Phlebology Practice Research Articles

Multidetector spiral computed tomography–venography in outpatient phlebological practice

Duplex ultrasound scanning (DUS) and magnetic resonance imaging are sometimes insufficient to meet our clinical needs due to specifics of given pathology and intrinsic technical limitations of these methods. This study aims to assess the need for multispiral computed tomography–venography (CT-venography) and to evaluate its diagnostic capabilities for various disorders in primary ambulatory patients in phlebology practice.Material and Methods. From January, 2017 to December,2019, a total of 10,112 patients sought initial consultation of a phlebologist. Upon examination, the physician assigned patients to one of the proposed categories using dedicated software. Analysis of these categories demonstrated the following pattern of morbidity: 2,167 patients (21.4%) had chronic venous disorders of class С0S-1 (CEAP classification); 4,460 patients (44.1%) had varicose veins of class C2-3 (CEAP classification); 351 patients (3.5%) had varicose veins of class C4-6; 570 patients (5.6%) had other diseases including post-thrombotic syndrome, acute thrombosis, thrombophlebitis, and venous malformations; and 2,564 patients (25.4%) were suffering from non-venous disorders. DUS was performed in all cases.Results. The study demonstrated that 260 patients required CT-venography constituting 2.6% of the total number of patients who came to the clinic in the indicated period. The direct venography with contrast medium injection through the peripheral veins was used in 156 cases (60%). Patients did not have any significant complications, such as acute kidney injury or worsening of chronic renal failure, severe allergic reactions to the contrast agent, or problems with the puncture site of peripheral veins.Conclusions: 1) CT-venography allowed to achieve the accurate three-dimensional imaging of the venous system, providing, in some cases, the necessary information for finding solutions on optimal management. 2) The need for CT-venography may occur in 2.6% of patients in ambulatory phlebology practice. 3) CT-venography is useful for diagnosing angiodysplasias, postthrombotic and non-thrombotic lesions, complicated varicose veins, especially in recurrence, and in some cases of acute deep vein thrombosis. 4) DUS is mandatory for hemodynamic assessment in all patients before CT-venography.

Restless legs syndrome, anxiety, and depression in phlebology practice

The aim was to analyze the prevalence and overlapping of chronic venous disorders, restless legs syndrome, anxiety and depressive conditions. There were 582 subjects enroll; 450 (77.5%) women and 132 (22.5%) men (mean age 45.0). The examination included a physical exam with ultrasound scanning, restless legs syndrome questionnaire, and the hospital anxiety and depression scale (HADS). The prevalence of chronic venous disorders was in 82.6% subjects, restless legs syndrome - 13.9%, anxiety - 28% and depression - 8.6%. Chronic venous disorders were more frequent in anxious patients (34%; P<0.05) vs non-anxious (25%; P<0.05). Significant interrelations between chronic venous disorders and depression were not found (P>0.05). Anxiety and depression were significantly more frequent in patients with restless leg syndrome (anxiety 54.3% vs non-anxiety 23.8%, P<0.001; depression 24.7% vs non-depression 6%, P<0.001). There were not relevant interrelations between chronic venous disorders and restless leg syndrome or anxiety/depression. Anxiety and depressive were significantly correlated with restless legs syndrome.

Anesthesia in outpatient phlebology practice

Tumescent and/or conductive anaesthesia is the most frequently performed procedure to anesthetize the thermal types of surgical interventions, mini-phlebectomy and stripping of subcutaneous veins in outpatient settings. These interventions have become a common outpatient procedure almost everywhere, which made the issue of local anaesthesia more sensitive over the past 5 years in Russia. The aim is to compare the efficacy, safety and comfort when injecting various anaesthetic solutions to relieve pain during endovenous laser obliteration/radio frequency catheter ablation, stripping of the subcutaneous veins and mini-phlebectomy. Searching method. We searched for original articles in PubMed, in the archives of «Phlebology» and «Angiology and Vascular Surgery» journals issued for the period between 2001 and November 2018 and the search for official instructions in the state register of medicinal products. Selection criteria. We included all comparative studies: randomized and non-randomized, in which pain was assessed both during injection of a tumescent solution before EVLO and/or mini-phlebectomy and during surgery, as well as systematic reviews and monographs. Data analysis. In total, we identified 9 studies: 7 randomized and 2 non-randomized, one systematic review and two monographs. The advantage of a buffered solution over unbuffered one in terms of reducing pain during injection is revealed in three randomized, one simple comparative study and on the basis of systematic review data. A great efficacy of combining tumescent anaesthesia with a femoral nerve blockade, which was equivalent to spinal anaesthesia, was found in 4 randomized trials, two of which were double-blind, and one non-randomized. In addition, a smaller degree of motor block was reported after blocking the femoral nerve in comparison with spinal anaesthesia. In one randomized trial in which pain was assessed using cold and warm solutions, no significant differences in pain were observed either during or after surgery. In order to prepare a tumescent solution, lidocaine, prilocaine and mepivacaine were used at concentrations ranging from 0.028% to 0.2%; the advantages of higher concentrations over the lower ones have not been revealed. No adverse reactions and complications of anaesthesia have been reported in the studies, except for one where methaemoglobinemia of mild degree was detected in a small number of patients when using 0.2% prilocaine. The conclusion. Local anaesthesia, namely, conductive and tumescent anaesthesia, is an effective and safe anaesthesia method in outpatient surgery. Even very low concentrations of anaesthetic solutions are effective for tumescent anaesthesia. The use of buffered solutions increases significantly patient comfort during the injection. The combination of tumescent anaesthesia and femoral nerve block increases the effectiveness of anaesthesia. The femoral nerve block has significant advantages in comparison with spinal anaesthesia in terms of safety.

