Saphenopopliteal Junction Research Articles

Clinical Anatomy of Vessels of Popliteal Region

INTRODUCTION: A modern standard for noninvasive diagnostics of the vascular system is duplex scanning. The knowledge of variability of vascular anatomy is essential for ultrasound doctors. AIM: To clarify variants of the clinical anatomy of vessels of the popliteal region using duplex scanning and anatomical preparation. MATERIALS AND METHODS: The work used data of duplex scanning of the arteries and veins of the lower extremities of patients without pathology of the vascular system of the lower extremities, who underwent examination of the vascular system: 200 patients aged from 18 to 92 years. As control, the data of anatomical preparation of 50 amputated lower extremities were taken, with preliminary filling the venous system with a blue synthetic gel. RESULTS: In the course of anatomical preparation, two trunks of the popliteal vein were identified in the distal popliteal region in 86.0% of observations. A typical drain of the small saphenous vein with formation of the saphenopopliteal junction was encountered in 60.0% of cases. In duplex scanning, a high bifurcation of the popliteal artery was detected in 1.9% of observations. The two trunks of the popliteal vein in the distal part of the popliteal region were encountered in 82.4% of cases, and the medial trunk was almost always larger than the lateral one. The small saphenous vein drained into the popliteal vein in 63.0% of cases. In 7.2% of observations, it drained into one of the intramuscular veins. In 0.95% of observations, a perforator vein was identified in the popliteal region. The sural veins were identified in all the patients — two on the medial and lateral surface positioned at the sides of the two trunks of the sural arteries, forming a single trunk before confluence with the popliteal vein. CONCLUSIONS: TThe study revealed the following anatomic variants of vessels of the popliteal region: two trunks of the popliteal vein below the knee joint cleft in 85.7% to 86.0% of observations; a high bifurcation of the popliteal artery in 1.9%; saphenopopliteal junction in 60.0% to 63.0%; perforator veins of the popliteal region in 0.95% of observations; upon that, the small saphenous vein does not form the saphenopopliteal junction.

Treatment of Superficial Vein Thrombosis: Recent Advances, Unmet Needs and Future Directions.

Once considered relatively benign, superficial vein thrombosis (SVT) of the lower limbs is linked to deep vein thrombosis (DVT) or pulmonary embolism (PE) in up to one fourth of cases. Treatment goals include alleviating local symptoms and preventing SVT from recurring or extending into DVT or PE. Fondaparinux 2.5 mg once daily for 45 days is the treatment of choice for most patients with SVT. Potential alternatives include intermediate-dose low-molecular-weight heparin or the direct oral factor Xa inhibitor rivaroxaban, however, these require further evidence. Despite these treatment options, significant gaps remain, including the role of systemic or topical anti-inflammatory agents alone or combined with anticoagulants, and the optimal duration of anticoagulation for patients at varying risk levels. Additionally, the efficacy and safety of factor Xa inhibitors other than rivaroxaban, management of upper extremity SVT, and optimal treatment for SVT near the sapheno-femoral or sapheno-popliteal junctions are not well understood. This narrative review aims to summarize current evidence on anticoagulant treatment for SVT, highlight key unmet needs in current approaches, and discuss how ongoing studies may address these gaps.

Relationship between body figure and stump length in cyanoacrylate closure of varicose veins.

Recurrence of incompetent saphenous veins after treatment is associated with remnant reflux to the branches close to the saphenofemoral or saphenopopliteal junctions, which originate from the residual patent stump after saphenous vein treatment. This study aimed to determine the factors affecting residual stump length after cyanoacrylate closure. This retrospective study used prospectively collected data of patients who underwent cyanoacrylate closure. Postoperative Duplex scanning was performed to evaluate occlusion of the target vein, stump length, and the presence of endovenous glue-induced thrombosis. The clinical outcomes and patient characteristics were also evaluated. Seventy procedures for incompetent saphenous veins were performed in 67 limbs of 47 patients. The average patient age was 43 (range, 43-89) years; 34 (72%) were female patients. Target vein occlusion was achieved in all patients and endovenous glue-induced thrombosis occurred in 1.5 % of patients. The mean stump length was 18.3 mm. Total occlusion from the junction was observed in 13 vessels (19%). Particularly, higher total occlusion rate was found in treatments of the small saphenous vein compared with those of the great saphenous vein (GSV). In 6 GSV treatments, longer stumps (>45 mm) remained. Those with a stump >45 mm were all female patients, with significantly shorter height and higher Body Mass Index compared with those with stump lengths <45 mm. Body figure should be considered when performing cyanoacrylate closure to treat insufficient saphenous varicose veins. However, further investigations are to be warranted.

