Summaries of recent phlebological papers

Eur J Vasc Endovasc Surg 2015. Epub ahead of print. pii: 1078-5884(15)00054-4. DOI: 10.1016/j.ejvs.2015.01.013.

In a retrospective study spanning one year, one center, and 376 limbs (311 patients), the authors studied the clinical results of incompetent perforating veins (IPVs) following treatment of superficial venous insufficiency, with or without endovenous laser ablation (EVLA) of IPVs. A total of 156 limbs (132 patients) were treated with laser of IPVs and varicose vein surgery; the remaining 220 limbs (179 patients) served as controls and were treated with varicose vein surgery alone. The fate of the IPVs, complications, and clinical results were evaluated. The technical success rate of EVLA of IPVs was 100%; however, at one-year follow-up, 68 perforators were recanalized and still incompetent in the EVLA-treated IPV group compared with 437 incompetent perforators in the untreated IPV group (18.7% vs. 92.6%; p < 001). There was no statistical difference in complications between the two groups. Of interest, a faster median ulcer healing time (1.40 months) was found in the laser-treated IPV group (95% confidence interval [CI] 1.15–1.66 vs. 3.30 months [95% CI 2.50–4.10]; p = .001), even though no statistical difference in the 12-month ulcer healing rate was observed between the two groups (p = .584). There were no significant differences between the two groups for varicose vein recurrence rates or changes in the Venous Clinical Severity Score (VCSS). The authors conclude that EVLA is safe and effective in reducing the number of IPVs. However, the addition of IPV EVLA had no effect on ulcer healing rate, VCSS, or varicose vein recurrence at one-year follow-up.

J Vasc Surg: Venous and Lym Dis 2015; 3: 147–153

Sixty primigravida women volunteered to undergo clinical evaluation and duplex ultrasound examination of both lower limb veins to monitor changes in vein diameter and valve closure time (VCT) during pregnancy and three months postpartum by duplex ultrasound. A total of four readings were taken for each subject, one reading for each trimester and the last reading at three months postpartum. The mean (± standard deviation) age of participants was 26.82 ± 2.47 years; 39 limbs (32.5%) and 65 limbs (54.2%) developed C1–C3 venous changes during the second and third trimesters, respectively. Three months post partum, 36 limbs (30%) continued to have C1–C2 changes. Only four limbs in four subjects developed varicose veins along the great saphenous vein, and their VCT was more than 1 s. These subjects were found to have a family history of varicose veins. Duplex examinations showed that there was a gradual increase in the diameter and VCT from the second trimester through the third trimester of pregnancy in all examined venous segments. These changes were statistically significant by Friedman and related-samples Wilcoxon signed-rank tests within the same legs (P = .001) but not between legs in the same subject (P > 05), even with adjustment for body mass index (P = .001–.049). The study demonstrated that in primigravida women, lower limb veins showed gradual increase in vein diameter and in VCT starting from the second trimester. These changes reverted to baseline in most cases three months after delivery.

PLoS One 2014;19:e100582. DOI: 10.1371/journal.pone.0100582.

The authors studied the cost-effectiveness of silver dressings using a health economic model based on time-to-wound-healing in hard-to-heal chronic venous leg ulcers (VLUs). The use of silver dressings to control bioburden and improve wound healing rates remains controversial.

A decision tree was constructed to evaluate the cost-effectiveness of treatment with silver compared with non-silver dressings for four weeks in a primary care setting. The outcomes ‘Healed ulcer’, ‘Healing ulcer’ or ‘No improvement’ were developed, reflecting the relative reduction in ulcer area from baseline to four weeks of treatment. A data set from a recent meta-analysis, based on four RCTs, was applied to the model.

Treatment with silver dressings for an initial four weeks was found to give a cost saving (£141.57) compared with treatment with non-silver dressings; patients treated with silver dressings had a faster wound closure compared with those who had been treated with non-silver dressings.

The authors conclude that the use of silver dressings improves healing time and can lead to overall cost savings.

Vasc Surg 2015; 61: 741–746

This randomized clinical trial compared endovenous laser ablation (EVLA) and surgical ligation with attempted stripping in the treatment of small saphenous vein (SSV) insufficiency. The early results demonstrated that EVLA was more likely to eradicate axial reflux and was also associated with a faster recovery, lower periprocedural pain, and fewer sensory complications. The aim of this two-year follow-up was to establish whether these benefits remained stable over time and whether these improved technical outcomes were associated with less clinical recurrence. A total of 106 patients with primary saphenopopliteal junction and SSV reflux were equally randomized to EVLA or saphenopopliteal junction ligation and attempted stripping/excision. All patients were treated successfully with 83% follow-up at two years. At two years, EVLA remained superior to surgery in eliminating axial reflux in 81.2% compared with 65.9% in the surgery group (P = .002). There was no significant difference in clinical recurrence (EVLA: 7 of 44 [16%] vs. surgery: 10 of 44 [23%]; P = .736), sensory disturbance (EVLA: one [2.4%] vs. surgery three [6.8%]; P = 1.000) or any quality-of-life domain.

