Evaluation of VTE prophylaxis and the impact of alternate regimens on post-operative bleeding and thrombotic complications following bariatric procedures.

BACKGROUND: Studies examining utilization and impact of venous thromboembolism (VTE) chemoprophylaxis for patients undergoing bariatric surgery are limited. Determination of the optimal prophylactic regimen to minimize complications is crucial. METHODS: The Cerner Health Facts database from 2003 to 2013 was queried using ICD-9 codes to identify patients undergoing laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB). VTE chemoprophylaxis regimens were divided into pre-operative alone (PreP), post-operative alone (PostP), both pre-operative and post-operative (PPP), or no prophylaxis (NP). Specific chemoprophylaxis agents were compared. Comparisons in inpatient clinical outcomes were based on univariate analysis and multivariable logistic regression when appropriate. RESULTS: We identified 11,860 patients who underwent LSG and RYGB. 634 (5.35%) had PreP, 4593 (38.73%) had PostP, 2646 (22.31%) had PPP, and 3987 (33.62%) had NP. The overall rates of transfusion, DVT, and PE were 2.48, 0.27, and 0.18%, respectively. Patients without chemoprophylaxis had higher rate of DVT compared to any chemoprophylaxis (0.58 vs 0.11%, p < 0.0001), without any significant difference in PE rate. Patients with pre-operative chemoprophylaxis were more likely to receive transfusion compared to patients with post-operative prophylaxis alone (OR 1.98, 95% CI 1.28-3), without significant difference in having VTE. When examining heparin versus enoxaparin versus mixed regimen in the PostP group, mixed regimen was associated with increased transfusion requirements (p < 0.001). CONCLUSIONS: Bariatric surgical VTE chemoprophylaxis utilization is inconsistent. In this study, post-operative VTE chemoprophylaxis was associated with decreased VTE events compared to NP, while minimizing bleeding compared to PreP. Mixed therapy using heparin and enoxaparin was associated with more bleeding.

Effect of junctional reflux on the venous clinical severity score in patients with insufficiency of the great saphenous vein (JURY study).

OBJECTIVE: Effective treatment options are available for chronic venous insufficiency associated with superficial venous reflux. Although many patients with C2 and C3 disease based on the CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification have combined great saphenous vein (GSV) and saphenofemoral junction (SFJ) reflux, some may not have concomitant SFJ reflux. Several payors have determined that symptom severity in patients without SFJ reflux does not warrant treatment. In patients planned for venous ablation, we tested whether Venous Clinical Severity Scores (VCSS) are equivalent in those with GSV reflux alone compared with those with both GSV and SFJ reflux. METHODS: This cross-sectional study was conducted at 10 centers. Inclusion criteria were: candidate for endovenous ablation as determined by treating physician; 18 to 80 years of age; GSV reflux with or without SFJ reflux on ultrasound; and C2 or C3 disease. Exclusion criteria were prior deep vein thrombosis; prior vein ablation on the index limb; ilio-caval obstruction; and renal, hepatic, or heart failure requiring prior hospitalization. An a priori sample size was calculated. We used multiple linear regression (adjusted for patient characteristics) to compare differences in VCSS scores of the two groups at baseline, and to test whether scores were equivalent using a priori equivalence boundaries of +1 and -1. In secondary analyses, we tested differences in VCSS scores in patients with C2 and C3 disease separately. RESULTS: A total of 352 patients were enrolled; 64.2% (n = 226) had SFJ reflux, and 35.8% (n = 126) did not. The two groups did not differ by major clinical characteristics. The mean age of the cohort was 53.9 ± 14.3 years; women comprised 74.2%; White patients 85.8%; and body mass index was 27.8 ± 6.1 kg/m2. The VCSS scores in patients with and without SFJ reflux were found to be equivalent; SFJ reflux was not a significant predictor of VCSS score; and mean VCSS scores did not differ significantly (6.4 vs 6.6, respectively, P = .40). In secondary subset analyses, VCSS scores were equivalent between C2 patients with and without SFJ reflux, and VCSS scores of C3 patients with SFJ reflux were lower than those without SFJ reflux. CONCLUSIONS: Symptom severity is equivalent in patients with GSV reflux with or without SFJ reflux. The absence of SFJ reflux alone should not determine the treatment paradigm in patients with symptomatic chronic venous insufficiency. Patients with GSV reflux who meet clinical criteria for treatment should have equivalent treatment regardless of whether or not they have SFJ reflux.

