Management Of Chronic Venous Disease Research Articles

Bioactive Compounds in Citrus Species with Potential for the Treatment of Chronic Venous Disease: A Review.

Chronic venous disease (CVD) significantly impacts global health, presenting a complex challenge in medical management. Despite its prevalence and the burden it places on healthcare systems, CVD remains underdiagnosed and undertreated. This review aims to provide a comprehensive analysis of the bioactive compounds in the Citrus genus, exploring their therapeutic potential in CVD treatment and addressing the gap in current treatment modalities. A narrative review methodology was adopted, focusing on the pharmacological effects of Citrus-derived bioactive compounds, including flavonoids and terpenes. Additionally, the review introduced the DBsimilarity method for analyzing the chemical space and structural similarities among Citrus compounds. The review highlights the Citrus genus as a rich source of pharmacologically active compounds, notably flavonoids and terpenes, which exhibit significant anti-inflammatory, antioxidant, and veno-protective properties. Some of these compounds have been integrated into existing therapies, underscoring their potential for CVD management. The DBsimilarity analysis further identified many clusters of compounds with more than 85% structural similarity. Citrus-derived bioactive compounds offer promising therapeutic potential for managing CVD, showcasing significant anti-inflammatory, antioxidant, and veno-protective effects. The need for further comparative studies, as well as safety and efficacy investigations specific to CVD treatment, is evident. This review underlines the importance of advancing our understanding of these natural compounds and encouraging the development of novel treatments and formulations for effective CVD management. The DBsimilarity method's introduction provides a novel approach to exploring the chemical diversity within the Citrus genus, opening new pathways for pharmacological research.

Cardiovascular Insights for the Appropriate Management of Chronic Venous Disease: A Narrative Review of Implications for the Use of Venoactive Drugs.

Evidence suggests that chronic venous disease (CVD) may be a cardiovascular disorder, as patients with CVD are prone to developing arterial (atherosclerosis) and venous (thromboembolism) diseases. This may be partly explained by shared risk factors. Thus, patients with CVD or cardiovascular disease require careful history-taking and physical assessment to identify coexisting pathologies and risk factors. This article summarises a symposium at the XIX World Congress of the International Union of Phlebology held in Istanbul, Turkey, in September 2022. Common pathophysiological features of CVD and cardiovascular disease are endothelial injury, hypercoagulability and systemic inflammation. In CVD, inflammation primarily affects the microcirculation, with changes in capillary permeability, vein wall and valve remodelling and increase in oxidative stress. Once patients develop symptoms/signs of CVD, they tend to reduce their physical activity, which may contribute to increased risk of cardiovascular disease. Data show that the presence of CVD is associated with an increased risk of cardiovascular disease, including peripheral arterial disease and heart failure (HF), and the risk of adverse cardiovascular events increases with CVD severity. In addition, patients with cardiovascular disease, particularly those with HF, are at increased risk of venous thromboembolism (VTE) and should be assessed for VTE risk if they are hospitalised with cardiovascular disease. Therefore, CVD management must include a multi-specialty approach to assess risk factors associated with both the venous and arterial systems. Ideally, treatment should focus on the resolution of endothelial inflammation to control both CVD and cardiovascular disease. International guidelines recommend various conservative treatments, including venoactive drugs (VADs), to improve the symptoms/signs of CVD. Micronized purified flavonoid fraction (MPFF) is a VAD, with high-quality evidence supporting its use in relieving symptoms/signs of CVD and improving quality of life. Moreover, in large-scale observational studies, MPFF has shown superior effectiveness in real-world populations compared with other VADs. Video Abstract. (MP4 97173 kb).