The authors conclude that the results of treatment of SSV insufficiency with EVLA appear durable up until two years. The study does not suggest that the improved elimination of reflux after EVLA compared with surgery is associated with superior outcomes.

Clin Appl Thromb Hemost 2015. Epub ahead of print. pii: 1076029615575344.

Venous thromboembolism (VTE) is the most common preventable cause of hospital death; the burden of VTE includes the management of the acute event (deep vein thrombosis [DVT]/pulmonary embolism) and the chronic subsequents such as postthrombotic syndrome and recurrent DVT. All experts agree that despite the abundance of knowledge available on VTE and how to prevent it, it is still underused, and since the first step in prophylaxis is to identify those who are at high risk of VTE, several risk assessment models have been developed to identify these patients and provide appropriate prophylaxis. In our study, the institutional guideline in a tertiary educational hospital is the Caprini score (2006), a comparison was conducted between the institutional guideline and the American College of Chest Physicians guideline (ACCP Ninth Edition [ACCP-9]) in terms of the degree of agreement of the actual prophylaxis with the institutional guideline and the ACCP-9 and the differences in risk levels. The concordance with the ACCP-9 guideline was higher than with the institutional guideline, specifically in those patients receiving prophylaxis, and there was an overestimation of the risk levels in the institutional guideline, especially in medical patients. The replacement of the existing Caprini 2006 with the ACCP-9 is prudent, since it agrees with the physicians’ clinical judgment and may result in reduced use of pharmacologic prophylaxis which could lead to lower costs and fewer adverse effects.

Ann Vasc Surg 2015. pii: S0890-5096(15)00090-4. DOI: 10.1016/j.avsg.2014.11.025.

In this study, the authors utilized the American College of Surgeons (ACS-NSQIP) database for all patients who underwent surgical procedures from 2005 to 2010. The purpose of this study was to report the incidence of DVT within 30 days among cardiac and vascular patients compared to general surgical patients. Risk factors for developing post-operative DVT were identified and compared.

A total of 2,669,772 patients underwent surgical operations in the time period between 2005 and 2010. Of all the patients, 18,670 patients (0.69%) developed DVT. The incidence of DVT among different surgical specialties was cardiac surgery (2%), vascular surgery (0.99%) and general surgery (0.66%). The odds ratio for developing DVT was 1.5 for vascular surgery patients and 3 for cardiac surgery patients, when compared with general surgery patients (p < 0.001). The odds ratio for developing DVT after cardiac surgery was 2, when compared to vascular surgery (p < 0.001).

The incidence of DVT is higher among vascular and cardiac surgery patients as compared with general surgery patients. Intra-operative anticoagulation does not prevent occurrence of DVT in the post-operative period. These patients should receive DVT prophylaxis in the peri-operative period, similar to other surgical patients according to evidence-based guidelines.

J Vasc Surg: Venous and Lym Dis 2015; 3: 154–160

Duplex measurements of reflux are performed invariably with a single probe. Because many anatomic locations are studied, repeated provocation maneuvers are required. However, this fails to appreciate reflux as a circulation. The use of two probes placed concurrently in different regions may address this limitation. The study compared venous reflux duration and cessation, above the knee and below the knee simultaneously, with two duplex probes. Seventeen legs from 17 consecutive patients (12 female, 9 left) with great saphenous vein reflux were studied. Their median (range) age was 51 (28–71) years; weight, 76.8 (63.5–189) kg; height, 169 (153–180) cm; and Venous Clinical Severity Score, 5 (1–12). The clinical class of the Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) classification was as follows: C2, 6; C3, 4; C4a, 5; and C4b, 2. After 2 min of elevation, the leg was assessed for reflux duration with duplex ultrasound. This occurred when the patient stood up during venous filling. One probe was positioned 10 cm below the saphenofemoral junction over the great saphenous vein (point A) and the other over a refluxive saphenous vein or tributary below the knee (point B). Concurrent images were displayed on adjacent monitors and recorded by a single video camera. Reflux duration was from the onset of dependency, indicated by the start of the video, to the termination of the red color (reflux) on video playback. The probes were swapped to negate for differences in machine sensitivity. Each leg was tested three times. Simultaneous was defined when there was <0.1 second difference between the two sites. The median (range) vein diameters at points A and B were 6.1 (2.8–9.3) mm and 5.5 (2.5–8.1) mm, respectively, with an intertransducer distance of 41 (23–59) cm. There was no significant difference in reflux duration between point A with 27 (9–150) s and point B with 27 (10–149) s (P = .943 [Wilcoxon]). The correlation was excellent (r = .986; P < 0005 [Spearman]). The study demonstrated that reflux may stop simultaneously above and below the knee with the use of the elevation to dependency maneuver to provoke reflux. It has shown that either site may be used to measure reflux duration. Furthermore, the two-probe technique confirms the belief that the mechanism of reflexive venous filling is through the descending path of a recirculation circuit.

