Therapy Of Chronic Venous Insufficiency Research Articles

Effectiveness of compression therapy in chronic venous insufficiency

The article provides an overview of modern literature on the problem of etiology, pathogenesis and principles of complex therapy of chronic venous insufficiency. Data on possible surgical correction methods of this pathology are given. Also, modern tactics assign a significant role to pharmacotherapy, and an overview of the phleboprotectants used is given. Efficiency of compression therapy application is evaluated. A critical review of literature of modern compression agents was carried out, advantages and disadvantages of elastic binting, compression knitting and application of variable compression are described. In comparison with elastic bandages, compression knitting has a number of advantages, such as: patients independently and correctly use compression laundry, the created therapeutic pressure does not depend on the correct application of compression, is more convenient and aesthetic when wearing, is air-permeable and can be used at any time of the year. Evaluation of efficiency of application of compression knitwear in therapy of chronic venous insufficiency is given. The effect of the compression article is due to a decrease in capillary permeability, a decrease in blood viscosity, which leads to a decrease in edema, lymphoprotective action and an increase in vascular wall tone. Modern means of compression have proved to be effective due to the polyvalent mechanism of action on all factors of disease pathogenesis, high bioavailability and minimal side effects. Early application of compression knitwear allows to buy or reduce clinical manifestations of venous insufficiency and its complications, as well as to influence indicators of patients quality of life. Detailed study of literary data will help to correctly select the method and type of compression therapy in case of chronic venous insufficiency.

Getting Ready for Wound Certification: Assessing and Managing Lower Extremity Venous Disease.

Getting Ready for Wound Certification: Assessing and Managing Lower Extremity Venous Disease.

The randomized, controlled ATLANTIS trial of aquatic therapy for chronic venous insufficiency

ObjectiveThere are conflicting reports on the efficacy of exercise in chronic venous insufficiency (CVI). Exercise in water or aquatic activity (AA) can have additional advantages. We sought to evaluate the clinical effects of AA in CVI in a randomized prospective open label fashion. MethodsA total of 201 patients with advanced CVI were randomized to receive AA vs no such treatment. In the Aquatic Group (AG), 91 patients reached the 24-month follow-up point, and in the Control Group (CG), 90 patients did. The primary efficacy end point was a predefined reduction of ≥4 points in the modified Venous Clinical Severity Score (VCSS) at 3 months. Instruments of venous disease severity and quality of life were compared at baseline, 3 months, and 24 months between and within the two groups. These included the modified VCSS, Villalta score, leg and thigh circumference, the Physical Health Component of the 36-Item Short Form Health Survey, and the Venous Insufficiency Epidemiological and Economic Study Quality of Life/Symptom scores. Aquatic activity consisted of a minimum of 15 minutes of walking in a swimming pool at 1 m/s, 3 times/wk for 3 months. ResultsThe primary end point of 4-point reduction in the modified VCSS at 3 months was reached in 28% of AG and 3% of CG (odds ratio = 12.08; 95% confidence interval: 3.51, 41.59; P < .001). Comparison of changes in secondary end points from baseline to 24 months between AG and CG demonstrated the following: modified VCSS −4.08 ± 2.08 vs −1.15 ± 1.26, Villalta score −4.00 ± 2.68 vs −1.01 ± 1.34, thigh circumference −3.40 ± 1.78 cm vs −1.40 ± 2.55 cm, leg circumference −1.27 ± 1.34 cm vs −0.49 ± 1.21 cm, Physical Health Component of the 36-Item Short Form Health Survey 3.82 ± 2.36 vs 1.16 ± 1.18, Venous Insufficiency Epidemiological and Economic Study Quality of Life 3.35 ± 1.67 vs 1.30 ± 1.43, and Venous Insufficiency Epidemiological and Economic Study Symptom 3.53 ± 1.71 vs 1.23 ± 1.26 (P < .001 for all comparisons; ± denotes mean ± standard deviation). ConclusionsThe addition of AA to the treatment of patients with advanced CVI is safe and effective, leading to a significant improvement in clinical status and quality of life. These beneficial changes occur rapidly within 3 months of initiation of AA and are continued at a slower rate of improvement from 3 months to 2 years.

