[Definitions and epidemiology of varicose vein disease]. / Définitions et épidémiologie de la maladie variqueuse.

DEFINITIONS AND EPIDEMIOLOGY OF VARICOSE VEIN DISEASE. Chronic superficial venous disorders are a frequent reason for medical consultation. Depending on the study, between 20% and 60% of the general population suffer from varicose veins of the lower limbs. The socio-economic cost of venous disease is considerable, accounting for between 1% and 3% of national healthcare budgets. The factors leading to the formation of varicose veins and the pathogenesis are not clearly elucidated, but two factors have been identified: weakness of the venous wall and hemodynamic disorders. Symptoms and clinical signs are highly variable, ranging from aesthetic dissatisfaction to leg ulcers. The CEAP classification (clinical, etiological, anatomical, pathophysiological) enables the practitioner to precisely define chronic venous disease, providing a precise diagnostic description as well as enabling the patient to be monitored over time. Various quality-of-life scales have also been developed.

DÉFINITIONS ET ÉPIDÉMIOLOGIE DE LA MALADIE VARIQUEUSE. Les troubles veineux superficiels chroniques représentent un motif fréquent de consultation médicale. Entre 20 et 60 % de la population générale souffre de varices des membres inférieurs, selon les études. Le coût socio-économique des maladies veineuses est considérable et grève d'environ 1 à 3 % les budgets nationaux de santé. Les facteurs aboutissant à la formation des varices et la pathogénie ne sont pas clairement élucidés ; mais deux facteurs sont retenus : la faiblesse de la paroi veineuse et les désordres hémodynamiques. Les symptômes et les signes cliniques sont très variables, allant de l'insatisfaction esthétique à l'ulcère de jambe. La classification CEAP (clinique, étiologique, anatomique, physiopathologique) permet au praticien de définir précisément la maladie veineuse chronique, apportant ainsi une description diagnostique précise pour un suivi du patient sur le long terme. Différentes échelles de qualité de vie ont également été développées.

[Complications of varicose disease]. / Complications de la maladie variqueuse.

COMPLICATIONS DE LA MALADIE VARIQUEUSE. La maladie variqueuse est souvent considérée, à tort, comme une pathologie benigne. Les troubles trophiques représentent 10 % des complications de la maladie variqueuse et, dans 1 % des cas, un ulcère de jambe peut apparaître. L'hyperpression veineuse est impliquée, mais il existe égalment des phénomènes pro-inflammatoires responsables de lésions endothéliales chroniques qui favorisent le remodelage et la fibrose tissulaire à l'origine des complications cutanées. Stade ultime de l'insuffisance veineuse chronique et témoin de sa gravité, l'ulcère de jambe est souvent négligé et relégué à des soins infirmiers. Véritable problème de santé publique, générant des coûts importants et une altération significative de la qualité de vie des patients, l'ulcère veineux nécessite une meilleure connaissance et une meilleure prise en charge par les soignants. Par ailleurs, des complications graves et potentiellement mortelles ecistent, telles que l'hémorragie aiguë par rupture de varices et la maladie thromboembolique veineuse. Une amélioration de la prise en charge des varices est nécessaire pour limiter la survenue de ces complications.

COMPLICATIONS OF VARICOSE DISEASE. Varicose vein disease is often mistakenly considered as a benign pathology. Trophic disorders account for 10 % of varicose disease complications, and in 1 % of cases, a leg ulcer may develop. Venous hyperpressure is involved, but there are also pro-inflammatory thenomena responsible for chronic endothelial lesions that promote tissue remodeling and fibrosis, the cause of skin complications. The ultimate stage of chronic venous insufficiency, and a trestament to its severity, leg ulcers are often neglected and relegated to nursing care. A genuine public health problem, generating high costs and signicantly impairing patients' quality of life, venous ulcers need to be better understood and managed by healthcare professionals. In additon, serious and potentially fatal complications exist, such as acute hemorrhage from ruptured varicose veins and venous thrombo-embolic disease. Improving care of varicose veins is essential to limit the occurence of these complications.

[Management of varicose disease]. / Prise en charge de la maladie variqueuse.

