Vein Sclerosis Research Articles

P-746. Characterizing Deep Neck Infections (DNI) at a Tertiary Care Center in Philadelphia with a High Population of People Who Inject Drugs (PWID)

Abstract Background Acute bacterial skin and skin structure infections (ABSSSI) including cellulitis and abscess are common complications of intravenous drug use (IVDU). With the widespread introduction of xylazine in the Philadelphia drug supply since 2019, more patients are injecting into their neck due to limited peripheral access from vein sclerosis or xylazine wounds. Herein, we have characterized DNI in PWID and their outcomes. Figure 1 Injection behavior Methods The IRB approved this study. We conducted a retrospective chart review of patients with documented opioid use disorder (OUD) with injection behavior and a diagnosis of DNI from January 2016 through December 2022. We collected data on demographics, microbiology, drug use and treatment to characterize infection, surgical intervention, and outcomes.Figure 2.Substances used Results We identified 153 patients with OUD and injection behavior who were diagnosed with DNI. 80 (52%) patients were male and 73 (48%) were female. 101 (66%) were experiencing homelessness. 139 (91%) patients reported injecting into their neck and 25 (16%) patients reported using their neck as the only site of injection due to limited peripheral access. Figure 1. 83 (54%) endorsed polysubstance drug use with cocaine or amphetamines. Figure 2. Types of infection include: 131 (86%) neck abscess, 22 (14%) neck phlegmon, 14 (9%) internal jugular (IJ) septic thrombophlebitis, 3 (2%) sternoclavicular septic arthritis, 3 (2%) with mediastinal involvement, and 2 (1%) osteomyelitis (OM) of clavicle or mandible. 124 (81%) patients underwent drainage. 103 (83%) of these patients had cultures sent from the abscess. The predominant organisms were MRSA (47, 46%), MSSA (15, 15%), GAS (23, 22%), and alpha-hemolytic Strep (26, 25%). Figure 3. 137 (90%) patients had blood cultures sent, 115 (84%) without growth, 10 (7%) MRSA, 10 (7%) GAS, and 3 (2%) MSSA. 21 (17%) required repeat intervention. Within 30 days there were 48 (31%) readmissions and 1 (0.5%) death.Figure 3.Microbiologic data from abscess cultures Conclusion Since 2016, there has been a sixfold increase in incidence of DNI in PWID. Figure 4. The complications of neck infection can be catastrophic with extension into mediastinum, septic thrombophlebitis, bloodstream infections, or bone and joint infections. It is important to recognize neck infections early and intervene as soon as possible before further complications occur. Figure 4. Neck abscess incidence Disclosures Sara K. Schultz, MD FACP FIDSA, AbbVie: Advisor/Consultant

Steam Vein Sclerosis for Nonsaphenous varicose veins.

The treatment of nonsaphenous varicose veins (NSVV), including incompetent perforating veins (IPV) and recurrent varicose veins (RVV), remains challenging for many reasons, including vein tortuosity, deep location and short vein to be treated. Data and recommendations are lacking. Steam vein sclerosis (SVS) is an endothermal therapy that has been used in the treatment of incompetent saphenous veins, achieving occlusion rates similar to other thermal ablation techniques with good patient tolerance and minimal postoperative pain. We report here the results of a cohort of SVS used to treat NSVV, including RVV and IPV. From October 2017 to March 2020, consecutive patients presenting with NSVV treated with SVS were included. Patients were followed at 3months with both clinical and duplex scan examinations. The primary endpoint was efficacy defined as target vein occlusion at 3months; secondary endpoints were: safety with analysis of per procedural and 3months complications, evolution of functional stage and symptoms between inclusion and 3months. Ninety-six patients were included in the study. Five patients were lost to follow-up. Fifty-nine percent (n=60) were women. Lesions were recurrent (recurrent varicose vein after surgery) in 61% (n=62). The location of the NSVV was sapheno-femoral residual stump in 8% (n=8), inguinal neovascularization in 14% (n=14), sapheno-popliteal residual stump in 12% (n=12), popliteal neovascularization in 7% (n=7), and IPV in 59% (n=60). Complete occlusion after treatment occurred in 86% (n=83) of patients, partial occlusion in 4% (n=4), and complete recanalization in 10% (n=9). The occlusion rate in the IPV group was 93%. Complications at 30days postoperatively were 2 (2%) deep vein thrombosis, 1 (1%) hematoma, and 2 (2%) late paresthesias in the superficial peroneal nerve area. The use of SVS has been shown to be effective and safe in the short-term treatment of NSVV, including IPV and RVV. Further studies are needed to evaluate its long-term effects.

Histopathological features of idiopathic portal hypertension: A systematic review and meta-analysis.

