Deep Reflux Research Articles

Short-Term Outcomes of Double Omentopexy in One Anastomosis Gastric Bypass Surgery: A Controlled Clinical Trial

ABSTRACT Purpose: This study aims to assess the efficacy of implementing a novel technique of reinforcement of gastric pouch and remnant stomach staple line with Double Omentopexy (DO) in patients undergoing One-Anastomosis Gastric Bypass (OAGB) surgery and evaluate its impact in reducing the early postoperative complications. Materials and Methods: The 123 patients were allocated into two groups: 61 in the standard OAGB group and 62 in OAGB with DO group. The primary outcomes are postoperative complications (including early postoperative bleeding, leakage, gastric twist, reflux, etc.) and hospital stay. The secondary outcome is excess body weight loss. Follow-up visits were planned after discharge: at two weeks, two months, and three months postoperatively. Results: Postoperative complications were significantly lower, 3 (4.84%) in OAGB with DO compared with 10 (16.39%) in standard OAGB (P =0.037). There was no statistically significant difference in the incidence of early postoperative bleeding, deep vein thrombosis, biliary reflux, and gall bladder stone (P >.05). No patient had leakage in either group. The mean operative time was significantly longer (68.66 ± 6.68 min) in OAGB with the DO group when compared with the standard OAGB group (62.16 ± 7.54 min) (P <.001). Conclusion: Applying the DO technique may be a good measure to be added during OAGB to decrease the incidence of potential postoperative complications, especially the rate and severity of bleeding.

O018 Determining the relationships between venous reflux patterns, clinical severity, and health-related quality of life

Abstract Introduction Various classification systems have been created to describe the anatomical distribution of venous reflux, including the VEIN-TERM and Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification. It is still unclear whether different reflux patterns correlate with health-related quality of life (HRQoL) and clinical severity. Methods Some 507 chronic venous disease patients and 105 asymptomatic controls underwent duplex ultrasound assessment. Patients were stratified according to VEIN-TERM and the CEAP classification systems. The Aberdeen Varicose Vein Questionnaire (AVVQ) score was used to compare HRQoL and the Venous Clinical Severity Score (VCSS) was used to compare clinical severity between groups. Results Patients were significantly older than controls (p<0.00001). All VEIN-TERM reflux patterns had significantly greater VCSS than no reflux (p<0.001). Superficial axial and combined axial reflux were associated with significantly greater VCSS than superficial segmental reflux (p<0.001, p=0.042 respectively). All VEIN-TERM reflux types had significantly worse AVVQ scores than no reflux (p<0.03). However, there were no significant differences in AVVQ scores across all VEIN-TERM reflux patterns. Most CEAP reflux patterns had increased VCSS and worse AVVQ scores when compared to no reflux (all p<0.05), except for deep reflux, and deep and perforator reflux only. The deep, superficial and perforator reflux group had significantly higher VCSS (p=0.013) and AVVQ (p<0.001) versus the superficial reflux only group. Conclusion When compared to no reflux, both classification systems show associations of any reflux pattern with worse VCSS and AVVQ scores. Combined reflux patterns were associated with the greatest clinical severity and worst HRQoL scores.

Lotus leaf polysaccharides prepared by alkaline water, deep eutectic solvent and high pressure homogenization-assisted dual enzyme extraction: A comparative study of structural features, prebiotic activities and functionalities

Currently, there is a shortage of lotus leaf pectin-type polysaccharide (LLP)-based prebiotic functional foods due to its low extraction efficiency and indistinct prebiotic and functional properties. In the study, medium-temperature alkali water, deep eutectic solvent, high pressure homogenization-assisted dual enzyme, and reflux extraction methods were used to screen out a process for LLP with high extraction efficiency, in vitro prebiotic activity, and functionality. It was demonstrated that LLPs prepared by high pressure homogenization-assisted dual enzyme, deep eutectic solvent (choline chloride and urea) and reflux extraction methods showed excellent prebiotic activities. Among them, LLP prepared by high pressure homogenization-assisted dual enzyme extraction (LLP-EP) had high extraction efficiency, high purity, high content of RG-I domain, fine homogeneity, low esterification degree, strong in vitro prebiotic activity, and comprehensive functional properties i.e. good water dispersibility and stability, rheological property, and emulsification stability. According to the structure-activity relationship analysis using a series of partially acid-hydrolyzed LLP-EP as prebiotics, the prebiotic activity of LLP-EP was mainly depended on high content of RG-I domain. These findings indicated that LLP had the potential to be used in beverages-based prebiotic functional foods, and also provided the theoretical basis for structural features of pectins to be better prebiotics.

