[Varicosis-Current treatment concepts]. / Varikosis ­ aktuelle Therapiekonzepte.

Varicosis is a chronic progressive disease characterized by varicose veins of the lower extremities. Pain, swelling and heaviness of the legs are typical symptoms. These symptoms are caused by a pathological venous reflux, arising from a weakness of the vein wall and progressive venous insufficiency. The indications for invasive surgery are the symptomatic clinical, etiological, anatomical, pathophysiological (CEAP) stages C2s-C6. Compression therapy and venoactive drugs can be recommended for conservative therapy. When it comes to surgical treatment conventional open vein surgery is associated with the best long-term results. Endovenous thermal ablation is associated with few postoperative complications and favors earlier mobilization of the patient. Sclerotherapy has become established with good clinical results for the ablation of reticular and telangiectatic veins, for recurrences and complicated vein anatomy.

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.

[Pelvic congestion syndrome : from diagnosis to treatment]. / Syndrome de congestion pelvienne : du diagnostic au traitement.

Pelvic congestion syndrome is a debilitating condition that is often under-diagnosed and under-treated, defined by chronic pelvic pain in the presence of pelvic varicose veins in women or, more rarely, in men. The differential diagnosis of chronic abdominal pain is vast and often leads to lengthy and costly diagnostic procedures. Conservative treatment is often insufficient, and embolization of pelvic varices is the treatment of choice to improve symptoms. A multidisciplinary management algorithm is proposed to facilitate the clinical path for these patients.

Le syndrome de congestion pelvienne est une maladie invalidante souvent sous-diagnostiquée et sous-traitée, définie par de douleurs pelviennes chroniques, en présence de varices pelviennes chez les femmes ou plus rarement les hommes. Le diagnostic différentiel des douleurs chroniques abdominales est vaste et mène souvent à des parcours diagnostiques longs et coûteux. Le traitement conservateur est souvent insuffisant et une embolisation des varices pelviennes est le traitement de choix pour améliorer la symptomatologie. Un algorithme de prise en charge multidisciplinaire est proposé afin de faciliter le parcours de soins de ces patients.

Risk of osteoporosis among individuals with varicose veins: a multi-institution cohort study.

The present study showed a significant association between varicose veins and the development of osteoporosis, especially women and patients older than 50 years. Physicians should be alerted to this issue and consider screening for osteoporosis in patients with varicose veins. PURPOSE: Osteoporosis might be associated with many skin diseases. However, only a paucity of data addressing the association between varicose veins and subsequent osteoporosis development. The study was aimed to evaluate whether there is an increased risk of osteoporosis among patients with varicose veins. METHODS: This multi-institution database study was based on Chang Gung Research Database from January 1, 2003, to December 31, 2015. Patients aged 20 years and older with varicose veins were enrolled. Participants in the control group were selected by matching in a 4:1 ratio by sex, age, index date, and comorbidities. The hazard ratios associated with osteoporosis were estimated using Cox regression analysis with competitive risk model. Incidence rate of osteoporosis was assessed in individuals with and without varicose veins. RESULTS: A total of 11,959 patients with varicose veins and 47,633 matched controls were enrolled in the study. The varicose veins group had higher incidence rates than the control group for osteoporosis (46.40 vs 31.92 per 10,000 person-years; adjusted HR 1.481 [95%CI, 1.314-1.669; P < 0.001]). Compared with matched controls, varicose veins patients with or without venous ulcers had 1.711- and 1.443-times increased risk of developing osteoporosis, respectively. Subgroup analysis showed varicose veins were associated with osteoporosis in women and patients older than 50 years. CONCLUSION: The present study demonstrated individuals with varicose veins had an increased risk of osteoporosis. Physicians should be alerted to this issue and consider screening for osteoporosis in patients with varicose veins, especially among women and patients older than 50 years.

Unsuccessful linguistic validation of the Symptom Questionnaire for assessing quality of life in Polish patients with pelvic vein disorders.

