Clinical, Etiologic, Anatomic, Pathophysiologic Research Articles

Clinical efficacy of sodium aescinate administration following endovenous laser ablation for varicose veins.

Endovenous interventions and minimally invasive procedures are effective in the management of varicose veins. However, they can cause postoperative discomfort. To evaluate the clinical efficacy of sodium aescinate (SA) in improving edema, pain, vein-specific symptoms, and quality of life in patients following endovenous laser ablation (EVLA) for varicose veins. In this single-center randomized controlled trial (RCT), patients were allocated into two groups: in Group A, 60mg SA was administered twice daily for 20days, and in Group B (control), no venoactive drug was prescribed. The Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification system for chronic venous disorders was used to assess the varicose veins. The circumferences of the calf and ankle were recorded for evaluating edema. The 10-point Visual Analog Scale (VAS), Venous Clinical Severity Score (VCSS), and Aberdeen Varicose Veins Questionnaire (AVVQ) were used to measure the pain intensity, overall varicose vein severity, and patient's quality of life, respectively. The study included 87 patients (mean age, 59.9 ± 10.7years; 54 men) with CEAP class C2-C5 varicose veins who underwent EVLA and phlebectomy or foam sclerotherapy. The calf circumference recovered quicker in Group A than in Group B by days 10, 21, and 30 (difference from baseline was 1.04 ± 0.35 vs 2.39 ± 1.15 [p < .001], 0.48 ± 0.42 vs1.73 ± 1.00 [p < .001], and 0.18 ± 0.64 vs 0.82 ± 0.96 [p < .001], respectively). The ankle circumference recovered quicker in Group A than in Group B by days 10 and 21 (the difference from baseline was 1.37 ± 0.52 vs 2.36 ± 0.93 [p < .001] and 0.58 ± 0.60 vs 1.14 ± 0.88 [p = .002], respectively). Pain relief was achieved quicker in Group A than in Group B (0.257 ± 1.097 [p = .0863] vs 0.506 ± 1.250 [p = .0168] by day 21). There were no significant differences in the VCSS and AVVQ scores between both groups. There were no drug-related adverse effects. SA, in combination with compression therapy, can relieve edema and alleviate pain in patients following EVLA for varicose veins.

[Varicosis-Current treatment concepts].

Varicosis is achronic progressive disease characterized by varicose veins of the lower extremities. Pain, swelling and heaviness of the legs are typical symptoms. These symptoms are caused by apathological venous reflux, arising from aweakness of the vein wall and progressive venous insufficiency. The indications for invasive surgery are the symptomatic clinical, etiological, anatomical, pathophysiological (CEAP) stages C2s-C6. Compression therapy and venoactive drugs can be recommended for conservative therapy. When it comes to surgical treatment conventional open vein surgery is associated with the best long-term results. Endovenous thermal ablation is associated with few postoperative complications and favors earlier mobilization of the patient. Sclerotherapy has become established with good clinical results for the ablation of reticular and telangiectatic veins, for recurrences and complicated vein anatomy.

Factors associated with recanalization and reintervention following below knee polidocanol endovenous microfoam ablation for great saphenous and small saphenous veins

