[Anatomic challenges of foam sclerotherapy for varicose veins]. / Anatomische Herausforderungen der Schaumsklerosierung von Varizen.

BACKGROUND: Foam sclerotherapy is well established in the treatment of varicose veins of different sizes. METHODS: A literature review was performed to determine whether specific anatomical findings could be a limitation for foam sclerotherapy. RESULTS: The following anatomical aspects are relevant as a potential limitation for foam sclerotherapy: treatment of pudendal veins, varicose veins in patients with chronic lymphedema and lymph fistulas. CONCLUSION: In some indications foam sclerotherapy is the treatment of choice. It is an effective and safe treatment option.

Characteristics, risk factors and treatment reality in livedoid vasculopathy - a multicentre analysis.

BACKGROUND: Livedoid vasculopathy (LV) is a rare cutaneous thrombotic disease. It is characterized by occlusion of dermal vessels resulting in livedo racemosa, ulceration and atrophie blanche. Clear guidelines for diagnosis and treatment are missing. OBJECTIVE: The purpose of this study was to better characterize epidemiology, clinical appearance and treatment reality of LV in a well-defined patient cohort. METHODS: The cohort was allocated within a prospective, multicentre, phase IIa trial that investigated the effect of rivaroxaban in LV. RESULTS: Analysis of 27 patients revealed that LV patients had an increased Body Mass Index (BMI; 11/27), hypertension (19/27) and increased levels of lipoprotein (a) (5/12) and homocysteine (10/12) in the blood. The female-to-male ratio was 2.1 : 1, and the median age was 53.0 years [interquartile range (IQR) 40.5-68]. Investigation of the clinical appearance found that 82% of patients had livedo racemosa, and the ankle region was most likely to be affected by ulceration (56-70%). The analysis of patient treatment history showed that heparin was most effective (12/17), while anti-inflammatory regimens were, although often used (17/24), not effective (0/17). CONCLUSION: We add clinical clues for a data supported diagnosis of LV, and we provide evidence that anticoagulants should be administered in monotherapy first line (EudraCT number 2012-000108-13-DE).

[Mimetics of systemic sclerosis]. / Imitatoren der systemischen Sklerose.

BACKGROUND: Systemic sclerosis (SSc) is characterized by heterogeneous clinical symptoms. Peripheral skin fibrosis can be a common symptom. Nevertheless, a variety of diseases with different etiologies are associated with a thickening of the skin and make the initial diagnosis of systemic sclerosis more difficult. OBJECTIVE: The different disease entities that can lead to dermal fibrosis should be differentiated. An earlier diagnosis of SSc would therefore be facilitated. METHODS: A literature search was carried out for clinical pictures that can be associated with skin fibrosis. The clinical picture, the etiology and the treatment of the individual diseases are described. RESULTS: Diseases that can mimic the cutaneous symptoms of SSc include morphea, scleroderma, diabetic cheirarthritis, scleromyxedema, nephrogenic systemic fibrosis and eosinophilic fasciitis. The characteristic pronounced skin involvement, an accompanying Raynaud's phenomenon, capillary microscopy, histopathology and antinuclear antibodies help to enable a differentiation of SSc from its mimics. CONCLUSION: An early differential diagnostic distinction between SSc and other sclerosing diseases is important due to SSc-associated and potentially life-threatening systemic organ involvement. If a diagnosis of SSc has been made, a critical and organ-specific evaluation with respect to pulmonary, gastrointestinal, renal and cardiac involvement is mandatory and should be repeated at regular intervals.

[Specific indications for foam sclerotherapy]. / Spezifische Indikationen zur Schaumsklerosierung.

BACKGROUND: Foam sclerotherapy is well established in the treatment of varicose veins of different sizes. METHODS: A literature review was performed to determine which specific indications for foam sclerotherapy exist. RESULTS: Treatment of venous leg ulcers, varices that might rupture, varicose veins in geriatric patients, pudendal veins and seroma could be determined as specific indications for foam sclerotherapy. CONCLUSION: In some indications, foam sclerotherapy is the treatment option of first choice. It is an effective and safe treatment option.

Are Sonographically Measured Vascular Haemodynamic Parameters Reproducible Using Magnetic Resonance Imaging?

