Primary Chronic Venous Disease Research Articles

The sonographic features of lymph node venous networks and flow patterns in patients with primary chronic venous disease.

Our study aims to enhance the understanding of lymph node venous networks (LNVNs) by summarising their anatomical, sonographic features, and reflux patterns. We examined 241 legs from 141 patients with primary chronic venous disease (CVD) using duplex ultrasound. The findings indicated variations in the shape, size, vascularity, and echogenicity of LNVN. The superficial inguinal lymph node with reflux appeared slightly larger, exhibiting higher velocities in the hilar artery. Regarding connections, venous flow within LNVN was predominantly drained through the saphenofemoral junction (SFJ), anterior accessory great saphenous vein (AAGSV), and great saphenous vein (GSV). A significant number of LNVNs were observed to be associated with anterolateral thigh tributaries. The study also identified valve cusps within LNVN. This study revealed a 12% prevalence of primary LNVN. Understanding the anatomical and haemodynamic features of LNVN informs treatment strategies and potentially helps prevent the recurrence of varicose veins.

May thermal imaging be useful in early diagnosis of lower extremities chronic venous disease?

Abstract Introduction: World statistics confirmed that about 40-50% of men and 50-55% of women suffer from chronic venous disease. Currently, the Duplex ultrasound is the leading diagnostic method for chronic venous disease (CVD), but it has some limitations. Therefore, it is important to find a new diagnostic technique that will provide additional parameters, describing not only structural but also early metabolic and functional changes. Materials and Methods: This study aimed to demonstrate the usefulness of the thermal imaging technique in the diagnosis of chronic venous disease. Results were obtained for two groups: 61 patients suffering from the primary chronic venous disease (CVD group) and 30 healthy people (control group). The obtained results compared the thermal imaging parameters to data obtained from the ultrasound examination. Parameters such as the reflux duration and extent of the CEAP classification were correlated with the mean temperature of the limb, the mean temperature of the lesion (determined using two methods), and the thermal range. Based on data obtained during the study, correlation coefficients were calculated for individual parameters. Results: The results obtained show that the mean limb temperature, and especially the mean temperature of a proposed isothermal area, is significantly correlated with the range of reflux. The conducted tests showed the correlation between some thermal and ultrasonic parameters determined by Spearman's coefficient is 0.4 (p < 0.05). Conclusions: Thus, parameters such as the isothermal area and the thermal range may be used as a preliminary quantitative diagnosis, similarly to those derived from the Duplex ultrasound.

Integrated anatomic and hemodynamic classification for primary superficial venous disease: results from an expert survey.

There is general perception among vascular physicians that primary lower limb superficial chronic venous disease (CVD) can present in various clinical, anatomical and hemodynamical patterns. Nonetheless, and despite the diversity of classifications on this subject, none specifically addresses such patterns in an integrative form. In the authors opinion, an integrated anatomic and hemodynamic classification could prove a valuable tool for both patient stratification and treatment, as well as postoperative outcomes assessment and homogeneous comparison among groups. The purpose of this study was to collect expert opinion on the usefulness and applicability of a new integrated anatomic and hemodynamic classification for primary superficial venous disease, as well as the anatomic and hemodynamic variables to consider. A survey was administered via a web-based platform to a worldwide selected group of experts on vascular pathology. The survey included 27 questions and collected data on physician demographics and clinical experience (6 questions); usefulness and applicability of a new classification (6 questions); and anatomic and hemodynamic variables to consider (15 questions). A 5-point Likert Scale was used for categorization, and open-ended questions were included for commentary. A total of 278 surveys were sent to experts worldwide, out of which 122 participated (response rate 43.9%). Most participants were European based (85.2%) vascular surgeons (85.2%), but experts from 39 countries across all continents were represented. 88.9% of the respondents agreed that primary varicose veins can be divided in different anatomic and hemodynamic patterns, although only 45.1% believe current classifications are appropriate to differentiate such patterns; 58.2% of respondents agree with an anatomical classification of varicose veins (VV) according to their area of distribution in the lower limb (anterior, posterior, medial, lateral), and 77.1% agree with a hemodynamic categorization of VV in 3 major patterns: VV related with saphenous insufficiency; VV related with pelvic insufficiency; isolated insufficient tributaries and perforator veins. There is general consensus that an integrated anatomic and hemodynamic classification for primary superficial venous disease would be of great use for patient stratification (80.3%), treatment selection (72.2%) and postoperative outcome assessment (70.5%); furthermore, 68.9% of the respondents would use the aforementioned classification, as long as it remained simple and easy to apply in a clinical practice daily basis. The results of the present survey demonstrate that vascular physicians involved in the treatment of primary superficial venous disease recognize the limitations on current varicose vein classifications and agree on the need for a more comprehensive classification for such pathology. Experts agree that an integrated anatomic and hemodynamic classification for primary superficial venous disease would be of great use for patient stratification, treatment selection and postoperative outcome assessment, as long as it remained simple and easy to apply in a clinical practice daily basis. Collected evidence provides significant insights on expert opinion on anatomic and hemodynamic variables to assess and may set the bases for a new classification. Further validations using methodologically solid strategies for expert consensus are required.