BackgroundPolidocanol endovenous microfoam (PEM) has been used to treat lower extremity venous reflux for almost one decade with specific advantages for below knee (BK) truncal veins where thermal ablation poses a risk of injury to adjacent nerves. The current literature of the BK segment often examines short-term outcomes with modest sample sizes. We aim to identify factors associated with recanalization and reintervention in this subset of patients. MethodsWe performed a retrospective study of a prospectively maintained database of patients from a single institution who underwent PEM ablation for BK great saphenous vein (GSV) and small saphenous vein (SSV) reflux. Patients underwent duplex ultrasound (DU) within 7 days after injection, every 3 to 6 months for 1 year, and every 6 to 12 months thereafter. Patients with symptomatic recanalization underwent reintervention. The 26 patients lost to follow-up without DU after ablation were excluded. The factors associated with recanalization and reintervention were examined by multivariate and nonparametric analyses. ResultsBetween March 2018 and July 2023, 411 patients (166 male, 245 female) with 573 treated limbs (284 right, 289 left) met the study criteria. Of the 573 included limbs, 457 (79.8%) had undergone prior above knee saphenous ablations. A total of 554 BK GSV and 42 SSV ablations were performed. The most recent DU was performed at a mean of 231 ± 329 days. The overall recanalization rate was 10.6% (55 GSVs and 8 SSVs) at a mean follow-up of 104 ± 180 days. Comparing the closed and recanalized veins, we found no significant difference in age (P = .90), treated laterality (P = .14), patient body mass index (P = .59), preprocedural CEAP (clinical-etiology-anatomy-pathophysiology) score (P = .79), recanalization rate in GSVs vs SSVs (P = .06), or administered PEM volume (P = .24). The recanalized veins had significantly larger preprocedural diameters than the veins that remained closed (recanalized, 4.9 mm; closed, 4.3 mm; P = .001). Men had higher incidence of recanalization than women (men, 14.2%; women, 8%; P = .015). Anticoagulation use was associated with recanalization (odds ratio, 1.96; 95% confidence interval, 1.1-3.6; P = .03). Early recanalization at the first DU accounted for 31 failures (49.2%) and had a significantly lower administered PEM volume compared with later recanalization (early, 4 mL; late, 5 mL; P = .025). There were no significant differences between the 33 recanalized patients requiring reintervention (52.4%) and the 30 who did not. Twenty-four reinterventions were performed with PEM, 100% of which remained closed at a median of 160 days (interquartile range, 257 days). ConclusionsPEM is successful for the treatment of BK GSV and SSV reflux with a closure rate of 89% at a mean of 231 days and shows promise as salvage therapy. Most cases of recanalization were noted in the early postprocedure period and were associated with a lower PEM volume. A larger vein diameter, male sex, and anticoagulation use are associated with higher rates of recanalization.

A prognostic nomogram for recurrence survival in post-surgical patients with varicose veins of the lower extremities

Varicose veins of the lower extremities (VVLEs) are prevalent globally. This study aims to identify prognostic factors and develop a prediction model for recurrence survival (RS) in VVLEs patients after surgery. A retrospective analysis of VVLEs patients from the Third Hospital of Nanchang was conducted between April 2017 and March 2022. A LASSO (Least Absolute Shrinkage and Selection Operator) regression model pinpointed significant recurrence predictors, culminating in a prognostic nomogram. The model’s performance was evaluated by C-index, receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA). The LASSO regression identified seven predictors for the nomogram predicting 1-, 2-, and 5-year RS. These predictors were age, body mass index (BMI), hypertension, diabetes, the Clinical Etiological Anatomical Pathophysiological (CEAP) grade, iliac vein compression syndrome (IVCS), and postoperative compression stocking duration (PCSD). The nomogram’s C-index was 0.716, with AUCs (Area Under the Curve scores) of 0.705, 0.725, and 0.758 for 1-, 2-, and 5-year RS, respectively. Calibration and decision curve analyses validated the model’s predictive accuracy and clinical utility. Kaplan–Meier analysis distinguished between low and high-risk groups with significant prognostic differences (P < 0.05). This study has successfully developed and validated a nomogram for predicting RS in patients with VVLEs after surgery, enhancing personalized care and informing clinical decision-making.

Obese patients with CEAP (clinical, etiology, anatomy, pathophysiology) C2 and C3 disease show enhanced symptom improvement after endovenous thermal ablation

