Symptomatic Chronic Venous Disease Research Articles

Randomized Double-Blinded Study Comparing Clinical Versus Endovascular Treatment of Iliac Vein Obstruction.

Randomized Double-Blinded Study Comparing Clinical Versus Endovascular Treatment of Iliac Vein Obstruction.

Compression versus inner sole for venous patients with foot static disorders: a prospective trial comparing symptoms and quality of life

To prospectively compare the improvement in quality of life and symptoms achieved when using two treatments-medical compression stockings and inner sole-in subjects with symptomatic chronic venous disease in the presence of foot static disorders. This prospective study included 24 patients with a symptomatic chronic venous disease associated with foot static disorders. The basic CEAP was used to classify the patients. The venous symptoms were recorded using a 10-point visual analog scale and scored using a customized questionnaire. Patient-reported quality of life data were acquired using a CIVIC questionnaire. A standardized measurement of the Djian-Annonier angle was used to quantify the foot static disorders. We compared the use of the following two treatments: medical compression stockings (18 mm of Hg) and inner sole. For this comparison, we used a crossover technique over 4 successive weeks. One male and 23 female patients were included in this study. We found significant improvement in quality of life scores when only medical compression stockings were used (p < 0.005), only inner sole were used (p < 0.01) and also when both treatments were used together (p < 0.001), compared with no treatment. This was mainly observed for the somatic component of CIVIC. The symptoms of pain, heaviness, swollen feeling, and cramps were significantly improved by the two treatments, whether given separately (p < 0.001) or together (p < 0.0001). No additive effect of the treatments was observed. This study suggests that a number of leg symptoms occurring in varicose veins patients are not likely to have a venous origin. They are frequently related to a foot static disorder, which is responsible for postural changes. This study also strongly demonstrates the need for correction of the foot static disorder if such a disorder is present in any patient with chronic venous disease. The use of the inner sole will improve the symptoms and also the quality of life with an efficiency that is almost equal to that provided by the medical compression stockings and the combined use of both treatments is recommended.

Comparison of the Villalta post‐thrombotic syndrome score in the ipsilateral vs. contralateral leg after a first unprovoked deep vein thrombosis

Post-thrombotic syndrome (PTS) is the most frequent complication of a deep vein thrombosis (DVT). International guidelines recommend assessing PTS with the Villalta scale, a clinical measure that incorporates venous symptoms and signs in the leg ipsilateral to a DVT. However, these signs and symptoms are not specific for PTS and their prevalence and relevance in the contralateral leg have not previously been studied. Using data from the REVERSE prospective multicentre cohort study, we compared the Villalta total score and prevalence of venous signs and symptoms in the ipsilateral vs. contralateral leg in patients with a first, unilateral DVT 5 to 7 months previously. Among the 367 patients analyzed, the mean Villalta score was higher in the ipsilateral than in the contralateral leg (mean ± standard deviation [SD] 3.7 [3.4] vs. 1.9 [2.5], respectively; P<0.0001). Villalta scores in the ipsilateral and contralateral legs were strongly correlated (r=0.68; P<0.0001). Ipsilateral PTS (defined by a Villalta total score >4) was present in 31.6% (n=116) of patients. Among these, 39.7% (n=46) of patients had a Villalta score >4 in the contralateral leg, and the distribution of Villalta symptoms and signs components was similar between the legs. Villalta scores in the ipsilateral and contralateral legs are strongly correlated. Almost half of cases considered to be PTS might reflect pre-existing symptomatic chronic venous disease. Alternatively, patients with pre-existing chronic venous disease might be more prone to developing PTS after a DVT. Performing a bilateral assessment of Villalta scores at the acute phase of DVT could be of clinical interest from a diagnostic, prognostic and therapeutic point of view.