Blood flow from competent tributaries is likely contributor to distally increasing reflux volume in incompetent great saphenous vein

ObjectiveVenous reflux is the sole pathophysiologic process in primary chronic venous disease and its progression. We hypothesize that the reflux volume (RV) increases along a great saphenous vein (GSV) in a distal direction. We aimed to compare simultaneously measured RV in the upper and lower GSV segments in a thigh. MethodsPatients meeting the inclusion criteria were enrolled (70 limbs of patients with primary incompetence of the GSV) and consented to this participate in the single-center study. Patients were stratified into two groups: incompetent terminal valve and competent terminal valve. A cross-section area of the GSV was measured at the upper (CSA1, cm2) and distal (CSA2, cm2) points in a thigh. A cross-section area of each tributary that joined with the GSV between the points was measured, and their total cross-section area was calculated (CSAtrib). After a distal cuff compression-decompression maneuver, a time average mean velocity (cm/s) and reflux duration (seconds) were measured at both points simultaneously. The RV (mL) was calculated for each point (RV1 and RV2). The difference in absolute values of ΔRV (mL) and its relative changing (ΔRV, %) were calculated. ResultsThe main result was RV increases caudally from saphenofemoral junction (SFJ) to the knee level (RV1 12.7 ± 8.4 and RV2 20.5 ± 14.0 mL; P < .0001). There was no difference between CSA1 and CSA2 (0.34 ± 0.17 and 0.33 ± 0.17 cm2, respectively; P = .9) but the time average mean velocity was a statistically significant different in two points (7.3 ± 3.9 and 11.4 ± 5.7 cm/s, respectively; P < .0001). All of the tributaries between the points were competent. ConclusionsThe RV in the GSV increases caudally from SFJ to the knee level. The observed RV was an aggregate of all GSV tributaries' flow and the flow via the SFJ if incompetent.

Association of High Serum Homocysteine Levels and Severe Chronic Venous Disease

Homocysteine (Hcy) is considered as a modifiable risk factor for vascular disease. This study was aimed to explore the association between serum concentration and the severity of primary chronic venous disease (CVD). Clinical data of 582 patients diagnosed with primary CVD were collected and analyzed retrospectively. The Clinical Etiology Anatomy Pathophysiology classification system was used to grade the severity of chronic venous disease. Patients were divided into 2 groups (group A: C1-C3; group B: C4-C6). The association between serum homocysteine levels and the severity of primary chronic venous disease was investigated using rank sum test and logistic regression. The difference between the level of homocysteine in each grade has statistical significance. Group A has higher median Hcy concentrations than Group B (15.40 μmol/L vs. 14.05 μmol/L, P< 0.01). Further binary logistic regression showed no statistical significance among the level of Hcy (11.00-14.75 μmol/L [OR 0.66, 95% CI 0.40-1.11, P= 0.12], 14.75-20.38μmol/L [OR 0.97, 95% CI 0.59-1.69, P = 0.89], ≥20.38 μmol/L [OR 0.67, 95% CI 0.41-1.10, P = 0.11]), but age (OR 1.03, 95% CI 1.01-1.04, P< 0.01) and female (OR 0.41, 95% CI 0.28-0.59, P< 0.01) are associated with more severe stages of CVD. Higher level of Hcy is associated with more severe stages of CVD, but it not an independent risk factor. However, Advanced age and female are risk factors for CVD development based on logistic regression analysis.