Management and outcomes of superficial vein thrombosis: a single-center retrospective study

BackgroundGuidelines suggest but cannot recommend the optimal management of superficial vein thrombosis (SVT). ObjectivesTo identify the prevalence of asymptomatic deep vein thrombosis (DVT) at the time of SVT diagnosis, and to report the treatment and 3-month complications of patients with only SVT more than 3 cm from deep vein junction (or unknown distance). MethodsWe performed a single-center retrospective review of patients referred to the Ottawa Hospital thrombosis unit with ultrasound (US)-diagnosed SVT, and followed patients with only SVT for 3 months. ResultsThree hundred sixteen patients with SVT were included. Of the 218 patients without DVT symptoms at presentation, 19 (8.7%; 95% CI, 5.7%-13.2%) were found to have asymptomatic concomitant DVT (11 proximal and 8 distal), and 45 (20.6%) had SVT within 3 cm of the saphenofemoral or saphenopopliteal junctions. Among the 192 patients diagnosed with SVT only, we observed 3-month thrombotic complications in 56 (29.2%; 95% CI, 23.2%-36.0%) patients, with a total of 69 events: 11 (5.7%) DVTs, 2 (1.0%) pulmonary embolisms, 37 (19.2%) SVT extensions, and 19 (9.8%) SVT recurrences. Eighty-two percent (9/11) of the 3-month DVT and pulmonary embolism events occurred in patients who initially received conservative management. Therapeutic treatment doses were most effective. ConclusionAt the time of SVT diagnosis, many patients had asymptomatic DVT and SVT near the deep venous system, supporting the systematic use of initial US in patients clinically diagnosed with SVT. The observed differences in 3-month complication rates, according to the treatment provided, highlight the need for large-scale randomized controlled trials to establish optimal management.

Endovenous laser ablation vs phlebectomy of foot varicose veins

ObjectiveThe aim of this study was to compare the outcomes and complications of selected patients treated with endovenous laser ablation (EVLA) or ambulatory phlebectomy for foot varicose veins. MethodsFrom October 2016 to February 2022, selected patients undergoing EVLA (using 1470-nm with radial-slim or bare-tip fibers) or phlebectomy of foot varicose veins for cosmetic indications were analyzed, and the outcomes were compared. Patients were classified according to the Clinical, Etiologic, Anatomical, and Pathophysiological (CEAP) classification. Anatomic criteria provided the basis for the decision to perform EVLA or phlebectomy. Clinical and ultrasound assessments were performed on postoperative days 7, 30, and 90 for visualization of the sapheno-femoral and sapheno-popliteal junctions and the deep venous system. Disease severity was graded with the Venous Clinical Severity Score (VCSS), and quality of life was measured with the Aberdeen Varicose Vein Questionnaire (AVVQ) before and after treatment. Treatment outcomes were evaluated based on changes in VCSS and AVVQ scores. The groups were also compared for procedure-related complications. Data were statistically analyzed in SPSS v. 20.0 using the χ2, Student t test, Mann-Whitney test, Wilcoxon test, and analysis of variance. The results were presented as mean (standard deviation or median (interquartile range). ResultsThe study included 270 feet of 171 patients. Mean patient age was 52.3 (standard deviation, 13.1) years, ranging from 21 to 84 years; 133 (77.8%) were women. Of 270 feet, 113 (41.9%) were treated with EVLA and 157 (58.1%) with phlebectomy. The median preoperative CEAP class was 2 (interquartile range, 2-3) in the phlebectomy and EVLA groups, with no statistically significant difference between the groups (P = .507). Dysesthesia was the most common complication in both groups. Only transient induration was significantly different between EVLA (7.1%) and phlebectomy (0.0%) (P = .001). The two approaches had an equal impact on quality of life and disease severity. ConclusionsTreatment complications were similar in phlebectomy and EVLA and to those previously described in the literature.