Chameleon™ PTA balloon catheter: A single device in managing thrombosed AV access.

Thrombectomy is a common procedure for maintenance of arteriovenous (AV) access and is critical to prolong access life. Techniques for performing thrombectomy are incredibly diverse, ranging from open surgical procedures to percutaneous interventions. Percutaneous interventions include a combination of thrombectomy devices to clear the thrombus and balloon angioplasty to treat the underlying lesion. In this case report we describe a novel technique using a single device, the Chameleon™ PTA balloon catheter (Medtronic, Minneapolis, MN) balloon catheter, to safely and efficiently perform a percutaneous intervention.

Immediate and delayed complications of inferior vena cava filters.

OBJECTIVE: Inferior vena cava (IVC) filter placement has increased dramatically in the past two decades. However, literature supporting the efficacy of these devices has been limited and controversial. In the present study, we have evaluated the predictors and rates of technical complications after IVC filter insertion in a large national database. METHODS: The Vascular Quality Initiative registry was explored (January 2013 to December 2020). Immediate complications were defined as venous injury requiring treatment, filter misplacement (failure to open, deployed >20 mm from intended site or in wrong vein, embolized to the heart), angulation >20°, and insertion site complications. Delayed complications were defined as migration, angulation >15°, fracture, caval and/or iliac thrombosis, filter thrombus, fragment embolization, and perforation. The Pearson χ2 test was used to compare the baseline characteristics between the patients who had developed immediate and/or delayed complications and those who had not. The predictors of these complications were evaluated using multivariable logistic regression, Cox proportional hazard regression, and Kaplan-Meier survival analysis. RESULTS: A total of 14,784 patients were included in the present analysis, with a median follow-up of 11 months (interquartile range, 4-16 months). The rate of immediate and delayed complications was 1.8% and 3.1%, respectively. Angulation (1.2%) was the most common immediate complication, and filter thrombosis (1.6%) was the most common delayed complication. Compared with the patients with no immediate complications, those with immediate complications were more likely to have had abnormal anatomy (6.0% vs 1.7%; P < .001) and a landing zone other than infrarenal (7.0% vs 4.2%; P = .02). Compared with their counterparts, those with delayed complications were less likely to have received statins (21.0% vs 29.5%; P = .006) and were more likely to have a family history of venous thromboembolism (8.0% vs 5.1%; P = .047). Logistic regression analysis revealed that renal vein visualization was associated a 50% reduction (adjusted odds ratio [aOR], 0.50; 95% confidence interval [CI], 0.27-0.92; P = .027) in the odds of immediate complications and female sex and abnormal anatomy were associated with a 41% (aOR, 1.41; 95% CI, 1.08-1.85; P = .013) and 244% (aOR, 3.44; 95% CI, 1.66-7.16; P < .001) increase in the odds of immediate complications, respectively. Immediate (P = .21) and delayed (P = .51) complications did not result in increased mortality. CONCLUSIONS: The immediate and delayed IVC filter complication rates were 1.8% and 3.1%, respectively, but the occurrence of complications was not associated with increased mortality. Female sex was associated with an increase in the development of immediate complications. The incidence of immediate complications might be mitigated if advanced imaging were used for renal vein visualization before IVC filter deployment. Delayed complications might be avoided if IVC filter retrieval were performed in a timely fashion and institutional retrieval protocols were optimized.

Endovascular strategy for recanalization of long-segment central vein occlusion with concomitant arteriovenous fistula creation.