Can we predict and prevent the postthrombotic syndrome?

Postthrombotic syndrome (PTS) remains one of the major late complications of deep vein thrombosis (DVT) with a reported prevalence from 10 to 50%. Many factors were found to be related with the development and severity of PTS such as ipsilateral recurrent DVT, advanced age, obesity, ilio-femoral DVT and primary chronic venous disease presence. Some PTS prediction models have been proposed based on risk factor weight. However, it is still difficult to predict which patient with DVT will develop PTS and thus, the clinical application of these models remains limited. Among the identified problems the heterogeneity of the DVT patient population together with the variety of PTS clinical presentations and difficulties concerning PTS severity assessment should be mentioned. Difficulties on the implementation of the specific and objective PTS identification method have also the significant influence on the research focusing on PTS prevention modalities including risk factor modification, compression treatment, anticoagulation and invasive DVT treatment. In this review, the current approach and knowledge on PTS prediction and prevention are presented, including the conservative and invasive DVT treatment possibilities.

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.

Biases of Villalta scale in classifying post-thrombotic syndrome in patients with pre-existing chronic venous disease

ObjectiveThe Villalta scale (VS) is a recommended and widely used clinical severity score for diagnosis and grading of post-thrombotic syndrome (PTS). However, patients with primary chronic venous disease (CVD) who have a history of deep venous thrombosis (DVT) may be classified as having PTS even though post-thrombotic disease is not actually present. The purpose of this study was to investigate the biases of the VS with use in patients with pre-existing CVD. MethodsThis single-center, prospective, observational study included patients who were diagnosed with CVD during a 12-month period from 2016 to 2017. The VS and the Venous Clinical Severity Score (VCSS) were completed, and bilateral lower extremity venous duplex ultrasound studies were performed. The correlation of the VS with the VCSS was analyzed. Sensitivity, specificity, positive bias, and negative bias of the VS combined with a history of DVT were calculated. For patients in whom DVT developed during the study, the VS score was taken 12 months after the onset of DVT and compared with the score before DVT. ResultsA total of 288 patients were included. The VS score correlated well with the VCSS, with a correlation coefficient of 0.86 (P < .001). The two scores changed similarly over time. The accuracy of the VS combined with a history of DVT was 94.1%, with a sensitivity of 71.4% and a specificity of 95.9%. The positive bias was as high as 42.3%, although the negative bias was 2.3%. The VS score decreased to a normal level during follow-up in 41.7% of the CVD patients in whom a new DVT developed (n = 12). ConclusionsThe use of the VS for defining PTS appeared to misclassify those with primary CVD and a history of DVT as having PTS by 42.3%. Using the VS at follow-up in patients with PTS and pre-existing CVD may be misleading. Re-evaluation of the results of previous studies that used the VS may be needed.

Association between right heart diastolic function and clinical presentation of chronic venous disease and primary varicose veins of lower extremities.

