Clinical Etiologic Anatomic Pathophysiologic Classification Research Articles

Dislodged Endovascular Heat-induced Thrombus Resulting in Pulmonary Embolus Following Postoperative Ultrasound Compression

Venous insufficiency and consequent varicose veins are common problems faced by many patients. Fortunately, there are many treatment options available including a minimally invasive method known as radiofrequency ablation (RFA). Radiofrequency ablation is not without complications; among those are endovascular heat-induced thrombosis (EHIT). This rare complication is typically managed conservatively; however, in rare occasions, the thrombus can detach and embolize causing further issues for patients. A 48-year-old male underwent an uneventful RFA procedure for a Clinical Etiologic Anatomic Pathophysiologic classification (CEAP) 4a venous insufficiency. On the postoperative ultrasound (US) venous duplex evaluation, the patient was found to have EHIT type 1 in the right greater saphenous vein extending to the sapheno-femoral junction. During compression and release of the US probe by the US technologist the thrombus detached from the venous wall and embolized to a right lung subsegmental branch. This case report focuses on the possibility of secondary sequela that may arise from EHIT affecting other organ systems from the RFA procedure, the classification system of EHIT, and management options.

Prevalence, clinical presentation, and risk factors of chronic venous disease in Cameroon: A general population-based study.

Chronic venous disease is a global public health problem, with high morbidity and economic distress. There is scarcity of data on this disease in sub-Saharan Africa. We conducted the first population-based study over a period of 20months from 1st February 2020 to 30th September 2021 in the 10 regions of Cameroon. A stratify sampling method was chose to select study site. Socio-demographic data, personal and family history, anthropometric parameters, clinical signs, illustrative images, CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification revised in 2004, VCSS (venous Clinical Severity Score) and risk factor assessment score were used to construct the survey form. Chi-squared test and Fischer exact test were used to compare the prevalence of chronic venous disease across different potential risk factors (sex, age category, previous history of deep vein thrombosis, hypertension, diabetes, smoking status, obesity). Simple and multiple logistic regression models were used to obtain crude and adjusted odds ratio for risk factors associated with chronic venous insufficiency. Statistical analyses were done with R version 4.2 for Linux and the threshold for statistical significance was 0.05. A total of 6578 participants were included in the study, with a mean age of 41.09 ± 16.02years with female predominance (54.3%). The prevalence of chronic venous disease was 21.8% (95% CI: 20.8-22.9) and the prevalence of chronic venous insufficiency (C3-C6) was 7.02% (n = 462). Night cramps (43.2%), oedema (21.7%), lower limbs pain (20.4%) mostly worsens by walking and heavy legs (16.2%) were more common symptoms. The mean total venous clinical severity score was 0.69 ± 1.76 and this score had a significant positive correlation with C classification (p < .001). In the multivariate analysis, the following factors were independently associated with CVD: Male gender (aOR: 1.27; 95%CI: 1.04-1.56; p = .021), retired people (aOR: 46.9; 95% CI: 12.6-174.5; p < .001), hypertension (aOR: 289.5; 95%CI: 169.69-493.1; p < .001), diabetes (aOR: 2.19; 95% CI: 1.21-3.96; p = .009), obesity (aOR: 10.22; 95%CI: 7.67-13.62; p < .001). Smoking appears as a protective factor (aOR: 0.18; 95%CI: 0.10-0.30; p < .001). Chronic venous disease is frequent in Cameroon and main traditional cardiovascular risk factors are associated to this condition. Systematic screening of the CVD in these specific groups could reduce the burden of the disease and its economic impact.

Effect of junctional reflux on the venous clinical severity score in patients with insufficiency of the great saphenous vein (JURY study)

ObjectiveEffective treatment options are available for chronic venous insufficiency associated with superficial venous reflux. Although many patients with C2 and C3 disease based on the CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification have combined great saphenous vein (GSV) and saphenofemoral junction (SFJ) reflux, some may not have concomitant SFJ reflux. Several payors have determined that symptom severity in patients without SFJ reflux does not warrant treatment. In patients planned for venous ablation, we tested whether Venous Clinical Severity Scores (VCSS) are equivalent in those with GSV reflux alone compared with those with both GSV and SFJ reflux. MethodsThis cross-sectional study was conducted at 10 centers. Inclusion criteria were: candidate for endovenous ablation as determined by treating physician; 18 to 80 years of age; GSV reflux with or without SFJ reflux on ultrasound; and C2 or C3 disease. Exclusion criteria were prior deep vein thrombosis; prior vein ablation on the index limb; ilio-caval obstruction; and renal, hepatic, or heart failure requiring prior hospitalization. An a priori sample size was calculated. We used multiple linear regression (adjusted for patient characteristics) to compare differences in VCSS scores of the two groups at baseline, and to test whether scores were equivalent using a priori equivalence boundaries of +1 and −1. In secondary analyses, we tested differences in VCSS scores in patients with C2 and C3 disease separately. ResultsA total of 352 patients were enrolled; 64.2% (n = 226) had SFJ reflux, and 35.8% (n = 126) did not. The two groups did not differ by major clinical characteristics. The mean age of the cohort was 53.9 ± 14.3 years; women comprised 74.2%; White patients 85.8%; and body mass index was 27.8 ± 6.1 kg/m2. The VCSS scores in patients with and without SFJ reflux were found to be equivalent; SFJ reflux was not a significant predictor of VCSS score; and mean VCSS scores did not differ significantly (6.4 vs 6.6, respectively, P = .40). In secondary subset analyses, VCSS scores were equivalent between C2 patients with and without SFJ reflux, and VCSS scores of C3 patients with SFJ reflux were lower than those without SFJ reflux. ConclusionsSymptom severity is equivalent in patients with GSV reflux with or without SFJ reflux. The absence of SFJ reflux alone should not determine the treatment paradigm in patients with symptomatic chronic venous insufficiency. Patients with GSV reflux who meet clinical criteria for treatment should have equivalent treatment regardless of whether or not they have SFJ reflux.

