Complication Of Chronic Venous Insufficiency Research Articles

Some new aspects of the pathogenesis of venous trophic ulcers

Venous trophic ulcers are one of the most common in the population, and costly in terms of treatment costs for complications of chronic venous insufficiency. The prevalence of venous trophic ulcers ranges from 0.18 to 1%. Over the age of 65 it increases to 4%. The cause of the formation of venous trophic ulcers is chronic diseases of the veins of the lower extremities. Chronic disease of the veins is a term that includes a wide range of morphological and functional disorders affecting the venous system. At the same time, even after conservative treatment, the level of recurrence of venous trophic ulcers remains extremely high, which leads to an increase in the duration of treatment for patients in the hospital, in some cases causing permanent disability in patients of working age. The literature has accumulated a huge volume of both fundamental and clinical research on the etiology, pathogenesis, diagnosis and treatment of venous ulcers. However, despite the numerous studies, the number of patients with this disease continues to steadily increase, and a number of important aspects of the pathogenesis have not yet been studied. In addition, these works do not allow us to formulate a unified concept of the pathogenesis of venous ulcers, which in turn affects the effectiveness of treatment of venous trophic ulcers. Our study highlights modern aspects of the pathogenesis of venous trophic ulcers, which may be of key importance in the treatment of this pathology. Promising directions of scientific research in this area are determined. This requires a more in-depth study of aspects of intercellular interactions, and also opens up the prospect of searching for new methods of influencing the pathogenesis of venous trophic ulcers, taking into account the presence of microflora resistant to standard antibacterial agents.

Holistic Approach in the Management of Venous Ulcer: A Case Study

Introduction: Venous ulcers (stasis ulcers, varicose ulcers) are wounds occurring due to inappropriate functioning of venous valves, usually of the legs. It is one of the most serious chronic venous insufficiency complications. When a venous valve gets damaged, it prevents the backflow of blood, which causes pressure in the veins that leads to hypertension and, in turn, venous ulcers.
 Incidence: Between 1.5 and 3.0/1000 people have active leg ulcers. Prevalence increases with age to about 20/1000 people aged over 80 years.
 Material and Methods: Varicose veins were defined as dilated, tortuous, subcutaneous veins usually seen in an upright posture. An unbiased consultant surgeon assessed any suspected chronic venous insufficiency on clinical examination. The severity of varicose vein was assessed by clinical grading from CEAP (Clinical-Etiological-Anatomical-Pathophysiological) system in which there are six classes.
 Discussion: Due to the lekahana effect of kshara is does srotoshodhana and hence increases the peripheral circulation and helps in woundbed healing by increasing the blood flow to the wound bed to improve the vitalityand metabolites supply to aid healing. the patient was given manjista which by virtue of its rakta sodhaka and praasdana property will increase the metabolites in the blood and helps in providing sufficient substrates in the wound bed for its healing.
 Conclusion:Chronic venous ulcers that did not heal after a few months of multiple courses of antibiotics & and anti-inflammatory treatment healed within 20 days after Ayurveda treatment. This indicates that Ayurveda therapy is effective in healing chronic venous wounds. Non-reoccurrence of ulcer after a 3-month break from medicines indicates a complete reversal of venous level pathology. However, a more in-depth study with a larger sample size will help to develop treatment protocols in such cases.

Efficacy of Irsal-i-Alaq (Hirudotheraphy) in the Management of Venous Ulcer: A Case Report

Background: The most frequent and recurring type of leg ulcers seen in general practise is a venous ulcer (stasis ulcer). Its neglect has a considerable negative influence on quality of life, might result in gangrene, and may necessitate amputating the affected limb. The most serious and incapacitating complication of chronic venous insufficiency is venous ulcer. The conventional system of medicine offers limited clinical evidence for its effectiveness and usually needs amputation. Hence, it can be managed well by one of the Unani regimens, i.e., Irsal-e-Alaq (Hirudotherapy). Objective: The purpose of this case report is to provide insight into the effects of Irsal-e-Alaq (Hirudotherapy) in venous ulcer. Intervention: A 53-year-old male who has complaints of ulcer in left lower leg near lateral malleolus with swelling, pain, discharge and darkening of skin of left lower limb. Four leeches were applied once every 15 days for 45 days. Ulcer was assessed on 0th day, 15th day, 30th day and 45th day on the basis of area of the wound in a square centimetre, appearance of healthy granulation tissues, epithelization in percentage and depth of wound in centimetres, pain (VAS scoring), discharge, smell and number of wounds. Results: on the first day wound size was 4 cm long, 3 cm wide, 2 cm deep and the floor filled with dark granulation tissue with 0 % epithelization, discharge, pain and smell. On the 45th day ulcer was completely healed with 100% epithelization. Conclusion: Irsal-e-Alaq has been proven beneficial in treating venous ulcers and enhancing patients' quality of life. To determine the effectiveness of Irsal-e-Alaq in the management of venous ulcer, rigorous, controlled, randomised, blinded, and long-term follow-up studies on high sample sizes are required.
 Keywords: Hirudotherapy, Unani Medicine, Leech Therapy, Varicose Ulcers

