Severe Chronic Venous Disease Research Articles

Asociación entre sistemas venosos insuficientes y manifestaciones clínicas en enfermedad venosa crónica de miembros inferiores

Introduction: The clinical, etiological, anatomical, and pathophysiological classification (CEAP) standardizes the manifestations of lower limb venous disease. Objective: To investigate the association between insufficient venous systems and the clinical classification of CEAP. Methods: A quantitative, cross-sectional, analytical, correlational study was conducted. Sampling was non-probabilistic and convenience-based. The sample size was 136 lower limbs from 71 patients. Chi-square, Monte Carlo and Odd ratio (OR) statistical tests were used with 95% confidence intervals through bivariate logistic regression (p<0.05). Results: 71.8% of the subjects were female, with an average age of 66.1 years. The most frequent insufficient venous system was the superficial system, present in 61.7% of cases. 100% of the dilated great saphenous veins (GSV) had insufficiency. The most common CEAP clinical class was C2 (44.9%); 35.1% of C1 (telangiectasia) cases had an insufficient venous system; 50% of C2 cases had GSV insufficiency (p=0.227). There was an association between the insufficiency of both superficial and deep venous systems and the CEAP clinical classification (p=<0.001). The deep venous system was associated with severe chronic venous disease of the lower limbs, OR (6.04) with a 95% CI (1.02-35.73) and p=0.047. Conclusions: The study demonstrated an association between the insufficiency of both superficial and deep venous systems and the CEAP clinical classification. One third of the lower limbs with C1 (telangiectasias) had an insufficient venous system.

Factors associated with lack of clinical improvement after vein ablation in the vascular quality initiative

BackgroundInsurance companies have adopted variable and inconsistent approval criteria for chronic venous disease (CVD) treatment. Although vein ablation (VA) is accepted as the standard of care for venous ulcers, the treatment criteria for patients with milder forms of CVD remain controversial. This study aims to identify factors associated with a lack of clinical improvement (LCI) in patients with less severe CVD without ulceration undergoing VA to improve patient selection for treatment. MethodsWe performed a retrospective analysis of patients undergoing VA for CEAP C2 to C4 disease in the Vascular Quality Initiative varicose veins database from 2014 to 2023. Patients who required intervention in multiple veins, had undergone prior interventions, or presented with CEAP C5 to C6 disease were excluded. The difference (Δ) in venous clinical severity score (VCSS; VCSS before minus after the procedure) was used to categorize the patients. Patients with a ΔVCSS of ≤0 were defined as having LCI after VA, and patients with ≥1 point decrease in the VCSS after VA (ΔVCSS ≥1) as having some benefit from the procedure and, therefore, “clinical improvement.” The characteristics of both groups were compared, and multivariable regression analysis was performed to identify factors independently associated with LCI. A second analysis was performed based on the VVSymQ instrument, which measures patient-reported outcomes using five specific symptoms (ie, heaviness, achiness, swelling, throbbing pain, and itching). Patients with LCI showed no improvement in any of the five symptoms, and those with clinical improvement had a decrease in severity of at least one symptom. ResultsA total of 3544 patients underwent initial treatment of CVD with a single VA. Of the 3544 patients, 2607 had VCSSs available before and after VA, and 420 (16.1%) had LCI based on the ΔVCSS. Patients with LCI were more likely to be significantly older and African American and have CEAP C2 disease compared with patients with clinical improvement. Patients with clinical improvement were more likely to have reported using compression stockings before treatment. The vein diameters were not different between the two groups. The incidence of complications was overall low, with minor differences between the two groups. However, the patients with LCI were significantly more likely to have symptoms after intervention than those with improvement. Patients with LCI were more likely to have technical failure, defined as vein recanalization. On multivariable regression, age (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00-1.02) and obesity (OR, 1.47; 95% CI, 1.09-2.00) were independently associated with LCI, as was treatment of less severe disease (CEAP C2; OR, 1.82; 95% CI, 1.30-2.56) compared with more advanced disease (C4). The lack of compression therapy before intervention was also associated with LCI (OR, 6.05; 95% CI, 4.30-8.56). The analysis based on the VVSymQ showed similar results. ConclusionsLCI after VA is associated with treating patients with a lower CEAP class (C2 vs C4) and a lack of compression therapy before intervention. Importantly, no significant association between vein size and clinical improvement was observed.