MANAGEMENT OF VARICOSE DISEASE. Chronic venous disease (CVD) is a chronic condition for which there is no cure. The therapeutic approach to CVD varies depending on the severity of the disease and must be individually adapted. There are two main treatment options: conservative treatment and interventional treatment. Conservative treatment consists in applying the classic venous hygiene guidelines to prevent the progression of the disease by encouraging the patient to modify his lifestyle. It includes general measures such as recommending exercise, weight management and the use of compression products. Pharmacological treatment, although controversial, may be prescribed to relieve symptoms associated with CVD. However, its effectiveness may vary from one individual to another. Interventional treatment has changed a lot. During the 20th century, open surgery was the dominant method for treating varicose disease. Nevertheless, the indications for this intervention have recently evolved thanks to the development of endovenous intervention techniques, whether they are thermal or not. These advances now make it possible to treat varicose veins on an outpatient basis. The management of CVD is not based on a single treatment, but rather on a combination aiming at relieving symptoms, preventing complications and slowing its progression.

PRISE EN CHARGE DE LA MALADIE VARIQUEUSE. La maladie veineuse chronique (MVC) est une affection chronique pour laquelle il n'existe pas de traitement curatif. L'approche thérapeutique de la MVC varie en fonction de la gravité de la maladie et doit être adaptée individuellement. Il existe deux principales options thérapeutiques : le traitement conservateur et le traitement interventionnel. Le traitement conservateur consiste à appliquer les règles classiques « d'hygiène veineuse ¼ pour prévenir la progression de la maladie en encourageant le patient à modifier son mode de vie. Il englobe des mesures générales telles que l'incitation à l'exercice physique, la gestion du poids et l'utilisation d'articles de compression médicale. Le traitement pharmacologique, bien que controversé, peut être prescrit pour soulager les symptômes associés à la MVC. Cependant, son efficacité peut varier d'un individu à l'autre. Le traitement interventionnel a beaucoup changé. Au cours du XXe siècle, la chirurgie à ciel ouvert était la méthode dominante pour traiter la maladie variqueuse. Néanmoins, les indications de cette intervention ont évolué récemment grâce au développement de techniques d'intervention endoveineuse, qu'elles soient thermiques ou non. Ces avancées permettent désormais de traiter les varices de manière ambulatoire. La prise en charge de la MVC ne repose pas sur un seul traitement mais plutôt sur une combinaison visant à soulager les symptômes, prévenir les complications et en ralentir la progression.

[Diagnosis of varicose disease]. / Diagnostic de la maladie variqueuse.

DIAGNOSIS OF VARICOSE DISEASE. Varicose vein disease corresponds anatomically to an alteration of the venous wall and/or the valve system of one or more superficial veins, or segments of these veins, and is characterized by reflux causing venous hypertension. The clinical signs, precisely described by the CEAP classification (clinical, etiological, anatomical, pathophysiological), include aside asymptomatic forms, telangiectasias, varicose veins, edema, and skin disorders up to the stage of leg ulcers. The functional signs, also very variable and sometimes absent, are not limited to leg heaviness. Non-specific, they are mainly characterized by their timing and mode of occurrence. Duplex ultrasound (DU) examination allows to confirm the existence of venous reflux, to specify its extension, to measure the diameter of the pathological veins and to analyze their wall remodeling. DU is essential to precisely characterize the varicose disease to define the therapeutic modalities to be considered. Its results are recorded on a venous cartography which graphically represents all the echo-anatomical and hemodynamic data collected. In the event of varicose disease, a specialized medical consultation is necessary to offer therapeutic care adapted to the specific problem of each patient.

