Mechanochemical ablation: disappointing long-term anatomic results and worsening symptoms.

An updated report on the five-year results in the treatment of great saphenous vein incompetence with mechanochemical ablation (MOCA) provides additional evidence for higher rates of anatomic recanalization compared to other treatment modalities and progressive worsening of symptoms with time.

Diagnosis of chronic lliac venous obstruction

Stenting has become the first line of treatment for symptomatic chronic iliofemoral venous obstruction in patients with quality-of-life impairing clinical manifestations who have failed conservative therapy. Patient selection for such intervention is however dependant on clear identification of relevant clinical manifestations and subsequent testing to confirm the diagnosis. In this regard the physician engaged in management of such patients need to be well aware of symptoms and signs of chronic iliofemoral venous obstruction (CIVO), instruments used to grade chronic venous insufficiency (CVI) and determine quality of life in addition to diagnostic tests available and their individual roles. This review serves to provide an overview of the diagnosis of CIVO and patient selection for stenting.

Arterial and venous peripheral vascular assessment using wearable electro-resistive morphic sensors.

Peripheral vascular diseases (PVDs) represent a significant burden on global human health and healthcare systems. With continued growth in obesity and diabetes, it is likely that the incidence of these conditions will increase. As many PVDs remain undiagnosed, low-cost and easy to use diagnostic methods are required. This work uses newly developed wearable electro-resistive morphic sensors to assess venous and arterial competence in the lower limbs of 36 healthy subjects. Comparison of this HeMo device was made to currently available benchtop light reflection rheography and photoplethymography devices. Results indicate that HeMo can detect the physiological signals of interest for both chronic venous insufficiency and peripheral arterial disease and all subjects were interpreted as healthy by each system. However, measurement repeatability of HeMo was highlighted as an issue that requires further system development. Furthermore, as HeMo captures changes in a section of limb circumference due to changes in underlying blood movement, rather than at a single point, the recorded signal is typically damped by comparison. This factor should be considered in any future developments.

A comparison of tablet-based and paper-based venous insufficiency epidemiologic and economic study quality of life/symptom questionnaire for assessment of chronic venous disease.

OBJECTIVE: To comparatively evaluate performances of tablet-based versus paper-based Venous Insufficiency Epidemiologic and Economic Study-Quality of Life/Symptom (VEINES-QOL/Sym) questionnaire. METHODS: We prospectively evaluated 78 consecutive patients who completed tablet-based and paper-based VEINES-QOL/Sym questionnaires and compared their scores, completion time, data entry time, and ease of use. We used Student's t-test and Wilcoxon test for quantitative variables, Bland-Altman test and kappa coefficient for agreement between questionnaires and patients, respectively. Spearman's correlation coefficient was used to assess correlations. RESULTS: Most participants (83.3%) found it easier to use the tablet device. Less time was needed to complete the tablet-based (median, 4.75; IQR, 3-7 min) than the paper-based (median, 8.3; IQR, 6.3-11.3 min) questionnaire (p < .001). Better educated patients took less time to complete paper-based (p = .003) and tablet-based (p = .001) questionnaires and considered the latter easier to use (p = .010). CONCLUSIONS: The tablet-based VEINES-QOL/Sym proved to be an easy-to-use and time-saving tool.

Risk factors for venous ulceration in patients with varicose veins of lower extremities.

The aim of this case-control study was to explore the potential risk factors for venous ulceration in patients with varicose veins of lower extremities and to establish a simplified diagnostic score model. Seventy subjects with varicose veins of lower extremities and venous ulceration were compared with 1164 controls with varicose veins of lower extremities and no history of venous ulceration. Stepwise multivariate logistic regression analysis was used to identify the risk factors for venous ulceration. The steps in developing the diagnostic score model were based on the Framingham Heart study. The area under the receiver operating characteristic curve (AUC) was calculated to assess the diagnostic ability of the diagnostic score model. Multivariate analysis showed that men, overweight, obesity, longer duration varicose veins, deep venous valve insufficiency, low lymphocyte counts, and high fibrinogen content were independently associated with an increased risk of venous ulceration. The AUC for the diagnostic score model was 0.75, which indicated good discriminatory ability. Special attention should be paid to the high-risk group of patients with lower extremity varicose veins. The diagnostic score model might be a useful screening tool for clinicians, policy makers, and patients.