Portal hypertension (PH) is a clinically significant entity that could present with life-threatening gastrointestinal bleeding. Cirrhosis is the most common cause of PH, with well-documented histopathology and etiology. However, in idiopathic portal hypertension (IPH), no single histopathologic finding is associated with PH. Our systematic review aims to identify and summarize the prevalence of the common histological findings of IPH. We systematically searched PubMed, Cochrane CENTRAL, Web of Science, and Scopus till 1ST March 2022 for studies describing the histopathological features of IPH. Data were extracted from eligible studies and pooled as events rate and 95% confidence interval (CI) using binary random-effects model by open meta-analyst software. We included 23 retrospective studies with a total sample size of 813 patients. The overall incidence of nodular regenerative hyperplasia was 38.6%, 59.8% for portal fibrosis, 51.3% for periportal fibrosis, 39.3% for perisinusoidal fibrosis, 89.8% for portal vein sclerosis, 42.2% for portal inflammation, 53.3% for mega-sinusoids, 39.5% for thickening of portal vein branches, 93.8% for narrowing of portal veins, 53.3% for hepatic veins/venous outflow obstruction, 51.4% for aberrant portal/periportal vessels, 42.4% for shunt vessel, 50.9% for ductular proliferation, and 16.3% for steatosis. Due to the relatively non-pathognomonic and non-specific nature of IPH, a combination of different histological features such as the portal and periportal fibrosis, portal vein sclerosis, mega-sinusoids, narrowing of portal veins, hepatic venous outflow obstruction, aberrant portal or periportal vessels, and ductular proliferation may be of value in diagnosing IPH as the incidence rate of these features was at approximately 50%.

Neurodegeneration in chronic glaucoma analysed according to different hypertensive models induced in rats

AbstractPurpose: To compare four different animal models of chronic glaucoma with normal ageing over 6 months.Methods: Chronic glaucoma was induced in 138 Long‐Evans rats and compared to 43 healthy rats (healthy cohort). Rats were injected in their right eye to increase intraocular pressure (IOP). 25 rats received biweekly episcleral vein sclerosis injections (EVS cohort) and the remaining rats received an intraocular injection with a suspension of biodegradables microspheres (Ms): 25 rats received no‐loaded Ms at 0‐2‐4‐8‐12‐16 and 20 weeks (Ms20/10 cohort), 45 rats received Ms loaded with dexamethasone at baseline and week 4 (MsDexa cohort), and 43 rats received Ms co‐loaded with dexamethasone and fibronectine at baseline (MsDexaFibro cohort), in the anterior chamber of the eye. IOP, functionality of neuroretina by electroretinography (ERG), structure of neuroretina and vitreous interface by optical coherence tomography (OCT) were analysed.Results: The EVS cohort showed the steepest and strongest increase in IOP, whereas the Ms models had a more progressive increase. Each model showed a specific retinal damage and vitreous signal in OCT. The EVS cohort experienced the highest vitreous intensity and percentage loss in ganglion cell layer, MsDexa in the retinal nerve fibre layer and MsDexaFibro in total thickness of the retina at 24 weeks of the study. Ganglion cells' signal using ERG was bigger in the glaucomatous cohorts compared to healthy rats.Conclusions: Different models of chronic glaucoma resulted in different curves of IOP and patterns of neuroretinal degeneration. Modulable degeneration was generated using models by the injection of biodegradable Ms. The biodegradable Ms models simulated accurately the neurodegeneration seen in human chronic glaucoma. Our results reinforced the multifactorial condition of glaucoma according to several noxa.

Tunable degrees of neurodegeneration in rats based on microsphere-induced models of chronic glaucoma

This study compares four different animal models of chronic glaucoma against normal aging over 6 months. Chronic glaucoma was induced in 138 Long–Evans rats and compared against 43 aged-matched healthy rats. Twenty-five rats received episcleral vein sclerosis injections (EPIm cohort) while the rest were injected in the eye anterior chamber with a suspension of biodegradable microspheres: 25 rats received non-loaded microspheres (N-L Ms cohort), 45 rats received microspheres loaded with dexamethasone (MsDexa cohort), and 43 rats received microspheres co-loaded with dexamethasone and fibronectin (MsDexaFibro cohort). Intraocular pressure, neuroretinal function, structure and vitreous interface were evaluated. Each model caused different trends in intraocular pressure, produced specific retinal damage and vitreous signals. The steepest and strongest increase in intraocular pressure was seen in the EPIm cohort and microspheres models were more progressive. The EPIm cohort presented the highest vitreous intensity and percentage loss in the ganglion cell layer, the MsDexa cohort presented the greatest loss in the retinal nerve fiber layer, and the MsDexaFibro cohort presented the greatest loss in total retinal thickness. Function decreased differently among cohorts. Using biodegradable microspheres models it is possible to generate tuned neurodegeneration. These results support the multifactorial nature of glaucoma based on several noxa.