Pelvic venous disorder (PeVD) is a prevalent chronic condition characterized by the presence of varicose veins in the pelvis, leading to the development of chronic pelvic pain. Despite the growing interest in assessing quality of life in PeVD, well-designed and validated disease-specific questionnaires are missing. The objective of this study was a linguistic and clinical validation of the Symptom Questionnaire (SQ) in a cohort of Polish females with pelvic vein incompetence. The Polish version of SQ was developed using a standardized validation process that involved a back-and- forth translation protocol. A total of 58 female patients diagnosed with pelvic varicose veins, representing diverse educational back- grounds, participated in the study. Multiple issues were observed during linguistic validation, primarily originating from disparities between the Polish and British healthcare systems, as well as differing levels of sexual health education of those two populations. Cronbach α was calculated separately for each part of the questionnaire with results exceeded 0.6 for each section. Test-retest analysis indicated most Pearson correlation coefficients surpassing 0.70. The absolute agreement consistency between pretest and post-test measures, evaluated using the Intra Class Correlation (ICC), exceeded 0.8 in three sections and 0.7 in the remaining three sections. However, the clinical validation failed due to the lack of standardized score calculation proposed by the authors of the questionnaire and inaccurately assigned values in the answer key for five questions. Consequently, the practical utility of SQ in daily clinical settings remains uncertain, highlighting the urgent need for the development of a new, user-friendly questionnaire specifically tailored to assess the quality of life in individuals with PeVD.

Proposed public policies to improve outcomes in vascular surgery: an experts' forum.

OBJECTIVE: To evaluate outcomes of vascular surgeries and identify strategies to improve public vascular care. METHODS: This was a descriptive, qualitative, and cross-sectional survey involving 30 specialists of the Hospital Israelita Albert Einstein via Zoom. The outcomes of vascular procedures performed in the Public Health System extracted through Big Data analysis were discussed, and 53 potential strategies to improve public vascular care to improve public vascular care. RESULTS: There was a consensus on mandatory reporting of some key complications after complex arterial surgeries, such as stroke after carotid revascularization and amputations after lower limb revascularization. Participants agreed on the recommendation of screening for diabetic feet and infrarenal abdominal aortic aneurysms. The use of Telemedicine as a tool for patient follow-up, auditing of centers for major arterial surgeries, and the concentration of complex arterial surgeries in reference centers were also points of consensus, as well as the need to reduce the values of endovascular materials. Regarding venous surgery, it was suggested that there should be incentives for simultaneous treatment of both limbs in cases of varicose veins of the lower limbs, in addition to the promotion of ultrasound-guided foam sclerotherapy in the public system. CONCLUSION: After discussing the data from the Brazilian Public System, proposals were defined for standardizing measures in population health care in the area of vascular surgery. Notification of complications of arterial surgeries is essential in identifying strategies to improve surgical outcomes. Screening of prevalent and/or morbid diseases allows early intervention and prevention of complications. Use of telemedicine in vascular follow-up allows optimizing the use of resources and reducing the burden on health services. Concentrating complex cases in reference hospitals leads to improved surgical outcomes.

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.

High Physical Activity Volume Is Associated With an Increase in the Calibre of the Lower Limb Veins Without Impact on Functional Discomfort: the VARISPORT Study.

