CEAP Clinical Class Research Articles

Asociación entre sistemas venosos insuficientes y manifestaciones clínicas en enfermedad venosa crónica de miembros inferiores

Introduction: The clinical, etiological, anatomical, and pathophysiological classification (CEAP) standardizes the manifestations of lower limb venous disease. Objective: To investigate the association between insufficient venous systems and the clinical classification of CEAP. Methods: A quantitative, cross-sectional, analytical, correlational study was conducted. Sampling was non-probabilistic and convenience-based. The sample size was 136 lower limbs from 71 patients. Chi-square, Monte Carlo and Odd ratio (OR) statistical tests were used with 95% confidence intervals through bivariate logistic regression (p<0.05). Results: 71.8% of the subjects were female, with an average age of 66.1 years. The most frequent insufficient venous system was the superficial system, present in 61.7% of cases. 100% of the dilated great saphenous veins (GSV) had insufficiency. The most common CEAP clinical class was C2 (44.9%); 35.1% of C1 (telangiectasia) cases had an insufficient venous system; 50% of C2 cases had GSV insufficiency (p=0.227). There was an association between the insufficiency of both superficial and deep venous systems and the CEAP clinical classification (p=<0.001). The deep venous system was associated with severe chronic venous disease of the lower limbs, OR (6.04) with a 95% CI (1.02-35.73) and p=0.047. Conclusions: The study demonstrated an association between the insufficiency of both superficial and deep venous systems and the CEAP clinical classification. One third of the lower limbs with C1 (telangiectasias) had an insufficient venous system.

Endovenous laser treatment vs conventional surgery for great saphenous vein varicosities: A propensity score matching analysis.

Varicosis is a common venous condition, which is typically treated surgically. However, selection of the optimal surgical approach can be challenging. Previous studies comparing endovenous laser treatment (EVLT) and conventional surgery were retrospective and observational in nature and the results may therefore have been influenced by selection bias and the presence of other confounding factors. In this study, we used propensity score matching to reduce selection bias when comparing EVLT and conventional surgery for the treatment of varicose great saphenous veins. To compare the perioperative and postoperative outcomes of EVLT and conventional surgery in patients with great saphenous vein varicosis. We retrospectively reviewed the records of 1063 patients treated for primary varicosis of the great saphenous vein at the Second Affiliated Hospital of Xuzhou Medical University between January 2009 and December 2019. Among them, 56 patients were excluded owing to additional small saphenous varicose vein involvement, 81 owing to recurring varicose veins, 83 owing to complicated varicose veins (CEAP clinical classification C5-C6), and 6 owing to perioperative phlebitis. Finally, 772 patients were enrolled in this study. Standard demographic and clinicopathological data were collected from the medical records of the patients. For propensity score matching, 522 patients (261 who underwent EVLT and 261 who underwent conventional surgery) were randomly matched 1:1 by age, sex, onset time, smoking status, presence of diabetes, family history, stress therapy, C class, and the affected leg. Of the 772 patients included in the study, 467 underwent EVLT and 305 underwent conventional surgery. There were significant differences in age, onset time, smoking and diabetes status, and family history between the two groups. Following propensity score matching, no significant differences in patients' characteristics remained between the two groups. ELVT was associated with a shorter operation time and hospital stay than conventional surgery, both before and after propensity score matching. There were no differences in complications between the two groups after propensity score matching. Patients who underwent EVLT had a higher recurrence rate during the two-year follow-up period than those who underwent conventional surgery (33.33% vs 21.46%, χ2 = 11.506, P = 0.001), and a greater percentage of patients who underwent EVLT experienced pain one week after the procedure (39.85% vs 19.54%, P = 0.000). EVLT may not always be the best option for the treatment of great saphenous vein varicosis.

