Signs Of Chronic Venous Insufficiency Research Articles

The association between the “T” vein and ulceration of the lateral aspect of the leg

The “T” vein is a tributary of The Great Saphenous Vein (GSV) located in the upper third of the leg with a perpendicular course to the GSV. It usually crosses the tibial bone and feeds by reflux of varicose veins of the lateral aspect of the leg. It is of surgical interest because it is involved with a significant percentage of varicose networks. The aim of this study is to analyze the prevalence of the T vein pattern in a cohort of patients affected by Chronic Venous Insufficiency (CVI), as well as its possible association with Venous Leg Ulcers (VLU) of the lateral aspect of the leg. One thousand nine hundred and twenty-two consecutive patients (1441 females and 481 males) were evaluated from January 2013 to May 2024 by means of clinical examination and the same Duplex Ultrasound Scanning (DUS) protocol. We assessed the frequency of patients presenting with the T vein pattern and the percentage of patients in which it causes symptomatic reflux. We also evaluated the susceptibility, respectively in the T vein and in the CVI cohort, of venous ulcerations (C5-C6 clinical classes according to the Clinical, Etiological, Anatomical, and Pathophysiological, CEAP, classification) in the medial and/or in the medial and lateral aspect of the leg vs exclusively in the lateral aspect of the leg. A p-value <0.05 has been considered significant. Overall, the presence of the T vein pattern was observed in 64 patients (3.33%). There is no statistically significant difference in the prevalence of T vein configuration in males (4.16%) and in females (3.05%) (p-value=0.24). A bilateral T vein pattern has been detected in just one case. T vein was involved in varicose vein networks, with only 2 patients being asymptomatic and without signs of CVI (3.1%). Noteworthy VLU (C5-C6) affected respectively 10 patients of the T vein cohort and 74 of the control population; in the T vein cohort, 80% of patients presented with VLU in the lateral perimalleolar region, while 72.9% of patients in the control group had VLU in the typical medial perimalleolar area (p-value=0.000852). Sometimes the clinician is doubtful about the venous pathogenesis of ulcerations visible in the lateral area of the leg. Our study suggests in these cases to investigate by DUS an eventual reflux coming from the T vein.

P09 A case of suspected COVID-19 vaccine-induced antiphospholipid syndrome

Abstract A 50-year-old man presented with an acute onset, painful leg ulcer affecting his right calf. This developed 2 weeks after his second COVID-19 vaccine. It started with a painful erythematous plaque, which evolved slowly into a deep-seated 5-cm ulcer over a 6-week period. A thorough review was unremarkable. He had no significant medical history and was a keen athlete and nonsmoker. His father had an unspecified stroke in his 80s. Examination revealed no signs of chronic venous insufficiency or discoloration to his foot, and his neurovascular examination was unremarkable. Investigations for antineutrophil cytoplasm antibodies, antinuclear antibody, complement, paraprotein, HIV and hepatitis were all unremarkable. Biopsy demonstrated nonspecific inflammatory changes, and wound swabs were unremarkable. Initial treatment with oral antibiotics, regular dressings, compression, topical emollients, Dermovate® and prednisolone (0.5 mg kg−1) was only partially effective. He subsequently developed additional painful superficial erosions and ulcers affecting the same limb involving the calf and shin, with a surrounding erythematous livedoid-like rash involving his shin. Rebiopsy demonstrated superficial and deep dermal and subcutaneous thrombosis without vasculitis. Direct immunofluorescence showed the presence of fibrinogen within dermal vessels. Further investigations demonstrated the presence of lupus anticoagulant. Factor V Leiden, protein C and S, anti-B2-GP1 and anticardiolipin antibodies, antithrombin III, homocysteine and coagulation profile were all unremarkable. Histological confirmation of thrombosis and the presence of serum lupus anticoagulant confirmed the diagnosis of antiphospholipid syndrome (APS). He was started on warfarin and the ulcers improved. APS is a rare autoimmune disorder characterized by recurrent miscarriage, thrombophilia and the presence of antiphospholipid autoantibodies (either serum lupus anticoagulant, anti-B2-GP1 or anticardiolipin autoantibodies). Positivity for APS antibodies can be found in up to 5% of the general population. An individual must have the clinical features and antibody positivity to be diagnosed with APS. The temporal relationship with his second COVID-19 vaccine raises the possibility of vaccine-induced APS. COVID-19 vaccine-induced APS is limited to just a few case reports (Moreno-Torres V, Gutiérrez A, Valdenbro M et al. Catastrophic antiphospholipid syndrome triggered by mRNA COVID-19 vaccine. Clin Exp Rheumatol 2022; 40:1054–5). It is postulated that mRNA vaccines may induce a rare complex immunogenic response characterized by a type 1 interferon reaction. This results in a prothrombotic cascade in individuals with pre-existing APS autoantibody positivity (Talotta R, Robertson E. Antiphospholipid antibodies and risk of post-COVID 19 vaccination thrombophilia: the straw that breaks the camel’s back? Cytokine Growth Factor Rev 2021; 60:52–60).