Modern view on the therapy of chronic venous insufficiency with micronized purified flavonoid fraction

The high prevalence of varicose veins has been established in numerous population studies. Currently, guidelines have been developed for the treatment of patients with varicose veins for various stages of chronic venous insufficiency. Nevertheless, despite the use of modern drugs, leg compression, surgical and other interventions, it is not possible to completely reverse the symptoms of venous insufficiency. The article is devoted to the analysis of micronized flavonoid purified fraction. The development of modern drugs for chronic venous diseases is an important direction in medicine. The creation of a drug pool manufactured InRussiais a priority in the development of the country’s pharmaceutical industry. The review presents data on the study of Detravenol (Russia), which is a combination of diosmin and hesperidin (micronized purified flavonoid fraction).

Open-label, randomised, multicentre crossover trial assessing two-layer compression bandaging for chronic venous insufficiency: results of the APRICOT trial.

Compression bandaging is the mainstay therapy for chronic venous insufficiency and venous leg ulcers, but patient compliance can be challenging due to associated discomfort. The study discussed here aimed to compare AndoFlex TLC Calamine and Coban2 compression bandaging in relation to patient comfort and pruritus symptomology, with severity of pruritus as the primary outcome. This was a multi-centre, prospective, non-blinded, randomised controlled crossover trial involving 39 randomised patients with chronic venous insufficiency patients. In two periods, the patients wore AndoFlex TLC Calamine or Coban2 for 3 weeks each. No significant differences in validated pruritus outcome measures were observed, including a non-significant treatment effect for the severity of pruritus scale (n=35 trial completers; p-value=0.24, Wilcoxon test). However, after trying both bandages, 21 of the 35 patients (60%) definitely preferred AndoFlex TLC Calamine, whereas 4 patients (11%) definitely preferred Coban2. Thus, AndoFlex TLC Calamine compression bandage therapy was preferred by most patients, although this observation could not be confirmed using validated patient-reported outcome measures for pruritus. Further research is indicated to establish if patient preference translates into favourable clinical outcomes. ISRCTN number: ISRCTN95282887.

Chronic Venous Insufficiency and Post-thrombotic Syndrome; Approach to Management and Health Resort Treatment

Introduction: Post- thrombotic syndrome (PTS) is the most common complication of deep vein thrombosis (DVT), and develops in 20–50% of patients after a proximal DVT. Balneotherapy and hydrotherapy is justified in treatment of primary or post-thrombotic chronic venous insufficiency (CVI). M aterial: A review of articles was done in electronic databases Pubmed and Medline by keywords: postthrombotic syndrome, chronic venous insufficiency in conjunction with balneotherapy, hydrotherapy, kinesitherapy, coagulation. Results: Main risk of PST is considered as extensive proximal character of DVT, pre-existing CVI, older age, high body mass index, pre-existent varicosities. PTS refers to clinical manifestations of CVI, and is common cause of unilateral CVI. The thrombus itself may lead to venous valves destruction and reflux. The Villalta PTS scale may define and classify the severity of PTS Venous leg ulcers is the most advanced clinical manifestation of the disease. Prevention of PTS begins with prevention of initial and recurrent DVT includes use of compression stockings and anticoagulant medications. Treatment guidelines recommend anticoagulant therapy - five days with heparin followed by three months of oral anticoagulant after acute event, with subsequent long-term of extended therapy depending on patient’s risk of recurrence. Recent clinical trials indicate that the use of new anticoagulants (NOAS) reduces the incidence of PTS. Ultrasound compression test of the leg veins evaluates the degree of obstruction by clots. Medical therapy of CVI has still not efficient. Carbon dioxide baths and ozone baths have favorably affect hemostasis system. However there are only a few controlled studies evaluating effects of balneotherapy in primary and post-thrombotic CVI. The favorable effect of these mineral baths may result from both hydrostatic effects as well as the contribution with specific chemico-physical properties. The controlled trials (in patients with C3 -C5 stage) shown that balneohydrotherapy and kinesitherapy have decreased signs and symptoms in patients with primary and post - thrombotic CVI. Conclusions: The Health Resort treatment of patients with CVI in the mechanism of post-thrombotic syndrome should be preceded by evaluation of the venous system of the lower limb by compression ultrasound. Balneotherapy and hydroteraphy seem to be effective and safe procedures even in patients with advanced primary and post-thrombotic CVI stage.