High Physical Activity Volume Is Associated With an Increase in the Calibre of the Lower Limb Veins Without Impact on Functional Discomfort: the VARISPORT Study

The relationship between physical activity and lower limb veins is complex. If a sedentary lifestyle is considered to be negative on lower limb veins, specific information on physical activity varicose vein volume is sparse, especially the effect of high physical activity volume. The main objective of the VARISPORT study was to evaluate lower limb veins (clinically, morphologically, and haemodynamically) and chronic venous disease symptoms in subjects exposed to high physical activity volume compared with a group of non-exposed subjects. A cross sectional study compared a group of high exercise training volume volunteers (more than eight hours of uninterrupted vigorous intensity physical activity per week for more than six months: high physical activity volume group, HPAV group) with a volunteer control group matched for age, sex, and body mass index. Clinical examination was performed to determine the Clinical, Etiological, Anatomical, Pathophysiological (CEAP) classification of each subject and the Carpentier score was used to assess symptoms related to possible chronic venous disease. Duplex ultrasonography was used to assess vein diameters and reflux in the deep and superficial veins. One hundred and nineteen subjects were included in each group. The lower limb veins (deep and superficial) were significantly more dilated in the HPAV group. More reflux was found in the great saphenous veins and non-saphenous veins in the HPAV group. High physical activity volume was associated with a higher frequency of visible varicose veins (stage C2 of the CEAP classification), odds ratio 3.37 (95% confidence interval 1.66 - 7.25) without impact on functional discomfort (44 subjects with a Carpentier score ≥ 1 in each group). The VARISPORT study reported an increase in the calibre of the lower limb veins without impact on functional discomfort. Further studies are needed to determine whether these athletic veins are truly pathological varicose veins or simply an adaptation to high physical activity volumes.

Duplex ultrasound abnormalities of the lower limb veins might precede clinical venous reflux signs in post-Fontan adolescents and young adults

ObjectiveAfter the Fontan operation (ie, direct anastomosis of the caval veins to the pulmonary arteries, constituting right ventricular bypass circulation), high central venous pressure can lead to peripheral venous stasis and venous valvar insufficiency. We hypothesized that post-Fontan patients are at a higher risk of developing lower extremity venous lesions detectable using duplex ultrasound, even if clinical signs of chronic venous disease might not be evident. MethodsA total of 87 transplantation-free survivors after the Fontan procedure who reached adolescence or young adulthood (current age, 15-30 years) participated in a leg vein duplex ultrasound study. The median age at the Fontan procedure, median age at the vein study, and median interval between the two were 3.65 years (interquartile range [IQR], 3.1-5.3 years), 21.7 years (IQR, 18.9-24.7 years), and 16.6 years (IQR, 14.9-19.4 years), respectively. Duplex ultrasound scanning was performed using a venous ultrasound imaging system (Logiq P7; GE Healthcare). The patients were categorized according to the presence of venous reflux (VR) in the superficial, deep, or perforating venous systems: no VR, superficial VR (SVR), deep VR (DVR), perforating VR (PVR), and a combination of multiple venous systems. Correlation of the duplex ultrasound-detected venous lesions with clinical severity using the modified CEAP (clinical, etiological, anatomical, pathophysiological) classification was analyzed using Spearman's correlation analysis. ResultsLeg pain was reported by 48 of 87 patients (55.2%). The duplex ultrasound findings for the cohort were no VR in 21 patients (24.1%), SVR in 22 (25.3%), isolated PVR in 21 (24.1%), and reflux of multiple venous systems in 23 patients, including SVR and PVR in 19, DVR and PVR in 1, and SVR, PVR, and DVR in 3 patients. Although the patients with advanced venous lesions detected by duplex ultrasound tended to have a higher CEAP clinical class (P < .001), VR of any venous system on duplex ultrasound was present even in patients with a lower CEAP clinical class. The CEAP clinical class was C0 for 66 patients (76%), and VR of any venous system was present on duplex ultrasound in 66 patients (76%). ConclusionsThe prevalence of lower extremity venous lesions detected by duplex ultrasound is strikingly high in post-Fontan adolescents and young adults, and duplex ultrasound-detected venous abnormalities can precede clinical manifestations. Early detection and timely intervention for leg vein problems are mandatory for post-Fontan patients, especially for those considered to have risk factors for developing chronic lower extremity venous disease.