Cytokine Activity Indicators Dynamics after Non-Drug Rehabilitation including Intravenous Laser Blood Irradiation in Patients with a Lower Limb Post-Thrombophlebitic Syndrome: a Randomized Study

INTRODUCTION. Previous studies have established the association of venous thrombosis risk factors with inflammation, and the important role of inflammatory mediators as prognostic markers of recanalization of veins after deep vein thrombosis and the progression of postthrombophlebitic syndrome (PTPS). Pro-inflammatory cytokines, as key inflammatory mediators, are part of several cascades of pathophysiology in venous thrombosis, as well as predictors of the occurrence and prolongation of acute thrombosis and its resolution. To date, new oral anticoagulants are used, but their use in medical practice does not lead to a decrease in the number of patients with PTPS.
 AIM. To study the dynamics of proinflammatory cytokine levels under the influence of a complex non-drug method including intravenous laser irradiation of blood (ILBI) in patients with PTPS.
 MATERIALS AND METHODS. We conducted a randomized study that included 60 patients aged 58.3 ± 12.56 years with lower extremity PTPS (CVI C4–C5 according to CEAP clinical classification) divided into 2 groups. The subjects of the 1st group (main, n = 30) received: ILBI, pulsed magnetotherapy and dry-air carbon dioxide baths. After a complex of physiotherapy procedures, patients underwent therapeutic gymnastics in the gym according to the Brunner U. method. Subjects of the main group received the above rehabilitation complex against the background of phlebotonics (combination of diosmin and hesperidin) and the use of knitwear of 2–3 compression classes. Patients of the 2nd group (control group, n = 30) received standard elastic compression (2–3 compression class), similar drug therapy with phlebotonics and therapeutic gymnastics in the gym according to the method of Brunner U.
 RESULTS. After the course of rehabilitation, the patients of the main group showed positive dynamics of the main clinical symptoms of the disease, a decrease in malleolar volume, correction of microcirculatory disorders and activity of proinflammatory cytokines, accompanied by an improvement in transcapillary metabolism and tissue hypoxia. In patients of the control group, only a decrease in the number of leukocytes and fibrinogen in peripheral blood was recorded, while no changes in the expression of proinflammatory cytokines were observed. In this group of subjects, there was a positive trend in the regression of edema in terms of malleolar volume.
 CONCLUSION. As a result of the application of the proposed rehabilitation complex, which includes, along with the traditionally used physical factors (pulsed magnetotherapy, dry-air carbon dioxide baths and therapeutic gymnastics) ILBI procedures, not only decongestant, hypocoagulating effects, positive dynamics of the main clinical symptoms of the disease were noted, but also correction of microcirculatory disorders and the level of pro-inflammatory cytokines was achieved, accompanied by an improvement in transcapillary metabolism and trophic tissues.

COMPARISON BETWEEN CONVENTIONAL HIGH LIGATION AND STRIPPING AND RADIOFREQUENCY ABLATION FOR GREAT SAPHENOUS VARICOSE VEINS

The prospective study was conducted from December 2022 to May 2023 to assess patient-based, radiological, and clinical outcomes after conventional surgery and radiofrequency ablation for great saphenous varicose veins. Patients were randomly divided to undergo conventional surgery or RFA. American Society of Anesthesiologists fitness grade, Venous Disability Score (VDS), Total Clinical Severity Score (TCSS), Michael's, and CEAP clinical classes were recorded. VEINES-QoL/Sym questionnaire and Aberdeen Varicose Vein Questionnaire were used to estimate baseline QoL. Patients were called for follow-up at the end of 1st and 5th week. The study was conducted on a total of 110 patients. Patients were randomly divided; 57 underwent RFA, and 53 underwent conventional surgery. Results showed that the difference between both groups regarding anesthesia induction, recovery, and discharge from surgery was insignificant. RFA had significantly longer total theater time compared to conventional surgery. Duplex imaging showed that RFA resulted in successful ablation except in two cases where veins had segmental brisk flow. These cases were retreated successfully. Conventional surgery only had the problem of incomplete stripping (6 cases). Post-operative pain, bruising, and the need for analgesia were significantly higher following conservative surgery. Patients in the RFA group returned to work and normal activities more quickly than the conventional surgery group. It is concluded that RFA had a longer intervention time but significantly better outcomes than conventional surgery.

Effectiveness of iliac vein stenting combined with endovenous laser treatment of recurrent varicose veins associated with iliac vein compression.