Medical compression stockings on the skin moisture in patients with chronic venous disease

Background: Because of side effects like skin dryness and consecutive symptoms like itching the therapy of chronic venous insufficiency (CVI) with medical compression stockings (MCS) can lead to a diminished wear comfort and restricted compliance. Compression stockings with integrated skin care may have a positive influence on the skin hydration and moreover a positive effect on patients compliance. Patients and methods: In this monocentric, randomized prospective, controlled trial a below knee conventional MCS was compared to a medical compression stocking with integrated skin care (MCS-SC), interface pressure range 23-32mmHg. Participants: 50 patients with CVI. Primary outcome: skin hydration. Secondary outcomes: transepidermal water loss, skin roughness, leg volume, interface pressure and questionnaires about quality of life and wear comfort. Results: In patients wearing MCS the skin moisture decreased (p=0.021) and the skin roughness increased significantly (p=0.001), whereas in patients wearing the MCS-SC skin moisture and skin roughness changed only slightly (n.s.). These protective effects of MCS-SC compared to MCS were most common in patients with CVI at stage 3 (p=0.046), in male patients (p=0.013) and patients with initial dry skin (p=0.034). Both MCS reduced lower leg volume, MCS by 80ml (p<0.001) and MCS-SC by 60ml (p<0.001), both MCS improved quality of life: leg complaints (p=0.0003); functional status (p=0.010), well-being and life satisfaction (p=0.030). Wear comfort: In terms of tightness, constriction in bond area and strenuous donning the MCS-SC was assessed significantly more comfortable than MCS (p<0.001). Conclusions: MCS-SC revealed to be superior to MCS with regard to skin moisture, particularly in patients with low skin humidity, in male patients and in patients with C3, varicose veins accompanied by edema.

A critical review on the three-dimensional finite element modelling of the compression therapy for chronic venous insufficiency

Compression therapy is an adjuvant physical intervention providing the benefits of calibrated compression and controlled stretch and consequently is increasingly applied for the treatment of chronic venous insufficiency. However, the mechanism of the compression therapy for chronic venous insufficiency is still unclear. To elaborate the mechanism of compression therapy, in recent years, the computational modelling technique, especially the finite element modelling method, has been widely used. However, there are still many unclear issues regarding the finite element modelling of compression therapy, for example, the selection of appropriate material models, the validation of the finite element predictions, the post-processing of the results. To shed light on these unclear issues, this study provides a state-of-the-art review on the application of finite element modelling technique in the compression therapy for chronic venous insufficiency. The aims of the present study are as follows: (1) to provide guidance on the application of the finite element technique in healthcare and relevant fields, (2) to enhance the understanding of the mechanism of compression therapy and (3) to foster the collaborations among different disciplines. To achieve these aims, the following parts are reviewed: (1) the background on chronic venous insufficiency and the computational modelling approach, (2) the acquisition of medical images and the procedure for generating the finite element model, (3) the definition of material models in the finite element model, (4) the methods for validating the finite element predictions, (5) the post-processing of the finite element results and (6) future challenges in the finite element modelling of compression therapy.

Clinical correlation with failure of endovenous therapy for leg swelling.