Race, sex, and socioeconomic disparities affect the clinical stage of patients presenting for treatment of superficial venous disease

ObjectiveSuperficial venous disease has a U.S. prevalence of nearly 30%, with advanced disease contributing to a significant healthcare burden. Although the risk factors for venous disease are well known, the correlation between race, sex, socioeconomic status, and disease severity on presentation is not well established. The area deprivation index (ADI) is a validated metric with respect to regional geography, social determinants of health, and degree of socioeconomic disadvantage. In the present study, we aimed to identify the disparities and the effect that the ADI, in addition to race and sex, has among patients associated with an advanced venous disease presentation. MethodsA retrospective review between 2012 and 2022 was performed at four tertiary U.S. institutions to identify patients who underwent endovenous closure of their saphenous veins. Patient demographics, state ADI, comorbidities, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, and periprocedural outcomes were included. Pearson's correlation was performed between the CEAP classification and ADI. Poisson regression analysis was performed to identify factors predicting for an increasing CEAP classification at presentation. Variables with P < .05 were deemed significant. ResultsA total of 2346 patients underwent endovenous saphenous vein closure during the study period, of whom 7 were excluded because of a lack of follow-up data. The mean age was 60.4 ± 14.9 years, 65.9% were women, and 55.4% were White. Of the 2339 patients, 73.3% presented with an advanced CEAP class (≥3). The mean state ADI for the entire cohort was 4.9 ± 3.1. The percent change in the CEAP classification is an increase of 2% and 1% for every level increase in the state ADI for unadjusted (incidence rate ratio [IRR] = 1.02; P < .001) and adjusted (IRR = 1.01; P < .001) models, respectively. Black race has a 12% increased risk of a higher CEAP class on presentation compared with White race (IRR = 1.12; P = .005). Female sex had a 16% lower risk of a higher CEAP presentation compared with male sex (IRR = 0.84; P < .01). ConclusionsLow socioeconomic status, Black race, and male sex are predictive of an advanced CEAP classification on initial presentation. These findings highlight the opportunity for improved mechanisms for identification of venous disease and at-risk patients before advanced disease progression in known disadvantaged patient populations.

Black or African American patients undergo great saphenous vein ablation procedures for advanced venous disease and have the least improvement in their symptoms after these procedures

ObjectiveChronic venous insufficiency is an increasingly prevalent problem in the United States, with >25 million individuals currently affected. Previous work has shown that racial minorities and low socioeconomic status are associated with a worse clinical presentation and response to treatment. The present study aimed to determine the relationship between race, patient variables, hospital outcomes, and response to treatment for patients presenting for chronic venous insufficiency intervention. MethodsWe performed a retrospective analysis of all patients who underwent endovenous ablation (radiofrequency or laser) of the great saphenous vein to treat symptomatic, chronic venous insufficiency using Vascular Quality Initiative data from 2014 to 2020. Patient characteristics and outcomes were analyzed stratified by patient race. The χ2 test and the Kruskal-Wallis equality-of-populations rank test were used to measure the study outcomes. The primary outcomes were an improved venous clinical severity score and improvement in patient-reported outcomes. Patient characteristics, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, prior venous interventions, length of stay, and time to follow-up were compared between races. ResultsThe database consisted of 9009 predominantly female patients (n = 6041; 67.1%), with a mean age distribution of 56 years. Of the 9009 patients, 7892 are White (87.6%), 627 Hispanic (6.9%), and 490 Black or African American (18.3%). The Hispanic cohort was younger than their White and Black/African American counterparts. Black/African American patients presented with more advanced clinical stages than did the White and Hispanic groups. The clinical stage according to race was as follows: C3—Black/African American, 32.9%; Hispanic, 38.9%; White, 46%; C5—Black/African American, 4.7%; Hispanic, 2.1%; White, 2.3%; and C6—Black/African American, 12.7%; Hispanic, 3.2%; White, 6.2%. Black/African American patients were more likely to present as overweight or obese (66%; P < .001) and less likely to be taking anticoagulation medication preoperatively (11%; P < .001). Non-White race was associated with a higher probability of treatment in the hospital setting (Black/African American, 63.6%; Hispanic, 87.5%; P < .001). Black/African American patients (3.25 ± 4.4; P < .001) demonstrated lower mean improvement postoperatively in both the venous clinical severity score and patient-reported outcomes than their White (4.25 ± 4.13, P <.001) and Hispanic (4.42 ± 3.78; P < .001) counterparts. ConclusionsDifferences exist in the clinical severity and symptom presentation based on race. Black/African American patients present with more advanced chronic venous insufficiency than do their White and Hispanic counterparts. Furthermore, the postprocedural analysis showed inferior clinical and self-reported improvement in chronic venous insufficiency for the Black/African American patients. Although the Hispanic population was younger, the White and Hispanic patients experienced similar responses to treatment.