Telangiectatic Matting is Associated with Hypersensitivity and a Bleeding Tendency

The aim was to investigate the pathogenesis of telangiectatic matting (TM) and identify possible risk factors. This study had two parts. The clinical records of consecutive patients were retrospectively analysed to identify risk factors for TM. In the second part, the haemostatic and coagulation profile of the subset of patients with TM were analysed and compared with controls using standard coagulation tests, platelet function and a global assay of coagulation (rotational thromboelastometry, ROTEM). In 352 consecutive patients presenting to a phlebology practice, 25 patients had TM (7.1%). All 25 patients were female with the median age of 45 (27-57) years. A comprehensive medical history was taken. Among 27 possible risk factors assessed, statistically significant associations included recurrent epistaxis, easy bruising, hypersensitivity (eczema, hives, hay fever, and rhinitis), previous treatment with sclerotherapy or endovenous laser for lower limb veins, and a family history of telangiectasias. Variables not associated with TM included oral contraceptive intake, hormone replacement therapy, and age. The haemostatic and coagulation profile of 12 patients (6 male and 6 female) with TM did not differ significantly from those without TM. TM is associated with both hypersensitivity and a bleeding tendency. This study revealed no significant increase in the incidence of haemostatic abnormalities in patients with TM compared with the control group. Given the significant association with hypersensitivity disorders, the underlying mast cell hyper-reactivity may contribute to both hypersensitivity and a bleeding tendency and predispose patients to TM.

Patient safety in phlebology: The ACP Phlebology Safety Checklist.

Objectives To assess the current use of safety checklists among the American College of Phlebology (ACP) members and their interest in implementing a checklist supported by the ACP on their clinical practices; and to develop a phlebology safety checklist. Method Online surveys were sent to ACP members, and a phlebology safety checklist was developed by a multispecialty team through the ACP Leadership Academy. Results Forty-seven percent of respondents are using a safety checklist in their practices; 23% think that a phlebology safety checklist would interfere or disrupt workflow; 79% answered that a phlebology safety checklist could improve procedure outcomes or prevent complications; and 85% would be interested in implementing a phlebology safety checklist approved by the ACP. Conclusion A phlebology safety checklist was developed with the intent to increase awareness on patient safety and improve outcome in phlebology practice.

Syncope for phlebologists

Emergencies during phlebology procedures are rare. Nonetheless, a phlebologist needs to be prepared to manage such a situation (like syncope due to anaphylaxis) if it occurs, to distinguish a true emergency from a more benign scenario (like vasovagal syncope), and even to manage an emergency unrelated causally to the procedure itself (like a heart dysrhythmia which happens to occur during sclerotherapy). The focus of such preparations should be actions and information which affect patient outcomes. Physician mental and even medical team rehearsal of such scenarios can improve phlebologist and team responses. This article discusses the differential diagnosis and management of the patient with syncope in a phlebology practice, with emphasis on anaphylaxis.

What's New in Veins?

Reflux cannot be interpreted without knowledge of the function of the calf muscle pump. The presence or absence of reflux alone has an insufficient predictive value for excellent functional treatment results. Valves are not simple moving slips but have an autonomous 4-step cycle movement that helps the calf muscle pump to be very effective. New calculations of the Starling equilibrium have shown that capillary filtration fraction returns mainly by the lymphatics. All these new findings help the phlebologist design a more precise and thus better treatment plan in phlebology practice.

