Eight-year follow-up of a randomized clinical trial comparing ultrasound-guided foam sclerotherapy with surgical stripping of the great saphenous vein.

BACKGROUND: This was an 8-year follow-up of an RCT comparing ultrasound-guided foam sclerotherapy (UGFS) with high ligation and surgical stripping (HL/S) of the great saphenous vein (GSV). METHODS: Patients were randomized to UGFS or HL/S of the GSV. The primary outcome was the recurrence of symptomatic GSV reflux. Secondary outcomes were patterns of reflux according to recurrent varices after surgery, Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification, Venous Clinical Severity Score (VCSS) and EuroQol Five Dimensions (EQ-5D™) quality-of-life scores. RESULTS: Of 430 patients originally randomized (230 UGFS, 200 HL/S), 227 (52·8 per cent; 123 UGFS, 103 HL/S) were available for analysis after 8 years. The proportion of patients free from symptomatic GSV reflux at 8 years was lower after UGFS than HL/S (55·1 versus 72·1 per cent; P = 0·024). The rate of absence of GSV reflux, irrespective of venous symptoms, at 8 years was 33·1 and 49·7 per cent respectively (P = 0·009). More saphenofemoral junction (SFJ) failure (65·8 versus 41·7 per cent; P = 0·001) and recurrent reflux in the above-knee GSV (72·5 versus 20·4 per cent; P = 0·001) was evident in the UGFS group. The VCSS was worse than preoperative scores in both groups after 8 years; CEAP classification and EQ-5D® scores were similar in the two groups. CONCLUSION: Surgical stripping had a technically better outcome in terms of recurrence of GSV and SFJ reflux than UGFS in the long term. Long-term follow-up suggests significant clinical progression of venous disease measured by VCSS in both groups, but less after surgery. Registration number: NCT02304146 (http://www.clinicaltrials.gov).

Intravenous pressure changes in patients with postthrombotic deep venous obstruction: results using a treadmill stress test.

UNLABELLED: Essentials Little is known about the hemodynamic consequences of deep venous obstructive disease. We investigated pressure changes in 22 patients with unilateral postthrombotic obstruction. Common femoral vein pressure significantly increased after walking, compared to control limbs. Common femoral vein hypertension could explain the debilitating effect of venous claudication. Click to hear Dr Ten Cate's perspective on postthrombotic syndrome SUMMARY: Background Little is known about the hemodynamic consequences of deep venous obstructive disease. Objectives The aim of this study was to investigate the hemodynamic effect of postthrombotic obstruction of the iliofemoral veins and to determine what pressure parameters differentiate best between limbs with post-thrombotic obstructive disease of the iliofemoral veins and those without obstruction. Methods Twenty-two participants with unilateral obstruction of the iliac and common femoral veins underwent a standardized treadmill test with simultaneous bilateral invasive pressure measurements in the common femoral vein and dorsal foot vein. Results Mean age was 42.8 ± 11.9 years and 86.4% of participants were female. Postthrombotic limbs showed a mean common femoral vein (CFV) pressure increase of 28.1 ± 21.0 mmHg after walking, compared with 2.1 ± 6.2 mmHg in control limbs (26.0 mmHg difference; 95% confidence interval [CI], 17.1-34.9). Less difference was observed in the dorsal foot vein (net drop of 36.8 ± 22.7 mmHg in affected limbs vs. 48.7 ± 23.1 mmHg in non-affected limbs, 11.9 mmHg difference; 95% CI, -1.3 to 25.0). Change in CFV pressure after walking yielded the best discrimination between affected and non-affected limbs (area under the receiver operated characteristic curve of 0.94 [95% CI, 0.85-1.00], compared with 0.57 [95% CI, 0.37-0.76] in the dorsal foot vein, P < 0.001). Conclusions Common femoral vein pressure significantly increases during ambulation in patients with iliofemoral postthrombotic obstruction, which could explain the debilitating effects of venous claudication. This is an indication that patients with an iliofemoral obstruction may benefit from further treatment that resolves the deep vein obstruction. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/show/NCT01846780.

