Clinical Features and Management of "Phlebitis-like Abnormal Reaction" After Cyanoacrylate Closure for the Treatment of Incompetent Saphenous Veins.

BACKGROUND: Cyanoacrylate closure for the treatment of incompetent saphenous veins does not cause thermal damage and demonstrates satisfactory outcomes with rapid recovery. However, the characteristics of phlebitis-like abnormal reaction (PLAR), the most common adverse event after cyanoacrylate closure, have not been clarified. Moreover, it differs from typical phlebitis after thermal ablation. The objective of our study is to investigate the clinical features of PLAR after cyanoacrylate closure and to report its management. METHODS: A total of 160 patients with 271 incompetent saphenous veins (great saphenous veins, 201; small saphenous veins, 70) underwent cyanoacrylate closure with the VenaSeal™ system. We defined PLAR as any unusual skin condition that develops suddenly, such as erythema, itching, swelling, and pain/tenderness, over the treated veins several days after cyanoacrylate closure. Oral antihistamines and intravenous dexamethasone were administered to manage PLAR. RESULTS: Of the 271 treated veins, 69 experienced PLAR (25.4%). The mean time of occurrence was 13.6 ± 4.6 days after treatment. The rate of occurrence of erythema, itching, swelling, and pain/tenderness were 92.2%, 91.2%, 66.2%, and 48.5%, respectively. The occurrence of PLAR was significantly higher for great saphenous veins than for small saphenous veins (P < 0.001). Occurrences were more frequent in cases with a suprafascial great saphenous vein of length >10 cm than in cases with a subfascial great saphenous vein (P = 0.001). The proportion of patients who reported swelling decreased by more than half after the administration of oral antihistamine. The pain score on the 10th day also decreased significantly after the administration of antihistamine (P = 0.006). CONCLUSIONS: PLAR must be distinguished from classic phlebitis. We believe that PLAR is a type IV hypersensitivity reaction due to a foreign body, and in our experience, antihistamines or steroids are effective for the prevention and management of PLAR.

[Ultrasound elastography in assessing efficacy of treatment for lower limb varicose veins with a phlebotrophic drug containing a micronized purified flavonoid fraction].

UNLABELLED: Venous hypertension combined with other pathogenetic links of the development of chronic venous insufficiency creates conditions for activation of an inflammatory process. Chronization of inflammation leads to alterations in the histological structure of the vascular wall and perivasal tissues, which is reflected by changes in their physical properties (elasticity or compressibility), which may be studied by means of ultrasound elastography (USEG). OBJECTIVE: The study was aimed at exploring the possibility of using ultrasound elastography for monitoring efficacy of conservative treatment of varicose disease of lower extremities with an agent containing a micronized purified flavonoid fraction (MPFF). MATERIAL AND METHODS: we examined a total of 19 patients (38 limbs) presenting with varicose disease of clinical class C2 according to the CEAP classification. The standard ultrasound examination and USEG were carried out using the unit of expert-class "Toshiba" (Japan) with a multi-frequency linear transducer 5-12 Hz. We examined the great saphenous vein in the area of the femur and crus, its tributaries, and the small saphenous vein. All examinations were performed with the patient in the supine, prone and standing positions from the standard approaches in the second half of the day prior to treatment with a phlebotrophic agent containing MPFF (Detralex) and three months after taking the drug at a dose of 1,000 mg/day. RESULTS: at baseline, according to the findings of USEG the intact veins of the lower limbs had a homogeneous pattern of the elastogram in the perivasal area. The presence of varicose transformation was associated with an inhomogeneous elastographic picture. On the background of treatment with MPFF, all patients showed a positive clinical effect in the form of decreased intensity of manifestations of complaints or complete disappearance thereof. According to the findings of ultrasound examination, there was a tendency towards a decrease in the wall thickness and diameter of the examined veins. USEG demonstrated an increase in the perivasal zones of elastographic homogeneity of tissues. The USEG-revealed alterations were more pronounced in large-diameter vessels. On the background of treatment with Detralex there was a trend towards normalization of the elastographic pattern of the vessel as a whole. CONCLUSION: the obtained findings confirm feasibility of using the technique of ultrasound elastography for identification of objective markers of treatment response to MPFF in varicose disease.