A Narrative Review of Advancements in Understanding and Treating Varicose Veins.

Chronic venous disease, with varicose veins as its archetypal manifestation, stands as a pervasive and intricate health quandary, encompassing a vast array of contributing factors. Age, genetics, obesity, pregnancy, and prolonged immobility weave a complex tapestry, underscoring the omnipresence of this ailment. Its societal and economic footprint is undeniably formidable, as diverse classifications underscore its multifaceted character. The intricate interplay of chronic venous disease with diabetes mellitus and neuropathy compounds the challenge, fostering soaring healthcare expenditures and a palpable erosion of quality of life, particularly among women harboring cardiometabolic risk factors. Despite research shedding light on heightened susceptibility within certain demographics, the enigmatic determinants orchestrating the transition from mild to severe chronic venous disease continue to elude us. Varicose veins, marked by the presence of dilated and tortuous subcutaneous vessels, precipitate both physical discomfort and cosmetic concerns, frequently necessitating meticulous clinical evaluation coupled with ultrasound studies to secure a precise diagnosis. Treatment strategies are strategically crafted to ameliorate distressing symptoms, enhance aesthetic concerns, and forestall potential complications. Nevertheless, the prognostication of chronic venous disease remains ensconced in a degree of ambiguity, hinting at the vast terrain yet to be charted in this medical domain. The quest to fathom the intricacies of this condition uncovers an ever-evolving panorama where conservative interventions play an indispensable role in managing mild cases, while interventional procedures like endovenous laser ablation and sclerotherapy step onto the stage for patients grappling with severe symptoms, thus treading the fine line between efficacy and invasiveness. Moreover, a meticulous economic analysis underscores the cost-effectiveness of various therapeutic modalities, thereby bolstering the imperative of a patient-centered approach. As we navigate the labyrinthine complexities of chronic venous disease and varicose vein management, we are inexorably drawn to the pivotal role of customized treatment approaches, as well as the dynamic interplay between scientific progress, patient preferences, and therapeutic innovations in the relentless pursuit of optimized outcomes and an enhanced quality of life.

Polymorphisms in some proinflammatory genes (TNFα and β, IL-1β, IL-6, ADAM17) in severe chronic venous disease.

Chronic venous disease (CVD) is a common disorder of lower extremities. The study was scheduled to investigate the relationship between polymorphisms in major proinflammatory genes TNF α (-238 A/G; -308 A/G), TNF β (NcoI), IL-1β (+3953 T/C); IL-6 (-174 G/C; -596 G/C) and ADAM17 (3'TACE) and CVD risk. Genotype-phenotype study was calculated to test possible association between examined genotypes and phenotypes of CVD. Finally, 150 CVD patients and 227 control subjects were enrolled to the study. Genotypes in proinflammatory gene polymorphisms were identified from isolated DNA by PCR method and restriction analysis. Significant differences in genotype distribution/allelic frequencies in TNF β gene, IL-1 β gene and in ADAM17 gene polymorphisms were found between CVD women and control ones. In the genotype-phenotype study, identified genotypes were associated with arterial hypertension (ADAM17, IL-6-men), ischaemic heart disease (TNF α and β genes), diabetes mellitus (ADAM17-women, TNF β-men), age of CVD onset (TNF α and IL-6), ulceration (ADAM17), duration of ulceration (ADAM17), ulceration recurrence (ADAM17-women), home care necessity (TNF α), varices surgery (TNF α), erysipelas development (ADAM17-men) and tumour development (TNF α). Studying of these polymorphisms associations can help us better identify patients at higher risk of developing severe CVD.