What is a deep competitive reflux and why we should study it

Reflux of the GSV is considered the absolute criterion for its incompetence. However, there are 3 specific conditions in which, despite being dilated with all its valves incompetent (destroyed and/or coaptation defect due to excessive dilation of the vein), the GSV does not reflux during diastole of the valvo-muscular pump of the calf. The first of these conditions is what I have called deep competitive reflux, the second is occlusion of the reentry perforators, and the third is dilation due to a compensatory flow by-passing of a deep venous occlusion.

Correlation between reflux time and venous clinical severity score in patients undergoing saphenous vein ablation: A prospective study

It is unclear whether reflux time independently correlates with severity of symptoms in patients with great saphenous vein reflux. Eighty patients (mean age 64+/-12.7years, 56% female) undergoing great saphenous vein (GSV) ablation for symptomatic reflux were assessed prospectively. Fifty-seven underwent ablation with radiofrequency, 23 with cyanoacrylate adhesive. Venous clinical severity score (VCSS) was assessed at, or prior to the time of ablation. The highest reflux time in the GSV was selected. VCSS values ranged from 2 to 20 (median 7). Mean reflux time was 5.3 s (+/-3.3). The Spearman rank correlation yielded a value of rs = -0.123, p (2-tailed) = .279, which was not significant. The patients with concomitant deep vein reflux had higher VCSS (p < .05). Analysis of patients with only superficial vein reflux (n = 45) also demonstrated a poor correlation between VCSS and reflux time (rs = -0.051, p (2-tailed) = .741). This prospective study did not demonstrate a correlation between reflux time and VCSS.

Long-term results of minimally invasive deep reflux correction in patients with post-thrombotic disease

The OBJECTIVE was to trace the long-term results of the operation of a dosed narrowing of the femoral vein in the lower third of the thigh proposed by Professor P. G. Shvalb.METHODS AND MATERIALS. The study included 30 patients (20 men and 10 women) with post-thrombotic disease of the veins of the lower extremities of the recanalized form, C4–C6, who underwent surgical correction of deep reflux in the period from 2012 to 2013. In 23 patients, additional phlebectomy of superficial and perforating veins was performed. The research method was duplex scanning (DS). The ratio of antegrade and retrograde blood velocities was used to quantitatively characterize deep reflux. Additionally, the state of the popliteal-tibial segment of the deep veins was determined using the Psatakis reflux index.RESULTS. The positive effect of the operation was noted in 96.7 % of patients at a follow-up period of 4 years. During follow-up periods of up to 8 years, the numbers decreased to 60.7 %. Relapse of trophic ulcers occurred in 39.3 % of patients. However, all patients noted that ulcers were much smaller in size than before surgery. According to DS data, incompetent perforator veins were detected in 16 patients: in all nine patients with recurrent ulcers and in seven patients without worsening. Vein diameter, maximum and average velocities of retrograde blood flow were greater in patients with worsening: diameter – 4.2±0.5 mm, υ (m) 91.2±19.8 cm/s, υ (average) 90.5±18.5 cm/s versus a diameter of 2.9±0.5 mm, υ (m) 39±15.6 cm/s, υ (average) 35±9 cm/s (p&lt;0.05).CONCLUSIONS. Operation of dosed narrowing of the femoral vein had good clinical results in 96.7 % of follow-up periods up to 4 years, 60.7 % – after 8 years. Isolated correction of deep reflux with the preservation of insufficient perforator veins can lead to recurrence of trophic ulcers.