Diagnosing and Managing Venous Stasis Disease and Leg Ulcers.

Venous insufficiency is a common medical condition that affects many individuals, especially those with advanced age. Chronic venous insufficiency can lead to secondary cutaneous changes that most commonly present as stasis dermatitis but can progress to more serious venous ulcers. Although venous ulcers are the most common cause of lower extremity ulcers, the differential diagnosis of leg ulcers is broad. This article will discuss clinical clues to help guide patient workup and will review basic clinical evaluation and management of common leg ulcers.

Prevalence, clinical presentation, and risk factors of chronic venous disease in Cameroon: A general population-based study.

INTRODUCTION: Chronic venous disease is a global public health problem, with high morbidity and economic distress. There is scarcity of data on this disease in sub-Saharan Africa. METHODS: We conducted the first population-based study over a period of 20 months from 1st February 2020 to 30th September 2021 in the 10 regions of Cameroon. A stratify sampling method was chose to select study site. Socio-demographic data, personal and family history, anthropometric parameters, clinical signs, illustrative images, CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification revised in 2004, VCSS (venous Clinical Severity Score) and risk factor assessment score were used to construct the survey form. Chi-squared test and Fischer exact test were used to compare the prevalence of chronic venous disease across different potential risk factors (sex, age category, previous history of deep vein thrombosis, hypertension, diabetes, smoking status, obesity). Simple and multiple logistic regression models were used to obtain crude and adjusted odds ratio for risk factors associated with chronic venous insufficiency. Statistical analyses were done with R version 4.2 for Linux and the threshold for statistical significance was 0.05. RESULTS: A total of 6578 participants were included in the study, with a mean age of 41.09 ± 16.02 years with female predominance (54.3%). The prevalence of chronic venous disease was 21.8% (95% CI: 20.8-22.9) and the prevalence of chronic venous insufficiency (C3-C6) was 7.02% (n = 462). Night cramps (43.2%), oedema (21.7%), lower limbs pain (20.4%) mostly worsens by walking and heavy legs (16.2%) were more common symptoms. The mean total venous clinical severity score was 0.69 ± 1.76 and this score had a significant positive correlation with C classification (p < .001). In the multivariate analysis, the following factors were independently associated with CVD: Male gender (aOR: 1.27; 95%CI: 1.04-1.56; p = .021), retired people (aOR: 46.9; 95% CI: 12.6-174.5; p < .001), hypertension (aOR: 289.5; 95%CI: 169.69-493.1; p < .001), diabetes (aOR: 2.19; 95% CI: 1.21-3.96; p = .009), obesity (aOR: 10.22; 95%CI: 7.67-13.62; p < .001). Smoking appears as a protective factor (aOR: 0.18; 95%CI: 0.10-0.30; p < .001). CONCLUSION: Chronic venous disease is frequent in Cameroon and main traditional cardiovascular risk factors are associated to this condition. Systematic screening of the CVD in these specific groups could reduce the burden of the disease and its economic impact.

Enhancing identification and treatment of patients with concomitant chronic venous insufficiency and diabetes mellitus. A modified Delphi study from the CODAC (ChrOnic venous disease and Diabetes Advisory Council) group.

