Venous disorders as an occupational disease - a systematic review on epidemiology, pathophysiology, and modification strategies.

Forced postures are common in the workplace. Work in the primary economic sector is characterised by a high degree of physical activity and movement; however, activities in the secondary and tertiary sectors commonly require workers to stand or sit. An expansion of the tertiary sector in recent decades has meant that people in industrialised and emerging economies primarily sit or stand at work. The aim of the systematic review was to identify occupational factors relating to the presence of chronic venous disease (CVD), to place these in the context of developments in the workplace, and to determine whether measures are in place to prevent CVD. We performed a systematic literature review to analyse studies assessing work-related risk factors for CVD. We searched for publications in the PubMed database, the clinic library of BG Hospital Bergmannstrost Halle, and the registry of the German Statutory Accident Insurance. Using occupation-specific keyword combinations, we identified 27,522 publications. The publications underwent an automatic and manual filtering process according to the PRISMA guidelines and 81 publications qualified for the review. Ultimately 25 studies were included in the systematic review. All of the subjects of the studies worked in the secondary and tertiary sectors. No studies looked at the relationship between venous disorders and primary sector occupations. Standing at work for more than four hours a day, repeated heavy lifting, and cumulative time working in a sitting or standing position are risk factors for the development of CVD. Sitting is less of a risk factor than standing or walking. Occupational history and the patient's activity profile are important diagnostic tools which can help confirm a diagnosis and justify treatment when findings are inconsistent. Compression therapy is the primary form of secondary and tertiary prevention. There continues to be a lack of primary preventive measures related to workplace design.

Differences in risk profile associated with varicose veins and chronic venous insufficiency - results from the Bonn Vein Study 1.

Background: The aim of this publication is to demonstrate similarities and differences in the association of risk factors with the prevalence of different manifestations of chronic venous disease (CVD), like varicose veins (VV), venous oedema (C3) and severe chronic venous insufficiency (CVI) in the population-based cross-sectional Bonn Vein Study 1 (BVS). Patients and methods: In the BVS 1 between 13.11.2000 and 15.3.2002, 3.072 participants, 1350 men and 1722 women, from a simple random sample of the general population of the city of Bonn and two rural townships aged 18-79 years were included. The overall response proportion was 59%. All participants answered a standardized questionnaire including information about socio-economic data, lifestyle, physical activity, medical history, and quality of life. Venous investigations were performed clinically and by a standardized duplex examination by trained investigators. The CEAP classification in the version of 1996 was used to classify the findings. Logistic regression models were performed for the association of possible risk factors with VV, venous edema (C3) and severe CVI (C4-C6). The predictive risk (PR) describes the association of the diseases and the possible influencing factors. Results: VV, venous oedema (C3) and severe CVI (C4-C6) have common risk factors like higher age, number of pregnancies, family history of VV and overweight or obesity. Female gender is significantly associated with VV and C3 but not with severe CVI (C4-C6). High blood pressure and urban living are only associated with C3 and C4-C6 disease whereas prolonged sitting is associated with C3 and lower social class with C4-C6 exclusively. Discussion: In many epidemiological studies risk factors were associated with chronic venous disorders in general. Our data show that VV, venous edema and severe CVI may have different risk profiles. Venous edema is more often associated with arterial hypertension and sedentary lifestyle whereas lower social class seems to be a risk factor for severe CVI including venous ulcers. Conclusions: The differences in the association of risk factors to VV, venous edema and severe CVI should be considered if prevention and treatment of chronic venous diseases are planned. As examples, compression stockings could be proposed in sitting profession to prevent oedema, VV patients with risk factors like obesity might benefit from early treatment for VV and obesity. More longitudinal evaluation of risk factors is necessary to evaluate the true risk profile of CVD.

Diagnosis and treatment of venous leg ulcers: S2k Guideline of the German Society of Phlebology and Lymphology (DGPL) e.V.