This study examines the association between right heart diastolic function and clinical presentation of chronic venous disease and primary varicose veins of lower extremities. We performed retrospective analysis of clinical, peripheral venous Duplex and tricuspid Doppler (early diastolic inflow E-wave, late diastolic inflow A-wave, ratios of E to A waves, early diastolic annular e'-wave, late diastolic annular a'-wave and systolic annular s'- wave) data of 85 patients, 133 legs with primary varicose veins. We found following significant (p-value < 0.05) associations between tricuspid Doppler and clinical presentation of chronic venous disease and primary varicose veins: Clinical Etiological Anatomical Pathophysiological clinical class influenced late diastolic inflow velocities (C6 class A-wave +11.2 cm/s or +27% in comparison with C2), late diastolic annular velocities (C6 class a'-wave +3.3 cm/s or +22% in comparison with C2), systolic annular velocities (C6 class s'-wave +3.7 cm/s or +27% in comparison with C2) and E/A ratios (C6 class E/A ratio -0.22 or -21% in comparison with C2). Recurrent varices in comparison with previously untreated are associated with significantly lower late diastolic inflow velocities (A-wave -4.4 cm/s or -9%) and preserved E/A ratios. Age significantly influenced tricuspid Doppler (E-, A-, e'-, a'-waves and E/A ratios) in patients with chronic venous disease. Clinical presentation of primary varicose veins and chronic venous disease can be associated with the right heart diastolic function: C6 Clinical Etiological Anatomical Pathophysiological class in comparison with C2 is associated with increased right ventricular filling and impaired ventricular relaxation - right heart diastolic dysfunction; recurrent varices in comparison with previously untreated are associated with reduced right ventricular filling and preserved right heart diastolic function. Older age is the most important risk factor for varicose veins and chronic venous disease possible due to significant changes in right ventricular filling and in right heart diastolic function with age.

Advanced Stages of Chronic Venous Disease: Evolution of Surgical Techniques and Advantages of Associated Medical Treatment.

Contemporary interventional treatment of primary chronic venous disease (CVD) is mainly focused on the treatment of venous reflux. The long-term results of endovenous ablation (EVA) and high ligation and stripping are not different with respect to varicose vein recurrence, and this recurrence appears to be a manifestation of disease progression. Since inflammation is one of the key mechanisms of CVD development and progression, efforts to minimize inflammation and angiogenic potential in endovenous and surgical procedures are worthwhile. As techniques continue to be refined, surgery remains a valid option; in particular, the techniques that minimize trauma can be beneficial regarding recurrence. Medical treatment with venoactive drug therapy such as micronized purified flavonoid fraction (MPFF; Daflon®), which has proven clinical benefits in patients with CVD, can be used before and after EVA or surgery to minimize inflammation, pain, hemorrhage, and reduce CVD symptoms.

LEV 6. Hyperhomocysteinemia: A Risk Factor or Predictor of Severity in Primary Chronic Venous Disease

LEV 6. Hyperhomocysteinemia: A Risk Factor or Predictor of Severity in Primary Chronic Venous Disease

Клініка та діагностика первинного варикозного розширення вен пахових каналів як одна з форм несафенового первинного хронічного захворювання вен під час вагітності

