Axial Vein Research Articles

Protocol-based treatment of spontaneous hemorrhage from varicose veins prevents recurrence of bleeding

BackgroundSpontaneous hemorrhage from erosion of varicose veins through the skin is a serious and occasionally fatal complication of varicose vein disease. Various treatments, both acute and delayed, have been advocated. Our two-step clinical protocol was designed to prevent further hemorrhage without delay and to provide durable freedom from recurrent bleeding. MethodsAll patients referred to our surgical vein practice with hemorrhage from varicose veins were entered into a prospective registry. On presentation, all patients underwent diagnostic duplex ultrasound for venous reflux. Immediate treatment consisted of ultrasound-guided polidocanol/CO2 foam sclerotherapy of the bleeding varicosity and adjacent veins. Subsequent endovenous ablation of underlying incompetent axial veins, with concurrent microphlebectomy when indicated, was scheduled and performed within 8 weeks. ResultsFifty-nine patients were referred with recent hemorrhage from varicose veins over a period of 4 years. Fifty-six (95%) had an ultrasound-identified tributary varicosity underlying the point of bleeding, and three had a skin-surface erosion only and no ultrasound-identified underlying tributary. Of the 59 study patients, 52 underwent prompt polidocanol/CO2 foam sclerotherapy, targeted to both the underlying tributary (when present) as well as the cutaneous bleeding varicosity. The remaining seven either declined sclerotherapy or were ineligible. Underlying incompetence of axial (great, small, or anterior saphenous) veins was found in 54 patients (92%). Of these patients with truncal vein incompetence, 48 underwent ablation—5 declined and 1 was too frail for any further intervention. There were no recurrent bleeds in the interval between immediate sclerotherapy and scheduled ablation. During a mean follow-up of 2.2 years, 55 of the 59 patients (93%) had no recurrence of bleeding. Four patients (7%) had late, recurrent hemorrhage: one had failed to return for their scheduled ablation, two were on chronic anticoagulation, and one had severe right heart failure. All four were retreated without further recurrence. ConclusionsA two-step protocol of immediate ultrasound-guided foam sclerotherapy, followed within 8 weeks by endovenous ablation of incompetent axial veins and concurrent microphlebectomy, provided rapid and efficient treatment with durable freedom from subsequent hemorrhage.

Clinical Anatomy of the Lower Extremity Veins—Topography, Embryology, Anatomical Variability, and Undergraduate Educational Challenges

Veins of the lower extremity can be categorized into three hierarchically ordered groups: the epifascial, the interfascial, and the deep ones. In the past, the interfascial veins, e.g., the great saphenous vein, were categorized as superficial veins. But nowadays, experts recommend regarding these veins as a separate group because of their unique topography and clinical relevance. In order to better understand the venous anatomy of the lower limbs, which is highly variable, one should also comprehend their embryological development. Venous embryogenesis in the lower limb consists of three stages. During the first stage the primitive fibular vein is the main vein of the extremity. During the second stage it is replaced by the axial vein and finally by the femoral vein. In some adult individuals this embryonic or fetal venous anatomy is still present. Unfortunately, current anatomical textbooks and atlases, as well as traditional cadaver dissections, are not very useful regarding these issues. Therefore, undergraduate teaching of anatomy can be challenging. New educational tools, such as ultrasonography, seem indispensable to teach the anatomy of these veins properly.

Finding Perforator "Freeway" for Design Optimization of Expanded Flaps by Indocyanine Green Angiography.

Indocyanine green angiography (ICGA) is a useful tool for the visual assessment of superficial blood flow. Herein, we used ICGA to visualize perforator branches and linking vessels to provide a road map for flap design of an expanded flap. Twenty-eight expansions were planned to use back-cut technique in 26 patients. ICGA was used to visualize perforator branching pattern with the linking vessels and the venous network in the expanded flap before expander explantation. The appropriate perforator was selected, and the flap was designed following the axiality of its branch linked by true anastomoses. The vein running closely was chosen as the axial vein. The back cut was designed to avoid transection of the axial artery and vein. Patient demographics, defect characteristics, and reconstructive outcomes were assessed. ICGA clearly visualized the perforator branches and the linking vessels in the expanded flap at the head and neck, trunk, and extremity. The back-cut flap containing the axial artery and vein was raised successfully in 27 expansions. The arterial perforator and superficial vein separated greatly and resulted in design modification from back-cut to advancement flap in one expansion. All expanded flaps met the reconstructive needs and exhibited complete survival. ICGA allowed the visualization of the preoperative topography of the vascular network in the expanded flap and helped surgeons locate the vascular axis and perform an appropriate back-cut design for efficient and safe flap transfer.

The cytoskeleton adaptor protein Sorbs1 controls the development of lymphatic and venous vessels in zebrafish.