Background The development and use of minimally invasive procedures provide improved options for the management of symptoms of chronic venous insufficiency. While many patients with iliac venous occlusive disease and superficial venous insufficiency improve with combined iliac venous stenting and correction of superficial venous reflux, some patients have symptoms which persist. The goal of this study was to identify clinical factors related to persistent symptoms in patients with leg swelling after treatment of both iliac vein stenting and thermal ablation. Methods This observational study analyzed data for patients who underwent both iliac vein stent placement as well as endovenous ablation (either RFA or EVLT) as a management for chronic venous insufficiency between February 2012 and February 2014. Follow-up was performed after completion of both procedures and inquiring for improvement of swelling. Statistical analysis performed using Chi-square and student's t-test. Results Of the total 173 patients who underwent both endovenous closure and iliac vein stent placements, 55 (31.8%) patients were men; 29 (16%) patients stated they had no improvement after these procedures. The average age of patients who did not improve was 68.8 (±16.7 SD) years and 66.2 (±13.3 SD) years for patients who improved. Over all, the classification of the presenting symptoms by CEAP classification demonstrated 25.4%, 53.2%, 5.8%, and 15.6%, for C3-C6, respectively. There was no correlation with failure to improve the swelling with: age ( P = .44), gender ( P = .33), presenting symptom ( P = .67), use of calcium channel blockers ( P = .85), nitroglycerin ( P = .86), Plavix ( P = .07), aspirin ( P = .55), Synthyroid ( P = .55), Coumadin ( P = .14), angiotensin receptor blocker ( P = .81), β Blockers ( P = .61), angiotensin converting enzyme inhibitors ( P = .88), furosemide 40 mg ( P = .74), hydrochlorothiazide 12.5 mg ( P = .07), hydrochlorothiazide 25 mg ( P = .48), and EVLT vs. RFA ( P = .91). The use of furosemide (20 mg) was associated with continued swelling ( P = .01). The use of dual diuretics (furosemide and hydrochlorothiazide) was associated with persistent swelling even after these combined endovenous procedures P = .03). Conclusion These preliminary data suggest that the treatment with diuretics may be associated with failure to relieve lower extremity swelling despite combined endovascular therapy for chronic venous insufficiency.

Interface pressure and venous drainage of two compression stocking types in healthy volunteers and in patients with hemodynamic disturbances of the legs.

Standard of care in the therapy of chronic venous insufficiency (CVI) is the use of graduated elastic stockings (GECS). This paper is based on a prospective, mono-centric, open randomised, controlled and cross over study and discusses the hemodynamic effects of GECS and inverse graduated compression stockings (PECS) in 32 healthy volunteers and 32 patients with CVI and the consecutive impact on comfort. The application of stockings was performed sequentially, the allocation of the first stocking was randomized and double blind, wearing period for each stocking type about 7 days with one week of break between wearing periods. Measurements of the interface pressure were carried out by Picopress®(Microlab Elettronica, Italy) and the venous drainage were registered by strain gauge plethysmography. Mean interface pressure: GECS (level B1): 27.3 mmHg; GECS (level C): 19,6 mmHg; PECS (level B1): 17,8 mmHg; PECS (level C): 24,7 mmHg. Significant increase of EF and decrease of VFI by wearing both types of compression stockings, comparatively GESC resulted in a significantly greater improvement of EF than the PECS. PECS were significantly easier to don and put on compared to the GECS, the PECS tended to slip towards the foot more often.

Chronic venous insufficiency in a geriatric collective

SummaryAim: Investigation of symptoms of chronic venous insufficiency (CVI) in geriatric patients &gt; 65 years and their relation to activities of daily life and locomotion.Methods: This monocenter pilot study collects data from patients of a geriatric hospital. We qualified Activities of daily live by Barthel Index, locomotion via Timed-Up-and-Go-test and clinical CEAP levels and included data from the Venous Clinical Severity Score and the patient questionnaire of the German Society of Phlebology. Additionally a duplex-sonographic screening was performed. Identified CEAP levels were correlated with results of the scores mentioned above.Results: 42 patients with an average age of 80.5 (64–93) years were included. 76.2 % of them had a CEAP-score of ≥3. CEAP-score 5-6 correlated with limited locomotion and independence in activities of daily life. 81 % of the patients had previous venous therapies.Conclusion: CVI is an underestimated disease in elder patients. In our collective a great part of patients showed relevant clinical symptoms of CVI which were aggravated by limitations of higher age. Early diagnostic and therapy of CVI are indicated to reduce complicated clinical courses.

Horse chestnut seed extract for chronic venous insufficiency.