Reflux origin of the insufficient small saphenous vein by duplex ultrasound determination and consequences for therapy considering the saphenopopliteal junction type: Presented at the Sixty-third Annual Meeting of the German Society of Phlebology (DGP), Aachen, German, September 8-11, 2021, and presented at the Twenty-third Annual Meeting of the European Venous Forum, Berlin, Germany, June 22-24, 2023.

Reflux origin of the insufficient small saphenous vein by duplex ultrasound determination and consequences for therapy considering the saphenopopliteal junction type: Presented at the Sixty-third Annual Meeting of the German Society of Phlebology (DGP), Aachen, German, September 8-11, 2021, and presented at the Twenty-third Annual Meeting of the European Venous Forum, Berlin, Germany, June 22-24, 2023.

Reflux origin of the insufficient small saphenous vein by duplex ultrasound determination and consequences for therapy considering the saphenopopliteal junction type

ObjectiveThe reflux pathophysiology of the saphenofemoral junction (SFJ) of the insufficient great saphenous vein (GSV) has already been investigated and stratified. These results are still lacking for the small saphenous vein (SSV). The aim of the study was to analyze the pathophysiology of the saphenopopliteal junction (SPJ) in case of refluxing SSV. MethodsThe study included 1142 legs investigated between April 1, 2019, and February 15, 2023, with chronic venous insufficiency scheduled for endoluminal thermal ablation of the insufficient SSV. Preoperatively, a standardized duplex ultrasound assessment of the SPJ including the cranial extension of the SSV and the Giacomini vein, respectively, was performed to determine the origin of reflux. Having in mind, that the draining type according to Cavezzi is relevant to the treatment planning, after having scanned 152 legs, the protocol was extended to this feature: Cavezzi type A1 or A2 was recorded on 990 legs. ResultsIn 984 cases (86%), saphenopopliteal reflux from the popliteal vein into the insufficient SSV was detected, and in 181 cases of these (16%), simultaneous refluxing blood from the cranial extension or Giacomini vein was found. In 119 cases (10%), reflux resulted only from the cranial extension or Giacomini vein with a competent SPJ, and in 39 cases (3%), the reflux source was diffusely from side branches and/or perforating veins. Cavezzi’s junction types A1 (independent junction of SSV and muscle veins) and A2 (muscle veins join into SSV, draining together into the popliteal vein through the SPJ) were found in 65% and 35% of cases, respectively. ConclusionsThe insufficient SSV shows a high frequency of axial reflux from the deep into the saphenous vein with an indication for high ligation or thermal ablation at the level of the SPJ or immediately distal to the inflow of muscular veins depending on the junction type. In 14%, based on this study, we observed a competent junction of the SSV without indication for ligation or thermal destruction of the SPJ.

Prospects of Endovenous Laser Ablation (EVLA) Standardization-Mid-Term Results of a Four-Zone Dosimetry Guiding Tool for 1940 nm Laser.

Heterogeneity regarding dosimetry and reporting of endovenous laser ablation (EVLA) mandates the development of a standardized protocol. This study presents the mid-term results of EVLA with 1940 nm-laser and radial-fibre, supported by a four-zone dosimetry tool. Four anatomical dosimetry zones for great saphenous veins (GSV) and two for small saphenous veins (SSV) were defined with set power levels. Zone-1G (4 W) extended from the inguinal ligament to the apex of femoral triangle, Zone-2G (4 W) from the apex of femoral triangle to the upper border of patella. Zone-3G (3 W) from the patella to the tibial tuberosity. Zone-4G (2 W) extended from the tibial tuberosity to the ankle. Zone-1S from the sapheno-popliteal junction to the tibial tuberosity. Zone-2S from the tibial tuberosity to the ankle. Power was increased by 1 W for veins >10 mm and decreased by 1 W when fibre sticking was encountered. Pullback-velocity was max. 1 mm/s. A total of 152 consecutive patients (185 procedures) were recruited. Mean follow-up time was 11.9 months. Mean linear endovenous energy density for GSV was Zone-1G:42 J/cm, Zone-2G:33 J/cm, Zone-3G:27 J/cm, Zone-4G:22 J/cm, Zone-1S:34 J/cm, Zone-2S:27 J/cm. Occlusion rates were 98.9% (1-month) and 93.7% (12-months). Complications at 1 M were low, namely laser-induced paraesthesia (LIP) 2.2% and endovenous heat-induced thrombosis (EHIT) 1.6%. Persistent LIP (12 M) was observed in 0.5%. The proposed four-zone guiding tool is a step towards standardizing dosimetry and documentation for EVLA with 1940 nm. This strategy shows good mid-term results with minimal complications. Long-term follow-up and application in further centres are necessary to prove its reproducibility. Such a guiding tool could improve the ability to analyse, compare and review different EVLA wavelengths and fibre types.