Utility of Vrana Basti in the Management of Venous Ulcer. A Single Case Report

Varicose ulcer or Venous ulcer is open wounds in the skin that occurs with sustained venous hypertension and improper functioning of venous valve, usually in the lower limbs. It is one of the most serious chronic venous insufficiency complications, accounting for 80% of lower extremity ulcerations. Gangrene, cellulitis and risk of amputation are the complications if it is left untreated. Symptomatologies of venous ulcer indicate the correlation towards sirajanyadushtavrana, which is explained in Sushruta Samhita. A case of 26- Year- old male who presented with complaints of venous ulcer in medial aspect of lower 1/3rd of left leg associated with pain, swelling, and discoloration of the skin since 3 months has been taken for the current study. Vranabasti for 5 days was done Followed by cleaning and dressing with NS and jatyaditaila. oral medicines are Sahacharaadikashaya two times a day, tab Kaishoraguggulu three times a day, cap viscovas three times a day, khadiraaristha two times a day, sahacharaaditaila for local application twice a day. There was Significant improvements in the size of the wound and nature of tissues.

Features of laser therapy of venous trophic ulcers of the lower extremities in outpatient surgery

Introduction. Trophic ulcers of venous etiology are a severe complication of chronic venous insufficiency of the lower extremities. At the same time, in most cases, ulcerative defects do not heal for a long time and are prone to recurrence, which leads to a significant deterioration in the quality of life of patients.Aim. To clarify the features of the effect of low-intensity laser radiation to determine the optimal conditions for conservative treatment of venous ulcerative defects.Materials and methods. A randomized prospective clinical trial was performed in which 126 patients with chronic venous insufficiency were monitored. During the conservative treatment of 44 patients of the comparison group, phlebotropic drugs, compression therapy, wound coverings and ointment dressings were used in the conservative treatment of trophic ulcers. In 82 patients of the main group, lowintensity laser radiation was used along with the methods described above.Results. Laser therapy in the complex treatment of venous trophic ulcers helps to reduce the number of microbial bodies vegetating on the surface of ulcerative defects, but does not significantly affect the sensitivity of microflora to antibacterial drugs. Low-intensity laser radiation certainly contributed to a significant and earlier increase in the number of neutrophils, monocytes and macrophages on the surface of trophic ulcers, as well as activation of phagocytic activity of cells.Conclusion. Low-intensity laser radiation improves the results of conservative treatment of venous trophic ulcers, does not adversely affect the sensitivity of the isolated microflora to antibiotics and does not have a “direct” bactericidal effect.

Tissue remodelling and increased DNA damage in patients with incompetent valves in chronic venous insufficiency.

Chronic venous insufficiency (CVI), in which blood return to the heart is impaired, is a prevalent condition worldwide. Valve incompetence is a complication of CVI that results in blood reflux, thereby aggravating venous hypertension. While CVI has a complex course and is known to produce alterations in the vein wall, the underlying pathological mechanisms remain unclear. This study examined the presence of DNA damage, pro‐inflammatory cytokines and extracellular matrix remodelling in CVI‐related valve incompetence. One hundred and ten patients with CVI were reviewed and divided into four groups according to age (<50 and ≥50 years) and a clinical diagnosis of venous reflux indicating venous system valve incompetence (R) (n = 81) or no reflux (NR) (n = 29). In vein specimens (greater saphenous vein) from each group, PARP, IL‐17, COL‐I, COL‐III, MMP‐2 and TIMP‐2 expression levels were determined by RT‐qPCR and immunohistochemistry. The younger patients with valve incompetence showed significantly higher PARP, IL‐17, COL‐I, COL‐III, MMP‐2 and reduced TIMP‐2 expression levels and a higher COL‐I/III ratio. Young CVI patients with venous reflux suffer chronic DNA damage, with consequences at both the local tissue and systemic levels, possibly associated with ageing.

