Lower Limb Varicose Research Articles

Modern methods of conservative and surgical treatment of patients with lower limb varicose vein disease

Modern methods of conservative and surgical treatment of patients with lower limb varicose vein disease

Decreasing traumatic nature of operations during treatment of lower limb varicose veins

Over the period from 2015 to 2016, a total of 409 patients presenting with CEAP C4-C6 class chronic venous diseases and lower limb varicose veins were examined and operated on. Depending on technical peculiarities of the operations performed, all patients were divided into 2 groups. Group 1 patients (n=212) underwent thermal obliteration of major veins, miniphlebectomy and administration of a sclerosant into varicose veins under the zone of trophic impairments of the crural skin. Group 2 patients (Control group, n=197) underwent only phlebectomy, ligation of perforant veins and miniphlebectomy, with no use of sclerosants. In order to decrease the traumatic nature of the intervention we devised an original phlebextractor for mobilization of subcutaneous and perforant veins without skin incision. A structural element of the phlebextractor is a hook made in the form of a rod-coaxial tip whose acute angle is within the range of 72-78 degrees, thus ensuring minimally traumatic penetration of the hook through tissues and satisfactory holding of the major vein inside the hook. The proposed minimally traumatic radical method of surgical treatment for varicose veins makes it possible to improve the aesthetic results of the operation and to eliminate functional manifestations of chronic venous insufficiency.

Efficacy and safety of radiofrequency ablation for lower limb varicose veins

Background: Endovenous Radiofrequency Ablation (RFA) is gradually gaining widespread acceptance as a minimally invasive modality for treatment of varicose veins (VV). The objective of this study was to evaluate the efficacy based on Venous Doppler and Venous Clinical Severity Score (VCSS) and the safety of radiofrequency ablation for varicose veins.Methods: This is a prospective study of 58 consecutive patients who underwent Radiofrequency ablation of Varicose veins from January 2015 to January 2017 in a single unit of a Multispecialty Tertiary Care Hospital. The mean age was 44.10±13.74 years (19-75 years). A total of 78 limbs were treated in 58 patients. RFA was performed using Closure FastTM catheter according to the manufacturer’s recommendation. Treatment outcomes were estimated 15 days, 3 months, 6 months and 1 year after the procedure using Doppler scan and VCSS score.Results: There was 100% occlusion of the treated veins with no evidence of partial/complete recanalization. However, 2 (2.56%) patients had a GSV stump length > 3cm on Doppler at 6 months, without evidence of significant reflux. Minor complications such as ecchymosis erythema, pain and induration rapidly improved over short term. One patient (1.3%) had evidence of Deep Vein thrombosis (DVT) on follow up Venous Doppler. The mean VCSS improved from mean of 7.98 preoperatively to 2.24 after 1 year (P value <0.001).Conclusions: Radiofrequency ablation is a safe and effective procedure with minimal major complications. The minor complications were early and resolved rapidly.

Tumescence Anesthesia Solution–Assisted Laser Ablation Treatment of Lower Limb Varicose Veins: The Effect of Temperature of the Tumescence Anesthesia Solution on Intraoperative and Postoperative Pain, Clinical Observations, and Comprehensive Nursing Care

To investigate the effect of cold and room temperature tumescence anesthesia solution (TAS) on the treatment of lower limb varicose veins via endovenous laser ablation. On the basis of the TAS temperature, patients were divided into two groups: group A (n = 26) received room temperature (24°C) TAS, and group B (n = 25) received cold (4°C) TAS. A numerical rating scale was used to evaluate pain. Perioperative and intraoperative nursing care and clinical observations were performed following a generalized standard. Percentages of patients who felt pain in groups A and B were 69.2% and 36.0%. Average numerical rating scale scores of patients in the two groups (A and B) on the day of surgery and on postoperative days 1, 2, and 3 were 4.3 versus 2.1, 3.5 versus 1.0, 3.0 versus 0.8, and 1.6 versus 0.3, respectively. Cold TAS reduces intraoperative and postoperative pain more effectively than room temperature.