Clinical and instrumental associations of knee osteoarthrosis and pathology of the veins of the lower extremities

Knee osteoarthritis (OA) and varicose disease of the lower extremities (VD) are two diseases common in middle– aged and older women. Questions about whether their combination is accidental or natural and whether VD affects the course and severity of OA, remain unresolved.The aim of the study was to look for the possible association between knee OA and lower limb vein pathology on the basis of clinical and modern instrumental investigation sand to study the effect of the VD on the clinical manifestations and severity of knee OA.Materials and methods. A case-control study was conducted in 85 women 40–60 years old with knee OA diagnosed in accordance with the criteria of ACR (1986) and 50 women of the same age without signs of knee OA. Women of both groups were evaluated for complaints and objective examination with an emphasis on diseases of the joints and veins of the lower extremities, radiography of the knee joints, ultrasound duplex scanning of the veins of the lower extremities. The severity of OA was assessed by the Lequenne indices. The clinical assessment of venous pathology was carried out according to the CEAP classification.Results. Patients with knee OA more often than their peers without joint pathology have VD (43% vs 22%; p=0.015), signs of chronic venous insufficiency (28% vs 12%; p=0.03), as well as valve failure of several lower limb veins simultaneously (53% vs 20%; p=0.0004). After correction by body mass index, the association of knee OA with detected vascular pathology remained clinically and statistically significant. The presence of VD with moderate manifestations of chronic venous insufficiency, as well as ultrasound signs of venous pathology, was not associated with the clinical signs and course of knee OA.Conclusions. Knee OA in middle-aged and older women, regardless of body mass index, is associated with VD and ultrasound signs of simultaneous valves failure of several veins. Manifestations of chronic venous insufficiency did not affect the clinical picture and severity of knee OA.

Diagnosis of arteriovenous compression in small pelvic varicose veins

The study was aimed at assessing the incidence of arteriovenous compression in women with chronic venous insufficiency of the inferior vena cava and at developing an optimal diagnostic algorithm. During the period 2019-2020, we performed a cross-sectional study including a total of sixty-six 18-to-55-year-old (mean 33.5±5.0) women with clinical manifestations of chronic venous insufficiency of the basin of the inferior vena cava. A diagnostic algorithm included questionnaire, transvaginal ultrasound examination, multislice computed tomography, direct phlebography in combination with phlebotonometry. Chronic venous insufficiency of lower limbs was diagnosed in 66 (100%) cases and was presented by the following clinical classes according to the CEAP classification: C0 - 4.5%, C1 - 60.6%, C2 - 27.2%, C3 - 3%. Symptoms of pelvic venous plethora were revealed in 36 (55.5%) examined patients. Arteriovenous compression syndrome according to the findings of multislice computed tomography was verified in 16 (24%) women, including May-Turner syndrome in 5 (7.6%), aortomesenteric compression syndrome in 8 (12%) women, with a combination of both syndromes observed in 3 cases; the frequency of their detection did not differ statistically in subgroups of women with and without clinical signs pelvic varicose veins. Direct phlebography in combination with phlebotonometry was performed in 9 women, the diagnosis of arteriovenous compression (May-Thurner syndrome) was confirmed in 1 case only. In women with signs of chronic venous insufficiency in the system of the inferior vena cava the frequency of detecting arteriovenous compression on multislice computed tomography may reach 24% and does not depend on the presence of symptoms of pelvic venous plethora. The proportion of arteriovenous compression according to the findings of direct phlebography and phlebotonometry in the structure of causes of the development of pelvic varicose veins did not exceed 11%. An algorithm for diagnosing arteriovenous compression syndromes should obligatorily include multislice computed tomography, direct phlebography and phlebotonometry.

Хроническая цереброваскулярная болезнь: роль венозных расстройств и возможности патогенетической коррекции