OBJECTIVE/BACKGROUND: Hemodynamic measurements of blood flow in the common femoral vein and artery can be performed readily using duplex sonography. The ratio of venous to arterial volume flow in these vessels, the venous arterial flow index (VAFI), is increased in patients with varicose veins and/or chronic venous disease. The objective was to determine the reproducibility of sonographically measured hemodynamic flow parameters using phase contrast magnetic resonance imaging (MRI). METHODS: Based on hemodynamic volume flow measurements from the common femoral vein and artery the VAFI was calculated in seven patients with varicose veins (C2, Ep, As, Pr) and 32 healthy controls using standard duplex sonography and MRI. RESULTS: Based on duplex sonography, the average VAFI (VAFI_d) was 1.05 ± 0.17. The same ratio, using MRI (VAFI_mri) was 1.05 ± 0.19. There was a significant correlation between the VAFI_d and the VAFI_MRI (p = .0021). In patients with venous disease, the average VAFI_d and VAFI_mri were 1.36 ± 0.21 and 1.36 ± 0.20, respectively. In contrast, in the healthy cohort the VAFI_d was 1.00 ± 0.12 and the VAFI_mri measured 1.01 ± 0.15. As expected, there was a significant difference between the VAFI measured in those with venous disease when compared with that of healthy controls (p < .0001). CONCLUSION: There is a significant correlation between the VAFI measured using sonography and MRI. The study confirmed the elevation of VAFI in patients with chronic venous disease.

Catheter-directed foam sclerotherapy of great saphenous veins in combination with pre-treatment reduction of the diameter employing the principals of perivenous tumescent local anesthesia.

OBJECTIVES: The aim of this study was to evaluate occlusion rates of great saphenous veins (GSV) with a diameter between 5-10 mm that received a pre-treatment size reduction via perivenous tumescent application (TA) followed by catheter-directed foam sclerotherapy (CDFS). METHODS: A prospective blinded randomized clinical trial comparing the occlusion rates of GSV at 1-, 6-, and 12-month follow-up. Fifty patients were included and randomized into two groups. CDFS was performed accessing the GSV at knee level and applying 8 mL of 2% polidocanol-foam (EasyFoam) while the catheter was withdrawn. Strictly perivenous TA was performed in group 1 before applying the sclerosant agent. Occlusion rates and clinical scores were assessed by blinded examiners. RESULTS: After 12 months in group 1 full occlusion was achieved in 73.9%, partial occlusion in 8.7%, and 17.4% were classified as treatment failure. In group 2, 75% of the targeted GSV were fully occluded, 20% were partially occluded, and 5% were diagnosed as treatment failure. Both groups showed a significant reduction of the vein diameter. Patient's tolerance and satisfaction with the treatment was high in both groups. CONCLUSION: No benefit could be found using additional TA to reduce the vein diameter before the treatment.

[Primary antiphospholipid syndrome: newly developed leg ulcer and history of stroke]. / Diagnose eines primären Antiphospholipidsyndroms bei Ulcus cruris unter Marcumar-Therapie.

Antiphospholipid syndrome features not only deep vessel thrombosis but also may have cutaneous manifestations such as Raynaud phenomenon, acral necrosis, livedo reticularis, subcutaneous nodules, and leg ulcers. A 72-year-old man presented with a rapidly progressing leg ulcer. He was already on anticoagulation with warfarin due to atrial fibrillation and disclosed a history of stroke with temporary paresis of the left leg. Histopathology of a biopsy of the edge of the ulcer revealed occlusive arteriosclerosis of medium-sized arteries. Serology showed autoantibodies against cardiolipin, ß2- glycoprotein I, and phosphatidylserine which led to the diagnosis of antiphospholipid syndrome. Therapy with low molecular weight heparin, dexamethasone, and azathioprine in combination with stage-adjusted wound care led to complete healing of the ulcer within 5 months.

Noninvasive bioengineering assessment of the skin barrier function in patients with chronic venous insufficiency.

BACKGROUND: Chronic venous insufficiency (CVI) comprises all symptoms caused by permanent venous and capillary hypertension. While the clinical manifestations of the disease have been well characterized, there is little knowledge on the skin barrier function in the affected patients. OBJECTIVES: The aim of the study was to assess noninvasively the barrier function in patients with CVI stage C2 and stage C4 according to the CEAP classification in comparison with healthy controls (stage C0). METHODS: Thirty patients with CVI without concomitant diseases and 15 healthy, aged-matched controls were recruited for the study. The skin barrier function was assessed by measuring transepidermal water loss (TEWL), capacitance and skin colour symmetrically on the calf, medial and lateral malleolus, posterior arch (arcus venosus) and volar forearm. RESULTS: Compared with the forearm, there was a tendency for increased TEWL and significant reduction of capacitance on all measurement sites on the lower limb. Compared with the control group, the patients with CVI had significantly higher TEWL values on all measurement sites on the lower extremities while no difference in capacitance between patients and controls was observed. CONCLUSIONS: Changes in the epidermal barrier function in patients with CVI are readily detectable by bioengineering methods as early as stage C2 and are manifested by significantly increased TEWL. Our results suggest that the reduced stratum corneum hydration in patients with CVI is due to anatomical differences rather than venous disease. These findings may help better understand the factors contributing to disease progression and its complications.