Comparative Study between Ultrasound-Guided Foam Sclerotherapy, Radiofrequency Ablation &amp; Endo-Venous Laser Ablation in Treatment of Great Saphenous Vein Reflux

Abstract Background: The main goal in the treatment of varicose veins is to reduce the symptoms and complications of chronic venous insufficiency and to improve health related quality of life (QoL) of patients. Surgery has been the standard of care in the treatment of saphenous varicose veins for more than a century. Aim of Study: The aim of this work is to compare between the outcome after UGFS, RFA & EVLA concerning the treat-ment of great saphenous vein reflux, regarding success rate, recurrence rate and complications rate. Subjects and Methods: This study was carried out at the Vascular Surgery Department, Zagazig University Hospitals during the period from August 2016 to August 2018, included a total of 51 treated lower limbs in 39 patients were divided into three different groups: Endovenous Laser Ablation (EVLA group) (n=18 legs in 13 patients; 1470nm, continuous mode, radial fiber), Radiofrequency Ablation (RFA group) (n=16 legs in 13 patients) and Ultrasound Guided Foam Sclerotherapy (UGFS group) (n=17 legs in 13 patients). All patients were subjected to complete clinical examination and laboratory investigations. Post procedure follow-up was done after one week, three month, six months & one year following treatment and all limbs were assessed clinically and by using DUS. Results: All the three treatment modalities significantly improved VCSS and QoL as reflected by significant improve-ments in VCSS and CIVIQ; with no significant differences in the outcome between the groups. The improvements per-sisted throughout the 2 years and showed that EVLA, RFA and UGFS are efficient treatments with longerterm beneficial effects in patients with GSV varicose veins. This is true even though some patients in the UGFS group developed recanal-ization of the GSV. UGFS group was significantly longer regarding duration to return to work (p < 0.01) than EVLA and RFA group which both had non-significant difference between them. Conclusion: Our study demonstrated that EVLA & RFA are efficient modalities for the treatment of GSV varicose veins in the medium term. Notinga moderate rate of recanal-ization after UGFS, it appears that EVLA & RFA are superior to UGFS regarding clinical recurrence, VCSS and QoL. Post-operative patient comfort and the outcome of EVLA & RFA in short & medium-terms are superior to those after UGFS in terms of recanalization & effective ablation.

Using compression therapy in a primary care setting to treat complications of chronic venous insufficiency.

Patients with chronic venous insufficiency (CVI) are prone to developing complications such as slow-healing venous leg ulcers. Nurse practitioners can assess patients for complications of CVI during routine examinations. If found, they can implement compression therapy and possibly prevent the development of slow-healing venous leg ulcers. A retrospective chart review of patient occurrences with complications due to CVI between 2011 and 2018 was conducted to evaluate patient outcomes when treated with compression therapy by their primary care providers (PCPs). Patients were identified by the Unna boot's Current Procedural Technology code, the compression therapy used by the providers. Patients included in the review had the diagnosis of or symptoms of CVI. Patient outcomes were identified as improved, unchanged, or deteriorated. The use of compression therapy for patients with documented complication of CVI. The Unna boot was the compression device used at this practice. There were 60 occurrences distributed among 40 patients who met the inclusion criteria. Of the 60 occurrences, 54 or 90% of patient occurrences had an improvement of symptoms. According to the Wound Healing Society Guidelines, high compression therapy, such as the Unna boot, is classified as most supportive, for treatment of venous ulcers. The results of this study demonstrate the positive impact PCPs, including nurse practitioners, may have when initiating compression therapy for patients with complications of CVI.