Conservative therapy of chronic venous insufficiency (CVI) consists largely of compression treatment. However, this often causes discomfort and has been associated with poor compliance. Therefore, oral drug treatment is an attractive option. This is an update of a Cochrane review first published in 2002 and updated in 2004, 2006, 2008 and 2010. To review the efficacy and safety of oral horse chestnut seed extract (HCSE) versus placebo, or reference therapy, for the treatment of CVI. For this update the Cochrane Peripheral Vascular Diseases Review Group searched their Specialised Register (last searched June 2012) and CENTRAL (Issue 5, 2012). For the previous versions of the review the authors searched AMED (inception to July 2005) and Phytobase (inception to January 2001) for randomised controlled trials (RCTs) of HCSE for CVI. Manufacturers of HCSE preparations and experts on the subject were contacted for published and unpublished material. There were no restrictions on language. RCTs comparing oral HCSE mono-preparations with placebo, or reference therapy, in people with CVI. Trials assessing HCSE as one of several active components in a combination preparation, or as a part of a combination treatment, were excluded. Both authors independently selected the studies and, using a standard scoring system, assessed methodological quality and extracted data. Disagreements concerning evaluation of individual trials were resolved through discussion. Overall, there appeared to be an improvement in CVI related signs and symptoms with HCSE compared with placebo. Leg pain was assessed in seven placebo-controlled trials. Six reported a significant reduction of leg pain in the HCSE groups compared with the placebo groups, while another reported a statistically significant improvement compared with baseline. One trial suggested a weighted mean difference (WMD) of 42.4 mm (95% confidence interval (CI) 34.9 to 49.9) measured on a 100 mm visual analogue scale. Leg volume was assessed in seven placebo-controlled trials. Six trials (n = 502) suggested a WMD of 32.1ml (95% CI 13.49 to 50.72) in favour of HCSE compared with placebo. One trial indicated that HCSE may be as effective as treatment with compression stockings. Adverse events were usually mild and infrequent. The evidence presented suggests that HCSE is an efficacious and safe short-term treatment for CVI. However, several caveats exist and larger, definitive RCTs are required to confirm the efficacy of this treatment option.

High Compression Pressure over the Calf is More Effective than Graduated Compression in Enhancing Venous Pump Function

BackgroundGraduated compression is routinely employed as standard therapy for chronic venous insufficiency. AimThe study aims to compare the haemodynamic efficiency of a multi-component graduated compression bandage (GCB) versus a negative graduated compression bandage (NGCB) applied with higher pressure over the calf. MethodsIn 20 patients, all affected by greater saphenous vein (GSV) incompetence and candidates for surgery (Clinical, etiologic, anatomic and pathophysiologic data, CEAP C2-C5), the ejection fraction of the venous calf pump was measured using a plethysmographic method during a standardised walking test without compression, with GCB and NGCB, all composed of the same short-stretch material. Sub-bandage pressures were measured simultaneously over the distal leg and over the calf. ResultsNGCBs with median pressures higher at the calf (62 mmHg) than at the distal leg (50 mmHg) achieved a significantly higher increase of ejection fraction (median +157%) compared with GCB, (+115%) with a distal pressure of 54 mmHg and a calf pressure of 28 mmHg (P < 0.001). ConclusionsPatients with severe venous incompetence have a greater haemodynamic benefit from NGCB, especially during standing and walking, than from GCB.

Systemische medikamentöse Therapie von chronischen Venenerkrankungen

The therapy of chronic venous insufficiency is multifactorial. Compression, interventional and operative approaches are available along with the possibility of systemic treatment. The efficacy of systemic venotonic medications, mostly phytotherapeutic agents, is controversial. Nonetheless in a number of clinical and laboratory studies, an effect was seen after use for 8-12 weeks. When administered appropriately, venotonic agents can show anti-edematous, anti-inflammatory, anti-oxidative, proteolytic effects as well as reducing capillary leakage. Furthermore they increase vein tone and lymph flow. Venotonic agents should be used if compression therapy alone is either not sufficient, contraindicated or not tolerable. They can be useful as a temporizing measure until surgical intervention is performed. Some of them can even be used in pregnancy, but the indications are very strict.