Aim: to evaluate the efficacy and safety of the L-lysine escinate venotropic drug in the treatment of cephalgic, atactic and asthenic syndromes in patients with chronic cerebral ischemia, mainly caused by venous disorders. Patients and Methods: the study involved 60 patients with a diagnosis of chronic cerebral ischemia with signs of chronic venous insufficiency. All patients were randomly divided into two groups consisting of 30 people. Patients in the main group received L-lysine escinate, and the control group received Vinpocetine. The drugs were administered by intravenous drip for 10 days. A dynamic assessment was performed using a modified subjective scale of asthenia evaluation (MFI-20), 100 mm long visual analogue scale (VAS) for headache, subjective neurological impairment scale (SNIS), and Tinetti test. An ophthalmic examination with an assessment of the fundus vessels and an ultrasound duplex scanning of head vessels (veins) were also conducted. Results: it was shown that L-lysine escinate therapy showed a statistically more significant reduction in the severity of headache (according to VAS) and an improved stability measured by Tinetti test versus during Vinpocetine treatment. There were no significant differences in the level of asthenia (MFI-20), the severity of emotional disorders, and the SNIS score. Also, the number of patients with dilated fundus veins significantly decreased during treatment in the main group (p<0.05), which was not the case in the control group. According to ultrasound duplex scanning data, the venous flow velocity through the veins of Rosenthal and angular veins during L-lysine escinate therapy was significantly higher (p<0.05) than in patients receiving Vinpocetine. Conclusion: the inclusion of vasotropic drugs (in particular, the L-lysine escinate venotonic drug) in the treatment regimen of patients with chronic brain ischemia seems appropriate, especially if there are signs of venous insufficiency. KEYWORDS: systemic venous insufficiency, chronic cerebrovascular disease, venous dyscirculation, glymphatic system, L-lysine escinate, Vinpocetine. FOR CITATION: Schukin I.A., Fidler M.S., Koltsov I.A. Chronic cerebrovascular disease: the role of venous disorders and the possibility of pathogenetic correction. Russian Medical Inquiry. 2020;4(9):544–551. DOI: 10.32364/2587-6821-2020-4-9-544-551.

Ulcers in leprosy patients, an unrecognized clinical manifestation: a report of 8 cases

BackgroundLeprosy is a chronic granulomatous infection caused by Mycobacterium leprae. It is a polymorphic disease with a wide range of cutaneous and neural manifestations. Ulcer is not a common feature in leprosy patients, except during reactional states, Lucio’s phenomenon (LP), or secondary to neuropathies.Cases presentationWe report eight patients with multibacillary leprosy who presented specific skin ulcers as part of their main leprosy manifestation. Ulcers were mostly present on lower limbs (eight patients), followed by the upper limbs (three patients), and the abdomen (one patient). Mean time from onset of skin ulcers to diagnosis of leprosy was 17.4 months: all patients were either misdiagnosed or had delayed diagnosis, with seven of them presenting grade 2 disability by the time of the diagnosis. Reactional states, LP or neuropathy as potential causes of ulcers were ruled out. Biopsy of the ulcer was available in seven patients: histopathology showed mild to moderate lympho-histiocytic infiltrate with vacuolized histiocytes and intact isolated and grouped acid-fast bacilli. Eosinophils, vasculitis, vasculopathy or signs of chronic venous insufficiency were not observed. Skin lesions improved rapidly after multidrug therapy, without any concomitant specific treatment for ulcers.ConclusionsThis series of cases highlights the importance of recognizing ulcers as a specific cutaneous manifestation of leprosy, allowing diagnosis and treatment of the disease, and therefore avoiding development of disabilities and persistence of the transmission chain of M. leprae.

Evaluation of hemodynamic parameters in patients with trombosis inferior vena cava system dependent on the treatment method

The aim — to evaluate blood flow parameters in patients with thrombosis inferior vena cava system depending on the treatment method.Materials and methods. The article presents the evaluation of hemodynamic parameters in 665 patients with different forms of deep thrombosis inferior vena cava system. The patients were divided into the following groups, according to the treatment method. The first A group consisted of 380 patients which underwent an open full or partial thrombectomy with or without surgical prophylactic of pulmonary thromboembolism. The first B group consisted of 50 patients which underwent the combined treatment with surgical prophylaxis of pulmonary thromboembolism. The second group included 235 patients which received only the conservative therapy. The laboratory and instrumental methods: ultrasound duplex scanning, X­ray phlebography, computer tomography, radionuclide fleboscintigraphy and echocardioscopy were used to carry out the study in patients. The combined treatment included regional thrombolytic therapy and a cava­filter implantation (n = 31) or surgical thrombectomy followed by intraoperative regional thrombolytic therapy (n = 19). All patients received anticoagulant, infusion­anesthetic and compression therapy regardless of surgical treatment.Results and discussion. The disabsorption of large venous collectors in the first group with partial thrombectomy resulted in a considerable increase in blood volume, whereas undergoing the radical thrombectomy recovered the blood volume back to normal values. The average transport time through the deep veins of shin and hip decreased from 53 — 68 s tо 7 — 12 s and tо 11 — 18 s in case of radical and partial thrombectomy, respectively. The linear blood speed increased from 1 — 3 сm/s tо 9 — 18 сm/s and 4 — 9 сm/sеconds in case of radical and partial thrombectomy, respectively. The load index increased from 1 — 2 to 2.8 — 3.4 and 2.2 — 2.8 in case of radical and partial thrombectomy, respectively. In the second group of patients, the average transport time after treatment was 22 — 32 seconds, the linear blood speed — 2 — 6 cm/sec, the load index — 1 — 1.5. The results of the blood renewal after the combined treatment in the first B group took an intermediate position between radical and partial thrombectomy: the average transport time is 9 — 14 seconds, the linear blood speed — 7 — 11 cm/sec and the loading index — 2.3 — 3.0. Any signs of right heart overload and symptoms of «stealing» of the peripheral arterial channel were not detected while forming an arteriovenous fistula with diameter of up to 4 mm. We found that the completion of hardware cavaplication, after thrombectomy from the inferior vena cava, did not aggravate the venous blood return to the heart.Conclusions. After the partial thrombectomy and combined treatment the surgical renewal of venous trunk permeability improved the venous blood flow, and with radical thrombectomy — restored it back to normal values. With conservative treatment, the venous blood flow did not restore due to pronounced signs of chronic venous insufficiency.