Clinical, ultrasonographic and histological findings in varicose vein surgery

This study aims to correlate the demographic data, different clinical degrees of chronic venous insufficiency (CEAP), ultrasound findings of saphenofemoral junction (SFJ) reflux, and anatomopathological findings of the proximal segment of the great saphenous vein (GSV) extracted from patients with primary chronic venous insufficiency (CVI) submitted to stripping of the great saphenous vein for the treatment of lower limb varicose. This is a prospective study of 84 patients (110 limbs) who were submitted to the stripping of the great saphenous vein for the treatment of varicose veins of the lower limbs, who were evaluated for CEAP clinical classification, the presence of reflux at the SFJ with Doppler ultrasonography, and histopathological changes. We study the relationship between the histopathological findings of the proximal GSV withdrawal of patients with CVI with a normal GSV control group from cadavers. The mean age of the patients was higher in the advanced CEAPS categories when comparing C2 (46,1 years) with C4 (55,7 years) and C5-6(66 years), as well as C3 patients (50,6 years) with C5-6 patients. The normal GSV wall thickness (mean 839,7 micrometers) was significantly lower than in the saphenous varicose vein (mean 1609,7 micrometers). The correlational analysis of reflux in SFJ with clinical classification or histopathological finding did not show statistically significant findings. The greater the age, the greater the clinical severity of the patients. The GSV wall is thicker in patients with lower limb varicose veins, but those histopathological changes are not correlated with the disease's clinical severity or reflux in the SFJ on a Doppler ultrasound.

Role of Ultrasound Guided foam Sclerotherapy in Treatment of Lower Limb Varicose Vein

Background: Veins have one-way valves which prevent blood from backing up into the legs when we stand or sit. When the valves become incompetent (or begin to have reflux), blood pools and causes an increase in pressure in the leg veins becoming enlarged and twisted. Objective: It was to evaluate the safety and efficacy of foam sclerotherapy in the treatment of primary varicose veins. Methodology: This study was carried out in Radiology Department of Ain Shams University Hospitals. 20 patients with sonographically proven primary varicose veins for which they had foam sclerotherapy injection. Result: The 20 patients enrolled in this study were ranging from 24 to 52 years with mean age of 36.4 years. Conclusion: Foam Slcerotherapy is effective & safe in treatment of primary varicose veins.

Role of Ultrasound Guided foam Sclerotherapy in Treatment of Lower Limb Varicose Vein

Background: Veins have one-way valves which prevent blood from backing up into the legs when we stand or sit. When the valves become incompetent (or begin to have reflux), blood pools and causes an increase in pressure in the leg veins becoming enlarged and twisted. Objective: It was to evaluate the safety and efficacy of foam sclerotherapy in the treatment of primary varicose veins. Methodology: This study was carried out in Radiology Department of Ain Shams University Hospitals. 20 patients with sonographically proven primary varicose veins for which they had foam sclerotherapy injection. Result: The 20 patients enrolled in this study were ranging from 24 to 52 years with mean age of 36.4 years. Conclusion: Foam Slcerotherapy is effective & safe in treatment of primary varicose veins.

A study to compare the usefulness of a careful clinical examination with venous Doppler studies in patients with varicose veins

Background: The significance of recognizing and locating incompetent perforating veins for treating the patients with varicose vein and venous ulcers is well established. Several methods of diagnosing incompetent perforating veins have been evaluated in the past, however, none show satisfactory accuracy in predicting incompetent perforating veins. Clinical examination with digital palpation of fascial defects is the most widely used method. These fascial clefts are generally thought to keep up a correspondence to incompetent perforating veins. Further evidence is obtained when digital pressure relief on the defect leads to filling of superficial varicose veins or if a tourniquet applied beneath the defect prevents it. The purpose of the present study was to compare clinical examination with that of Doppler venous study in the diagnosis of incompetent perforating veins of lower limbs.Methods: T This is a Cross-sectional comparative study which was carried out in 34 (13 women, 21 men) patients with lower limb varicose veins admitted to the department of general surgery in Aarupadai Veedu medical college and hospital. 38 limbs were studied in 34 patients. They were evaluated by clinical tests and Doppler ultrasound. Results: Saphenofemoral incompetence was correctly diagnosed in all the 38 limbs both by clinical test and Doppler ultrasound. In the evaluation of perforator competency, the sensitivity was 88.14% by clinical tests and 98.31% by Doppler ultrasound.Conclusions: From this study and results, it shows that doppler ultrasound evaluation of the varicose veins should be done for accurate diagnosis in all patients before planning surgery.