Comparison of the Villalta Post Thrombotic Syndrome (PTS) Score in the Ipsilateral Versus Contralateral Leg After a First Unprovoked Deep Vein Thrombosis (DVT): Results From the REVERSE Study

Abstract 1236 Background:Post thrombotic syndrome (PTS) occurs in up to 40% of persons after a proximal DVT despite optimal anticoagulant therapy. International guidelines issued by the ISTH recommend assessing PTS with the Villalta scale, a clinical measure that incorporates ratings of 5 patient-rated venous symptoms and 6 clinician-rated venous signs in the leg ipsilateral to DVT (range of scores: 0–33). However, these signs and symptoms are not specific for PTS and their presence and relevance in the contralateral leg have not been studied. The objectives of this analysis were to assess the Villalta score in the contralateral leg and its correlation with the Villalta score in the ipsilateral leg after a first DVT. Methods:Using data from the REVERSE prospective multicentre cohort study, we compared the Villalta score in the ipsilateral vs. contralateral leg in patients with a first, unprovoked, unilateral proximal DVT 5–7 months previously. As per ISTH standards, PTS was considered present if the Villalta score was >4 in the leg ipsilateral to DVT. We also compared the distribution of the Villalta scale’s signs and symptoms components in both legs in patients with PTS in the ipsilateral leg and Villalta score >4 in the contralateral leg. Results:Between October 2001 and March 2006, 664 patients with a first unprovoked venous thromboembolism (VTE) were enrolled in the REVERSE study after having received a 5–7 month course of anticoagulant therapy. The population for the present analysis consisted of the 360 REVERSE patients who had unilateral DVT as the index event, no previous secondary DVT or pulmonary embolism, and non-missing Villalta score data.Overall, mean Villalta score was higher in the ipsilateral than in the contralateral legs: 3.7 (interquartile range [IQR] 1.0 – 5.0) and 1.9 (IQR 0.0 – 3.0), respectively (paired t-test: p <0.0001).PTS was present in 31.9% (n=115) of patients. With increasing severity of venous ectasia in the contralateral leg, prevalence and severity of PTS gradually and significantly increased (both p<0.0001). Prevalence of any PTS increased from 25% (59/238) in the absence of contralateral venous ectasia to 100% (4/4) in the presence of severe contralateral venous ectasia, whereas the prevalence of severe PTS (Villalta score >15) increased from 0.9% (2/238) in patients without contralateral venous ectasia to 25% (1/4) in patients with severe contralateral venous ectasia.Villalta scores were strongly correlated in the ipsilateral and contralateral legs (r=0.68; R-Square: 0.4686; paired t-test: p<0.0001). Among the 13.9% (n=50) of patients with a Villalta score >4 in the contralateral leg, 92% (n=46) had PTS in the ipsilateral leg. Similarly, 40% (n=46) of patients with ipsilateral PTS had a Villalta score>4 in the contralateral leg. Among these 46 patients, the distribution of Villalta signs and symptoms components in both legs were similar: symptoms accounted for an average of 61% of the Villalta score in the ispsilateral leg and for 63% in the contralateral leg (paired t-test: p=0.3; 80% power to detect a paired difference of 7% using our standard deviation of 0.165 with a bilateral test at 5% alpha). Conclusions:Villalta scores in the ipsilateral and contralateral legs are strongly correlated. Almost half of patients with ipsilateral PTS had a Villalta score>4 in the contralateral leg. Among patients with Villalta score > 4 in both legs, distribution of venous signs and symptoms were similar between the two legs. This suggests that up to half of incident PTS diagnosed with the Villalta scale might in fact reflect pre-existing symptomatic chronic venous disease. Performing bilateral Villalta assessments after DVT both clinically and in PTS-related research could be of interest to distinguish PTS from previous primary venous disorders. Disclosures:Kahn:sanofi aventis: Honoraria, Research Funding; Leo Pharma: Honoraria.

Truncular vascular malformations in a varicose vein surgery patient cohort

To determine the incidence and significance of vascular malformations in a varicose vein surgery patient cohort in a prospective cohort study. During a ten year time span we prospectively searched for patients with vascular malformations within a varicose vein surgery cohort. All patients underwent colour duplex sonography and surgery for symptomatic chronic venous disease or chronic venous insufficiency corresponding to clinical classes C2 to C6 according to CEAP. Five out of 1488 patients had truncular vascular malformations. One patient had an arterio-venous malformation in the groin. Venous malformations were found in three marginal veins and one bone perforating vein. Two of these five patients had a mitral valve prolapse syndrome, one a persistent foramen ovale, one had a bone cyst in a finger and one ectromelia of the hands and feet, respectively. No complications occurred following surgical treatment of these five malformations. Truncular arterio-venous and venous malformations in a varicose vein surgery patient cohort are rare. In our cohort the hemodynamic impact of the vascular malformations was low, the surgical treatment combined with varicose vein surgery resulted in technical and clinical success.