ObjectiveEndovenous thermal ablation (EVTA) is a prevalent treatment option for patients with severe venous disease. However, the decision to intervene for patients with less severe disease (CEAP [clinical, etiology, anatomy, pathophysiology] C2 and C3) is less clear and becomes further complicated for patients with obesity, a pathology known to increase venous disease symptom severity. Therefore, the objective of this study was to use the Society for Vascular Surgery Vascular Quality Initiative database to evaluate outcomes after EVTA in obese patients with CEAP C2 and C3 venous insufficiency. MethodsUsing the Society for Vascular Surgery Vascular Quality Initiative database, we retrospectively analyzed the initial procedure of all patients with a CEAP clinical class of C2 or C3 who underwent EVTA from January 2015 to December 2021. Patients were grouped by obesity, defined as a body mass index of ≥30 kg/m2. The primary outcome was the change in venous clinical severity score (VCSS) from the procedure to the patient's initial follow-up. The secondary outcomes included the change in patient-reported outcomes at follow-up via the HASTI (heaviness, achiness, swelling, throbbing, itching) score, incidence of follow-up complications, and recanalization of treated veins. The change in the VCSS and HASTI score were analyzed using the Student t test, and complications and recanalization were assessed using the Fisher exact test. Significant outcomes were confirmed by multiple variable logistic regression. The remaining significant variables were then analyzed, with obesity categorized using the World Health Organization classification system to analyze how increasing obesity levels affect outcomes. ResultsThere were 8146 limbs that met the inclusion criteria, of which 5183 (63.6%) were classified as nonobese and 2963 (36.4%) as obese. Obesity showed no impact on improvement in the VCSS (−3.29 vs −3.35; P = .408). Obesity was found to be associated with a larger improvement in overall symptoms, as evidence by a greater improvement in the HASTI score (−7.24 vs −6.62; P < .001). Obese limbs showed a higher incidence of superficial phlebitis (1.5% vs 0.7%; P = .001), but no difference was found in recanalization or any other complication. ConclusionsThese data suggest that obese patients with CEAP clinical class C2 or C3 experience greater improvement in their perceived symptoms after EVTA with little difference in clinical improvement and complications compared with nonobese patients. Although obesity has been associated with increased severity of venous disease symptoms, obese patients are able to derive significant relief after treatment during the short term and might experience greater relief of symptoms than nonobese patients when treated at more mild disease presentations.

A Study of Blood Viscosity and Inflammatory Biomarkers’ Levels in Bilateral Primary Varicose Veins/Reticular Veins as Predictive Markers

Objectives Cross-sectional data was collected for a period of 1 year to assess the biomarkers of inflammation, and blood viscosity as predictive markers in patients with primary bilateral varicose veins or reticular veins that might progress to varicose veins. Material and Methods A sample of 40 participants, 20 controls and 20 patients aged 18–65 years falling under the reticular veins and symptomatic varicose veins (C1, 2s), primary etiology (Ep), superficial veins (As), reflux pathology (Pr) categories of Clinical, etiologic, anatomic, Pathophysiologic (CEAP) classification with the exception of telangiectatic veins, were included in the study. Blood viscosity was measured using a Capillary Viscometer. Evaluated inflammatory markers were tissue Plasminogen Activator (tPA), Plasminogen Activator Inhibitor-1 (PAI-1), and fibrinogen. Analysis was done using Statistical Package for the Social Sciences (SPSS) software and Chi-square, Fisher’s, Bonferroni, and Analysis of Variance (ANOVA) tests were applied. Results There was a statistically insignificant relationship between occupation and different study groups. Standing hours and serum fibrinogen levels had a significant difference in different study groups. Serum tPA, Serum PAI-1, and blood viscosity had an insignificant difference between different study groups. It was revealed that the pairwise group comparisons of study group C2 vs. control group C0, study group C1 vs. control group C0 and study group C2 vs. study group C1, and study group C2 vs. control group C0 each were significantly different pairwise. Conclusion Blood viscosity, tPA and PAI-1 cannot be used as predictive markers in patients with bilateral (B/L) primary varicose veins/reticular veins. Serum fibrinogen levels can be used as predictive markers for the development of B/L primary varicose veins and in our particular study with a predictive range of 189.4–327.9 mg/dL but not for B/L reticular veins. Prolonged standing, irrespective of the occupation of the patient, is associated with the development of B/L reticular veins and B/L varicose veins.

Noninvasive measurement of ambulatory venous pressure via column interruption duration in chronic venous disease