DIAGNOSTIC DE LA MALADIE VARIQUEUSE. La maladie variqueuse correspond anatomiquement à une altération de la paroi veineuse et/ou du système valvulaire d'une ou plusieurs veines superficielles ou de certains segments de ces veines et se caractérise par un reflux à l'origine d'une hypertension veineuse. Sa présentation clinique très variée, bien décrite par la classification CEAP (clinique, étiologique, anatomique, physiopathologique), inclut, outre les formes asymptomatiques, des télangiectasies, des varices, un œdème et des troubles trophiques cutanés jusqu'au stade des ulcères de jambe. Les signes fonctionnels, très variables eux aussi et parfois absents, ne se limitent pas aux seules lourdeurs de jambe. Non spécifiques, ils sont principalement caractérisés par leur horaire et leur mode de survenue. L'écho-Doppler permet d'affirmer l'existence d'un reflux veineux, d'en préciser l'extension, de mesurer le diamètre des veines pathologiques et d'analyser leur paroi. L'écho-Doppler est indispensable pour caractériser précisément la maladie variqueuse et pour définir les modalités thérapeutiques à envisager. Ses résultats sont consignés sur une cartographie veineuse qui représente de façon graphique toutes les données écho-anatomiques et hémodynamiques recueillies. En cas de maladie variqueuse, un avis spécialisé est nécessaire pour proposer une prise en charge thérapeutique adaptée à la problématique spécifique de chaque patient.

Technique and early results of endovenous laser ablation in morphologically complex varicose vein recurrence after small saphenous vein surgery.

BACKGROUND: Recurrences after varicose vein treatment occur frequently and represent a significant health and economic problem. In contrast to primary treatments of superficial truncal venous insufficiency, their management is often more difficult. Here we assessed the technical feasibility and early results of endovenous laser ablation (EVLA) for recurrences with stumps or subfascial meandering varices after small saphenous vein (SSV) surgery. METHODS: This single-center retrospective study included 45 consecutive EVLA procedures from July 2019 to December 2021 in 40 patients (19 male, 21 female, mean age 62.8 ± 12.7 years). Patients had clinically relevant recurrent varicose veins after SSV surgery, with clinical, etiologic, anatomic and pathophysiologic (CEAP) classification stage of C2S or higher. We categorized the recurrences morphologically according to duplex sonographic criteria. Ablations were done with a 1470 nanometers laser and dual ring radial fibers and aimed at thermal closure as proximal as possible to the upper inflow. Analyses were performed by descriptive statistics and the Kaplan-Meier method. The primary outcome analyzed was the technical success, defined by thermal occlusion not requiring re-intervention during the observation period. The secondary outcome was the occurrence of postoperative complications. RESULTS: A complex morphology with residual stumps or tortuous venous connections to the popliteal vein was present in 35 cases (77.8%). Immediate technical success at the first postoperative visit after a median of 11 days (interquartile range 8-13 days) was 97.8%. During the follow-up period (median 77 days, interquartile range 13-256 days), 6 limbs (13.3%) required redo EVLA due to symptomatic persistent or newly presenting reflux. The median freedom from re-recurrence was 791 days. Otherwise, no medical or surgical complications requiring specific treatment were observed, particularly no endothermal heat-induced thrombosis (EHIT) or other thrombotic complications, and no nerve damage. CONCLUSION: According to our pilot data, EVLA is technically feasible for complex popliteal variceal recurrence, although the success rate appears substantially lower than for primary treatment of truncal venous insufficiency.

[Ectopic biliary varices as a cause of portal biliopathy and mechanical jaundice syndrome]. / Ektopicheskie biliarnye varikoznye veny kak prichina portal'noi biliopatii i sindroma mekhanicheskoi zheltukhi.

The authors consider ectopic biliary varices as a possible cause of portal biliopathy in extrahepatic portal hypertension. The main diagnostic methods including ultrasound CT, MRI, endoscopic ultrasonography, cholangioscopy, difficulties of differential diagnosis and clinical manifestations of portal biliopathy are presented. Various treatment options including portosystemic shunting and endoscopic biliary decompression are discussed. The authors emphasize the role of differentiated treatment depending on bile duct lesions. The study not only reviews this problem, but also highlights the issues requiring further analysis for selection of optimal diagnostic and treatment methods.

[Safety and efficacy analysis of a varicose vein sealant kit in the treatment of great saphenous vein dysfunction].