Iliac vein compression syndrome (IVCS) is an underlying cause of varicose vein (VV) recurrence after venous surgery. However, the management of recurrent varicose veins (RVVs) combined with IVCS has rarely been reported. This study aimed to investigate the outcomes of a one-stop procedure to correct outflow obstruction and superficial reflux for patients with RVVs and IVCS. A retrospective analysis was conducted of 102 consecutive patients diagnosed with RVVs. Computed tomography venography (CTV) was performed to confirm IVCS. The cases were divided into 2 groups: the IRVVs group, including patients with RVVs and IVCS (n=48), and the RVVs group, including patients with RVVs only (n=54). The characteristics, vein reflux, and clinical, etiological, anatomical, and pathophysiological (CEAP) distribution were investigated. Then, the IRVVs group patients who underwent endovenous laser ablation (EVLA) (n=39) were divided into a further 2 groups: the EVLA + S group (n=19), who received EVLA and stenting of iliac vein, and the EVLA group (n=20), who received EVLA treatment alone. The great/small saphenous vein (GSV/SSV) trunk occlusion, VV recurrence, visual analogue scale (VAS), and venous clinical severity score (VCSS) were investigated. The prevalence rate of femoral vein reflux was 81.2% in IRVVs group and 50% in RVVs group (P<0.05). In the IRVVs group, 72.9% of patients manifested as CEAP clinical class >3, which was higher than that in RVVs group (48.1%) (P<0.05). The 12-month GSV/SSV occlusion rate in the EVLA + S and EVLA groups were 94.7% and 90.0%, respectively. Totals of 9 patients in EVLA + S group and 6 patients in EVLA group had active venous ulcers, and the ulcer healing time in EVLA + S group was significantly shorter (27.22±7.12 vs. 46.67±9.83 days, P<0.05). The reductions in the VAS and VCSS values between baseline, 1 month, and 12 months in the EVLA + S group were more obvious than those in EVLA group (P<0.05). The one-stop combination treatment of iliac venous stenting and EVLA in patients with RVVs and IVCS is safe and effective and provides prominent symptom relief, improved quality of life, and a more satisfactory ulcer healing than EVLA alone.

Perivascular Administration of Hyaluran-Cyanoacrylate Complex Gel for Deep Venous Reflux

Objective: Deep venous insufficiency is an important health issue affecting the population worldwide. In this study we aimed to assess the effectiveness and safety of a novel antireflux treatment procedure in patients with primary deep vein insufficiency.&#x0D; Methods: Between October 2016 and December 2018, 81 valvular leak operations consisting of perivenous hard gel injection were performed in 81 patients with primary deep venous insufficiency. The clinical symptoms of the patients were between C3-C6 according to the CEAP clinical classification. Venous insufficiency associated with only one deep venous valve was verified with Doppler ultrasonography. Patients were assessed with physical and ultrasound examination on the follow-up visits, which were achieved on the third day and at the first, sixth, and twelfth months. The nonexistence of reflux in the treated valve level was defined as the success of the procedure. Any reflux, which lasted 0.5 seconds or more, was regarded as a lack of success.&#x0D; Results: The ages of the patients ranged between 32 and 78. All the patients had deep venous insufficiency. The follow-up could be achieved in all the patients. The mean volume of the gel administered was 2.4±0.9 ml. The mean procedure duration was 22.3±8.9 (range 14–42) minutes. The procedures could be performed successfully in all of the patients confirmed perioperatively and on the third day of follow-up with the elimination of reflux. The sixth-month follow-up, with the same vein diameter after the treatment without any reflux, revealed the same findings as to the first-month follow-up. The treatment was not associated with any significant morbidity or mortality. The VCSS decreased significantly when preprocedural and twelfth-month VCSS were compared as 21.8 ± 4.8 and 3.8±0.7, respectively (p

Effect of Obesity and Bariatric Surgery on Saphenous Veins.