Early and Remote Results of Surgical Treatment of Inferior Vena Cava Thrombosis

The objective of the research was to estimate the early and remote results of surgical treatment in patients with deep vein thrombosis of the inferior vena cava.Material and methods. The results of treating 790 patients with lower limb deep vein thrombosis and thrombosis of the inferior vena cava were analyzed. Depending on treatment, all the patients were divided into the following groups: Group IA consisted of 380 (68.5%) patients with deep vein thrombosis who underwent open complete or partial thrombectomy with or without surgical prevention of pulmonary thromboembolism; Group IB consisted of 50 (9.0%) patients with deep vein thrombosis who received combined treatment with surgical prevention of pulmonary thromboembolism; Group IC consisted of 125 (22.5%) patients with transfascial thrombosis who underwent thrombectomy of the apical thrombotic masses of deep veins followed by radical venectomy; Group II consisted of 235 (29.7%) patients with deep vein thrombosis who received conservative anticoagulant therapy only.For investigation of patients, there were used the following laboratory methods of examination: duplex ultrasound scanning, X-ray phlebography, computer tomography, echocardioscopy and radionuclide phleboscintigraphy.Results. The results of surgical and combined methods of treating deep vein thrombosis in clinical subgroups were evaluated using a three-point scale - good, satisfactory and unsatisfactory. The cumulative analysis of the results of the postoperative period during 3 years of follow-up showed that good and satisfactory results were observed in 89.3% of patients of Group IA, 81.7% of patients of Group IB, 88.4% of patients of Group IC, and 35.3% of patients of Group II. Three years after treatment, the signs of chronic venous insufficiency were found in 51.6% of patients who underwent conservative treatment, 36.4% of patients who received combined treatment, 10.2% of patients who underwent partial thrombectomy, 2.9% of patients who received surgical treatment of transfascial thrombosis; they were absent in patients who underwent radical thrombectomy.Conclusions. In quantitative evaluation of the early and remote results of treating deep vein thrombosis of the inferior vena cava, a significant improvement in the patients’ condition in all parameters was observed in the main group as compared to the control one.

Panniculitis in rheumatology: features of course and outcomes.

The study of the course and outcomes of panniculitis (PN) in modern rheumatology practice. We observed 209 patients (pts) (f-185, m-24 in age 17 to 80 years) with the input diagnosis "Erythema nodosum? Undifferentiated panniculitis?" and duration of illness in from 1 week to 25 years, observed in V.A. Nasonova Research Institute of Rheumatology in 2009-2016 years. Along with the general clinical examination, serological, immunological histological and immunohistochemical studies, CT scan of the chest, Doppler (Doppler ultrasound) of the veins of the lower extremities, tuberculin tests and consultations with doctors of other specialties were conducted. Outcomes were assessed after 1-6 years. In 23 pts a secondary character of PN was identified and discovered non-rheumatic underlying disease. Of the remaining 186 cases, the most frequent were pts with erythema nodosum (EN) (n=121), lipodermatosclerosis (LDS) (n=38) and panniculitis of Weber-Christian (PWCh)(n=18). For EN average age (AA) amounted to 38.9±12.6 years, the nodes the nodes were located symmetrically in 93% of cases on all surfaces of the lower and upper extremities (LUE). For LDS AA of the pts was 54±13 years, 68% of the pts noted the increase in the average body mass index (BMI), 79% - showed signs of chronic venous insufficiency (CVI). In 60% of the pts the items were located asymmetrically, localized mainly in the medial (92%) of the surface of the tibia (s). For PWCh AA amounted to 48.4 ± 17.6 years, seals were located on all surfaces of LUE and in 14 cases - on the trunk. To clarify the nature of PN it is necessary to conduct a comprehensive survey. The EN is characterized by symmetric defeat of all surfaces LUE more common in people of young age. A distinctive feature of LDS is asymmetrical lesions of the lower extremities in patients with increased BMI and signs of CVI. For PWCh seals are often localized on the trunk.