A shear-wave sonoelastography investigation of calf muscle pump biomechanics in patients with chronic venous disease and healthy controls

Background: chronic venous disease (CVD) is a common progressive disorder with incompetence of calf muscle pump due to weakness and ankle mobility abnormality is an important etiological factor in CVD, but the biomechanical properties of calf muscle pump are remain unknown. ObjectivesThe purpose of the present study was to evaluate group differences between the biomechanical properties changes of the medial gastrocnemius muscle (GM) and its fascias in participants with CVD and healthy controls. MethodsIn this case-control study, thirty patients with CVD in three equal groups (mild: C1 – C2, moderate: C3 – C4, severe: C5 – C6) and 20 healthy subjects in a control group participated. The medial GM and its fascias shear modulus (stiffness) were measured using a shear-wave sonoelastography in rest and active dorsiflexion positions of ankle joint. ResultsThe results of variance (ANOVA) analysis showed a significant difference in shear wave elastography (SWE) value between the groups for medial GM and its fascias at rest and active dorsiflexion of the ankle joint (P < 0.05). There was a statistically significant increase in SWE value of the medial GM and its fascias in moderate (c3-c4) and severe CVD groups (C5–C6) compared to the control and mild (C1–C2) CVD groups. A positive correlation was discovered between disease grades and the medial GM and its fascias SWE in patients with CVD ranging between r = 0.846 to 0.891; P < 0.001. ConclusionAn alteration stiffness in calf myofascial pump as compared to control group indicated an impaired myofascial biomechanics. Calf myofascial SWE may be valuable information in the diagnosis and follow-up processes of patients with CVD.

Risk Factors for and Treatment of Chronic Venous Disease in Thai Patients.

IntroductionThe prevalence of chronic venous disease (CVD), a common health care problem, is still underestimated. A few previous epidemiologic studies have report Asian patients with this condition in western countries, but not in Asian countries. The aim of this study was to determine risk factors for CVD and its treatment in Thai individuals.MethodsIn this cross-sectional study, we collected data of patients with CVD visiting Chulabhorn Hospital Vascular Clinic from 1 December 2018–1 October 2021. We reviewed medical records for patient characteristics, comorbidities, Clinical, Etiology, Anatomy, Pathophysiology (CEAP) categories, Venous Clinical Severity Score (VCSS), ultrasound findings and treatment.ResultsThe study cohort comprised 260 CVD patients with CVD of mean age 61.92 ± 12.82 years. Almost 80% of participants were female. A history of deep vein thrombosis (DVT) was the strongest risk factor for severe CVD. Other identified risk factors comprised body–mass index (BMI) >30 kg/m2, and older age. The most common CEAP categories were C2 (39%) and C1 (33.8%). Superficial venous reflux was the most common location of venous reflux in this study, 67.32% of participants having great saphenous vein reflux and 16.99% small saphenous vein reflux. Only 4.76% of our cohort had both reflux and obstruction. Most of the participants had undergone compression therapy, approximately half of them complying well with wearing of stockings. Nineteen percent of our cohort had undergone sclerotherapy and 14% surgery, which comprised radiofrequency ablation in 97% of them.ConclusionThe major risk factors for severe CVD identified in this study were deep vein thrombosis, body mass index>30 kg/m2 and older age. The most common CEAP category was C2 (39%). GSV was the most commonly involved venous system. Involvement of numerous venous systems was a risk factor for severe CVD.