Association of duplex ultrasonography findings with the severity of chronic venous disease in Thai patients

IntroductionChronic venous disease (CVD) is characterized by venous hypertension and stasis, which occur because of valvular incompetence and/or venous outflow obstruction. This study aimed to investigate the relationship between CVD clinical presentation and duplex ultrasonography findings in a Thai patient population. MethodThis cross-sectional study examined patients diagnosed with CVD at the Chulabhorn Hospital Vascular Clinic (Bangkok, Thailand) between December 1, 2018 and October 1, 2021. Patient data was obtained from the medical records and review of lower limb venous ultrasonography studies. Patients were assessed using the Clinical, Etiological, Anatomical, and Pathological (CEAP) classification of venous disorders: mild-to-moderate CVD was defined as C1 to C3 and severe CVD was defined as C4 to C6. ResultsOverall, 260 CVD patients were analyzed (60 men and 200 women). More than 75% of the patients were women and more than 80% had bilateral lower limb involvement. Factors associated with severe CVD were older age, female sex, high body mass index, hypertension, diabetes mellitus, and history of deep venous thrombosis. The most common CEAP classification was C2 (38.8%), followed by C1 (33.85%), C4 (12.2%), C3 (9.23%), C6 (3.46%), and C5 (2.31%). Two-thirds of the patients had great saphenous vein reflux and nearly half had perforator vein reflux. Perforator reflux and small saphenous vein reflux were significantly associated with severe CVD (P < 0.001 and P = 0.028, respectively). Higher number of venous systems involved was significantly associated with severe CVD (P = 0.005). Reflux time of the great saphenous vein correlated with severe CVD and VCSS (P = 0.026 and P = 0.037, respectively). Mean diameters of the superficial vein, perforator vein, and deep vein and reflux times of the perforator and deep veins were not significantly associated with severe CVD. ConclusionThe major risk factors for severe CVD are older age, female sex, high body mass index, hypertension, diabetes mellitus, and history of deep venous thrombosis. The most common CEAP classification was C2 (39%). Great saphenous vein reflux was the most common type of reflux in our study population. Increasing number of venous systems involved increased the risk of severe CVD. The presence of perforator vein reflux and small saphenous vein reflux also increased the risk of severe CVD. Reflux time of the great saphenous vein correlated with severe CVD and venous clinical severity score.

Clinical tolerance of untreated reflux after iliac vein stent placement

BackgroundWe have recently demonstrated in a large patient cohort that the prevalence and severity of reflux will improve in most limbs after stenting and that most limbs will not develop new-onset reflux. In the present report, we have focused on the long-term clinical outcomes associated with untreated reflux in the same patient cohort who had undergone iliofemoral venous stenting without correction of residual reflux. MethodsThe clinical outcomes data from 1379 limbs treated with only iliac vein stenting without correction of superficial or deep reflux from 1997 to 2018 were analyzed (23-year follow-up period). Of the 1379 limbs, 632 (46%) had had preexisting reflux before stenting and 747 (54%) had did not. The reflux data (reflux segmental score, air plethysmography, ambulatory venous pressure) for these patients have been previously reported in detail. The subsets were compared perioperatively with each other using the following variables: grade of swelling, visual analog scale for pain score, venous clinical severity score, venous stasis dermatitis, ulceration, and quality of life measures. ResultsBoth groups demonstrated improvements in the venous clinical severity score, grade of swelling, visual analog scale score, and quality of life. No differences were found in ulcer healing (5% vs 3% for limbs with and without prestent reflux, respectively) and resolution of dermatitis (6% vs 5% for limbs with and without prestent reflux, respectively) between the two groups. Of the 632 limbs with preexisting reflux, 218 (34%) had had axial reflux and 414 had had nonaxial reflux (66%). The clinical outcomes were similar between the two groups. Using a multisegment reflux score, the limbs with prestent reflux (n = 632) were divided into two groups. A segmental score of ≥3 indicated severe reflux and a score of <3 indicated moderate reflux. Of these 632 limbs, 161 (25%) had severe reflux and 471 (75%) had moderate reflux. The two groups demonstrated similar outcomes for most clinical parameters. The post-thrombotic limbs and nonthrombotic limbs also showed similar outcomes. ConclusionsThe long-term follow-up of patients after iliac vein stenting showed that uncorrected reflux is well tolerated by most patients across most clinical measures.