Objective: To investigate the safety and efficacy of a varicose vein sealant kit in the treatment of great saphenous vein dysfunction. Methods: It was a randomized controlled trial. A total of 180 patients with great saphenous vein dysfunction were enrolled prospectively, and scheduled for surgical treatment in 9 hospitals, including the Second Affiliated Hospital of Naval Medical University, Shanghai Oriental Hospital Affiliated to Tongji University, Xuanwu Hospital Capital Medical University, the First Hospital of Hebei Medical University, Ganzhou People's Hospital, Shanxi Bethune Hospital, the Second Affiliated Hospital of Zhejiang University School of Medicine, the Fourth Affiliated Hospital of Zhejiang University School of Medicine, and Zhongshan Hospital Affiliated to Xiamen University, from June to October 2022. Using a random number table method, the subjects were divided into an experimental group and a control group, with 90 cases in each group. The patients of experimental group received treatment with varicose vein sealant kit, while the patients of control group received radiofrequency ablation. The main outcome measure was the complete closure rate of the great saphenous vein in both groups of patients 3 months after surgery. The secondary outcome measures were the complete closure rate of the great saphenous vein in both groups of patients immediately after surgery and 6 months after surgery, the operation time for closing the main trunk of the great saphenous vein, pain score, venous clinical severity score (VCSS), Aberdeen varicose veins questionnaire (AVVQ) at different times before and after surgery, and the incidence of complications in both groups of patients. The non inferiority threshold for the two treatment methods is set at "-10.00%". Results: A total of 177 patients were ultimately enrolled. There were 89 cases in the experimental group, including 38 males and 51 females, with a median age [M (Q1, Q3)] of 59.7(49.6, 66.7) years, and 88 cases in the control group, including 30 males and 58 females, with a median age of 57.2(46.9, 65.9) years. A total of 174 patients completed a 3-month follow-up, and 167 patients completed a 6-month follow-up. The closure time of the main saphenous vein in the experimental group was (22.1±11.1) min, which was longer than the control group, which was (18.7±9.8) min (P=0.031). The complete closure rate of the great saphenous vein immediately after surgery in both the experimental group and the control group was 100%. The complete closure rates of the great saphenous vein at 3 months after surgery were 98.8% (85/86) and 98.9% (87/88), respectively. The lower limit of the 95%CI for the difference between the two groups was -3.19%, which was greater than the non-inferiority threshold of -10.00% (non-inferiority P<0.001). The complete closure rates of the great saphenous vein at 6 months after surgery were 97.6% (81/83) and 100% (84/84), the lower limit of the 95%CI for the difference between the two groups was -5.71%, which was greater than the non-inferiority threshold of -10.00% (non-inferiority P<0.001). The immediate pain scores after complete anesthesia awakening of the experimental group and the control group were both 1.0 (0, 2.0), with no statistically significant difference (P=0.365). The incidence of bruising in the experimental group and the control group one week after surgery was 61.2% (52/85) and 67.1% (57/85), respectively, with no statistically significant difference (P=0.181). There was no statistically significant difference in VCSS and AVVQ scores between groups before surgery and at 1, 3, and 6 months after surgery (all P>0.05). There was no statistically significant difference in the incidence of complications such as deep vein thrombosis, phlebitis, pain, and subcutaneous hematoma in the lower limbs 3 months after surgery (all P>0.05). Conclusion: The varicose vein sealant kit is safe and effective in treating great saphenous vein dysfunction, and can achieve a complete closure rate of great saphenous vein that is not inferior to traditional radiofrequency ablation.

Comparison of the effects of training in the standing and lying positions on the quality of life and clinical symptoms in women with mild varicose veins: A randomized controlled trial.

BACKGROUND: Patients with varicose veins are prevented from prolonged standing. Considering that exercise can be implemented in different positions, the aim of the current study was to compare the effects of training at standing and lying positions on quality of life, and clinical symptoms in women with mild varicose veins. METHODS: Twenty-five women with mild varicose veins aged 35-50 years were randomly assigned to three groups; exercise at standing position (n=10), exercise at lying position (n=8) and control (no treatment) group (n=7). Each exercise program involved 6 weeks of training. Quality of life, pain severity, ankle swelling, and lower leg and ankle circumferences were measured using the Aberdeen Varicose Vein Questionnaire, Visual Analog Scale (VAS), four-point pitting edema grading scale, and tape measure, respectively at baseline and at the end of the study. Data were analyzed using one-way analysis of variance (ANOVA) and the least significant difference (LSD) as post hoc test. RESULTS: Following a 6-week exercise program, there was a significant improvement in the quality of life of the participants in both exercise groups, and a significant reduction in pain, ankle swelling, and lower leg and ankle circumferences compared to pre-training and control group (P <0.05). However, there was no significant difference between two exercise groups in terms of study variables (P >0.05). CONCLUSIONS: The current study showed that exercise program comprising standing position exercises can significantly reduce the symptoms of mild varicose veins.