A distinct form of chronic venous disease (CVD) which meet the obstetrician-gynecologists, surgeons and vascular surgeons on the stages of pregnancy management is the primary varicose veins of the inguinal canals named non-saphenous varicose veins. This pathology is little studied and little known but there is a rather big obstetric problem for obstetricians-gynecologists, vascular surgeons, and as a surgical problem for surgeons and clinical and cosmetic for patients. The objective: to study the primary varicose veins of the inguinal canals frequency and forms, as well as development dynamics during pregnancy. Materials and methods. Based on Rivne Regional Perinatal Center Rivne Regional Council Municipal Institution for the period from 2013 to 2019, the observation of 1,367 pregnant women with primary chronic venous disease pool of saphenous and non-saphenous veins (according to the CEAP classification as of 2002). In 285 (20.8%) of them, one of the forms of non-saphenous varicose vein the primary varicose veins of the inguinal canals was diagnosed: in isolated form 129 (45.3%) patients, in 156 (54.7%) pregnant women combined with lower extremities’ primary chronic vein disease. All pregnant women for the diagnosis of venous pathology and the venous hemodynamics study in the lower extremities veins, the iliac veins pool, inguinal canals, a study of the sources, forming the primary varicose veins of the inguinal canals, used the second diagnostic level, under the guidance of Ukrainian Consensus on the treatment of lower extremities’ varicose veins as of 2005 which included the anamnesis data, clinical examination and duplex angioscanning. For all patients, ultrasound examination was performed in the supine standing position (orthostasis) with Valsalva maneuvre using Mc Kenna D. A. and co-authors criteria (2008). Results. Among 285 (20.8%) pregnant women with the primary varicose veins of the inguinal canals, 129 (45.3%) patients were diagnosed with an isolated form; 28 (21.7%) had varicose veins within the inguinal canal, and 101 (78.3%) of the pregnant women spread through the outer inguinal ring to the external genitals, perineum, and lower limbs. 156 (54.7%) pregnant women in the primary varicose veins of the inguinal canals different forms combined with primary CVD of the lower extremities saphenous veins pool. Found that among 285 patients with the primary varicose veins of the inguinal canals sources on duplex angioscanning in 141 (49.7%) was dominated by reflux from the uterine plexus veins, 73 (25.61%) mainly from the ovaries veins, 42 (14.73%) of pregnant women primarily from the veins of the uterus + ovaries, 18 (6.32%) mainly from the veins of the uterus + ovaries + cremasteric vein, failed to clearly identify the source for 11 (3.86%) patients. This pathology progressed throughout pregnancy and during subsequent pregnancies for 285 (100%) patients. The primary varicose veins of the inguinal canals isolated form did not progress between pregnancies. At that time all the 156 pregnant women with the concomitant disease, marked by the progression of primary CVD pool of saphenous veins during pregnancy and between pregnancies. Conclusion. The use of the second level diagnosis during pregnancy which combined the data of anamnesis, clinical examination and LANWIND MIRROR 2 duplex angioscanning apparatus with 8–10 MHZ linear sensor frequency, McKenna D.A. and co-authors criteria (2008) in the supine and standing (orthostasis) with the Valsalva maneuvre in 100% is safe for both mother and fetus. The use of the inguinal canals venous pathology’s second level diagnosis among the pregnant women gave one hundred percent diagnosis of this pathology’s various forms. On duplex angioscanning the primary varicose veins of the inguinal canals found in 20.23% among pregnant women with primary chronic vein disease to 45.3% in isolated form, but more often in 54.7% in combination with lower extremities’ primary chronic vein disease. Sources of the primary varicose veins of the inguinal canals’ formation were mostly uterus venous plexuses’ reflux in 49.7% of pregnant women, the ovaries in 25.61% of the patients. Key words: D.A. McKenna and co-authors criteria (2008), duplex angioscanning, non-saphenous varicose veins, inguinal canal varicose veins.

Використання програми ERAS у роботі перинатального центру для безпечного планового хірургічного лікування первинного прогресуючого хронічного захворювання вен під час вагітності

The article presents 457 pregnant women’s planned surgical treatment results in the 2nd and 3rd trimesters with primary progressive chronic venous disease (CVD) C2-4s, Ep, As, p, Pr (according to CEAR 2002 classification) according to the ERAS program. As a result of the study, it was noted that the use of the ERAS’ ideology for the pregnant women planned surgical treatment with CVD required the implementation in general and in some of its components adaptation to these patients, scrupulous compliance with them at all stages (before, during and after) surgery. The most important in this program is a multidisciplinary approach to treating pregnant women, their hospitalization in a specialized obstetric hospital on the day of surgery, the use of perinatal psychotherapy for preparing the pregnant woman and the fetus before surgery, performing surgical interventions by a vascular surgeon so-called mono technologist or obstetric vascular surgeon. These factors contributed to the clinical 97% effectiveness achievement elective surgical treatment with 100% absence of all postoperative complications for the fetus and mother, prevented premature birth, helped to reduce the number and severity of postoperative complications from postoperative wounds that did not require additional treatment, did not affect fetal development, pregnancy course; ensured the childbirth and the postpartum period safety; comfortable pregnancy in the postoperative period with a decrease in the hospital stay length with the fastest possible patient’s return of the patient to their daily lifestyle was formed. All operated patients did not need medical support in the postoperative and postpartum periods, except for the use of elastic knitwear with compression class 2 (stockings or socks) during physical activity. Key words: non-obsessive-compulsive disorder, ERAS program, non-obstetric scheduled surgical treatment.