Assessment of Relationship between Saphenofemoral Junction Reflux and Great Saphenous Vein Diameter using Doppler Ultrasonography in Patients with Chronic Venous Disease: A Cross-sectional Study

Introduction: Chronic venous disease is a commonly occurring disease that includes a variety of pathological conditions like varicose veins, oedema, skin abnormalities, and ulceration, among which the most prevalent are the varicose veins. Doppler imaging is presently the first investigation for evaluating chronic venous disease. Aim: To investigate the relationship between Saphenofemoral Junction (SFJ) reflux and Great Saphenous Vein (GSV) diameter in patients with chronic venous disease and to determine the best cut-off value of GSV diameter in predicting reflux. Materials and Methods: The present cross-sectional study was conducted in the Department of Radiology, SRM Medical College and Hospital, Tamil Nadu, India, from December 2019 to June 2021 on 76 patients with chronic venous disease. The study was conducted on a GE Logic P9 ultrasound machine, the diameter of GSV was measured close to the SFJ, at the Proximal Thigh (PT); 15cm distal to the SFJ, and at the calf. The diameter of the GSV was compared with the presence of SFJ reflux. Similarly, Short Saphenous Vein (SSV) diameter was also measured posterior to the knee and was correlated with Saphenopopliteal Junction (SPJ) reflux. Chi-square and student t-tests were used for analysis with a cut-off value determined through Receiver Operating Characteristic (ROC) curve analysis. Results: The mean age of study participants was 51±15.85 years with age range of 19 years to 78 years. Of total, 42 (55.26%) had chronic venous insufficiency on the left side and 34 (44.74%) had on the right side. The mean GSV diameter at SFJ and at PT was higher in patients with SFJ incompetence and was statistically significant with a p-value of 0.001 and 0.002, respectively by t-test. Although the mean GSV diameter at calf was higher in patients with SFJ incompetence, it was statistically insignificant. The GSV diameter at the SFJ had the best cut-off value for predicting incompetence, with a mean diameter of 5.95 mm with 76.3% sensitivity and 76.3% specificity. The cut-off of SSV at the posterior knee for predicting SPJ incompetence was 4.6 mm which had a sensitivity of 72.7% and specificity of 88.7% and diagnostic accuracy of 86.84%. Conclusion: The GSV diameter at SFJ and PT help in predicting SFJ incompetence. The SSV diameter at SPJ aids in predicting SPJ incompetence.

Factors Affecting Residual Stump Length Following Endovenous Laser Ablation.