A Comparison of Concomitant Tributary Laser Ablation and Foam Sclerotherapy in Patients Undergoing Truncal Endovenous Laser Ablation for Lower Limb Varicose Veins

PurposeTo compare outcomes of patients who received simultaneous tributary endovenous laser ablation (EVLA) or foam sclerotherapy (FS) with EVLA of the great saphenous vein (GSV) trunk. Methods and MaterialsThis study recruited 418 patients (542 legs) with diagnosed varicose veins. Patients in the EVLA/FS group (255 patients, 327 legs) received concomitant FS for the tributaries with truncal lasering. For the EVLA-alone group (163 patients, 215 legs), tributaries (8W) were ablated with EVLA in addition to the GSV trunk (14W). Complications, Aberdeen Varicose Vein Questionnaire (AVVQ), EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D), numerical rating scale (NRS) scores, and condition of residual varicosities were assessed at 3 days, 4 weeks, and 6 months after procedure. All residual varicosities were identified and treated with a staged FS at 6 months. ResultsExcept for ecchymosis, incidence of other complications was not significantly different between both groups at 6 months. Pain NRS scores of the EVLA/FS group were remarkably elevated at 4 weeks and then, at 6 months, declined to a level similar to the EVLA-alone group. The EVLA/FS group exhibited more significant improvement in both AVVQ and EQ-5D scales than the EVLA group at 6 months, while exhibiting poor improvement at 4 weeks. The EVLA/FS group had a significantly lower rate of residual varicosities than the EVLA group, thus reducing the need for the staged FS. ConclusionsThese results confirm the feasibility and safety of simultaneous tributary EVLA and FS. In addition, they indicate better early quality-of-life improvement and a reduced reoperation rate of simultaneously combined truncal EVLA and tributary FS.

Surgical Outcomes of Varicose Veins at Universal College of Medical Sciences, Bhairahawa, Nepal

INTRODUCTION: This study was conducted to analyse the surgical outcomes of varicose vein at Universal College of Medical Sciences (UCMS), Bhairahawa. MATERIALS AND METHODS: A hospital based prospective study done at UCMS, Bhairahwa, Nepal over the period of one year, where all the patients who had lower limb varicose vein underwent surgery were analyzed. RESULTS: A total of 25 cases of varicose vein were operated at UCMS from August 2015 to July 2016. The post-operative complications like pain, wound abscess, aching, itching were minimal. CONCLUSION: Surgical treatment by SFJ ligation with stripping long and short saphenous vein is an established effective treatment of varicose vein in our center with minimal post-operative complications. Journal of Universal College of Medical Sciences (2016) Vol.04 No.02 Issue 14, page: 14-16

Clinical Tests Combined with Color Doppler Versus Color Doppler Alone in Identifying Incompetent Perforator Veins of the Lower Limb: A Prospective Analytical Study.

BackgroundThe color Doppler, a better investigation to identify the perforators objectively has replaced the clinical examination for the same. However, this has led to a significant number of negative explorations and cosmetic disfigurement.ObjectiveTo compare the efficacy of the clinical tests combined with the color Doppler versus color Doppler alone to identify the perforator incompetence during the surgery for primary varicose veins of the lower limb.MethodsThis was a prospective analytical study, including 61 lower limb varicose vein patients who belonged to the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class four-six, planned for the surgical treatment for perforator incompetence, excluding those requiring additional vascular or nonvascular procedure, recurrent varicose veins and those who had injection sclerotherapy prior to the surgery. The clinical tests, including Trendelenburg’s test, multiple tourniquet tests and, the Fegan’s tests were performed and incompetent perforators were marked on a template as ‘C’ to indicate the clinically positive perforator incompetence. The patients were then examined with the color Doppler ultrasound and the pathological incompetent perforators were marked as ‘D’. The surgical management of the perforator incompetence was done by stab ligation. The incision was made in the color Doppler ‘D’ marked sites as it has been the standard protocol. The number of incompetent perforators identified during the surgical exploration were categorized as ‘D’ positive or ’C’ and ‘D’ positive and were recorded in the specified proforma.ResultsIt was found that the mean number of the perforator incompetence identified by the color Doppler alone was 8.2 whereas during the surgery, only a mean of six perforators was identified, leading to 20 unnecessary explorations per 10 patients (8.2 vs. 6; mean difference 2.229; P <0.001). The mean number of the perforator incompetence identified by the color Doppler combined with the clinical tests was 4.5 and during the surgery, a mean of four perforators was identified (4.5 vs. 4; mean difference 0.377; P <0.001). The color Doppler combined with the clinical examination lead to only four unnecessary explorations per 10 patients.ConclusionA combination of both the clinical tests and the color Doppler ultrasound has a higher accuracy in detecting perforator incompetence and can reduce the number of negative explorations by the rate of 16 unnecessary explorations per 10 patients.