BackgroundColumn interruption duration (CID) is a noninvasive surrogate for venous refill time (VFT), a parameter used in ambulatory venous pressure measurement. CID is more accurate than invasive VFT measurement because it avoids errors involved with indirect access of the deep system through the dorsal foot vein. The aim of this retrospective single center study is to analyze the clinical usefulness of CID in assessment of chronic venous disease (CVD). MethodsA total of 1551 limbs (777 patients) were referred with CVD symptoms over a 5-year period (2018-2023); CID, air plethysmography, and duplex reflux data were analyzed. Of these limbs, 679 had supine venous pressure data as well. The pathology was categorized as obstruction if supine peripheral venous pressure was >11 mm Hg and as reflux if duplex reflux time in superficial or deep veins was >1 second. CID was measured via Doppler monitoring of flow in the great saphenous vein (GSV) and one of the paired posterior tibial (PT) veins near the ankle in the erect posture. The calf is emptied by rapid inflation cuff. CID is the time interval in seconds when cephalad venous flow in great saphenous vein and posterior tibial veins reappear after calf ejection. A CID <20 seconds in either vein is abnormal similar to the threshold used in VFT measurement. ResultsThirty-two percent of the limbs had obstruction, 17% had reflux, and 37% had a combination; 14% had neither. Higher clinical-etiology-anatomy-pathophysiology (CEAP) clinical classes (C4-6) were prevalent in 44% of pure reflux, significantly less (P < .0001) than in pure obstruction (73%) or obstruction plus reflux subsets (72%), partly reflecting distribution of pathology. There is a progressive increase in supine venous pressure and abnormal CID (P < .0001 and P < .0001, respectively) in successive CEAP clinical class. No such correlation between CEAP and any of the reflux severity grading methods (reflux segment score, Venous Filling Index, and Kistner axial grading) was observed. Abnormal CID (55%) was more prevalent in higher CEAP classes (>4) (P < .0001) than in lesser clinical classes (0-2) or limbs with neither obstruction nor reflux (P < .01). ConclusionsObstruction seems to be a more dominant pathology in clinical progression among CEAP clinical classes than reflux. CID is abnormal in both obstructive and refluxive pathologies and may represent a common end pathway for similar clinical manifestations (eg, ulcer). These data suggest a useful role for CID measurement in clinical assessment of limbs with CVD.

Impact of static foot disorders on the conservative treatment success in chronic venous disease patients without wounds

ObjectiveChronic venous disease (CVD) and static foot disorders (SFDs) are prevalent conditions that commonly cause lower extremity pain. These conditions share common factors such as age and weight in their etiology. This study aimed to investigate the impact of SFDs on the treatment response of patients undergoing conservative treatment for CVD without wounds. Materials and MethodsA retrospective evaluation was conducted on 328 patients (60 males, 268 females) with CVD. Parameters including age, gender, affected side, body mass index, Visual Analog Scale (VAS), Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification, and revised Venous Clinical Severity Score (rVCSS) were considered for evaluation. Radiological measurements of calcaneal pitch angle (CPA) were analyzed as a determinant of SFDs. ResultsVAS and rVCSS of the patients were evaluated before and after conservative treatment of CVD without concomitant treatment of SFDs. The presence of SFDs was associated with decreased treatment success (P < .001). Among different types of SFDs, the pes cavus group exhibited the lowest change in VAS and rVCSS scores before and after conservative CVD treatment. In contrast, the normal group demonstrated the highest improvement. Patients with a normal foot medial arch consistently achieved the best treatment outcomes compared with patients with other SFDs. ConclusionsIn conclusion, SFDs affect outcomes of conservative treatment of CVD in CEAP 0 to 3 patients, with the efficacy of treatment dependent upon the severity of SFDs.

Effectiveness of herbal drug Terminalia Arjuna in chronic venous insufficiency - A prospective observational study

IntroductionChronic venous insufficiency (CVI) manifests in various clinical presentations ranging from asymptomatic but cosmetic problems to severe symptoms, such as lower limb edema, skin trophic changes, and ulceration. CVI substantially affects the quality of life and work productivity of the patients. Ayurveda, an ancient traditional medicine in India, evaluates the various pathological stages of CVI with a wide range of pathological conditions such as Siragranthi (venous abnormalities), Raktavaritavāta (disorders of vāta occluded by rakta ∼ blood), ApanaVaigunya (vitiated apānavāyu), Arsha (hemorrhoids), VataRakta (rheumatism due to rakta), Kushtha (integumentary disease) and Dushta Vrana (putrefied wound) depending upon the presentations of the patient. Ayurvedic texts mention Terminalia arjuna as a potential herb for treating various conditions related to the circulatory system. The drug is an effective anti-inflammatory, anti-oxidant, and anti-hypertensive and has a definite role in improving cardiovascular hemodynamics and wound healing. These attributes suggest that the potential of Terminalia arjuna needs to be explored as a promising venoactive drug. MethodsThis prospective observational study included 25 patients (31 limbs) with CVI who were treated with Tab Terminalia arjuna (Bark extract of Terminalia arjuna in a dose of 500 mg, given twice a day) and were observed on two visits on day 30 and day 90. Follow-up was carried out for three months to evaluate post-treatment complications or adverse effects. The clinical outcome assessment was done using Venous Clinical Severity Score (VCSS), and clinical grading was performed using clinical classification (C0 – C6) of CEAP (Clinical–Etiology–Anatomy–Pathophysiology) classification. ResultsThe median VCSS score (of both limbs) during the third visit was comparatively lower than the first, with a statistically significant improvement at 0.05 level. Further, there was a substantial positive improvement in the clinical classification of CEAP among the patients in pre and post treatment phase. ConclusionThe prospective observational study shows that Tab Terminalia arjuna is safe and effective in CVI, reducing the symptoms like pain, edema, inflammation, pigmentation, induration and also expediting ulcer healing.