Comparison of outcomes following polidocanol microfoam and radiofrequency ablation of incompetent thigh great and accessory saphenous veins

BackgroundMicrofoam ablation (MFA) and radiofrequency ablation (RFA) are both approved by the Food and Drug Administration for treatment of proximal saphenous truncal veins. The objective of our study was to compare early postoperative outcomes between MFA and RFA following treatment of incompetent thigh saphenous veins. MethodsA retrospective review of a prospectively maintained database was conducted of patients who underwent treatment of incompetent great saphenous veins (GSVs) or anterior accessory saphenous veins (AASVs) in the thigh. All the patients underwent duplex ultrasound of the treated leg at 48 to 72 hours postoperatively. Patients were excluded from analysis if concomitant stab phlebectomy was performed. Demographic data, CEAP (clinical, etiologic, anatomic, pathophysiologic) class, venous clinical severity score (VCSS), and adverse events were recorded. ResultsBetween June 2018 and September 2022, 784 consecutive limbs (RFA, n = 560; MFA, n = 224) underwent venous closure for symptomatic reflux. A total of 200 consecutive thigh GSVs and ASVs treated within the study period using either MFA (n = 100) or RFA (n = 100) were identified. The patients were predominantly women (69%) with a mean age of 64 years. The preoperative CEAP classification was similar between the MFA and RFA groups. The mean preoperative VCSS was 9.4 ± 2.6 for the RFA patients and 9.9 ± 3.3 for the MFA patients. Among the RFA patients, the GSV was treated in 98% and the AASV in 2% compared with the GSV in 83% and the AASV in 17% in the MFA group (P < .001). The mean operative time was 42.4 ± 15.4 minutes in the RFA group and 33.8 ±16.9 minutes in the MFA group (P < .001). The median follow-up was 64 days for the study cohort. The mean postoperative VCSS declined to 7.3 ± 2.1 in the RFA group and 7.8 ± 2.9 in the MFA group. Complete closure occurred in 100% of the limbs after RFA and 90% after MFA (P = .005). Eight veins were partially closed and two remained patent following MFA. The incidence of superficial phlebitis was 6% and 15% (P = .06) after RFA and MFA, respectively. Overall, symptomatic relief was 90% following RFA and 89.5% following MFA. The complete ulcer healing rate for the entire cohort was 77.8%. Deep venous proximal thrombus extension (RFA, 1%; vs MFA, 4%; P = .37) and remote deep vein thrombosis (RFA, 0%; vs MFA, 2%; P = .5) showed a trend toward being higher following MFA but the difference did not reach statistical significance. All were asymptomatic and resolved with short-term anticoagulation therapy. ConclusionsMFA and RFA are both safe and effective for treating incompetent thigh saphenous veins, with excellent symptomatic relief and a low incidence of postprocedure adverse thrombotic events. RFA resulted in improved complete closure rates following initial treatment compared with MFA. The operative times were shorter with MFA. Both modalities can be used for patients with active venous ulcers with good healing rates. Longer term studies are required to characterize the durability of MFA closure for above knee truncal veins.