Correlation of obesity & comorbid conditions with chronic venous insufficiency: Results of a single-centre study.

Background & objectives:Chronic venous insufficiency (CVI) is a common clinical problem among obese patients. This study was conducted to evaluate the impact of body mass index (BMI) and associated morbidities such as diabetes, hypertension and hypothyroidism on venous disease clinical scores as per Clinical, Etiological, Anatomical, Pathological (CEAP) classification.Methods:In this study, adult patients with BMI more than 30 kg/m2 with signs of CVI were evaluated clinically and by using Duplex ultrasonography of venous system. The patients with C0, C1, C2, C3 and C4, C5, C6 clinical scores in CEAP classification were grouped as lower and higher clinical scores of CVI, respectively.Results:Of the 200 enrolled patients, 147 (73.5%) were males and were associated with higher grades of clinical scores (P=0.051). Superficial venous system was involved in 96 per cent patients and 91 per cent patients had reflux in the sapheno-femoral junction. A negative association was observed between hypertension and male gender (P=0.001). Higher BMI was associated with higher clinical scoring (P=0.053). BMI >40 kg/m2 was associated with primary aetiology (P=0.007) of CVI. There was no correlation between superficial, deep or perforator incompetence with BMI (P=0.506). Duplex-confirmed significant reflux was observed in patients with higher BMI (P=0.006). Age and BMI were positively correlated with clinical score (r=0.176; P=0.013 & r=0.140; P=0.049), respectively.Interpretation & conclusions:Our findings indicated that elderly male patients with high BMI seemed to be at a higher risk of advanced clinical grades of CVI. The impact of comorbid conditions such as diabetes, hypertension and hypothyroidism on CVI could not reach at significance in the present study.

Venous function after pharmacomechanical thrombolysis for extensive iliofemoral deep vein thrombosis

Background: Chronic venous insufficiency is an important complication following iliofemoral deep venous thrombosis. Early thrombus removal may preserve venous function and prevent this complication. This study represents the largest reported South African series of pharmacomechanical thrombolysis for iliofemoral deep venous thrombosis to date.Objective: To evaluate the long-term outcome following pharmacomechanical thrombolysis for proximal and extensive deep venous thrombosis in a private, specialist vascular unit.Methods: All patients who underwent pharmacomechanical thrombolysis for iliofemoral deep venous thrombosis between August 2009 and January 2016 were invited to return for clinical assessment and venous ultrasound. Clinical findings were recorded according to the Villalta score and clinical, etiology, anatomic and pathology (CEAP) classification. The quality of life (QoL) was assessed utilising the VEINES-QoL/Sym questionnaire, providing two scores per patient, one describing the QoL and the other symptom severity (Sym).Results: Thirty two patients (35 legs) were evaluated. There were 25 females and 7 males, with a mean age of 33.5 years (±14 years). The mean follow-up period was 31 months (range 3 months – 80 months). Results of the CEAP classification were C0 = 24 (75%), C1 = 1 (4%), C2 = 2 (6%), C3 = 2 (6%) and C4 = 3 (9%). Thirty-one (97%) patients had Villalta scores from 0 to 4, indicating no or mild evidence of venous disease. One patient (3%) had a Villalta score of 6, indicating post-thrombotic syndrome. The mean QoL score was 87% (±12) and the mean Sym score was 86% (±14). Twenty-four (75%) patients had no abnormality on ultrasound, with fibrosis the most observed abnormality.Conclusion: Most patients who had undergone pharmacomechanical thrombolysis for extensive iliofemoral deep venous thrombosis showed few significant clinical signs of chronic venous insufficiency, had excellent function on venous ultrasound and reported excellent QoL.

Lower extremity venous diseases in primary knee osteoarthritis

To establish a possible association between knee osteoarthritis (OA) and lower extremity venous diseases ((LEVDs) on the basis of thorough clinical and instrumental studies. A case-control study recruiting 40-60-year-old women was conducted. A study group included 85 women with knee OA; a control group consisted of 50 women without this condition. The patients of both groups underwent assessment of complaints and goal-directed objective examination to identify joint diseases and chronic LEVDs, knee X-ray study, and duplex scanning of the lower extremity veins. The patients with knee OA were more frequently diagnosed with lower extremity varicose vein disease (VVD) (43% vs 22%; p=0.015) and had signs of chronic venous insufficiency (28% vs 12%; p=0.03). Duplex scanning of the lower extremities showed that knee OA was characterized by generalized LEVD (bilateral valve lesions of the great and small saphenous veins and severe valvular incompetence in the veins) that was detected in 53% of the patients in this group versus 20% of the women in the control group (p = 0.0004). After adjustment for body mass index, the differences in the incidence of VVD between the groups remained clinically and statistically significant (odds ratio (OR), 2.7; 95% confidence interval, 1.1-6.7; p=0.036). The 40-60-year-old patients with knee OA more commonly develop symptoms of chronic venous insufficiency than their healthy peers. Although obesity is a risk factor for both diseases, there is an independent association between knee OA and lower extremity VVD.