OBJECTIVE: The relationship between physical activity and lower limb veins is complex. If a sedentary lifestyle is considered to be negative on lower limb veins, specific information on physical activity varicose vein volume is sparse, especially the effect of high physical activity volume. The main objective of the VARISPORT study was to evaluate lower limb veins (clinically, morphologically, and haemodynamically) and chronic venous disease symptoms in subjects exposed to high physical activity volume compared with a group of non-exposed subjects. METHODS: A cross sectional study compared a group of high exercise training volume volunteers (more than eight hours of uninterrupted vigorous intensity physical activity per week for more than six months: high physical activity volume group, HPAV group) with a volunteer control group matched for age, sex, and body mass index. Clinical examination was performed to determine the Clinical, Etiological, Anatomical, Pathophysiological (CEAP) classification of each subject and the Carpentier score was used to assess symptoms related to possible chronic venous disease. Duplex ultrasonography was used to assess vein diameters and reflux in the deep and superficial veins. RESULTS: One hundred and nineteen subjects were included in each group. The lower limb veins (deep and superficial) were significantly more dilated in the HPAV group. More reflux was found in the great saphenous veins and non-saphenous veins in the HPAV group. High physical activity volume was associated with a higher frequency of visible varicose veins (stage C2 of the CEAP classification), odds ratio 3.37 (95% confidence interval 1.66 - 7.25) without impact on functional discomfort (44 subjects with a Carpentier score ≥ 1 in each group). CONCLUSION: The VARISPORT study reported an increase in the calibre of the lower limb veins without impact on functional discomfort. Further studies are needed to determine whether these athletic veins are truly pathological varicose veins or simply an adaptation to high physical activity volumes.

The relative area score for sublingual varices reliability measurement: a diagnostic study.

BACKGROUND: Sublingual varices (SV) and their predictive potential for other clinical parameters is a much studied topic in oral medicine. SVs have been well studied as predictive markers for many common diseases such as arterial hypertension, cardiovascular disease, smoking, type 2 diabetes mellitus and age. Despite many prevalence studies, it is still unclear how the reliability of SV inspection affects its predictive power. The aim of this study was to quantify the inspection reliability of SV. METHODS: In a diagnostic study, the clinical inspection of 78 patients by 23 clinicians was examined for the diagnosis of SV. Digital images of the underside of the tongue were taken from each patient. The physicians were then asked to rate them for the presence of sublingual varices (0/1) in an online inspection experiment. Statistical analysis for inter-item and inter-rater reliability was performed in a τ-equivalent measurement model with Cronbach's [Formula: see text] and Fleiss κ. RESULTS: The interrater reliability for sublingual varices was relatively low with κ = 0.397. The internal consistency of image findings for SV was relatively high with α≈ 0.937. This shows that although SV inspection is possible in principle, it has a low reliability R. This means that the inspection finding (0/1) of individual images often cannot be reproduced stably. Therefore, SV inspection is a difficult task of clinical investigation. The reliability R of SV inspection also limits the maximum linear correlation [Formula: see text] of SV with an arbitrary other parameter Y. The reliability of SV inspection R = 0.847 limits the maximum correlation to [Formula: see text] (SV, Y) = 0,920-a 100% correlation was a priori not achievable in our sample. To overcome the problem of low reliability in SV inspection, we propose the RA (relative area) score as a continuous classification system for SV, which normalises the area of visible sublingual veins to the square of the length of the tongue, providing a dimensionless measure of SV. CONCLUSIONS: The reliability of the SV inspection is relatively low. This limits the maximum possible correlation of SV with other (clinical) parameters. SV inspection reliability is an important indicator for the quality of SV as a predictive marker. This should be taken into account when interpreting previous studies on SV and has implications for future studies. The RA score could help to objectify the SV examination and thus increase its reliability.

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.

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.

A Case of Intra-Amniotic Umbilical Vein Varices Misdiagnosed as an Omphalocele.

Background: Intra-amniotic umbilical vein varices are characterized by a focal dilatation of the extra abdominal umbilical vein. Case report: We report a full-term baby female with extra-abdominal umbilical vein varices misdiagnosed clinically as an omphalocele. The umbilical vein was ligated and excised near the level of the liver. The infant died one day after surgery due to extrinsic compression of the renal pedicle by a massive thrombus, resulting in severe renal failure and life-threatening hyperkalemia despite intensive resuscitation. Conclusion: Large intra-amniotic umbilical vein varices can be clinically misdiagnosed as an omphalocele. Their resection near the level of the fascia, as with normal umbilical veins, could be a better management with a better prognosis.

Individual and population screening of varices needing treatment by a simple, safe and accurate test.

