The Impact of Race on Advanced Chronic Venous Insufficiency.

BACKGROUND: The study aimed to determine the association between race and patient variables, hospital covariates, and outcomes in patients presenting with advanced chronic venous insufficiency. METHODS: The National Inpatient Sample was queried to identify all Caucasian and African-American patients with a primary International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for venous stasis with ulceration (454.0), inflammation (454.1), or complications (454.2) from 1998 to 2011. CEAP scores were correlated with ICD-9 diagnosis. Demographics, CEAP classification, management, cost of care, length of stay (LOS), and inpatient mortality were compared between races. Statistical analysis was via descriptive statistics, Student's t-test, and the Fisher's exact test. Trend analysis was completed using the Mann-Kendall test. RESULTS: A total of 20,648 patients were identified of which 85% were Caucasian and 15% were African-American. Debridement procedures had the highest costs at $6,096 followed by skin grafting at $4,089. There was an overall decrease in the number of ulcer debridements, vein stripping, and sclerotherapy procedures between 1998 and 2011 (P < 0.05) for both groups. However, African-American patients had significantly more ulcer debridements than their Caucasian counterparts. CONCLUSIONS: African-American patients with a primary diagnosis of venous stasis present with more advanced venous disease at a younger age compared with their Caucasian counterparts. This is associated with increased ulcer debridement, deep vein thrombosis rates and hospital charges in the African-American cohort. There are no differences in sclerotherapy or skin grafting procedures, LOS or inpatient mortality between races.

[Giant retinal tear detachment]. / Riesenrissamotio.

Giant retinal tears with possible tear inversion are a special group of rhegmatogenous retinal detachments. A good knowledge of the pathogenesis and surgical specifics is very important for the retinal surgeon to achieve the best anatomic results with a low PVR rate. The technical progress that was made since the 1960 s obviously led to better results in the therapy for giant retinal tears. To avoid a giant retinal tear of the second eye, a prophylactic treatment has to be discussed with the patient.

Treatment pattern of consecutive patients with chronic venous disease.

BACKGROUND: No clear data exist on the treatment patterns in patients with chronic venous disease. This study was designed to determine how such patients were treated in our center. METHODS: Consecutive patients presenting for a vein consultation at our center were collected during a 9-month period, allotting for at least 6 months of follow-up. All patients had a detailed history and physical examination by experienced vascular surgeons and a complete venous ultrasound evaluation by registered vascular technologists having experience in venous imaging. Charts were reviewed for patient factors including body mass index, age, clinical class (Clinical, Etiology, Anatomy, and Pathophysiology [CEAP] classification), and treatment. Deidentified data from the chart review were entered into a local database. Queries were designed to identify trends in the data. The results of the queries were exported to a spreadsheet program for analysis per patient and per limb. RESULTS: There were 506 patients evaluated for venous disease during a period of 9 months. We identified 200 patients with chronic venous disease who required superficial vein treatment. There were 136 (68%) women. Ablation was required in 156 patients (78%), whereas 44 (22%) required only adjunctive therapy (microphlebectomy or sclerotherapy). The average number of ablations in patients with venous disease was 1.3 (259 ablations in 200 patients). In patients who needed at least one ablation, the average was 1.7 ablations per patient (259 ablations in 156 patients). Unilateral ablation was done in 94 patients (60%), and 62 patients (40%) had bilateral treatment. Of those who underwent unilateral ablations, 61% required adjunctive treatment of the contralateral limb. In patients who required only adjunctive therapy (no ablation), 73% underwent bilateral treatment. There were 182 limbs (45.5%) that did not require ablation as no reflux was found in the saphenous systems. Of the 156 patients who underwent ablation, 218 limbs had at least one ablation; 52% of limbs had C2 disease and on average underwent 1.1 ablations/limb. Only 7 of 113 (6%) limbs required more than one ablation. Average ablations per limb increased with clinical class, C3 having 1.2 ablations/limb, C4 having 1.4 ablations/limb, and C5 and C6 having 1.56 ablations/limb. CONCLUSIONS: Patients with venous disease required on average 1.3 ablations/patient. Most (78%) require at least one ablation for an average of 1.7 ablations/patient. There were 182 limbs (45.5%) with no saphenous reflux that did not require an ablation. The average number of ablations/limb increased with CEAP class.

Current management of venous ulcers: an evidence-based review.

Chronic venous ulceration is a common and important medical problem that causes significant morbidity. Venous ulcers are expensive to treat, have substantial economic effects in terms of days of work lost, and adversely impact the patient's quality of life. Relying on evidence allows for a rationale of clinical decision making. The objectives of venous ulcer management include the healing of the ulcer, prevention of recurrence, and improvement of edema. Compression is the cornerstone of venous ulcer therapy. Adjunctive modalities such as surgery, growth factors, grafting, biologic skin substitutes, dressings, and oral medication have differing levels of evidence supporting their use, and may also facilitate the healing process.

New methods for the management of esophageal varices.

Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatments for EVs. In the 1970s, interventional radiology procedures such as transportal obliteration, left gastric artery embolization, and partial splenic artery embolization were introduced, improving the survival of patients with bleeding EVs. In the 1980s, endoscopic treatment, endoscopic injection sclerotherapy (EIS), and endoscopic variceal ligation (EVL), further contributed to improved survival. We combined IVR with endoscopic treatment or EIS with EVL. Most patients with EVs treated endoscopically required follow-up treatment for recurrent varices. Proper management of recurrent EVs can significantly improve patients' quality of life. Recently, we have performed EVL at 2-mo (bi-monthly) intervals for the management of EVs. Longer intervals between treatment sessions resulted in a higher rate of total eradication and lower rates of recurrence and additional treatment.