Recanalization of long-segment central vein flush occlusion in hemodialysis patients has been advocated in lieu of central vein bypass and thoracotomy to restore arteriovenous access availability. We report a challenging case of complex central venous flush occlusion in a 50-year-old woman on hemodialysis who presented with right arm and facial swelling. A concise step-by-step description of endovascular strategy with retrograde and antegrade balloon angioplasty techniques for central vein recanalization with concomitant arteriovenous fistula creation is provided.

The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment.

BACKGROUND: Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts' opinions on the available literature on lymphedema while following the Delphi methodology. METHODS: In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever >70% agreement was achieved. RESULTS: The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3-C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment. CONCLUSION: This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.

Improving retrieval rates of temporary inferior vena cava filters.

PURPOSE: Most studies have shown that the rate of inferior vena cava filter (IVCF) retrieval rarely exceeds 30%. A review of practices in our own institution revealed similar results (18%). Within the last year, few centers have demonstrated improved retrieval rates. Our hypothesis was that developing a dedicated program would improve IVCF retrieval. We report the results of an ongoing study following the development of this program. METHODS: This is a cohort of nontrauma consecutive patients who had an IVCF placed by the vascular service over a 12-month period (January 2010-January 2011) and were followed prospectively. A dedicated nurse practitioner was responsible in developing a database, maintaining contact with all the patients, and ensuring that arrangements were made for retrieval when indications for IVCF protection were no longer present. Demographics, indication for filter placement, timing to filter retrieval, and complications during placement and retrieval were prospectively collected. Retrieval rate was compared to the baseline institution data. RESULTS: During the study period, 42 patients had an IVCF placed. There were 27 men and 15 women with a mean age of 58 (25 to 88 years old). Two patients were excluded (one due to mortality and one had multiple filters) leaving 40 patients in the study. Indications for IVCF placement were absolute in 23 of 40 patients (58%), relative in 10 of 40 patients (25%), while seven patients (17%) had an IVCF placed for prophylaxis as they were considered high risk for pulmonary embolism (PE) and could not receive any chemical regimen. During follow-up, five filters were converted to permanent. Therefore, retrieval was successful in 19 of 22 patients with an 86% success rate and no complications. Median time to retrieval was 21 days ranging from 4 to 140 days. Retrieval rate for IVCFs designated as temporary at the time of placement was 70% (19 of 27), which was significantly higher compared to our baseline data of 18% (P < .001). CONCLUSION: Initial data show that a dedicated program that closely monitors patients with temporary IVCFs for ongoing need of filter prophylaxis can result in high retrieval rates. The endurance and long-term success of such a program needs to be further validated.

Management of true aneurysms of hemodialysis access fistulas.

OBJECTIVES: This study was designed to determine the clinical presentation, characteristics, and management of true aneurysms in dialysis access fistulas. METHODS: Patients presenting with symptoms or functional arteriovenous fistula (AVF) problems and aneurysmal enlargement of the outflow vein were evaluated with duplex ultrasound scans. Dilatation to more than three times the native vessel diameter was considered aneurysmal. Pseudoaneurysms were excluded from the study. Patients' demographics, aneurysm characteristics (diameter, location, thrombus, association with stenosis, and outflow obstruction), symptoms, type of treatment, and follow-up were recorded. RESULTS: Twenty-three patients with a mean age of 55 years were found to have 29 upper extremity aneurysms of the outflow vein on duplex ultrasound scan. Nine patients (39%) had radiocephalic, 11 patients (48%) had brachiocephalic, 2 patients (9%) had brachiobasilic, and 1 patient (4%) had radiobasilic arteriovenous fistula. The average aneurysm size was 3.3 cm and the mean time from fistula placement to treatment was 47.1 months. Four patients (17%) were asymptomatic and were repaired due to technical and mechanical problems with AVFs, including stenosis and lack of normal vein for cannulation, compromising continued use. Nineteen patients (83%) presented with symptoms, including pain (48%), skin changes (30%), venous hypertension (22%), steal syndrome (22%), and high output failure (9%). Four patients (17%) were found to have outflow vein stenosis, 2 patients (9%) had central venous stenosis, and 2 patients (9%) had central venous occlusion. In 13 patients (56%) who had a functioning kidney transplant, the fistula was ligated with or without aneurysm excision. Three of the 13 patients developed superficial phlebitis with 1 patient requiring surgical evacuation of a clot; the other 2 patients were managed conservatively. Two of the 13 patients required creation of new access due to renal transplant failure. In the remaining 10 patients, the aneurysm was treated and the fistula salvaged due to a persistent need for hemodialysis. The median follow-up of these patients was 19 months ranging from 8 to 25 months. Seven patients (30%) underwent excision and repair with the great saphenous vein and 3 patients (13%) had excision and repair with prosthetic material, 2 of which underwent central venous angioplasty and stenting. Two patients developed thrombosis of their repair requiring new access in the contralateral arm. Three patients needed secondary percutaneous interventions for anastomotic stenosis. CONCLUSION: Although true aneurysms in patients with dialysis access are uncommon, significant complications may occur as a consequence of their presence. These complications can be treated and the fistulas can usually be salvaged.