This S2k guideline on venous leg ulcers was created on the initiative and under the leadership of the German Society of Phlebology and Lymphology (DGPL). The guideline group also consisted of representatives from the German Society for Phlebology and Lymphology, German Dermatological Society, German Society for General Medicine, German Society for Angiology, German Society for Vascular Surgery and Vascular Medicine, German Society for Surgery, German Society for Dermatosurgery, German Society for Wound Healing and Wound Treatment, Professional Association of Phlebologists and Lymphologists and Initiative Chronische Wunden. The aim of this guideline is to combine the different approaches and levels of knowledge of the respective professional groups on the basis of consensus, so that a basic concept for the best possible treatment of patients with venous leg ulcers can be provided. A total of 70 specific recommendations were formulated and agreed upon, divided into the subject areas of diagnostics, therapy, prevention of recurrences, and everyday challenges. The guideline thus reflects the current state of scientific knowledge and is intended to be widely used as the best available document for the treatment of patients with venous leg ulcers in everyday clinical practice.

Determinants of Late Venous Thromboembolic Events After Acute Isolated Superficial Vein Thrombosis in Daily Practice: 12 Month Results of the INSIGHTS-SVT Study.

OBJECTIVE: Long term incidence of symptomatic venous thromboembolism (VTE) and bleeding events in patients with superficial vein thrombosis (SVT) was investigated. METHODS: In this prospective, observational study, patients with acute SVT were treated at the discretion of the responsible physician. The primary efficacy outcome was symptomatic VTE including deep vein thrombosis (DVT), pulmonary embolism (PE), and recurrent or extending SVT. The primary safety outcome was clinically relevant bleeding, recorded at periodic clinic visits over a 12 month period. RESULTS: The mean age of 872 patients with 12 month follow up was 60.6 ± 14.5 years, 64.5% were female, 80.1% had chronic venous disease (defined as chronic venous insufficiency and or varicose veins), and 41.9% had a history of VTE. They were receiving fondaparinux in 62.1% (mean duration 34.9 ± 15.7 days), low molecular weight heparin (LMWH) in 25.0% (mean duration 26.2 ± 23.2 days), any other anticoagulants in 6.2%, and no anticoagulant in 6.7%. At 12 months, 108 patients (14.3%) achieved the primary efficacy outcome. The most common VTE event was recurrent or extending SVT in 11.0%, followed by symptomatic DVT in 2.7%, symptomatic PE in 2.4%, hospitalisation due to VTE in 1.8%, and death in 1.1%. Clinically relevant bleeding events occurred in 2.1% of patients, and major bleedings in 0.3%. By drug, the rate of the primary efficacy outcome was highest in the LMWH group (22.4%) and lowest in the fondaparinux group (10.4%). In a multivariable model, patients with events between three months and 12 months were significantly more likely to have higher BMI (hazard ratio [HR] 1.06; p = .002), history of VTE (HR 2.89; p = .002), and severe systemic infections (HR 7.59; p = .006). CONCLUSION: The risk of symptomatic VTE remained elevated over 12 months of follow up. Therefore, anticoagulation beyond 45 days may be considered in patients with risk factors. [ClinicalTrials.gov identifier: NCT02699151.].

Lower prevalence of stump reflux after endovenous laser flush ablation of the great saphenous vein.

Background: This single center prospective randomized study was performed to compare the effect of endovenous laser flush ablation (EVLAf) of the great saphenous vein (GSV) close to the sapheno-femoral junction (SFJ) with a standard ablation (EVLAs) up to two cm distally of the SFJ on reflux in the GSV stump. Patients and methods: Between April 2013 and January 2016, 146 legs in 146 consecutive patients, meeting the inclusion/exclusion criteria, were treated by EVLA. All patients were randomized into 2 groups. In group 1 EVLAf started from the SFJ level, and in group 2 EVLAs started two cm below the SFJ. The primary endpoint was reflux in the GSV stump after 900 days. Secondary endpoints were reflux in the anterior accessory saphenous vein (AASV), proximal clinically recurrent varicose veins related to reflux in the stump and/or the AASV. Results: At day 900, 27 patients were lost to follow-up. Reflux in the stump was detected in 3.6% in group 1 and in 22.2% in group 2 (p<0.05). Reflux in the AASV was present in 7.1% in group 1 and in 17.46% in group 2 (p=0.09). Proximal clinically recurrent varicose veins were observed in 8.9% in group 1 and in 19.1% in group 2 (p=0.12). The greatest diameter of the stump was significantly larger in group 2 (group 1: 0.41 cm, group 2: 0.6 cm, p<0.001). Conclusions: EVLAf is associated with a significantly lower incidence of reflux in the GSV stump, with a trend to a lower incidence of reflux in the AASV and with a lower incidence of proximal recurrent varicose veins after 900 days follow-up compared to EVLAs. EVLAf may improve the clinical recurrence rate after EVLA of the GSV.

