Abstract
Endovenous thermal ablation for healing venous ulcers and preventing recurrence
N Samuel, D Carradice, T Wallace, GE Smith and IC Chetter
Cochrane Database Syst Rev 2013; 10: CD009494. doi: 10.1002/14651858.CD009494.pub2
Many of us have hypothesized that the new thermal venous techniques – radiofrequency/laser – when coupled with compression, ablation may reduce venous pressures in the leg veins, resulting in improved rates of healing. Furthermore, since compliance with compression is dismal at best perhaps these newer techniques will improve the healing rate and decreased ulcer recurrence. The authors selected randomized clinical trials comparing endovenous thermal ablative techniques with compression therapy alone for venous leg ulcers eligible for inclusion. After thorough search by the authors, no eligible randomized controlled trials were identified. The authors conclude that there is an absence of evidence to substantiate the effects of endovenous thermal ablation on ulcer healing, ulcer recurrence or quality of life improvement. The authors plead for randomized control trials to answer the questions.
Bortezomib protects from varicose-like venous remodeling
L Pfisterer, R Meyer, A Feldner, O Drews, M Hecker and T Korff
FASEB J 2014 April 25. [Epub ahead of print]
“Despite the high prevalence of venous diseases that are associated with and based on the structural reorganization of the venous vessel wall, not much is known about their mechanistic causes. In this context, we demonstrated that the quantity of myocardin, a transcriptional regulator of the contractile and quiescent smooth muscle cell phenotype, was diminished in proliferating synthetic venous smooth muscle cells (VSMCs) of human and mouse varicose veins by 51 and 60%, respectively. On the basis of the relevance of proteasomal activity for such phenotypic changes, we hypothesized that the observed VSMC activation is attenuated by the proteasome inhibitor bortezomib. This drug fully abolished VSMC proliferation and loss of myocardin in perfused mouse veins and blocked VSMC invasion in collagen gels by almost 80%. In line with this, topical transdermal treatment with bortezomib diminished VSMC proliferation by 80%, rescued 90% of VSMC myocardin abundance, and inhibited varicose-like venous remodeling by 67 to 72% in a mouse model. Collectively, our data indicate that the proteasome plays a pivotal role in VSMC phenotype changes during venous remodeling processes. Its inhibition protects from varicose-like vein remodeling in mice and may thus serve as a putative therapeutic strategy to treat human varicose veins. Bortezomib protects from varicose-like venous remodeling.”
This abstract is quoted verbatim from the authors' paper. – Abstract Editor
Changes in the diameter and valve closure time of leg veins across the menstrual cycle
AM Asbeutah, M Al-Enezi, NM Al-Sharifi, A Almajran, JD Cameron, BP McGrath and SK Asfar
J Ultrasound Med 2014; 33: 803–809
The authors' objective was to study by duplex the changes in the diameter and valve closure time of the lower limb veins in 53 healthy young nulliparous women at different phases of the menstrual cycle. The menstrual cycle was divided into three groups: days 1 to 4, days 14 to 16, and day 25. The subjects' mean age was 20.60 years and their mean body mass index was 23.90 kg/m2. There was a gradual increase in the vein diameter and valve closure time at the specified phases of the menstrual cycle. When adjusted for body mass index, statistical significance existed for the same venous segments in the same limbs (p = .001–.049). There was no statistical significance for the same venous segments at the same phase of the menstrual cycle between limbs. The authors concluded that the lower limb veins show an increase in their diameter and valve closure time during the menstrual cycle probably mediated by the female sex hormones.
Improvement of periulcer skin condition in venous leg ulcer patients: Prospective, randomized, controlled, single-blinded clinical trial comparing a biosynthetic cellulose dressing with a foam dressing
V Dini, M Romanelli, A Andriessen, S Barbanera, MS Bertone, C Brilli and M Abel
Adv Skin Wound Care 2013; 26: 352–359
Forty-six patients with a venous ulcer received compression therapy with a short-stretch bandage system and either a BWD + foam (study group (SG)) or foam (control group (CG)). Periulcer skin condition was compared with the untreated lower leg skin and the forearm skin, using noninvasive parameters, comparing day 0 versus day 28 results. Ulcers were further evaluated for healing rate. The study period was 28 days, and the follow-up period was 12 weeks. A total of 46 out of 50 patients (SG, n = 26; CG, n = 20) completed the study. The authors found that BWD showed a more improved periulcer skin condition. In addition, transepidermal water loss was less in the SG (p = .003). Ulcer healing rate was better in SG (p = .0001). The authors concluded that BWD + foam was safe and efficacious in improving periwound skin leading to more expeditious wound healing than foam alone.
The effectiveness of a novel neuromuscular electrostimulation method versus intermittent pneumatic compression in enhancing lower limb blood flow
Huda Jawad, Duncan S Bain, Helen Dawson, Kate Crawford, Atholl Johnston and Arthur Tucker
J Vasc Surg: Venous and Lym Dis 2014; 2: 160–165
This study compares the effectiveness of a geko T-1 neuromuscular electrostimulation device in enhancing lower limb blood perfusion with two leading intermittent pneumatic compression (IPC) devices. Ten healthy subjects were recruited and the devices were fitted bilaterally, in a sequential manner, for 30 min. Ultrasound and laser Doppler fluxmetry assessments were performed. The geko T-1 device was superior to both IPC devices in increasing both venous and arterial blood volume flow by 30% (95% CI, 23.7%–82.4%; p < .001). The geko T-1 increased arterial blood velocity by 24% (95% CI, 9.7%–24.5%; p < .001). A substantial increase in the total microcirculatory blood velocity by 370% (95% CI, 13.5%–39.7%) was reported after the use of the geko T-1 (p < .001). With use of the visual analog scale, no significant differences in discomfort were found between the geko T-1 device and the IPC devices (p > .05). The authors concluded that the geko T-1 neuromuscular electrostimulation device is more effective than the IPC devices in increasing venous, arterial, and microcirculatory blood velocity. The devices studied were safe and well tolerated by healthy subjects.
