Venous Disease Research Articles

Abstract P186: Does Lipoprotein (a) Level Have a Predictive Value in Reintervention After Iliofemoral Vein Stenting?

Background: Lipoprotein (a), Lp(a), is associated with cardiovascular complications and atherothrombosis in arteries. However, the effects of Lp(a) in venous disease are unknown and uninvestigated. Hypothesis: Utilizing a patient population with iliofemoral stenosis from external compression (May-Thurner Syndrome) of which 30% had a prior deep vein thrombosis (DVT), we hypothesize that elevated Lp(a) levels may be associated with an increased risk of major reoperations after intravascular vein stenting (IVS) when compared to patients with non-elevated Lp(a) levels. Methods: In this study, 584 patients who underwent IVS for chronic iliofemoral stenosis between 2011 and 2019 were retrospectively studied. Patients with acute DVT, any prior IVS, or no Lp(a) results were excluded. Patients were stratified into two groups according to Lp(a) levels: non-elevated Lp(a) <50 mg/dL (N=472 patients), and elevated Lp(a) ≥50 mg/dL (N=112). Statistical analysis of demographics, clinical outcomes, and venous clinical severity score (VCSS) included paired t-tests and chi-squared tests. Kaplan-Meier curves and Cox proportional hazard models assessed the relationship of Lp(a) with time to major reoperation requiring venography and/or intravascular ultrasound (IVUS). Results: Patients with elevated Lp(a) levels were more likely to be Black (14% vs. 2.3%; p <0.001), hypertensive (56% vs. 44%; p = 0.025), higher preop VCSS pain (2.0 vs. 1.6; P<0.01), and greater number of reoperations (2.1 vs. 1.7; p = 0.037), specifically major reoperations (54% vs. 21%; p = 0.012) than those with non-elevated Lp(a) levels. Both non-elevated and elevated Lp(a) demonstrated comparable changes in composite VCSS scores during post-op, 1, 2, and 3-year follow-up (p = 0.12, 0.3, 0.4, and 0.5, respectively). However, multivariate analysis, controlling for demographic variables and comorbidities, showed no significant association between elevated Lp(a) and major reoperation (HR: 1.3; 95% CI: 0.84-2.00; p = 0.2). A statistically significant interaction was found between Lp(a) and hypertension status (p = 0.003). Compared with the reference group (Lp(a)) <50 mg/dL and no hypertension), those with Lp(a) ≥50 mg/dL and hypertension demonstrated a statistically significant increase in risk for reoperation (p = 0.01). Conclusion: This study found that elevated Lp(a) levels were not associated with major reoperations in patients undergoing IVS for chronic iliofemoral stenosis. While Lp(a) levels have a significant impact in arterial disease, this study suggested that Lp(a) may have a lesser influence in venous disease. As such, the utility of Lp(a) as a predictive biomarker in venous disease may be limited.

Obese patients with CEAP (clinical, etiology, anatomy, pathophysiology) C2 and C3 disease show enhanced symptom improvement after endovenous thermal ablation

ObjectiveEndovenous thermal ablation (EVTA) is a prevalent treatment option for patients with severe venous disease. However, the decision to intervene for patients with less severe disease (CEAP [clinical, etiology, anatomy, pathophysiology] C2 and C3) is less clear and becomes further complicated for patients with obesity, a pathology known to increase venous disease symptom severity. Therefore, the objective of this study was to use the Society for Vascular Surgery Vascular Quality Initiative database to evaluate outcomes after EVTA in obese patients with CEAP C2 and C3 venous insufficiency. MethodsUsing the Society for Vascular Surgery Vascular Quality Initiative database, we retrospectively analyzed the initial procedure of all patients with a CEAP clinical class of C2 or C3 who underwent EVTA from January 2015 to December 2021. Patients were grouped by obesity, defined as a body mass index of ≥30 kg/m2. The primary outcome was the change in venous clinical severity score (VCSS) from the procedure to the patient's initial follow-up. The secondary outcomes included the change in patient-reported outcomes at follow-up via the HASTI (heaviness, achiness, swelling, throbbing, itching) score, incidence of follow-up complications, and recanalization of treated veins. The change in the VCSS and HASTI score were analyzed using Student t tests, and complications and recanalization were assessed using the Fisher exact test. Significant outcomes were confirmed by multiple variable logistic regression. The remaining significant variables were then analyzed, with obesity categorized using the World Health Organization classification system to analyze how increasing obesity levels affect outcomes. ResultsThere were 8146 limbs that met the inclusion criteria, of which 5183 (63.6%) were classified as nonobese and 2963 (36.4%) as obese. Obesity showed no impact on improvement in the VCSS (−3.29 vs −3.35; P = .408). Obesity was found to be associated with a larger improvement in overall symptoms, as evidence by a greater improvement in the HASTI score (−7.24 vs −6.62; P < .001). Obese limbs showed a higher incidence of superficial phlebitis (1.5% vs 0.7%; P = .001), but no difference was found in recanalization or any other complication. ConclusionsThese data suggest that obese patients with CEAP clinical class C2 or C3 experience greater improvement in their perceived symptoms after EVTA with little difference in clinical improvement and complications compared with nonobese patients. Although obesity has been associated with increased severity of venous disease symptoms, obese patients are able to derive significant relief after treatment during the short term and may experience greater relief of symptoms than nonobese patients when treated at more mild disease presentations.

