding of potential benefits. The need for a better understanding of vascular effects of sexual hormones is growing, since the incidence of chronic venous insufficiency of the legs increases with age. The life prognosis will not be affected by a deterioration of a chronic venous insufficiency. In contrast, the quality of life, morbidity and the cost of treatment will be expected to change. In addition, thromboembolic events have to be considered, as has been shown in recent studies. These findings outline the need for further studies on the relation between hormones and venous function and for some caution when prescribing hormonal substitution.

Ergotism and vascular insufficiency: a case report and review of literature.

We report a case of ergot-induced peripheral vascular insufficiency of the lower limbs and review the vascular complications, angiographic findings and the different modalities of treatment. The following case report highlights the clinical features and course of ergot toxicity, and the difficulty in early diagnosis.

Effects of progestogens on haemostasis.

Epidemiological data suggested an involvement of the progestogen component in the pathomechanism of venous and arterial diseases during intake of oral contraceptives. The influence of progestogens on haemostasis parameters depend on type and dose of the progestogen, the presence of an estrogen, the route of application, and the duration of use. Treatment of women with progestogen-only preparations caused only minor effects on coagulation and fibrinolysis. Similarly, during hormone replacement therapy with natural estrogens, the additional application of progestogens induced no unfavourable changes on haemostasis. In contrast, the use of ovulation inhibitors resulted in an acceleration of coagulation and fibrinolysis. This is primarily induced by the marked action of ethinylestradiol on hepatic and vascular function. Progestogens with androgenic properties may counteract the estrogen-induced changes in the hepatic synthesis of platelet aggregation and readiness for coagulation. Estrogen and progesterone receptors are localized in endothelial and smooth muscle cells of the vessel wall, but there are differences in the response of veins and arteries to sex steroids. Estrogens and progestogens may influence collagen and elastin synthesis, and the release of vasoactive compounds and of factors controlling fibrinolysis from endothelium. In veins, progestogens may increase distensibility and capacitance resulting in a decreased blood flow. In predisposed women, this may lead to venous stasis and thrombosis. In arteries, progestogens may act as vasoconstrictors, and may enhance vasospasms at sites of injured endothelium which finally may lead to ischemic diseases.

[Chronic venous insufficiency of the forefoot as a complication of intravenous drug abuse]. / Chronisch-venöse Insuffizienz am Vorfuss als Komplikation nach intravenösem Drogenabusus.

We report a 23 years old woman exhibiting localized chronic venous insufficiency of the forefeet after cocaine and heroin application into the foot veins. The diagnosis was confirmed by capillaroscopy (characteristic microangiopathy).

Influence of estrogens and progesterone on the venous system of the lower limbs in women.

Treatments with estrogens and progestogens are suspected of causing vascular complications either directly or by metabolic consequences. Although many studies have demonstrated an increased incidence of arterial and deep venous thrombosis, since 1970 the dose of estrogens and progesterones have been lowered with a proportional lowering of side effects. After classification of estrogens and progestogens, we studied their peripheral vascular effects. In our study, we demonstrated that the effects of estroprogestogen treatment on the superficial venous system depend on the dose of estrogen and progestogen.

PIP: Physicians examined the charts of 2295 21-40 year old oral contraceptive (OC) users who presented at 2 hospitals in France with venous disorders to determine the effect of various OCs on the functional symptomatology of venous disorders. The hospitals are the Hospital Notre Dame du Bon Secours in Paris and the Hospital Beaujon in Clichy. The various symptoms have existed between more than 1 year and greater than 3 years. The women used OCs with either a monophsic, biphasic, or triphasic minimal dose (304-40 mcg estrogen and 0.15-1 mg progestogen) or a monophasic normal dose (50 mcg estrogen and 500 mg progestogen). Over the course of OC use, the normal dose OC caused more significant intensity of heaviness, pain, and abnormal sensation (e.g., burning, prickling, or formication) than the minimal dose OCs. Other symptoms examined but not significantly affected by estrogen and progestogen dose are cramps and edema. These results and the fact that functional symptomatology appears several years before dilatation with or without reflux of the saphenous veins and other varices indicate that estrogens, progestogens, or their associative action facilitate varicose vein development in individuals with factors which predispose them to vascular disorders (familial history, prolonged standing, obesity, and sedentary). They also aggravate the superficial venous state in these patients.

[Comparative study of the effectiveness of continuous or intermittent courses of a phlebotonic drug on venous disorders disclosed or aggravated by oral, estrogen-progesterone contraceptives]. / Etude comparative de l'efficacité des cures continues ou discontinues d'un phlébotonique sur les troubles veineux révélés ou aggravés par la contraception orale estroprogestative.

In patients with venous disorders related to oral contraceptives, venotonic treatment should be prescribed for as long as contraception is maintained. 2,295 patients between the ages of 20 and 40 years with venous insufficiency revealed or aggravated by oral contraceptives were randomised to receive venotonic treatment for one month either continuously or in parallel with active contraceptive treatment, from the 10th to the 28th day. The results demonstrated the values of prolonged treatment of venous disease, as its effects persisted and were reinforced with time. The possibility of intermittent prescription would appear to improve compliance and lower the cost of treatment while ensuring comparable long-term efficacy.