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.

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

[Box: see text]With the support of the American College of Obstetricians and Gynecologists, the American Vein & Lymphatic Society, the American Venous Forum, the Canadian Society of Phlebology, the Cardiovascular and Interventional Radiology Society of Europe, the European Venous Forum, the International Pelvic Pain Society, the International Union of Phlebology, the Korean Society of Interventional Radiology, the Society of Interventional Radiology, and the Society for Vascular Surgery.

Recurrent deep vein thrombosis: long-term incidence and natural history.

OBJECTIVE: To determine the long-term incidence, risk factors, and associated morbidity and mortality of recurrent deep vein thrombosis (DVT). SUMMARY BACKGROUND DATA: Few studies have examined the long-term natural history and impact of recurrent DVT. METHODS: We conducted a prospective observational study that followed 153 consecutive patients with an acute first episode of DVT. Clinical examination and ultrasound were performed serially for at least 5 years. Location and extent of the initial DVT, recurrence, pulmonary embolism, cause of mortality, signs and symptoms of post thrombotic syndrome (PTS), and the risk factors were recorded. RESULTS: The incidence of recurrence at 5 years was 26.1%. Patients with both proximal and distal DVT had a higher recurrence rate than proximal (17/48 35% vs. 12/49, 24%, P = 0.27) or calf alone (11/56, 20%, P = 0.08). Unprovoked DVT and age >65 years were associated with higher recurrence rates (P < 0.001; relative risk [RR]: 2.9, 95% confidence interval [CI]: 1.5-5.7) and (P = 0.025; RR: 1.5, 95% CI: 1-2.3), respectively. Thrombophilia was not associated with increased risk of recurrence (P = 0.21). Patients with DVT due to surgery or trauma had a lower recurrence (P < 0.001). Ipsilateral recurrence was associated with increased severity of PTS (P < 0.001; RR: 1.6, 95% CI: 1.4-2.2). PE occurred 47 times, 12 (25%) of which were fatal events. CONCLUSIONS: Factors associated with a higher rate of recurrence included unprovoked DVT and age >65. Elevated thrombus burden had a trend towards higher risk. Patients with surgery and trauma had low recurrence rates. Ipsilateral recurrence was strongly associated with PTS. PE occurred frequently and was a common cause of death.

Recurrent popliteal vein aneurysm.

A 28-year-old female presented with a soft mass in the left popliteal fossa. She had a popliteal vein aneurysm repair 4 years ago. Magnetic resonance venography and ultrasound revealed a recurrent saccular aneurysm on the site of the repair. It measured 3 x 4 cm and had no thrombus. The aneurysm was resected, and as the vein had adequate length, it was primarily repaired with an end-to-end anastomosis. She was placed on coumadin for 3 months. At follow-up, the vein was competent and free of thrombosis.

The distribution and significance of varicosities in the saphenous trunks.