Management and Outcomes of Patients with Isolated Superficial Vein Thrombosis under Real Life Conditions (INSIGHTS-SVT).

OBJECTIVE: Management and outcomes of superficial vein thrombosis (SVT) are highly variable and not well described. Therefore, the INvestigating SIGnificant Health TrendS in the management of SVT (INSIGHTS-SVT) study collected prospective data under real life conditions. METHODS: Prospective observational study of objectively confirmed acute isolated SVT. The primary outcome was a composite of symptomatic deep vein thrombosis (DVT), pulmonary embolism (PE), and extension or recurrence of SVT at three months. The primary safety outcome was clinically relevant bleeding. RESULTS: A total of 1 150 patients were included (mean age 60.2 ± 14.7 years; 64.9% women; mean BMI 29.4 ± 6.3 kg/m2). SVT was below the knee in 54.5%, above the knee in 26.7%, above and below the knee in 18.8%. At baseline, 93.6% received pharmacological treatment (65.7% fondaparinux, 23.2% heparins, 4.3% direct oral anticoagulants [DOACs], 14.5% analgesics), 77.0% compression treatment, and 1.9% surgery; 6.4% did not receive any anticoagulation. The primary outcome occurred in 5.8%; 4.7% had recurrent or extended SVT, 1.7% DVT, and 0.8% PE. Clinically relevant non-major bleeding occurred in 1.2% and major bleeding in 0.3%. Complete clinical recovery of SVT was reported in 708 patients (62.4%). Primary outcome adjusted by propensity score and for treatment duration was lower with fondaparinux compared with low molecular weight heparin (4.4% vs. 9.6%; hazard ratio [HR] 0.51; 95% confidence interval [CI] 0.3 - 0.9; p = .017). On multivariable analysis, associated factors for primary outcome included another SVT prior to the present SVT event (HR 2.3), age per year (HR 0.97), duration of drug treatment per week (HR 0.92), and thrombus length (HR 1.03). CONCLUSION: At three month follow up, patients with isolated SVT are at risk of thromboembolic complications (mainly recurrent or extended SVT), despite anticoagulation. In this real life study, about one third had received either heparins, oral anticoagulants, or no anticoagulation.

[What is evidence-based in the treatment of chronic venous insufficiency?] / Was ist gesichert in der Therapie der chronischen Veneninsuffizienz?

Chronic venous diseases belong to the most frequent diseases. They can be asymptomatic, cause subjective symptoms or lead to objectif alterations, such as edema, cutaneous alterations and venous leg ulcers. This ultimately results in chronic venous insufficiency (CVI). Varicose veins are a progressive degenerative disease of the venous walls in the superficial venous system of the legs, which can decisively impair the quality of life of those affected. The classification of chronic venous diseases is carried out with the CEAP classification according to clinical, etiological, anatomical and pathophysiological criteria. Instruments, such as the venous clinical severity score, are used for assessment of the severity. The treatment of chronic venous diseases targets the improvement of the subjective complaints and objectifiable alterations. In addition, complications, such as phlebitis and formation of ulcers should be avoided. Invasive procedures, compression treatment and pharmaceutical treatment are complementary and a combination of these procedures can be meaningful. General physical measures, such as propping up the legs and frequent walking, are part of the basic measures for every patient with venous diseases. Compression therapy with medical compression stockings is the gold standard in the noninvasive treatment of symptomatic venous diseases, possibly supplemented by anti-inflammatory drugs. A varicose vein should be eliminated whenever possible. Stripping operations and the less invasive endovenous thermal ablation show comparable results for saphenous vein varicosis. Foam sclerotherapy and percutaneous phlebectomy are the methods of choice for elimination of side branch varicosis; however, recurrences of varicose veins are frequent.

Superficial vein thrombosis treated for 45 days with rivaroxaban versus fondaparinux: rationale and design of the SURPRISE trial.