Conservative versus surgical treatment of venous leg ulcers: 10-year follow up of a randomized, multicenter trial.

INTRODUCTION: Leg ulcers have a large socio-economic impact. Treatment modalities are either conservative or surgical. Conservative treatment involves local treatment and compression therapy. Surgical treatment of venous ulcers is based on correcting venous hypertension, by treating incompetent superficial, deep, and perforating veins. A prospective randomized multicenter trial comparing surgical treatment (combined superficial and perforating vein surgery) with ambulatory compression therapy was conducted during 1998 and 2001. This paper presents the results of a 10-year follow-up period of this trial. MATERIALS AND METHODS: All patients enrolled in the original prospective trial were approached and invited for additional examination and duplex ultrasound evaluation. Secondary, disease specific and generic quality-of-life (QoL) was assessed. Current ulcer state and recurrence during the follow-up period was assessed. RESULTS: After a mean of 97 months follow up, 80 (41%) out of 196 legs could be inspected. The incidence of "ulcer-free", the main outcome, was significantly (p = 0.007) higher in the surgical group (58.9%), compared to the conservative group (39.6%). Observed ulcer recurrence was 48.9% for the surgical group and 94.3% for the conservative group. The number of incompetent perforating veins appears to be a significant (p < 0.001) risk factor for not being ulcer-free. Disease specific QoL showed no significant difference between the surgical and conservative groups. CONCLUSIONS: The addition of surgical treatment in patients with venous ulceration leads to a significantly higher chance of being ulcer-free, than just ambulatory compression therapy. This effect persists after 10 years of follow up. The number of incompetent perforating veins has a significant effect on the ulcer-state and recurrence.

Quality-of-life in interventionally treated patients with post-thrombotic syndrome.

INTRODUCTION: New developments in the treatment of complex deep venous disease have become available in the last decade. Besides analysing patencies as a surrogate outcome for these treatments we analysed the Quality-of-Life (QoL) changes for successful and failed deep venous treatments. MATERIALS AND METHODS: Patients with proven venous occlusive disease, referred to our department of Venous Surgery at the Maastricht University Medical Centre, were included. After inclusion patients were treated by percutaneous transluminal angioplasty and stenting and when indicated endophlebectomy with an arteriovenous fistula. QoL was assessed with the disease specific VEINES-QOL/Sym and the generic Short-Form (SF)-36 questionnaires preoperatively at baseline and post-operatively after 3, 12 and 24 months. RESULTS: One hundred fifty-three interventions were analysed, showing a primary, assisted primary and secondary patency of respectively 65%, 78% and 89% at 24 months. The VEINES-QOL and Sym scores improved at 3, 12 and 24 months. The overall improvement at 24 months is 22.7 for QoL and 18.18 for Sym with respective p values of 0.013 and 0.016. The improvement of the VEINES-QOL and Sym scores after a successful (patent) treatment remained highly significant (QoL: p < 0.001, Sym: p = 0.004). Also the generic QoL (Short-Form 36v2) shows significant improvement after 12 months for physical functioning (p = 0.004) and role physical (p = 0.004) scales. CONCLUSIONS: The overall patencies of interventions for deep venous pathology are exceptionally good after two years. Concomitantly the VEINES-Sym and VEINES-QOL scores improve significantly for 3, 12, and 24 months when compared to the baseline (T0) after treatment. Successful interventions showed, as expected, a significant greater QoL improvement between T0 and T3, T12, T24 for both VEINES-QOL and VEINES-Sym scores when compared to the failed interventions. The one-year linear improvement of two SF-36 scales (PF and RP) is also significant.

Tumescent, how do I do it?

Local perivenous anaesthesia has evolved from tumescent anaesthesia which has had a huge impact on liposuction procedures. Perivenous anaesthesia has had a similar effect on peripheral venous surgery. Safety during its application is further enhanced when combined with skilled ultrasound guidance and astute operator awareness.

