Polidocanol-foam treatment of varicose veins: Quality-of-life impact compared to conventional surgery.

BACKGROUND AND OBJECTIVE: Lower limb varicose veins are a prevalent disease associated with several available treatment options, including conventional surgery and polidocanol foam sclerotherapy. However, few studies have analyzed therapeutic modality outcomes based on Patient-Reported Outcome Measures (PROMs). This large sample-size study was designed to evaluate the outcomes of polidocanol foam sclerotherapy compared to conventional surgery based on an analysis of PROMs. METHODS: This was a prospective, observational, and qualitative study of 205 patients who underwent varicose vein treatment with either polidocanol foam sclerotherapy (57 patients, 90 legs) or conventional surgery (148 patients, 236 legs). Patients were preoperatively assessed and re-evaluated 30 days after the procedure using the Venous Disease Severity Score (VCSS) and specific venous disease quality-of-life questionnaires (VEINES-QoL/Sym). RESULTS: Both treatments significantly improved VCSS and VEINES results 30 days after the procedure (p < 0.05). However, surgery promoted greater improvements in VCSS (on average 4.02-points improvement, p < 0.001), VEINES-QoL (average 8-points improvement, p < 0.001), and VEINES-Sym (average 11.66 points improvement, p < 0.001) than did sclerotherapy. Postoperative pain and aesthetic concerns about the legs were the domains of the questionnaires in which the results varied the most between the treatment modalities, with worse results for sclerotherapy. CONCLUSION: Both polidocanol foam sclerotherapy and conventional surgery positively impact patients' quality of life after 30 days, but the improvement is more significant for patients who undergo conventional surgery.

Effects of high ligation plus endovenous laser therapy in patients with varicosis of great saphenous vein and type 2 diabetes.

To analyze the effects of high ligation plus endovenous laser therapy on intraoperative blood loss, postoperative visual analogue scale (VAS) score, and complications in patients with varicosis of great saphenous vein and type 2 diabetes. About 61 patients with varicosis of great saphenous vein and type 2 diabetes treated at our hospital were included. About 32 patients (37 affected limbs) receiving conventional surgery were included in control group, while 29 patients (34 affected limbs) receiving high ligation plus endovenous laser therapy were included in study group. The intraoperative blood loss, operation time, length of postoperative hospital stay, postoperative VAS scores, blood glucose levels, Venous Clinical Severity Score (VCSS), and incidence of complications were compared between the two groups. Compared with the control group, there were less intraoperative blood loss (P < .05), shorter operation time (P < .05), and shorter length of postoperative hospital stay in the study group (P < .05). Besides, there was also lower VAS scores at different time points after surgery in the study group than in the control group (P < .05). Blood glucose levels were decreased in both groups after surgery (P < .05). Moreover, VCSS was decreased in either group at 3 months after surgery (P < .05). Blood glucose levels of patients in the study group were lower than those of the control group after surgery (P < .05). The VCSS was also lower in the study group at 3 months after surgery than in the control group (P < .05). High ligation with endovenous laser therapy for varicosis of great saphenous vein in patients with type 2 diabetes was safe and feasible.

The anterior saphenous vein. Part 4. Clinical and technical considerations in treatment. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology.

BACKGROUND: The decision to treat a refluxing anterior saphenous vein (ASV) should be a clinical decision based on the assessment on the ASV's contribution to patient's signs and symptoms. Once the decision to treat has been made, there are anatomic, clinical, and technical considerations in treatment planning. METHODS: Clinical scenarios were discussed by a panel of experts and common anatomic, clinical, and technical considerations were identified. RESULTS: There are unique clinical considerations such as whether both the great saphenous vein (GSV) and ASV should be concomitantly treated, if a normal ASV should be treated when treating a refluxing GSV and when and how to treat the associated tributary varicose tributaries. Being aware of the anatomic, clinical, and technical considerations allows development of a treatment plan that optimizes long-term outcomes in patients with ASV reflux. CONCLUSIONS: Ultimately the treatment plan should be tailored to address these types of variables in a patient-centered discussion.

The anterior saphenous vein. Part 2. Anatomic considerations in normal and refluxing patients. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology.