Use of aspirin for the prevention of lower extremity deep venous thrombosis
Nirvana Sadaghianloo, Elixène Jean-Baptiste, Serge Declemy, Réda Hassen-Khodja and Alan Dardik
J Vasc Surg: Venous and Lym Dis 2014; 2: 230–239
Whereas aspirin is recommended and widely used to prevent arterial thrombosis, its role in the prevention of deep venous thrombosis is not well defined. Recent guidelines include aspirin as an acceptable thromboprophylactic agent after hip and knee orthopedic surgery despite continued publication of underpowered and contradictory studies. Two large randomized controlled trials pooled together suggest that low-dose (100 mg) aspirin is a reasonable alternative to prevent recurrence of venous thromboembolism (VTE) in patients who have been treated for a first episode of unprovoked VTE. The investigators suggest that the current practice using aspirin to prevent thromboembolism include cautious discussion of the benefits and risks of this agent before use in a patient until precise clarification of dosage and treatment length is available. Despite inclusion of aspirin in the guidelines for orthopedic surgery, there is little evidence to support its use for primary prevention of VTE. Until definitive unbiased trials are published, we suggest that aspirin remains a realistic option to use for secondary prevention of VTE, especially compared with the option of using no prophylaxis.
Measurement of thrombus resolution using three-dimensional ultrasound assessment of deep vein thrombosis volume
Limin Zhao, Steven J Prior, Meghan Kampmann, John D Sorkin, Kevin Caldwell, Melita Braganza, Sue McEvoy and Brajesh K Lal
J Vasc Surg: Venous and Lym Dis 2014; 2: 140–147
This group from Baltimore evaluated the reliability of a new, commercially available method of acquiring and analyzing three-dimensional (3D) ultrasound images of DVTs that measures thrombus volume and echogenicity. Twenty-five consecutive hospital in-patients (18 males, age 37–87 years) with a first episode of acute DVT were scanned by two independent sonographers. A combination of grayscale, color-flow, and power Doppler modes (2D transducer) along with volumetric imaging (3D transducer) was performed. Patients underwent imaging at baseline and on one or more follow-up days 7, 14, 21 and 30. Image processing software loaded on the ultrasound machine was used to obtain thrombus volume and echogenicity measurements. The median volume of thrombus at baseline was 0.4 cm3 and mean inter- and intraobserver differences in volume measurements were 0.006 ± 0.26 cm3 and−.12 ± 0.29 cm3 (mean ± SD). Thrombus resolved over time at a rate of −0.042 ± 0.01 cm3/day (p < .003). The median echogenicity of thrombus at baseline expressed as the grayscale median value was 59. There was a trend for thrombus organization (measured as echogenicity) to increase with time, +0.36 ± 0.23 grayscale median units/day (p < .13). Adjustment for the use of anticoagulation, gender of subject, or location of DVT in the upper vs. lower extremity did not alter the relationship between time and volume or time and echogenicity. The major findings of this study are that (a) a clinical 3D ultrasound protocol can reliably quantify thrombus volume and echogenicity in patients with acute DVT with excellent within- and between-observer agreement, (b) the technique can objectively quantify changes in thrombus volume and echogenicity over time, (c) thrombus volume decreases and echogenicity tends to increase over time, and (d) gender, thrombus location, or use of anticoagulation therapy did not affect the findings.
Assessment of residual thrombus after venous thrombolytic regimens
Seshadri Raju, Micah Davis and Amy Martin
J Vasc Surg: Venous and Lym Dis 2014; 2: 148–154
The group from Mississippi looked at 67 limbs who underwent (median age, 57; range, 24–83) pharmacomechanical thrombectomy (PMT) after deep venous thrombosis (DVT) (35 limbs) or iliac vein stent thrombosis (32 limbs). Assessment after PMT included venography and IVUS. If flow was not established or residual thrombus was present on IVUS examination, follow-up catheter-directed thrombolysis (CDT) up to three days was used to clear the thrombus. PMT was successful in establishing flow across occluded segments in 82%, but complete lysis per IVUS was achieved in only 9% with residual thrombus present in 91% (18% occlusive) of treated limbs. Follow-up CDT was feasible in 48 limbs. This resulted in establishment of inline flow in nine additional limbs; complete thrombus clearance per IVUS was achieved in 15 others (many with prior inline flow with thrombus). Overall, 96% of limbs were patent, but as many as 69% of limbs had residual thrombus after treatment with one or both lytic regimens. There was significantly more complete clot clearance (p < .04) in virgin DVT compared with thrombosis in stented limbs. IVUS was significantly more sensitive (p = .03) than venography in estimating residual thrombus burden. However, there was no significant difference in PTS incidence whether the clot was completely lysed or not. The authors concluded that venographic patency was a poor guide to the presence and extent of residual thrombus. Follow-up CDT was useful in significantly increasing complete clot clearance, but residual thrombus remained on IVUS in over two-thirds of treated limbs overall. The implications of residual thrombus after inline flow has been re-established with thrombolytic regimens for the development of PTS are unknown.