Compression therapy for chronic venous insufficiency

Compression therapy provides a means to treat venous stasis, venous hypertension, and venous edema. Different methods of compression therapy have been described periodically over the last 2,000 years. In addition to static compression, specialized compression pumps have been developed and a technique of massage called manual lymphatic drainage has emerged to treat primary and secondary lymphedema. Objectives of compression therapy are to reduce the swollen limb to minimum size, maintain that size, and allow the patient to participate in the care of his limb whenever possible. Reduction therapy is achieved by limb elevation, compression pumps as necessary, and compression wraps. Maintenance therapy largely consists of compression wraps or compression stockings. Nonelastic devices have found a place in treating severe lymphedema but it should be emphasized that periodic follow-up must be done during maintenance therapy so that adjunctive maintenance measures can be added as needed.

Troxerutin protects the isolated perfused rat liver from a possible lipid peroxidation by coumarin

For more than 40 years coumarin has been successfully used in the therapy of chronic venous insufficiency (CVI). The occurrence of liver injuries is rather rare and happens predominantly when doses are administered which are significantly higher than necessary for therapeutical use. Such effects caused by high coumarin concentrations are reproducible in in vivo experiments in mice or rats and HepG2-cells. In order to characterize the mechanism of liver injuries, the isolated perfused rat liver has been chosen as model. Since liver injuries are quite rare, if coumarin is used in co-medication with troxerutin, a possible protective influence of this flavonoid has been investigated. In concentrations higher than 4 mmol/l, coumarin alone is effective in the isolated perfused rat liver. Then the release of the enzymes alanine aminotransferase (ALT) and lactate dehydrogenase (LDH) increases and there is a measurable reduction of perfusion flow, oxygen consumption and rate of bile secretion. Additionally, the concentrations of hepatic adenosine triphosphate (ATP) and oxidized and total glutathione (GSSG/GSH) decrease. In the livers of fasting animals, coumarin doubles the concentration of hepatic malondialdehyde (MDA). This effect cannot be detected if troxerutin is added. In general, troxerutin reduces the concentration of all coumarin-metabolites in the perfusate and bile and changes the ratio of the main metabolites, coumarin: 3-hydroxycoumarin: 7-hydroxycoumarin. An analysis of the metabolic steps also shows that the amount of coumarin eliminated via faeces does not stem from absorbed coumarin, because the amount of orally applied coumarin detectable in the bile is less than 1%. The study demonstrates that troxerutin has hepatoprotective properties and thus protects the liver from a possible lipid peroxidation caused by coumarin. However, it is necessary to point out that these adverse effects caused by coumarin can be detected only in very high concentrations considerably above the regular therapeutical dosage. This allows the conclusion that troxerutin is a beneficial cofactor in coumarin preparations used for the therapy of chronic venous insufficiency.

Horse chestnut seed extract for chronic venous insufficiency.

Conservative therapy of chronic venous insufficiency (CVI) consists largely of compression treatment. However, this often causes discomfort and has been associated with poor compliance. Therefore, oral drug treatment is an attractive alternative. To review the evidence from rigorous clinical trials assessing the efficacy and safety of oral horse chestnut seed extract (HCSE) versus placebo, or other treatments for CVI. Randomised controlled trials (RCTs) of HCSE for chronic venous insufficiency were sought through EMBASE (inception to December 2001), MEDLINE and AMED (from inception to February 2004), The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2004), the Specialised Trials Register of the Cochrane Peripheral Vascular Diseases Group (last searched February 2004), and Phytobase (from inception to January 2001, no longer operational). Manufacturers of HCSE preparations and experts on the subject were contacted for published and unpublished material. There were no restrictions on language. RCTs were included if they compared oral HCSE mono-preparations with placebo, or other treatments, in patients with CVI. Trials assessing HCSE as one of several active components in a combination preparation, or as a part of a combination treatment, were excluded. Two reviewers independently selected and assessed methodological quality of the studies using a standardised scoring system, and extracted data. Disagreements concerning evaluation of individual trials were resolved through discussion. Overall, there appeared to be an improvement in CVI related signs and symptoms with HCSE compared with placebo. Leg pain was assessed in seven placebo-controlled trials. Six reported a significant reduction of leg pain in the HCSE groups compared with the placebo groups, while another reported a statistically significant improvement compared with baseline. One trial suggested a weighted mean difference (WMD) of 42.4 mm [95% confidence interval (CI) 34.9 to 49.9] measured on a 100 mm visual analogue scale. Leg volume was assessed in six placebo-controlled trials. Meta-analysis of five trials (n = 289) suggested a significant reduction in favour of HCSE compared with placebo (WMD 56.3 ml [95% CI 24.1 to 88.5]). One trial indicated that HCSE may be as effective as compression stockings at reducing leg volume. Adverse events were usually mild and infrequent. The evidence presented implies that HCSE is an efficacious and safe short-term treatment for CVI. However, several caveats exist and more rigorous RCTs are required to assess the efficacy of this treatment option.