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

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

РЕЗУЛЬТАТЫ КОМБИНИРОВАННОЙ МИНИИНВАЗИВНОЙ ФЛЕБЭКТОМИИ И PRP-ТЕРАПИИ ПРИ СОЧЕТАНИИ ВАРИКОЗНОЙ БОЛЕЗНИ С ГОНАРТРОЗОМ

Objective: To analyze the results of combined minimally invasive phlebectomy (CMIP) with platelet-rich plasma (PRP) therapy for the treatment of chronic venous insufficiency (CVI) and knee osteoarthritis (KOA). Methods: The study analyzed the treatment results of 26 patients (11 men, 15 women, average age of 49.3±4.6 years) with CVI and KOA who underwent CMIP with PRP therapy. The patients' average body mass index (BMI) was 28.9±2.1 kg/m². It was observed that patients with CVI exhibited different grades of severity according to the Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification. Out of 26 patients, 7 (27%) were classified as CEAP class 2, 15 (58%) as class 3, and 4 (15%) as class 4. Isolated insufficiency of the great saphenous vein (GSV) and its tributaries was noted in 9 (35%) patients and the small saphenous vein (SSV) – in 2 (8%) patients. Of the 26 patients, 15 (58%) had combined insufficient GSV and SSV trunks and tributaries. All patients presented with bilateral saphenous vein insufficiency, predominantly on the left side in 19 (73%) cases and on the right side in 7 (27%) cases. Of 26 patients, 17 (65%) had insufficient tibial perforators. According to the Kellgren JH &amp; Lawrence JS classification of osteoarthritis (OA), 4 (15%) of the patients had grade I KOA, 14 (54%) had grade II, and 8 (31%) had grade III. Phlebological status was assessed visually and with duplex scanning (DS) of the venous system in the lower extremities. The knee joints were evaluated using the WOMAC Osteoarthritis Index. Results: The median total index on the WOMAC scale before treatment was 65.5 (61.0-74.0) points, including pain index – 14.0 (13.0-16.0) points, knee joint stiffness – 6.0 (5.0-6.0) points and joint functioning – 47.0 (45.0-49.0) points. All patients underwent CMIP as the first stage, followed by four sessions of PRP therapy, one per week as the second stage. The average duration of surgical procedures was 115.5±35.5 minutes, and patients stayed an average of 2.8±0.4 days in the hospital. There were no significant complications in any case. After the treatment, there was a substantial decrease in pain and stiffness and an improvement in knee joint function. Therapy was ineffective in 4 (15%) cases. The effectiveness of PRP therapy is lower when certain factors are present. These factors include an advanced stage of KOA with a longer duration of the degenerative process in the joint, chronic use of painkillers, and the combined insufficiency of the GSV and SSV trunks. There is a direct correlation between these factors and the low effectiveness of platelet-rich autologous plasma. Conclusion: In patients with CVI and KOA, performing CMIP and PRP therapy can significantly decrease pain and improve daily knee joint function. Keywords: Varicose veins, knee osteoarthritis, microphlebectomy, stripping, PRP therapy.

Prevention of relapses of varicose veins in patients with true doubling of the great saphenous vein

Introduction. True doubling of great saphenous vein is observed in 1.6–2.1% of patients with varicose veins and may be one of the reasons for the development of postoperative relapse of the disease. Performing endovasal laser coagulation (EVLC) of both great saphenous vein trunks makes it possible to increase the radicality of the intervention and reduce the likelihood of a recurrence of varicose veins.Aim. Based on the study of immediate and long-term results, to substantiate the expediency of using EVLC of the main and true additional stem of great saphenous vein in patients with varicose veins.Materials and methods. From 2014 to 2020, 24 patients with a true doubling of great saphenous vein were treated. Among the applicants there were 12 women and 12 men aged 23 to 62 years with clinical class C2–C4 according to the CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) classification. All patients under tumescent anesthesia underwent simultaneous EVLC of the main and accessory trunk of the BPV, followed by miniflebectomy or sclerobliteration of varicose tributaries.Results and discussion. The use of simultaneous coagulation of both trunks was performed by all patients, thus the technical success of the operation was observed in 100% of cases. There were no intraoperative complications. The use of such a volume of intervention is accompanied by an increase in the duration of the operation by 29.3%. Hyperpigmentation in the projection of the coagulated trunk was observed in 2 (8.3%) patients, neurological disorders – in 1 (4.2%) patient. During the examination of patients 1–2 years after the operation, no relapses of the disease were detected, and the cosmetic result of the intervention on a ten-point scale, patients on average estimated at 7.6 points.Conclusions. True doubling of the great saphenous vein is rare and may increase the likelihood of relapses of the disease. EVLC of the main and additional BPV trunks is accompanied by an increase in the duration of surgery by an average of 29.3%, and the number of patients with hyperpigmentation by 1.5 times. Simultaneous EVLC of both tables with true duplication of BPV makes it possible to reliably block a potential source of varicose disease recurrence and reduce the likelihood of recurrent veins.

An observational study of the correlation between Clinical/Etiological/Anatomical/Pathophysiological, Venous Clinical Severity Score, and heaviness/ache/swelling/throbbing/itching classifications for chronic venous insufficiency

OBJECTIVE: This study aimed to evaluate consecutive patients with chronic venous insufficiency (CVI) describing the relationship between Clinical/Etiological/Anatomical/Pathophysiological (CEAP) classification, leg heaviness/ache/swelling/throbbing/itching (HASTI) score, and Venous Clinical Severity Score (VCSS) and assessing the correlation between them. MATERIALS AND METHODS: The CEAP classification, HASTI, and VCSS of consecutive patients were recorded, and their correlations were evaluated. RESULTS: Four hundred eighty-four consecutive patients from March 2018 to March 2019 were studied. Significant correlations were detected between the HASTI and CEAP classification (F = 16.558, P &lt; 0.001) and between VCSS and CEAP classification (F = 57.073, P &lt; 0.001). The VCSS correlated more positively with CEAP (Spearman's correlation coefficient r = 0.740, P &lt; 0.001) than HASTI (Spearman's correlation coefficient r = 0.536, P &lt; 0.001). Using CEAP ≥2 as the cutoff, the areas under the receiver operating characteristics curve of the HASTI and VCSS were 0.694 and 0.774, respectively (P &lt; 0.001 or both). The HASTI and VCSS cutoff values of 6.50 and 4.50, respectively, were identified as indicators of significant CVI with corresponding sensitivities of 63.8% and 78.7% and specificities of 65.6% and 47.0%, respectively. CONCLUSION: Increasing HASTI and VCSS corresponded to increasing CEAP class in patients with CVI. The result may be applicable for early screening of patients with CVI.