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.

Assessment of skin and associated soft tissue changes with ultrasonography in chronic venous disease.

Chronic venous disease (CVD) is accompanied by a spectrum of skin changes. The aim of this study was to assess skin changes in CVD in different classes of the classifications such as the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification using ultrasound (US). This study was conducted from July 2020 to July 2021 after obtaining approval from Institutional Ethical Committee. Patients with chronic venous insufficiency were enrolled after taking informed consent. Assessment of cutaneous layer (CL), subcutaneous layer (SCL), dermo-hypodermal junction (D-HJ), and other significant US findings were noted. Ninety-eight limbs were evaluated. Most common skin finding was dermal edema in 59 (60.2%) legs. Other findings included infiltrates, CL thickening, hyper echogenicity and thickening of SCL, anechoic lacunae, disappearance of D-HJ, and epidermal loss or change in thickness of epidermis. Notably, US detected dermal edema in 15 and infiltrates in five C2 legs (normal on inspection). US evaluation of skin changes adds insight to clinical assessment and may reveal skin changes in legs affected with CVD that may appear normal on clinical examination.

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.

Prevalence and associated factors of chronic venous disease among a modern non-western population

Abstract Background Chronic venous disease (CVD) of the lower extremities is a commonly occurring vascular disease with varied clinical manifestations and an uncertain prevalence due to differences in population characteristics and measurement techniques. Purpose The aim of this study was to assess chronic venous disease prevalence and identify associated risk factors in a modern non-western urban population. Methods 2227 adults aged 30–75 years with no overt cardiovascular diseases were randomly selected from different city districts to participate in a cardiovascular cohort. After they were informed about the examination methods, including total lower extremities exposure, 1176 (52%) of them agreed to participate. Two trained interventional cardiologists evaluated CVD using the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification ensuring that all participants were evaluated by the same criteria in order to obtain reliable results. CVD was classified as C1–C6, and chronic venous insufficiency (CVI) as C3–C6. In this study, CVD associations were investigated using a multivariable regression model that accounted for pre-specified variables such as age, sex, body mass index (≥30 kg/m2), smoking, hypertension, diabetes mellitus, physical activity, dyslipidemia, and delivery. Results The prevalence of CVD and CVI among the participants was 36.5% (95% CI, 33.8 to 39.3) and 0.7% (95% CI, 0.3 to 1.3), respectively, and CVD prevalence was more frequent in women (44.2% vs. 23.5%). Based on multivariable analysis advanced age (OR, 1.06; 95% CI, 1.04 to 1.08), female sex (OR, 2.98; 95% CI, 2.14 to 4.14), and a body mass index of ≥30 (OR, 1.36; 95% CI, 1.03 to 1.81) were independently associated CVD. Physical activity (OR, 0.77; 95% CI, 0.58 to 1.02) was nearly protective, whereas other factors, including traditional cardiovascular risk factors, did not appear to have any meaningful association with CVD. Conclusions Our results showed that CVD was prevalent in a modern non-western urban population. Due to the low prevalence of advanced stages of the disease, mass screening is debatable, and better risk discriminators are needed.Figure 1Table 1

The beneficial role of complex decongestive therapy in patients with symptomatic chronic iliofemoral venous obstruction with phlebolymphedema