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

Double-barrel iliocaval reconstruction using closed-cell dedicated venous stents

ObjectiveDouble-barrel iliocaval reconstruction is performed by deploying two stents simultaneously in a side-by-side, or “double-barrel,” configuration in the inferior vena cava (IVC) with extension into the bilateral common iliac veins. The aim of this study was to examine the outcomes of double-barrel reconstruction using closed-cell dedicated venous stents for the treatment of iliocaval deep venous thrombosis and iliac vein compression syndrome. MethodsAll endovascular procedural reports comprising vascular surgery and interventional radiology operators from a single urban academic hospital between May 1, 2019, and April 30, 2021, were retrospectively searched. A cohort of 22 consecutive patients who underwent double-barrel iliocaval stenting with closed-cell dedicated venous stents for chronic or acute-on-chronic iliocaval venous disease without prior endovascular iliocaval repair was identified. Baseline characteristics, procedural data, and patient outcomes were determined via a manual review of preprocedure clinical notes, diagnostic imaging studies, procedure notes and images, and follow-up clinical notes. ResultsThe median (range) age was 59 (27-81) years, and the cohort consisted of 59.1% female. The most common presenting symptoms of venous disease were lower extremity swelling (90.9%) and pain (50.0%). CEAP clinical classification was C3 in 86.4% of patients, whereas the remainder had C4 disease. Most patients (72.7%) had post-thrombotic syndrome, 22.7% had a nonthrombotic iliac vein lesion, and one patient (4.5%) had the congenital absence of the infrarenal IVC. A total of 40.9% of patients had a pre-existing IVC filter at the time of treatment. Six of the 22 patients underwent concurrent pharmacomechanical thrombectomy during the index iliocaval reconstruction and stenting procedure. The number of stents placed ranged from 2 to 5. With a mean follow-up period of 7.1 months, ranging from 12 days to 16.7 months, the freedom from reintervention rate was 90.9%. Twenty of 22 patients achieved subjective improvement or resolution of symptoms. The major adverse event rate was 9.1%, as two patients had access site complications requiring intervention. ConclusionsDouble-barrel iliocaval reconstruction with closed-cell dedicated venous stents for the treatment of post-thrombotic syndrome or iliac vein compression syndrome is technically feasible and clinically effective with a low reintervention rate.

Treatment and contemporary outcomes associated with adjunct tourniquet use during phlebectomy of complex, voluminous truncular varicosities

ObjectivePhlebectomy of large voluminous varicose veins comes with a risk of substantial blood loss. The purpose of the present study was to investigate the outcomes associated with the use of an adjunct tourniquet during varicose vein surgery of complex and large truncular varicosities. MethodsThe prospectively collected registry data included anatomic and outcomes details for patients who presented with complex and large truncular varicosities with a CEAP clinical class of C2, or higher (indicating more serious venous disease) from December 2014 to December 2021. Of all patients, those treated with an adjunct tourniquet for large complex varicosities (largest diameter varicosity ≥1 cm by visual inspection) were selected for analysis. The venous clinical severity scores (VCSSs) and patient-reported outcomes (PROs) were obtained. Additional parameters, including operative time, tourniquet time, and blood loss, were obtained retrospectively via a review of the medical records. Univariate descriptive statistics of the demographic and procedural data were performed pre- and postoperatively, with comparisons performed using the Student two-tailed t test. ResultsThe data from 19 patients (22 limbs; 7 women and 12 men) were analyzed. Of the 22 limbs, 11 (50%) had advanced venous disease of C4 or higher preoperatively. A review of the preoperative duplex ultrasound scans confirmed the presence of large varicosities (average, 1.0 ± 0.54 cm; n = 18). All the limbs were treated using radiofrequency ablation of axial reflux and phlebectomy (a combination of powered and stab) under tourniquet control (82%) or phlebectomy under tourniquet control alone (18%). The average tourniquet time was 40 ± 12 minutes, with a median blood loss of 50 mL (interquartile range, 30-100 mL). The average follow-up was 332 ± 422 days after 19 procedures for 16 patients (2 patients moved out of state during the immediate postoperative period and 1 patient was lost to follow-up). Of the patients who completed >3 months of follow-up, 14 limbs experienced improvement in the CEAP class, 5 limbs had no change, and 3 were limbs of patients who moved or were lost to follow-up. The VCSSs significantly improved (8.8 ± 2.8 vs 3.9 ± 1.9; P < .0001). The PROs also improved significantly (16.1 ± 5.0 vs 2.2 ± 2.3; P < .0001). ConclusionsTourniquet use in the treatment of varicosities has only been described in the setting of high ligation and stripping. Our data suggest that in the modern era of minimally invasive endovenous treatment of axial reflux and phlebectomy, adjunct tourniquet use during the treatment of large complex varicosities can result in significant improvements in the VCSSs and PROs, with minimal blood loss.