Lymphangiogenesis, the formation of lymphatic vessels, is tightly linked to the development of the venous vasculature, both at the cellular and molecular levels. Here, we identify a novel role for Sorbs1, the founding member of the SoHo family of cytoskeleton adaptor proteins, in vascular and lymphatic development in the zebrafish. We show that Sorbs1 is required for secondary sprouting and emergence of several vascular structures specifically derived from the axial vein. Most notably, formation of the precursor parachordal lymphatic structures is affected in sorbs1 mutant embryos, severely impacting the establishment of the trunk lymphatic vessel network. Interestingly, we show that Sorbs1 interacts with the BMP pathway and could function outside of Vegfc signaling. Mechanistically, Sorbs1 controls FAK/Src signaling and subsequently impacts on the cytoskeleton processes regulated by Rac1 and RhoA GTPases. Inactivation of Sorbs1 altered cell-extracellular matrix (ECM) contacts rearrangement and cytoskeleton dynamics, leading to specific defects in endothelial cell migratory and adhesive properties. Overall, using in vitro and in vivo assays, we identify Sorbs1 as an important regulator of venous and lymphatic angiogenesis independently of the Vegfc signaling axis. These results provide a better understanding of the complexity found within context-specific vascular and lymphatic development.

Closed randomized comparative study of great saphenous vein crossectomy laser ablation versus standard laser technique to minimize recurrence in the treatment of primary varicose veins

Background Incompetence at the saphenofemoral junction (SF) is the most common cause (70%) of varicose veins. Endovenous laser ablation (EVLA) uses laser energy to ablate incompetent axial veins selectively and was originally described for the treatment of GSV reflux and its related varicosities. The venous system is a network of interconnected vessels; any preserved inflow of the saphenous-femoral mouth can cause postoperative recurrence. However, according to the literature, the greatest risk of recurrence is associated with the stump of the GSV of venous tributaries, including great venous trunks parallel to the GSV in the thigh. Aim of the work Comparison of the standard endovenous laser ablation technique (1.5–2 cm from SFJ) versus crossectomy ablation for the treatment of varicose veins regarding recurrence of reflux and incidence of endovenous heat-induced thrombus (EHIT) in the first week. Patients and methods In all, 80 patients admitted to Ain Shams University Hospitals and Alexandria Armed Forces Hospital from Jan. 1st, 2021 to Jan. 30th, 2023 participated in the study. The patients were divided evenly into two groups: Participants were randomly assigned to one of the trial groups using the sealed envelope method.Group A was treated by ablation of the great saphenous vein at the saphenofemoral junction (0 cm from SFJ) using 1470 nm radial double-ring diode laser fibers (ELVeS Radial 2ring™ fiber) and Biolitec Ceralas E1470/15 W laser machine. Group B was treated by ablation of the great saphenous vein at 1.5–2 cm from the saphenofemoral junction using the same laser fiber and machine. Ablation was done after putting an appropriate amount of tumescent anesthesia (500 mg lidocaine, 1 mg of epinephrine, and 12.5 mEq sodium bicarbonate added to a 1-liter solution of 0.9% normal saline). The ultrasound machine was used for the accurate placement of the laser fiber. Postoperative duplex was done on day 1, 1 week, and at 6, 12, and 18 months. Results Mean age: 39.28+/– 12.27 years in both groups; M/F: 23/17 in the first group, 20/20 in the second group. Postoperative duplex showed the absence of reflux in both groups after 1 day, after 6 months. One patient (2.5%) in group A and four patients (10%) in group B showed recurrent reflux, while recurrent refluxes were observed in one case (2.5%) in group A and five cases (12.5%) in the other group after 12 and 18 months of follow-up. One patient (2.5%) developed superficial thrombophlebitis along the course of the ablated great saphenous vein in both groups while extension to the deep veins was not detected in both groups. Conclusion Crossectomy (ablation at 0 cm at SFJ) ablation of varicose veins with 1470 radial double rings and nm diode laser with an appropriate amount of tumescent showed better results with less recurrence rate due to neovascularization or tributaries left than the standard technique of endovenous laser ablation of varicose veins (1.5–2 CM from SFJ). Along with showing a lesser incidence of thermal propagation into the deep system (EHIT) both crossectomy and standard techniques showed the same complication rate regarding venous thrombosis.