BACKGROUND: The term Anterior Accessory of the Great Saphenous Vein suggests this is a branch tributary vein despite this vessel's anatomic features of a truncal vein. A multisocietal group suggested to designate this the anterior saphenous vein (ASV). This study was aimed to evaluate its ultrasound anatomy in normal and varicose limbs. METHODS: The clinical anatomy of the ASV was evaluated by narrative review of the literature. Additionally, the course of the ASV was evaluated in 62 limbs with no evidence of venous disease and 62 limbs with varicosities. RESULTS: The ASV length, patterns of origin and termination are reported in both normal and patients with varicose veins. Discussion of the patterns is supported by the narrative review of the literature. CONCLUSIONS: The ASV must be considered a truncal vein and its treatment modalities should be the same that for the great and small saphenous veins rather than a tributary vein.

A comprehensive ultrasound approach to lower limb varicose veins and abdominal-pelvic connections.

OBJECTIVE: Pelvic venous reflux may be responsible for pelvic venous disorders and/or lower-limb (LL) varicose veins. Ultrasound investigation with Doppler allows a complete study of the entire infra-diaphragmatic venous reservoir. The aim of this study was to guide and standardize the investigation of the pelvic origin of venous reflux in female patients with LL varicose veins. METHODS: In this case-control study, we applied a comprehensive ultrasound investigation protocol, which involved four steps: (1) venous mapping of the lower limbs; (2) transperineal and vulvar approach; (3) transabdominal approach; and (4) transvaginal approach. RESULTS: Forty-four patients in group 1 (patients with LL varicose veins and pelvic escape points [PEPs]) and 35 patients in group 2 (patients with LL varicose veins without PEPs [control group]) were studied, matched by age. The median age was 43 years in both groups. The calculated body mass index was lower in group 1 (23.4 kg/m2) compared with the control group (25.4 kg/m2), and this difference reached statistical significance (P < .001). The presence of pelvic varicose veins (PVs) by transvaginal ultrasound was 86% in group 1 and 31% in group 2. Perineal PEPs were the most prevalent, being found in 35 patients (79.5%), more frequent on the right (57.14%) than on the left (42.85%) and associated with bilateral PVs 65.7% of the time. In group 1, 23 patients (52%) reported recurrent varicose veins vs eight patients (23%) in the control group (P = .008). Regarding the complaint of dyspareunia, a significant difference was identified between the groups (P = .019), being reported in 10 (23%) patients in group 1 vs one patient (2.9%) in the control group. The median diameters in the transabdominal approach of the left gonadal veins were 6.70 mm for group 1 and 4.60 mm for group 2 (P < .001). In patients with PVs in group 1, the median diameter of PEPs at the trans-perineal window was 4.05 mm. In the transvaginal examination, the mean diameter of the veins in the peri uterine region was 8.71 mm on the left and 7.04 mm on the right. CONCLUSIONS: The identification of PEPs by venous mapping demonstrates the pelvic origin of the reflux and its connections with the LL varicose veins. For a more adequate treatment plan, we suggest a complete investigation protocol based on the transabdominal and transvaginal study to rule out venous obstructions, thrombotic or not, and confirm the presence of varicose veins in the pelvic adnexal region.

Hypersensitivity reactions following vein closure therapy with venasealTM (n-butyl- 2-cyanoacrylate).

VenaSealTM is composed of a cyanoacrylate adhesive compound often utilized for chronic venous stasis treatment. Rare case reports of hypersensitivity reactions to this compound exist. We present the first case of dermatographism and angioedema after utilization of VenaSealTM successfully treated via high dose antihistamines. We also present a case of type IV hypersensitivity to VenaSealTM, a cyanoacrylate, occurring in a patient with known meth(acrylate) allergy indicating a possible cross reactivity between these acrylate groups.

[Recurrent Bacteremia after Cyanoacrylate Sclerotherapy of Ectopic Duodenal Varices]. / Bacteriemias Recorrentes após Escleroterapia de Varizes Ectópicas Duodenais com Cianoacrilato.

Sclerotherapy with N-butyl-2-cyanoacrylate is the first-line endoscopic approach for gastric and ectopic variceal bleeding, but it can be associated with local or systemic complications. Episodes of transient bacteremia after the procedure are frequent, but documented cases of recurrent bacteremia are rare. The authors report a 47-year-old female patient with liver cirrhosis who underwent duodenal sclerotherapy with cyanoacrylate after upper gastrointestinal bleeding. Subsequently, she developed five episodes of bacteremia with unknown origin. A definitive diagnosis of recurrent bacteremia due to cyanoacrylate was only possible after an exhaustive study to exclude other infectious foci. This case highlights a rare complication in an unusual topography (ectopic varices) and with a high number of episodes of bacteremia. A multidisciplinary management was paramount due to the patient's high surgical and anesthetic risk, comorbidities, and surgical aggressiveness.