Current instruction for endovenous laser ablation (EVLA) recommends that the laser fibre tip should be at least 2cm caudal to the saphenofemoral or saphenopopliteal junction. This is to reduce risk of deep vein thrombosis (DVT) whilst ensuring that the Great Saphenous Vein (GSV)/Short saphenous vein (SSV) occlusion (residual stump) is close to the SFJ/SPJ to reduce recurrence rates. Our aim was to primarily assess the effects of pre-operative junction distance of the laser fibre on stump length but also look at other factors affecting this. This was a retrospective analysis of an electronic collected database performing EVLA of the GSV and SSV under local anaesthesia. Patients with previous venous thromboembolic events and incomplete data were excluded. Patients were reviewed at 6weeks with venous Duplex scan to assess for the residual stump distance and DVT. Multivariable logistic regression was used to account for confounders. Between 2012 and 2018, 2341 patients underwent EVLA and complete data were available on 825 (35.2%) patients. All patients were scanned 6weeks after procedure. Sixty-nine patients (8.4%) had flush occlusion, 3 patients (.4%) had extension into femoral or popliteal vein but not considered to be a DVT and 1 patient had a DVT. High BMI and increasing length of the pre-operative junction was associated with lower incidence of flush occlusion; higher rates of flush occlusions were noted in patients undergoing short saphenous vein (SSV) EVLT (OR 4.11, 95% CI 2.34-7.20; P < .001). Consideration should be given to increase the intra-procedure laser tip junction to more than 2cm particularly in patients undergoing SSV treatment to ensure that residual stump is sufficiently distal to SPJ and SFJ reducing risks of thrombus into the femoral or popliteal veins. Lower BMI may be associated with higher risk of this though the reasons for this are unclear.

Persistent sciatic vein.

Venous anomalies of the lower extremity are a challenge when found as rare variations. Physicians should be aware of morphological variations in this region for correct diagnosis and management of diseases such as deep vein thrombosis. During the routine dissection of the lower extremities of a Caucasian male cadaver, a case of persistent sciatic vein was found. A persistent sciatic vein originating from the saphenopopliteal junction coursed proximally and laterally to enter into the adductor magnus muscle, at the right side. Running through the fibres of the adductor magnus anteriorly, the variant vein drained into the deep femoral vein just medial to the vastus medialis muscle. As being a rare congenital vascular anomaly, the persistent sciatic vein should be correctly diagnosed and defined during the radiologic assessments, surgical interventions and blockades for better outcomes and lesser complications.

Superficial venous thrombosis, varicose veins, and chronic venous insufficiency: an update for clinical practice

Venous disorders affect alarge proportion of the German population (varicose veins 13.3%, chronic venous insufficiency 40.8%). Based on current literature, apractically oriented update on superficial venous thrombosis, varicosis, and chronic venous insufficiency is provided. Superficial vein thrombosis of the legs requires comprehensive duplex ultrasonography of the superficial and deep leg veins. Only superficial vein thrombosis less than 5 cm in length and more than 3 cm from the saphenofemoral or saphenopopliteal junction can be treated conservatively with compression, cooling, and relative immobilization. Superficial vein thrombosis greater than 5 cm in length with more than 3 cm distance to the deep venous system is treated pharmacologically with fondaparinux for 45days (approved for 30-45days). If the surface thrombus reaches the saphenofemoral or saphenopopliteal junction at adistance of less than 3 cm, therapy analogous to deep vein thrombosis is required for 3months. The most effective therapy for varicose veins is invasive removal. In this regard, endovenous thermal ablation has become particularly important in recent years, given that its effectiveness is of asimilar order of magnitude to that of crossectomy and stripping surgery, but the complication rates are significantly lower. Invasive removal of varicose veins not only improves patients' quality of life, but also significantly reduces the risk of deep vein thrombosis. Recent epidemiological data demonstrate an increased risk of cardiovascular disease in patients with chronic venous insufficiency. There is preliminary evidence that this risk of cardiovascular disease in varicose vein patients can be lowered by varicose vein therapy.

Anterior accessory great saphenous vein as a cause of postoperative recurrence of veins after radiofrequency ablation.

There are problems of postoperative relapse of veins after radiofrequency ablation (RFA). The study aims to analyze the causes of postoperative recurrence of veins after RFA. 928 patients with varicose veins of the lower extremities, clinical classes C2-C4 according to the CEAP classification, were treated in the ambulatory surgery centers using RFA. The causes of varicose recurrence showed that it was caused by: a) high fusion of the anterior accessory great saphenous vein (AAGSV) with great saphenous vein (GSV) directly in the saphenofemoral junction (SFJ), which was not revealed by preoperative ultrasound (1.7%); a long stump of the GSV after the RFA (7.8%); progression of varicose disease with the small saphenous vein (SSV) and formation of new reflux associated with insufficiency of the saphenopopliteal junction (SPJ) (4.7%); d) insufficiency of perforating veins of the tibioperoneal group (Sherman, Boyd), as well as Gunter (3.8%); e) neovascularization with dilation of small vessels in the area of the saphenofemoral junction (0.97%). A comparative assessment of the quality of life (QL) after different surgery methods 3 years after implementation was carried out. Thus, QL in all patients who underwent surgery significantly improved than before surgery. However, after the RFA GSV+AAGSV, the patients had better QL by all scales than those who underwent only RFA GSV. Operations performed simultaneously on GSV and AAGSV have better functionality than GSV-only RFA.