Symptom Relief and Reintervention after Iliac Vein Stenting Stratified by CEAP Clinical Classification

This study sought to evaluate long-term symptom relief and reintervention rates after iliac vein stenting (IVS) in patients with chronic venous outflow obstruction. A single-institution database of patients undergoing IVS from August 2011 to June 2021 was analyzed. Patients were stratified into three cohorts based on the clinical component of the clinical, etiology, anatomical, and pathophysiology (CEAP) classification: C3, C4, and C5/6. Symptoms were quantified using the venous clinical severity score (VCSS). Reintervention was defined as any procedure using venography. Edema, pigmentation, and ulceration progression-free survival as well as reintervention-free survival were assessed with Kaplan Meier analysis. Among 737 total patients, there were 435 C3, 206 C4, and 96 C5/6 patients. The C5/6 cohort had the highest percentage of patients undergo reoperation (36.4%). C5/6 patients yielded the poorest ulceration progression-free survival (P<0.001) while C3 patients had the poorest skin pigmentation progression-free survival (P=0.009). On adjusted analysis there was no significant difference in odds of reintervention between study cohorts. Mean composite VCSS scores were significantly different at each yearly post-operative follow-up visit up to 6 years. The present study is one of the largest investigations of long-term outcomes in IVS patients. Most patients with long-term follow-up experienced an improvement in their composite VCSS. CEAP clinical classification at the time of IVS had a significant influence on the likelihood and quantity of reintervention.

Artificial Intelligence CEAP C0-2 Clinical Class Assessment Compared to Health Professionals and Patients Scoring

Telemedicine brings the benefit of compensating the patient distance while optimizing the consult. Telehealth potential advantage has been reported in rural areas and recently in the COVID-19 lock-down context. Lower limb chronic venous disease (CVD) wide prevalence and impact on the healthcare costs are known. While software applications are validated for venous ulcers assessment, up to our knowledge, no investigations have been published on CVD early stages remote assessment. This investigation objective is to assess artificial intelligence (AI) feasibility for detection of CEAP clinical classes 0, 1, and 2 and to determine the interobserver variability among health professionals, patients, and AI.

Functional Features of Vascular Endothelium After Endovenous Laser Therapy and Pharmacotherapy (Sulodexide) in Patients with Varicose Veins with CEAP Clinical Class C4

Functional Features of Vascular Endothelium After Endovenous Laser Therapy and Pharmacotherapy (Sulodexide) in Patients with Varicose Veins with CEAP Clinical Class C4

Ten-year follow-up of a randomized controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia

ObjectiveThe long-term results of saphenofemoral ligation and stripping (SFL/S) were compared with 980-nm bare fiber endovenous laser ablation (EVLA) for the treatment of great saphenous vein (GSV) incompetence. MethodsThis was a single-center, randomized, controlled trial with a follow-up time of 10 years. Patients with GSV incompetence were randomized to undergo SFL/S or EVLA under tumescent anesthesia. The primary outcome was recurrence of groin-related varicose veins seen on duplex ultrasound imaging and clinical examination. The secondary outcomes were (changes or improvement in) CEAP clinical class, venous symptoms, cosmetic results, quality of life, reinterventions, and complications. ResultsBetween June 2007 and December 2008, 122 patients (130 limbs) were included; of these, 68 limbs were treated with SFL/S and 62 limbs with EVLA. The 10-year estimated freedom from groin recurrence as seen on duplex ultrasound imaging was higher in the SFL/S group (73% vs 44% in the EVLA group; P = .002), and the same trend was seen for clinically evident recurrence (77% vs 58%, respectively; P = .034). Nine reinterventions (17%) were deemed necessary in the SFL/S group vs 18 (36%) in the EVLA group (P = .059). All reinterventions in the SFL/S group consisted of foam sclerotherapy. Reinterventions in the EVLA group included foam sclerotherapy (n = 5), crossectomy (n = 2), and endovenous procedures (n = 11). There was no significant differences in quality of life and relief of venous symptoms. Cosmetic appearance improved, with a better cosmetic rating in the SFL/S group compared with the EVLA group (P = .026). One patient in the SFL/S group had a persisting neurosensory deficit remaining at 10 years. ConclusionsThis study showed no clear long-term advantage of EVLA with a 980-nm wavelength and bare-tip fiber over high ligation and stripping of the GSV under local tumescent anesthesia.