A Summary of European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs: Japanese Translation by Japanese Society of Phlebology and Japanese Society for Vascular Surgery

A Summary of European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs: Japanese Translation by Japanese Society of Phlebology and Japanese Society for Vascular Surgery

Cyanoacrylate adhesive closure in the European and American 2022 clinical practice guidelines

Over the last decade non-thermal non-tumescent (NTNT) methods of truncal reflux elimination in chronic venous disease (CVD) are becoming increasingly popular. The main NTNT modalities are mechanochemical ablation and cyanoacrylate adhesive closure (CAC). The advantages of non-thermal ablation are avoidance of tumescent anesthesia, low periprocedural pain and bruising, high patient comfort and satisfaction rates. CAC method has an additional benefit of avoiding the postprocedural compression. CAC is one of promising non-thermal ablation procedures, that leads to truncal vein occlusion and reflux elimination via endovenous delivery of n-butyl-2-cyanoacrylate. This review is aimed at assessment of the updated European and American clinical practice guidelines on CVD management, particularly the role of CAC. Current evidence shows high efficacy and safety of the CAC, its advantages regarding the periprocedural pain and ecchymoses, risk of adverse events, closure rates in the long-term, procedure and recovery time and patients’ quality of life. Therefore, along the current gold standard of varicose vein treatment – thermal ablation, the updated 2022 European and American clinical practice guidelines have significantly emphasized the role of NTNT modalities in general and CAC in particular. Specifically, the European Society for Vascular Surgeons guidelines recommend CAC for patients with great saphenous vein (GSV) incompetence when the NTNT technique is preferred. American guidelines recommend both thermal and non-thermal ablation for the patients with symptomatic axial reflux of the GSV, depending on the available expertise of the treating physician and the preference of the patient.

Improving Chronic Venous Disease Management with Micronised Purified Flavonoid Fraction: New Evidence from Clinical Trials to Real Life.

Chronic venous disease (CVD) develops in the microvessels, and is perpetuated by a vicious cycle of inflammation and endothelial activation, structural and functional changes to vessels and valves, and progressive venous hypertension. Data from animal models indicate that micronised purified flavonoid fraction (MPFF) has beneficial effects on a range of pathophysiological processes that contribute to CVD, including inflammation, micro-vessel permeability, valve and vessel wall remodelling, and reflux in microvalves. These effects explain its beneficial effects on the signs and symptoms of CVD, which have been seen across the spectrum of Clinical, Etiological, Anatomical and Pathophysiological (CEAP) categories of CVD severity. This includes patients with symptoms but no detectable anatomical or pathophysiological anomalies (C0s or C1) and patients with varicose veins (C2). In addition to symptomatic improvement, MPFF has been shown to reduce oedema in patients with C3 CVD, resolve skin symptoms in patients with C4 CVD, and accelerate the healing of venous ulcers in patients with C6 CVD. MPFF is highly recommended in international guidelines of CVD management and is the only veno-active drug to receive guideline endorsement for an improvement in patient quality of life.

Trends In the Epidemiology and Management of Chronic Venous Disease In the UK

Objective: Previous epidemiological estimates for chronic venous disease (CVD) suggest that 19% of the adult population have varicose veins (VV) while 0.4% have a history of venous leg ulceration (VLU).1 However, since studies generated these estimates, there have been initiatives to improve venous care. Initiatives in the UK include national guidelines for venous disease in 2014 and subsequent changes to national healthcare commissioning criteria.2 Longitudinal studies are required to evaluate the impact of such initiatives with respect to trends in the management and epidemiology of CVD. This research aims to investigate changes in both the epidemiology and management of CVD in the UK.

Optimising Decision Making in Chronic Venous Disease Management with Micronised Purified Flavonoid Fraction.