Frequency of Sapheno-Femoral Junction and Sapheno-Popliteal Junction Incompetence on Duplex Ultrasonography in Patients with Varicose Veins

Objective: To determine frequency of sapheno-femoral junction (SFJ) and sapheno-popliteal junction (SPJ) incompetence on duplex ultrasonography in patients with varicose veins.Study Design: Cross-sectional study.Place and Duration of Study: Shaikh Khalifa Bin Zayed Al-Nahyan/Combined Military Hospital, Rawalakot, Azad Jammu &amp; Kashmir, from Aug 2019 to Feb 2020.Methodology: A total of 70 patients were selected using non-probability, consecutive sampling. After ethical approval, informed consent and relevant history taking, duplex ultrasonography (DUS) was done in standing and supine positions in patients with varicose veins, fulfilling inclusion and exclusion criteria. Presence or absence of SFJ and SPJ incompetence was assessed.Results: Mean age was 41.99 ± 11.08 years with 36 (51.43%) patients between 36-50 years. Mean duration of disease was 6.33 ± 2.29 months while 47 (67.14%) patients had symptoms for more than 6 months at the time of presentation. Occupation wise, 40 (57.14%) patients were field workers while 30 (42.86%) were office and domestic workers. Isolated SFJ, SPJ and combined junction incompetence were found in 27 (38.57%), 20 (28.57%) and 23 (32.86%) patients respectively. Both SFJ and SPJ incompetence were more in obese patients (78.6% and 71.4% respectively) as compared to non-obese patients.&#x0D; Conclusion: Frequency of SFJ incompetence was more than SPJ incompetence on DUS. Obesity, male gender and prolonged motionless standing predispose to the development of varicose veins. Preventive measures and early diagnosis can decrease disease burden.

Association between the saphenous vein diameter and venous reflux on computed tomography venography in patients with varicose veins.

Three-dimensional computed tomography venography is a useful tool to identify increased saphenous vein diameter and provides a complementary road map for surgery in patients with varicose veins. In this study, we investigated the correlation between saphenous vein diameter on computed tomography venography and venous reflux detected on duplex ultraonography. We enrolled 152 patients (213 extremities) who underwent endovenous laser ablation therapy, following high ligation of the saphenofemoral junction between January 2014 and December 2019. All patients underwent preoperative computed tomography venography evaluation. The saphenous vein diameter was measured on computed tomography venography, and venous reflux was evaluated in the operating room using Doppler ultrasonography. Among the 152 patients included in the study, 61 showed varicose veins affecting the bilateral extremities. Among the 213 extremities investigated, 165 (77.5%) and 48 (22.5%) extremities showed varicosities involving the greater and lesser saphenous veins, respectively. Among all extremities, venous reflux was detected in 172 (80.8%). The mean diameter of the greater saphenous vein measured 5 cm distal to the saphenofemoral junction was 8.07±1.82 mm in patients with reflux and 5.11±1.20 mm in patients without reflux (p < .05). The small saphenous vein diameter measured 5 cm distal to the saphenopopliteal junction was 7.65±1.74 mm in patients with reflux and 5.04±1.80 mm in patients without reflux (p < .05). Based on the receiver operating characteristic curve, the greater saphenous vein threshold diameter of 5.880 mm measured 5 cm distal to the saphenofemoral junction was the optimal cut-off value to predict reflux (sensitivity 91.4%, specificity 81.8%). The lesser saphenous vein diameter of 5.285 mm measured 5 cm distal to the saphenopopliteal junction was the optimal cut-off value to predict reflux (sensitivity 94.9%, specificity 75.0%). Vein diameter cannot be used as an absolute reference for venous reflux; however, it may have predictive value in patients with varicose veins. Computed tomography venography based measurements of vein diameter may serve as a useful diagnostic tool to predict venous reflux and recommend treatment.