Symptom improvement after cyanoacrylate glue adhesion and endovenous laser ablation in low-grade CEAP clinical classes

ObjectiveLow-grade primary superficial venous reflux (C0-C3 EpAsPr [Ep (primary), As (superficial), and Pr (reflux)]) is a common feature of chronic venous disease. However, the procedural efficacy focusing on symptom characteristics and improvement patterns in this population has not been fully explored. MethodsFrom 2018 to 2019, 325 limbs from 279 patients with C0-C3 EpAsPr (including 66.1% with C0-C1) who had undergone cyanoacrylate ablation (CA) with ultrasound-guided foam sclerotherapy (UGFS) or endovenous laser ablation (EVLA) with UGFS were included in the present study. Venous symptoms were classified into five categories: leg heaviness, calf cramping, itching sensation, pain, and numbness. A retrospective propensity score-matched analysis of data collected using a prospectively designed case report form was performed to identify the improvement magnitude of each symptom. As secondary outcomes, the postoperative changes in symptom severity (0-5 points), venous reflux-originated severity score, venous clinical severity score (VCSS), and 14-item chronic venous insufficiency quality of life questionnaire (CIVIQ-14) were evaluated in a 3-month postoperative data analysis. ResultsAfter adjusting the data, 174 limbs (CA with UGFS, n = 87; EVLA with UGFS, n = 87) were matched. The symptoms with the greatest improvement after treatment were night cramping (94.7%) and itching (93.8%), followed by heaviness (85.2%), numbness (77.8%), and pain (60.9%). All symptom improvement scores after each endovenous procedure showed similar patterns in both groups. The advantages of CA with UGFS over EVLA with UGFS were a shorter procedure time (20.1 ± 10.6 minutes vs 28.4 ± 10.9 minutes; P = .001) and lower perioperative visual analog for pain scores (2.99 ± 2.34 vs 3.74 ± 2.49; P = .03). Compared with the preoperative values, the venous reflux originated severity score, VCSS, CIVIQ-14 score, and symptom severity score were significantly improved in both groups (P < .001 for all). Improvements in all five symptoms (P = .085 to P = 1.0), VCSS (P = .435), CIVIQ-14 score (P = .788), and satisfaction score (P = .392) at 3 months postoperatively were comparable between the two groups. In the CA group, 2 cases of endovenous glue-induced thrombosis and 24 cases (27.6%) of type IV hypersensitivity reactions occurred. ConclusionsMinimally invasive endovenous surgery with CA and EVLA provides significant symptom improvement for patients with low-grade CEAP classes.

ГЕМОДИНАМИЧЕСКИЕ НАРУШЕНИЯ ПРИ ВАРИКОЗНОЙ БОЛЕЗНИ

Aim. Duplex ultrasound scanning (DUS) is a routine diagnostic procedure in patients with varicose vein disease. DUS mostly evaluates the qualitative (anatomical) parameters of the disease. Still, it is difficult to assess the microcirculatory parameters in trophic disorders based only on the anatomy, therefore assessment of quantitative blood flow parameters is needed. Our aim was to determine the potentials of conventional DUS in assessment of the hemodynamic disorders in patients with varicose disease. Materials and Methods. The study included 583 patients with varicose disease, 348 of which had trophic alterations. The patients were divided into 4 groups according to the CEAP clinical classes. Standard Valsalva and Siegel tests were performed during DUS. The following parameters were assessed in the superficial and deep veins: diameter of veins, antegrade blood flow velocity, retrograde blood flow velocity, reflux time; in the perforator veins (PV) – diameter, maximum velocity and average velocity of reflux. Peripheral resistance index (RI) in the arteries accompanying the PV was also analyzed. Results. A statistically significant difference in the diameter of the GSV was obtained between classes C2 and C3, C3 and C4, but not between class C5, 6 and class C4. Similar findings were observed in the assessment of diameter of the PVs and the velocity of retrograde blood flow through them. A gradual increase in these parameters could be seen with the progression of the disease, but a statistically significant difference was obtained only between classes C2 and C3 for the diameter of the PV and the peak velocity of retrograde blood flow. As for the average blood flow velocity, a statistically significant difference was obtained between classes C2 and C3, C3 and C4. Arteries in the perforator bundles demonstrated low RI which may be attributed to the presence of an arteriolo-venular bypass. Statistically significant differences were obtained for CEAP classes C2 and C3. Conclusions. Ultrasound duplex scanning of the study with use of Superb Micro-Vascular Imaging mode is an effective method in assessing the quantitative and microcirculatory parameters of hemodynamic disorders in patients with varicose vein disease of the lower extremities. Trophic ulcers in varicose vein disease are not an obligatory component of the disease, but only its complication.