O70: A Novel Screening Tool for Pelvic Venous disorders

Abstract Objective Pelvic venous disease (PeVD) remains a common yet under-diagnosed condition, and there remains no standardised diagnostic work-up. A self-assessment questionnaire was developed to aid the identification of women with PeVD. The study aimed to assess the performance of the questionnaire score in identifying patients with PeVD. Methods Retrospective data analysis from consecutive referrals to a vascular surgery clinic in Singapore between 2018-2022. Before diagnostic evaluation, patients completed a novel, 6-item questionnaire, resulting in a Basic Score. From 2022, patients completed an additional 4-item questionnaire developed as an adjunct, resulting in a Specific Score - adding Basic and Specific Scores yields the Combined Score. Duplex US was used as the reference standard. Results A total of 94 women were assessed. Of these, 73 (77.8%) met DUS criteria for PeVD. All completed the Basic questionnaire, which demonstrated high discriminatory ability (area under the receiver-operating curve (AUC) of 0.878 [95% CI:0.779-0.977]). A Basic Score ≥3 had high sensitivity and moderately high specificity of 93.2% [95% CI: 84.7 -97.7] and 81.0% [95% CI:58.1 – 94.6], respectively. 36.2% (34/94) of patients answered both questionnaires. There was insufficient evidence that the Specific questionnaire improved performance (AUC 0.979 [95% CI: 0.937 – 1.00] vs 0.966 [95% CI:0.903 -1.00], for Basic Score vs Combined Score). Conclusions Our findings suggest that the Basic questionnaire may be useful in the diagnostic workup of PeVD, potentially increasing referral to vascular specialists for appropriate management. However, diagnostic accuracy may be over-estimated due to high disease prevalence in the cohort, prohibiting generalisation of results.

Final 3-Year Study Outcomes from the Evaluation of the Zilver Vena Venous Stent for the Treatment of Symptomatic Iliofemoral Venous Outflow Obstruction (The VIVO Clinical Study)

PurposeTo report 3-year outcomes from a prospective, multicenter, nonrandomized, single-arm study designed to assess the safety and effectiveness of the Zilver Vena Venous Stent for the treatment of symptomatic iliofemoral venous outflow obstruction. Materials and MethodsThe VIVO study included patients with symptomatic obstruction of 1 iliofemoral venous segment (ie, 1 limb), characterized by a Clinical, Etiological, Anatomic, Pathophysiology (CEAP) clinical classification of ≥3 or a Venous Clinical Severity Score (VCSS) for pain of ≥2. Patients were retrospectively grouped based on baseline clinical presentation as postthrombotic syndrome (PTS), nonthrombotic iliac vein (NIVL) obstruction, or acute deep vein thrombosis (aDVT). Clinical improvement was assessed by change in VCSS, Venous Disability Score, Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-20) scores, and CEAP C classification. Stent performance was evaluated by rates of patency by ultrasound (US), freedom from clinically driven reintervention, and freedom from stent fracture. ResultsThe 3-year results for the 243 patients in the VIVO cohort included a 90.3% rate of patency by US and a 92.6% rate of freedom from clinically driven reintervention. The 3-year rates of patency by US for the NIVL, aDVT, and PTS groups were 100%, 84.0%, and 86.1%, respectively. Sustained clinical improvement through 3 years was demonstrated by changes in VCSS, Venous Disability Score, CIVIQ-20, and CEAP C classification. No stent fractures were observed. ConclusionsThe VIVO study demonstrated sustained high rates of patency and freedom from clinically driven reintervention and improvements in venous clinical symptoms through 3 years. Each patient group (NIVL, aDVT, and PTS) showed clinical improvement and sustained patency through 3 years; some variation existed among groups (eg, only the NIVL group had a 100% patency rate).