Patients with superficial vein thrombosis (SVT) are commonly treated with low-molecular weight heparin or fondaparinux in prophylactic, intermediate or therapeutic dosages for treatment periods of 10-45 days. This practice is also reflected by the current guideline recommendations. However, given the broad range of thromboembolic complication rates in SVT (between 0 and 30 % have been reported) it seems reasonable to suspect that risk stratification is needed to differentiate patients at low risk who may not benefit from anticoagulation from those at high risk who may need higher dosages or a longer duration of anticoagulation. Furthermore, prolonged treatment with injectable anticoagulants has been shown to result in poor patient adherence. Direct oral anticoagulants have recently been approved for venous thromboembolism therapy and these new drugs may offer advantages also for SVT patients. The prospective, randomized, open-label, blinded adjudication trial superficial phlebitis treated for 45 days with rivaroxaban versus fondaparinux (SURPRISE) will evaluate the efficacy and safety of 10 mg rivaroxaban OD compared to fondaparinux 2.5 mg OD for SVT treatment in a subset of high-risk SVT patients over a treatment period of 45 days. The purpose of the study is to demonstrate non-inferiority of rivaroxaban compared to fondaparinux in preventing the combined efficacy endpoint of thrombus progression, SVT recurrence, DVT, PE and death. The results of the SURPRISE trial will provide evidence for the concept of risk stratification in SVT and for the value of rivaroxaban 10 mg in SVT treatment (clinicaltrials.gov NCT01499953).

Toe elevation manoeuvre to assess venous reflux in comparison to manual calf compression and release.

BACKGROUND: In the daily office setting, flow and reflux in leg veins is assessed to investigate patients with chronic venous disease. Valsalva manoeuvre and manual calf compression and release are frequent manoeuvres used to elicit blood flow in leg veins. Toe elevation manoeuvre (TEM) was proposed as a further alternative to provoke blood flow in veins. We compared both methods. PATIENTS AND METHODS: Patients consulting a venous office referring no previous treatment on their leg veins were evaluated with duplex ultrasound in the standing position. Age, body mass index, C of CEAP, venous clinics severity score, diameter of great saphenous vein and reflux duration at proximal thigh following TEM and manual calf compression and release were assessed. RESULTS: In total, 53 legs were evaluated with both manoeuvres, applied in a randomised sequence. Reflux >0.5s was found in 40 legs (group "reflux") and no reflux in 13 legs (group "no reflux"). No significant difference was found following manual calf compression and release or TEM (2.11s vs. 2.31s in "reflux-group" and 0.11s vs. 0.13s in "no-reflux-group"), but good correlation was found between both with Pearson's test (r=0.72). CONCLUSIONS: Both manoeuvres showed a good correlation with respect to reflux detection and reflux duration. The advantage of TEM is the easy and painless performance, low fatigability and independence from examiner.

Konsensuspapier zur symptomorientierten Therapie der chronischen Venenerkrankungen.

HINTERGRUND: Chronische Venenerkrankungen sind eine Volkskrankheit. Venöse Symptome wie Schwellungs- und Schweregefühl können bereits früh ohne sichtbaren Befund auftreten und werden als belastend erlebt. Ein Fortschreiten im Sinne einer objektivierbaren Varikose bzw. chronischen venösen Insuffizienz schränkt die Lebensqualität erheblich ein. METHODIK: Pubmed-gelistete Publikationen sowie relevante Leitlinien zur Therapie chronischer Venenkrankheiten bilden die Basis der vorliegenden Konsensusempfehlungen. Inkludiert in die Bewertung wurden ausschließlich aussagekräftige randomisierte Studien (RCT) und Übersichtsarbeiten (Reviews/Metaanalysen). ERGEBNISSE: Die symptomorientierte Behandlung chronischer Venenerkrankungen stützt sich auf drei Säulen mit nachgewiesener Wirksamkeit: invasive Therapie, Kompressionstherapie und orale medikamentöse Therapie. Gemäß Empfehlungen aktueller Leitlinien sollte zunächst eine Sanierung des venösen Gefäßbetts erwogen werden, um einen störungsfreien venösen Blutfluss wiederherzustellen und Symptome und pathologische Veränderungen zu beseitigen oder zu bessern. Ist ein invasiver Eingriff nicht möglich bzw. nicht erwünscht oder bestehen nach einem Eingriff noch Restsymptome, gilt es, die symptomatischen Therapieoptionen optimal auszuschöpfen. Kompressionstherapie und medikamentöse Therapie können allein oder in Kombination angewendet werden. Welche Strategie den größten Erfolg verspricht, ist individuell zu entscheiden. SCHLUSSFOLGERUNGEN: Chronische Venenerkrankungen sollten auf der Basis der individuellen pathophysiologischen Störung behandelt werden. Sie symptomorientierte Behandlung chronischer Venenerkrankungen fußt auf der invasiven Therapie, der Kompressionstherapie und der medikamentösen Therapie. Bei der Indikationsstellung sind objektive Symptome ebenso wie subjektive Beschwerden zu berücksichtigen.