Role of conservative treatment of chronic venous insufficiency for regression of the features of desadaptive cardiac remodeling in patients with comorbid obesity

Aim. To evaluate the influence of conservative treatment tactics for chronic venous insufficiency on the processes of cardiac remodeling in patients with comorbid obesity. 
 Methods. 32 males with obesity class 1 (BMI 32.57±2.25 kg/m2) at the age of 40.7±11.5 years and with clinical and instrumental signs of chronic venous insufficiency were divided into 2 groups: patients from group 1 (n=14) followed the recomendations to wear compression stockings and to use hesperidin + diosmin 500 mg twice a day, and the patients from group 2 (n=18) did not follow those recommendations. All patients had echocardiography performed before the treatment and 2 months after the first visit. For the evaluation of echocardiographic dynamics paired Student’s t-test was used. 
 Results. After 2 months statistically significant dynamics of the following echocardiographic findings was revealed: in group 1 index of eccentric left ventricular shape increased from 0.94±0.06 to 1.01±0.03, in group 2 - from 0.96±0.08 to 0.97±0.07 (р=0.023). In group 1 tricuspid annular plane systolic excursion decreased from 30.07±5.31 to 26.64±4.14 mm, in group 2 - from 29.6±4.72 to 29.88±6.04 mm (р=0.008), and the right atrial volume in group 1 decreased from 53.57±11.48 to 46.64±13.18 ml, in group 2 - from 52.77±11.27 to 51.38±8.54 ml (р=0.044). In group 1 statistically significant trend to decreased ratio of maximal velocity of RV early diastolic filling to maximum diastolic tricuspid valve lateral annular velocity was revealed (from 4.75±1.35 to 4.25±1.23 cm/sec) compared to group 2 (from 4.79±1.62 to 4.75±1.58 cm/sec; р=0.076). 
 Conclusion. Conservative treatment of chronic venous insufficiency in patients with obesity is associated with indirect indicators of decreasing volume overload of the heart and can influence positively on heart geometry leading to regression of spheric LV remodeling and decrease of RA volume.

Interventional treatment of postthrombotic syndrome.

BackgroundPostthrombotic syndrome (PTS) is the development of symptoms and signs of chronic venous insufficiency following deep vein thrombosis (DVT) and has a significant negative effect on the quality of life. The current understanding is that the clinical manifestation of PTS is related more to venous obstruction than it is to venous reflux. The use of interventional techniques for the treatment of venous obstruction and/or venous occlusion has rapidly increased in recent years.ObjectiveThis article summarizes the current concept of endovenous and hybrid interventions and presents the optimized treatment of choice in patients with chronic symptomatic venous obstruction.MethodsWe performed a systematic literature search in the Medline database to identify relevant studies on the treatment of patients with PTS.ResultsA meta-analysis of the relevant studies showed that this minimally invasive procedure is an effective treatment option with low morbidity and no mortality. Use of the newly developed dedicated venous stents showed promising results with good mid-term patency rates and a significant decrease in related symptoms.ConclusionInterventional therapy for the treatment of symptomatic chronic venous obstruction has become the method of choice in recent years. More studies are needed to evaluate the long-term success rate of dedicated venous stents.

VENOUS OUTFLOW AFTER HARVESTING OF FEMORAL VEIN FOR RECONSTRUCTION OF AORTOILIAC SEGMENT

Objective: to define the state of venous outflow after femoral vein harvesting for aortoiliac reconstruction. Material and methods. The distant results of 22 aortoiliac reconstructions with deep femoral veins performed at Gomel Regional Vascular Surgery Department over 2010-2015 have been studied. 5 patients were operated for late complications (false aneurisms) of previous aorto-femoral bypass, 8 patients were treated for acute prosthetic infection and 9 patients underwent initial surgery for terminal stage of critical limb ischemia. Results and discussion. The group of the patients after initial reconstructions revealed significant edema and lymphorea immediately after the surgery. It was not necessary to perform fasciotomy in all the cases. There were no signs of chronic venous insufficiency in all the patients in the remote postoperational period. Conclusion. The application of femoral vein for aortoiliac bypass is safe from the point of view of venous morbidity. Outflow disturbances were transient in all the cases and no additional treatment was needed.