ObjectivePhlebolymphedema has been noted to be one of the most common causes of lymphedema in the lower extremity in western societies. Although complex decongestive therapy (CDT) represents the mainstay of lymphedema treatment, its role for phlebolymphedema arising from chronic iliofemoral venous obstruction (CIVO) merits further exploration. We evaluated this through the use of a protocol of CDT first for limbs with CEAP (clinical, etiologic, anatomic, pathophysiologic) clinical C3 disease and stent correction of obstruction before CDT for those with more advanced disease (CEAP C4-C6). In the present study, we analyzed the outcomes after the use of such a protocol. MethodsWe analyzed prospectively collected data for 192 limbs (166 patients) that underwent treatment of quality-of-life (QoL) impairing symptoms from CIVO due to lymphoscintigraphically determined phlebolymphedema between 2017 and 2022. The characteristics evaluated included CEAP clinical class, venous clinical severity score (VCSS), grade of swelling (GOS), visual analog scale (VAS) pain score, QoL (CIVIQ-20 [20-item chronic venous disease quality of life questionnaire]), stenting for CIVO, and outcomes related to CDT and stenting. For the limbs undergoing CDT or stenting followed by CDT, the outcomes were evaluated at 6 weeks and 3, 6, and 12 months after completion of CDT. Paired and unpaired t tests, χ2 tests, and analysis of variance were used for comparisons of clinical variables. Kaplan-Meier analysis was used to evaluate stent patency, with the log-rank test used to discriminate between different curves. ResultsOf the 192 limbs (166 patients) in the entire cohort, 74 were in the C3 group and 118 were in the C4-C6 group. The median patient age was 63 years; 57 were men and 109 were women. In the C3 group, after CDT, improvement had occurred in the VCSS and VAS pain score at 6 weeks (P < .0001) and at 3 (P < .0001), 6 (P < .0001), and 12 (P < .0001) months. Improvement in the GOS was noted at 6 (P < .0001) and 12 (P = .0005) months. The CIVIQ-20 score improved from 63 to 38 (P = .009). Nine limbs (12%) in the C3 group required stenting after CDT. In the C4-C6 group, of the 118 limbs, 75 (64%) underwent stenting only and 43 (36%) underwent stenting followed by CDT for persistent QoL impairing symptoms. For this latter group, after CDT, improvement occurred in the VCSS, GOS, and VAS pain score at 6 weeks (P < .0001) and 3 (P < .0001), 6 (P < .0001), and 12 (P < .0001) months. The CIVIQ-20 score improved from 61 to 34 (P < .0001). The primary, primary assisted, and secondary patency in the C4-C6 group at 36 months was 92%, 100%, and 100%, respectively. ConclusionsFor CEAP C3 patients with phlebolymphedema due to CIVO, CDT should be a part of the first line of treatment. Stenting should be reserved for those with QoL impairing symptoms despite the use of CDT. Additionally, CDT helps provide symptom relief for patients with more advanced CEAP C4-C6 disease with persistent or residual edema after stenting. Further study is warranted.

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.

Venous thrombosis following endovenous laser ablation with and without thromboprophylaxis

ObjectiveVenous thromboembolism (VTE) occurs infrequently after endovenous laser ablation (EVLA). The purpose of this study was to assess the incidence of VTE after EVLA with and without pharmacologic prophylaxis. MethodsFrom October 2019 to March 2020, a series of consecutive patients from the prospectively maintained VEINOVA (vein occlusion with various techniques) registry was retrospectively analyzed. All the patients underwent EVLA with and without postoperative thromboprophylaxis. A 1470-nm laser wavelength with a radial fiber was used for EVLA. Concomitant phlebectomy or sclerotherapy of insufficient tributaries was allowed. Perivenous tumescence was applied with 1% Rapidocaine (lidocaine hydrochloride monohydrate; Sintetica SA). Ablation of varicose veins was performed by continuously drawing back the laser fiber at a power of 10 W, aiming for a linear endovenous energy delivery of 60 to 90 J/cm. Compression stockings were applied postoperatively, and the patients were advised to wear them for 1 week. Duplex ultrasound was performed at the 1- and 4-week follow-up visits to determine the occlusion rate and the occurrence of EHIT and VTE. ResultsOverall, 249 patients were identified from the registry. Of the 249 patients, 26 were omitted because of treatment of recurrent varicose veins. Finally, 223 consecutive patients with 223 legs and 227 saphenous veins (159 great saphenous veins, 49 small saphenous veins, and 19 anterior accessory saphenous veins) were included in the final analysis. Their mean age was 58.1 ± 13.8 years, and 167 patients (73.1%) were women. The clinical CEAP (clinical, etiology, anatomy, pathophysiology) classification was C2 for 11 legs (4.9%), C3 for 123 legs (55.2%), C4a or C4b for 86 legs (38.6%), and C5 to C6 for 3 legs (1.4%). Thromboprophylaxis was given to 132 patients (59.2%) for 3 days (rivaroxaban 10 mg once daily to 130 patients [98.5%] and low-molecular-weight heparin to 2 patients [1.5%]). No thromboprophylaxis was administered to 91 patients (40.8%) after EVLA. The average treatment length was 34.2 ± 19.3 cm and the average diameter was 5.0 ± 1.3 mm. At 1 week of follow-up, no thrombotic event had occurred in either group. At 4 weeks of follow-up, one case of EHIT class 2 (1.1%) and one case of pulmonary embolism (1.1%) had occurred in the group without thromboprophylaxis. In the thromboprophylaxis group, one deep vein thrombosis (0.8%) event had occurred (adjusted P = .135). At 1 and 4 weeks of follow-up, the treated varicose veins remained occluded in both groups. ConclusionsEndovenous ablation of truncal varicose veins appears to be safe with a low thrombotic event rate with or without pharmacologic thromboprophylaxis. However, more data are needed before a final recommendation regarding the best thromboprophylaxis treatment option can be given.