The story of N-butyl cyanoacrylate saphenous vein ablation

In 2009, our group was approached by an experienced radiologist who proposed to close refluxing saphenous veins with glue; an idea based on his experience with N-butyl cyanoacrylate (TRUFILL) embolization of cerebral arterial venous malformations. We henceforth began with a swine model, 1 Almeida J.I. Min R.J. Rabe R. McLean D.J. Madsen M. Cyanoacrylate adhesive for the closure of truncal veins: 60-day swine model results. Vasc Endovascular Surg. 2011; 45: 631-635 Crossref PubMed Scopus (74) Google Scholar and then moved to first-in-human studies 2 Almeida J.I. Javier J.J. Mackay E. Bautista C. Proebstle T. One-year follow-up of first human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. J Vasc Surg Venous Lymphatic Disord. 2013; 1: 174-180 Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar for nonthermal ablation of the saphenous vein with their proprietary N-butyl cyanoacrylate glue. Of interest, during the regulatory development pathway, this product was approved as a device, not a drug. It's efficacy has proved excellent, and during the past decade cyanoacrylate closure (CAC) has been adopted widely worldwide. However, reports of hypersensitivity-related adverse events, and granulomas, have begun to surface. It is timely that Dr Athavale and his team have recently published an excellent systematic review on CAC. Based on the available literature, the adverse events related to cyanoacrylate glue can be divided into the following: phlebitis, hypersensitivity (type I and type IV), foreign body granuloma, endovenous glue induced thrombosis and infection. These adverse events may require prolonged steroid use or vein excision. Cyanoacrylate glue reactions: A systematic review, cases, and proposed mechanismsJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 11Issue 4PreviewCyanoacrylate glue closure was first used in humans 10 years ago to treat venous reflux of the axial veins. Studies have since shown its clinical efficacy in vein closure. However, great need exists to elucidate further the types of specific adverse reactions that cyanoacrylate glue can cause for better patient selection and to minimize these events. In the present study, we systematically reviewed the literature to identify the types of reported reactions. In addition, we explored the pathophysiology contributing to these reactions and proposed the mechanistic pathway with inclusion of actual cases. Full-Text PDF

Venous leg ulcers and prevalence of surgically correctable reflux disease in a national registry

BackgroundChronic venous disorders are common, with varicose veins occurring in ∼40% of the population. Venous leg ulcers affect 1% to 2% of the population, with the prevalence increasing ≤4% for those aged >65 years. Both conditions are expensive and together are responsible for ≤2% of the annual healthcare budget expenditure of Western societies. The ESCHAR (effect of surgery and compression on healing and recurrence) and EVRA (early venous reflux ablation) trials demonstrated that surgical correction of superficial venous reflux reduced ulcer recurrence, resulted in faster healing times (EVRA), and was proved cost-effective. Largescale data regarding patients with chronic venous leg ulcers presenting to venous centers with treatable superficial venous insufficiency has not been previously reported. Our study was designed to evaluate the percentage of patients with leg ulcers presenting to dedicated vein centers who were found to have surgically correctable superficial venous insufficiency. MethodsThe American Vein & Lymphatic Society Patient Reported Outcome Venous Registry began collecting data in 2014 and is one of two national registries focused on chronic venous disorders. The database was queried first for the presence of an ulcer using the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification (C6 status). These de-identified data were further correlated by crossing the number of ulcers for the same limb using the revised venous clinical severity score (rVCSS). The demographics, index duplex ultrasound details, and rVCSS features for ulcer duration and compression use were analyzed. Once the presence of an ulcer had been validated by CEAP and rVCSS, the population was divided into groups according to the ultrasound-reported anatomic pathology (eg, normal, reflux, obstruction, reflux plus obstruction). The query was directed toward all patients seeking a venous evaluation at participating centers from January 2018 through January 2022. ResultsMore than 270,000 unique patient records were reviewed. Of the 270,000 records, 163,027 (60%) had had duplex ultrasound scans available, for 1794 unique patients (1879 limbs), representing 1.1% with a leg wound. Of these patients, 55.4% were men and 44.6% were women. Group S included patients with isolated superficial pathology (n = 1291; 68.7%). Group M included patients with mixed superficial and deep pathology (n = 238; 12.7%). Group D included patients with isolated deep vein pathology (n = 58; 3.1%). Finally, group N included patients with leg wounds but no venous pathology (n = 292; 15.5%). The rVCSSs for groups S and M were significantly higher than those for group N. In group S, the dominant patterns involved the great saphenous vein (GSV) above the knee (54.8%), the small saphenous vein (30.7%), and the anterior accessory GSV (14.4%). The frequency of single, double, and triple axial vein reflux identified 1.45 vessels eligible for ablation treatment per limb. In group M, the dominant patterns involved the GSV above the knee (61.7%), the small saphenous vein (26.2%), and the anterior accessory GSV (12.1%), for 1.52 axial segments per limb. Of the 84.4% of venous ulcer patients, duplex ultrasound analysis revealed that 97% of this large subset had had surgically correctable disease. ConclusionsThe American Vein & Lymphatic Society Patient Reported Outcome Venous Registry demonstrated that 85% of the leg wounds in the present study were venous in origin and 97% possessed surgically correctable disease. Our findings support early referral to dedicated vein centers with appropriate venous reflux management as a part of the multidisciplinary team caring for patients with venous leg ulcers.