S2945 Check Point SOS! A Case of Cemiplimab-Associated Sinusoidal Obstruction Syndrome

Introduction: Hepatic veno-occlusive disease (VOD) or sinusoidal obstruction syndrome (SOS), is a clinical syndrome characterized by hepatomegaly, right-upper quadrant pain, and ascites that occurs most commonly in the setting of high-dose chemotherapy or hematopoietic stem cell transplantation (HSCT). The diagnosis can be confirmed on biopsy. Cemiplimab is an immune checkpoint inhibitor recently approved for the treatment of cutaneous squamous cell carcinoma. There are currently no known reports of immune checkpoint inhibitor-related VOD/SOS. Case Description/Methods: A 58-year-old female with a history of locally advanced basal cell carcinoma of the left eye treated with six months of Cemipilimab presented with ascites. On admission, labs were notable for a total bilirubin of 1.2, mildly elevated liver function tests, alkaline phosphatase 884, and international normalized ratio 2.1. A diagnostic tap revealed a high SAAG ascites that was negative for infection. A comprehensive serological workup for viral, metabolic and autoimmune causes was unrevealing. A transjugular liver biopsy demonstrated a hepatic venous pressure gradient of 18mmHg, nodular regenerative hyperplasia (NRH), and portal venopathy. The patient was discharged on steroids but returned one month later for recurrent ascites and worsening bilirubin to 12.6 (direct 7.3); COVID PCR was negative. A full rheumatologic and vasculitis workup was unremarkable. Repeat biopsy (Figure 1) demonstrated moderate NRH changes, prominent central vein sclerosis with fibrous obliteration, signs of SOS/VOD and central venulitis with fibrotic changes with sinusoidal portal hypertension. Discussion: VOD occurs most often with hematopoietic stem cell transplantation, and chemotherapeutic agents. Here we present the first case of checkpoint inhibitor-induced VOD/SOS. Despite discontinuation of the offending agent and a trial of steroids, the patient’s clinical course continued to deteriorate. She eventually developed refractory ascites and portosystemic encephalopathy. She was deemed not a candidate for liver transplant given her underlying malignancy. She was transitioned to home hospice before further treatment, such as Defibrotide could have been pursued. VOD associated with immune checkpoint inhibition should be considered in the differential of patients who develop new onset liver dysfunction and ascites while receiving these medications.Figure 1.: Sinusoidal dilatation and congestion alongside central vein sclerosis. These are common findings of sinusoidal obstruction syndrome on liver biopsy.

Advanced Techniques for Ethanol Ablation of Left Ventricular Summit Region Arrhythmias.

Coronary venous ethanol ablation (VEA) can be used as a strategy to treat ventricular arrhythmias arising from the left ventricular summit, but collateral flow and technical challenges cannulating intramural veins in complex venous anatomies can limit its use. Advanced techniques for VEA can capitalize on collateral vessels between target and nontarget sites to improve success. Of 55 patients with left ventricular summit ventricular arrhythmia, advanced techniques were used in 15 after initial left ventricular summit intramural vein mapping failed to show suitable targets for single vein, single-balloon VEA. All patients had previous radiofrequency ablation attempts. Techniques included: double-balloon for distal protection to block distal flow and target the proximal portion of a large intramural vein where best signal was proximal (n=6); balloons in 2 different left ventricular summit veins for a cross-fire multivein VEA (n=4); intramural collateral vein-to-vein cannulation to reach of targeted vein via collateral with antegrade ethanol and proximal balloon block (n=2); prolonged ethanol dwell time for vein sclerosis of large intramural vein and subsequent VEA (n=3); and intramural collateral VEA (n=1). Fifteen (8 females) patients (age 60.6±17.6 years) required advanced techniques. Procedure time was 210±49.9 minutes, fluoroscopy time was 25.3±14.1 minutes, and 113±17.9 cc of contrast was utilized. A median of 7 cc of ethanol was delivered (range, 4-15 cc). Intraprocedural radiofrequency ablation was delivered before ethanol in 9 out of 15 patients but failed. Ethanol achieved acute success in all 15 patients. Ethanol was used as the sole treatment in two patients. At a median follow-up of 194 days, one patient experienced recurrence. Advanced techniques capitalizing on venous anatomy can enable successful VEA and selective targeting of arrhythmogenic sites, by blocking distal flow, utilization of collaterals between nontarget and target veins and multivein VEA. Understanding individual anatomy is critical for VEA success.

Improvement of dynamic venous function after thermal ablation with steam vein occlusion - 6-weeks and 1-year follow-up after 167 treatments.