Consensus statement on the symptom-based treatment of chronic venous diseases.

BACKGROUND: Chronic venous diseases are very common. Early symptoms such as a sensation of swelling and heaviness may occur without objectifiable findings, but are nevertheless perceived as bothersome. Progressive disease - marked by varicose veins and symptoms of chronic venous insufficiency - is associated with considerable impairment in quality of life. METHODS: The present consensus recommendations are based on publications in Pubmed-listed journals as well as relevant international therapeutic guidelines on chronic venous diseases. Only conclusive randomized controlled trials (RCTs) and review articles/meta-analyses were included. RESULTS: Symptom-based treatment of chronic venous diseases is based on three therapeutic pillars with proven efficacy: invasive therapy, compression therapy, and oral pharmacological treatment. According to current therapeutic guidelines, invasive procedures aimed at restoring unimpaired venous blood flow as well as improving or eliminating pathological changes should be the first-line approach. If an invasive approach is infeasible or undesirable, or if symptoms persist following a therapeutic intervention, optimal use of symptom-based treatment options is recommended. Compression and pharmacological therapy may each be used as sole treatment or in combination. To guarantee maximum therapeutic success, individual treatment decisions should be made on a case-by-case basis. CONCLUSIONS: Chronic venous diseases should be treated on the basis of individual pathophysiological disturbances. Symptom-based treatment of chronic venous disorders encompasses invasive therapy, compression therapy, and oral pharmacological therapy. Considerations in choosing the appropriate treatment option should include both objective signs as well as subjective symptoms.

[Epidemiology of chronic venous diseases]. / Epidemiologie der chronischen Venenkrankheiten.

AIM: Overview of the recent knowledge in epidemiology of chronic venous diseases. METHODS: Systematic search and discussion of recent studies concerning epidemiology of chronic venous diseases. RESULTS: The more recent epidemiologic studies of venous diseases in which the CEAP classification was used showed a prevalence of 60-70 % CEAP clinical class C0 and C1, app. 25 % for C2 and C3 and up to 5 % for C4 to C6 with skin changes or venous ulcers. The incidence of varicose veins is app. 2 % per year. CONCLUSIONS: Chronic venous diseases like varicose veins and chronic venous insufficiency belong to the most frequent diseases in our adult population.

Varicose vein surgery after acute isolated superficial vein thrombosis in daily practice: INSIGHTS-SVT study.

OBJECTIVE: The aim of this study was to assess the utilization of surgical interventions in patients diagnosed with superficial vein thrombosis (SVT) and its potential association with the occurrence of venous thromboembolism (VTE) and bleeding events. METHODS: INSIGHTS-SVT, a prospective, non-interventional, multicenter study in Germany, investigated the management and outcomes of patients with acute SVT who received conservative and/or invasive treatments at the discretion of the treating physician. RESULTS: Among the 872 patients with 12-month data, 657 had medical therapy only, and 215 patients underwent vascular surgery (70 within 3 months of SVT diagnosis, 136 between months 4 and 12, and nine had an intervention in both periods). The most commonly performed procedures included endovenous thermal ablation, ligation of the saphenofemoral or saphenopopliteal junction, and vein stripping. The primary outcome of symptomatic VTE was observed in 5.8% of conservatively treated patients and 6.3% of those who underwent surgical intervention. Additionally, the secondary outcome of recurrent or extended SVT was documented in 4.7% of conservatively treated patients and 5.3% of invasively treated patients. Bleeding events occurred in 1.4% of conservatively treated patients and 2.1% of surgically treated patients. These differences were statistically not significant. Furthermore, our analysis indicated a potential protective effect associated with surgical treatments, such as ligation of the saphenofemoral or saphenopopliteal junction, stripping and endovenous thermal ablation, concerning the endpoint of VTE for patients when applied after 3 months from the index SVT event. CONCLUSIONS: In line with previous research, our study suggests that surgical interventions are not frequently employed in the management of SVT, although they may be warranted in select cases. Nevertheless, additional research is essential to gain a deeper understanding of the indications, criteria, and benefit of surgical interventions in the treatment of SVT.