Evidence-based medicine favours randomised controlled trials to limit bias and establish the effects of a treatment with statistical rigour. However, the controlled conditions and careful patient selection of randomised trials may produce results that cannot be generalised to a more diverse patient population in clinical practice. Therefore, there is growing recognition of the importance of supplementing randomised trial data with real-world evidence. Micronised purified flavonoid fraction has been investigated in several large-scale real-world studies, including the RELIEF and DECIDE studies, each of which included more than 1000 patients with chronic venous disease. These studies demonstrated a significant reduction in the prevalence and severity of chronic venous disease symptoms, and an improvement in quality of life. The chronic VEnous dIsorders maNagement and treatment effectivenesS evaluaTion in chronic vEnous disease, an international Program (VEINSTEP) study (NCT04574375), is currently underway in more than 6000 patients with chronic venous disease in nine countries. Preliminary data from one country (Morocco) indicate that chronic venous disease drug treatment, which was micronised purified flavonoid fraction in 75.7% of patients, was associated with a statistically significantly reduction in symptoms and improved quality of life. The overall results are awaited with interest. International chronic venous disease guidelines grade the evidence for micronised purified flavonoid fraction highly, as the benefits of micronised purified flavonoid fraction have been proven in randomised clinical trials and meta-analyses. Real-world studies demonstrate that the randomised evidence for micronised purified flavonoid fraction is generalisable to a clinical practice setting. Treatment decisions in chronic venous disease should consider evidence-based recommendations, including real-world data, as well as patient goals of symptom relief, functional improvement and/or better quality of life.

RETRACTED: Australian and New Zealand Society for Vascular Surgery clinical practice guidelines on venous outflow Obstruction of the femoral-iliocaval veins

BackgroundThe overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO) in Australia and New Zealand. MethodsA group of vascular surgeons from the Australian and New Zealand Society for Vascular Surgery with specific interest, training, and experience in the management of VOO were surveyed to assess current local practice. The results were analyzed and areas of disagreement identified. Following this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. Finally, a selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. ResultsThe document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with a CEAP (Clinical-Etiologic-Anatomic-Physiologic) score of ≥3 or a venous clinical severity score for pain of ≥2, or both, and evidence of >50% stenosis on venography, computed tomography venography, magnetic resonance venography, and/or intravascular ultrasound should be considered for venous stenting (level of recommendation Ib) Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion has been uncovered, should be considered for venous stenting (level of recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should be considered for venous stenting (level of recommendation Ic). Asymptomatic patients should not be offered venous stenting (level of recommendation IIIc). ConclusionsPatients with deep VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. The advent of simpler and safer treatment options has revolutionized its management, but, unfortunately, formal training for venous disease has not grown at the same rate. Simplifying the technology and training required can result in inconsistent outcomes. These guidelines are aimed at developing standards of care and will serve as an educational platform for future developments.

Treatment of early-stage chronic venous disease – management standards for 2023

Chronic venous disease (CVD) is one of the most prevalent diseases in the world. Most patients with early-stage CVD willeventually deteriorate, which will result in an increase in treatment costs, but most importantly, a decrease in quality of life.The advances made with regard to the knowledge of the natural history and pathophysiology of CVD as well as the results ofresearch on effects of different drugs depending on the severity of the disease suggest the likely cost-effectiveness of CVDpatients being treated at an early stage of the disease. Recommendations in this group of patients may include lifestylechanges, compression therapy and venoactive drugs (VADs). Combination of ruscus, hesperidin methyl chalcone, andvitamin C is a well-established VAD presenting with anti-inflammatory effects, reducing endothelial activation and leukocyteadhesion, increasing capillary resistance and integrity and improving venous tone and performance of the lymphatic vesselsthus leading to a reduction in CVD symptoms in patients and an improvement in quality of their lifes. This article is based onthe latest guidelines regarding the management of chronic venous disease.

An Overview of Specific Considerations in Chronic Venous Disease and Iliofemoral Venous Stenting.

Unlike arterial disease, chronic venous disease (CVD) is rarely life-threatening or limb-threatening. However, it can impose substantial morbidity on patients by influencing their lifestyle and quality of life (QoL). The aim of this nonsystematic narrative review is to provide an overview of the most recent information on the management of CVD and specifically, iliofemoral venous stenting in the context of personalized considerations for specific patient populations. The philosophy of treating CVD and phases of endovenous iliac stenting are also described in this review. Additionally, the use of intravascular ultrasound is described as the preferred operative diagnostic procedural tool for iliofemoral venous stent placement.