In this paper, the method of steam vein occlusion for the treatment of the great/small saphenous vein (GSV/SSV) was analyzed in terms of a therapeutic influence on the dynamic parameters of global vein function, its effects on subjective symptoms based on chronic venous insufficiency (CVI) and the side effects of the steam vein sclerosis (SVS). It has been questioned whether the effects of this method lead to a recommendation for routine clinical practice. The venous drainage and the venous refilling time (T0) of the leg treated were determined by photoplethysmography (Elcat, Wolfratshausen, Germany) before, six weeks and one year after the intervention to examine the effects on global venous function. Further changes of clinical symptoms and findings were assessed by the Venous Clinical Severity Score (VCSS), preoperatively and after one year, and the complication rate at 6-week follow-up was monitored. The SVS was performed on 167 veins (GSV: 124; SSV: 43) in a total of 156 patients. Eight patients (5.1%) did not attend the 6-week follow-up, while 29 patients (18.6%) were lost in the 1-year follow-up. Patients were suffering from symptoms such as leg pain and leg edema, which resulted in a VCSS of 9.4 (cumulated mean score of all patients) preoperatively. The T0 was reduced to mean values of 20.6 s (GSV cohort) and 21 s (SSV cohort). The VCSS improved to 6.0 after one year. This correlated with the hemodynamic parameters. The T0 increased in the GSV cohort after six weeks to 31.8 s, p < 0.001, and showed a nonsignificant improvement to 32.2 s, p = 0.509, in the 1-year check. The T0 also increased in the SSV cohort significantly after 6 weeks to 30.1 s, p < 0.001, and showed a nonsignificant reduction after one year, p = 0.289. A total of 71%of the GSV and 69.8%of the SSV of the patients involved no complications following the treatment. Light complications (grade 1) occurred (reddening, hematoma, hyperpigmentation) in the majority: 24.2%of the GSV and 18.6%of the SSV. We noticed one grade 3 complication with thrombosis in the SSV cohort, which led to a pulmonary embolism. Forty-seven complete questionnaires were analyzed (responder rate: 28.1%); 40.4%of the patients had light complaints after the treatment, such as pain, warmth or local pressure sensations (Fig.7); 63%of those patients noticed only slight pain at a maximum of 3 out of 10. The majority (91%) would recommend this procedure. The SVS revealed endoluminal catheter-based intervention to abolish venous reflux of the G/SSV as safe. As one therapeutic target is to eliminate venous reflux, effectiveness of a method cannot be based on sonographic data alone; one must further assess patients' symptoms and dynamic venous function. This data shows an improvement of patients' symptoms which correlated well with the improvement of the venous function in digital photoplethysmography. The SVS can be recommended as a catheter-based treatment in the future.

Novel Use of PLGA Microspheres to Create an Animal Model of Glaucoma with Progressive Neuroretinal Degeneration.

Progressive degeneration of neuroretinal tissue with maintained elevated intraocular pressure (IOP) to simulate chronic glaucoma was produced by intracameral injections of poly (lactic-co-glycolic) acid (PLGA) microspheres (Ms) in rat eyes. The right eye of 39 rats received different sizes of PLGA-Ms (2 µL suspension; 10% w/v): 14 with 38–20 µm Ms (Ms38/20 model) and 25 with 20–10 µm particles (Ms20/10 model). This novel glaucoma animal model was compared to the episcleral vein sclerosis (EPI) model (25 eyes). Injections were performed at baseline, two, four and six weeks. Clinical signs, IOP, retina and optic nerve thicknesses (using in vivo optical coherence tomography; OCT), and histological studies were performed. An IOP increment was observed in all three groups, however, the values obtained from the PLGA-Ms injection resulted lower with a better preservation of the ocular surface. In fact, the injection of Ms20/10 created a gentler, more progressive, and more sustained increase in IOP. This IOP alteration was correlated with a significant decrease in most OCT parameters and in histological ganglion-cell count for the three conditions throughout the eight-week follow-up. In all cases, progressive degeneration of the retina, retinal ganglion cells and optic nerve, simulating chronic glaucoma, was detected by OCT and corroborated by histological study. Results showed an alternative glaucoma model to the well-known episcleral vein model, which was simpler to perform, more reproducible and easier to monitor in vivo.

Key histopathologic features in idiopathic noncirrhotic portal hypertension: an interobserver agreement study and proposal for diagnostic criteria.

Histologic features of idiopathic noncirrhotic portal hypertension (INCPH), loosely termed as obliterative portal venopathy (OPV), are heterogenous, often subtle, and overlap with other entities. To this date, no consensus histopathologic diagnostic criteria have been established for INCPH. For these reasons, rendering a reproducible consensus histologic diagnosis of OPV on a liver biopsy may often be challenging even for experienced hepatopathologists. We report herein a two-phase interobserver agreement study on the diagnosis of OPV and assessed the relative value of histologic features in 104 liver biopsies in distinguishing between INCPH and non-INCPH with the goal to obtain a consensus on specific practical diagnostic criteria. Six hepatopathologists blinded to clinical information and original pathologic diagnosis reviewed internet-based case study sets with high-resolution whole-slide images. The initial interobserver agreement on OPV was expectedly low, but significantly improved (moderate agreement in most categories) upon adopting a consensus view recognizing portal vein sclerosis as the only strong independent histologic predictor for INCPH, and that contrary to the conventional view, aberrant portal/periportal vessels does not significantly contribute to the positive assignment of OPV status. We propose a three-tiered classification with diagnostic criteria to facilitate the histologic assignment of OPV status for the evaluation of INCPH. Furthermore, we have validated the performance of the proposed criteria either based on histology alone or coupled with clinicopathologic correlation. This classification may aid in practical histologic assessment of liver biopsies with or without portal hypertension and help to improve diagnostic consistency and accuracy.