Improvement in Venous Clinical Severity Score Following Ultrasound Guided Foam Sclerotherapy

Background: Ultrasound guided foam Sclerotherapy (UGFS) is a simple and cost effective procedure in the management of lower limb varicose vein with very few studies on Indian population. This study is focused on clinical improvement evaluated by venous clinical severity score (VCSS) at 2 months following UGFS, in a rural population in South Kerala. Objective: To assess improvement in Venous Clinical Severity Scoring (VCSS), two months following UGFS in lower limb varicose veins. Methods: A prospective, observational study of 58 cases was done between December 2015 and November 2016, in a rural population in Kerala. 58 patients underwent UGFS during the study and their pre UGFS VCSS score was documented. Of these, 49 patients came back for follow up at 2 months, for post UGFS VCSS and Duplex Doppler evaluation to assess the effectiveness of UGFS. Results: Pre procedure VCSS score of 49 patients, ranged between 3.0-19.0 (Mean=10.7) and post procedure VCSS were between 2-16 (Mean=7.6), which is statistically significant (P=0.01). Decrease in VCSS score by about 3-5 was noted in 44 out of the 49 patients who had successful outcome with no persistent reflux and clinical improvement was also seen in 5 patients with persistent reflux. Of the 19 patients with venous ulcer, there was healing of ulcer at 2 month post UGFS review. Conclusion: UGFS is a simple, cost effective procedure which leads to significant improvement in clinical symptoms and decreasing morbidity associated with chronic venous disease.

Foam sclerotherapy for lower-limb varicose veins: impact on saphenous vein diameter.

ObjectiveTo assess changes in the great saphenous vein (GSV) after foam sclerotherapy for varicose veins.Materials and MethodsThis was a prospective study of 33 patients who were treated with polidocanol foam sclerotherapy after having had varicose veins with a clinical severity-etiology-anatomy-pathophysiology classification of C4-C6 for three months. The patients were evaluated by ultrasound before, during, and after the procedure (on post-procedure days 7, 15, 30, 60, and 90). The GSV diameter, the rate of venous occlusion, and the rate of reflux elimination were determined. Two patients were excluded for having a history of deep vein thrombosis history, and one was excluded for having bronchial asthma.ResultsThirty patients (26 females and 4 males, with mean age of 62 years) completed the protocol. The mean pre-procedure GSV diameter was 6.0 ± 0.32 mm (range, 3.6-11.2 mm). During the sclerotherapy, the mean GSV diameter was reduced to 1.9 ± 0.15 mm (range, 0.6-3.8 mm). On post-procedure day 7, the mean GSV diameter increased to 6.3 ± 0.28 mm (range, 3.9-9.7 mm). On post-procedure day 90, the mean GSV diameter was 4.0 ± 0.22 mm (range, 1.9-8.2 mm). The rate of GSV reflux was significantly lower in the assessment performed on post-procedure day 90 than in the pre-procedure assessment (p < 0.0028).ConclusionOn the basis of our ultrasound analysis, we can conclude that foam sclerotherapy for varicose veins results in a significant reduction in GSV diameter, as well as in the elimination of GSV reflux.

Evaluation of Plasma Growth Factors (VEGF, PDGF, EGF, ANG1, and ANG2) in Patients with Varicose Veins Before and After Treatment with Endovenous Laser Ablation.