The role of intravenous drug use in venous leg ulceration.

V enous leg ulceration is thought to be a disease of old age and prevalence is around 1% of the adult population. However, as many as 46% of sufferers may develop their ulceration before the age of 50 (Mackenzie et al, 2003) and, increasingly, venous leg ulcers are occurring in younger people as a result of intravenous injecting. A recent study showed a high leg-ulcer prevalence of 15% in a sample of 200 people (aged under 44) who had injected drugs (Coull et al, 2014). The assessment process is important in the care of patients with leg ulceration. However, many leg ulcer assessments do not include a question about intravenous (IV) drug use, and IV drug use is rarely mentioned as a risk factor in literature about venous leg ulceration. Chronic venous disorders (CVDs) are classified in a staging system that ranges from no visible or palpable signs of venous disease through the signs of chronic venous insufficiency (CVI), varicose veins, oedema, skin changes, to ulceration as end-stage venous disease (EklOf et al, 2004). CVI commonly occurs in the sixth or seventh decade of life, but occurs in the third or fourth decade for people who inject drugs (PWID) (Pieper, 1996). It is important to recognise that prevalence is higher than expected, and be aware of key contributing factors that might cause leg ulceration in PWID, especially as ulceration may occur long after injecting has ceased (Pieper, 1996). Most significant is injecting in the femoral vein or the legs, and the presence of deep vein thrombosis (DVT). PWID may use the femoral vein as a site to inject into (groin injecting). This site can be used for many years and is associated with a lack of alternative access, easier technique, improved drug effect, and the fact that the site is easily hidden (Williams and Abbey, 2006). Femoral injecting is risky, with many reported problems. Repeated puncturing of the femoral vein may result in a noticeable dimples in the skin and eventually a sinus may form in some individuals (Maliphant and Scott, 2005). Swellings or aneurysms can occur in the groin area and there is a risk of inadvertent arterial injection, venous insufficiency, infection and pain (Gan et al, 2000; Senbajo et al, 2012). Scarring or thickening of the femoral vein can occur causing difficulty with injecting, such as needle breakage and a requirement to use longer, thicker needles. Swelling or thickening can lead to a narrowing of the lumen causing a slowing in venous blood flow, resultant back pressure and venous hypertension. Consequently, as the blood flow becomes sluggish, a DVT may form (MacKenzie et al, 2000). Injecting directly into the legs increases the likelihood of skin breakdown and ulceration. This is partly owing to the venous damage inflicted by repeated needle punctures and increased risk of infection and DVT in the lower legs (Pieper et al, 2009). DVT is a risk factor in the development of venous ulceration, and, although DVT is relatively common in PWID, there is a lack of awareness of the long-term consequences on the lower limb (Williams and Abbey, 2006). A clot in the leg, especially proximal to the knee, also increases the likelihood of post–thrombotic syndrome (PTS), which is characterised by signs of venous insufficiency with limb swelling, pain, skin changes, difficulty in walking and venous ulceration (Kahn and Ginsberg, 2004). PTS has been known about for many years (Linton, 1953) but little is known about the risk factors or why it occurs in some and not others. Despite this, it is possible that the PTS sequelae, including ulceration that follows DVT, could be prevented in up to 50% of sufferers by using compression hosiery (Prandoni et al, 2004). However, a study by Kahn et al (2014) contradicted earlier results and showed elastic compression stockings did not prevent PTS. Further trials are needed, but hosiery may offer symptomatic relief and would be advised for those with a proximal DVT at or above the popliteal vein (Arumugaswamy and Tran, 2014). Other guidelines suggest that those with PTS should wear compression hosiery constantly and forever, to minimise the extension of disease and venous ulcer formation (Robson et al, 2008). Compression can also have a dramatic effect on reducing pain (Ettridge, 2011). Health professionals caring for PWID should be aware of the high prevalence of leg ulceration in this group, and consider their role in the prevention of ulceration following DVT and in PTS. Early recognition of PTS may help reduce the prevalence of leg ulceration. Educating this group about the long-term consequences is also worthy of consideration. BJN

Chronic Venous Insufficiency: prevalence and effect of compression stockings.