Hyperemic maximal venous outflow unmasks symptomatic lower extremity venous obstruction

Venous obstruction is an underappreciated and often unrecognized component of the pathophysiology of symptomatic chronic venous disease (CVD). Moreover, standard methods used to detect venous obstruction, such as maximal venous outflow, are inadequate as they typically test patients at rest and in the supine position when the pathophysiology of CVD is defined in the upright patient performing exercise. This report describes a patient with incapacitating venous claudication in whom standard noninvasive venous function tests were normal and whose phlebography was interpreted as showing no evidence of venous obstruction. A postocclusive reactive hyperemic technique was used to unmask significant outflow obstruction, leading to operative correction and subsequent symptom resolution.

Chronic deep venous obstruction: definition, prevalence, diagnosis, management

Ilio-caval venous obstruction has an important role in the expression of symptomatic chronic venous disease regardless of aetiology. The presence of obstruction has been more or less previously ignored and emphasis placed on reflux alone. Stenting of the ilio-femoral veins guided by intravascular ultrasound (IVUS) can now be performed with low morbidity and mortality using appropriate technique. Current diagnostic modalities do not allow a definitive assessment of haemodynamically critical venous obstruction, which hampers selection of limbs for treatment. The diagnosis must be based on morphological studies (preferably IVUS) in patient selected with specific history, signs and symptoms. A high index of suspicion and generous use of morphological investigations are critical in the initial recognition of venous outflow obstruction. Stenting of the ilio-femoral vein appears to be durable with a substantial improvement in limb pain and swelling, high rate of ulcer healing, enhanced quality of life and decreased disability. The beneficial clinical outcome occurs regardless of the presence of remaining reflux, adjunct saphenous procedures or aetiology of obstruction.

Spontaneous Onset of Bacterial Cellulitis in Lower Limbs with Chronic Obstructive Venous Disease

Background Cellulitis, often recurrent is a common complication of severe chronic venous disease (CVD) when dermatitis or ulcer is present. The skin breakdown obviously provides easy entry for bacteria but other factors such as oedema and lymphatic dysfunction likely play a role in pathogenesis as well. An iliac obstructive lesion is commonly present and correction with stent(s) often heals dermatitis/ulcer and relieves cellulitis. The current manuscript focuses on a relatively infrequent “spontaneous” variety of cellulitis which also occurs in obstructive venous disease in the absence of overt skin breakdown. Stenting results are of particular interest in this subset because its therapeutic efficacy can be related to factors other than healing of dermatitis/ulceration (portal of entry). Material and methods One thousand and nine limbs underwent iliac vein stenting for symptomatic CVD over a 7 year period; 29 limbs that were stented to treat spontaneous recurrent cellulitis of two or more prior attacks and 16 additional limbs with only one prior episode (stented for other indications) are analysed. Eighty two percent of the limbs had obvious swelling and the remainder had none at the time of stenting when cellulitis was inactive. Iliac vein outflow obstruction was found by intravascular ultrasound (IVUS) and all limbs were stented. Results Median age was 54 and male to female ratio 1:2. Aetiology of iliac obstruction was post-thrombotic in 33% and non-thrombotic in 67%. Preoperatively, lymphatic abnormalities were present in 17 (38%) of the limbs: no activity in 7, delayed flow in 8 and pooling of isotope in the lower leg in 2 limbs. Swelling and pain improved significantly after stent placement. Cumulative freedom from recurrent attacks of cellulitis was 76% at 3 years. Conclusion Iliac vein outflow obstruction may underlie CVD limbs afflicted with cellulitis. IVUS examination is recommended if cellulitis is recurrent and conventional therapy had failed. Correction of outflow obstruction by venous stent placement appears to yield moderate freedom from repeat infections in the near term.