Women benefit from endovenous ablation with fewer complications: Analysis of the Vascular Quality Initiative Varicose Vein Registry

ObjectiveTo evaluate the association between gender and long-term clinician-reported and patient-reported outcomes after endovenous ablation procedures. MethodsThis retrospective cohort study of prospectively collected data from the Vascular Quality Initiative’s Varicose Vein Registry included patients undergoing endovenous ablation procedures on truncal veins with or without treatment of perforating veins between 2015 and 2019. A univariate analysis included comparisons of preprocedural, postprocedural, and periprocedural change in Venous Clinical Severity Score (VCSS) and total symptom score by gender. Rates of complications including deep vein thrombosis, endovenous heat-induced thrombosis, leg pigmentation, blistering, paresthesia, incisional infection, and any postprocedural complications were reported by gender. Multivariable analysis leveraged linear regression to examine how gender affected the relationships between patient characteristics, complication rates, and periprocedural change in VCSS score and total symptom score. ResultsOf 9743 patients who met the inclusion criteria, 3090 (31.7%) were men and 6653 (68.2%) were women. The perioperative change in VCSS score was greater for men than women (average –4.46 for men vs –4.13 for women; P < .0001). Perioperative change in total symptom score was greater for women than for men (average –10.64 for women vs –9.64 for men; P < .0001). Women had lower incidence of any leg complication (6.1% vs 8.6%; P = .001) endovenous heat-induced thrombosis (1.1% vs 2.2%; P = .002), and infection (0.4% vs 0.7%; P = .001). In multivariable analysis, among patients with a body mass index of more than 40, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2, women had a greater periprocedural change in VCSS score than men. ConclusionsWomen benefited from endovenous ablation similarly as men, with a lower incidence of postprocedural complications. Gender may be useful for patient selection and counseling for endovenous ablation, with particular usefulness among patients with a high body mass index, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2.

Correlation of Clinical Class with Duplex Ultrasound Findings in Lower Limb Chronic Venous Disease

BackgroundThis study investigated the distribution of valve incompetence in patients with chronic venous disease (CVD) and its correlation with the clinical category of the clinical, etiological, anatomical, and pathophysiological (CEAP) classification.MethodsIn total, 1,386 limbs with clinically suspected CVD were categorized according to the CEAP classification and consecutively underwent duplex ultrasonography between April 2017 and December 2020.ResultsThere were 362 limbs in male patients and 1,024 limbs in female patients. The limbs were classified as C0s–C1 (608 limbs, 43.8%), C2 (727 limbs, 52.5%), or C3–C6 (51 limbs, 3.7%). The prevalence of saphenous vein incompetence in CEAP C0s–C1 limbs was 43.6%. The saphenofemoral junction (SFJ) was competent in 37% of CEAP C2–C6 limbs. The CEAP C3–C6 category was not correlated with reflux patterns of the saphenous vein system (Cramer’s V=0.07), incompetent SFJ (Cramer’s V=0.07), deep vein reflux (Cramer’s V=0.03), or the distribution of incompetent segments in the great saphenous vein (GSV) (Cramer’s V=0.11).ConclusionDuplex ultrasonography is necessary to formulate a proper treatment plan for limbs categorized as CEAP C0s–C1. The SFJ was competent in more than one-third of CEAP C2–C6 limbs with GSV reflux; as such, flush ligation of the GSV may be unnecessary in these patients. The CEAP C3–C6 category showed no correlations with reflux patterns of the saphenous vein system, SFJ reflux, deep vein reflux, or the distribution of incompetent segments in the GSV.

Initial US experience with the BlueLeaf Endovenous Valve Formation System

Chronic venous insufficiency (CVI), owing to deep vein reflux (DVR) and venous obstruction, is widespread and associated with significant morbidity. The BlueLeaf System has been designed to treat patients with symptomatic CVI with evidence of DVR. The BlueLeaf device is intended to form autogenous tissue leaflets from vein walls without the use of a permanent vascular implant. This report describes the early outcomes of the initial 6 patients treated in the United States.

Management of Post-thrombotic Syndrome: A Comprehensive Review.