BACKGROUND: Chronic venous insufficiency (CVI) and diabetes mellitus (DM) pose significant burdens to patients and healthcare systems. While the two diseases share a number of commonalities in risk factors and pathophysiology, they are often assessed and managed separately. This can lead to a worsening of comorbidities and limitations in a patient's quality of life. This project aims to develop recommendations to enhance the identification and treatment of patients with concomitant CVI and DM. METHODS: Using a modified Delphi method, a panel of experts developed 38 Likert Scale and two multiple choice questions across six key themes. These were used to form an online survey which was disseminated through a convenience sampling approach to CVI and DM healthcare professionals across Europe, Central America, South America, and the Middle East. The threshold for consensus was set at ≥75%. RESULTS: A total of 238 responses were received. 27/38 statements attained >90% agreement, nine of 38 attained between 75-90%, and two failed to meet the threshold (<75%). The awareness around the impact of the two diseases was high, but a gap was highlighted in the identification of patients with concomitant CVI and DM. CONCLUSIONS: The high level of agreement shows that healthcare professionals are aware of the gaps in identification and treatment of patients with concomitant CVI and DM, and of the need to approach this as a combined therapy area. An algorithm is proposed to help the identification of at-risk patients and to provide recommendations on the management of patients with concomitant disease.

[Comparison of three dimensional CT venography and ascending phlebography based on propensity score matching in the evaluation of recurrent varicose veins].

Objective: To compare the efficacy of lower extremity three dimensional CT venography (CTV) and lower extremity ascending phlebography in evaluating recurrent varicose veins. Methods: A retrospective analysis was conducted on clinical data from 235 patients with unilateral recurrent varicose veins who were treated at the Department of Vascular Surgery,Beijing Shijitan Hospital,Capital Medical University, between January 2015 and December 2020.There were 112 males and 123 females, with an age of (62.5±11.4)years (range:24 to 75 years).Patients were stratified into two groups based on preoperative imaging examination:the CTV group (utilizing lower extremity venous ultrasound+lower extremity CTV) and the control group (employing lower extremity venous ultrasound+lower extremity ascending phlebography).The two groups were matched in a 1∶1 ratio using propensity score matching, resulting in 43 cases per group.Comparative analyses between the groups at the one-year postoperative follow-up were performed using independent sample t tests, Wilcoxon rank-sum tests, χ2 tests, and linear regression analysis. Results: One year post-surgery,the CTV group exhibited a lower venous clinical severity score (VCSS) compared to the control group(M(IQR),3.0(4.3) vs.4.0(5.8),Z=-2.038,P=0.040).Additionally, the chronic venous insufficiency patients' quality of life questionnaire (CIVIQ-20) scores were significantly higher in the CTV group than in the control group (89.0(8.0) vs.82.5(17.0), Z=-2.627, P=0.010).Patients in the CTV group also experienced a shorter ulcer healing time compared to the control group (4.0(4.0) weeks vs.12.0(7.0) weeks, Z=-3.217,P<0.01).Both groups showed no clinically symptomatic recurrent varicose veins or ulcers.However, they exhibited ultrasound-detectable varicose vein recurrence, with no statistically significant difference (χ2=0.453,P=0.500).The number of diseased vessels requiring management based on ultrasound supplemented by CTV was 16, while the number supplemented by ascending phlebography was 7,with a statistically significant difference (χ2=4.800,P=0.030).Linear regression analysis demonstrated that clinical-etiology-anatomy-pathology clinical grading and the preoperative imaging examination method exerted independent influences on VCSS and CIVIQ-20 during the one-year postoperative assessment. Conclusions: CTV-assisted ultrasound enables a direct and comprehensive evaluation and localization of diseased veins in patients with recurrent varicose veins.The utilization of lower extremity vein ultrasound combined with CTV-guided management of lower extremity vessels in minimally invasive treatment significantly improves patient prognosis, surpassing the assessment provided by ascending phlebography.

Varicose Veins: Approach, Assessment, and Management to the Patient with Chronic Venous Disease.

Varicose veins are tortuous and dilated veins commonly seen in chronic venous disease. This article will review chronic venous disease, including its differential diagnosis, workup, and treatment.

Calf extra-Fascial compartment area affects calf muscle pumping action: an air plethysmography and computed tomography study.