Effect of Pycnogenol on the Healing of Venous Ulcers

Venous ulcers are common complications of chronic venous insufficiency that result in severe physical and mental suffering to patients. The oral administration of diosmin/hesperidin has been used as adjuvant therapy in the treatment of chronic venous insufficiency. The purpose of this study was to evaluate and compare the effect of pycnogenol and diosmin/hesperidin on the healing of venous ulcers. This longitudinal, prospective, randomized clinical trial was conducted with 30 adult patients with venous ulcers from a vascular surgery outpatient clinic of a university hospital. The patients were randomly allocated to 2 groups: Group 1 (n=15) was treated with pycnogenol (50mg orally, 3 times daily) and Group 2 (n=15) was treated with diosmin/hesperidin (450/50mg orally, twice daily). They were assessed every 15days for 90days. During follow-up visits, photo-documentation was obtained and the ulcer area and circumference of the affected limb were measured. Friedman's test and Mann-Whitney test were used to compare ulcer areas and circumference of affected limbs between and within groups at different time points. The level of significance was set at 5% (P<0.05) for all tests. Both the pycnogenol and diosmin/hesperidin treatments had a similar effect on the healing of venous ulcers and led to a significant decrease in the circumference of affected limbs (P<0.0001). The results suggest that pycnogenol has an adjuvant effect on the healing of venous ulcers, similar to diosmin/hesperidin.

A new option for endovascular treatment of leg ulcers caused by venous insufficiency with fluoroscopically guided sclerotherapy.

IntroductionUlcers of lower legs are the most bothersome complication of chronic venous insufficiency (CVI).AimTo assess the effectiveness of endovascular fluoroscopically guided sclerotherapy for the treatment of venous ulcers.Material and methodsThirty-eight limbs in 35 patients with crural venous ulcers were treated with guided sclerotherapy under the control of fluoroscopy. Patients with non-healing ulcers in the course of chronic venous insufficiency, with and without features of past deep vein thrombosis, were qualified for the study. Doppler ultrasound and dynamic venography with mapping of venous flow were performed. Ambulatory venous pressure measurements, leg circumference and varicography were performed just before and following the procedure.ResultsIn 84% of cases, ulcers were treated successfully and healed. Patients with post-thrombotic syndrome (n = 17) healed in 13 (76.5%) cases, whereas patients without post-thrombotic syndrome (n = 21) healed in 19 (90.5%) cases. The mean time of healing of an ulcer for all patients was 83 days (in the first group it was 121 days and in the second group 67 days). Recurrence of an ulcer was observed in 10 limbs: 6 cases in the first group and 4 cases in the second group. Occurrence of deep vein thrombosis associated with the procedure was not observed. Temporary complications were reported but none giving a serious clinical outcome.ConclusionsEndovascular fluoroscopically guided sclerotherapy can be an alternative method of treatment of venous ulcers, especially in situations when surgical procedures or other options of treatment are impossible.

An integrated approach in the treatment of varicose ulcer

Venous ulcers (stasis ulcers, varicose ulcers) are the wounds occurring due to inappropriate functioning of venous valves, usually of the legs. It is one of the most serious chronic venous insufficiency complications. The overall incidence rate is 0.76% in men and 1.42% in women. When a venous valve gets damaged, it prevents the backflow of blood, which causes pressure in the veins that leads to hypertension and, in turn, venous ulcers. These are mostly along the medial distal leg, which is often very painful, can bleed, and get infected. Treating varicose ulcers is a difficult task to the physician and a nightmare to the suffering patients, though a good number of the treatment principles are mentioned and practiced in allied sciences. In Ayurveda, this condition is considered as duṣṭa vraṇa. It can be managed with the specific s’odhana therapy. So, the same treatment protocol was used to treat the case discussed here, i.e. with Nitya virecana and by Basti karma. The wound was successfully treated and, therefore, is discussed in detail.

Subcutaneous paratibial fasciotomy in the treatment of chronic venous ulcer

Chronic venous ulcer (CVU), a disease of high incidence, is one of the most serious chronic venous insufficiency complications. It has been estimated that there are 1%-2% of adults with CVU deriving a high social significance. The aim of this study was to, using the clinical experience, determine the influence of subcutaneous paratibial fasciotomy (SPF) on the course and the treatment outcome of CVU. From February 2006 to September 2009 SPF was applied in a group of 43 patients treated for CVU along with other standard methods of treatment, and its influence on the course of ulcus cruris was followed up regarding the control group of another 43 patients treated with standard methods with no paratibial fasciotomy. In the group of patients treated with SPF there was a significantly better clinical course of ulcus cruris closing as compared with the group of patients in which this method was not applied. In the group with paratibial fasaciotomy there was no Thiersch skin transplant rejection recorded nor ulcus recurrence within a 6-month after-surgery period, while in the control group there was Thiersch skeen transplant rejection in 11 patients, and ulcus recurrence in 9 patients within the same period. SPF is a useful method with a favorable influence on better clinical course of ulcus cruris closing, reducing recurrence rate and improving local microcirculation in the affected region. Operation act itself is safe, requires no specific equipment nor special training of the team of surgeons, thus being applicable to the majority of patients with ulcus cruris indicated for surgery.