Assessment of Endovenous Microwave Catheter Ablation in the Treatment of Primary Lower Limb Varicose Veins

Background: Many Adults often have varicose veins, and the CEAP classification is a widely used method of staging the condition. Surgery is the standard course of therapy, which comprises sapheno-femoral and/or sapheno-opopliteal junction disconnection, along with or without superficial axial vein stripping. The endovenous ablation treatment is now the most popular and has a 95% occlusion rate. Endovenous Microwave Ablation (EMA), an endovenous ablation method, operates by producing radio-frequency radiation. The MICROTAZE OT-110 M device produces radiofrequency radiation. Aim of the study: The aim of this study is using endovenous microwave ablation as a new technique in treating of lower limb varicose veins according to the results, advantages, disadvantages and complications. Subjects and Methods: Thirty patients with lower limb varicose veins participated in this study. It was conducted at the vascular surgery department of Al-Azhar university hospitals (Al-Hussein and sayed-Galal). Patients were exposed to a clinical assessment and a duplex ultrasound after providing written permission. Results: over weighted and patients with 30-50 years were the most. A statistically significant improvement was observed in AVVQ at different follow-up intervals. Conclusion: This prospective, single-center study found endovenous microwave ablation of the great saphenous vein to be safe and effective. There were few complications, no DVT or paresthesia, a little amount of postoperative discomfort, and positive midterm radiological and clinical data.

Assessment of endovenous microwave catheter ablation in the treatment of primary lower limb varicose veins

Background: Lower limbs varicose veins are common in the adult population, The CEAP classification is a conventional way of staging varicose vein disease.Traditional treatment is surgery, which involves disconnection of sapheno-femoral and/or sapheno-opopliteal junctions with or without stripping of the superficial axial vein. the endovenous ablation is now the most widely used procedure and approximately occlusion rate of 95%. the Endovenous ablation techniques is Endovenous Microwave Ablation (EMA) which works by generating radio-frequency energy. It generates radiofrequency energy with the MICROTAZE OT-110 M machine. Aim: The aim of this study is using endovenous microwave ablation as a new technique in treatment of lower limb varicose veins according to the results, advantages, disadvantages and complications. Subjects and Methods: This study was conducted on 30 patients with varicose veins of lower limbs. It was conducted in the department of vascular surgery, Al- Azhar University Hospitals – Cairo (Al-Hussein and and said-Galal Hospitals). After taking a written consent, patients were subjected to Clinical evaluation and Duplex Ultrasound. Results: over weighted and patients with 30-50 years were the most. A statistically significant improvement was observed in AVVQ at different follow-up intervals.

Clinical presentation of isolated calf deep vein thrombosis in inpatients and prevalence of associated pulmonary embolism

ObjectiveControversy exists regarding the clinical significance and optimal treatment of isolated calf deep vein thrombosis (DVT). In the present study, the clinical presentation of isolated calf DVT and the association of isolated calf DVT with pulmonary embolism (PE) in hospitalized patients were investigated. MethodsA total of 1435 hospitalized patients had undergone whole leg duplex ultrasound between January 2018 and June 2020. Isolated calf vein DVT was diagnosed in 135 of these 1435 patients. ResultsThe soleal vein was the most frequently involved (52.6%). Thrombus was detected only in the axial veins in 57 patients (42.2%), muscular veins in 46 patients (34.4%), and both axial and muscular veins in 32 patients (23.7%). Of the 135 patients, 44 (32.6%) had undergone recent orthopedic surgery, 31 (23.0%) had active cancer, and 22 (16.3%) had a history of recent stroke. The reasons for duplex ultrasound examination were leg edema and/or pain for 57 patients (42.2%), the diagnosis of PE for 33 (24.4%), and an elevated D-dimer level for 27 patients (20.0%). For 16 patients (11.9%), DVT had been diagnosed as an incidental finding on imaging studies performed for other purposes. Of the 135 patients, 96 (71.1%) had received anticoagulation therapy. Concurrent PE was diagnosed in 45 patients (33.3%), 14 of whom had had lesions in the main pulmonary artery. Of the 45 patients with concurrent PE, 35 had not experienced leg edema and/or pain. Recurrent venous thromboembolism was observed in four patients (3.0%) at a mean follow-up of 15.5 ± 12.7 months. ConclusionsIn the present study, isolated calf DVT was associated with a high prevalence of PE in the hospitalized patients. Patients with isolated calf DVT, even without leg edema and/or pain, could have concurrent PE. Anticoagulation therapy should be considered for inpatients with isolated calf DVT. The muscular veins were frequently involved and, thus, should be thoroughly evaluated with imaging studies.