Post-thrombotic syndrome (PTS) is the most common long-term complication of acute deep venous thrombosis (DVT). The cumulative incidence of PTS in the first two years after the first acute DVT diagnosis approximates 25%. This study aims to summarize the most recent updates and provide a comprehensive review of the current management of PTS. We searched MEDLINE/PMC/NCBI Bookshelf (PubMed), Cochrane, Embase, Scopus, ClinicalTrials, and OpenGrey databases for relevant articles in English published from the establishment of each separate database until February 9, 2021. PTS constitutes the most frequent long-term complication of lower limb deep venous thrombosis (DVT). Lifestyle changes and compression treatment represent an integral part of PTS management and have a clear benefit to offer in PTS patients. Pharmacological treatment with phlebotonic and non-phlebotonic medications, such as micronized purified flavonoid fraction (MMPF) and sulodexide, respectively, may have a more central and significant role in PTS management than previously thought. The introduction of percutaneous transluminal venoplasty (PTV) and stenting has again raised our expectations with the field, along with new concerns and considerations. There is a growing number of studies that report promising results on patientoriented outcomes on PTS patients who were treated with PTV and stenting. Moreover, hybrid (endovascular/ surgical) interventions may also represent a safe and efficacious treatment option for a subset of patients with PTS. Patient selection criteria for endovascular and hybrid interventional treatment should be carefully set and standardized. Post-operative care after venoplasty is an important field of future research with potential clinical impact. Management of deep and superficial reflux remains controversial. Hopefully, future prospective studies shall provide more robust evidence on the management of PTS.

Mechanochemical Endovenous Ablation of the Saphenous Vein: A Look at Contemporary Outcomes

Endovenous ablation techniques have replaced greater saphenous vein (GSV) ligation and stripping for treatment of venous insufficiency. Our objective was to investigate our initial procedural experience and clinical presentation of patients undergoing mechanochemical ablation (MOCA) at a single institution. We hypothesized that closure level and success rate improved over time and were comparable to other endovenous ablation techniques. We retrospectively reviewed all MOCA procedures performed at the Greater Los Angeles Veterans Affairs Hospital from 2015 - 2020. Variables included CEAP and VCSS scores, patient symptoms, post procedure duplex ultrasound, closure level, and need for anticoagulation. Success was defined as GSV thrombosis on initial post procedure duplex ultrasound. Procedure associated extension of thrombus into the deep veins was defined using the American Venous Forum (AVF) endothermal heat induced thrombosis (EHIT) classification. 104 venous ablation procedures were performed on 86 patients. Eleven (12.8%) patients received bilateral interventions, and six (7%) patients had asynchronous interventions on the same leg. The average age was 58.4 years (SD 12) and 93% were male. Pre-procedural symptoms included pain (102, 98.1%), varicose veins (87, 83.7%), edema (58, 55.8%), and active ulcers (19, 18.3%). A CEAP category of C2 was the most common indication (34.6%), followed by C3 (22.1%) and C6 (21.2%). Forty-five (43.2%) patients had deep system reflux, and 53% had concomitant phlebectomies. Average VCSS score was 7.5 (SD 3.5).We observed a GSV ablation rate of 92.7% (n=89) in the 96 procedures which had post-procedure follow up, with no temporal evidence of a learning curve. On post procedure duplex of the 89 technically successful ablations, 77 (86.5%) patients had AVF EHIT level 1 closure, three (3.4%) had level 2 closure, eight (8.9%) had level 3 closure, and one had a level 4 closure. Fourteen (15.7%) patients were newly started on anticoagulation for an average of 33.2 days (SD 34.1). Of the 19 legs treated for active venous ulcers, 13 (68.4%) had improvement or resolution of their venous ulcers. No pulmonary embolic complications were reported. We observed a successful GSV thrombosis rate of 92.7% using MOCA without evidence of a learning curve and comparable to that reported in the literature. The rate of thrombus extension into the deep veins was 14.6%, with no adverse effects associated with anticoagulation or clinically significant sequelae of AVF EHIT level 2 or greater. Comparisons with MOCA associated thrombus extension into deep veins in the literature are limited as post procedure screening duplex are not standard of care. However, we demonstrated that MOCA ablation of the GSV is a safe procedure that may be performed with good technical success.

Women Benefit From Endovenous Ablation With Fewer Complications: Analysis of the Vascular Quality Initiative Varicose Vein Registry