A escleroterapia com N-butil-2-cianoacrilato é a abordagem endoscópica de primeira linha nas hemorragias por varizes gástricas ou ectópicas, podendo estar associada a complicações locais ou sistémicas. São frequentes situações de bacteriemia transitória após o procedimento, mas são raros os casos documentados de bacteriemias recorrentes. O caso relata uma doente de 47 anos com cirrose hepática submetida a esclerose de varizes duodenais com cianoacrilato após hemorragia digestiva alta. Posteriormente, desenvolveu cinco episódios de bacteriémia sem foco evidente. O diagnóstico definitivo de bacteriemias recorrentes com ponto de partida no cianoacrilato só foi possível após estudo exaustivo para excluir outros focos infeciosos. Este caso evidencia uma complicação rara, numa topografia também incomum (varizes ectópicas) e com um elevado número de episódios de bacteriémia. Destaca-se a importância de uma abordagem multidisciplinar para gerir esta doente, tendo em conta as comorbilidades, o elevado risco anestésico e a agressividade cirúrgica para extração do foco infecioso.

The Stability of Physician-Compounded Foam is Influenced by the Angle of Connector.

BACKGROUND: Foam sclerotherapy is an effective treatment for varicose veins and venous malformations, with its efficacy influenced by foam stability. The methods for preparing physician-compounded foam (PCF) are the double syringe system (DSS) and Tessari method. Few studies have been performed to compare the PCF stability produced by the 2 methods and their mechanisms. We aim to compare the stability of PCF produced by 2 two methods in the same connector and explore the reasons for the difference. METHODS: Foam was generated by the 2 methods under different circumstances. In the Tessari method, 2 syringes were connected at right angles (90°) by a 3-way tap. In the DSS method, 2 syringes were connected by the same 3-way tap in a straight line (180°). The stability and uniformity of foam produced by the 2 methods were compared using foam half-time and optical microscopy, respectively. Assuming that the difference in foam stability between the 2 methods was related to the angles of a connector, we compared the foam stability when 2 syringes were connected with a plastic connector bent to different angles. RESULTS: The DSS method could produce more uniform foam with longer foam half-time than the Tessari method, which was related to the angle of the connector. CONCLUSIONS: The stability of PCF is influenced by the angle of the connector.

Partial splenic embolization improved stomal varices in patient with decompensated liver cirrhosis: a case report.

A 63-year-old man with decompensated liver cirrhosis was admitted for treatment of stomal hemorrhage. Eighteen months earlier, he was diagnosed with rectal and sigmoid colon cancer with multiple lymph node metastases, and he underwent colostomy surgery and postoperative chemotherapy. Sixteen months after the surgery, his stoma began to bleed repeatedly, and he required frequent blood transfusions. A contrast-enhanced computed tomography revealed ectopic varices around the stoma. We considered surgical or endoscopic treatment; however, these approaches would have been technically difficult in this patient. The patient was treated with partial splenic embolization to improve thrombocytopenia and portal hypertension. After two-stage partial splenic embolization, the platelet counts increased, and the concentration of the liver fibrosis marker, Mac-2 binding protein, decreased. In addition, blood flow in the stomal varices decreased, with no recurrence of bleeding. This is a case of recurrent hemorrhage from stomal varices that was successfully treated with partial splenic embolization in a patient with liver cirrhosis. There are no guidelines for hemorrhage from ectopic varices. PSE may present potential utility as a treatment for ectopic variceal bleeding, such as stomal varices.

Management of ectopic intestinal variceal bleeding following pancreatic transplant: Two cases.

Ectopic variceal bleeding is a potentially under recognized source of gastrointestinal (GI) hemorrhage. While vascular complications following pancreatic transplant are relatively common, the development of symptomatic ectopic venous varices has rarely been reported. We report two patients with a remote history of simultaneous kidney pancreas transplant (SPK) presenting two decades after transplant with an occult GI bleed. In both cases, a lengthy diagnostic course was required. The varices were treated with coil embolization via transhepatic approach. Our findings add to the limited literature on this topic and aid in the recognition, diagnosis, and management of this unusual presentation.

COmpressioN following endovenous TreatmenT of Incompetent varicose veins by sclerotherapy (CONFETTI).