Identification of biological significance of different stages of varicose vein development based on mRNA sequencing.

Normal veins could develop to varicose vein (VV) by some risk factors, and might further progress to shallow vein thrombosis (SVT). However, the molecular mechanism of key genes associated with the progression and regression of VV are still not thorough enough. In this study, the healthy control (HC), VV, and SVT vascular samples were collected for transcriptome sequencing. The differentially expressed genes (DEGs) were screened by "DESeq2", including DEGs1 (HC vs. VV), DEGs2 (HC vs. SVT) and DEGs3 (VV vs. SVT). And their functional enrichment analyses were conducted by "ClusterProfiler". The receiver operating characteristic (ROC) curve was used to obtain the key genes (KGs) of the pathogenesis of VV and SVT. The qRT-PCR assay was performed to validate the expressions of KGs. Immune cell infiltration analyses were conducted based on ssGSEA method. The competitive endogenous RNAs (ceRNAs) regulatory network was constructed. The target drugs of KGs were predicted using DrugBank database. The biofunctions of DACT3 were further investigated through a series of experiments in vitro. All of these DEGs were associated with inflammation and immunity related functions. Immune cell infiltration was significantly different between VV and SVT. Six key genes including PLP2, DACT3, LRRC25, PILRA, MSX1 and APOD that were associated with the progression and regression of VV were screened. The expression of LRRC25 and PILRA was significantly negatively associated with central memory T cell, and significantly positively associated with B cell. Besides, XIST was the critical regulator of multiple KGs. Cimetidine was potential drug for VV and SVT therapy. Overexpression of DACT3 significantly inhibited the proliferation and migration of vascular smooth muscle cells (VSMCs), and affected their cell cycle and phenotypic transition. This study identified six key genes associated with the progression and regression of VV. Among them, DACT3 was proved to hinder VV progression. These findings may help to deepen understanding its underlying mechanisms.

Exploring the causal relationship between plasma lipids and varicose veins of lower extremity: A comprehensive two-sample Mendelian randomization study.

Varicose veins of the lower extremities (VVs) is a common chronic vascular disease, with high prevalence rates in some countries; however, their pathogenesis remains unclear. Some studies have identified associations between changes in specific plasma lipid molecules, such as phosphatidylethanolamine (PE), phosphatidylcholine (PC), and sphingomyelin (SM), and the onset of VVs, but due to confounders and reverse causality, the causal relationship remains unclear. Meanwhile, studies on the potential link between other plasma lipids beyond PE, PC, and SM and the risk of VVs in the lower extremities are lacking. This study aimed to explore the potential causal relationship between VVs and plasma lipid levels to provide theoretical insights into the interrelation of plasma lipids and VVs in their occurrence and progression. We conducted a two-sample Mendelian randomization (MR) analysis to assess the potential connection between genetically predicted levels of individual plasma lipids and the risk of developing VVs. We utilized data from a large-scale genome-wide association study involving 7174 Finnish individuals for 179 plasma lipidomes along with VVs genome-wide association study data from 408,455 UK individuals. MR analysis employed methods, such as inverse-variance weighting, weighted median, Bayesian Weighted Mendelian Randomization, and MR-Egger regression. The inverse-variance weighting method was primarily used to assess causality. The validity of the results was demonstrated through sensitivity analysis. In total, 12 lipids were found to have their plasma levels associated with an increased risk of VVs. This includes 3 types of PE, 7 types of PC, and 2 types of phosphatidylinositol. However, no significant causal relationship was found between the plasma levels of 11 types of SM and VVs. These results support the existence of a potential causal relationship between specific types of lipid levels and the risk of VVs, which can provide clues for further studies on biological mechanisms and the exploration of potential therapeutic targets.