OBJECTIVE: The purpose of this study was to determine the prevalence, distribution, and extent of varicosities and focal dilatations in the saphenous trunks, their association with the sites of reflux, and their correlation with CEAP classes. METHODS: This prospective study included patients belonging to different CEAP classes (2-6) and a control group of age- and gender-matched healthy volunteers (group C). Color-flow duplex scan imaging was used to evaluate the entire venous system from groin to ankle for reflux and obstruction. Varicose segments and focal dilatations of the great and small saphenous veins (GSV and SSV) were recorded, and the diameters throughout the length of the saphenous trunks were measured. The presence of varicosities in the tributaries and accessory veins were documented. RESULTS: From the 739 consecutive patients, 239 were excluded due to superficial venous thrombosis (SVT), deep venous thrombosis (DVT), both SVT and DVT, previous interventions, or C3-C6 presentation with no chronic venous disease (CVD). The included 500 patients (681 limbs) were divided into two groups based on CEAP class: group A (C2 + C3) and group B (C4-6). Group A had significantly more women than group B and a younger mean age (48 vs 56 years). Overall, GSV reflux (86%) was more prevalent than SSV reflux (17%), P < .0001. Saphenous trunk diameters, saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) involvement were greater in group B, (P < .01). Group C had smaller saphenous diameters compared to group A in all locations (P < .05) but the malleoli. The prevalence of the saphenous varicose segments in both groups was small with the GSV in group B being the highest (4.3%) and the SSV in group A being the smallest (1.2%). Focal dilatations were significantly more prevalent than varicosities in the saphenous trunks (P < .0001). Varicosities of tributaries and accessory veins were more prevalent than those of saphenous trunks (P < .0001). The mean length of varicose segments in the saphenous trunks was short (3.8 cm, range, 2.1-6.4 for group A vs 4.1 cm, range, 2.3-8.3 for group B, P = .09). CONCLUSION: A novel definition for varicosities in the saphenous trunks was established. Using this definition, it was determined that focal dilatations are far more common than varicosities. Because both of these entities are more prevalent in the accessory saphenous veins and tributaries, and CEAP class correlates positively with the extent of reflux and saphenous trunk diameter, studies on earlier interventions are warranted to prevent CVD progression.

Prospective determination of candidates for thrombolysis in patients with acute proximal deep vein thrombosis.

PURPOSE: To prospectively determine the distribution, extent, and age of venous thrombosis in patients presenting with acute signs and symptoms of venous thromboembolism and identify candidates for thrombolysis. MATERIALS AND METHODS: Five hundred seventy-six consecutive patients (281 male, 295 female; mean age 58) referred for lower extremity deep vein thrombosis (DVT) assessment between November 2007 and April 2008 were included in the study. Documented cases of DVT were categorized by age (acute, chronic, and acute on chronic), anatomic location, and extent. Patients with iliofemoral and femoropopliteal DVT were evaluated for thrombolysis using standard criteria. RESULTS: DVT was found in 19% of patients (112/576). Of these, 31 patients (27.7%, 31/112) had isolated calf DVT, 61 patients (54.5%, 61/112) had proximal vein thrombosis extending into the femoropopliteal venous segments, and 20 patients (17.9%, 20/112) presented with iliofemoral DVT. Using standard criteria, 12 patients were selected as potential candidates for pharmacomechanical thrombolysis (PhMT). This equated to an incidence of 2% (12/576) in the population studied, 11% of patients (12/112) with DVT, 26.1% of patients (12/46) presenting with acute proximal DVT, and 20% of patients (4/20) with iliofemoral DVT. CONCLUSION: The incidence of potential candidates for thrombolysis is low. These data should be considered when recruiting centers to participate in ongoing clinical trials assessing the efficacy of these techniques.

Diagnostic approach to lower limb edema.