A novel scoring system for lower-extremity venous pathology analysed using magnetic resonance venography and duplex ultrasound.

OBJECTIVES: To present a novel scoring system for lower-extremity venous pathology (the LOVE score) and our experiences using it in our clinical practice to identify venous pathology with duplex ultrasound (DUS) and magnetic resonance venography (MRV). METHOD: A total of 40 patients, 30 suspected of chronic venous disease and 10 with acute deep vein thrombosis (DVT) were examined from the inferior vena cava (IVC) to the popliteal vein using DUS and MRV. The image findings were reported using the LOVE score. RESULTS: The majority of deep veins (368 out of 378 segments) were completely visualized by both our imaging techniques and could be analysed using the LOVE score. Both imaging techniques reported comparable findings with regard to the visualization of thrombus, obstruction, collaterals, trabeculations, anatomic variations and central venous compression (e.g. May-Thurner). CONCLUSIONS: The LOVE score can be used to expand and standardize the documentation of imaging the deep venous system beyond thrombosis, to help identify (optimal) treatment options in patients with venous disease, in both the clinical and research setting. This first assessment shows that both DUS and MRV are capable of systematically identifying a multitude of changes in the venous system.

Dialysis fistulae patency and preoperative diameter ultrasound measurements.

BACKGROUND: This study was designed to investigate the possibility of defining a vascular diameter with a practical cut-off point, which predicts a successful patency for radiocephalic arteriovenous fistulae in dialysis patients. METHODS: This is a retrospective analysis of prospectively gathered data. Consecutive patients (n=148) with chronic renal failure, needing vascular access for haemodialysis, were included if they underwent duplex ultrasound examination to evaluate preoperatively the vascular status and diameters for radiocephalic arteriovenous fistulae (RCAVF) construction. The associations between the diameter of the radial artery and cephalic vein and primary failure at six weeks, primary and secondary patency at one year were investigated. RESULTS: There was no significant association between either radial artery diameter or dilated cephalic vein diameter and primary failure. There was an association between radial artery diameter and primary patency (Overall P=0.042). Males had a significantly larger mean radial artery diameter than females (P=0.005). Gender did not influence primary patency. CONCLUSION: We recommend using radial artery diameters of > or = 2.1 mm and < or = 2.5 mm for RCAVF construction, this diameter category having the highest patency at 1 year. A single cut-off guideline cannot be recommended.

Harnessing haemodynamic forces for the suppression of anastomotic intimal hyperplasia: the rationale for precuffed grafts.

OBJECTIVES: Standardisation of cuff geometry by manufacturing prosthetic precuffed grafts (PCG) theoretically optimises haemodynamic forces. This study was designed in order to determine whether these beneficial flow patterns are replicated in vivo in PCG. PATIENTS AND METHODS: Flow visualisation and Doppler studies performed on anatomically accurate PCG models characterised in vitro anastomotic flow patterns. Thirty-two patients (median age 68 years) in whom autologous vein was unavailable, underwent bypass using PCG. Post-operative analysis included qualitative assessment of flow within the distal anastomosis using Doppler colour flow mapping. Cardiac gating techniques and assessment of velocity distribution were performed to gain additional information. These in vivo results were validated against the bench studies. RESULTS: A cohesive vortex was identified within the distal anastomosis of in vitro models and had an integral relationship with the cardiac cycle. This flow structure was also characterised using Doppler colour flow mapping in both longitudinal and transverse planes, confirming the location of the vortex within the body and proximal part of the anastomosis. Twenty-two patients (69%) undergoing bypass with a PCG underwent successful Doppler assessment one week post-operatively, of whom 17 (77%) had a vortical flow structure identified at the distal anastomosis, similar to that characterised in vitro. Cardiac gating verified the same integral relationship of the vortex with the cardiac cycle as that described in vitro. CONCLUSION: The geometric configuration of precuffed grafts induced vortices within the distal anastomoses in 17 out of 22 patients undergoing arterial reconstruction, thereby harnessing the haemodynamic forces that may suppress anastomotic hyperplasia and improve patency rates.