Public awareness of chronic venous disease in Korea

ObjectiveThis study aimed to evaluate the current level of chronic venous disease (CVD) awareness and its relevant influencing factors. MethodsOnline and interview surveys were conducted in two distinct groups from May 14 to June 16, 2020. An online survey was conducted among 900 adults aged 20 to 64 years from the research database, whereas interviews were conducted among 124 patients who presented with CVD symptoms, which covered the awareness of such symptoms and their impact on quality of life. ResultsMost respondents reported low levels of CVD awareness by recognizing the disease only by an entity. In 53 respondents who visited the hospital with suspected venous symptoms, the actual diagnosis was made in only 30.2%. CVD diagnosis was associated with increased CVD awareness. Female sex, age of >29 years, higher educational level, and higher income were associated with increased CVD awareness. Approximately 60% of the patients with CVD responded that physical symptoms had a negative impact on their quality of life rather than emotion or appearance. ConclusionsThe public is largely unaware of CVD but not in detail. Educational programs to improve CVD awareness should be implemented to enable appropriate CVD management.

New Perspectives on Micronised Purified Flavonoid Fraction in Chronic Venous Disease: From Microvalves to Clinical Effectiveness.

The importance of chronic venous disease (CVD), as a cause of reduced quality of life and increased costs to healthcare systems, is expected to rise in parallel with population aging and the increasing prevalence of obesity. Venoactive drugs (VADs) are frequently used to treat the symptoms and signs of CVD. The most commonly used and widely studied VAD, micronised purified flavonoid fraction (MPFF), is effective at all stages of CVD, and has been shown to significantly reduce leg pain, leg heaviness and swelling, as well as ankle oedema and functional discomfort, in clinical trials. Recently, experiments employing animal models of CVD have demonstrated that MPFF has anti-inflammatory and venotonic effects at the microvalve level, and a pilot clinical study in patients with CVD has provided support for these findings. Collectively, these results suggest that early initiation of MPFF treatment may have the potential to favourably alter the clinical course of the disease, although further clinical data are required to confirm these findings. International guidelines on CVD management strongly recommend MPFF to reduce symptoms and improve quality of life. Studies are now needed to investigate the impact of long-term treatment on disease progression.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-022-02218-x.

Delphi case: Sharing of clinical experiences for improvement in the treatment of chronic venous disease.

Chronic venous disease (CVD) is a common condition with major health consequences that is associated with poor long-term prognosis, significant socioeconomic impact, disabling symptoms, and reduced quality of life. To provide a novel evidence-based approach in the management of CVD, a consensus process (“Delphi Case”) following a first Delphi Consensus was conceived. With a real-life fashion analysis, a steering committee formed by 3 expert leaders on chronic venous disease drove a panel of 77 expert Italian angiologists/vascular surgeons along a collegial discussion, integrating data coming from the guidelines recommendations of different Vascular Scientific Societies with the consensus agreement statements gathered from the first Delphi Consensus, and with data coming from the discussion of few statements in which there was disagreement. From July 15 to October 16, 2020, demographic, anamnestic, objective, and therapeutic data coming from a total of 2,275 patients were collected by the experts panel using a predefined case report form. The results of this second consensus provided a real-life picture of CVD management in the Italian population and clearly showed that a tailored therapeutic approach together with an appropriate lifestyle (e.g., diet, physical activity, weight loss) must be considered as the milestones for the CVD-related signs and symptoms clinical improvement in daily clinical practice. An evaluation of the adherence and of the efficacy of the prescribed pharmacological and compressive treatment in a medium-long term follow-up of the study population has been planned as the last step of this course and will be object of a future final publication.

Conservative therapy significantly reduces patients' chronic venous disease symptoms: A Caribbean insight into the VEIN Act Program.