Patients with lower limb edema are frequently referred to vascular specialists for evaluation. Multiple etiologies must be considered and often more than one cause may be present. Notably, the role of lymphatic system regardless of the underlying pathology has been underestimated. A thorough history and physical examination and a carefully considered laboratory and imaging evaluation are critical in differentiating causes. In this opinion article, we propose a diagnostic algorithm that incorporates a systematic approach to the patient with leg swelling and provides an efficient pathway for the differential diagnosis for this problem.

Extraluminal lipoma with common femoral vein obstruction: a cause of chronic venous insufficiency.

A 49-year-old man, with a misdiagnosis of common femoral vein deep vein thrombosis presented with advanced chronic venous insufficiency. Further imaging revealed a patent common femoral vein with augmentation that was compressed by an extrinsic mass. Exploration identified a lipoma that was extravascular and was resulting in venous outflow obstruction. Excision of the lipoma resulted in clinical improvement and ulcer healing.

Prospective evaluation of the clinical deterioration in post-thrombotic limbs.

OBJECTIVE: Several studies have evaluated the natural history of deep vein thrombosis (DVT), but few have correlated the clinical progression using duplex ultrasound (DU) imaging during the first year. This study was designed to determine the relationship of changes in the venous system and correlate them with long-term progression of disease. METHODS: Consecutive patients with a first episode of proximal DVT documented by DU imaging were included prospectively. Clinic examinations were performed at 3, 6, and 12 months, and yearly thereafter. The CEAP system was used to grade disease severity. DU imaging was performed at least once, 1 year after the diagnosis, and repeated at 5 years. The proximal veins were divided the common femoral vein, femoral vein, and popliteal vein segments for analysis. Thrombosed veins were subsequently graded as completely, partially, and fully recanalized. Recurrent DVT cases were also recorded. RESULTS: The study included 64 patients with 73 involved limbs; of which, skin damage was documented in three (4%) at 1 year and in 18 (25%) at 5 years (P = 0.0006; relative risk [RR], 3.92; 95% confidence interval [CI], 1.36-11.3). Overall from 1 to 5 years, 50 limbs remained the same. A change in clinical class occurred in 23 limbs (31.5%), including five limbs that progressed from class 0 to 3, 15 limbs from class 3 to 4 and 6, and three from class 4 to 5 and 6. DU imaging of these 23 limbs progression showed that the most important predictor for class progression was ipsilateral recurrent DVT (RR, 4.4; 95% CI, 1.4-13.3). Recurrent DVT at 1 year occurred in 21.9%, including ipsilateral in 15.6% and contralateral in 6.3%. Total recurrence at 5 years was 31.3%, including ipsilateral in 23.4% and contralateral in 7.8%. Limbs with ipsilateral recurrence were more likely to have partial recanalization, reflux, and more vein segments involved compared with those with contralateral recurrence or no recurrence (11 of 15 vs 16 of 58; RR, 4.7; 95% CI, 1.7-13.3). CONCLUSION: Clinical class progression from year 1 to 5 occurs in 30% of post-thrombotic limbs. The most important predictor for progression in clinical class was ipsilateral recurrent DVT.

Veins along the course of the sciatic nerve.