OBJECTIVE: The evidence for post-foam sclerotherapy compression stockings for varicose veins is limited. Thus, we examined the effects of post-procedural compression stockings on varicose vein patients undergoing foam sclerotherapy. METHODS: The CONFETTI study was a prospective, single-center, randomized controlled trial. Patients with foam sclerotherapy-suitable varicose veins were randomly assigned to the compression group (CG) or the no compression stockings group (NCG) for 7 days. The primary outcome was post-procedural pain measured on a 100-mm visual analog scale for 10 days. Secondary outcomes included clinical severity, generic and disease-specific quality of life scores, return to normal activities and/or work, occlusion rates, degree of ecchymosis, CG compliance, and complications. Patients were reviewed at 2 weeks and 6 months. RESULTS: A total of 139 patients were consented to and randomly assigned. The intention-to-treat analysis included 15 patients who did not receive the allocated intervention. Both groups had similar baseline characteristics. Of the patients, 63.3% and 55.4% returned for follow-up at 2 weeks and 6 months, respectively. Most of the veins treated were tributaries. The CG experienced significantly lower pain scores than the NCG, with median scores of 7 mm and 19 mm, respectively (Mann-Whitney U-test; P = .001). At 2 weeks, no differences were observed in ecchymosis or the time to return to normal activities or work. Both groups showed improvements in clinical severity and quality of life, and occlusion rates were comparable. The NCG experienced one deep venous thrombosis and superficial thrombophlebitis, whereas the CG experienced two superficial thrombophlebitis. CONCLUSIONS: The CONFETTI study suggests that short-term post-procedural compression stockings are beneficial for reducing post-procedure pain.

Attributing practice variation by its sources: the case of varicose veins treatments in the Netherlands.

BACKGROUND: Unwarranted practice variation refers to regional differences in treatments that are not driven by patients' medical needs or preferences. Although it is the subject of numerous studies, most research focuses on variation at the end stage of treatment, i.e. the stage of the treating specialist, disregarding variation stemming from other sources (e.g. patient preferences, general practitioner referral patterns). In the present paper, we introduce a method that allows us to measure regional variation at different stages of the patient journey leading up to treatment. METHODS: A series of logit regressions estimating the probability of (1) initial visit with the physician and (2) treatment correcting for patient needs and patient preferences. Calculating the coefficient of variation (CVU) at each stage of the patient journey. RESULTS: Our findings show large regional variations in the probability of receiving an initial visit, The CVU, or the measure of dispersion, in the regional probability of an initial visit with a specialist was significantly larger (0.87-0.96) than at the point of treatment both conditional (0.14-0.25) and unconditional on an initial visit (0.65-0.74), suggesting that practice variation was present before the patient reached the specialist. CONCLUSIONS: We present a new approach to attribute practice variation to different stages in the patient journey. We demonstrate our method using the clinically-relevant segment of varicose veins treatments. Our findings demonstrate that irrespective of the gatekeeping role of general practitioners (GPs), a large share of practice variation in the treatment of varicose veins is attributable to regional variation in primary care referrals. Contrary to expectation, specialists' decisions meaningfully diminish rather than increase the amount of regional variation.

Distal outpatients hemodynamic treatment of chronic venous insufficiency of the lower limbs: a new proposal.

The etiology of the venous insufficiency of the lower limbs is related to the increase of the district pressure. This occurs in case of pressure overload of the afferent compartment with a progressive increase of the gradient until the reversal of the flow direction. Varicose veins would be the effect and not the cause of the pressure overload which must always be researched in the efferent (draining) compartment. The gradient inversion in a compartment causes a reflux circuit (venous shunt) only if - in addition to the escape point - one re-entry point is also active, The closure of the escape point does not solve the etiological moment of the district pressure overload. It is therefore a symptomatic treatment that cannot reduce the potential of the system to cause recurrences. During walking, reflux will cause Transmural Pressure Peaks (PPT): in diastole if the reflux is systolic; in systole if the reflux is diastolic; in diastole and in systole if the reflux is diastolic-systolic. On this basis, it has been proposed CHIVA 2 distal outpatient treatment without CHIVA 1 with interesting haemodynamic effects. In the subcutaneous area by the pressure overload block it improves compartment drainage, reduces the peak of trans-mural pressure and the caliber of the varicose veins. In the intrafascial district: reduces peak and trans-mural walking pressure; does not change the drainage of the reflux; can restore an antegrade flow. KEY WORDS: Hemodyamic venous treatment, Vricose veins, Venous Hemodynamic Map (VHM).