[Experimental study of Duffy antigen receptor for chemokines in tissue and the inflammatory reaction of limb with venous hypertension].

OBJECTIVE: To explore the role and mechanism of Duffy antigen receptor for chemokines (DARC) of tissue in promoting the inflammatory reaction of the limb with venous hypertension. METHODS: moral arteriovenous fistula was surgically created to establish the rat model of venous hypertension. A total of 36 SD rats were randomly divided into pcDNA3.1-DARC (Group A), empty plasmid of pcDNA3.1 (Group B) and control (Group C) groups. The animals were sacrificed at Days 14 and 42 post-operation respectively. The expressions of DARC at the RNA and protein level were detected by real-time polymerase chain reaction (PCR) and Western blot. And the serum level of interleukin (IL)-8 was detected by enzyme linked immunosorbent assay (ELISA) and the degrees of apoptosis and leukocytic infiltration of local tissue were detected by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) and hematoxylin and eosin (HE) staining. RESULTS: With the elapsing time of venous hypertension, the DARC expression in tissue, the extent of apoptosis and leukocytic infiltration in tissue showed an increasing trend in Groups A and B. Group A was obviously higher than Group B during the corresponding period. And the differences were statistically significant (P < 0.05). The serum levels of IL-8 of Groups A and B showed a decreasing trend. And Group A was obviously lower than Group B. Both groups were higher than the control group. The differences were statistically significant (P < 0.05). CONCLUSIONS: The level of DARC in tissue and the degree of inflammatory reaction of venous hypertension have a positive correlation. And DARC may promote the development of venous hypertension inflammation through augmenting the adhesion and migration of leukocytes.

[Medicamentous protection of lower limb veins in a subacute period of varicophlebitis of the great saphenous vein].

The study was aimed at determining the dynamics of saphenous veins in patients with varicophlebitis of the great saphenous vein (GSV) in a subacute period (during compression therapy) and at assessing efficacy of 4-month medicamentous protection thereof. We examined a total of 32 patients presenting with the first episode of non-embolic varicophlebitis of the great saphenous vein. The comparison group comprised 16 patients undergoing 4-month compression (degree 2) therapy alone, and the study group patients (n = 16) were subjected to compression therapy combined with a 4-month course of micronized diosmin (1 tablet twice a day). The patients were included into the groups alternately as they attended our medical facility. Duplex scanning before and after the treatment course was used to measure the following parameters: 1) the evening diameter of veins and 2) an increase in the vein's diameter measured overnight as compared to the morning measures - the orthostatic gradient. The obtained results showed that the subacute period of varicophlebitis of the GSV is accompanied and followed by an increase in the diameter of the GSV and SSV and that of their orthostatic gradient, caused by imparted tonicity and viscoelastic properties. Compression therapy alone in the subacute period of varicophlebitis does not provide complete safety of saphenous veins from secondary lesions. Compression therapy combined with a 4-month-long course of taking micronized diosmin increases the efficacy of treatment.

Visual pathway involvement in multiple sclerosis: Look straight in the eyes.

Visual symptoms are a common clinical manifestation of multiple sclerosis (MS) and are frequently due to acute optic neuritis (ON). However, the entire visual pathway can be involved throughout the disease course. We describe the case of a young MS patient who experienced visual symptoms that were eventually found to be caused by retinal periphlebitis, an inflammatory process of the anterior visual pathway, which is common during MS, but rarely symptomatic. This case reinforces the concept that in all MS patients complaining visual symptoms, a complete work-up should be performed in order to rule out possible ON mimicries.

Evaluation of a visual infusion phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters.

Approximately 150 million peripheral intravenous (PIV) catheters are inserted annually in the United States, with a 5% incidence rate of phlebitis as an acceptable benchmark. In 2002, the Centers for Disease Control and Prevention recommended that PIV sites and administration sets be changed at least every 96 hours, yet clinical practice supported that at least 25% of PIV catheters showed no signs of phlebitis at 96 hours' dwell time. This study reports the assessment results of 850 PIV catheters over the indwelling life of the catheter, using the Visual Infusion Phlebitis scale as the measure determining when a PIV should be removed.

[Acute, idiopathic, bilateral uveitis with periphlebitis--case report]. / Ostre, idiopatyczne, obustronne zapalenie blony naczyniowej z towarzyszacym zapaleniem okolozylnym--opis przypadku.