OBJECTIVES: We aimed to elucidate whether lower limb extra-fascial compartment and muscle areas affect the calf muscle pumping action on lower limbs. METHOD: This study included 90 patients (180 limbs) who underwent preoperative air plethysmography (APG) and preoperative non-contrast computed tomography (CT) of the lower limbs for diagnosis of unilateral or bilateral primary varicose veins. A correlation between cross-sectional CT images and preoperative APG was confirmed. Cross-sectional CT was used to measure the extra-fascial compartment and muscle areas of the calf. The lower limbs were divided into two groups: those that were normal and those with primary varicose veins. RESULTS: The extra-fascial compartment area was significantly correlated with the ejection fraction in normal (r = 0.388, n = 53, p = 0.004) and varicose limbs (r = 0.232, n = 91, p = 0.027). CONCLUSIONS: In normal and varicose limbs, evaluation of ejection fraction, an indicator of muscle pumping, requires consideration of the extra-fascial compartment area.

Quality of Life in Chronic Venous Disease: Bridging the Gap Between Patients and Physicians.

Chronic venous disease (CVD) has a negative impact on patients' quality of life (QoL). This was demonstrated in the recent Patient Journey on CVD study, which examined QoL in patients with early- and advanced-stage CVD (Clinical, Etiological, Anatomical and Pathophysiological classification C0 to C4), and the gaps between the way in which physicians and patients viewed the impact of CVD on QoL. The study was conducted in five countries (Brazil, China, Czech Republic, Italy and Russia) and included 100 patients with CVD and 60 CVD specialists. Patients completed the 14-item Chronic Venous Insufficiency Questionnaire (CIVIQ-14) to assess their QoL, and all patients and physicians were questioned during a 60-minute qualitative structured interview, focusing on four key dimensions-physical symptoms, aesthetics/appearance, emotional impact and impact on relationships. The study found that physicians tended to focus more on physical symptoms than on other impacts of CVD and rarely measured QoL in clinical practice. Patients were significantly less satisfied with the management of their QoL than physicians perceived them to be. About 25% of patients with CVD reported disturbed sleep, but physicians did not routinely ask them how CVD affected their sleep. These data reinforce the importance of physicians obtaining information about the impact of CVD on all aspects of the patient's life, including sleep and QoL. Evidence from randomised controlled trials and real-world studies demonstrates that some veno-active drugs, particularly micronised purified flavonoid fraction, can positively impact QoL in patients with CVD.

Improving Chronic Venous Disease Management with Micronised Purified Flavonoid Fraction: New Evidence from Clinical Trials to Real Life.

Chronic venous disease (CVD) develops in the microvessels, and is perpetuated by a vicious cycle of inflammation and endothelial activation, structural and functional changes to vessels and valves, and progressive venous hypertension. Data from animal models indicate that micronised purified flavonoid fraction (MPFF) has beneficial effects on a range of pathophysiological processes that contribute to CVD, including inflammation, micro-vessel permeability, valve and vessel wall remodelling, and reflux in microvalves. These effects explain its beneficial effects on the signs and symptoms of CVD, which have been seen across the spectrum of Clinical, Etiological, Anatomical and Pathophysiological (CEAP) categories of CVD severity. This includes patients with symptoms but no detectable anatomical or pathophysiological anomalies (C0s or C1) and patients with varicose veins (C2). In addition to symptomatic improvement, MPFF has been shown to reduce oedema in patients with C3 CVD, resolve skin symptoms in patients with C4 CVD, and accelerate the healing of venous ulcers in patients with C6 CVD. MPFF is highly recommended in international guidelines of CVD management and is the only veno-active drug to receive guideline endorsement for an improvement in patient quality of life.

Female Gonadal Venous Insufficiency in a Clinical Presentation Which Suggested an Acute Abdomen-A Case Report and Literature Review.