Association of varicose veins with incidence risk of atrial fibrillation: a population-based cohort study.

BACKGROUND: Varicose veins (VV) were once considered benign and common ailments; however, recent research suggests a potential link between VV and cardiovascular diseases or mortality. VV share common risk factors and pathophysiology with cardiovascular disease, potentially influencing the vascular system. Therefore, the authors aimed to investigate the association between VV and the incidence risk of atrial fibrillation (AF) using a population-based cohort. METHODS: Our retrospective cohort study included 2 680 971 individuals who underwent examination through the Korean National Health Screening Service from 2010 to 2011. VV was defined by two or more claims with the International Classification of Diseases 10th Revision diagnostic codes: I83.0, I83.1, I83.2 (VV of lower extremities with ulcer or inflammation, severe VV), and I83.9 (asymptomatic VV of lower extremities, mild VV). The 1:3 propensity score matching (PSM) was used to assess the risk of newly developed AF, identified via insurance claims coded as I48. RESULTS: The mean age of all participants was 48.5±14.2 years, with 51.4% being male. Among the population, 24 557 (0.91%) had VV, including 3684 (0.14%) of severe VV and 20 873 (0.77%) of mild VV. During a median follow-up of 10.06 years, 24 557 (0.92%) cases of AF occurred. Participants with VV exhibited an increased incidence risk of AF compared to those without it before (HR: 1.13, 95% CI: 1.06-1.21, P <0.001) and after PSM (HR: 1.17, 95% CI: 1.08-1.27, P <0.001). This positive association was consistently observed in severe VV both before (HR: 1.19, 95% CI [1.09-1.28], P =0.002) and after PSM (HR: 1.20, 95% CI [1.10-1.30], P =0.003) and mild VV also before (HR: 1.10, 95% CI [1.04-1.16], P =0.003) and after PSM (HR: 1.13, 95% CI [1.03-1.-20], P <0.001). CONCLUSIONS: These findings suggest that VV may be associated with an increased risk of AF. Hence, the presence of VV should be considered as an association factor for AF occurrence.

Ten-year outcomes of a randomized clinical trial of endothermal ablation versus conventional surgery for great saphenous varicose veins.

BACKGROUND: Surgical ligation and stripping (surgery) and endothermal ablation are both effective treatments for varicose veins, improving quality of life (QoL) up to 5 years. Few data are available on long-term outcomes. The aim of this study was to evaluate the outcomes 10 years after interventions in an RCT. Previously this RCT demonstrated that endothermal ablation is associated with superior postprocedural QoL, more rapid recovery, and lower rates of early clinical recurrence. This analysis reports outcomes at 10 years. METHODS: Patients with symptomatic varicose veins owing to unilateral great saphenous vein reflux were randomized to either surgery or endovenous laser ablation (EVLA). Outcomes at 10 years included clinical recurrence and QoL. RESULTS: Data were obtained for 206 of 280 patients (73.6%) at 10 years. Both groups retained significant QoL improvement compared with pretreatment levels (Aberdeen Varicose Vein Questionnaire (AVVQ), Short Form 36 (SF-36®), and EQ-5D™; P < 0.001). Clinical disease progression from baseline was observed in only 10.7% of patients. The clinical recurrence rate was lower in the EVLA group (37 versus 59%; P = 0.005). The number needed to treat with EVLA to avoid one clinical recurrence within 10 years was five. This was associated with significantly higher (better) generic QoL scores with EVLA in several SF-36® domains, including bodily pain (median 84 (i.q.r. 51-100) versus 62 (41-84); P = 0.009) and general health (77 (62-87) versus 67 (52-82); P = 0.017). AVVQ scores in the EVLA group were also lower (better) (3.1 (0-7.7) versus 6.3 (0.7-13.3); P = 0.029). CONCLUSION: Both surgery and endothermal ablation are effective treatments for varicose veins at 10 years, with durable improvement in QoL and a very low rate of disease progression. However, endothermal ablation was associated with superior clinical and QoL outcomes. Registration number: NCT00759434 (http://www.clinicaltrials.gov).