OBJECTIVE: To describe the anatomic variations, symptomatology, and pathophysiology associated with the sciatic nerve (SN), and report the results after treatment of the incompetent veins. PATIENTS AND METHODS: Retrospective analysis of prospectively collected data from patients with signs and symptoms of chronic venous disease that had superficial varicosities associated with incompetent veins along the SN. Patients were evaluated with duplex ultrasound scans. In patients with enlarged veins along the SN, the anatomy of the incompetent veins, their size and association with superficial varicosities, and the severity of insufficiency were analyzed. The symptoms associated with their presence and the treatment results were also noted. Patients were re-evaluated following treatment for recurrence of varicosities and symptoms. RESULTS: We identified 24 limbs in 21 patients with varicosities along the SN and its branches. The duration of signs and symptoms was 4.5 years ranging from 1 to 14. Reflux was detected in 18 veins of the SN, in three persistent sciatic veins and in three veins of the tibial nerve. All limbs with sciatic and tibial nerve veins had varicosities in the lateral and posterior aspect of thigh and calf and were symptomatic. Ten limbs presented with CEAP class 2, 5 with class 3, 2 with class 4, and 1 with class 1. Pain or tingling was reported in 15 limbs, itching in 8, and heaviness in 7. The distribution of pain and tingling was present along the nerves in 19 limbs. One patient had acute thrombosis in a persistent sciatic vein and died from pulmonary embolism. Of the 21 limbs with SN veins, 16 were treated with subfascial vein ligation and phlebectomies. Three patients had sclerotherapy, 1 refused treatment, and 1 had mild symptoms not requiring treatment. Of the 19 treated limbs, in 11 there was relief of their symptoms, 6 had significant improvement, and 2 had no change. Within a year, 4 patients required additional treatment for veins along the same area. Eleven limbs had a follow-up duplex scan 3 to 19 months after their treatment. All limbs showed significant diameter reduction in the nerve veins while mild reflux was present in 3 (4.1 mm vs 2.1 mm, P < .001). CONCLUSION: Reflux is the most common pathology of the sciatic and tibial nerve veins which produces significant symptoms along the distribution of the nerves. Treatment of the varicosities offers significant relief while recurrence or residual varicosities are easily managed.

Secondary chronic venous disease progresses faster than primary.

PURPOSE: To compare the progression rate of primary with secondary chronic venous disease (CVD). METHODS: Patients with a first episode of proximal deep vein thrombosis (DVT), diagnosed by duplex ultrasound (DU) were included in group A - secondary CVD (41 patients, 46 limbs). DU was performed at least once, 1 year after the diagnosis, and repeated at 5 years. Group B - primary CVD (41 patients, 50 limbs) included age- and sex-matched patients with primary CVD and duration of 5 to 10 years to be comparable with that of group A. They had no history of DVT and were referred for reflux evaluation. All their veins were free of postthrombotic signs upon DU examination. Group C (15 patients, 30 limbs) had no signs and symptoms of CVD and were examined at baseline and 5 years later. This group of patients was also matched for age and sex. Clinic examinations were performed at 3, 6, and 12 months and yearly thereafter. The CEAP system was used to grade disease severity. The proximal veins were divided in the CFV, FV, and POPV segments for analysis. Thrombosed veins were subsequently graded as complete, partial, and fully recanalized. Recurrent DVT cases were also recorded. RESULTS: At 5-year follow-up, the prevalence of skin damage was significantly higher in group A (11/46 vs group B 3/50, P = .019 and vs group C 0/30, P < .01). The progression to skin damage in group A was faster as it changed from 4% (2/46) at 1 year (P = 0.014) compared with the two other groups. In group A, 22 limbs had reflux, three had obstruction, 19 had combine reflux and obstruction, and two were normal. In group B, superficial, deep, and perforator vein reflux were seen in 50, 4, and 15 limbs, respectively. In group C, five limbs in four patients developed superficial reflux in which only two had symptoms. The CEAP class in this group was C0N = 25, C1 = 3, and C2 = 2. In group A, skin damage was significantly higher in limbs with combined proximal and distal obstruction as well as in limbs with combined reflux and obstruction (P = .012 and P = 0.013, respectively). DVT was found in 108 segments (25 CFV, 40 FV, and in 43 POPV), 82 at the first episode and 26 as an ipsilateral recurrence. Ipsilateral and contralateral recurrences were seen in 21.9% and 9.8% of patients, respectively. Complete recanalization occurred in 43 segments, partial in 55, and none in 10. Reflux occurred in 85.5% and 60.5% of the partially and completely recanalized segments, respectively (P = .006). CONCLUSIONS: The progression of CVD is more rapid in postthrombotic limbs when compared with those with primary CVD. The incidence of CVD in normal individuals is small and its progression is slow. Poor prognostic factors for progression to advanced CVD include the combination of reflux and obstruction, ipsilateral recurrent DVT, and multi-segmental involvement.