The purpose of this paper is to present the case of a 35 years old healthy male suffering from acute, bilateral uveitis with periphlebitis which despite broad ophthalmic and internal diagnosis remained of unknown origin. Despite anti-inflammatory treatment with acyclovir, ciprofloxacin and Encorton remission of inflammation was not achieved. Due to the failure of steroid treatment the decision of immunosuppressive therapy with Rapamycine and Endoxan was made. New therapeutic regimen caused the remission of inflammation and preserved patient's useful visual acuity.

Inter-rater agreement on PIVC-associated phlebitis signs, symptoms and scales.

RATIONALE, AIMS AND OBJECTIVES: Many peripheral intravenous catheter (PIVC) infusion phlebitis scales and definitions are used internationally, although no existing scale has demonstrated comprehensive reliability and validity. We examined inter-rater agreement between registered nurses on signs, symptoms and scales commonly used in phlebitis assessment. METHODS: Seven PIVC-associated phlebitis signs/symptoms (pain, tenderness, swelling, erythema, palpable venous cord, purulent discharge and warmth) were observed daily by two raters (a research nurse and registered nurse). These data were modelled into phlebitis scores using 10 different tools. Proportions of agreement (e.g. positive, negative), observed and expected agreements, Cohen's kappa, the maximum achievable kappa, prevalence- and bias-adjusted kappa were calculated. RESULTS: Two hundred ten patients were recruited across three hospitals, with 247 sets of paired observations undertaken. The second rater was blinded to the first's findings. The Catney and Rittenberg scales were the most sensitive (phlebitis in >20% of observations), whereas the Curran, Lanbeck and Rickard scales were the most restrictive (≤2% phlebitis). Only tenderness and the Catney (one of pain, tenderness, erythema or palpable cord) and Rittenberg scales (one of erythema, swelling, tenderness or pain) had acceptable (more than two-thirds, 66.7%) levels of inter-rater agreement. CONCLUSIONS: Inter-rater agreement for phlebitis assessment signs/symptoms and scales is low. This likely contributes to the high degree of variability in phlebitis rates in literature. We recommend further research into assessment of infrequent signs/symptoms and the Catney or Rittenberg scales. New approaches to evaluating vein irritation that are valid, reliable and based on their ability to predict complications need exploration.

Benign vascular invasion in vasitis nodosa.

Vasovasostomy specimens were examined for vascular changes in 50 cases of vasitis nodosa. In five, benign gland- or ductule-like structures were seen invading small veins and, in one, also the small arteries. The intravascular ductules appeared benign, and there was no clinical evidence of malignancy. The presence of ductules in the blood vessels always was accompanied by marked elastosis. In 12 additional cases, elastosis of arteries and veins was seen without intravascular ductules. These changes suggest that proliferating ductules in vasitis nodosa invade the blood vessels after they have become obliterated by regressive and reparative processes.

The substitute "valve" operation by technique II in patients with postthrombotic syndrome.

The substitute "valve" operation with use of a silicone tendon designed to produce a valvelike mechanism in the popliteal veins of 29 patients with 31 postphlebitic limbs caused by reflux in the deep veins is described. The results have been assessed by measurements, taken during ambulation, of venous pressure before operation, 1 week after operation, and 1 year after operation and by phlebography. In 29 limbs there was clinical improvement associated with improvement in the venous pressure assessed during ambulation and phlebographic evidence of a functioning substitute valve.

A proposed model of cerebrospinal fluid circulation: observations with radionuclide cisternography.

PURPOSE: To determine the mechanisms of the tracer distribution at radionuclide cisternography (RC). METHODS: Ten patients with venous vasculitis were studied with RC. Flow phantom studies were performed mimicking cerebrospinal fluid (CSF) circulation with and without a main outlet comparable to the pacchionian granulations. RESULTS: Nine of the 10 patients had normal findings on RC images, including a maximum uptake over the vertex at 24 hours. In all patients, a second maximum occurred in the lumbosacral area. The flow phantom studies showed no tracer accumulation at an open outlet corresponding to the pacchionian granulations. On the contrary, a maximum arose without such an outlet. A maximum always arose at the closed dead ends of the phantom, including the lumbosacral area. CONCLUSION: The commonly accepted flow model for CSF circulation needs to be revised. The pattern of the normal RC cannot be explained by a bulk flow transport of the tracer to an outlet at the pacchionian granulations but rather by a primary mixing caused by pulsatile flow with a secondary dilution by newly formed CSF from the ventricular system. We suggest that the main absorption of the CSF is through the central nervous system to the blood.