Genetic risk factors of chronic venous leg ulceration: Can molecular screening aid in the prevention of chronic venous insufficiency complications?

Venous leg ulceration is a severe complication of chronic venous insufficiency. Despite numerous studies, understanding of the possible mechanisms involved in venous ulceration development remains incomplete. It is assumed that, in addition to well-documented behavioral and/or environmental conditions, as yet poorly defined genetic risk factors may play important roles in chronic wound progression or healing. It is difficult to overestimate the clinical usefulness of genetic screening in the determination of the risk of wound development and/or its healing course. From a pharmacogenomic perspective, genetic screening may aid in the planning of individualized treatment. In addition, the detection of venous ulcer-promoting gene variants may facilitate the decision to introduce prophylaxis or, if necessary, appropriate treatment for venous insufficiency, long before a leg ulcer develops. In addition to significant economic benefits, this approach would reduce the risk of health- and life-threatening conditions. In this review, we focus on several gene mutations/polymorphisms with previously documented significance in leg ulceration pathophysiology, and briefly speculate about possible candidates for further study.

Genetic risk factors of chronic venous leg ulceration: Can molecular screening aid in the prevention of chronic venous insufficiency complications?

Venous leg ulceration is a severe complication of chronic venous insufficiency. Despite numerous studies, understanding of the possible mechanisms involved in venous ulceration development remains incomplete. It is assumed that, in addition to well-documented behavioral and/or environmental conditions, as yet poorly defined genetic risk factors may play important roles in chronic wound progression or healing. It is difficult to overestimate the clinical usefulness of genetic screening in the determination of the risk of wound development and/or its healing course. From a pharmacogenomic perspective, genetic screening may aid in the planning of individualized treatment. In addition, the detection of venous ulcer-promoting gene variants may facilitate the decision to introduce prophylaxis or, if necessary, appropriate treatment for venous insufficiency, long before a leg ulcer develops. In addition to significant economic benefits, this approach would reduce the risk of health- and life-threatening conditions. In this review, we focus on several gene mutations/polymorphisms with previously documented significance in leg ulceration pathophysiology, and briefly speculate about possible candidates for further study.

Lipodermatosclerosis: A Commonly Misdiagnosed Complication of Chronic Venous Insufficiency

Lipodermatosclerosis: A Commonly Misdiagnosed Complication of Chronic Venous Insufficiency

An Overview of the Surgical Aspects of Lower Limb Venous Disease

Lower limb venous disease encompasses a wide spectrum of pathology, the importance of which relates to high prevalence rather than mortality. The complications of chronic venous insufficiency (CVI), namely lipodermatosclerosis and chronic venous ulceration, represent a major burden to healthcare providers and a high degree of personal morbidity for patients. Management is based upon accurate clinical diagnosis supported by non-invasive imaging. Open surgical and minimally invasive techniques are used to treat varicose veins. Chronic skin complications of CVI require a multidisciplinary approach.

Case study: A minimally invasive approach to the treatment of Klippel-Trenaunay syndrome

Klippel-Trenaunay syndrome (KTS) is a congenital developmental disorder characterized by port wine stain, venous abnormalities, soft tissue, and bony deformities of the affected extremity. It is usually diagnosed in early childhood and has many long-term sequelae. Patients not only have physical health problems but also must learn to cope with psychosocial factors that will affect their self-esteem and interpersonal relationships. This article describes the syndrome of KTS and the minimally invasive techniques used in the treatment of superficial varicosities in patients with reasonably mild KTS with an intact deep venous system. Treating the varicosities relatively early to avoid the long-term complications of chronic venous insufficiency may improve the quality of life, maintain limb function, and decrease the risk of long-term venous complications.