We evaluated the association between gender and long-term clinical outcomes after endovenous ablation procedures. Using data from the Vascular Quality Initiative from 2015 to 2019, we identified patients who had undergone endovenous ablation procedures on truncal veins with or without treatment of perforating veins. We excluded patients with preoperative CEAP (clinical, etiologic, anatomic, physiologic) class <2. We used univariate analysis to determine the preprocedure, postprocedure, and periprocedural changes in the Venous Clinical Severity Score (VCSS) stratified by gender. We also determined the rates of deep vein thrombosis, leg pigmentation, blistering, paresthesia, incisional infection, and any postprocedural complications for each gender. We then used multivariate linear regression to examine how gender affects the relationships between the periprocedural change in the VCSS, patient characteristics, and complication rates. A total of 9743 patients were included in the present study. The women had lower pre- and postprocedural VCSSs, but both genders had similar a periprocedural change in the VCSS (Table). The women had a lower incidence of any postprocedural leg complications, blistering, deep vein thrombosis, and paresthesia. The men had lower incidence of leg pigmentation. Women with deep reflux experienced greater benefit from endovenous ablation than did men with deep reflux (Fig). At the extremes of body mass index (<25 and >35 kg/m2), women experienced greater benefit from endovenous ablation than did men. Women after endovenous ablation experienced improvements similar to those of men in the VCSS but with a lower incidence of postprocedural complications. Of those with deep venous reflux and at the extremes of body mass index, women were more likely to benefit from endovenous ablation than were men. These data are useful in predicting the results after venous ablation.TablePre- and postprocedure VCSS and periprocedural change in VCSS stratified by genderVariableMen (n = 3090)Women (n = 6653)P valueVCSS Preprocedure8.84 ± 4.107.54 ± 3.11<.001 Postprocedure4.47 ± 4.093.50 ± 3.23<.001 Change−4.46 ± 3.73−4.13 ± 3.23.001Complication, % Any leg complication8.66.10.001 Leg blistering0.60.40.2 Deep vein thrombosis1.10.60.06 Paresthesia1.91.70.5 Leg pigmentation0.30.70.1 Leg infection0.70.40.07VCSS, Venous clinical severity score.Data presented as mean ± standard deviation, unless noted otherwise. Open table in a new tab

Safety and feasibility report on nonimplantable endovenous valve formation for the treatment of deep vein reflux

ObjectiveDefinitive treatment techniques for symptomatic deep venous reflux have been relegated to complex and invasive open surgery which is rarely performed today. The BlueLeaf System provides an endovenous method for the formation of deep venous valves without an implant, avoiding the complications associated with permanent foreign materials. The system has the adaptability to form valves within the femoral and popliteal veins at multiple levels in a single procedure. The aim was to determine the midterm safety and efficacy of this novel device in an early feasibility study. MethodsFeasibility of endovenous deep venous valve formation was assessed in patients with chronic venous insufficiency (Clinical, Etiologic, Anatomic, Pathophysiologic [CEAP] 4-6). Follow-up was completed through 1 year, assessing vein patency and reflux time (RT) with duplex ultrasound examination. Venous clinical improvement was evaluated using the revised Venous Clinical Severity Scale. ResultsOf the 14 patients, 13 (93%) had successful formation of at least one monocuspid valve, with a mean number of 1.4 valves (range, 0-3 valves) per patient. There were no device-related serious adverse events during the index procedure. There were no deep venous thromboses reported at any time point, including 10 patients through the 1-year follow-up. In patients with at least one valve formed, site reported duplex ultrasound examination measured the average RT in the popliteal vein below valve formations, was 3.0 ± 1.0 seconds at baseline, 3.9 ± 3.1 seconds at 30 days, and 3.6 ± 2.1 seconds at 360 days. The revised Venous Clinical Severity Scale improved in all 13 successfully treated patients, decreasing from 15.0 ± 6.0 at baseline to 11.6 ± 5.5 at 30 days, 10.7 ± 5.3 at 210 days, and 9.4 ± 5.0 at 360 days (P = .0002; baseline to 360 days). Among the five patients with an ulcer who reached the 360-day follow-up visit, all (100%) healed at least one ulcer. Two patients (40%) healed all ulcers and three patients (60%) had a decrease in ulcers number but remained at C6 at 360 days. The five patients with a total of nine active ulcers at baseline had four active ulcers at 360 days. ConclusionsThe BlueLeaf System holds promise as a minimally invasive means to safely form fully autogenous deep venous valves. Reconstructed deep veins remained patent, without deep venous thrombosis and symptomatic improvement was consistently observed; however, a decrease in the RT was not. Incremental device design improvements have been undertaken to improve valve function. The results of these iterations await further clinical evaluation.

Distribution patterns of pathological venous reflux and risk factors in patients with skin changes due to primary venous disease in North India.