The sonographic features of lymph node venous networks and flow patterns in patients with primary chronic venous disease.

Our study aims to enhance the understanding of lymph node venous networks (LNVNs) by summarising their anatomical, sonographic features, and reflux patterns. We examined 241 legs from 141 patients with primary chronic venous disease (CVD) using duplex ultrasound. The findings indicated variations in the shape, size, vascularity, and echogenicity of LNVN. The superficial inguinal lymph node with reflux appeared slightly larger, exhibiting higher velocities in the hilar artery. Regarding connections, venous flow within LNVN was predominantly drained through the saphenofemoral junction (SFJ), anterior accessory great saphenous vein (AAGSV), and great saphenous vein (GSV). A significant number of LNVNs were observed to be associated with anterolateral thigh tributaries. The study also identified valve cusps within LNVN. This study revealed a 12% prevalence of primary LNVN. Understanding the anatomical and haemodynamic features of LNVN informs treatment strategies and potentially helps prevent the recurrence of varicose veins.

High yield clinical applications for photon counting CT in neurovascular imaging.

Photon-counting CT (PCCT) uses a novel X-ray detection mechanism that confers many advantages over that used in traditional energy integrating CT. As PCCT becomes more available, it is important to thoroughly understand its benefits and highest yield areas for improvements in diagnosis of various diseases. Based on our early experience, we have identified several areas of neurovascular imaging in which PCCT shows promise. Here, we describe the benefits in diagnosing arterial and venous diseases in the head, neck, and spine. Specifically, we focus on applications in head and neck CT angiography (CTA), spinal CT angiography, and CT myelography for detection of CSF-venous fistulas. Each of these applications highlights the technological advantages of PCCT in neurovascular imaging. Further understanding of these applications will not only benefit institutions incorporating PCCT into their practices but will also help guide future directions for implementation of PCCT for diagnosing other pathologies in neuroimaging.

Factors associated with clinical severity in chronic venous disease: The role of functional parameters

IntroductionChronic venous disease (CVD) is a highly prevalent disease that presents a wide spectrum of clinical expressions due to abnormalities in the venous system. Patients often have major functional changes that can limit daily activities. However, the functional factors associated with the severity of the disease remain poorly understood. ObjectiveTo identify the functional factors associated with CVD severity. MethodsSeventy-five patients with CVD (92.0% females, 49.6 ± 13.3 years) were evaluated through clinical examination, lower limb perimetry, ankle range of motion (AROM), and lower limb muscle strength by the Heel Rise test, and Sit-to-stand test. Patients were stratified according to the disease severity as mild (telangiectasia, varicose veins, or edema in the lower limbs) or severe CVD (trophic changes or venous ulcer). ResultsPatients with severe CVD (n = 13) were older (p = 0.002), predominantly male (p = 0.007), with reduced AROM in dorsiflexion (p = 0.028) and inversion (p = 0.009), reduced lower limb strength by the Heel Rise test (p = 0.040), and greater circumference of the calf (p = 0.020), ankle (p = 0.003), and plantar arch (p = 0.041) when compared to mild CVD (n = 62). Advanced age, male sex, lower ankle range of motion in dorsiflexion, and greater ankle and plantar arch circumferences were associated with CVD severity. However, the ankle circumference (OR 1.258, 95% CI: 1.008–1.570; p = 0.042), together with advanced age and male sex, was the only functional variable that remained independently associated with CVD severity. ConclusionThe increased ankle circumference was a determinant of the CVD severity and may assist in risk stratification and guide treatment goals in this population.