Dermatologic Complications of Chronic Venous Disease: Medical Management and Beyond

Patients with venous insufficiency commonly develop complications which can result in significant morbidity and occasional mortality. Venous leg ulcers, the most prevalent type of lower extremity ulcer, are the most frequent sequela of venous insufficiency and negatively affect quality of life for the patient. Most have focused on venous ulceration, but other complications may arise including dermatitis, atrophie blanche, lipodermatosclerosis, and malignancy. Contact dermatitis is a common complication seen in the treatment of venous disease. Patients with venous insufficiency have a disrupted epidermal barrier, making them more susceptible than the general population to contact sensitization and subsequent dermatitis. Venous dermatitis is often the first manifestation of venous insufficiency and needs to be addressed promptly. Atrophie blanche, an end point of a variety of conditions, appears as atrophic plaques of ivory white skin with telangiectasias. Lipodermatosclerosis is an indurated plaque in the medial malleolus which can, at times, be quite tender and painful. Malignant degeneration is a rare but important complication of venous disease since tumors which develop in the setting of an ulcer tend to be more aggressive. Pain is a feature of venous disease often overlooked and commonly undertreated. Finally, psychosocial issues such as anxiety and depression are more common in patients with venous disease and should be adequately addressed. Recognizing these complications of chronic venous insufficiency is important as early intervention is the key to preventing unnecessary patient suffering and discomfort.

A Review of the Microcirculation in Skin in Patients With Chronic Venous Insufficiency: The Problem and the Evidence Available for Therapeutic Options

Impairment of the cutaneous microcirculation is a major predisposing factor in inflammation and ulceration in patients with chronic venous insufficiency (CVI). Increase of capillary filtration rate predisposes to the formation of edema. Local lymphedema is a complication of CVI, often underdiagnosed. This review is focused on CVI but excludes the complication of ulceration. Treatment of microcirculatory dysfunction can be done by pharmacologic intervention or compression therapy or using a combination of both. This review is focused on drugs that have been evaluated by randomized prospective controlled trials. The following compounds are discussed: horse chestnut seed extracts, flavonoids, red vine leaves extracts, total triterpenic fraction of Centella asiatica (L), prociadins, calcium dobesilate, and pentoxifylline. The microcirculatory effects of compression therapy using bandages or stockings are also reviewed. The major microcirculatory effects that have been shown are the reduction of capillary filtration rate and improvements in levels of transcutaneous partial pressures of oxygen and carbon dioxide (TcPO(2) and TcPCO(2)). Available data suggest that a combination of pharmacologic and compression therapy may have some additive effects.

Invasive therapeutic options in truncal varicosity of the great saphenous vein

It is known from current pathophysiology that disease stages I and II of truncal varicosity of the great saphenous vein do not cause changes in venous pressure on dynamic phlebodynamometry. This is possibly also the case for mild cases of the disease in stage III. In pronounced cases of stage III and all cases of stage IV, however, venous hypertension occurs which triggers the symptoms of secondary deep venous insufficiency and all the complications of chronic venous insufficiency. From these facts the therapeutic consequence is inferred that in stages I and II and perhaps also in very mild cases of stage III disease, it is enough "merely" to remove varicose veins without expecting there to be any other serious complications in the patient's further life caused by the varicosity. Recurrence rates are not included in this analysis. In marked cases of disease stages III and IV of the great saphenous vein, however, secondary deep venous insufficiency is to be expected sooner or later. The classical operation with saphenofemoral high ligation ("crossectomy") and stripping strictly adheres to the recognized pathophysiologic principles. It also takes into account in the greatest detail aspects of minimally invasive surgery and esthetics. In the past few years, developments have been advanced to further minimize surgical trauma and to replace the stripping maneuver using occlusion of the trunk vein which is left in place. Obliteration of the vessel is subsequently performed via transmission of energy through an inserted catheter. This includes the techniques of radiofrequency ablation and endovenous laser treatment. High ligation is not performed as a matter of principle. In a similar way, sclerotherapy using microfoam is minimally invasive in character. All these procedures may be indicated for disease stages I and II, and with reservations also in mild forms of stage III disease. Perhaps high ligation previously constituted overtreatment in some cases. Targeted studies are still needed to prove whether secondary deep venous insufficiency can be avoided in advanced stages of varicose vein disease without high ligation and thus without exclusion of the whole recirculation circuit.