We sought to determine the baseline demographic and clinical characteristics of patients with Chronic Venous Disease (CVD) across the Caribbean, and to evaluate patients' compliance to conservative therapy and the effectiveness of such therapy in reducing patients' CVD symptoms. Patients were enrolled into the VEIN Act Program, and their demographic data, CVD symptoms (and their intensity) and CEAP C-classification was recorded at the first visit. Patients were prescribed conservative therapy, and symptom intensity and patient compliance and satisfaction evaluated at a follow-up visit. We enrolled 193 patients into the study, most of which (76%) were female, between 39-78years (80%) and within the C2-C4a classes (56.1%). Pain (61.1%) and heaviness (58.5%) were the most common symptoms. Patient compliance to the prescribed treatment was relatively high for all modalities (>75%) and most patients (92.1%) were at least somewhat satisfied with their treatment. Patient compliance to conservative therapy for management of CVD is high across the Caribbean, and such therapy is effective in reducing intensity of CVD symptoms.

European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs

Compared with the 2015 version of the guidelines on the management of chronic venous disease (CVD),1 the global structure of the document has been modified considerably in an attempt to make it more practical and user friendly. Special subsections on management strategy with accompanying flowcharts have been added to the different chapters.•An extensive chapter has been entirely dedicated to superficial venous incompetence. A new subsection on evidence supporting endovenous non-thermal ablation has been included. A new subsection on incompetence of perforating veins has been added, as well as a subsection on practical strategies for special anatomical presentations. The management of recurrent varicose veins is discussed at the end of this chapter.•Deep venous pathology is discussed in a separate chapter, with an emphasis on the increasing evidence in the field of managing iliofemoral and iliocaval obstruction. In addition, new topics in this chapter are the combination of superficial and deep venous problems, aneurysms of the deep veins and popliteal vein entrapment syndrome.•An entirely new chapter has been dedicated to the management of patients with venous leg ulcers.•A new chapter describes the management of patients with varicose veins, related to underlying pelvic venous disorders.•A new chapter considers special patient characteristics and their potential influence on management strategy.•Gaps in evidence and future perspectives are briefly discussed in a separate chapter.•A lay summary of the guidelines provides useful information for patients.

Management of chronic venous disease in general practice: a cross-sectional study of first line care in Belgium.

The aim of this observational study was to examine how general practitioners (GP) in Belgium treat patients with chronic venous disease (CVD). This cross-sectional study was carried out in Belgium by GPs who recruited 15 consecutive patients who were consulting them and suffered from CVD. By following a standardized questionnaire, they collected information on patient characteristics, risk factors, signs and symptoms, and how they were being managed. Two hundred fifty-three GPs recruited 3055 patients, who were predominantly female (75.6%), with a mean age of 62.7 (SD=14.6). 20.1% of the population suffered from CVD without clinical signs (C0s). 8.7% of the population had advanced disease (C5-C6). Most common symptoms were respectively "heavy legs" (43.7%), "swollen feeling" (28%) and "pain" (24.1%). The primary care physicians decided 95.3% of patients needed therapy of some sort. The most used treatment option used in 83.3% of subjects was the use of venoactive medication. Lifestyle advice was recommended in 64.5% of patients and recommendations regarding compression stockings were given in 46.9% of patients. Referral to a specialist was warranted for 24.5% of the population. Patients with a lower C Classification were more often treated conservatively compared to those with a higher C Classification. Most patients were treated conservatively, which includes lifestyle changes, medication, and compression. Only one in four patients is referred to a vascular specialist and this referral is significantly positively correlated with the C Classification.