BACKGROUND: Several tests have been developed to screen varices needing treatment (VNT) in different screening settings. We aimed to develop simple estimators to quantify VNT risk and spare endoscopy while missing <5% of VNT, adapted to different screenings in the main etiologies. METHODS: 2,368 patients with chronic liver disease were included. The main VNT predictors were platelets, prothrombin index (PI) and LSM. Their interactions led to score construction, LIP: (LSM*45)/(PI*platelets), and BLIP: BMI-adjusted LIP in NAFLD. Scores were categorized either for population (VNT sensitivity ≥95%) or individual (negative predictive value ≥95%) VNT screening. RESULTS: 1) Scores diagnosing VNT. AUROCs were, PLER: 0.767 Anticipate: 0.773 (p=0.059 vs previous), LIP: 0.779 (p=0.136), PLEASE: 0.789 (p=0.196). 2) Population screening performance was in increasing order (with missed VNT rate), Baveno6 criteria: 23.9% (2.5%), Anticipate: 24.5%, p=0.367 vs previous (3.3%), PLER: 27.3%, p<0.001 (3.6%), LIP: 33.4%, p<0.001 (4.2%), PLEASE: 35.2%, p=0.006 (3.6%). In NAFLD, LIP: 38.6%, BLIP: 40.8%, p=0.038. 3) Individual screening performance was, expanded Baveno6 criteria: 42.7%, LIP: 54.1%, p<0.001. In NAFLD, performance was, NAFLD-cirrhosis criteria: 66.7%, BLIP: 74.6%, p<0.001. CONCLUSION: LIP combined simplicity, performance and safety in each etiology. In NAFLD, BMI-adjusted LIP outperformed other tests.

[Diagnosis of chronic venous insufficiency]. / Diagnostische Verfahren bei chronischer venöser Insuffizienz.

For the treatment of chronic venous insufficiency (CVI), various therapeutic options are available. In addition to conservative compression therapy, classical vein surgery, sclerotherapy and endoluminal therapies are increasingly being used to treat varicose veins. For a differentiated indication and correct treatment planning, a stepwise diagnosis with clinical examination and documentation of typical symptoms, dynamic vein function measurement to assess the global venous status as well as a qualitative assessment of the exact insufficient vein segments by means of color-coded duplex sonography is required. Due to the non-invasiveness of the examination and the good assessability of therapeutically relevant parameters such as anatomic conditions, diameter, and reflux of insufficient veins, color-coded duplex sonography is considered the gold standard for imaging diagnostics.

Evaluation of the Information Content for Determining the Vascular Tone Type of the Lower Extremities in Varicose Veins: A Case Study.

The incidence of cardiovascular diseases is continuously increasing around the world. Therefore, the study of new methods for diagnosing cardiovascular diseases is very important. Early diagnosis and evaluation of the effectiveness of treatments are among the most important tasks. In this work, we study changes in vascular compliance and vascular tone of the lower extremities in a patient diagnosed with an early stage of varicose veins. The study is based on recording the bioimpedance signals of the lower extremities and their parts using the Rheo-32 multichannel device. Registration in the monitoring system takes place in two stages: the first in a state of relaxation, and the second after applying a local massage on one of the legs for five minutes. The results indicate a change in the type of vascular tone of the lower extremities after the massage, while the type of vascular tone changes and shifts on average towards the normotonic type. The method proposed in this study makes it possible to quantitatively and qualitatively assess changes in the tone of the vessels of the extremities.

Fluctuating Cutaneous Varices as a Diagnostic Clue for a Huge Right Atrial Mass in a Dialysis Patient.

A 72-year-old man presented with altered consciousness. His past medical history included left renal cell carcinoma status post nephrectomy 3 years earlier, end-stage renal disease with regular hemodialysis, and central venous obstruction with stenting at the right subclavian vein and superior vena cava 8 months earlier. He was intubated and placed on a mechanical ventilator and inotropes for managing respiratory failure and shock. After numerous tests, it was evident that a right atrial mass was hindering blood flow into the right ventricle and causing blood to flow back into the peripheral venous system. This could cause obstructive cardiogenic shock and fluctuating cutaneous varices. The patient refused further intervention and died from multiple organ failure. This unusual phenomenon can provide a clue for the discovery of atrial masses in dialysis patients.