Surgical prevention and therapy of chronic venous insufficiency

Die chronisch venose Insuffizienz beschreibt als klinisches Syndrom alle Folgeerkrankungen sowohl der primaren Varikosis als auch der Phlebothrombose. Der nachfolgende Beitrag stellt die Indikationen und Erfolgsraten der operativen Therapie bei primarer Varikosis, Thrombophlebitis bzw. Varikophlebitis, Ulcus cruris venosum und akuter Thrombose der tiefen Becken- und Beinvenen vor. Wahrend die Chirurgie der Varicosis und des Uleus cruris weitgehend standardisiert ist, bedarf die operative Therapie der Phlebothrombose einer individuellen Indikationsstellung. Es wird gezeigt, dass durch sorgfaltige praoperative Diagnostik, zusatzliche intraoperative Masnahmen wie Phlebographie, lokale Thrombolyse und Stenting und geeignete postoperative Vorkehrungen hinsichtlich Antikoagulation und Kompressionstherapie die Langzeitergebnisse der operativen Therapie der Phlebothrombose deutlich verbessert werden konnen.

Horse chestnut seed extract for chronic venous insufficiency.

Conservative therapy of chronic venous insufficiency (CVI) consists largely of compression treatment. However, this often causes discomfort and has been associated with poor compliance, which renders oral drug treatment an attractive option. To review the evidence from rigorous clinical trials assessing the efficacy and safety of oral horse chestnut seed extract (HCSE) versus placebo, or reference therapy for the treatment of CVI. Publications describing randomised controlled trials (RCTs) of HCSE for chronic venous insufficiency were sought through EMBASE, MEDLINE, Amed, and Phytobase (from inception to January 2001), The Cochrane Controlled Trials Register (Issue 1, 2001) and the Specialised Trials Register of the Cochrane Peripheral Vascular Diseases Group (April 2001). Manufacturers of HCSE preparations and experts on the subject were contacted and asked to contribute published and unpublished material. There were no restrictions on the language of publication. Randomised controlled trials of oral HCSE mono-preparations for patients with CVI were included. Trials comparing HCSE with placebo or reference medications were included. Trials assessing HCSE as one of several active components in a combination preparation or as a part of a combination treatment were excluded. Data were extracted systematically and methodological quality was evaluated using a standard scoring system. The screening of studies, selection, data extraction and the assessment of methodological quality were performed independently by two reviewers. Disagreements concerning evaluation of individual trials were resolved through discussion. Overall, the included placebo controlled trials suggest an improvement in CVI related signs and symptoms. Leg pain was assessed in six placebo-controlled trials that reported a significant reduction of leg pain in the HCSE groups compared with the placebo groups. One trial, which reported adequate data suggested a weighted mean difference (WMD) of 42.4 mm [95% confidence interval (CI) 34.9-49.9] measured on a 100 mm visual analogue scale. Leg volume was assessed in five placebo-controlled trials. Meta-analysis of four trials (n = 239) reporting adequate data suggested a significant reduction in favour of HCSE compared with placebo (WMD 58.6 ml [95% CI 24.9-92.2]). One trial indicated that HCSE may be as effective as treatment with compression stockings. Adverse effects are usually mild and infrequent. The evidence presented implies that HCSE is an efficacious and safe short-term treatment for CVI. However several caveats exist and more rigorous RCTs are required to assess the efficacy of this treatment option.