To measure pre- and postoperative plasma concentrations of growth factors (VEGF, PDGF, EGF, ANG1, and ANG2) in patients with primary lower limb varicose veins (VVs) treated with endovenous laser ablation (EVLA). Many studies have explored the potential relationship between primary VVs and growth factors. No previous studies were done for patients treated with EVLA. Blood samples were obtained from 30 patients with primary VVs undergoing treatment with EVLA before and 1 week after treatment. Similar samples were obtained from 20 healthy matched adults as a control. Plasma concentrations of growth factor derivatives (VEGF, PDGF, EGF, ANG1, and ANG2) were measured through commercially available enzyme-linked immunosorbent assay. There was statistically significant reduction in median plasma growth factor (VEGF, PDGF, EGF, and ANG1) levels in the preoperative group (p = 0.001) when compared with the control group except for ANG2, which showed increased plasma level (p = 0.001). However, values of plasma concentration of those growth factors after treatment with EVLA were nearly equal to the control group, especially in EGF and VEGF (p = 0.564, 0.515, respectively). The altered plasma concentrations of growth factors VEGF, PDGF, EGF, ANG1, and ANG2 among patients with VVs normalized 1 week after treatment with EVLA compared with the control group. This may support the role of these factors in the pathogenesis of the disease. Future studies may evaluate if these changes can play a prognostic and/or predictive value regarding the adequacy of treatment and the possibility of recurrence.

Ultrasound-guided foam sclerotherapy for severe chronic venous insufficiency.

Chronic venous insufficiency is characterized by cutaneous alterations caused by venous hypertension; in severe forms, it progresses to lower limb ulcers. Lower limb varicose veins are the main cause of chronic venous insufficiency, and the classic treatment includes surgery and compressive therapy. Minimally invasive alternative treatments for varicose veins include new techniques such as venous thermal ablation using laser or radiofrequency. The use of different methods depends on clinical and anatomical factors. Ultrasound-guided foam sclerotherapy is the venous injection of sclerosing foam controlled by Doppler ultrasound. Sclerotherapy is very useful to treat varicose veins, and probably, is cheaper than other methods. However, until the present, it is the less studied method.

A description of the 'smile sign' and multi-pass technique for endovenous laser ablation of large diameter great saphenous veins.

Aims To report on great saphenous vein diameter distribution of patients undergoing endovenous laser ablation for lower limb varicose veins and the ablation technique for large diameter veins. Methods We collected retrospective data of 1929 (943 left leg and 986 right leg) clinically incompetent great saphenous vein diameters treated with endovenous laser ablation over five years and six months. The technical success of procedure, complications and occlusion rate at short-term follow-up are reported. Upon compression, larger diameter veins may constrict asymmetrically rather than concentrically around the laser fibre (the 'smile sign'), requiring multiple passes of the laser into each dilated segment to achieve complete ablation. Results Of 1929 great saphenous veins, 334 (17.31%) had a diameter equal to or over 15 mm, which has been recommended as the upper limit for endovenous laser ablation by some clinicians. All were successfully treated and occluded upon short-term follow-up. Conclusion We suggest that incompetent great saphenous veins that need treatment can always be treated with endovenous laser ablation, and open surgery should never be recommended on vein diameter alone.

Marketing research of the pharmaceutical market of drugs for treating varicose veins and inflammatory diseases of joints

According to the data of the International Union of Phlebologists venous pathologies in various forms occur in 60-75% of the population. InEurope, the lower limb varicosity is observed in 25-33% of women and 10-20% of men; it allows to reliably refer the varicose disease to “diseases of civilization”. When introducing a new medicine the marketing calculations are of particular importance taking into account the competitiveness of the product at the domestic market.Aim. To perform the marketing analysis of the wholesale market of drugs used in the treatment of varicose veins and inflammatory diseases of the joints.Materials and methods. The assortment of drugs was analyzed in accordance with the State Registry of Medicines of Ukraine and the ATC classification. The pharmaceutical market of the following drugs was studied: group M02AX – other remedies applied locally for joint and muscular pain, C05VA – heparin or heparinoids for local application and C05CX – other capillary stabilizing agents.Results. Based on results of our studies it can be stated that the market of drugs under research is characterized by a favorable environment for consumers in terms of a large number of interchangeable drugs. It should be noted that the local market of drugs with the antivaricose activity is widely represented by synthetic drugs that have side effects, including allergic reactions to substances. Therefore, application of the combined herbal medicinal products is increasingly rational.Conclusions. The analysis by medicinal forms among the drugs used in joint and muscle pain has revealed that soft dosage forms are the leaders (54.6 % of the total number of drugs). The analysis by the pack size of antivaricose medicines has determined that all drugs in the group are presented only in soft dosage forms, namely gels (75 %), ointments (16.67 %) and creams (8.33 %). The analysis of the pack size of capillary stabilizing drugs has shown that solid dosage forms prevail in the group, namely tablets, granules and capsules (43.25%).