Patterns and Distribution of Deep Vein Thrombosis and Its Effects on Clinical Outcomes After Opening-Wedge High Tibial Osteotomy.

Background:Although a few studies have reported the incidence of deep vein thrombosis (DVT) after opening-wedge high tibial osteotomy (OWHTO), previous studies focused only on symptomatic DVT. Information is lacking regarding the overall incidence of DVT after OWHTO, thrombus location, and the relationship between DVT and clinical outcome.Purpose:To determine the overall incidence of DVT and classify the location of DVT after OWHTO. We also determined whether significant differences in clinical improvement exist in patients with and without DVT at 6 months and at 2 years after OWHTO.Study Design:Case-control study; Level of evidence, 3.Methods:This study included 46 patients (47 knees) who underwent OWHTO. All patients were instructed to perform knee range of motion exercises and partial weightbearing after drain removal. None of the patients received a chemoprophylaxis for DVT except intermittent pneumatic compression. DVT was diagnosed using 128-row multidetector computed tomography performed before discharge on the fourth postoperative day. The location was classified into 6 segments in the distal portion (muscular and axial veins) and proximal portion (popliteal, femoral, and common femoral veins and veins located above the iliac vein). International Knee Documentation Committee (IKDC) score was assessed preoperatively and postoperatively at 6 months, 1 year, and 2 years using a linear mixed model.Results:Although the incidence of symptomatic DVT was 8.5% (n = 4), the overall incidence of early DVT was 44.7% (n = 21). All DVTs were located in the distal portion of the lower extremity vein, and 76.2% of the DVTs were located in an axial vein. The IKDC scores were 33.6 ± 7.2 and 35.3 ± 9.1 (P = .910) preoperatively, 38.1 ± 5.6 and 40.6 ± 8.4 (P = .531) at 6 months after surgery, and 44.8 ± 6.9 and 45.9 ± 11.4 (P = .786) at 2 years after surgery in patients without and those with DVT, respectively.Conclusion:The overall incidence of early DVT after OWHTO was 44.7%. DVT after OWHTO was found particularly around the osteotomy site (76.2%). Patients with DVT did not have inferior short-term clinical outcomes after surgery.

Clinical Presentation of Varicose Veins

Varicose vein is one type of venous insufficiency that presents with any dilated, elongated, or tortuous veins caused by permanent loss of its valvular efficiency. Destruction of venous valves in the axial veins results in venous hypertension, reflux, and total dilatation, causing varicosities and transudation of fluid into subcutaneous tissue. The first documented reference of varicose veins was found as illustrations on Ebers Papyrus dated 1550 B.C. in Athens. Evidence of surgical intervention was found in the 1860s. However dramatic advances of varicose vein management occurred in the latter half of twentieth century. Varicose veins affect from 40 to 60% of women and 15 to 30% men. Multiple intrinsic and extrinsic factors including age, gender, pregnancy, weight, height, race, diet, bowel habits, occupation, posture, previous DVT, genetics, and climate are considered to be the predisposing factors for formation of varicose vein. Other reported factors are hereditary, standing occupation, chair sitting, tight underclothes, raised toilet seats, lack of exercise, smoking, and oral contraceptives. Common symptoms are unsightly visible veins, pain, aching, swelling, itching, skin changes, ulceration, thrombophlebitis, and bleeding. The signs of varicose vein disease are edema, varicose eczema or thrombophlebitis, ulcers (typically found over the medial malleolus), hemosiderin skin staining, lipodermatosclerosis (tapering of legs above ankles, an “inverted champagne bottle” appearance), and atrophie blanche. Varicose vein is classified according to CEAP classification, the components of which are clinical, etiological, anatomy, and pathophysiology. The revised CEAP classification was published on 2020 based on four principles which were preservation of the reproducibility of CEAP, compatibility with prior versions, evidence-based medicine, and practicality.

Comparison of high saphenous ligation and stripping, radiofrequency ablation, and subfascial endoscopic perforator surgery for the treatment of active venous ulcers: Retrospective cohort with five-year follow-up.