Analysis Of The Natural Course Of Pediatric Portal Hypertension

Presenter: Al-Faraaz Kassam MD | Cincinnati Children's Hospital Medical Center Background: The etiology of portal hypertension (pHTN) in children varies from that of adults and requires understanding of the differences in management strategies. We set out to assess the epidemiology and natural history of pediatric pHTN. Methods: 154 patients with pHTN from 2008-2018 were identified at a free-standing children’s hospital. Etiology, disease course, and interventions were assessed. Patients were then stratified by etiology of pHTN. The primary outcome was overall survival, with a secondary outcome of understanding the interventions and management required. Survival was calculated using Kaplan-Meier survival analysis. Statistical significance was set at p<0.05. Results: The distribution of etiology included 105 (68%) patients with cholestatic disease (CD), 16 (10%) with fibrotic or hepatocellular disease (HFD), four (3%) with hepatic vein obstruction (HVO), and 29 (19%) with pre-hepatic pHTN (PRE) caused by portal vein obstruction or portal vein sclerosis. Median follow-up for the cohort was 4.63 (IQR 2.02-7.25) years. Median age at diagnosis (years) varied between etiologies (0.34, IQR 0.06-0.9 CD vs 0.51, 0.06-3.33 HFD vs 5.85, 1.26-9.52 HVO vs 2.51, 0.85-5.09 PRE; p<0.01). There were no differences in sex, comorbidities, or years of follow up. Patients with PRE were more likely to require an EGD (79.3% vs 40% CD, 50% HFD, 50% HVO, p<0.01) and patients with PRE (2.0±0.4) and HVO (1.8±1.0) required more endoscopic interventions than CD (1.1±0.2) or HFD (1.4±0.5) (p<0.01). However, there were no differences regarding gastrointestinal bleeding or need for banding or sclerotherapy (p=0.31 and p=0.94 respectively). Interventions differed based on etiology (p<0.01) with CD more likely undergoing a transplant only (71.4%) and PRE more likely to undergo a shunt only (44.8%). 24.8% of CD, 62.5% of HFD, 100% of HVO, and 41.4% of PRE patients did not undergo an intervention. Kaplan-Meier analysis revealed no difference in survival based on etiology, however, analysis by type of intervention revealed a significant increase in mortality in the group who received no intervention compared to shunt, transplant, or both (p<0.01) (Figure 1). Of the 18 patients who died without intervention, 7 patients died while listed for transplant, five patients were not candidates due to progression of disease, and six patients had clinical deterioration before workup was completed. Of the 36 patients who are alive and have not undergone intervention, 27 have stable pHTN, six are waitlisted for organs, and three are not candidates for intervention due to severity of disease. Conclusion: The sequelae of pHTN in children is distinct from the adult process and a better understanding of this disease is necessary. In this single institution study, we found that most patients presented with CD as the cause of pHTN followed by PVO. While no difference in overall survival was noted between groups, patients who received no intervention had higher mortality than those who received an intervention. Early referral to specialized centers with experience managing these complex disease processes may allow for improved risk stratification and early intervention which may improve outcomes. Further work is needed to understand the predictors of mortality in patients with pHTN.

Deep vein sclerosis following sclerotherapy: Ultrasonic and d-dimer criteria.