Foam sclerotherapy--a possible option in therapy of varicose veins.

The therapy of varicose veins is multimodal and depends on the individual clinical findings. In addition to compression therapy, invasive approaches for elimination of reflux for the treatment of varicose veins are available, such as surgical and interventional methods and sclerotherapy. The administration of a sclerosing agent into a varicose vein results in an occlusion of the treated vein. Recently the use of foam sclerotherapy had a renaissance. Several studies have documented the efficacy of foam sclerotherapy in selected patients. The possibility of treating patients in an outpatient setting, with low costs and rapidly, makes foam sclerotherapy very attractive compared to invasive and minimally invasive methods. However long-term follow-ups in properly controlled randomized trials are needed before foam sclerotherapy can be recommended as a routine procedure. This paper introduces the method and the treatment possibilities with foam sclerotherapy in chronic venous insufficiency.

An update on the currently available nonthermal ablative options in the management of superficial venous disease.

BACKGROUND: Chronic venous insufficiency affects millions of Americans with symptoms spanning a broad range. Saphenous incompetence resulting in chronic reflux is at the root of most disease and is amenable to surgical correction. METHODS: We conducted a systematic review of the literature on nonthermal ablative techniques using a MEDLINE (Ovid) search from January 2000 to August 2016. Only prospective studies and literature review articles in the English language were included for final analysis. RESULTS: A total of 358 unique articles were identified, with a total of 60 articles meeting the stated inclusion and exclusion criteria. Historically, nonthermal ablative techniques have not demonstrated clinical results on par with thermal ablative interventions. However, three newer nonthermal ablative techniques have become available for use in the United States. Review of the literature demonstrated significant improvements in nonthermal ablative results, with intermediate-term data suggesting improved durability. CONCLUSIONS: Advances in nonthermal ablative techniques have led to a developing role and acceptance in the primary management of varicose veins and venous insufficiency, even in the setting of challenging cases.

Emerging endoscopic therapies for nonvariceal upper gastrointestinal bleeding.

Several new devices and innovative adaptations of existing modalities have emerged as primary, adjunctive, or rescue therapy in endoscopic hemostasis of gastrointestinal hemorrhage. These techniques include over-the-scope clip devices, hemostatic sprays, cryotherapy, radiofrequency ablation, endoscopic suturing, and endoscopic ultrasound-guided angiotherapy. This review highlights the technical aspects and clinical applications of these devices in the context of nonvariceal upper gastrointestinal bleeding.

The horizon for treating cutaneous vascular lesions.

Dermatologists encounter a wide range of cutaneous vascular lesions, including infantile hemangiomas, port-wine stain birthmarks, arteriovenous malformations, venous malformations, Kaposi sarcomas, angiosarcomas, and angiofibromas. Current treatment modalities to reduce these lesions include topical and/or intralesional steroids, laser therapy, surgical resection, and endovascular therapy. However, each method has limitations owing to recurrence, comorbidities, toxicity, or lesion location. Photodynamic therapy, antiangiogenic therapy, and evolving methods of sclerotherapy are promising areas of development that may mitigate limitations of current treatments and offer exciting options for patients and their physicians.

Sclerotherapy: it is back and better.

With the recent US Food and Drug Administration (FDA) approval of polidocanol in the United States, there has been a resurgence of interest in sclerotherapy. Despite the popularity of laser therapy, sclerotherapy remains the gold standard for treating spider and reticular veins. Although this traditional method of treatment has been around for more than 100 years, better sclerosing agents and newer techniques have made sclerotherapy safer and more efficacious than ever before. This article is a primer for physicians interested in updating their skills in sclerotherapy. It reviews common sclerosants, sclerotherapy techniques, patient evaluation, complications, and recent advancements in sclerotherapy.

Trends in varicose vein therapy in England: radical changes in the last decade.

INTRODUCTION: We aimed to analyse national trends in varicose vein treatment in the UK National Health Service (NHS). SUBJECTS AND METHODS: The National Hospital Episode Statistics website (www.Hesonline.nhs.uk) was interrogated for patients treated (1998-2008) in the NHS for varicose veins. RESULTS: There has been a 34% decline in patients presenting for an intervention for varicose veins. For surgical procedures alone, the waiting times have fallen by 59%. In 2007-2008, 30,663 (72%) fewer bed days were used in comparison to 1998; accompanied by a 49% decline in the number of patients undergoing surgery. After a 47% decrease between 1998 and 2001, the number of patients requesting sclerotherapy treatment has increased by a substantial 311% over the subsequent 7 years. Transluminal procedures were used almost twice as often in 2007-2008 as in 2006-2007. CONCLUSIONS: There has been a steady decline in the number of patients treated for varicose veins. Fewer patients are undergoing surgery but are being managed more efficiently, with an increase in day cases and a reduction in total bed days. The demand for minimally invasive procedures has increased substantially. These trends will be of great importance for the future planning of vascular surgical services.

[Modern aspects of varicose vein surgery]. / Moderne Aspekte der Phlebochirurgie.

In Germany almost every third adult suffers from varicose veins requiring treatment. Conventional varicose vein surgery by high ligation and stripping is widely accepted as standard therapy for saphenous vein insufficiency, although associated with a high frequency of recurrent varicosities. Innovative endovascular procedures laying claim to be minimally invasive have been implemented over the last five years: endovenous radiofrequency obliteration, endovenous laser treatment and ultrasound-guided sclerotherapy with foam. The early treatment outcomes are promising in regard to recurrent varicose veins, cosmetic results and convalescence. Evidence-based prospective trials with large numbers of participants comparing the interventional procedures with high ligation and stripping are still missing. This report delineates current developments in varicose vein surgery and provides information on principles, effectiveness and side effect profiles of endovascular therapy procedures.