Skin blood flux and the venoarteriolar response in the perimalleolar area in patients with venous hypertension.

In patients with venous hypertension due to postphlebitic syndrome or varicose veins skin changes, liposclerosis and ulcerations are associated with increased skin blood flux at rest, a decreased venoarteriolar response and increased capillary filtration. Using laser-Doppler flowmetry we studied skin flux and the venoarteriolar response in the perimalleolar region in 100 normal limbs, 100 limb with varicose veins and 100 postphlebitic limbs with edema, skin changes and liposclerosis. The venoarteriolar response was studied with the leg on dependency, the foot being 50 cm below heart level. Flux at rest and on dependency were increased and the venoarteriolar response decreased in both groups of patients at a significantly greater extent in postphlebitic limbs. In conclusion laser-Doppler flowmetry measurements differentiate between normal limbs and those with venous hypertension and between postphlebitic limbs and limbs with venous hypertension due to varicose veins. The increase in skin flux and decrease in venoarteriolar response may be useful to define and quantify the degree of microangiopathy and the effects of treatments in venous hypertension.

Experimental infusion phlebitis: tolerance osmolality of peripheral venous endothelial cells.

This study aimed to determine the osmolality that peripheral venous endothelial cells can tolerate and to clarify the relationship between tolerance osmolality and duration of infusion. Nutrient solutions of 539-917 mOsm/kg, prepared to have no acidic effect, were infused into rabbit ear veins, and the veins were examined histopathologically. In each experiment of 8-, 12-, or 24-h infusion, the higher osmolality solutions caused some phlebitic changes, such as loss of venous endothelial cells, inflammatory cell infiltration, and edema; however, the lowest osmolality solution caused few changes. Infusion of 120 mL/kg of 814 mOsm/kg solution caused phlebitis at 5 or 10 mL.kg-1.h-1, however, the same volume of the same solution scarcely caused phlebitis at 15 mL.kg-1.h-1 because of the shortened infusion duration. These results suggest that the tolerance osmolality of peripheral venous endothelial cells with poor blood flow is about 820 mOsm/kg for 8 h, 690 mOsm/kg for 12 h, and 550 mOsm/kg for 24 h, and that the tolerance osmolality falls as the duration of infusion increases. In conclusion, hypertonic solutions should be infused at as high a rate as is clinically acceptable and compatible with nutrient bioavailability because increasing the infusion rate reduces the duration of infusion and phlebitis.

Effect of pH on injection phlebitis.

Formulation pH has been reported to be responsible for the incidence of phlebitis. In this study, the effect of pH on injection phlebitis is investigated. Buffers of varying pHs were examined for their ability to produce phlebitis in rabbits. Thermal measurements as well as visual evaluations were used for phlebitis quantitation. The results show that formulation pH between 3.0 and 11.0 does not contribute to the incidence of phlebitis when administered as an iv bolus injection.

Case report: extensive pulmonary and aortic thrombosis and ectasia.

Progressive shortness of breath developed in an elderly woman with a 25-year history of recurrent superficial phlebitis and hemoptysis. Extensive mural thrombosis and ectasia of the large and medium-sized pulmonary arteries and aorta were revealed on echocardiography and computerized tomography. The patient died 2 months later. On autopsy, the gross morphologic findings were similar with those observed by imaging. Histologically, there was mild inflammation in the intima and media of the aorta and the large pulmonary arteries, consistent with nonspecific arteritis. The extensive thrombosis and ectasia of the pulmonary arteries and aorta differ from previously published cases and cannot be assigned to a known nosologic entity. Two alternative explanations are proposed. First, an endothelial disorder was responsible for a diffuse vasculopathy that involved veins, pulmonary arteries, and aorta. Second, a vasculopathy of the Hugh-Stovin type, characterized by phlebitis and pulmonary thromboembolism, caused pulmonary hypertension and low cardiac output. The low flow state favorized aortic thrombosis and, at the site of interaction between the clot and the arterial wall, arteritis developed as an epiphenomenon, which induced arterial dilatation. Combined idiopathic pulmonary artery and aortic thrombosis and ectasia is rare and calls for corroboration of sporadic observations such as the current one.