Subcutaneous calcifications in legs with chronic venous diseases

BackgroundCalcifications in the subcutaneous layer (SCL) have been described by radiographic studies of legs with advanced chronic venous disease (CVD). However, SCL calcifications have rarely been included among the CVD-related changes. The aim of the present study was to evaluate the prevalence and morphology of SCL calcifications in legs with CVD of all grades of severity determined by ultrasound. MethodsA total of 500 legs in 250 patients (148 women and 102 men; mean age, 51 years; range, 18-87 years) referred to our vascular clinic for symptoms and signs of CVD were included. After duplex ultrasound evaluation of the deep, superficial, and perforating veins, the skin and SCL were investigated using duplex ultrasound. Those patients with other possible causes of SCL calcification were excluded. ResultsUsing the C component of the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, 43 legs were classified as C1, 189 as C2, 34 as C3, 16 as C4A, 45 as C4B or C, 18 as C5, and 16 as C6. Varicose veins were reported in 273 legs, and lipodermatosclerosis in 79 legs. Subcutaneous calcifications were demonstrated in 35 of 361 legs with CVD in two different locations: the wall of superficial varicose veins and in subcutaneous tissue unrelated to the path of the superficial veins. Superficial veins calcifications were found in 12 of 273 legs with varicose veins (4.4%) and were found in older patients with severe varicose vein disease (grade 3 using the venous clinical severity score and disease duration >30 years). Subcutaneous tissue calcifications (STCs) were found in 24 of 95 legs with a more advanced CVD stage (C4A-C6). No STCs were found in legs with a C1, C2, or C3 class. ConclusionsSuperficial veins calcifications were found only in the legs with severe and long-lasting varicose veins and seemed to be related to chronic severe inflammation of the venous wall. STCs were independent of the vein wall and were found only in the damaged areas of legs with severe CVD (C4-C6). STCs are possibly related to chronic inflammation of the subcutaneous tissue. Their avulsion from the ulcer bed has been recommended to facilitate ulcer healing and prevent recurrence.

Association of chronic venous disease with major adverse cardiovascular events

ObjectiveThe aim of the present study was to examine whether severe chronic venous disease (CVD) is associated with a greater risk of major adverse cardiovascular events (MACE) compared with mild CVD. MethodsParticipants with CVD were prospectively recruited from outpatient vascular departments at two hospitals in North Queensland, Australia. CVD severity was ascertained by vascular specialists using the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification. MACE, defined as myocardial infarction, stroke, or cardiovascular death, were identified from the outpatient follow-up and linked medical records. Kaplan-Meier and Cox proportional hazard analyses were used to examine the association of CVD severity with the occurrence of MACE. A subanalysis was performed in which participants with CEAP C5 and C6 (severe CVD) were compared with those with CEAP C2 to C4 (mild CVD). ResultsA total of 774 participants were included and followed up for a median of 3.09 years (interquartile range, 1.09-8.14 years). The participants with C6 CVD (n = 69) had a threefold greater risk of MACE (hazard ratio, 3.03; 95% confidence interval, 1.02-9.03; P = .046) compared with those with C2 CVD (n = 326) after adjusting for other risk factors. Participants with severe CVD had an increased risk of MACE compared with those with mild CVD (adjusted hazard ratio, 2.37; 95% confidence interval, 1.12-5.04; P = .024). ConclusionsIndividuals with severe CVD have an increased risk of MACE compared with those with mild CVD, independently of traditional risk factors. Further research is required to clarify the cause of the excess risk.

Ultrasound-Guided Foam Sclerotherapy of Insufficient Perforator Veins in Patients With Severe Chronic Venous Disease

Ultrasound-Guided Foam Sclerotherapy of Insufficient Perforator Veins in Patients With Severe Chronic Venous Disease

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.

Major risk factors for chronic venous disease development in women: is childbirth among them?

ABSTRACTMany studies have reported that Chronic venous disease (CVD) occurs more in females than males, due to pregnancy. The study was conducted over the period 2014–2015 at the Dermatovenereological clinic, Novi Sad, Serbia. We performed a cross-sectional study of 554 women. According to Clinical-Etiology-Anatomy-Pathophysiology (CEAP) staging, the sample was divided into three groups: Mild CVD (classes 1–3 by CEAP) – n = 72; Severe CVD (classes 4–6 by CEAP) – n = 122 and a Control (no CVD) – n = 360 patients. The age range of participants was 18 to 93 years (average 54.92 years). Most important CVD risk factors were examined in detail. Out of 554 examinees, 22.03% had severe CVD, and 12.99% had mild CVD. Bivariate analyses showed a significantly higher proportion of women who had deliveries in the severe CVD and mild CVD groups, compared with the control group. Other significantly related factors were older age, family history of varicose veins, standing job position and hypertension. After performing multiple logistic regression analysis, older age, standing job position and family history of varicose veins remained significant, while childbirth lost its significance. Our results suggest that childbirths are not associated with the occurrence of CVD

The Seriousness of Chronic Venous Disease: A Review of Real-World Evidence.