Monitoring of endostatin, TNF-a VEGFs, MMP-9, and cathepsin-L during three months of diosmin treatment in patients with chronic venous disease (CVD)

Introduction: Primary CVD as a result of increased venous hypertension caused mostly by reflux from valvular incompetence as an indication for venoactive drug treatment. The objective of the study was the association between three months of treatment with diosmin and changes to the angiogenic factors involved in the pathophysiology and clinical symptoms of CVD. Material and methods: 41 patients were included in the study. Plasma levels of tumour necrosis factor a (TNF-a), vascular endothelial growth factor (VEGF-A and VEGF-C), matrix metalloproteinase 9 (MMP-9), Cathepsine-L and endostatin were measured using an ELISA assay at baseline and after three months of diosmin administration. Clinical evaluation was performed using duplex Doppler, the VAS scale, leg circumference measurement and BMI score. Results: Three-month treatment with diosmin was associated with a statistically significant decrease in TNF-a, VEGF-A, VEGF-C, MMP-9, Cathepsin-L and endostatin plasma levels with p < 0.01 and p < 0.05 respectively. The average ankle circumference decreased significantly from 30.45 (± 2.05) to 29.0 (± 1.43) (p < 0.05). Conclusion: Diosmin influence on the inflammatory and proteolytic mechanisms involved in the pathology of CVD, could modify endostatin release and angiogenic processes.

Compliance with compression therapy in primary chronic venous disease: Results from a tropical country.

To describe compliance rates of compression therapy in a cohort of patients with chronic venous disease and also to describe frequent causes of non-compliance. A total of 889 patients with primary chronic venous disease were prescribed compression therapy after being evaluated by vascular surgeons. Subjects had a first visit during which time compression therapy was prescribed in addition to a follow-up visit. Strength of compression, type, prescription duration, and reasons of non-compliance were queried at follow-up. Only 31.8% of the patients reported wearing compression therapy as prescribed, 31.4% reported wearing compression most days, 28.3% reported wearing compression intermittently, and 8.5% of the patients reported not wearing compression at all. The main reasons of non-compliance were: uncomfortable (49.4%), too difficult to put on (34.5%), skin problems (itching) (21.5%), and unattractive (19.8%). Compliance with compression therapy in chronic venous disease is still a subject of concern as most patients are not using compression therapy as prescribed.

Sclerotherapy with foam in primary chronic venous disease: follow-up of 1000 cases

Sclerotherapy with foam in primary chronic venous disease: follow-up of 1000 cases

Use of Villalta Score for Defining Post-Thrombotic Disease May Lead to False-Positive Diagnosis in 42% of Patients With Primary Chronic Venous Disease

Use of Villalta Score for Defining Post-Thrombotic Disease May Lead to False-Positive Diagnosis in 42% of Patients With Primary Chronic Venous Disease

Benefits of micronized purified flavonoid fraction as adjuvant therapy on inflammatory response after sclerotherapy.

Sclerotherapy is the treatment of choice for telangiectasias. The aim of this study was to investigate the systemic and local inflammatory response after sclerotherapy in women with chronic venous disease (CVD) and to assess the effects of micronized purified flavonoid fraction (MPFF) in combination with sclerotherapy on markers of inflammation and endothelial dysfunction. Sixty women with primary CVD CEAP class C1 were randomly assigned sclerotherapy in combination with MPFF treatment (N=30) or sclerotherapy alone (control) group (N.=30). In the treatment group, patients received MPFF tablets 1000 mg daily for 2 weeks before the scheduled sclerotherapy and for at least 2 months after the procedure. Microsclerotherapy was performed according to standard protocol using modern sclerosing agents. Blood samples were collected from the central vein of the target vascular cluster before and 10 days after sclerotherapy to evaluate markers of inflammation and endothelial dysfunction including: C-reactive protein within the high-sensitivity range, histamine, interleukin-1, tumor necrosis factor-alpha, and vascular endothelial growth factor. To measure the systemic inflammatory response, blood samples were also collected from the forearm vein in 15 control patients. Baseline levels of markers of inflammation and endothelial dysfunction obtained from the central vein of the treatment site showed no statistically significant differences between treatment groups. In both groups, all markers were significantly increased 10 days after sclerotherapy. In the control group, the same markers obtained from the forearm were not modified 10 days after sclerotherapy indicating the inflammatory reaction was local and not systemic. MPFF treatment reduced all markers of inflammation and endothelial dysfunction compared with the control group. Prescription of MPFF starting prior to sclerotherapy and throughout the post-operative period reduced the vein-specific pro-inflammatory reaction and may thereby reduce the unwanted side effects of sclerotherapy and improve treatment outcomes.