Relationship between iliofemoral venous stenting and femoropopliteal deep venous reflux

ObjectiveSevere presentations of chronic venous insufficiency can result from reflux or obstruction at the deep venous, perforator, or superficial venous levels. Iliofemoral venous stenting can be used to address central venous obstruction; however, its effects on deep venous reflux (DVR) have remained unclear. The purpose of the present study was to evaluate the effects of iliac vein stenting on femoropopliteal DVR with the hypothesis that ultrasound evidence of DVR would remain absent or would have improved after iliac vein stenting. MethodsThe present study was a retrospective review of patients who had undergone iliofemoral venous stenting from 2013 to 2018. The patients were divided into two cohorts according to the preprocedural presence (group A) or absence (group B) of femoropopliteal DVR. Baseline patient variables were collected, including age, gender, CEAP (clinical, etiologic, anatomic, pathophysiologic) class, presence of concomitant superficial or perforator reflux, deep vein thrombosis history, and additional venous interventions. The primary outcome evaluated was the persistent absence or resolution of DVR on the latest venous duplex ultrasound at follow-up. Other outcomes included the follow-up CEAP classification and the need for secondary deep venous interventions. ResultsA total of 275 consecutive patients had undergone iliofemoral venous stenting. Of the 275 patients, 58 had presented with DVR (group A). A comparison of groups A and B revealed that group A had had a greater likelihood of prior deep vein thrombosis (P = .0001) and a higher frequency of superficial venous ablation. The remaining demographic variables did not differ significantly between the two groups. Of the 58 patients in group A, DVR had resolved at follow-up in 17 (P = .0001). When stratified by level, 7 of these 17 patients had had isolated popliteal reflux. In group B, DVR had developed at follow-up in 6 of the 217 patients. The CEAP class had improved from before intervention (C0, 1.1%; C1, 0.4%; C2, 1.8%; C3, 41.4%; C4, 24.9%; C5, 5.9%; C6, 24.5%) to the latest follow up (C0, 4.9%; C1, 1.9%; C2, 5.7%; C3, 34.2%; C4, 22.8%; C5, 17.1%; C6, 13.3%). Significant improvement had occurred in C6 disease within both groups (group A, 16 of 58 [27.6%; P = .0078]; group B, 19 of 217 [8.8%; P = .0203]). ConclusionsFor patients who undergo iliofemoral venous stenting, DVR could improve if present initially and is unlikely to develop if not present before stenting. A cohort of patients had experienced persistent DVR and warranted further evaluation. Prospective studies are required to corroborate the safety, efficacy, and durability of iliofemoral venous stenting for patients with DVR.

The utility of hyperspectral imaging in patients with chronic venous disorders

ObjectiveThe underlying pathophysiology of lower limb changes in chronic venous disorders (CVD) may involve alteration in microcirculation and tissue oxygenation. Hyperspectral imaging (HSI) is a noninvasive tool that is used clinically to measure transcutaneous oxygenation in peripheral artery disease and diabetic foot disease. However, there has been little application in venous disease. The aim of this study was to determine if transcutaneous oxygenation in the lower limb, as measured by HSI, changes depending on the clinical component of the Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification in CVD. MethodsThis was an observational study of patients with CVD recruited from a vascular specialist clinic at a tertiary hospital from January 2020 to January 2021. Participants were allocated to eight groups according to the clinical component of CEAP classification of CVD. Baseline demographic and risk factor information were collected. Transcutaneous oxygenation was measured using HSI at seven sites around the foot and gaiter area in the supine and standing position. Participants rested supine for 15 minutes before the supine measurements and then stood for 15 minutes before the standing measurements. Tissue oxygenation was analyzed over a fixed circular surface area of 79 mm2 at the target location. Calculations of oxyhemoglobin level (artificial unit [AU]), deoxyhemoglobin level (AU), oxygen saturation (%), and temperature (°C) were obtained. The Northern Ethics Committee (18/NTA/78) approved this conduct of the study and participants signed written consent forms. ResultsThere were 94 participants (164 lower limbs) included in the study. The median age was 59 years and 59 participants (63%) were women. At all sites except the heel, deoxyhemoglobin measurements increased in the standing position compared with the supine position (P < .001). In the gaiter region, there was nearly a doubling in deoxyhemoglobin level at 5 cm above the medial malleolus (supine 43.88 AU vs standing 80.46 AU; P < .001) and 5 cm above the lateral malleolus (supine 46.33 AU vs standing 87.72 AU; P < .001). When measurements were stratified by clinical class of the CEAP classification, there was a greater increase in deoxyhemoglobin levels with increasing clinical class in the standing position (P < .001). This finding was not observed in the supine measurements. ConclusionsIn CVD, HSI shows an increase in deoxyhemoglobin in the standing compared with supine position, particularly in the gaiter region. Furthermore, standing deoxyhemoglobin increases as the CEAP clinical class increases. Thus, this noninvasive tool may respond to venous physiology and may supplement the clinical class of the CEAP classification system.