Disparities in access to endovenous treatment options in chronic lower extremity superficial venous insufficiency: A national 7-year analysis

ObjectiveThe goal of this study was to analyze trends in treatment access for chronic superficial venous disease and to identify disparities in care. MethodsThis retrospective study was exempt from institutional review board approval. The American College of Surgeon National Surgical Quality Improvement Program database was used to identify patients who underwent vein stripping (VS) and endovenous procedures for treatment of chronic superficial venous disease. Endovenous options included radiofrequency ablation (RFA) and laser ablation. Data was available from 2011 to 2018 and demographic information was extracted for each patient identified by Current Procedural Terminology codes. For all racial and ethnic groups, trend lines were plotted, and the relative rate of change was determined within each specified demographic. ResultsThere were 21,025 patients included in the analysis. The overall mean age was 54.2 years, and the majority of patients were female (64.8%). In total, 27.9%, 55.2%, and 16.9% patients underwent VS, RFA, and laser ablation, respectively. Patients who received laser ablation were older (P < .001). Hispanic ethnicity was associated with significantly lower odds of receiving endovascular thermal ablation (EVTA) over VS (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.64-0.78; P < .001). American Indian/Alaska Native patients were more likely to receive EVTA over VS (OR, 4.02; 95% CI, 2.48-6.86); similarly, Native Hawaiian/Pacific Islander patients were more likely to receive EVTA over VS, although this difference was not statistically significant (OR, 1.44; 95% CI, 0.93-2.27). On multinomial regression, Hispanic patients were less likely to receive RFA over VS, whereas American Indian/Alaskan Native patients were more likely to receive RFA over VS. In all racial and ethnic groups, the percentage of endovenous procedures increased, whereas vein stripping decreased. ConclusionsBased on a hospital-based dataset, demographic indicators, including age, sex, race, and ethnicity, are associated with differences in endovenous treatments for chronic superficial venous insufficiency suggesting disparities in obtaining minimally invasive treatment options among certain patient groups.

Can plethysmography have a greater place in the diagnosis, treatment and follow-up of chronic venous insufficiency?

Objectives: Chronic venous insufficiency (CVI) is one of the most common venous diseases. CVI is an important clinical picture with a high prevalence, low quality of life, and high diagnosis and treatment costs. Therefore, diagnosis, follow-up, and treatment are important for the patient's socioeconomic and life quality. In this study, we aimed to better examine a test used in the diagnosis, treatment, and follow-up of CVI. Methods: In this retrospective study, 683 patients diagnosed with CVI, who had endovenous laser ablation (EVLA) indications were evaluated between June 2013 and November 2018. EVLA procedure performed on all patients. Preoperative, postoperative 1st and 6th month Doppler USG (ultrasonography), plethysmography, and VCSS (Venous Clinical Severity Score) questionnaire was made to all patients. Results: As a result of our study, we found that there was a significant difference between the preoperative plethysmography and VCSS results of the patients and the postoperative 1st and 6th month results. With the significant difference in the VCSS questionnaire, we have shown that plethysmography gives accurate results in the diagnosis and treatment of CVI since it is an individual, quantitative, and easy test. Conclusions: EVLA is an effective and safe method in patients with venous insufficiency. Since Doppler USG is person and device dependent, we think that plethysmography, which can be used in every clinical setting and provides quantitative results independent of the person, can be used more frequently in the diagnosis and treatment of venous insufficiency. In addition, we think that plethysmography can be used as a valuable additional method in the diagnosis and follow-up of such patients, due to the venous hemodynamic data that Doppler USG cannot provide.