The aim of sclerotherapy is to induce fibrosclerosis of superficial veins. We postulated that inadvertent entry of sclerosants into deep veins can result in sclerotic occlusion, deep vein sclerosis, a non-thrombotic process distinct from spontaneous deep vein thrombosis. The aim of this study was to assess the role of d-dimer in differentiating between deep vein sclerosis and deep vein thrombosis. Proximal trunks of great and small saphenous veins were treated with endovenous laser ablation. Venous tributaries and perforators were treated with foam ultrasound guided sclerotherapy. Ultrasound studies of lower limb deep veins were performed before and one week after the procedures, to detect deep vein occlusions (DVOs). d-dimer levels were measured for DVOs and long-term ultrasound studies monitored the recanalisation rates. In a six-year period, 9143 procedures were performed in 1325 patients for bilateral varicose veins. This included 1124 endovenous laser ablation and 8019 foam ultrasound guided sclerotherapy procedures. A total of 259 DVOs (2.83%) were identified on ultrasound which included 251 deep vein sclerosis (2.74%), seven deep vein thrombosis (0.07%) and one endovenous heat-induced thrombosis (EHIT, 0.08%). d-dimer values <0.5 µg/mL excluded deep vein thrombosis s, 0.5-1.0 µg/mL were more likely to be associated with deep vein sclerosis and >1.0 µg/mL were a more likely to be associated with deep vein thrombosis. Lower sclerosant concentrations and higher foam volumes were associated with increased risk of DVO (p < .0001). No significant relationship was found between DVO and gender or thrombophilia. Deep vein thrombosis and EHIT cases but not deep vein sclerosis patients were anticoagulated. None had thromboembolic complications. Patients were followed up for a median of 299 days (37-1994 days). Recanalisation rates were 71.1% for deep vein sclerosis (92.3% competent) and 71.4% for deep vein thrombosis (60.0% competent). Deep vein sclerosis is a relatively benign clinical entity distinct from deep vein thrombosis and does not require anticoagulation. Majority of affected veins on long-term follow-up regain patency and competence. d-dimer can be used to assist in differentiating deep vein sclerosis from deep vein thrombosis.

Cost-effectiveness analysis of five procedures for great saphenous vein reflux in a Norwegian healthcare setting or societal setting.

Objective:The aim of this work was to estimate cost-effectiveness of five common procedures for varicose vein surgery (high ligation and stripping, radiofrequency ablation, endovenous laser ablation, steam vein sclerosis and cyanoacrylate glue) in a Norwegian setting from both a societal and a healthcare payer perspective.Design:Cost-effectiveness analysis using decision tree modelling.Methods:A structured literature search was conducted to estimate the clinical effectiveness and the rate of complications in the five methods. Data on costs and health-related quality of life associated with varicose vein disease were also collected. With the aid of an expert panel, a structured decision tree was developed. A 1-year perspective was modelled, and a variety of common complications were included. Monte Carlo simulation was used for probabilistic sensitivity analyses.Results:The laser ablation strategy was the most cost-effective option from a societal perspective, with an incremental cost-effectiveness ratio of €8448 compared to a no-treatment alternative, and had a 42% probability of being cost-effective using the Norwegian willingness-to-pay threshold of €59,880. From a healthcare payer perspective, however, the steam vein sclerosis strategy was the most cost-effective with an incremental cost-effectiveness ratio of €4072 compared to a no-treatment alternative, and this strategy had a 50% probability of being cost-effective.Conclusion:Results from this study did depend upon the perspective chosen for analyses. Although recent endovenous surgical procedures (including laser ablation and steam vein sclerosis) provide clinically effective treatment for advanced, symptomatic varicose vein disease, availability of high-level data is currently limiting the cost-effectiveness analyses.

Assessment of the efficacy and safety of steam vein sclerosis as compared to classic surgery in lower extremity varicose vein management.

IntroductionFor the last 10 years, endovenous thermal ablation methods have gradually predominated over the classic Babcock procedure in varicose vein treatment. Steam vein sclerosis is the newest thermal ablation technique.AimTo assess the efficacy and safety of steam vein sclerosis as compared to the Babcock procedure in lower extremity varicose vein treatment.Material and methodsOne hundred and two adult subjects with varicose veins of clinical grade C2 to C6 according to the CEAP classification, treated with varicose vein surgery between 2010 and 2012, were enrolled in the study. These were subdivided into two groups: the study group of 52 patients treated with endovenous steam vein sclerosis and the control group of 50 patients treated with the Babcock procedure. A single lower extremity with isolated great or small saphenous vein insufficiency was operated on in each subject. The groups were compared for demography, disease severity, involved veins, potential perioperative and postoperative complications, as well as treatment efficacy based on the VCSS score reduction.ResultsThere were no statistically significant differences between the groups in terms of demography, disease severity, involved veins, or perioperative and postoperative complications. The treatment efficacy of both methods, assessed based on the recurrence rate and the quantitative VCSS score reduction, was similar. Clinically significant recanalisation was observed in 1 (1.9%) patient in the study group.ConclusionsThe efficacy and safety analysis shows that steam vein sclerosis is a safe, simple method which can be recommended as effective varicose vein treatment.

Comment to: Great saphenous vein ablation with steam injection: results of a multicentre study, by Milleret R, Huot L, Nicolini P, Creton D, Roux AS, Decullier E, Chapuis FR, Camelot G. Eur J Vasc Endovasc Surg 2013;45:391-6.