Pharmacological correction of total venous reflux in patients with varicose veins

To evaluate the efficacy of a micronized purified flavonoid fraction in patients with primary venous disease. The study enrolled 31 patients, with varicose veins observed in a total of 47 lower extremities which were divided into 3 groups depending on the CEAP clinical class. The group of class C2 included 19 limbs, with the groups of C3 and C4 comprising 14 limbs each. The patients received a micronized purified flavonoid fraction (Detralex) in a daily dose of 1000 mg for 1 month. The venous function of the lower extremities was examined using venous photoplethysmography before and after the course of pharmacotherapy. Venous refilling time and venous half-refilling time were measured as indicators of total venous reflux. In the overall sample of patients with clinical class C2-C4, a significant increase in venous photoplethysmography parameters was found after the course of administration of the micronized purified flavonoid fraction. Thus, the venous refilling time increased from 15.5 (11; 19) s to 19.3 (13; 25) s, the venous half-refilling time increased from 6.5 (5; 7) s to 7.5 (5; 9) s. At the same time, in the group of patients with clinical class C2 and C3, a significant increase in the venous refilling time was found, and in patients with C4, the increase was not significant. There was an inverse correlation between the increase in venous refilling time after drug exposure and the clinical class of venous insufficiency according to the CEAP, as well as the patient's age. Thus, the administration of the micronized purified flavonoid fraction for 1 month in primary venous disease led to a decrease in the total venous reflux. The effect of the micronized purified flavonoid fraction on the total venous reflux was higher in younger patients and in patients with a lower clinical class of the disease.

Quality of life and associated factors in patients with lower limb chronic venous insufficiency

Background: Lower limb chronic venous insufficiency (CVI) is a global issue. The disease has significant effects on the quality of life (QoL) with substantial burden on the healthcare system. In Vietnam, the QoL of patients suffering from lower limb CVI has not received much attention. This study evaluated the QoL and associated factors in patients with lower limb CVI in order to improve care as well as the well-being of patients.Objectives: To identify the QoL score and associated factors in patients with lower extremity CVI.Study methods: This is a retrospective observational study of 68 randomly selected patients with lower limb CVI at Medicine and Pharmacy Hospital. All patients were interviewed using the SF-36 questionnaire. Multivariate linear regression was used to evaluate the relationship between QoL score and other factors.Results: The mean scores of patients with lower limb CVI in physical health was 51.56±14.53, mental health was 53.91±15.20, overall QoL was 52.74±10.30. Factors associated with QoL was gender, income, disease severity based on CEAP clinical classification, level of physical activities and the use of medial pressure socks.Conclusions: QoL of patients with lower limb CVI was decreased, both physically and mentally. Patients should be encouraged to exercise more and use medial pressure socks to improve the QoL.

Can Subfascial Endoscopic Perforator Surgery (SEPS) be Standard of Care in Advanced Chronic Venous Insufficiency (CVI)?

Subfascial Endoscopic Perforator Surgery (SEPS) is a minimally invasive technique to treat incompetent perforating veins. Thirty patients with advanced chronic venous insufficiency (CVI) belonging to CEAP clinical class C4–C6 with incompetent perforating veins in the leg and competent sapheno — femoral junction (SFJ) were subjected to SEPS. Patients with concomitant arterial disease and deep venous thrombosis (DVT) were excluded. Outcomes were evaluated after surgery up to 12 weeks. Out of 12 patients with active ulcer, complete healing was seen in 11 (92%) while one patient had partial healing at the end of 12 weeks. Wound dehiscence occurred in one patient (3.33%). On Doppler ultrasound at 12 weeks, postoperative persistence of perforators was seen in three patients (10%). Post-operatively, patients had minimal pain, negligible wound complications, short hospital stay, early return to normal activities and excellent ulcer healing. However, no significant improvement in skin changes was seen. SEPS can easily be considered as standard of care in advanced CVI.