Genetic and physiologic analysis of the role of uncoupling protein 3 in human energy homeostasis.

By virtue of its potential effects on rates of energy expenditure, uncoupling protein 3 (UCP3) is an obesity candidate gene. We identified nine sequence variants in UCP3, including Val9Met, Val102Ile, Arg282Cys, and a splice site mutation in the intron between exons 6 and 7. The splice mutation results in an inability to synthesize mRNA for the long isoform (UCP3L) of UCP3. Linkage (sib pair), association, and transmission disequilibrium testing studies on 942 African-Americans did not suggest a significant effect of UCP3 on body composition in this group. In vastus lateralis skeletal muscle of individuals homozygous for the splice mutation, no UCP3L mRNA was detectable; the short isoform (UCP3S) was present in an increased amount. In this muscle, we detected no alterations of in vitro mitochondrial coupling activity, mitochondrial respiratory enzyme activity, or systemic oxygen consumption or respiratory quotient at rest or during exercise. These genetic and physiologic data suggest the following possibilities: UCP3S has uncoupling capabilities equivalent to UCP3L; other UCPs may compensate for a deficiency of bioactive UCP3L; UCP3L does not function primarily as a mitochondrial uncoupling protein.

The reproducibility of the ratio of volume flow in the common femoral vein and artery for quantification of the severity of venous insufficiency.

BACKGROUND: The ratio of volume flow in the common femoral vein and artery denoted as venous-arterial Flowindex (VAFI) is significantly increased in venous insufficiency according the clinical grade of the disease. This study was done to investigate the reliability and reproducibility of VAFI as quantitative pattern. PATIENTS AND METHODS: In 43 patients with varicose veins C4-6 EPAS,D,PPR (PVV), 40 with postthrombotic syndrome C4-6 ESAS,D,PPR,O (PTS) and 48 healthy volunteers volume flow in the common femoral vein (VFV) and artery (VFA) were measured by duplex. Division of VFV by VFA calculated VAFI. VAFI-measurement was repeated 5 times at an interval of ten minutes in 63 subjects (23 PVV, 20 PTS, 20 healthy) and it was performed at three different days in 68 subjects (20 PVV, 20 PTS, 28 healthy). RESULTS: Mean VAFI +/- standard deviation was 1.39 +/- 0.26 in PVV, 1.42 +/- 0.26 in PTS and 0.93 +/- 0.13 in healthy veins (p < 0.001). VAFI remained stable and significantly increased (p < 0.001) in PVV and PTS compared to healthy veins during 40 minutes and also within three different days. CONCLUSION: The venous-arterial flowindex VAFI is a reproducible pattern of the hemodynamic severity in venous insufficiency.

[Vascular emergencies in dermatology]. / Vaskuläre Notfälle in der Dermatologie.

Life-threatening vascular complications of the skin are rare and usually reflect underlying systemic diseases. Lesions are sudden in onset, become necrotic and may be severe or life-threatening. Effective management requires an understanding of the underlying medical condition, such as arterial thrombosis, temporal arteritis, calciphylaxis and purpura fulminans. In contrast, the acute painful symptoms of erythromelalgia often lead to an urgent dermatologic consultation but pose no acute risk.

[Duplex ultrasound of post-thrombotic syndrome--quantification of venous flow parameters]. / Die Duplex-Sonographie des postthrombotischen Syndroms--Quantifizierung venöser Flussparameter.

In the last years Duplex-Sonography established itself in the diagnosis of venous diseases. This noninvasive method combines Doppler-ultrasound and real-time sonography. In this way an exact quantitative interpretation of the Dopplersounds in relation to the examined blood vessel is possible. Especially the venous bloodflow of postthrombotic veins will be explored. It will be discussed whether the data measured by Duplex-sonography allow a staging of venous diseases.

[Successful long-term therapy of Stewart-Bluefarb syndrome]. / Erfolgreiche Langzeittherapie bei Stewart-Bluefarb-Syndrom.

The Stewart-Bluefarb syndrome is defined as an unilateral angiodermatitis due to multiple arterio-venous fistules accompanied by acroangiodermatitis resembling Kaposi sarcoma (pseudo-kaposi sarcoma). The acroangiodermatitis is most common on the lower limb. It leads to ulcerated nodules with a high risk of bleeding and infection, as well as edema, pain and seldom limb hypertrophy. Curative therapy requires elimination of the arteriovenous shunts. Surgical destruction of the multiple small fistulae is a limitating factor. A better alternative is embolisation, but this approach carries the risk of ischemia and necrosis. A 32 year old female patient with Stewart-Bluefarb syndrome is presented; she has been successfully treated with embolisation on eight occasions.