Direct oral anticoagulant agents might be safe for patients undergoing endovenous radiofrequency and laser ablation

ObjectiveStudies assessing the effect of the use of anticoagulant agents on endovenous thermal ablation (ETA) have been limited to patients taking warfarin. Thus, the aim of the present study was to assess the efficacy and safety of ETA for patients taking direct oral anticoagulants (DOACs). We hypothesized that the outcome of ETA for patients taking DOACs would not be superior to the outcomes for patients taking DOACs. MethodsWe performed a retrospective review to identify patients who had undergone radiofrequency ablation or endovenous laser ablation with 1470-nm diode laser fibers for symptomatic great or small saphenous venous reflux from 2018 to 2020. The patients were dichotomized into those who had received a therapeutic dose of DOACs periprocedurally and those who had not (control group). The outcomes of interest included the rates of treated vein closure at 7 days and 9 months and the incidence of deep vein thrombosis (DVT), endothermal heat-induced thrombosis (EHIT), and bleeding periprocedurally. ResultsOf the 301 patients (382 procedures), 69 patients (87 procedures) had received DOACs and 232 control patients (295 procedures) had not received DOACs. The patients receiving DOACs were more often older (mean age, 65 years vs 55 years; P < .001) and male (70% vs 37%; P < .001), with a higher prevalence of venous thromboembolism and more severe CEAP (clinical, etiologic, anatomic, pathophysiologic) classification (5 or 6), than were the control patients. Those receiving DOACs were more likely to have had a history of DVT (44% vs 6%; P < .001), pulmonary embolism (13% vs 0%; P < .001), and phlebitis (32% vs 15%; P < .001). Procedurally, radiofrequency ablation had been used more frequently in the control group (92% vs 84%; P = .029), with longer segments of treated veins (mean, 38 mm vs 35 mm, respectively; P = .028). No major or minor bleeding events nor any EHIT had occurred in either group. Two patients in the control group (0.7%) developed DVT; however, no DVT was observed in those in the DOAC group (P = .441). At 9 months, the treated vein had remained ablated after 94.4% of procedures for patients receiving DOACs and 98.4% of the control group (P = .163). On multivariable analysis, DOAC usage was not associated with an increased risk of vein recanalization (hazard ratio, 5.76; 95% confidence interval, 0.57-58.64; P = .139). An increased preprocedural vein diameter and the use of endovenous laser ablation were associated with an increased risk of recanalization. ConclusionsIn our study of patients who had undergone ETA for symptomatic saphenous venous reflux, the periprocedural use of DOACs did not adversely affect the efficacy of endovenous ablation to ≥9 months. Furthermore, DOAC use did not confer an additional risk of bleeding, DVT, or EHIT periprocedurally. DOACs may be safely continued without affecting the efficacy and durability of ETA.

RETRACTED: The Leg Subcutaneous Tissue Calcification and Venous Ulcer-a Case Series.

Ultrasonography of patients with venous ulcers showed subcutaneous tissue calcification （STC）in some patients. However, calcification is rarely included in venous ulcer-related changes. The aim of this study was to evaluate the prevalence and morphological changes of STC in patients with ultrasonographically diagnosed with venous ulcers. A total of 80 legs of 40 patients with venous ulcers (28 women and 12 men, mean age 48 years, range 18-83 years) were included in this study. After ultrasonographic evaluation of the patient's deep, superficial, and perforating veins, continue to use ultrasonography to examine the patient's subcutaneous tissue for the presence of STC. According to the CEAP (Clinical, Etiological, Anatomical, Pathophysiological) classification of Group C, 18 legs were classified as C5 and 62 as C6. STC was present in 38 of the 80 legs, most of which were patients classified as C6.STC are easily detected by ultrasound, especially in the injured area of the leg in C6 patients. STC may be associated with chronic inflammation of the subcutaneous tissue. It is recommended to remove it from the ulcer bed to promote ulcer healing and prevent recurrence. Further studies are needed to determine its prognostic significance and other possible clinical implications.

Utility of Ultrasound for Evaluating Skin Changes in Chronic Venous Disease

Chronic venous disease (CVD) manifests as a spectrum of clinical features. Skin changes can be associated with CVD, and these changes can be appreciated on ultrasound (US) at different stages of CVD. Identification of these changes can be especially helpful in the early stages, when the skin changes might not be apparent on clinical examination, to further strategize their management and prevent disease progression. Our aim was to examine these skin changes with US and stratify the various findings for the different stages of CVD using the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification.

Cardiac Doppler Parameters and Progress in Clinical Manifestation of Primary Lower Extremity Varicose Veins: A Prospective Study in China.