Chronic venous insufficiency (CVI) is a common disease affecting mainly lower limbs and significantly influencing the quality of life. This study aims to estimate the prevalence of CVI in the Qassim Region and test the effectiveness of compression stockings as an intervention option. A cross sectional study was conducted to assess the prevalence of CVI among patients visiting primary health care (PHC) centers in the Qassim Region. CVI patients were diagnosed and classified using the clinical, etiologic, anatomical, and pathophysiological (CEAP) scale. They were randomly divided into two groups, one using compression stockings and the other standard medical therapy. A clinical follow up was done using multiple scale system including CEAP scale. Data analysis was performed using SPSS. Among the 226 screened patients, 138 (61.1%) were diagnosed as having CVI (69% female and 45% male, p<0.001). Compared to the baseline, both the clinical and venous scores for CVI at the follow-up were significantly lower among patients using compression stockings, p=0.002 and p=0.003, respectively. Regression analysis suggested that, after controlling for age, sex and body mass index, compliance was the main factor responsible for a significant reduction in the clinical score among CVI patients. Chronic venous insufficiency is very common in the Qassim Region. Compression stockings are highly effective in improving clinical symptoms and signs of CVI. This study is registered at www.clinicaltrials.gov(NCT02050061).

Echo-Doppler evaluation of recent onset chronic venous insufficiency in elderly patients: does the heart have a role?

The onset in elderly subjects of clinical signs of chronic venous insufficiency (CVI), without a previous history of venous disease of the lower limbs, raises questions about the etiology. In our study we evaluated the possible causes investigating the venous system of the lower limbs and right heart function in elderly subjects with signs of CVI. The alterations found were on the reduction of TAPSE, a significantly higher body mass index and a reduced ability to walk compared to the control group. The differences described could explain edema and skin changes of recent onset. If it is CVI functional type or of congestive heart failure in the preclinical stage will be clarified only by adequate follow-up.

VENOUS INSUFFICIENCY AND THROMBOEMBOLIC DISEASE IN BARIATRIC SURGERY PATIENTS

Morbid obesity is associated with various co-morbidities, including chronic venous insufficiency. Bariatric surgery is the only effective treatment for morbid obesity, but with potential risks and possible complications, including venous thromboembolism. To determine the prevalence of clinical and ultrasonographic signs of chronic venous insufficiency in morbid obese patients in preparation for bariatric surgery and the incidence of post-operative venous thromboembolic disease. Patients on work-up for bariatric surgery of Centro Terapêutico Especializado em Fígado (CETEFI) and Pro-Gastro surgical teams of the Hospital Beneficência Portuguesa de São Paulo were included. The analysed data were pre-operative findings for venous insufficiency (CEAP - clinical, etiological, anatomical, physiopathologic - classification and venous ultrasonographic findings), type of surgery (open or laparoscopic), abdominal circumference, body mass index (BMI) and post-operative ultrasonography search for venous insufficiency and deep venous thrombosis. Between March 2007 and December 2009, 95 patient candidates for bariatric surgery had clinical and duplex scan evaluation of the lower limbs venous system. Of the 95 patients, 53 were submitted to the surgical procedure. There was a predominance of women (77.9%), the average age was 38.5 years, average preoperative weight 124.6 kg and average BMI of 45.5 kg/m2. Regarding obesity, 16.8% were obese, and 83.1% were morbidly obese. In relation to the venous findings, 86.3% of the patients did fit CEAP classification less than 3 and 13.7% greater than or equal to 3. Among the post-operative complications, there were four cases of wound infection. Three patients developed post-operative distal venous thrombosis (7.5%), but no one had clinically manifested pulmonary embolism. No relation between BMI, CEAP classification and venous ultrasonographic findings were found. Although prophylaxis was used in all patients, the incidence of post-operative distal venous thrombosis was considerably high.

Leg Symptoms of Somatic, Psychic, and Unexplained Origin in the Population-based Bonn Vein Study

To assess the somatic and psychic components of venous-type leg symptoms. The psychic versus somatic venous disease questionnaire (PsySoVDQ) was applied to 1,800 participants of the Bonn Vein Study (BVS) II. Factor analysis of the PsySoVDQ made it possible to distinguish a psychic component (PC; 5 items, Cronbach's alpha = 0.73) separate from a somatic component (SC; 4 items, Cronbach's alpha = 0.67). The PC reflected anxiety and inhibition, was prevalent in 39.8% and explained 7.3% of the BVS findings. Higher PC scores were typically found in younger, slim women of higher social status, with feelings of leg heaviness and tension, and reduced psychic quality of life. The SC prevailed in 37.4% and explained 16.5% of BVS findings. Typical SC scorers were older, overweight women with lower social status, more symptoms (including swelling), signs of chronic venous insufficiency, ultrasound-documented venous abnormalities, and reduced multidimensional quality of life. The SC's predictive accuracy for CEAP 2 and 3 (classification according to clinical findings, etiology, anatomy, pathophysiology) was equal to that of the BVS assessment. The PsySoVDQ identified somatic and psychic components of the widespread and frequently reported leg symptoms in the general population. Nevertheless, in the majority of subjects symptoms remained unexplained. A neuropsychological and neurobiological hypothesis is advanced.