This open multicentre prospective cohort study carried out in four French centers report the obliteration rate of the great saphenous vein (GSV) in 75 patients treated using the steam vein sclerosis (SVS) system with high energy levels. Inclusion criteria were reflux at the sapheno-femoral junction (SFJ) and/or from the sub-terminal valve of the GSV of more than 0.5 s, vein diameter of between 4 and 13 mm (measured 3 cm distal to the SFJ) and a CEAP from C2 to C5. After pre-operative duplex ultrasound scan tumescent anesthesia was administered around the previously marked vein, in between the fascias, using a 21 gauge needle to inject a solution of 1.4% bicarbonate 500 mL, plus 20 mL 1% lidocaine with adrenaline. This was also performed in patients undergoing general anesthesia or loco-regional spinal anesthesia to provide a heat sink and protect the saphenous nerve. Access to the GSV under the knee was made through surgical incision or echo-guided percutaneous puncture placing a 16 G infusion catheter. Then, a flexible stainless steel SVS catheter covered with Teflon and with a diameter of 1.2 mm was inserted through the infusion catheter to a level of 2 and 3 cm below the SFJ. The SVS generator was calibrated to emit one pulse of steam with 60 J of energy every 1.8 s. The steam temperature delivered at the tip was 120&deg;C. Two (for up to 7 mm) or three (for over 7 mm) or four (for large trunks over 12 mm) pulses were emitted for every cm of vein treated with the catheter stationary. Post-operative treatment consisted of 2 weeks of compression by class II stockings worn during the day and pain-killers (ibuprofen) at the patient&rsquo;s discretion. Patients were then followed up at 1, 6 and 12 months with clinical examination, duplex ultrasound scanning, quality of life and safety assessments. A total of 75 patients (88 limbs-13 bilateral) underwent surgery with a median treatment time of 35 min (range 12-85) including patient preparation time; the median length of vein treated was 42 cm (range 15-57 cm). At 6-month visit the obliteration rate was 96% [95% CI: 89-99] at 12 months was 92% [95% CI: 83-97]. Vein diameter improved at 6 months from a median of 8 mm (range: 4-12 mm) to 1 mm (range: 0-9 mm) at mid-thigh. There were no adverse events either during or after the surgical procedure. The majority of adverse events occurred by day 8, the most common being ecchymosis at the entry site and pain in seven patients. At 1 month, inflammation of the venous pathway occurred in two patients and hypoesthesia in one patient. One protrusion of thrombus in the femoral vein (less than 1 cm) occurred fully resolved in 8 days under treatment by low molecular weight heparin. An ongoing study is focused on the treatment of tributaries. This could be a significant improvement as it allows an all-in-one endovenous procedure.

Is the treatment of the small saphenous veins with foam sclerotherapy at risk of deep vein thrombosis?

To assess the deep vein thrombosis risk of the treatment of the small saphenous veins depending on the anatomical pattern of the veins. A multicenter, prospective and controlled study was carried out in which small saphenous vein trunks were treated with ultrasound-guided foam sclerotherapy. The anatomical pattern (saphenopopliteal junction, perforators) was assessed by Duplex ultrasound before the treatment. All patients were systematically checked by Duplex ultrasound 8 to 30 days after the procedure to identify a potential deep vein thrombosis. Three hundred and thirty-one small saphenous veins were treated in 22 phlebology clinics. No proximal deep vein thrombosis occurred. Two (0.6%) medial gastrocnemius veins thrombosis occurred in symptomatic patients. Five medial gastrocnemius veins thrombosis and four cases of extension of the small saphenous vein sclerosis into the popliteal vein, which all occurred when the small saphenous vein connected directly into the popliteal vein, were identified by systematic Duplex ultrasound examination in asymptomatic patients. Medial gastrocnemius veins thrombosis were more frequent (p = 0.02) in patients with medial gastrocnemius veins perforator. A common outlet or channel between the small saphenous vein and the medial gastrocnemius veins did not increase the risk of deep vein thrombosis. Deep vein thrombosis after foam sclerotherapy of the small saphenous vein are very rare. Only 0.6% medial gastrocnemius veins thrombosis occurred in symptomatic patients. However, the anatomical pattern of the small saphenous vein should be taken into account and patients with medial gastrocnemius veins perforators and the small saphenous vein connected directly into the popliteal vein should be checked by Duplex ultrasound one or two weeks after the procedure. Recommendations based on our everyday practice and the findings of this study are suggested to prevent and treat deep vein thrombosis.

Great Saphenous Vein Ablation with Steam Injection: Results of a Multicentre Study

To assess the safety and efficiency of steam vein sclerosis (SVS) of the great saphenous vein (GSV) in a multicentre open prospective cohort study. 75 consecutive adult patients with GSV reflux, CEAP C2-C5 and vein diameter 4-13 mm. Patients treated using an SVS™ generator delivering homogenous pulses of superheated steam were followed up at 8 days and 1, 3, 6 and 12 months (clinical, duplex ultrasound, quality of life [QoL] with SF12). 88 veins were treated in 75 patients. At 6 months, 72/75 (96%) veins were obliterated (95% CI: 89-99) and Kaplan-Meier analysis found an obliteration rate of 96.1% at 12 months. QoL increased at 6 months for both the physical and mental components (p = 0.049 and p < 0.001 respectively). SVS was well tolerated: no major complications were reported. Adverse events occurred mainly at day 8 and incidents amounted to ecchymosis (n = 60) and pain (n = 7). SVS achieved an obliteration rate similar to that of other thermal ablation techniques. It was well tolerated with minimal post-operative pain.