To determine the distribution patterns of pathological venous reflux and risk factors in patients with skin changes due to primary venous disease. Two hundred limbs belonging to C4, C5 & C6 classes were examined with duplex ultrasound to determine the sites of reflux. We also analyzed the correlation of risk factors with patterns and severity of disease. Among 200 limbs, superficial system reflux was found in 163 limbs (81.5%), deep system reflux in 10 limbs (5%) and perforator system reflux in 180 limbs (90%). The most common pattern of abnormality was combined superficial and perforator system reflux. Of all the risk factors, prolonged standing, obesity and in the female history of pregnancy preceding varicose occurrence had the highest prevalence. In patients with primary chronic venous disease, lifestyle modification is required to avoid risk associated with obesity and prolonged standing. The higher prevalence of pathological perforator reflux in association with advanced venous disease necessitates careful treatment of this least reported pathology to achieve better treatment results.

Influence of Superficial Venous Ablation on Deep Venous Dilation and Reflux in Patients With Saphenous Varicose Veins.

To investigate the influence of superficial venous ablation on deep venous dilation and reflux in patients with saphenous varicose veins, and to elucidate the association between superficial venous reflux and deep venous morphology and hemodynamics. The data of 154 patients with 223 limbs, who underwent endovenous radiofrequency ablation (RFA) of the great saphenous vein for primary varicose veins between September 2014 and March 2016 in Eniwa Midorino Clinic, were retrospectively analyzed. Overall venous hemodynamics of the leg, including functional venous volume (VV) and venous filling index (VFI), was assessed using air-plethysmography. Saphenous and deep vein reflux and diameter were evaluated with duplex scanning. Hemodynamic and morphologic changes were evaluated before and 1 month after RFA. The VV and VFI were significantly decreased in postoperative values than in preoperative values (P < .001). Limbs with deep venous reflux significantly decreased postoperatively than preoperatively (P < .001). There were significant differences in the diameter of the common femoral vein (CFV) and popliteal vein (PV) between the preoperative and postoperative values (P < .001). There were strong to moderate correlations between the VV and the diameter of the CFV or PV (CFV, r = 0.47, P < .001; PV, r = 0.35, P < .001), while there were moderate to weak correlations between the VFI and the diameter of the CFV or PV (CFV, r = 0.23, P < .001; PV, r = 0.33, P <.001). Superficial venous ablation significantly reduced deep venous dilation and reflux in patients with saphenous varicose veins. Significant correlations existed between the VV or VFI, which reflected superficial venous reflux, and the diameter of the deep veins. These findings reveal that volume overload due to superficial venous reflux is associated with deep venous morphology and hemodynamics.

Effect of concomitant deep venous reflux on truncal endovenous ablation outcomes in the Vascular Quality Initiative

ObjectiveFew studies have investigated outcomes after truncal endovenous ablation in patients with combined deep and superficial reflux and no studies have evaluated patient-reported outcomes. MethodsWe investigated the short- and long-term clinical and patient-reported outcomes among patients with and without deep venous reflux undergoing truncal endovenous ablation from 2015 to 2019 in the Vascular Quality Initiative. Preprocedural and postprocedural comparisons were performed using the t-test, χ2, or their nonparametric counterpart when appropriate. Multivariable logistic regression models were used to assess for confounding. ResultsA total of 4881 patients were included, of which 2254 (46.2%) had combined deep and superficial reflux. The median follow-up was 336.5 days. Patients with deep reflux were less likely to be female (65.9% vs 69.9%; P = .003), more likely to be Caucasian (90.2% vs 86.5%; P = .003) and had no difference in BMI (30.6 ± 7.5 vs 30.6 ± 7.2; P = .904). Additionally, no difference was seen in rates of prior varicose vein treatments, number of pregnancies, or history of deep venous thrombosis; however, patients without deep reflux were more likely to be on anticoagulation at the time of the procedure (10.9% vs 8.1%; P < .001). Patients without deep reflux had slightly higher median preprocedural Venous Clinical Severity Score (VCSS) scores (8 [interquartile range (IQR), 6-10]) vs 7 [IQR, 6-10]; P = .005) as well as postprocedural VCSS scores (5 [IQR, 3-7] vs 4 [IQR, 2-6]; P < .001). The median change in VCSS from before to after the procedure was lower for patients without deep reflux (3 [IQR, 1.0-5.5] vs 3.5 [IQR, 1-6]; P = .006). Total symptom score was higher for patients without deep reflux both before (median, 14 [IQR, 10-19] vs median, 13.5 [IQR, 9.5-18]; P = .005) and postprocedurally (median, 4 [IQR, 1-9] vs median, 3.25 [IQR, 1-7]; P < .001), but no difference was seen in change in symptom score (median, 8 [IQR, 4-13] vs median, 9 [IQR, 4-13]; P = .172). Patients with deep reflux had substantially higher rates of complications (10.4% vs 3.0%; P < .001), with a particular increase in proximal thrombus extension (3.1% vs 1.1%; P < .001). After controlling for confounding, this estimate of effect size for any complication increased (odds ratio, 5.72; 95% confidence interval, 2.21-14.81; P < .001). ConclusionsNo significant difference is seen in total symptom improvement when patients undergo truncal endovenous ablation with concomitant deep venous reflux, although a greater improvement was seen in VCSS score in these patients. Patients with deep venous reflux had a significantly increased rate of complications, independent of confounding variables, and should be counseled appropriately before the decision for treatment.