Damage to Cranial Extension of the Small Saphenous Vein and Vein of Giacomini in Lower Limb Varicose Vein Disease

Abstract. The vein of Giacomini is often identified with the cranial extension of the small saphenous vein despite the fact that according to the international interdisciplinary anatomical nomenclature they are distinguished from one another.The objective of the research was to improve the results of treatment of patients with lower limb primary chronic venous disease disease studying the variation in anatomy and pathology of the vein of Giacomini and the cranial extension of the small saphenous vein with subsequent development of differential surgical tactics.Materials and methods. 502 patients with primary chronic venous disease on 605 legs were examined and treated. Each patient underwent preoperative ultrasonographic triplex scanning of the lower limb venous system.Results. Varicose dilatation of the vein of Giacomini was observed in 3.8% of patients (95% CI 2.4-5.6 %), and the pathology of the cranial extension of the small saphenous vein was detected in 1.7% of patients (95% CI 0.8-3.0%). When the arch of the small saphenous vein was present the following variations in the pathology of the vein of Giacomini were observed: 1) the spread of reflux from the great saphenous vein to the vein of Giacomini; 2) reflux from the terminal valve of the small saphenous vein intensified the antegrade flow of blood within the vein of Giacomini resulting in reflux in the great saphenous vein distal to the point where the vein of Giacomini drained into the great saphenous vein. The causes of failure of the valves in the trunk of the cranial extension of the small saphenous vein included: 1) reflux from the ostium of the cranial extension of the small saphenous vein; 2) perforating vein reflux; 3) reflux from the terminal valve of the small saphenous vein.Conclusions. The pathology of the vein of Giacomini and the cranial extension of the small saphenous vein is not homogeneous; therefore, surgical tactics in every patient has to be hemodynamically justified and differentiated depending on the pathways of pathological reflux spreading.

Review of Complex Iliocaval Reconstructions

Reconstruction of the iliocaval system is primarily performed in symptomatic patients with obstructive chronic venous disease (CVD). Such pathology can be primary/nonthrombotic or secondary/postthrombotic. The former encompasses pathology including May–Thurner syndrome, the most common etiology of primary CVD responsible for up to a third of the disease burden. Secondary CVD is usually due to postthrombotic syndrome. Other indications for iliocaval reconstructions include malignancy involving the iliocaval territory, trauma, or radiation injury. In this review, we evaluate complex iliocaval venous reconstructions vis-a-vis indications, approaches, outcomes, and complications. Treatment of CVD is initially conservative with the use of compression stockings. A surgical route is chosen when the former fails or cannot be applied. Both open and endovascular surgical approaches exist with the latter having supplanted open approaches as the choice of intervention except in cases where an endovascular approach cannot be pursued, has failed, or in patients with malignancy where tumor removal is required. Hybrid procedures are performed occasionally when femoral vein exposure and endophlebectomy or creation of an arteriovenous fistula is required to improve inflow following surgical intervention. Endovascular reconstruction of the iliocaval system can be done with minimal morbidity and mortality with excellent long-term results. Open iliocaval revascularization has a limited role in candidates with acceptable risk and is associated with good outcomes in such patients.