To compare the use of high saphenous ligation and stripping, radiofrequency ablation, and subfascial endoscopic perforator surgery for the treatment of active venous ulcers. One hundred ninety-five (n = 195) subjects who were treated for venous leg ulcers were enrolled between 2009 and 2014. Three groups were formed (Group A: high saphenous ligation and total stripping, Group B: radiofrequency ablation of the great saphenous vein + perforators, and Group C: radiofrequency ablation of the great saphenous vein + subfascial endoscopic perforator surgery) (n = 65 for each group). The venous clinical severity score for baseline, 1st, 6th, and 12th months, great saphenous vein occlusion at the 1st, 6th, and 12th months, and ulcer rates for the 1st, 2nd, 3rd, 4th, and 5th years were recorded. For venous clinical severity score, only the first month decrease was significant for the subfascial endoscopic perforator surgery group (p = 0.001). Great saphenous vein occlusion was higher at the 6th and 12th months for the high saphenous ligation and stripping and subfascial endoscopic perforator surgery groups than for the radiofrequency ablation group (p = 0.036 and p = 0.037). The rate of ulcers for the subfascial endoscopic perforator surgery group was lower at the second, third, fourth, and fifth years (p = 0.011). No significant difference was found between groups for the five-year recovery rates (p > 0.05). Subfascial endoscopic perforator surgery technique in conjunction with radiofrequency ablation of axial vein was superior to both high saphenous ligation and stripping and radiofrequency ablation of axial and perforators for ulcer healing.

The anatomic distribution and pulmonary embolism complications of hospital-acquired lower extremity deep venous thrombosis

ObjectiveThe anatomic distribution of lower extremity deep venous thrombosis (LEDVT) plays an important role in its prevention and treatment. This study aimed to evaluate the anatomic distribution of hospital-acquired LEDVT (HA-LEDVT) and its probable role in the occurrence of pulmonary embolism (PE). MethodsWe retrospectively analyzed the demographic data, ultrasound results, and PE-related findings of inpatients with HA-LEDVT in 28 clinical departments at Peking University People's Hospital between January 1, 2007, and December 31, 2018. ResultsThis study included 1431 HA-LEDVT events: 35.8%, 31%, and 33.3% were left, right, and bilateral LEDVT. Isolated distal, proximal, and blended DVT were detected in 83.4%, 7.3%, and 9.3% of the patients, respectively. The distribution of HA-LEDVT in the left and right lower extremities were not significantly different except in patients aged ≥40 years (left: 2.07 vs right: 1.88 per 1000 extremities, P = .04). For anatomic types of HA-LEDVT, isolated distal HA-LEDVT was 5.02 times more prevalent than proximal HA-LEDVT (1.24 vs 0.26 per 1000 extremities, P ＜ .01). The involvement rates of specific deep veins by HA-LEDVT were highest in the muscular calf vein (87.5%) followed by the popliteal vein (10.1%), superficial femoral vein (9.3%), and common femoral vein (9.2%). HA-LEDVT involving multiple vein segments simultaneously occurred in 338 extremities. HA-LEDVT involving the muscular calf vein and at least one of three connected axial veins of the muscular calf vein occurred most frequently. Eighty-eight patients with HA-LEDVT (6.15%) had PE. The frequency of PE among patients with proximal and distal DVT (7.89% vs 6.23% P = .275) was not significantly different. The incidence of PE was highest in patients with bilateral proximal DVT (15.4%) and lowest in patients with a single right distal DVT (4.5%). PE occurred in 6% of muscular calf vein HA-LEDVT. In isolated muscular calf vein DVT cases, PE were more likely to occur in cases with a ＞6.05-mm-diameter thrombus than in those with a ＜6.05-mm-diameter thrombus (10.3% vs 4.2%, P ＜ .0001). ConclusionsHA-LEDVT is characterized by a significantly high percentage of DVT in the muscular calf vein. Muscular calf vein thrombosis may be the primary origin of lower extremity deep vein thrombosis. The diameter of the thrombus in the muscular calf vein may be associated with the occurrence of PE. More prospective studies are needed to more fully determine the natural history of HA-LEDVT and develop prevention and treatment guidelines for HA-LEDVT.

Generation of cd63-deficient zebrafish to analyze the role of cd63 in viral infection

The tetraspanin superfamily proteins are transmembrane proteins identified in a diverse range of eukaryotic organisms. Tetraspanins are involved in a variety of essential biological functions, including cell differentiation, adhesion, migration, signal transduction, intracellular trafficking, and immune responses. For an infection to occur, viruses must interact with various cell surface components, including receptors and signaling molecules. Tetraspanin CD63 is involved in the organization of the cell membrane and trafficking of cellular transmembrane proteins that interact with many viruses. In this study, the cd63 gene was characterized by studying its expression and function in a zebrafish model. The functional domains and structural features of Cd63, such as the Cys-Cys-Gly (CCG) motif in the large extracellular loop and cysteine residues, are conserved in zebrafish. We confirmed that cd63 was expressed in immune system organs, such as the axial vein and pronephric duct, during the embryonic development of zebrafish. To better understand the role of cd63 in the zebrafish immune system, we established cd63-deficient zebrafish lines using the clustered regularly interspaced short palindromic repeats/CRISPR-associated protein 9 (CRISPR/Cas9) system. A 19 bp insertion mutation was generated in single guide RNA (sgRNA) target sequence of exon 3 of the cd63 gene, to create a pre-mature stop codon. We then analyzed the expression of cd63-related genes cxcr4a and cxcr4b in wild type (WT) and cd63-deficient zebrafish. We believe our study provides an important model that could be used to investigate the roles of cd63 in viral infection in vivo.