The use of a novel method of endovenous steam ablation in treatment of great saphenous vein insufficiency: own experiences

Endovascular procedures are gaining more and more popularity as treatment of great saphenous vein (GSV) incompetence. The purpose of the present study was to assess the efficacy of steam GSV ablation. Steam ablation using the steam vein sclerosis system (CERMA, France) was performed in 20 patients with GSV incompetence. The efficacy of the procedure was evaluated using ultrasound and the following parameters were assessed: changes in lumen diameter, GSV wall thickness, reflux and presence/absence of blood flow. The GSV steam ablation resulted in the obliteration of the vein lumen in all patients - reflux or blood flow were not observed in any subject. A significant decrease of GSV lumen diameter and an increase of GSV wall thickness were also observed in all subjects following the procedure. No postoperative complications were noted. The steam ablation technique was also positively assessed by the patients. Steam ablation is an endovascular surgical technique, which can become popular and widely used due to its efficacy and safety. It is also easy to use and patient-friendly. The research on its use should be continued.

THE SAFETY AND UTILITY OF ARGININE MONOHYDROCHLORIDE INFUSION IN THE TREATMENT OF METABOLIC ALKALOSIS

PURPOSE: Metabolic alkalosis has many consequences, notably arrhythmias, seizures, respiratory depression and oxygen transport problems. It occurs in various settings which include chronic hypercapnea, liver transplantation, and dehydration. When emergent correction is needed it can be treated with carbonic anhydrase inhibiting diuretics or acid infusion (which works much more quickly). Hydrochloric acid can be used but causes peripheral vein sclerosis, thus requiring use of a central vein catheter. Ammonium chloride is also used but can cause ammonia toxicity. Arginine monohydrochloride is not venosclerotic and contains no ammonia. It is commonly used to treat metabolic alkalosis, but no literature exists regarding its safety or efficacy. This report is presented to provide such informarion.

P0377 HEPATOPULMONARY SYNDROME IN CHILDREN: A SINGLE CENTRE EXPERIENCE

Introduction: Hepatopulmonary syndrome (HPS) is a rare complication of chronic liver disease or portal hypertension. The clinical presentation is dyspnoea on exertion or overt cyanosis. In the past, this complication contraindicated liver transplantation (LT). However, good outcome with reversal of symptoms after LT has been described. Methods: Single centre experience of management and outcome of HPS in 12 children. Results: Twelve children were diagnosed to have HPS on macroaggregated albumin (MAA) lung scintigraphy over a 15 year period (1988–2003), underlying liver disease being biliary atresia (BA) in 6, progressive intrahepatic cholestasis in 2, cryptogenic cirrhosis, billiary cirrhosis, portal vein sclerosis and alpha 1 antitrypsin deficiency in 1 each. Biliary atresia splenic malformation (BASM) syndrome was present in 3. There were 8 girls (65%) with a median (range) age at diagnosis of 6.6 years (1.4–15.4 years). All patients had clinical evidence of portal hypertension with 4 having a history of gastrointestinal bleeding. The presenting symptoms were dyspnoea (7), cyanosis (9)and clubbing (10). All children with BA had cleared their jaundice. Median (range) oxygen saturation by pulse oxymetry was 90% (56–95%) with mild increase on supplemental facial oxygen. MAA scintigraphy revealed median pulmonary shunting of 22% (range 4–49%). The degree of shunting was mild (<20%) in 5, moderate (20–40%) in 4 and severe (>40%) in 3. Cardiac echography revealed normal function of the heart in all. All children were listed for LT. Six children required oxygen therapy prior to LT. One child with BASM and a moderate shunt died of sepsis while awaiting LT. One child is currently listed for LT. Ten children underwent LT 6–20 months (median 12 months) after diagnosis of HPS. Six children were extubated after 24 hours with the longest period of ventilation being 10 days. Median (range) oxygen requirement after LT was 21 days (1–45 days). Two children died 1 week and 3.2 years post LT of multi-organ failure and post transplant lymphoproliferative disorder respectively. Nine children are alive and well 5.25 years (range 1 month-12.8 years) after diagnosis of HPS. Conclusion: HPS is reversible after LT and does not appear to complicate the postoperative course. Female preponderance in our study group remains unexplained but may be an effect of female sex hormones on pulmonary circulation.