3D visualization in venous disease: fixing the point in effectiveness avoiding chimeras

3D visualization in venous disease: fixing the point in effectiveness avoiding chimeras

VENOTONICS IN MODERN CLINICAL PRACTICE

Chronic venous diseases (CVD) are an extremely common pathology of the circulatory system. An important component of the treatment of CVD is the use of pharmaceuticals. Their tasks include reducing the specific symptoms of the disease, enhancing the effects of other methods of treating CVD, preventing further development and complications of the disease. The main means of pharmacotherapy of CVD are called venotonics or phlebotonics. The most studied and most commonly used form of venotonics are flavonoids, which reduce the permeability of capillaries, thereby having a beneficial effect on the vessels of the microcirculatory bed. The main indications for taking venotonics are specific symptoms of CVD: a feeling of heaviness, varying degrees of discomfort, pain, itching in the lower extremities, chronic swelling and trophic skin changes. This determines the active use of venoactive drugs in the treatment of various forms of CVD. Most clinical studies show that venotonics have decongestant, anti-inflammatory, antioxidant properties, and also maintain the tone of the venous wall. The main effect of venotonics is their ability to affect the state of blood vessels both at the macrocirculatory level and at the microcirculatory level. The wide effect of venotonics confirms the effectiveness of their use in modern clinical practice in the treatment of various forms of CVD.

Empty vein ablation (EVA) technique: an in-vivo animal model to assess the effects of sclerosing agent concentration and wall contact time on intima and media tunicae structure.

Sclerotherapy is a cornerstone of the treatment of chronic venous disease, despite some technical aspects (e.g., sclerosant liquid agent concentration [SLAC] and contact time between sclerosant agent and vein wall [ctSA/VW]) to maximize outcomes remain an unsolved problem and a source of debate. An innovative three-balloon catheter has been developed to allow sclerotherapy in empty vein conditions (Empty Vein Ablation technique, EVA), revolutionizing the definition of SLAC and ctSA/VW. Aim of this experimental study is to analyze EVA effects on intima and media vessel tunicae using different SLAC and ctSA/VW in an in-vivo animal model. Two adult sheep were treated by EVA using jugular and common iliac vein axes (eight vein segments). Different SLAC (polidocanol 0.5% or 1%) and different ctSA/VW (3 or 5 minutes) were combined for testing residual circumferential intima percentage and media thickness after EVA. Intact circumferential residual intima after the treatment was 21.3±4.9%, 18.2±7.4%, 15.7±2.4% and 8.9±2.0% using 0.5% (3 min), 0.5% (5 min), 1% (3 min) and 1% (5 min), respectively (R2=0.945; control sample: 97.6%). Media thickness after the treatment was 121.6±35.3 µm, 110.9±7.8 µm, 96.1±30.4 µm and 79.1±34.1 µm using 0.5% (3 min), 0.5% (5 min), 1% (3 min) and 1% (5 min), respectively (R2=0.990; control sample 125.7 µm). No significant modifications were detected analyzing the adventitia in all samples. EVA proved to be effective in venous wall destruction even with a very low SLAC and ctSA/VW (0.5% in 3 minutes), in quite large caliber veins. Direct comparisons with foam/liquid sclerotherapy should be done to confirm therapeutic effectiveness of these results, despite EVA has provided a maximized and controlled SA/VW contact time and ratio.

Early term results of venous leg ulcer treatment in chronic venous disease: a Latam perspective

Early term results of venous leg ulcer treatment in chronic venous disease: a Latam perspective

Differences in risk profile associated with varicose veins and chronic venous insufficiency - results from the Bonn Vein Study 1.

Background: The aim of this publication is to demonstrate similarities and differences in the association of risk factors with the prevalence of different manifestations of chronic venous disease (CVD), like varicose veins (VV), venous oedema (C3) and severe chronic venous insufficiency (CVI) in the population-based cross-sectional Bonn Vein Study 1 (BVS). Patients and methods: In the BVS 1 between 13.11.2000 and 15.3.2002, 3.072 participants, 1350 men and 1722 women, from a simple random sample of the general population of the city of Bonn and two rural townships aged 18-79 years were included. The overall response proportion was 59%. All participants answered a standardized questionnaire including information about socio-economic data, lifestyle, physical activity, medical history, and quality of life. Venous investigations were performed clinically and by a standardized duplex examination by trained investigators. The CEAP classification in the version of 1996 was used to classify the findings. Logistic regression models were performed for the association of possible risk factors with VV, venous edema (C3) and severe CVI (C4-C6). The predictive risk (PR) describes the association of the diseases and the possible influencing factors. Results: VV, venous oedema (C3) and severe CVI (C4-C6) have common risk factors like higher age, number of pregnancies, family history of VV and overweight or obesity. Female gender is significantly associated with VV and C3 but not with severe CVI (C4-C6). High blood pressure and urban living are only associated with C3 and C4-C6 disease whereas prolonged sitting is associated with C3 and lower social class with C4-C6 exclusively. Discussion: In many epidemiological studies risk factors were associated with chronic venous disorders in general. Our data show that VV, venous edema and severe CVI may have different risk profiles. Venous edema is more often associated with arterial hypertension and sedentary lifestyle whereas lower social class seems to be a risk factor for severe CVI including venous ulcers. Conclusions: The differences in the association of risk factors to VV, venous edema and severe CVI should be considered if prevention and treatment of chronic venous diseases are planned. As examples, compression stockings could be proposed in sitting profession to prevent oedema, VV patients with risk factors like obesity might benefit from early treatment for VV and obesity. More longitudinal evaluation of risk factors is necessary to evaluate the true risk profile of CVD.