Incidence and Distribution of Lower Extremity Reflux in Patients With Pelvic Venous Insufficiency

Fifty percent of women with pelvic venous insufficiency will present with symptomatic lower extremity venous reflux. The patterns of reflux have suggested an association between hormonal fluctuations and pregnancy. In this study, 227 women with documented pelvic venous insufficiency also had the following lower extremity symptoms: pain (66%), edema (32%), heaviness (26%), leg fatigue (13%), itching (13%), cramping (10%), skin changes and/or thrombophlebitis (2%), and venous ulceration and/or hemorrhage (0.8%). One third had axial vein reflux, and 28% had a history of previous endovenous ablation. Pelvic venous disorders are being increasingly recognized as contributing, not only to abdominal and pelvic symptoms, but also to lower extremity venous disease. In women with residual or recurrent varicose veins or persistent symptoms after treatment of lower extremity venous insufficiency, evaluation of the pelvic veins via ultrasonography or other imaging modalities should be performed. Regardless, in the evaluation of women with symptomatic varicose veins and a history of pregnancy, questions that might indicate the presence of pelvic venous insufficiency should be a part of the history-taking process.

Feasibility of a fetal anatomy 3D atlas by computer-assisted anatomic dissection

ObjectiveTo assess the feasibility of 3D modelisation of fetal anatomy by using the Computer-assisted anatomic dissection (CAAD) based on immunolabeled histologic slices and MRI slices with a specific 3D software. Study designFor pelvis and lower limbs, subjects came from legal abortion, medical pregnancy termination, or late miscarriage. Specimens were fixed in 10 % formalin, then embedded in paraffin wax and serially sectioned. The histological slices were stained using HES and Masson Trichrome. Protein S-100 and D2−40 markers were used for immuno-labelling. Serial transverse sections were digitalized and manually aligned. Fetal brain slices were obtained from in utero or post-mortem MRI. ResultsCAAD was performed on 10 fetuses: pelvis was modelised with 3 fetuses of 13, 15 and 24 W G, lower limbs with 2 fetuses of 14 and 15 W G and brain with 5 fetuses aged between 19 and 37 W G. Fetal pelvis innervation was analysed after immunolabelling and nerves appeared proportionally bigger than in adults with the same topography. Lower limbs analysis revealed that nerve development was guided by vascular development: the sciatic nerve along the big axial vein, the saphen nerve along the big saphen vein and the sural nerve along the small saphen vein. Fetal brain study allowed to describe the gyration process and the lateral ventricle development. ConclusionCAAD technique provides an accurate 3D reconstruction of fetal anatomy for lower limbs and pelvis but has to be improved for brain model since midline structures were not amendable for analysis. These results need to be confirmed with larger series of specimens at different stages of development.

Incidence and distribution of lower extremity reflux in patients with pelvic venous insufficiency.