Pelvic venous reflux in males with varicose veins and recurrent varicose veins.

Objectives To report on a male cohort with pelvic vein reflux and associated primary and recurrent lower limb varicose veins. Methods Full lower limb duplex ultrasonography revealed significant pelvic contribution in eight males presenting with bilateral lower limb varicose veins. Testicular and internal iliac veins were examined with either one or a combination of computed tomography, magnetic resonance venography, testicular, transabdominal or transrectal duplex ultrasonography. Subsequently, all patients received pelvic vein embolisation, prior to leg varicose vein treatment. Results Pelvic vein reflux was found in 23 of the 32 truncal pelvic veins and these were treated by pelvic vein embolisation. Four patients have since completed their leg varicose vein treatment and four are undergoing leg varicose vein treatments currently. Conclusion Pelvic vein reflux contributes towards lower limb venous insufficiency in some males with leg varicose veins. Despite the challenges, we suggest that pelvic vein reflux should probably be investigated and pelvic vein embolisation considered in such patients.

A Study on Prevalence and Risk Factors for Varicose Veins in Nurses at a University Hospital

BackgroundLower-limb varicose veins (VVs) are common and known to have a higher prevalence among people who work in occupations requiring prolonged standing. In the Republic of Korea, however, VV-related occupational factors have seldom been examined. This study was conducted to assess the prevalence of VVs among nurses, an occupational group considered to be at high risk of VVs, and determine the occupational risk factors of prolonged standing.MethodsBetween March and August 2014, a questionnaire survey coupled with Doppler ultrasonography was conducted on the nurses working at a university hospital.ResultsA total of 414 nurses participated in the survey and diagnostic testing. From the survey analysis and test results, the prevalence of VVs in nurses was estimated to be 16.18%. Significant factors for venous reflux were age [odds ratio (OR) = 1.06, 95% confidence interval (CI) = 1.03–1.10], pregnancy (OR = 2.15, 95% CI = 1.17–3.94), and delivery (OR = 2.02, 95% CI = 1.08–3.78). The statistical significance of these factors was verified after risk adjustment for sociodemographic factors (OR = 3.40, 95% CI = 1.27–9.09).ConclusionFactors significantly associated with venous reflux were increasing age and prolonged working hours (≥ 4 hours) in a standing position (OR = 2.80, 95% CI = 1.08–7.25), even after risk adjustment for sociodemographic factors. This study is significant in that an objective diagnosis of VVs preceded the analysis of the risk factors for VV incidence, thus verifying objectively that VVs are associated with occupations requiring prolonged hours of working in a standing position.

Study of different surgical management approach in lower limb varicose veins at tertiary care hospital

Background: The present study was conducted with the aim to evaluate the clinical features and management of varicose veins in terms of recurrence and symptoms improvement.Methods: This clinical study was conducted for a period of two years during January 1990 to February 1992. A total of 21 patients who presented with symptoms of varicose veins in lower extremities to Karnataka Medical College Hospital Hubli were involved in the study. After thorough clinical examination and investigation all the patients are subjected to relevant treatment.Results: Long saphenous system is the most common venous system affected by varicosity in 18 (85.7%) cases. Incompetence of perforator veins was seen in about 20 (95.3%) cases. Trendelenburg’s operation was done in all cases of long saphenous involvement. Sub fascial ligation of perforators was done in 2 patients. Wound infection is the common postoperative complication observed in 5 patients. Preoperative stay in hospital was longer in patients with ulcer (13 days), whereas patients with postoperative wound infection (14 days) had longer postoperative stay.Conclusions: This study showed that the prevalence of lower limb varicose veins has a male predominance and is more common in younger age group. Occupation involving standing for longer periods of time is one of the important contributing factors in the development of varicosities. There is no single method of appropriate treatment for all cases. Multiple ligations of saphenous vein and excision of varicosed tributaries were done in 9 patients. If cases are selected properly with good operative technique the complications are negligible.