Chronic venous disease (CVD) is a prevalent condition that tends to worsen with age. Patients initially seek treatment to relieve symptoms of leg pain, discomfort, heaviness and swelling, all of which impact their quality of life. As the disease increases in severity to include varicose veins, skin changes, and venous ulcer, the demand for treatment increases while the quality of life further diminishes. The prevalence of CVD is highest in Western countries where it already consumes up to 2% of healthcare budgets. With the aging of the global population, the prevalences of CVD and severe CVD are projected to increase substantially, foretelling unsustainably large increases in the healthcare resources and costs needed to treat CVD patients in the coming decades. Effective venoactive drug treatments and ablation procedures are available that provide symptom relief, improve quality of life, slow disease progression, and promote ulcer healing. In addition, venoactive drug treatments may be highly cost-effective. However, there is evidence that physician awareness of CVD is suboptimal and that many patients with CVD are not being treated or referred to specialists according to established guidelines. To decrease this treatment gap and prevent unnecessary disease progression, international guidelines are available to help physicians consider CVD treatment options and refer patients when warranted. Improved disease awareness and appropriate early treatment may help reduce the coming burden of CVD.Funding: Servier.

Men present with higher clinical class of chronic venous disease before endovenous catheter ablation

BackgroundRisk factors for chronic venous disease (CVD) have been widely reported in population health management. However, predisposing factors associated with patients treated for advanced stages of CVD have yet to be established. We examined the demographics and risk factors associated with advanced clinical presentation of CVD for patients referred for vein ablation. MethodsRetrospective analysis of our institutional Vascular Quality Initiative Varicose Vein Registry included endovenous laser treatment and radiofrequency ablation procedures at our tertiary institution, community hospital, and outpatient vein clinic between January 2015 and December 2016. All incompetent truncal veins were divided into two groups based on the Clinical, Etiology, Anatomy, and Pathophysiology clinical class of CVD: mild-moderate (C1-C3) and severe (C4-C6). The two groups were compared in terms of their demographics and medical comorbidities using univariate and multivariate analysis. Data analysis was conducted on SPSS 22.0 (IBM Corp, Armonk, NY). ResultsDuring the study period, a total of 650 incompetent truncal veins were ablated. The mean age of patients was 58 years, and 73% were female. Severe CVD composed 21% of the cohort. Male sex was a risk for advanced CVD (odds ratio, 2.6; P < .001). Older age was also associated with severe CVD; the average age was 63 years for patients with advanced stage CVD vs 56 years for mild to moderate CVD (P < .001). Race, diabetes, body mass index, number of pregnancies, congestive heart failure, history of venous thromboembolism, current anticoagulation, and history of smoking or current smoking status did not affect the severity of CVD. ConclusionsAmong patients treated with vein ablation for superficial venous insufficiency, older age and male sex were associated with increased severity of advanced CVD. Despite the higher incidence of varicose veins among women, men are more likely to have clinically advanced CVD when they present for truncal vein ablation.

Health related quality of life in chronic venous disease: Systematic literature review

Excepting life-threatening situations, improvement of health-related quality-of-life is the main therapeutic goal in chronic disease. The purpose of this review was to study the different ways of assessing Quality-of-Life (QoL) in patients with chronic venous disease (CVD) (CEAP classes C3 to C6). A literature search was conducted with three databases: MEDLINE, WEB OF SCIENCE and COCHRANE LIBRARY in order to identify articles with the PRISMA reporting guidelines. Then we compared psychometric performance of general and specific QoL questionnaires for a French population with CVD. A total of 481 articles were identified, from which 25 were selected and analyzed. CIVIQ 20, CIVIQ 14 and VEINES Qol/sym are the specific health related QoL scales validated for a French population with CVD. VEINES Qol/sym was specifically validated in patients with leg ulcer or post-thrombotic syndrome (PTS). CIVIQ 14 is a CIVIQ 20 optimized to be used more widely in international studies and validated in milder forms of the CVD spectrum (C0 à C4). The general health related QoL scales are SF-36, SF-12 and EQ-5D. EQ-5D is simple and provides health state utility values. CIVIQ 14 is a simple specific health-related QoL scale for less severe CVD. VEINES Qol/sym was developed for severe CVD and PTS but clinically relevant point scales remain to be assessed. EQ-5D is a generic scale to be preferred to assess economic impact based on a cost-utility analysis.