Mid-term results of endovascular treatment for symptomatic chronic nonmalignant iliocaval venous occlusive disease

Mid-term results of endovascular treatment for symptomatic chronic nonmalignant iliocaval venous occlusive disease

Mid-term results of endovascular treatment for symptomatic chronic nonmalignant iliocaval venous occlusive disease

The goal of this article is to present clinical and patency results of endovascular treatment of nonmalignant, iliocaval venous obstructive disease and to discuss the evolution of technical details. From November 1995 to June 2004, 44 patients (female-male ratio, 3.9:1; left-right lower limb ratio, 8.6:1; median age, 42 years; range, 21-80 years) had treatment for chronic disabling obstructive venous insufficiency with iliocaval stenosis or occlusion. The clinical class of CEAP was 2 in 11 limbs, 3 in 31, 4 in 4, 5 in 1, and 6 in 1; etiology was primary in 32 patients, secondary in 10, and congenital in 2. Anatomic involvement included superficial veins in 16 patients and perforator veins in 11. Obstruction was associated with superficial reflux in 4 patients, deep reflux in 13, and both in 13. Ten patients had occlusion. All procedures were performed in the operating room with perioperative angiography and angioplasty with or without self-expanding stent implantation. Venous clinical severity and disability scores were obtained before and after treatment. Patency and restenosis were evaluated by duplex Doppler ultrasonography. No perioperative death or pulmonary embolism occurred. The technical success rate was 95.5% (two recanalization failures), and two (4.5%) perioperative stent migrations occurred. One early thrombosis (2.4%) was treated by thrombectomy and creation of an arteriovenous fistula. One late death and one thrombosis occurred. Restenoses were found in five patients and were all treated successfully (four needed iterative stenting). Median follow-up was 27 months (range, 2-103 months). Median venous clinical severity score improved from 8.5 to 2, and median venous disability score improved from 2 to 0. Cumulative primary, assisted primary, and secondary patency rates of the venous segments at 36 months were 73%, 88%, and 90%, respectively, in intention to treat. The survival rate was 100% at 12 months and 97.3% at 60 months. Endovascular treatment of benign iliocaval occlusive disease is a safe and efficient minimally invasive technique with good mid-term patency rates. Moreover, it improves cases with obstruction only, as well as cases with associated reflux and obstruction. Primary stenting should always be performed by using self-expanding stents deployed under general anesthesia to avoid lumbar pain. In case of failure, the endovascular procedure does not preclude further surgical reconstruction.

Endovascular stenting to treat chronic long-segment inferior vena cava occlusion

Chronic inferior vena cava (IVC) occlusion is often associated with debilitating symptoms. Supportive therapy is the treatment offered to most patients, often with poor symptom control. Patients have had to learn to cope with the sequelae of the syndrome and to accept lifelong disability and pain. This may no longer be the case, because endovascular procedures have emerged as a promising alternative for treatment of chronic IVC occlusion. We present 2 case reports of long-standing long-segment IVC occlusion successfully treated with endovascular procedures that incorporated progressive balloon dilation and stenting. The remarkably rapid relief of pain and swelling and overall improvement in quality of life warrants attempts to correct the condition in other patients with IVC occlusion.

Clinical spectrum of recurrent postoperative varicose veins and efficacy of sclerotherapy management using the compass technique

Objectives: Tostudy the clinical spectrum of recurrent varices after surgery (REVAS) and the efficacy of sclerotherapy under the comprehensive objective mapping, precise image-guided injection, antireflux positioning and sequential sclerotherapy (COMPASS) technique in their management. Methods: Design: prospective open study with 1.5-5.7-year follow up. Patients: 253 legs of 168 consecutive patients who had received previous surgery for primary varicosity. Main outcome measures: obliteration, recanalization, residual reflux, neovascularization, venous dysfunction score and cumulative obliteration. Results: REVAS presents as a symptomatic chronic venous disease of women in their fifties, a decade later than primary varicosities are reported. Almost 75% of REVAS occurred at the groin, mostly with features of chronic venous disease. The COMPASS technique achieved sustained obliteration in 97% of the groin varices and in 100% of the thigh and isolated refluxes around the popliteal fossa. The cumulative obliteration rate was sustained at &gt;90% and obliteration of perforator reflux was sustained. There was a significant decrease in the venous dysfunction score. In the mean 3.1±1.7 years of follow up, only 3% possible neovascularization was seen. There were no serious adverse experiences reported. Conclusions: REVAS is a symptomatic chronic venous disease requiring skilled medical attention. The COMPASS technique appears to be more efficacious than the presently available surgical approaches to its long-term management.