Women with pelvic venous insufficiency often present with lower extremity symptoms and manifestations of chronic venous disorders. The purpose of this investigation was to determine the incidence of lower extremity chronic venous disorders and the types and distribution of lower extremity veins involved in patients with a known diagnosis of pelvic venous insufficiency. Between January 2012 and December 2015, we retrospectively reviewed the charts of 227 women with pelvic venous insufficiency as well as their lower extremity venous duplex investigations. Presenting symptoms, Clinical, Etiology, Anatomy, Pathophysiology (CEAP) class, initial revised Venous Clinical Severity Score (rVCSS) and the types of lower extremity veins with reflux and their locations were noted. Patients were also subcategorized according to their primary pelvic disorder as follows: Entire cohort (PVI), Ovarian vein reflux (OVR), Iliac vein stenosis (IVS) or both (OVR + IVS). The study group consisted of 227 women (454 limbs) with documented pelvic venous insufficiency. The average age was 44.71 ± 10.2 years. In decreasing order, patients presented with the following lower extremity symptoms: pain (66%), swelling (32%), heaviness (26%), limb fatigue (13%), itching (13%), leg cramps (10%), skin changes or Superficial Venous Thrombosis (SVT) (2%) and ulceration or bleeding (0.08%). Table 1 outlines the CEAP class for 215 of the 227 patients. For the entire cohort, 48% of right and 50% of left limbs demonstrated C0 or C1 disease. The incidence and type of symptomatic lower extremity veins were as follows: any axial vein, 32%; great saphenous vein (GSV), 21%; small saphenous vein (SSV), 11%; GSV and SSV, 5%; non-saphenous tributaries, 15%; saphenous tributaries, 12%; posterior or postero-lateral thigh distribution, 5%; vulvar distribution, 4%; perforators, 4%; deep veins, 2%; and anterior accessory saphenous veins, 1%. For the GSV and SSV, the following patterns of reflux were observed: entire GSV, 4%; entire above knee GSV, 2%; entire below knee GSV, 2%; above knee segmental GSV, 20%; below knee segmental GSV, 21%; above and below knee GSV segmental disease, 1%; entire SSV, 4%; and SSV segmental disease, 12%. The incidence of reflux in any axial vein, the GSV and anterior accessory GSV was greater in the OVR group compared to IVS or OVR + IVS (p ≤ 0.03). In addition, 64 of 227 (28%) patients had a history of prior lower extremity venous ablations: OVR (10/39, 26%), IVS (15/50, 30%) and OVR + IVS (39/127, 9%). The number of ablations per patient was as follows-OVR: 1.48 ± 0.5, IVS: 1.7 ± 0.7 and OVR + IVS: 1.65 ± 0.7. At least 50% of patients with pelvic venous insufficiency present with lower extremity venous disease. The incidence of reflux in any axial vein is greatest in the OVR group suggesting a correlation with hormonal fluctuations and pregnancy. The majority of symptomatic patients present with segmental axial GSV or SSV disease. Although vulvar and gluteal escape veins are highly associated with pelvic venous insufficiency, they are infrequently observed. In patients who experience residual or persistent symptoms after treatment for chronic venous disorders, a pelvic venous ultrasound should be performed to assess the presence of pelvic venous insufficiency.

Abstract No. 600 Clinical and technical success of 1% polidocanol chemical microfoam ablation for axial reflux

Evaluate clinical success in patient-reported quality of life metrics and technical success of closure in axial saphenous vein(s) using 1% polidocanol chemical microfoam for ablation of reflux in patients with C2-C6 disease. Retrospective database review of patients with symptomatic C2-C6 disease who had GSV, AAGSV, and/or SSV ± varicosities treated with Varithena from 2016-2018 by two IR staff at a single institution. Clinical success at 3-6 months, measured via VEINES-QOL/Sym, visual analogue scale, Venous Clinical Severity Score, CEAP classification, and Villalta scale. Technical success at 48 hours and 3-6 months measured with US. Pre-procedure evaluation included physical exam, US via accredited vascular lab, and documentation of patient’s baseline. Patients appropriate for treatment had SFJ and/or SPJ and/or axial vein reflux of >0.5 seconds who failed conservative treatment. Presence of deep system reflux, prior DVT, and/or prior venous intervention was recorded. Patients underwent Varithena ablation of 1 or > vessels in one limb or both, in tandem or at a later session. Volume administered per vessel was recorded. Limb(s) were placed into 2 weeks of compression per manufacturer’s guidelines. Technical success defined as complete or partial closure versus failure with non-closure of treated vessels. Clinical success defined as improvement in VEINES-QOL/Sym, VCSS, VAS, or Villalta. Data suggests positive effect of Varithena on both clinical and technical success outcomes. Average pain score decreased (5.03 to 3.31), Villalta score decreased (8.71 to 3.71), QOL increased (45.41 to 54.49), Sym component increased (45.29 to 53.98), and VCSS decreased (7.93 to 3.68); all showing statistical significance (p <.0001-.0003). Technical success at 48-hours was 89.5% and 92.6% at 3-6 months. Varithena yielded statistically significant improvement in patient-reported quality of life and physician-reported exam scores at 3-6 months and technical success at 48-hours and 3-6 months. GSV and SSV had high technical success with least technical success seen in the AAGSV. Clinical success does not appear to depend on technical success, but a high correlation is suggested.Tabled 1Patient DemographicsTotal patients55Total treated limbs75Age, mean (SD)51.3 (12.3)Range: 27-76GenderF: 37; 67.3%M: 18; 32.7%BMI, (mean) range31 (19.2-55)Deep reflux on 1st US (limbs)23 (30.7%)Prior venous intervention (limbs)13 (17.3%)Initial CEAP (limbs)2: 34 (45.3%)3: 19 (25.3%)4: 10 (13.3%)5: 2 (2.7%)6: 10 (13.3%)Volume of Varithena (ml)Mean (SD): 14.2 (6.9)Range: 5-33 Open table in a new tab

A paramedian forehead flap based on the axial artery and vein

A paramedian forehead flap based on the axial artery and vein