ObjectiveTo investigate the features of cardiac Doppler parameters in patients with primary lower extremity varicose veins in China.Materials and MethodsWe performed a prospective statistical analysis of cardiac Doppler parameters between 129 Chinese patients with varicose veins and normal controls. Furthermore, we evaluated the relationship between cardiac Doppler and the progress or severity of lower extremity varicose veins.ResultsCompared with normal controls, patients with primary varicose veins had significantly lower early mitral and tricuspid diastolic inflow and annular velocities (E- and e′-waves), significantly higher late mitral and tricuspid diastolic inflow and annular velocities (A- and a′-waves), significantly higher mitral systolic annular velocities (s′-wave), and significantly lower mitral and tricuspid E/A ratio. There was no significant association between deep venous reflux (DVR) of the lower extremities and cardiac Doppler parameters. The relationship between Clinical Etiological Anatomical Pathophysiological (CEAP) clinical class and cardiac Doppler parameters showed on that: In comparison with normal control, all cardiac Doppler parameters of C2 clinical class patients were basically unchanged, but the cardiac Doppler parameters of the C3 or higher CEAP class patients changed. Hence, we found a potential CEAP grade cut-off value (C3) linked to statistical changes in cardiac Doppler parameters.ConclusionCardiac Doppler parameters in patients with primary varicose veins could indeed be different from those of normal people, especially for C3 class or higher CEAP clinical class patients. Therefore, for those patients, pre-operative echocardiography can be used to evaluate cardiac hemodynamic changes, but large-scale clinical promotion requires further large sample studies.

Subcutaneous calcifications in legs with chronic venous diseases

BackgroundCalcifications in the subcutaneous layer (SCL) have been described by radiographic studies of legs with advanced chronic venous disease (CVD). However, SCL calcifications have rarely been included among the CVD-related changes. The aim of the present study was to evaluate the prevalence and morphology of SCL calcifications in legs with CVD of all grades of severity determined by ultrasound. MethodsA total of 500 legs in 250 patients (148 women and 102 men; mean age, 51 years; range, 18-87 years) referred to our vascular clinic for symptoms and signs of CVD were included. After duplex ultrasound evaluation of the deep, superficial, and perforating veins, the skin and SCL were investigated using duplex ultrasound. Those patients with other possible causes of SCL calcification were excluded. ResultsUsing the C component of the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, 43 legs were classified as C1, 189 as C2, 34 as C3, 16 as C4A, 45 as C4B or C, 18 as C5, and 16 as C6. Varicose veins were reported in 273 legs, and lipodermatosclerosis in 79 legs. Subcutaneous calcifications were demonstrated in 35 of 361 legs with CVD in two different locations: the wall of superficial varicose veins and in subcutaneous tissue unrelated to the path of the superficial veins. Superficial veins calcifications were found in 12 of 273 legs with varicose veins (4.4%) and were found in older patients with severe varicose vein disease (grade 3 using the venous clinical severity score and disease duration >30 years). Subcutaneous tissue calcifications (STCs) were found in 24 of 95 legs with a more advanced CVD stage (C4A-C6). No STCs were found in legs with a C1, C2, or C3 class. ConclusionsSuperficial veins calcifications were found only in the legs with severe and long-lasting varicose veins and seemed to be related to chronic severe inflammation of the venous wall. STCs were independent of the vein wall and were found only in the damaged areas of legs with severe CVD (C4-C6). STCs are possibly related to chronic inflammation of the subcutaneous tissue. Their avulsion from the ulcer bed has been recommended to facilitate ulcer healing and prevent recurrence.

Iliofemoral venous stenting in patients with central neuromuscular disorders

BackgroundLeg swelling in patients with various central neuromuscular disorders is a common clinical scenario and can lead to significant morbidity. The aim of the present study was to evaluate a subset of patients with central neuromuscular disorders who had undergone iliofemoral venous stenting at a specialty venous clinic at a tertiary care hospital. MethodsFrom January 2000 to December 2020, the medical records of all patients with a known central neuromuscular disorder who had undergone iliofemoral venous stenting for chronic iliofemoral venous obstruction were retrospectively analyzed. ResultsA total of 42 patients (45 limbs) with central neuromuscular disorders had undergone iliofemoral stenting after failure of a trial of conservative therapy. The central neuromuscular disorders included Parkinson disease (n = 20 limbs), multiple sclerosis (n = 15 limbs), and other neuromuscular conditions (n = 10 limbs). The mean age of the sample was 59 ± 14 years. The ratio of post-thrombotic to nonthrombotic iliac vein lesions was 3:1. Most of the patients had had CEAP (clinical, etiologic, anatomic, pathophysiologic) class ≥C4 (64.4%); 25 limbs had a history of venous thromboembolism (56%). A trend was seen toward improvement in all clinical parameters measured (venous clinical severity score, visual analog scale for pain score, and edema grade) after stenting. An ulcer healing rate of ≤90% was noted after stenting. Of the 45 limbs, 24 had required some form of reintervention (53%) after initial stent placement. ConclusionsVenous intervention in the form of endovenous stenting was associated with improvement in the clinical parameters for patients with central neuromuscular disorders. However, these patients should be counseled regarding the relatively higher rate of reinterventions that might be required to correct residual or recurrent symptoms.