Single-session mechanical thrombectomy for iliofemoral deep vein thrombosis using a dual mechanism of action device combining basket and rotational thrombectomy

ObjectiveInterventional treatments for acute iliofemoral deep vein thrombosis (DVT) remain controversial after publication of the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) study. Interventions have been shown to reduce post-thrombotic syndrome severity and improve quality of life in DVT patients, but have been accompanied by risk of major bleeding from thrombolytics. We describe thrombus removal using a novel combined basket-rotational thrombectomy device that minimizes the need for thrombolytics or repeat procedures. MethodsThe aim of this prospective, nonrandomized, multicenter, first-in-human study of 19 patients with acute iliofemoral DVT was to evaluate the safety and performance of the Pounce venous thrombectomy system ≤12 months after treatment. The primary performance end point was defined as procedural success through achievement of Society of Interventional Radiology (SIR) grade II lysis in treated vessels with freedom from procedural adverse events. Secondary end points included venous disease severity assessments using the Villalta scale and the Venous Clinical Severity Score, patient quality-of-life measurement using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life questionnaire, and calf circumference measurements taken at baseline, 24 hours, and 1 month. ResultsThe primary end point of complete or near-complete thrombus removal (Society of Interventional Radiology grade II or III) was achieved in all patients. All study device-related safety end points were met, with no major bleeding or device-related adverse events. Of the 19 patients treated, 16 (84.2%) did not receive thrombolytics during the procedure. Post-thrombotic syndrome (Villalta scale >4) was identified in 17 of 19 patients (89.5%) at baseline, 4 of 13 patients (30.8%) available for follow-up at 6 months, and 2 of 11 patients (18.2%) at 12 months. The median Venous Clinical Severity Score decreased (P < .001) from 8.5 (interquartile range [IQR], 7-10) at baseline to 4 (IQR, 2-4) at 1 month after the procedure and was similar at 6 months (2; IQR, 2-5) and 12 months (2; IQR, 1.5-3) after the procedure. The median Venous Insufficiency Epidemiological and Economic Study-Quality of Life questionnaire score improved (P < .001) by 62.7 from baseline (19.3; IQR, 10.8-34.5) to 1 month (82.0; IQR, 65.8-89.0) after the procedure, and remained high at 6 months (88.4; IQR, 61.9-93.3) and 12 months (93.7; IQR, 81.0-96.6). Median Venous Insufficiency Epidemiological and Economic Study-Quality of Life questionnaire score improved (P < .001) by 60.0 from baseline (27.5; IQR, 11.0-50.5) to 1 month (87.5; IQR, 80.5-93.0) after the procedure, and remained high at 6 months (88.0; IQR, 58.8-95.0) and 12 months (90.0; IQR, 84.0-97.0). The median calf circumference decreased (P = .089) from 39 cm (IQR, 35-47.8 cm) at baseline to 36 cm (IQR, 32.5-40.5 cm) at 24 hours after the procedure and was 34.5 cm (IQR, 33.2-38.5 cm) at 1 month. ConclusionsThe Pounce device is safe and effective for removal the of thrombus in patients with acute iliofemoral DVT. Initial results demonstrate improvements in venous disease severity and patient quality of life.