Flow measurements in dialysis shunts: lack of agreement between conventional Doppler, CVI-Q, and ultrasound dilution.

BACKGROUND: Measuring flow in dialysis shunts is recommended to predict imminent thrombosis. Multiple methods for measuring blood flow are in use. Numerous ultrasound protocols exist which determine volume flow using a conventional Doppler (CD) frequency shift analysis technique. All of these are subject to potentially large errors. Quantitative colour velocity index (CVI-Q) does not make use of the Doppler equation and is more precise in vitro. Ultrasound dilution (UD) measures access flow during dialysis in a non-operator-dependent way. The aim of the present study was to compare these three methods of measuring access flow in vivo for agreement with each other. METHODS: In 38 accesses flow was measured by CD, CVI-Q, and UD. All measurements were done during dialysis. Agreement was determined by intraclass correlation coefficient (ICC=R(i)) and Bland-Altman analysis. RESULTS: ICC between UD and CVI-Q was R(i)=0.56. ICC between UD and CD was R(i)=0.10, and ICC between CD and CVI-Q was R(i)=0.16. Bland-Altman analysis revealed a bias (mean difference) of -38 ml/min between UD and CVI-Q, a bias of 1129 ml/min between UD and CD, and a bias of 1167 ml/min between CVI-Q and CD. CONCLUSIONS: CD measurements did not agree with UD or CVI-Q much higher values were recorded with the former than with the latter two techniques. The agreement between UD and CVI-Q measurements is low but reasonable. Caution must be applied in comparing and interpreting values of access flow measured by different techniques.

Ultrasound-guided percutaneous coil embolization of incompetent perforating veins: not effective for treatment of venous ulcers and recurrent varicosities.

PURPOSE: To investigate the feasibility of ultrasound-guided percutaneous coil embolization of incompetent perforating veins as minimally invasive treatment for venous ulcers and recurrent varicosities in the lower leg. This could be an alternative to surgical ligation of perforating veins. MATERIALS AND METHODS: In 15 patients (six women, nine men; mean age, 50 years), 18 incompetent perforating veins in the lower leg were treated by ultrasound-guided percutaneous placement of embolization coils. RESULTS: Successful vein occlusion with one or more coils was achieved in 12 of the 18 veins (technical success rate, 67%). Clinical symptoms improved in only three of the 15 patients (clinical success rate, 20%). During follow-up (2-12 months), recanalization of coil embolized veins occurred in nine of the 12 initially occluded veins. CONCLUSION: Percutaneous ultrasound-guided coil embolization does not appear to be as effective as subfascial endoscopic perforator surgery in the treatment of incompetent perforator veins.

Validation of duplex ultrasonography in detecting competent and incompetent perforating veins in patients with venous ulceration of the lower leg.

PURPOSE: Incompetent perforating veins play an important role in the etiologic mechanism of venous ulceration and recurrent varicose veins. The anatomic and functional status of the venous system can be evaluated by duplex ultrasonography. To determine the value of this technique in the identification of competent and incompetent perforating veins, a prospective study was performed. METHODS: In patients who underwent subfascial exploration for venous ulceration of the lower leg, the preoperative findings of duplex ultrasonography were compared with the findings at surgical exploration. RESULTS: In 20 consecutive patients, 42 incompetent and 8 competent perforating veins were detected by duplex ultrasonography. During operation the location of all 50 perforating veins appeared to be predicted correctly. Eleven additional perforating veins that had not been detected by duplex ultrasonography were found during operation. The sensitivity and specificity of duplex ultrasonography in predicting the site of perforating veins at the medial side of the lower leg in our study were 79.2% and 100%, respectively, for incompetent perforating veins and 82% and 100%, respectively, for competent and incompetent perforating veins. CONCLUSION: These figures indicate that duplex-guided local exploration of the lower leg in patients with venous ulceration as a result of incompetent perforating veins would miss a substantial number of perforating veins, possibly leading to incomplete healing or recurrent ulceration.