Five-year extension study of patients from a randomized clinical trial (VeClose) comparing cyanoacrylate closure versus radiofrequency ablation for the treatment of incompetent great saphenous veins

ObjectiveThe proprietary cyanoacrylate closure (CAC) system vs radiofrequency ablation (RFA) trial (VenaSeal Sapheon Closure System Pivotal Study [VeClose]) showed that CAC, a nontumescent, nonthermal, nonsclerosant ablation technique, was effective and noninferior to RFA in vein closure with good 36-month outcomes. Conducted under a separate protocol, the aim of this extended follow-up was to assess the long-term safety and effectiveness of CAC and RFA for the treatment of incompetent great saphenous veins (GSV) at 5 years (60 months) of follow-up. MethodsThis 60-month extension study was conducted for all patients who completed the randomized VeClose study and who were willing to participate. The pivotal VeClose study included patients with symptomatic moderate to severe varicosities (Clinical, Etiology, Anatomy, and Pathophysiology [CEAP] class C2-C4b) and symptomatic GSV incompetence who were randomly assigned (1:1) to either CAC or RFA. The primary outcome measure of this 60-month extension study was complete closure of the target vein, with planned exploratory analysis of noninferiority. Secondary outcomes included CEAP class; completion of the Venous Clinical Severity Score, EuroQol-Five Dimension survey, and Aberdeen Varicose Vein Questionnaire; patient satisfaction with treatment; adverse events (AEs) related to target GSV; and details of adjunctive procedures. ResultsA total of 89 patients completed the 60-month visit, which included 47 from the CAC group, 33 from the RFA group, and 9 CAC roll-in patients. No new recanalization events have been observed in the groups between 36 and 60 months of follow-up. At 60 months, Kaplan-Meier estimates for freedom from recanalization in the randomized CAC and RFA groups were 91.4% and 85.2%, respectively, demonstrating noninferiority of CAC compared with RFA. Both groups demonstrated sustained improvements in EuroQol-Five Dimension and quality of life measures through 60 months. Whereas patients assigned to C0 or C1 clinical class were excluded from the original study, more than half of all returning patients (64% [57/89]) were now assigned to C0 or C1, suggesting an improved clinical class from baseline. Furthermore, 41.1% of returning CAC patients and 39.4% of returning RFA patients are presently at least two CEAP clinical classes lower than at baseline. No long-term device- or procedure-related serious AEs occurred in either group between 36- and 60-month follow-up. ConclusionsCAC and RFA were effective in achieving complete target vein closure of the GSV at long-term follow-up, with CAC demonstrating continued noninferiority to RFA. CAC was also associated with sustained improvements in symptoms and quality of life, lower CEAP class, and high level of patient satisfaction without serious AEs between 36 and 60 months.

CEAP clinical classes C0S-C4: differences, similarities and role of Ruscus + HMC + vitamin C in patients with chronic venous disease.

Since the publication of the CEAP classification, new research has enriched our knowledge; notably on the heritability of CVD and the genetic and environmental factors involved in this condition, as well as the symptoms apparent within the spectrum of the CEAP clinical classes and the benefits of medical treatment. Using the CEAP classification as a special theme, a symposium with the same title as the present paper was held at the annual meeting of the 2019 European Venous Forum. The lectures presented much valuable information, from which some key points can be extracted. The influence of environmental factors was demonstrated, and the fact that a large amount of information can be obtained from comprehensive history taking. There is robust evidence for heritability. Many candidate genes/loci have been identified, potentially offering new targets for treatment. More research is needed, notably using genome-wide association studies and also on microbiota, which may play a role in CVD through the inflammation pathway. Ruscus + HMC + vitamin C acts by increasing venous and lymphatic tone, protecting microcirculation, and reducing inflammation. It improves quality of life in C0S to C3 CVD patients, while a review of clinical studies and a meta-analysis have confirmed its clinical efficacy across a wide spectrum of CVD clinical classes: C0S, C1S, C2, C3 and C4. It has been awarded a Grade 1A recommendation by the international guidelines.