Pelvic venous insufficiency (PVI) is frequently associated with symptoms of abdominal pain or discomfort that is overlooked or under-diagnosed in women. Despite the fact that pelvic venous insufficiency in men is very well documented, its occurrence in women needs to be further studied. Patients with pelvic varicose veins undergo a long and inconclusive diagnostic work-up before the exact cause of the symptoms is identified. Gonadal venous insufficiency (GVI) is a condition that can present acutely, leading to diagnostic challenges. We present a case report of a 47-year-old female with acute abdominal pain and GVI, where endovascular embolization was used for successful treatment. The patient was diagnosed with GVI based on imaging findings of an enlarged left ovarian vein with retrograde flow and dilated pelvic veins seen on magnetic resonance imaging (MRI) with contrast material. Due to the severity of her symptoms and imaging findings, endovascular embolization was chosen as the treatment modality. The embolization was successful, and the patient's symptoms resolved completely. This case highlights the challenge of diagnosing GVI with acute clinical expression and the potential benefits of endovascular embolization as a treatment option. Further studies are needed to determine the optimal management strategies for acute GVI, but endovascular embolization should be considered a safe and effective option. At the same time, we present a short review of the recent literature data related to this topic.

Optimising Decision Making in Chronic Venous Disease Management with Micronised Purified Flavonoid Fraction.

Evidence-based medicine favours randomised controlled trials to limit bias and establish the effects of a treatment with statistical rigour. However, the controlled conditions and careful patient selection of randomised trials may produce results that cannot be generalised to a more diverse patient population in clinical practice. Therefore, there is growing recognition of the importance of supplementing randomised trial data with real-world evidence. Micronised purified flavonoid fraction has been investigated in several large-scale real-world studies, including the RELIEF and DECIDE studies, each of which included more than 1000 patients with chronic venous disease. These studies demonstrated a significant reduction in the prevalence and severity of chronic venous disease symptoms, and an improvement in quality of life. The chronic VEnous dIsorders maNagement and treatment effectivenesS evaluaTion in chronic vEnous disease, an international Program (VEINSTEP) study (NCT04574375), is currently underway in more than 6000 patients with chronic venous disease in nine countries. Preliminary data from one country (Morocco) indicate that chronic venous disease drug treatment, which was micronised purified flavonoid fraction in 75.7% of patients, was associated with a statistically significantly reduction in symptoms and improved quality of life. The overall results are awaited with interest. International chronic venous disease guidelines grade the evidence for micronised purified flavonoid fraction highly, as the benefits of micronised purified flavonoid fraction have been proven in randomised clinical trials and meta-analyses. Real-world studies demonstrate that the randomised evidence for micronised purified flavonoid fraction is generalisable to a clinical practice setting. Treatment decisions in chronic venous disease should consider evidence-based recommendations, including real-world data, as well as patient goals of symptom relief, functional improvement and/or better quality of life.

Association between lower extremity venous insufficiency and increased choroidal thickness.

PURPOSE: The goal of this study is to investigate the association between the choroid and lower extremity venous insufficiency (LEVI). METHODS: This prospective cross-sectional study includes 56 patients with LEVI and 50 age/sex-similar control subjects. Choroidal thickness (CT) measurements from 5 different points were captured from all participants by optical coherence tomography. In the group with LEVI on physical examination, reflux at the saphenofemoral junction, and the diameter of the great and small saphenous veins were evaluated via color Doppler ultrasonography. RESULTS: The mean subfoveal CT was higher in the varicose group than in the control group (363.04±99.75µm vs. 320.30±73.46µm, P=0.013). In addition, the CTs at the temporal 3mm, temporal 1mm, nasal 1mm, and nasal 3mm distance from the fovea were higher in the LEVI group compared to the controls (for all, P<0.05). There was no correlation between CT and diameter of the great and small saphenous vein in patients with LEVI (for all, P>0.05). However, the great and small saphenous veins of patients with CT above 400µm were observed to be wider in patients with LEVI (P=0.027 and P=0.007, respectively). CONCLUSION: Varicose veins can be a feature of systemic venous pathology. Another component of systemic venous disease may be increased CT. Patients with high CT should be investigated for susceptibility to LEVI.

[The term mixed leg ulcer should no longer be used today]. / Der Begriff Ulcus cruris mixtum sollte heute nicht mehr verwendet werden.