Development of recommendations for the use of venoactive drugs in the treatment of chronic venous disease - where they are effective and where they are not.

The article provides an overview of the development of recommendations for indications of venoactive drugs for treating symptoms and signs associated with chronic venous disease (CVD). Venoactive drugs may be beneficial in patients with subjective problems and/or swelling of the lower limbs, after surgery for varicose veins, in chronic venous insufficiency or in microcirculatory disorders. They are not indicated in asymptomatic patients with CVD, in the prevention of varicose veins or to prevent their progression. Drugs with proven efficacy in clinical trials should be preferred.

Risk of new onset major depressive disorder among patients with varicose veins: A multi-institution database study.

OBJECTIVE: Varicose vein is a vascular disorder that may cause negative impact on quality of life. However, little is known about the association between varicose vein and major depressive disorder. The aim of this study was to evaluate the risks of major depressive disorder among individuals with varicose veins. METHOD: The study subjects of this retrospective cohort study were selected based on Chang Gung Research Database data from January 1st, 2005, to December 31st, 2015. We used ICD-9-CM codes 454 to determine the subjects diagnosed with varicose veins. We matched patients with varicose veins to participants without varicose veins at a 1:4 ratio by gender, age, and index date. The follow-up period for new onset major depressive disorder was extended to December 31st, 2017. The hazard ratios of major depressive disorder were estimated using Cox regression analysis with competitive risk model adjusting with gender, age, and comorbidities. RESULTS: A total of 10,640 patients with varicose veins and 42,560 matched controls were enrolled. The varicose veins group had higher incidence rates of new onset major depressive disorder (adjusted hazard ratio 1.46; 95% confident interval, 1.17-1.82, p < 0.001). Compared with matched controls, varicose veins patients with or without venous ulcers had 2.26- and 1.39-times increased risk of developing new onset major depressive disorder, respectively. CONCLUSIONS: Patients with varicose veins have an increased risk in developing major depressive disorder. Clinicians should be aware of mental health in patients with varicose veins, and psychosocial support is important for these patients.

Comparison of the standardized Valsalva manoeuvre versus the cuff deflation method to elicit venous reflux.

Background: Two standardized methods to detect venous reflux, the Valsalva manoeuvre (VM) and the cuff deflation method (CM) are compared. Patients and methods: We included 72 patients with varicose veins (VV) and 106 patients with deep vein thrombosis (DVT). The proximal leg veins were examined. A survey was sent to the members of the Union of Vascular Societies to assess, which methods are used in the clinical practice. Results: In the VV-group the correlation coefficient (VM vs CM) for the reflux time (RT) amounted to 0.44 (p<0.0001) for the common femoral vein (CFV) and 0.4 for the femoral vein (FV) (p=0.0003). The sensitivity of the two tests in the VV group amounted to 87.5% for both methods in the CFV (p=0.4). The sensitivity for the FV amounted to 87.5% for the VM and 71.4% for the CM (p=0.4). In the DVT - group the correlation coefficient (VM vs CM) for RT amounted to 0.62 for the CFV (p<0.0001) and 0.77 for the FV (p<0.0001), as well as to 0.6 for the great saphenous vein (GSV) (p<0.0001). The sensitivity of the two tests amounted to 50.0% for the VM and 42.9% for the CM in the CFV (p=0.5). The sensitivity, if reflux was measured in the FV, amounted to 42.9% for the VM and 50.0% for the CM (p=0.5). 87.3% of the doctors who answered the survey use a non-standardized reflux measurement method. Conclusions: Both methods of reflux measurement (VM, CM) are comparable. Further studies have to address the issue, whether non standardized methods are as accurate as the standardized manoeuvres.