Editor's Choice – European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs

Editor's Choice – European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs

Study of Three Interface Pressure Measurement Systems Used in the Treatment of Venous Disease

The aim of the publication is to report the accuracy, repeatability and the linearity of three commercially available interface pressure measurement systems employed in the treatment of venous disease. The advances in the treatment and management of chronic venous disease by compression therapy have led to considerable research interest in interface pressure measurement systems capable of measuring low-pressure ranges (10–60 mmHg). The application of a graduated pressure profile is key for the treatment of chronic venous disease which is achieved by using compression bandages or stockings; the required pressure profiles are defined in standards (BSI, RAL-GZ, or AFNOR) for different conditions. However, achieving the recommended pressure levels and its accuracy is still deemed to be a challenge. Thus, it is vital to choose a suitable pressure measurement system with high accuracy of interface pressure. The authors investigated the sensing performance of three commercially available different pressure sensors: two pneumatic based (AMI and PicoPress®) and one piezoresistive (FlexiForce®) pressure sensors, with extensive experimental work on their performance in terms of linearity, repeatability, and accuracy. Both pneumatic based pressure measurement systems have shown higher accuracy in comparison to the flexible piezoresistive pressure sensors.

Effectiveness of iliac vein stenting combined with high ligation/endovenous laser treatment of the great saphenous veins in patients with Clinical, Etiology, Anatomy, Pathophysiology class 4 to 6 chronic venous disease

BackgroundLower limb chronic venous disease (CVD), resulting from iliac vein compression syndrome (IVCS), manifests as a series of symptoms ranging from varicose veins to venous ulcerations. Stent implantation has been considered an effective treatment method; however, the management of CVD has rarely been reported. In the present study, we evaluated the treatment and outcomes of patients with CVD. MethodsWe performed a retrospective cohort study of patients with severe iliac vein stenosis with lower limb CVD. The patients were divided into two groups: group 1 had received stenting alone (n = 42), and group 2 had received stenting and high ligation/endovenous laser treatment (n = 29). We evaluated the clinical outcomes using the Venous Clinical Severity Score and visual analog scale, and assessed the quality of life (QoL) using the Chronic Venous Disease QoL questionnaire at a median follow-up point of 15 months (range, 6-25 months). ResultsIn our cohort, the prevalence rate of nonthrombotic IVCS (NIVCS) was 11.7% (98 of 838 patients). The technical success rate was 100%, without severe complications. During the study period, three group 1 patients and two group 2 patients were lost to follow-up. The overall patency rate in the patients with NIVCS during a mean follow-up period of 15.0 months (range, 6-25 months) was 94.4%. For patients with a Clinical, Etiology, Anatomy, Pathophysiology (CEAP) clinical class of <4, all parameters showed similar improvements in the two groups, except for the disappearance of varicose veins. However, in patients with a CEAP clinical class of ≥4, the combination therapy significantly improved their QoL. The Venous Clinical Severity Score reduction was 4.64 ± 1.72 in group 1 and 11.89 ± 1.82 in group 2 (P < .01). Pain, scored using the visual analog scale, demonstrated a decrease from 4.41 to 2.52 (P < .05) in group 1 and 4.71 to 0.53 (P < .01) in group 2. The relief rate of stasis dermatitis in groups 1 and 2 was 26.9% and 90.5%, respectively (P < .05), and the venous ulceration healing rate was 16.7% and 87.5%, respectively (P < .05). ConclusionsThe prevalence of NIVCS should not be overlooked. The proposed combination treatment is an effective therapeutic strategy for patients with NIVCS and advanced CVD (CEAP clinical class, ≥4) during short-term follow-up.

Evaluation and Management of Chronic Venous Disease Using the Foundation of CEAP.

Venous disease is common. Depending on the population studied, the prevalence may be as high as 80%. Significant chronic venous disease with venous ulcers or trophic skin changes is reported to affect 1-10% of the population. A systematic assessment of the clinical findings associated with chronic venous disease will facilitate appropriate imaging. Based on imaging and assessment, patients with reflux or obstruction can be recommended proper medical and endovascular or surgical management. Many types of endovascular management are available to treat reflux and eliminate varicose veins and tributaries. More recently adopted non-thermal non-tumescent techniques have been shown to be comparable with more widely performed laser or radiofrequency ablation techniques. A thorough clinical assessment, appropriate duplex ultrasound imaging, and use of advanced imaging when needed will allow clinicians to optimize therapy for patients with chronic venous disease based on the etiology, anatomy involved, and the pathophysiology.