The Minimally Invasive Outpatient Treatment of Severe Chronic Venous Disease

The Minimally Invasive Outpatient Treatment of Severe Chronic Venous Disease

Utility of iliac vein stenting in elderly population older than 80 years.

The geriatric population aged 80 years and older with severe manifestations of chronic venous disease face diminishing therapeutic options. Self-applied compression is often not possible because of frailty or arthritis. Significant limb swelling diminishes mobility, affects independent living, and precipitates institutionalization. Limb ulceration and pain diminish quality of life at a time when it is paramount. Cellulitis uniquely poses septicemic risk in this age group. Family caregivers are often able to continue home care if the intensity of care can be reduced. Iliac vein stenting may have a role as it appears to be safe and effective in this advanced stage of life. Patients who had failed to respond to compression and desired palliation of continuing severe chronic venous disease symptoms were considered for iliac vein stenting. Intravascular ultrasound-guided stenting was carried out under fluoroscopy without venography in case of allergy to contrast material or decreased renal function. General anesthesia was used for better cardiopulmonary control. A total of 107 limbs (12 bilateral) were treated with iliac vein stents during a 13-year period, representing 5% of all stented limbs. Median age was 83 years (80-96 years), and 10 were ≥ 90 years; 59% were post-thrombotic. Clinical, etiologic, anatomic, and pathologic classification was as follows: C2 (with pain), 3%; C3, 32%; C4, 33%; C5, 5%; and C6, 27%. Concurrent saphenous ablation was carried out in 28% when saphenous reflux was considered ancillary and not the main disease. There was no mortality. Reintervention was required in 20% of limbs for nonocclusive stent malfunction; 2% of stents occluded. Primary and primary-assisted duplex patency rates at 5 years were 52% and 90%, respectively. The visual analog scale score of pain improved from median 4 (0-9) to 0 (0-10) after stenting (P < .0001). Pain was completely relieved in 43% of limbs. Cumulative improvement in the pain score of at least 3 points was 71% at 6 years. Swelling (grade 0, none; grade 1, pitting; grade 2, ankle edema; grade 3, gross) improved from median 3 (0-3) to 1 (0-3) (P < .0001). Swelling completely resolved in 25% of limbs. Cumulative improvement of at least one grade of swelling (examination) was 63% at 6 years; 70% of limbs (n = 33) with prior cellulitis were relieved of recurrence after stent placement; 61% of active ulcers healed, and 37% of patients were able to discard stockings (P < .001). Iliac vein stenting appears to offer a safe and effective option in octogenarians and nonagenarians when compression fails, is difficult, or is impossible.

PVSS19. Performing Complete Superficial Vein Ablation in Patients with Obesity and Severe Chronic Venous Disease: Who Benefits?

Objectives: The relationship between CEAP class and Venous Clinical Severity Score (VCSS) change following great saphenous vein ablation (GSVa) is under reported. We further defined this relationship in patients including those with severe chronic venous disease (CVD) and the obese. Methods: We reviewed our prospectively collected venous procedural database from January 2007 to October 2010 for patients who had undergone GSVa ( phlebectomies). A CEAP class 5 or 6 designated severe CVD. VCSS were obtained preoperatively and at the 1st, 2nd, and 3rd follow up visits.

The effectiveness of deep vein thrombosis prevention

The effectiveness of deep vein thrombosis prevention

Endovenous Ablation for the Treatment of Chronic Venous Insufficiency and Venous Ulcerations