Optimized selection of neodymium laser parameters for successful enlarged veins treatment.

Full clearance and no side effects method of treating enlarged veins was successfully accomplished by one laser session. This is the ambition and dream of both dermatologists and patients. Most vascularity treatment protocols had shown some unpleasant adverse effects. The purpose of the present work is to work out, in advance, the accurate dose of laser pulse duration and fluence in order to treat varicose veins in the face, arms and legs with no adverse effects. This mission required the calculation of the exact rise in temperature of the enlarged vein; prior to laser treatment. These pre-calculated temperature rise values were tested on 20 subjects in order to have the best clinical outcomes; using fundamental frequency (1064 nm) pulsed Nd: YAG laser. This work necessitated the use of pulse length (15-30 ms), spot size (3, 5 mm), fluence (110-190 J/cm2) and skin cooling temperature (3-18 °C). Cooling of the skin before and after the treatment was needed to guarantee ultimate impactful results without side effects.

Foam sclerotherapy for patients with Klipple-Trenaunary syndrome complicated by frequent cellulitis of lower extremity: A case report.

RATIONALE: Klipple-Trenaunary Syndrome (KTS) complicated by frequent cellulitis of lower extremity seriously affects a patient quality of life. The hemodynamic characteristics of the disease are still unclear. Direct skin incision or puncture to remove malformed veins at the lesion site carries the risk of non-healing of the surgical incision. Our aim is to explore initial management strategies based on the hemodynamic characteristics of this disease. PATIENT CONCERNS: A 29-year-old Manchu man was affected by KTS from childhood, characterized by an increase of the circumference and superficial varicose veins of the lower extremity. In the past 5 years, he suffered from frequent cellulitis in the left leg every 15 days or so. DIAGNOSES: KTS complicated by frequent cellulitis of lower extremity. INTERVENTIONS: The clinical and hemodynamic characteristics of KTS were evaluated by Doppler ultrasonography (DUS) combined with CT venography (CTV), and foam sclerotherapy and postoperative elastic bandage compression were performed accordingly. OUTCOMES: Based on evaluations, the reason for frequent cellulitis was the continuous increase of venous hypertension in the calf caused by the malformed superficial vein and its penetrating vein. After 3 operations, the patient had no recurrence of cellulitis of the leg. Follow-up for 1 year showed no recurrence of left leg cellulitis. LESSONS: This report emphasizes that foam sclerotherapy can significantly improve the clinical symptoms of KTS, such as cellulitis, and provide a safe skin environment for the implementation of other surgical methods, based on the evaluation of the pathological characteristics of KTS by DUS combined with CTV.

[An excerpt from the 2023 AASLD practice guidelines: TIPS, variceal embolization, and retrograde transvenous embolization for the treatment of variceal hemorrhage].

This is the American Association for the Study of Liver Diseases (AASLD) comprehensive guideline on the application of endovascular interventional radiological procedures in the treatment of variceal bleeding, which supplements Risk Stratification and Management of Portal Hypertensive Bleeding in Cirrhosis by describing recent advances in invasive surgery. Transjugular intrahepatic portosystemic shunt (TIPS) dates back to the 80s of the 20th century, and over the past few years, several new technical improvements have been made to TIPS stents. Another major treatment for gastric variceal bleeding in North America is the use of different forms of retrograde transvenous embolization. This guideline is intended to provide healthcare professionals with an in-depth understanding of the use of TIPS and/or variceal embolization/occlusion in the treatment of variceal bleeding, with the goal of facilitating multidisciplinary discussions on treatment strategies among hepatologists, gastroenterologists, interventional radiologists, and surgeons. Additionally, it provides a data-based approach to the endovascular treatment of variceal bleeding. However, it differs from the AASLD guidelines by being supported by a systematic review of the literature, a formal rating of the quality of the evidence, and the strength of the recommendations. Consequently, this guideline was developed by a consensus of an expert panel under the supervision of the AASLD Practice Guidelines Committee and provides guidance statements based on a comprehensive review and analysis of the literature on the relevant topic. Importantly, the AASLD Practice Guidelines Committee selected this topic because, for the most part, there are not a sufficient number of randomized controlled trials on this topic to provide meaningful systematic reviews and meta-analyses.