Anticoagulants in the treatment of superficial vein thrombosis of lower limbs: possibilities and limitations

This article presents a critical analysis of the results of three prospective randomized controlled trials of anticoagulant use in patients with superficial vein thrombosis of lower limbs CALISTO using fondaparinux sodium, STEFLUX using different doses of parnaparin sodium, and SURPRISE comparing the effectiveness and safety of fondaparinux sodium and the preventive dose of the oral anticoagulant rivaroxaban.Evidence from these clinical trials suggests that low-dose anticoagulants should be used for at least 1.5 months in superficial vein thrombosis of lower limbs with thrombus localization beyond 3 cm from the saphenofemoral and/or saphenopopliteal junction. However, anticoagulant treatment does not appear to prevent the progression of venous thrombosis after withdrawal, so in patients with persisting risk factors, it is reasonable to consider extended treatment. This seems to apply primarily to patients with superficial thrombophlebitis a history of superficial or deep venous thrombosis in the lower extremities, a family history of venous thromboembolic complications, and possibly a broader contingent of high-risk patients, not represented in the CALISTO and STEFLUX studies (with active malignancy, ongoing anticancer therapy, severe chronic heart or respiratory failure, inability to withdraw hormone replacement therapy, autoimmune disease). According to the accumulated evidence, subcutaneous injections of fondaparinux sodium, intermediate doses of low molecular weight heparin, and direct oral anticoagulant rivaroxaban in the dose of 10 mg once a day are effective and sufficiently safe in the treatment of superficial vein thrombosis of lower limbs with localization beyond 3 cm from the saphenofemoral and/or saphenopopliteal junction. Questions about the feasibility of increasing the doses of anticoagulants to further reduce the rate of superficial thrombophlebitis - progression during treatment and the optimal duration of their use remain open.

RECURRENT VARICOSE VEINS FOLLOWING SMALL SAPHENOUS VEIN SURGERY: A 5-YEAR FOLLOW-UP DUPLEX ULTRASOUND STUDY.

Chronic venous disease (CVD) of the lower limbs is a very prevalent medical condition with important socioeconomic repercussions. Small saphenous vein (SSV) incompetence, although less frequent than great saphenous vein (GSV) incompetence, presents a more challenging treatment, with higher rates of complication and recurrence. To determine the incidence and associated risk factors of varicose veins recurrence in patients submitted, for the first time and exclusively, to SSV surgery with 5 years of follow-up. Retrospective analysis of all exclusively first-time SSV surgeries, at Angiology and Vascular Surgery Service of Hospital Beatriz Ângelo, between January 1st, 2013, and December 31st, 2014. In March 2019, the authors performed clinical and venous doppler ultrasound reassessment of all included patients. A total of 23 limbs were evaluated, 56.5% were female and the mean age was 51.8 years. All patients were symptomatic and underwent ligation of the saphenopopliteal junction (SPJ), 26.1% and 43.5% had total and partial SSV stripping, respectively. After venous doppler ultrasound at 5-year follow-up, we found that 21.7% did not present a correct SPJ ligation due to failure to identify its location, with a statistically significant association between SPJ ligation and varicose vein recurrence. In follow-up, we also diagnosed GSV incompetence in 21.7% for the first time, which is in agreement with the fact that this is a chronic disease. Finally, we found that all patients with symptomatic recurrence at 5-year follow-up had CVD, however, some asymptomatic patients also had ultrasound changes. Routine preoperative localization of the SPJ by doppler ultrasound guidance could have an impact in minimizing varicose vein recurrence. Imaging recurrence does not always translate into clinical recurrence. Because this is a chronic disease, patients should keep general care to prevent disease progression, even after surgery.

Experience with VariClose® vein sealing system in the Czech Republic.