Satisfactory result of great saphenous vein endovenous laser ablation until below the knee on active venous leg ulcer: a case series

Background Active venous leg ulcer (VLU) is the most severe manifestation of chronic venous disease which not only affects patients’ health, but also decreases the quality of life, and delivers economic burdens. Treatment of superficial venous reflux with early endovenous laser ablation (EVLA) has been associated with reducing ulcer recurrence levels and promoting faster VLU healing. We reported three cases of patients with active VLU undergoing EVLA with different approaches. Case illustration Three patients came with complaint of leg ulcer, diagnosed with C6sEpAsdPr, with venous clinical severity scores (VCSS) of 15, 23, and 22 respectively. Severe great saphenous veins (GSV) reflux was found in all patients by duplex ultrasound examination. The second patient had undergone above-the-knee EVLA. All patients underwent EVLA using 1470-nano meter wavelength laser device and ELVeS radial fiber (Biolitec, Bonn, Germany). The laser energy protocol used was 6 W linear endovenous energy density (LEED) 50 J/cm for proximal until media ATK GSV ablation, 5 W LEED 40 J/cm for media ATK until proximal below-the-knee (BTK) GSV, and 2 W LEED 20 J/cm for proximal until distal BTK GSV. The third patient was also treated with EVLA for small saphenous vein severe reflux. Follow-up until 6 months post-EVLA showed significant healing of the ulcer with 14, 16, and 17 VCSS reduction consecutively without any complication. Conclusion We’ve reported three cases of patients with active VLU undergoing EVLA until BTK with significant results. The EVLA of GSV until BTK where there is still significant reflux is safe and provides satisfactory results in patients with VLU.

Noninvasive measurement of ambulatory venous pressure via column interruption duration in chronic venous disease

BackgroundColumn interruption duration (CID) is a noninvasive surrogate for venous refill time (VFT), a parameter used in ambulatory venous pressure measurement. CID is more accurate than invasive VFT measurement because it avoids errors involved with indirect access of the deep system through the dorsal foot vein. The aim of this retrospective single center study is to analyze the clinical usefulness of CID in assessment of chronic venous disease (CVD). MethodsA total of 1551 limbs (777 patients) were referred with CVD symptoms over a 5-year period (2018-2023); CID, air plethysmography, and duplex reflux data were analyzed. Of these limbs, 679 had supine venous pressure data as well. The pathology was categorized as obstruction if supine peripheral venous pressure was >11 mm Hg and as reflux if duplex reflux time in superficial or deep veins was >1 second. CID was measured via Doppler monitoring of flow in the great saphenous vein (GSV) and one of the paired posterior tibial (PT) veins near the ankle in the erect posture. The calf is emptied by rapid inflation cuff. CID is the time interval in seconds when cephalad venous flow in great saphenous vein and posterior tibial veins reappear after calf ejection. A CID <20 seconds in either vein is abnormal similar to the threshold used in VFT measurement. ResultsThirty-two percent of the limbs had obstruction, 17% had reflux, and 37% had a combination; 14% had neither. Higher clinical-etiology-anatomy-pathophysiology (CEAP) clinical classes (C4-6) were prevalent in 44% of pure reflux, significantly less (P < .0001) than in pure obstruction (73%) or obstruction plus reflux subsets (72%), partly reflecting distribution of pathology. There is a progressive increase in supine venous pressure and abnormal CID (P < .0001 and P < .0001, respectively) in successive CEAP clinical class. No such correlation between CEAP and any of the reflux severity grading methods (reflux segment score, Venous Filling Index, and Kistner axial grading) was observed. Abnormal CID (55%) was more prevalent in higher CEAP classes (>4) (P < .0001) than in lesser clinical classes (0-2) or limbs with neither obstruction nor reflux (P < .01). ConclusionsObstruction seems to be a more dominant pathology in clinical progression among CEAP clinical classes than reflux. CID is abnormal in both obstructive and refluxive pathologies and may represent a common end pathway for similar clinical manifestations (eg, ulcer). These data suggest a useful role for CID measurement in clinical assessment of limbs with CVD.

Connecting epigenetics and inflammation in vascular senescence: state of the art, biomarkers and senotherapeutics.