Observations on the deep lymphatic circulation of the limbs and on its function: (the deep lymphatic vessels in the post-phlebitic syndrome of the lower extremities).

In 60% of patients with post-phlebitic syndrome lymphography of the lower extremity shows involvement of the deep system. In 77% of the patients there was increase in the number and caliber of the deep lymphatic vessels. They frequently appear elongated, tortuous, and ectatic but usually do not show signs of insufficiency. It appears as if these vessels act as collaterals and compensate for difficiencies of the deep venous circulation. Multiple lympholymphatic and lymphovenous communications have been observed.

[Hemodynamics in venous diseases of the lower limbs]. / L'emodinamica nelle malattie venose degli arti inferiori.

Venous diseases of the lower extremities have been studied haemodynamically by analysis of variations in dynamic venous pressure, which is held to be a fundamental parameter. Pressure modifications point to the state of the deep venous system, the valves and the subfascial communicating veins or to the efficiency or otherwise of the muscular pump of the lower extremities. The venous pressure curve is a reliable indicator of the various clinical stages of chronic venous insufficiency and postphlebitis syndrome. As a clinical parameter, venous pressure is sensitive to all pathological changes in the venous system of the lower extremities. It presents variations proportional to the gravity of pure phlebopathies and of venous diseases secondary to congenital dysplasias (e.g. Klippel-Trenauny syndrome) and to congenital or acquired arteriovenous shunts. An attempt is made to classify venous diseases of the lower extremities on the basis of this parameter and examples are given of dynamic venous pressure curves encountered in the various disease pictures observed.

[Effort phlebitis of the upper limb. Report of 5 cases]. / Phlébite d'effort du membre supérieur. A propos de cinq observations.

Deep venous thrombosis (DVT) of upper limbs is extremely rare. DVT related to physical stress is a less known form. The purpose of this study was to outline the clinical pattern and laboratory features as well as the clinical course and outcome of this disease. The authors report 5 documented cases of upper limb DVT related to physical stress: 4 patients were hand workers and 1 was a young athletic man. None of the patients developed pulmonary embolism. Two patients had late sequelae. Treatment is based on prompt and early anticoagulation. Prevention can be achieved by contention, active physiotherapy and professional rehabilitation.

[Phlegmasia caerulea dolens . Acute venous stasis and ischemic phlebothrombosis]. / Les phlébites bleues. Stase veineuse aiguë et phlébothrombose ischémiante.

On the basis of the data of the literature and of 25 personal cases, the problem of phlegmasia caerulea is contemplated in its whole. Grégoire made an outstanding description of the condition in 1938; it was related to an arterial spasm, but later works showed the importance of the venous block and the secondary character of the arterial involvement. A severe form of venous thrombosis, phlegmasia caerulea dolens often occurs in elderly patients (11/25 in our series) or in persons in a poor general condition. The primary phenomenon is the occurrence, in various etiological circumstances, of an acute venous stasis giving rise to a number of phenomena, including extensive thrombosis and arterial involvement, which lead to irreversible lesions and to gangrene. Thus there is a first reversible phase of acute venous stasis with a still moderate arterial involvement, and a second phase of evolution with marketed ischemia, in which the tissular lesions can become irreversible. The necrosis results from the massive obliteration of the cutaneous venulae, not from the arterial failure. The old term of venous gangrene (Cruveilhier) points out to the mechanism and makes the practicioner aware of the extreme severity of any ischemic phlebitis, which can reach an irreversible stage within a few hours. The condition is therefore an emergency, and venous drainage must be re-established as quickly as possible in the limb, thus breaking the pathological cycle leading to irreversible lesions. In the simple venous stasis phase, a medical treatment may be attempted, but it must not be continued if it is not effective. Venous thrombectomy, a quick and safe procedure, therefore is the solution to choose either at once or after a short trial of medical treatment. Phlegmasia caerula certainly is the best indication for this procedure. If operated on time, the results are excellents: however, in very advanced cases with massive and total thrombosis of the venous system, amputation remains the only solution.