Therapy with compression stockings in Germany - results from the Bonn Vein Studies.

BACKGROUND: Despite the frequent use of medical compression stockings (MCS), reliable data are lacking on the frequency of MCS use and experience of patients with the treatment. PATIENTS AND METHODS: The Bonn Vein Study included 3,072 participants from the general population aged 18 to 79 years (1,350 men/1,722 women). Between 2007 and 2008 (Bonn Vein Study 2) 1,978 participants from the Bonn Vein Study 1 were reinvestigated. This paper combines the results of both investigations. RESULTS: 14.6% (7.5% men, 20.3% women) reported having previously undergone treatment with compression stockings. A mean of 71.3% reported an improvement in their venous disease as a result of MCS treatment. During the 6.6 years of follow-up (Bonn Vein Study 2), significantly more prescriptions of MCS were given to patients in higher CEAP clinical stages. 12.2% of the population in C2 was treated with MCS as were 19.1% in C3 and 27.0% in C4-C6. Among participants with chronic venous insufficiency (CVI) (skin changes up to venous ulcers), about 60% were not treated by MCS or bandages in the past years. CONCLUSIONS: These results show that MCS is the most common treatment of venous disorders in the German population. At the same time, these figures also demonstrate severely lacking treatment with MCS in CVI.

Enhancing identification and treatment of patients with concomitant chronic venous insufficiency and diabetes mellitus. A modified Delphi study from the CODAC (ChrOnic venous disease and Diabetes Advisory Council) group.

BACKGROUND: Chronic venous insufficiency (CVI) and diabetes mellitus (DM) pose significant burdens to patients and healthcare systems. While the two diseases share a number of commonalities in risk factors and pathophysiology, they are often assessed and managed separately. This can lead to a worsening of comorbidities and limitations in a patient's quality of life. This project aims to develop recommendations to enhance the identification and treatment of patients with concomitant CVI and DM. METHODS: Using a modified Delphi method, a panel of experts developed 38 Likert Scale and two multiple choice questions across six key themes. These were used to form an online survey which was disseminated through a convenience sampling approach to CVI and DM healthcare professionals across Europe, Central America, South America, and the Middle East. The threshold for consensus was set at ≥75%. RESULTS: A total of 238 responses were received. 27/38 statements attained >90% agreement, nine of 38 attained between 75-90%, and two failed to meet the threshold (<75%). The awareness around the impact of the two diseases was high, but a gap was highlighted in the identification of patients with concomitant CVI and DM. CONCLUSIONS: The high level of agreement shows that healthcare professionals are aware of the gaps in identification and treatment of patients with concomitant CVI and DM, and of the need to approach this as a combined therapy area. An algorithm is proposed to help the identification of at-risk patients and to provide recommendations on the management of patients with concomitant disease.

Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023.

BACKGROUND: Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events. OBJECTIVES: To categorise contraindications to sclerotherapy based on the available scientific evidence. METHODS: An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited. RESULTS: Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes. CONCLUSIONS: Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of 'no intervention as a treatment option' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.

Fake-news-free evidence-based communication for proper vein-lymphatic disease management.

Published scientific evidence demonstrate the current spread of healthcare misinformation in the most popular social networks and unofficial communication channels. Up to 40% of the medical websites were identified reporting inappropriate information, moreover being shared more than 450,000 times in a 5-year-time frame. The phenomenon is particularly spread in infective diseases medicine, oncology and cardiovascular medicine. The present document is the result of a scientific and educational endeavor by a worldwide group of top experts who selected and analyzed the major issues and related evidence-based facts on vein and lymphatic management. A section of this work is entirely dedicated to the patients and therefore written in layman terms, with the aim of improving public vein-lymphatic awareness. The part dedicated to the medical professionals includes a revision of the current literature, summing up the statements that are fully evidence-based in venous and lymphatic disease management, and suggesting future lines of research to fulfill the still unmet needs. The document has been written following an intense digital interaction among dedicated working groups, leading to an institutional project presentation during the Universal Expo in Dubai, in the occasion of the v-WINter 2022 meeting.