T-L-103 RESTLESS LEGS SYNDROME: THE RESPONSE OF RLS TO COMPREHENSIVE VARICOSE VEIN CARE

Introduction and Objectives: Restless Legs Syndrome (RLS) is a progressive disorder of uncomfortable sensations in the legs that leads to unwanted motor restlessness. Recent research has suggested a correlation between RLS and chronic venous disorders (CVD). The purpose of this study is to determine the effect that comprehensive vein treatment has in relieving RLS symptoms in those patients who have both RLS and CVD. Materials and Methods: This study is a case series report of a physician’s detailed account of 54 consecutive patients (mean age: 46±13 years) who presented to a specialty phlebology practice with CVD (CEAP C1 to C5) and who also had RLS conforming to the International Restless Legs Syndrome Study Group (IRLSSG) diagnostic criteria. The IRLSSG Rating Scale (RLSRS) ten question survey instrument (score: 0-40) was administered to each patient prior to treatment. Each patient was treated with sclerotherapy, with or without endovenous laser treatment, according to the presentation of their CVD. Each patient’s RLS symptoms were subsequently re-evaluated at predetermined intervals within their treatment course, using the RLSRS survey instrument. The study end points were defined as complete RLS symptom relief (score = 0) or completion of vein treatment protocol, whichever came first. No patients were prescribed any other pharmacologic intervention for their RLS. Results: Fifty patients completed the study. Four patients did not complete the study and/or their treatment and were lost to follow-up. The mean RLSRS baseline score was 22±6 (range: 9–36). Forty-eight of the 50 patients (96%) experienced complete relief of their restless legs symptoms (RLSRS = 0, p<0.001). The mean RLSRS score at the end of the study was 0.5±1 (p<0.01). Two patients (4%) experienced significant but incomplete relief. Conclusion: While the pathology of RLS is unclear, treating a patient’s concomitant chronic venous insufficiency provided them with complete or significant relief of their RLS symptoms. Patients having RLS should be evaluated for concomitant CVD and appropriately treated. Acknowledgements: JS Gibson, JT King, RC Guptan, Vein Clinics of America and Venous Research Foundation, IL, USA

T-L-104 SAFETY AND EFFICACY OF LONG-TERM TREATMENT WITH ROTIGOTINE IN JAPANESE PATIENTS WITH RESTLESS LEGS SYNDROME

Introduction and Objectives: Restless Legs Syndrome (RLS) is a progressive disorder of uncomfortable sensations in the legs that leads to unwanted motor restlessness. Recent research has suggested a correlation between RLS and chronic venous disorders (CVD). The purpose of this study is to determine the effect that comprehensive vein treatment has in relieving RLS symptoms in those patients who have both RLS and CVD. Materials and Methods: This study is a case series report of a physician’s detailed account of 54 consecutive patients (mean age: 46±13 years) who presented to a specialty phlebology practice with CVD (CEAP C1 to C5) and who also had RLS conforming to the International Restless Legs Syndrome Study Group (IRLSSG) diagnostic criteria. The IRLSSG Rating Scale (RLSRS) ten question survey instrument (score: 0-40) was administered to each patient prior to treatment. Each patient was treated with sclerotherapy, with or without endovenous laser treatment, according to the presentation of their CVD. Each patient’s RLS symptoms were subsequently re-evaluated at predetermined intervals within their treatment course, using the RLSRS survey instrument. The study end points were defined as complete RLS symptom relief (score = 0) or completion of vein treatment protocol, whichever came first. No patients were prescribed any other pharmacologic intervention for their RLS. Results: Fifty patients completed the study. Four patients did not complete the study and/or their treatment and were lost to follow-up. The mean RLSRS baseline score was 22±6 (range: 9–36). Forty-eight of the 50 patients (96%) experienced complete relief of their restless legs symptoms (RLSRS = 0, p<0.001). The mean RLSRS score at the end of the study was 0.5±1 (p<0.01). Two patients (4%) experienced significant but incomplete relief. Conclusion: While the pathology of RLS is unclear, treating a patient’s concomitant chronic venous insufficiency provided them with complete or significant relief of their RLS symptoms. Patients having RLS should be evaluated for concomitant CVD and appropriately treated. Acknowledgements: JS Gibson, JT King, RC Guptan, Vein Clinics of America and Venous Research Foundation, IL, USA

Is routine scanning for deep-vein thrombosis necessary following endovenous laser ablation and ultrasound-guided sclerotherapy? A statistical perspective in Australian Phlebology practice