A wound on the lower legs of patients with chronic venous insufficiency (CVI) and peripheral arterial disease (PAD) is today usually referred to as a mixed leg ulcer. This does not take into account the different stages of the diseases and, thus, their pathophysiological relevance. In everyday clinical practice, this often leads, among other things, to these patients not receiving compression therapy. The multidisciplinary professional association Initiative Chronische Wunden (ICW) e. V., therefore, recommends that this undifferentiated and misleading term should no longer be used. Instead, a leg ulcer with advanced CVI and concomitant PAD in stage I-IIb according to Fontaine or Rutherford category 0-3 should be classified as a venous leg ulcer, while a leg ulcer with advanced PAD in stage III or IV according to Fontaine or Rutherford category 4-6 and advanced CVI is termed an arteriovenous leg ulcer. A leg ulcer in advanced PAD stage IV according to Fontaine or Rutherford category 5 or 6 without advanced CVI is called an arterial leg ulcer. Other relevant comorbidities with an influence on wound healing should also be described separately.

Effect of Obesity and Bariatric Surgery on Saphenous Veins.

PURPOSE: Obesity is a risk factor for chronic venous disease (CVD) of the lower limbs (LL), affecting venous anatomy and physiology. Weight loss after bariatric surgery (BS) can reduce intra-abdominal pressure, improve mobility, and ultimately improve venous hemodynamics and CVD-related symptoms. There are no studies in the literature that adequately assess the effect of the obesity and BS on the LL veins, especially the saphenous veins (SV). The aim of this study was to evaluate the effects of obesity and BS on the saphenous veins. METHODS: This is a longitudinal prospective study carried out from 2019 to 2021 with 19 patients, totaling 38 LL, underwent clinical evaluation (CEAP Classification) and by Doppler ultrasonography, to analyze their SV diameter and reflux measurements, in the preoperative period and again 6 months to 2 years after BS being performed. RESULTS: There was no statistical difference between the groups regarding the characteristics of reflux in the SV among the evaluated LL. There was no significant increase in the diameter of the great SV in the majority of its segments. The groups were similar in terms of the small SV diameters. Moreover, a significant reduction in the clinical class of CEAP was observed after BS. CONCLUSION: Obesity and bariatric surgery had no influence on diameter or reflux in saphenous veins, but a reduction in the CEAP Clinical Classification was observed in the postoperative period.

Characteristics of ulcerated and non-ulcerated necrobiosis lipoidica.

BACKGROUND: Necrobiosis lipoidica (NL) is complicated by ulceration in up to 35% of cases. METHODS: Retrospective study of patients with NL seen at our institution between January 1, 1992, and May 25, 2021, was conducted. Ulcerated NL (UNL, n = 83) and non-ulcerated NL (NUNL, n = 233) groups were compared. RESULTS: Twenty-six percent (83/316) of patients with NL experienced ulceration. UNL was significantly more likely to be painful (52% vs. 36%, P = 0.01), was more likely to have a lesion-associated cutaneous malignancy (7% vs. 0%, P < 0.001), and had a larger median size (7 vs. 5 cm, P = 0.004) compared to NUNL. Vascular studies were performed on a subset of patients and revealed transcutaneous oxygen pressure (TcPO2) < 40 mm Hg in 53% and venous insufficiency in 62% with no significant differences between UNL and NUNL groups. In patients with unilateral ulceration, mean TcPO2 values (39.7 vs. 46.6 mm Hg), regional perfusion index <0.6 (29% vs. 14%), and TcPO2 < 40 mm Hg (43% vs. 14%) were worse in the ulcerated leg compared to the non-ulcerated leg, but these differences were not statistically significant. CONCLUSIONS: UNL was more likely to be painful, develop lesion-associated malignancy, and be larger in size compared to NUNL. There were no statistically significant differences in venous insufficiency, arterial Doppler/ankle brachial index, or TcPO2 values between UNL and NUNL patients, however, a significant portion of the cohort demonstrated abnormal vascular studies, particularly on TcPO2 and venous insufficiency testing.