Simultaneous MR arteriography and venography with blood pool contrast agent detects deep venous thrombosis in suspected arterial disease.

OBJECTIVE: The purpose of this study was to investigate the prevalence of incidental deep venous thrombosis (DVT) in patients with clinically suspected peripheral arterial occlusive disease (PAOD) using contrast-enhanced MR angiography (MRA) with a blood pool contrast agent. SUBJECTS AND METHODS: Two hundred fifty-nine MRA examinations with blood pool contrast agent in 245 consecutive patients (161 men; age range, 36-92 years), yielding a total of 4102 assessable arterial and venous vessel segments, were assessed with regard to the rate of incidentally observed acute and organized DVT and arterial stenosis grades. Incidental DVT was confirmed using duplex ultrasound. Contralateral nondiseased veins served as internal controls. The relationship between PAOD stages and acute and organized DVT was investigated using chi-square tests and a Mann-Whitney U test. RESULTS: Arterial stenosis grading using MRA with blood pool contrast agent revealed less than 50% luminal stenosis in 78% of segments (3199/4102), 50% or greater stenosis in 8% of segments (317/4102), and occlusion in 14% of segments (586/4102). Incidental DVT was observed in 26 of 245 patients (11%) (acute DVT was seen in 10 patients and 26 segments; organized DVT was seen in 17 patients and 35 segments; and one patient had both acute and organized DVT). All incidentally diagnosed cases of DVT were confirmed by duplex ultrasound. Internal controls revealed no false-positive or -negative findings (26 patients and 172 segments). Incidental acute DVT was significantly more common among patients without arterial stenosis greater than 50% (p < 0.05). Otherwise, there was no significant relationship between Fontaine PAOD stages and the occurrence of acute (p = 0.688) or organized (p = 0.995) DVT. CONCLUSION: Incidental DVT was prevalent in 11% of patients with clinically suspected PAOD. MRA with blood pool contrast agent has a potential role in the simultaneous assessment of arteries and veins and can detect concomitant venous disease affecting therapeutic management.

[Medical compression stockings for chronic venous diseases and lymphedema : Scientific evidence and results of a patient survey on quality of care]. / Medizinische Kompressionsstrümpfe bei chronischen venösen Erkrankungen und Lymphödem : Wissenschaftliche Evidenz und Ergebnisse einer Patient*innen-Befragung zur Versorgungsqualität.

BACKGROUND AND AIMS: Medical compression stockings (MCS) are indicated for chronic venous insufficiency (CVI) of all stages and are an indispensable component in lymphedema therapy. In all, 8% of the German population has been prescribed MCS by a physician-more women than men (12% vs. 5%), and especially persons aged 60 years and older (17%). Patient adherence is relevant for successful treatment with MCS. We examined MCS use from the patient's perspective. PATIENTS AND METHODS: This study examined the quality of care through structured interviews with 414 representative users in 2019. Findings are discussed taking into consideration scientific evidence on the efficacy of MCS. RESULTS: Venous conditions are the most common reason for prescription (44%), followed by lymphedema (22%) or multiple indications (27%). Patients generally wear MCS daily and on average 11 h/day. In all, 89% of patients were satisfied or very satisfied with MCS, whereby efficacy was dependent on the indication. This reflects the extensive scientific evidence on the clinical efficacy of MCS. An important factor for patient adherence is physician training and education. CONCLUSION: MCS are well accepted by patients. When prescribing them, practical aspects such as donning and doffing, recommended wearing time and frequency, and the mechanism of action of MCS should be clearly communicated.

Reticulate eruptions. Part 1: Vascular networks and physiology.

Reticulate pattern is one of the most important dermatological signs of a pathological process involving the superficial vascular networks. Vascular malformations, such as cutis marmorata congenita telangiectasia and benign forms of livedo reticularis, and sinister conditions, such as meningococcal meningitis or Sneddon's syndrome, can all present with a reticulate pattern. The clinical presentation and morphology is determined by the nature and extent of the underlying pathology and the involvement of a particular vascular network. This review has been divided into four instalments. In the present paper, we discuss the anatomy and physiology of the complex network of vascular structures that support the function of the skin and subcutis.