Identifying venous clinical severity score thresholds for Clinical-Etiology-Anatomy-Pathophysiology classifications of venous edema and higher.

Venous Clinical Severity Score (VCSS) is a widely used standard for assessing and grading the severity of chronic venous disease (CVD). Prior research highlighted its high validity in detecting and quantifying venous disease. However, there is little, if any, known about the precise thresholds at which VCSS discriminates important stages of deep venous disease. This study sought to elucidate the diagnostic accuracy, thresholds, and correlation at which VCSS detects salient CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classes in deep venous disease progression. A registry of 840 patients who presented with chronic proximal venous outflow obstruction (PVOO) secondary to non-thrombotic iliac vein lesions from August 2011 to June 2021 was retrospectively analyzed. VCSS and CEAP classifications were used to evaluate preoperative symptoms. VCSS was compared to CEAP classes to determine the precise VCSS composite values at which the instrument was able to detect CEAP C3 and higher, C4 and higher, and C5 and higher. Receiver operative characteristic (ROC) curve and area under the curve (AUC) were used to evaluate VCSS for its ability to discriminate disease at these stages of CEAP classification. Spearman's rank coefficient was used to determine the correlation between CEAP VCSS composite as well as individual VCSS components (pain, varicose vein, edema, pigmentation, inflammation, induration, ulcer number, ulcer size, ulcer duration, compression). VCSS composite was able to detect venous edema (C3) and higher at a sensitivity of 68.9% and a specificity of 54.8% at an optimized threshold of 8.5 (AUC = 0.648; 95% C.I. = 0.575-0.721). To detect changes in skin and subcutaneous tissue from CVD (C4) and higher, an optimal threshold of 11.5 was found with a sensitivity of 51.7% and specificity of 76.5% (AUC = 0.694; 95% C.I. = 0.656-0.731). Healed venous ulcer (C4) and higher was detectable at an optimized threshold of 13.5 at a sensitivity of 67.7% and a specificity of 88.9% (AUC = 0.819; 95% C.I. = 0.766-0.873). The correlation between VCSS composites and CEAP was weak (ρ = 0.372; p < .001). Attributes of VCSS that reflect more severe venous disease correlated more closely with CEAP classes, namely pigmentation (ρ = 0.444; p < .001), inflammation (ρ = 0.348; p < .001), induration (ρ = 0.352; p < .001), number of active ulcers (ρ = 0.497; p < .001), active ulcer size (ρ = 0.485; p < .001), and ulcer duration (ρ = 0.497; p < .001). The correlation between CEAP class and the other four components of VCSS were not statistically significant. VCSS composite thresholds of 8.5, 11.5, and 13.5 are threshold values for detecting CEAP classification C3 and higher, C4 and higher, and C5 and higher, respectively. Consistent with prior work, VCSS appears to have a better ability to discriminate CVD at more severe CEAP classifications. In this registry, the correlation between VCSS and CEAP was found to be weak while components of VCSS that suggest more advanced disease exhibited the strongest correlation with CEAP.