Effect of Concomitant Deep Venous Reflux on Truncal Endovenous Ablation Outcomes in the Vascular Quality Initiative

Abstract Objective Few studies have investigated outcomes after truncal endovenous ablation in patients with combined deep and superficial reflux and no studies have evaluated patient-reported outcomes. Methods We investigated the short- and long-term clinical and patient-reported outcomes among patients with and without deep venous reflux undergoing truncal endovenous ablation from 2015 to 2019 in the Vascular Quality Initiative. Preprocedural and postprocedural comparisons were performed using the t-test, χ2, or their nonparametric counterpart when appropriate. Multivariable logistic regression models were used to assess for confounding. Results A total of 4881 patients were included, of which 2254 (46.2%) had combined deep and superficial reflux. The median follow-up was 336.5 days. Patients with deep reflux were less likely to be female (65.9% vs 69.9%; P = .003), more likely to be Caucasian (90.2% vs 86.5%; P = .003) and had no difference in BMI (30.6 ± 7.5 vs 30.6 ± 7.2; P = .904). Additionally, no difference was seen in rates of prior varicose vein treatments, number of pregnancies, or history of deep venous thrombosis; however, patients without deep reflux were more likely to be on anticoagulation at the time of the procedure (10.9% vs 8.1%; P Conclusions No significant difference is seen in total symptom improvement when patients undergo truncal endovenous ablation with concomitant deep venous reflux, although a greater improvement was seen in VCSS score in these patients. Patients with deep venous reflux had a significantly increased rate of complications, independent of confounding variables, and should be counseled appropriately before the decision for treatment.

Bioelectrical impedance analysis of leg edema and its association with venous functions in patients with saphenous varicose veins.

To quantitatively evaluate edema of the lower legs in patients with saphenous varicose veins, and to determine the association between leg edema and venous hemodynamics of the lower legs. The data of 140 patients with saphenous varicose veins in Eniwa Midorino Clinic from April 2018 to November 2019 were retrospectively analyzed. Body composition values, including Body Mass Index, extracellular water/total body water (ECW/TBW) ratio of each leg, and skeletal muscle mass of each leg, were measured by segmental multi-frequency bioelectrical impedance analyzer. Overall venous hemodynamics of the leg, including functional venous volume, venous filling index (VFI), and ejection fraction, were assessed using air-plethysmography. Saphenous and deep vein reflux were evaluated by duplex scan. A total of 140 patients (58 men and 82 women) with a mean age of 66.0 years (range, 21 to 84 years) were analyzed. On visual inspection, 204 legs had saphenous-type varicose veins, while 76 legs did not. The legs were divided into two groups according to the presence or absence of leg edema, which was defined as ECW/TBW ≥0.390 and <0.390, respectively; 178 legs had leg edema and the remaining 102 legs had no leg edema. In univariate analysis, there were significant differences in age, sex, the presence of saphenous varicose veins, hypertension, and VFI between legs with edema and those without edema. Multivariable logistic regression analysis for leg edema detected age, female, and VFI as an independent risk factor for leg edema. Leg edema was objectively evaluated by bioelectrical impedance analysis in patients with saphenous varicose veins. Older age, female, and increased venous reflux were identified as independent risk factors for leg edema.