Is routine scanning for deep-vein thrombosis necessary following endovenous laser ablation and ultrasound-guided sclerotherapy? A statistical perspective in Australian Phlebology practice

The Fundamentals of Phlebology: Venous Disease for Clinicians

The Fundamentals of Phlebology: Venous Disease for Clinicians is a 98-page paperback book encompassing 17 chapters. The book is endorsed by the American College of Phlebology and edited by one of its former presidents, Helane S. Fronek. This book follows a logical progression, beginning with venous anatomy and physiology, continuing on with diagnosis, treatment options, and complications of treatment, and concluding with a chapter devoted to setting up a phlebology practice. The book stays true to its name by covering the fundamentals of venous disease without taking for granted the reader's existing knowledge of phlebology. This makes it an excellent introductory text for the interventionalist in training or for the individual who chooses to delve into venous intervention. That is not to say that it is of no use to experienced phlebologists. Indeed one of the aims of the book as written in the preface is a “… hope that erroneous teaching and archaic treatments can be laid aside, to make way for new understanding, new techniques and new skills that will afford patients with venous disease healthier and more productive lives.” The first few chapters illustrate the importance of pre-intervention evaluation by explaining venous anatomy, physiology, physical examination findings, and conservative treatments. The book then transitions smoothly into treatment options for those patients who will most likely benefit from such interventions. The chapters devoted to treatment are particularly well done, with detailed technical instructions and useful, easy-to-reference charts. The photographs, when provided, give the novice an excellent picture of what to expect before actually performing the procedure. The number of pictures is somewhat disappointing given their benefit. However, these chapters are so well written, particularly the ones devoted to sclerotherapy and endovenous thermal ablation, that the reader will not lack confidence in pursuing these procedures if they so choose. The book marches on toward more “invasive” type of treatments, including ambulatory phlebectomy and surgery for varicose veins. These chapters are not short-changed in that they continue to explain these techniques in the concise, detailed manner that is the strength of this book. The last chapter of the book, “Setting up a Phlebology Practice,” answers the question “okay, now what?” There is some wonderful information here, with tips and suggestions that may initially be overlooked by those starting a practice. Although there is only so much that can be provided in the four pages this chapter encompasses, it represents a good start. Those who read this text will not only find it to be an excellent introduction to venous disease, but it will be used as a reference time and again. For a book priced at $79, this is remarkable and a testament to the editor and its authors. If one is considering a vein practice, The Fundamentals of Phlebology: Venous Disease for Clinicians is a good place to start.

Restless legs syndrome in patients with chronic venous disorders: an untold story

To prospectively study the profile of restless leg syndrome (RLS) in patients presenting to a phlebology practice. The study uses prospective questionnaire and clinical observation study. In all, 174 consecutive patients and 174 matched controls were evaluated in detail. The diagnosis of restless legs syndrome (RLS) was established by the International RLS study group (IRLSSG) criteria. Detailed clinical, systemic and Duplex ultrasound evaluations were done to establish the presence of chronic venous disorders (CVD) (reflux > 0.5 s on augmentation manoeuvers and revised clinical, aetiological, anatomical and pathological [CEAP] criteria). Of the 174 consecutive subjects studied (22M: 152F), 63 (36%) had evidence of RLS compared with only 34 of 174 of the controls (19%, P < 0.05). Sixty-two (98%) of these RLS-positive study subjects were subsequently diagnosed with CVD. In comparison, 31 (91%) of the RLS-positive control subjects (n = 34) were found to have CVD. This prevalence of CVD was comparable with RLS-positive study subjects, but was significantly higher than the prevalence in CVD in RLS-negative controls (P < 0.01). Only three (9%) of the controls had RLS without CVD. RLS-positive subjects were typically women above the age of 40 years (P < 0.01 vs. men, P < 0.01 vs. below 40 years). A significant difference in clinical presentation in the study subjects was the high prevalence of leg cramps in the RLS-positive subjects (P < 0.01). None of the patients with RLS in this series gave history of anaemia, chronic renal failure or an established psychiatric or neurological disease as found pathognomic for RLS by others. RLS appears to be a common overlapping clinical syndrome in patients with CVD. Prospective blinded therapeutic trials are planned to study the influence of definitive treatments for CVD on sequential RLS scores.

Developing an Interventional Radiology Varicose Vein Practice

A varicose vein or phlebology practice can be incorporated into an outpatient interventional radiology practice with some proper planning. For an established interventional radiology clinic practice, the barriers to entry into such a phlebology practice are actually fairly low. A critical component in this process is establishing a business plan. An intact business plan can provide the proper foundation for any business venture, including a successful phlebology practice. Key steps in any business plan include an evaluation of the proposed venture, proper planning, organization, implementation, and periodic review. In this article, I describe how an active varicose vein practice was established in our outpatient radiology office in Charlotte, North Carolina, as well as highlight several important features that could, and probably should be, incorporated into any phlebology practice.