An Overview of Clinical Examinations in the Evaluation and Assessment of Arterial and Venous Insufficiency Wounds.

Arterial and venous insufficiency are two major causes of chronic wounds with different etiology, pathophysiology, and clinical manifestations. With recent advancements in clinical examination, clinicians are able to obtain an accurate diagnosis of the underlying disease, which plays an important role in the treatment planning and management of patients. Arterial ulcers are mainly caused by peripheral artery diseases (PADs), which are traditionally examined by physical examination and non-invasive arterial Doppler studies. However, advanced imaging modalities, such as computed tomography angiography (CTA) and indocyanine green (ICG) angiography, have become important studies as part of a comprehensive diagnostic process. On the other hand, chronic wounds caused by venous insufficiency are mainly evaluated by duplex ultrasonography and venography. Several scoring systems, including Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification, the Venous Clinical Severity Score (VCSS), the Venous Disability Score, and the Venous Segmental Disease Score (VSDS) are useful in defining disease progression. In this review, we provide a comprehensive overlook of the most widely used and available clinical examinations for arterial and venous insufficiency wounds.

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.&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D; Conclusion:Chronic venous ulcers that did not heal after a few months of multiple courses of antibiotics &amp; 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.

Transabdominal ultrasound accurately identifies a significant iliac vein area-reducing lesion in patients with pelvic venous insufficiency

BackgroundIn patients with pelvic venous disorders secondary to pelvic venous insufficiency (PVI), the optimal imaging modality is ill-defined. Transabdominal ultrasound (TAU) is widely used to identify the presence of iliac vein stenosis. The purpose of the present investigation is to determine the accuracy of TAU for determining the presence of an iliac vein area-reducing lesion compared with intravascular ultrasound (IVUS). MethodsFrom January to December 2020, a retrospective review of prospectively collected data from 96 patients treated for symptomatic PVI at the Center for Vascular Medicine was performed. All patients had complete history and physical examination findings, demographics, CEAP (clinical, etiologic, anatomic, pathophysiologic), revised venous clinical severity score, and TAU, diagnostic venography, and IVUS measurements recorded in our electronic medical record system. All TAU measurements were performed by the same ultrasound technician with the patient in the supine position. Iliac vein diameters of the common femoral, external iliac, and common iliac veins and the inferior vena cava were obtained. Differences in body habitus were normalized by dividing the minimum diameter measurement of the stenotic vessel with that of the ipsilateral common femoral vein, subtracting this number from 1 and multiplying by 100 (stenosis = [1 − minimal diameter/common femoral diameter] × 100). The normalized stenoses were then compared with the IVUS-derived area reducing measurements. A receiver operating characteristic curve was created, and logistic regression analysis for the probability of predicting an area-reducing lesion of >50% and >60% with TAU was performed. The sensitivity, specificity, and positive and negative predictive values were calculated. ResultsThe average age of the entire cohort was 49.8 ± 13.5 years, with 69 women and 27 men. The CEAP distribution was as follows: C0, 5%; C1, 5%; C2, 10%; C3, 40%; C4a,b, 30%; C5, 7%; and C6, 3%. The average revised venous clinical severity score was 6.2 ± 2.6. The indications for intervention were leg symptoms alone in 43%, pelvic symptoms alone in 3%, and combined leg and pelvic symptoms in 54%. TAU identified a stenosis of ≥50% in 92 of the 96 patients (96%). For a ≥50% stenosis, a normalized diameter of ≤3 mm demonstrated a sensitivity, specificity, and positive and negative predictive value of 75%, 75%, 98%, and 12%, respectively. Logistic regression analysis indicated that TAU was significant in predicting the presence of a ≥60% area-reducing lesion (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; P = .009). The area under the receiver operating characteristic curve (c-statistic) was 68.6%. The sensitivity, specificity, and positive and negative predictive values were 66.7%, 66.7%, 81.5%, and 47.6%, respectively, for a normalized diameter of ≥4 mm. ConclusionsThe ability of TAU to identify an iliac vein stenosis of ≥50% is 96%. The positive predictive value for TAU to identify a ≥60% iliac vein area-reducing lesion is high, with moderate sensitivity and specificity. For patients with symptoms consistent with pelvic venous disorders secondary to PVI, TAU is a good preintervention screening modality for properly trained vascular imaging specialists with findings that correlate well with IVUS measurements.