The aim of this study was to assess occlusion rates of saphenous veins treated with the VariClose vein sealing system. A retrospective analysis including a total of 64 patients from four centres from the Czech Republic. Occlusion was defined as a non-compressible vein with absence of flow with exception to the first 3 cm from the saphenofemoral or saphenopopliteal junction on duplex ultrasound. In 64 patients a total of 79 veins were treated. Technical success of the procedure was achieved in 74 (94%) of cases. The mean follow-up was 5.5 months. The closure rates calculated by the Kaplan-Meier method at 1, 3, 6 and 12 months were 94%, 85%, 69% and 36%, respectively, and there were no significant differences between centers. The average difference in VCSS score before and after the procedure was 1.8. The present study demonstrated surprisingly worse occlusion rates than the current literature.

Psychometric properties of the short version of the Freiburg Life Quality Assessment for chronic venous disease

BackgroundChronic venous disease is a frequent vascular condition. International societies have recommended the use of health-related quality of life (HRQoL) instruments in the assessment of patients with vascular diseases. Thus, the Freiburg Life Quality Assessment for chronic venous disease, 10-item questionnaire (FLQA-VS-10) was developed. The aim of the present study was to validate the FLQA-VS-10 in a prospective study. MethodsWe recruited 100 patients with recurrent varicosis or incomplete or complete venous insufficiency undergoing interventional vein treatment (high ligation of the great or small saphenous vein or endovenous ablation therapy). These patients completed the FLQA-VS-10 and instruments assessing convergent validation criteria at four points: preoperatively (T1), postoperatively (T2) and twice 3 years later with a 1-week interval (T3 and T4). ResultsThe mean age was 56.0 ± 13.7 years, and 66.0% were women. The patients had presented with recurrent varicosis of the saphenofemoral junction (28.0%), recurrent varicosis of the saphenopopliteal junction (1.0%), incomplete or complete insufficiency of the great saphenous vein (69.0%), or complete insufficiency of the small saphenous vein (2.0%). The items showed few missing values. The FLQA-VS-10 global score showed no ceiling effect (patients reporting the highest possible impairments in HRQoL) but did show a floor effect (patients reporting the lowest possible impairments in HRQoL), which was highest at the postoperative assessments. The internal consistency of the global score was high at all measurement points. A convergent validity and responsiveness analysis revealed that the FLQA-VS-10 correlated in the expected direction with the convergent instruments, including the Freiburg Life Quality Assessment for venous diseases (venous disease-specific HRQoL) and the five-level EQ-5D (generic HRQoL). Data from T3 and T4 revealed high test-retest reliability (intraclass correlation, 0.92). Overall, the patients stated that the FLQA-VS-10 was comprehensible, comprehensive, and easy to complete. ConclusionsOur data suggest that the FLQA-VS-10 is a reliable, valid, responsive, and feasible HRQoL questionnaire for patients with chronic venous diseases. This questionnaire can serve as short and easy-to-use instrument to assess patient-reported outcomes in the treatment of these patients.

Comparison of mechanochemical ablation versus ligation and stripping for the treatment of incompetent small saphenous vein.

to compare the outcomes of mechanochemical ablation (MOCA) versus saphenopopliteal junction ligation and stripping (OS) for symptomatic small saphenous vein (SSV) insufficiency. This is a retrospective study including symptomatic SSV patients treated with MOCA using the ClariVein catheter (Merit Medical, South Jordan, Utah, USA) or OS from 2015 to 2019. A total of 60 limbs (73.3% women, mean age 54.7 ± 14.4 years) were treated with MOCA and 58 limbs (63.8% women, mean age 54 ± 11.6 years) with OS. At 18 months follow-up, recurrence rates were 7.5% (4/53) for MOCA vs. 5.7% (3/52) for the OS group. MOCA group was associated with less pain at first postoperative day, and an early return to work (MOCA 3.5 ± 2.3 days vs. OS 14.2 ± 3.8 days, p < .0001). No cases of leg paresthesia/dysesthesia were observed in the MOCA group, while two patients (3.4%) presented neurological symptoms after OS treatment. MOCA and OS are both safe and effective techniques for symptomatic SSV insufficiency. MOCA group demonstrated to be associated with less postoperative pain and early return to work compared to OS.