Varicose Vein Treatment: Considerations for a Radiology Group Practice

Varicose vein management presents an exciting opportunity for the expansion of the interventional components of many practices. Although vein practice development has been addressed by other specialists, concerns unique to radiologists have only lately become important. Radiology groups are well suited to support the addition of this service line, and it may serve as a showcase for further clinical growth. Success depends on appropriate business planning, clinical and administrative infrastructure, and intelligent marketing. This article describes requisites for the successful development of a phlebology practice by a radiology group.

Roller coaster reflux: definition and clinical significance

Objective: Duplex scanning readily identifies typical proximal venous reflux that descends directly to varices. Occasionally, reflux may first descend in a saphenous or deep vein, and then reverse direction to ascend 10 cm or more in a tributary or varicose vein before descending again to clinically evident varicose veins. This pattern, here defined as roller coaster reflux (RCR), can be difficult to establish, since no immediate superior source of reflux feeds the uppermost varices. This study reviews recent clinical experience with RCR and illustrates the phenomenon in two patients. Methods: Over a two-year period in a solo phlebology practice, duplex ultrasound was used on patients with varicose veins to identify the initial descending reflux and the point of reversal where flow began to ascend. A Trendelenburg manoeuvre with direct compression over the point of reversal was used to prove whether the source of venous distention lay 10 cm or more below the most superior varices. Results: A total of 12 patients showed evidence of RCR with flow ascending 10-23 cm to feed the uppermost varices. The sources of descending reflux were the femoral (3), popliteal (2), great saphenous (4), short saphenous (2) and tibial (1) veins. The ascending veins were the great saphenous (3), Giacomini (2) or varices (7). Elimination of the source of reflux along with the varices routinely resulted in clinical success. Conclusions: Roller coaster reflux should be sought in individuals whose reflux does not appear to arise from a superior source.

Echoanatomical Patterns of the Long Saphenous Vein in Patients with Primary Varices and in Healthy Subjects

Objective:To evaluate the pathway of reflux in incompetent long saphenous veins (LSVs), paying particular attention to the role of longitudinal saphenous tributaries in the thigh (accessory saphenous veins, ASVs).Design:Prospective study in a group of patients with primary varices. Comparison with the anatomical patterns in a group of normal subjects.Setting:Private phlebology practice.Patients:Sixty-seven patients with primary varices (100 limbs) and 66 subjects without varices and with competent saphenous veins (120 limbs).Methods:Duplex ultrasound evaluation of the saphenous system in the thigh of patients and healthy subjects. The ‘eye’ ultrasonographic sign was used as the marker to distinguish the LSV from the longitudinal tributary veins of the thigh.Results:In 57% of limbs in patients with varices, reflux followed the saphenous vein, while in 43% the reflux spilled outside the LSV into an ASV (h or S types). When reflux followed the saphenous vein, no large calibre ASVs could be observed. In 30% of limbs in control subjects a parallel tributary vein with a similar calibre was found joining the LSV.Conclusion:Clinically visible varices in the thigh rarely comprise the LSV itself, but are usually dilated ASVs, the reflux stream passing from the proximal LSV into a more superficial ASV. The distal LSV running parallel beneath is often competent. In subjects with healthy LSVs, a large competent tributary vein is already present in the thigh in 30% of cases. This suggests that superficial deviation of reflux flow into an ASV in patients with varices may not arise from haemodynamically acquired changes, but could have a congenital origin. This could even be a predisposing factor in the development of varices.

The Out-Patient Therapy of Trunk Varicosis of the Greater Saphenous Vein by Means of Ligation and Sclerotherapy

The Journal of Dermatologic Surgery and OncologyVolume 17, Issue 10 p. 818-823 The Out-Patient Therapy of Trunk Varicosis of the Greater Saphenous Vein by Means of Ligation and Sclerotherapy. A Contribution from a German Phlebology Practice KLAUS HÜBNER MD, KLAUS HÜBNER MDSearch for more papers by this author KLAUS HÜBNER MD, KLAUS HÜBNER MDSearch for more papers by this author First published: October 1991 https://doi.org/10.1111/j.1524-4725.1991.tb03266.xCitations: 10 In private practice, Aachen, Germany Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume17, Issue10October 1991Pages 818-823 RelatedInformation