Conventional treatment of chronic venous disease with ulceration is layered compression dressings. Saphenous vein stripping is reserved for recurrent or nonhealing ulcers. This study examines outcomes of aggressive endovenous therapy in promoting ulcer healing and/or preventing ulcer recurrence. The role of additional perforator vein ablation also is analyzed. This retrospective chart review occurred during a 2.5-year time frame during which 356 patients with venous insufficiency were seen in our vein center and underwent 412 venous operations (56 with bilateral disease treated on separate dates). A cohort of 75 (21.1%) patients with severe chronic venous disease underwent 83 (20.1%) procedures (C5: n = 52, 63%; C6: n = 31, 37%); 8 patients had bilateral procedures. Data analysis included body-mass index (BMI), history of deep vein thrombosis (DVT) or previous vein surgery, and type of procedure (radiofrequency ablation (RFA) of greater saphenous vein (GSV) alone or GSV and perforator ablation (GSVP)). Complications, ulcer healing rates, and recurrent ulcerations were examined. Descriptive statistics are reported and contingency tables used when appropriate. Overall, the patients were 63.5 +/- 13.4 years of age (men: n = 36, women: n = 39) with a BMI of 32.4 (range, 20.8-53.4). All of the patients had GSV insufficiency and 30 (44%) patients had deep vein incompetence. Only 19 (28%) patients had a history of a DVT and 13 (19%) had previous vein procedures. The 31 extremities with C6 disease had been treated conservatively with compression for an average of 7.6 +/- 4.2 (range, 1-156) months before undergoing ablation. Ablation site was GSV in 49 (72%) and GSVP in 19 (28%). Only two (2.9%) complications occurred: excessive hemosiderin staining and paresthesias each occurred in one patient. Of the C5 patients treated, two (4.7%) developed recurrent ulcerations and five (20%) C6 patients did not heal completely or developed a recurrent ulcer. There was no statistically significant difference in ulcer healing or recurrence rates between C5 and C6 patients treated with and without the addition of perforator interruption. Chronic venous insufficiency with active or healed ulceration is commonly seen in our academic vein center. In this series, endovenous ablation allowed for excellent healing rates and acceptable recurrent ulcer rates. It is unclear from this small cohort whether the addition of perforator ablation was of benefit in improving venous hemodynamics.

DNA-array of gene variants in venous leg ulcers: Detection of prognostic indicators

Wound healing in venous leg ulcer (VLU) is a multi-step process involving complex pathways. Scanty knowledge at molecular level hinders clinical assessment and treatment. Anomalous handling of local iron overload, as well as unbalancing in matrix metalloproteinases (MMPs) and transglutaminase, has a recognized role in VLU establishment. We selected a number of single nucleotide polymorphisms (SNPs) in candidate genes (HFE, FPN1, MMP12, and FXIII) involved in VLU to identify potentially prognostic markers by means of DNA-array technology. The DNA-array-genotyping was assessed in 638 subjects for the following SNPs: HFE (C282Y, H63D), FPN1 (-8CG), MMP12 (-82AG) and FXIII (V34L). Of the subjects, 221 were affected by VLU (171 primary and 50 post-thrombosis), 112 by severe chronic venous disease (CVD) (CEAP, C3-C4), while 305 were matched healthy controls. The HFE and FXIII SNPs had been previously genotyped by conventional polymerase chain reaction (PCR)-methods on the same group of subjects (J Vasc Surg 2005;42:309; J Vasc Surg 2006;44:554; J Vasc Surg 2006;44:815). For the purpose of DNA-array, they were re-genotyped by means of array-techniques resulting in a 100% matching. Intergroup statistical comparisons were performed. In the risk computation, the FPN1 -8GG genotype had an overall CVD risk of 4.3 (95% CI, 1.6-12) and a VLU risk of 5.2 (95% CI, 1.9-15) virtually the same among primary VLU (4.98; 95% CI, 1.82-14.9). The MMP12-82AA genotype had a VLU risk of 1.96 (95% CI, 1.18-3.2) only in primary VLU (P = .01). In the genotype-ulcer size association studies, from a subgroup of 167 cases, we observed a smaller mean ulcer size in the MMP12 GG-genotype compared with the other genotypes (P = .001). Combining the present results with our previous published data on the same population, we suggest them to apply as tentative prognostic indicators in primary CVD. By analyzing simultaneously selected SNPs, it might be possible to glean precious information in predicting VLU onset or in stratifying patients according to their potential to heal. Although significant, our findings must be considered preliminary and the proposed prognostic indicators considered with caution, before ulterior more extensive studies in different populations can eventually confirm the present findings.