PIP: Throughout France, physicians randomly assigned 2295 women with vein insufficiency, which was either disclosed or aggravated by use of a combined oral contraceptive (OC), to the group treated by two doses of the extract of Ribes nigrum every day for 24 weeks or to the group treated with the same dose of the phlebotonic drug only during days 10-28 of the cycle (i.e., parallel with OC use). There were 968 women in the first group and 1023 in the second group. Continuous treatment significantly reduced signs and symptoms of vein insufficiency (p 0.001). In fact, after 24 weeks of treatment, pain and edema were absent in 89.1% and 79.6% of women, respectively. Treatment only during days 10-28 of the cycle also significantly reduced signs and symptoms (p 0.001). The disappearance rate of the various signs and symptoms among women in the second group were comparable with the rate of women in the first group. After 24 weeks of treatment parallel with OC use, the disappearance rate ranged from 61% to 96%, depending on the sign or symptom. The effects of both treatments continued and improved with time. These findings show that intermittent use of the phlebotonic drug equals that of daily use. It appears that intermittent use will improve compliance and reduce drug costs while maintaining long-term efficacy.

Treatment of chronic venous ulcers with sheets of cultured allogenic keratinocytes.

Cultured keratinocytes were used as allografts to treat 51 patients with chronic venous ulceration or rheumatoid ulcers unresponsive to all previous conventional treatments including split skin grafts. Although early epithelialization could be seen in the centre of some ulcers, a major effect appeared to be healing from the previously indolent edge. This treatment appears to provide some clinical benefit in healing of chronic ulceration.

Efficacy of O-(beta-hydroxyethyl)-rutosides at high dosage in counteracting the unwanted activity of oral contraceptives on venous function.

In a double-blind study the effect of a high dosage of O-(beta-hydroxyethyl)-rutosides (HR) was tested in women taking oral contraceptives and suffering from venous insufficiency of the lower limbs. Ten patients were treated for 28 days with HR (3 g/day) and ten with a placebo. In basal conditions and after therapy, the symptoms of venous disorders and the venous function, by means of strain gauge plethysmography, was evaluated in both groups. The results showed an increase of venous capacitance and a reduction of venous tone in the subjects treated including those without symptoms in the lower limbs. The HR treatment resulted in a significant improvement of the venous function parameters and of the symptoms in lower limbs.

PIP: Venous insufficiency of the lower limbs in oral contraceptive users was treated with Venoruton 1000 (o-(beta-hydroxyethyl)-rutoside) at a high dose of 3 g/day in a double-blind, placebo controlled trial. 20 women aged 19-42, who had taken pills 3 months to 7 years (mean 30.2 months) were randomly assigned to treatment vs. placebo. The soluble powder was prepared in sachets indistinguishable from placebos. Venous function was assessed by strain gauge plethysmography (Periflow, Janssen Scientific, Beerse, Belgium), and the following parameters were determined: maximal venous incremental volume, maximal venous incremental volume time, maximal venous outflow, time of total emptying, index of venous distensibility, index of venous tone, and venous pressure. Subjective symptoms were evaluated on a scale of 0-5: pain, swelling, nocturnal cramps, tingling, heaviness and restless legs. Basal measurements showed high values of venous capacity, distensibility, and reduced venous tone. After 28 days of treatment, several venous parameters were significantly improved in the test group vs. placebo: maximal venous incremental volume at 40 and 60 mm Hg (venous capacity), index of venous distensibility and index of venous tone. There was significant improvement in subjective reports of pain, swelling, heavy legs and restless legs in the treated over placebo group. No side effects or changes in laboratory findings were observed.

Effect of HR (O-(beta-hydroxyethyl)-rutosides) on the impaired venous function of young females taking oral contraceptives. A strain gauge plethysmographic and clinical open controlled study.

PIP: 3 groups of women were studied to determine the relationship of venous disease to use of oral contraceptives (OCs) by strain gauge plethysmography. Group A consisted of 14 women taking OCs and having symptoms of venous disorders in their legs but no evident venous disease. Group B was 12 women also taking OCs but with no leg symptoms. And Group C was 14 control women not taking OCs and with no leg symptoms. Plethysmography indicated that in Group A venous capacitance and venous distensibility were significantly higher, whereas venous tone was significantly lower than in controls. Also, Group B showed a significant but slightly inferior impairment of these parameters. No differences in venous pressure or in venous outflow were seen in the 3 groups. The effects of HR (O-)beta-hydroxyethyl)-rutoside), a flavonoid, were investigated and showed that the drug provoked a significant decrease in venous capacitance with increase in venous tone and decrease in venous distensibility in Group A patients. Findings were evident after 1 month of treatment (2 gm/day by os). Leg symptoms also improved significantly. Therefore use of this agent may prevent pill-induced venous damage.^ieng

Hepatic veno-occlusive disease due to pyrrolizidine (Senecio) poisoning in Arizona.

An infant with documented hepatic veno-occlusive disease due to ingestion of pyrrolizidine alkaloids is presented. The alkaloids were ingested in the form of an herbal tea commonly used as a folk remedy among the Mexican-American population. Among these people, this herb is known as gordolobo yerba. The patient presented with acute hepatocellular disease and portal hypertension which progressed over 2 months to extensive hepatic fibrosis. Other potential causes of hepatic venous occlusion were absent.