Vascular diseases pose major health challenges, and understanding their underlying molecular mechanisms is essential to advance therapeutic interventions. Cellular senescence, a hallmark of aging, is a cellular state characterized by cell-cycle arrest, a senescence-associated secretory phenotype macromolecular damage, and metabolic dysregulation. Vascular senescence has been demonstrated to play a key role in different vascular diseases, such as atherosclerosis, peripheral arterial disease, hypertension, stroke, diabetes, chronic venous disease, and venous ulcers. Even though cellular senescence was first described in 1961, significant gaps persist in comprehending the epigenetic mechanisms driving vascular senescence and its subsequent inflammatory response. Through a comprehensive analysis, we aim to elucidate these knowledge gaps by exploring the network of epigenetic alterations that contribute to vascular senescence. In addition, we describe the consequent inflammatory cascades triggered by these epigenetic modifications. Finally, we explore translational applications involving biomarkers of vascular senescence and the emerging field of senotherapy targeting this biological process.

Comparación de resultados clínicos de enfermedad tromboembólica venosa según manejo ambulatorio versus hospitalario

Objectives. To compare the occurrence of death, bleeding, and recurrence according to inpatient or outpatient management of venous thromboembolic disease (VTE). Materials and methods. Retrospective cohort that included a consecutive sampling of VTE consultations between 2016 and 2019 diagnosed in the Emergency Center of a private hospital in Argentina. Results. There were 1202 cases, 908 with isolated deep vein thrombosis (DVT), 205 with isolated pulmonary embolism (PE), and 89 cases of combined DVT - PE. 66% were women, with a median age of 77 years; 72% of cases were managed on an outpatient basis (n= 862). Comorbidities associated with hospitalization were obesity (p=0.03), chronic obstructive pulmonary disease (COPD) (p=0.01), heart failure (CHF) (p=0.01), chronic renal failure (CKD) (p=0.01), and cancer (p=0.01). At 90 days, the cumulative incidence of bleeding was 2.6% in inpatient compared to 2.9% in outpatient management (p=0.81); recurrence was 0% versus 0.9% (p=0.07), and mortality was 42.9% versus 18.9%, respectively (p=0.01). The HR for 90-day mortality in hospitalized patients adjusted for confounders (sex, age, type of VTE, obesity, CKD, CHF, COPD, and cancer) was 1.99 (95% CI 1.49-2.64; p=0.01). Conclusions. In this elderly, and predominantly female Argentine population, the 90-day mortality in patients hospitalized for VTE was higher than mortality in patients with outpatient management, without differences in recurrence or major bleeding.

Small Oversized Stent Graft Is Associated With Increased Patency for the Treatment of Central Venous Disease in Hemodialysis Patients.

The purpose of this study was to identify the independent predictors of higher patency rates and investigate the selection of specifications of stent graft in the treatment of central venous disease. This retrospective study included 54 patients who underwent stent-grafts' placement for the treatment of central venous disease between March 2017 and September 2022 at a tertiary hospital. The demographic data for the patients and the clinical data of the treated lesions were collected and analyzed. The patency rates of the treated lesions with different oversizing range were calculated via the Kaplan-Meier and log-rank analyses. The multivariate Cox proportional hazard models were constructed to identify the independent predictor of the target site primary patency. The median follow-up period was 21.5 months. The primary patency rates of the target sites were 90.7%, 72.2%, and 55.1% at 6, 12, and 24 months, respectively. The assisted primary patency rates of the lesions were 96.3%, 92.5%, and 80.3% at 6, 12, and 24 months, respectively. The log-rank analysis showed that the stent-grafts' placement with small oversizing had significantly higher primary patency rates than those with large oversizing (p=0.022). The multivariate analysis revealed that concomitant stenosis and large oversizing stent graft were the independent predictors of target site primary patency. Stent grafts showed reasonable primary patency for the treatment of central venous disease in hemodialysis patients. A stent graft with small oversizing is associated with better target site primary patency rates than those with large oversizing. Stent grafts showed reasonable primary patency for the treatment of central venous disease in hemodialysis patients. Few studies, however, have explored the efficiency of stent grafts to treat CVD by considering different factors such as sizing considerations, the rate of oversizing percentage, etc. A stent graft with small oversizing is associated with better target site primary patency rates than those with large oversizing. Excessive oversizing should be avoided to prevent infolding or stent collapse.