Thromb Res 2015. DOI:10.1016/j.thromres.2015.02.003.

The authors aim for this study is to identify whole blood gene expression profiles that distinguished patients with clinically distinct patterns of VTE provoked and unprovoked. A total of 107 patients with VTE were separated into three groups: (1) ‘low-risk’ patients had one or more provoked VTE; (2) ‘moderate-risk’ patients had a single unprovoked VTE; and (3) ‘high-risk’ patients had ≥2 unprovoked VTE. As for the standard, each patient group was also compared with 25 individuals with no history of VTE. Total RNA from whole blood was isolated and hybridized to Illumina HT-12 V4 Beadchips to assay whole genome expression. Using class prediction analysis, we distinguished high-risk patients from low-risk patients and healthy controls with good receiver operating curve characteristics (area under the curve (AUC) = 0.81 and 0.84, respectively). We also distinguished moderate-risk individuals and low-risk individuals from healthy controls with AUCs of 0.69 and 0.80, respectively. Using differential expression analysis, we identified several genes previously implicated in thrombotic disorders by genetic analyses, including selectin P(SELP), kallikrein B(KLKB1), annexin A5 (ANXA5), and complement regulatory protein (CD46). Protein levels for several of the identified genes were not significantly different between the different groups.

The authors conclude from their study that gene expression profiles are capable of distinguishing patients with different clinical presentations of VTE, and genes relevant to VTE risk are frequently differentially expressed in these comparisons.

J Vasc Surg Venous and Lym Dis 2015; 3: 142–142

Many believe the benefits of retrieval are self-evident, yet retrieval carries an inherent complication risk and cost. The purpose of this study was to quantitatively weigh the risks and benefits of IVC filter retrieval using formal decision analysis. A Markov state-transition model was used to simulate two clinical scenarios: to leave a previously placed IVC filter or to retrieve it. Analysis was performed during the lifetime of the individual, and outcomes were expressed in quality adjusted life-years (QALYs). The base case is a 60-year-old man with a filter placed within three months who no longer requires mechanical thromboprophylaxis. Potential events included PE, filter complications, and death from all other causes during each cycle. Tolls were used to incorporate the disutility of short-term treatment for PE and filter complications.

For the base case and sensitivity analyses, we used utilities and probabilities derived from the literature. In the base case scenario, leaving the filter in place was preferred to filter retrieval, yielding 22.3 vs. 21.9 QALYs. One-way sensitivity analysis demonstrated that filter retrieval may be preferable if the utility of living with a filter is <0.98. For all probabilities of retrieval and PE mortality, leaving the filter in place is preferred. The authors concluded that leaving a previously placed IVC filter provides a 0.4 QALY benefit over retrieving the filter for the average patient.

J Vasc Surg: Venous and Lym Dis 2015; 3: 161–167

Patients with femoral vein occlusion rapidly develop collateral flow through the deep femoral vein, an embryonic collateral. In contrast, iliac vein collateralization is sparser and functionally poorer. It is not uncommon to have femoral vein occlusions associated with iliac vein obstruction, even though the femoral vein occlusion is often more readily apparent on venograms and duplex scans, whereas the iliac vein obstruction may remain occult. We examined whether percutaneous stent correction of iliac vein obstruction associated with femoral vein occlusions would yield symptomatic relief. During a 13-year period, 39 patients with femoral vein occlusions underwent stenting of associated iliac vein stenoses. Median age was 51 years (17–86 years). The male-to-female and right-to-left ratios were 1:3 and 1:2, respectively. The clinical class of the Clinical, Etiologic, Anatomic, and Pathologic (CEAP) classification was as follows: C0-2 (with pain), 2 of 39 (5%); C3, 19 of 39 (48%); C4, 10 of 39 (26%); C5, 1 of 39 (3%); and C6, 7 of 39 (18%). Concurrent ablation of a refluxive saphenous vein was performed in 7 of 39 (18%). Reintervention was carried out in 14 of 39 limbs (36%). Median follow-up was 26 months (1–154 months). Median iliac vein stenosis was 80% (40%–100%). Primary, primary assisted, and secondary patency rates at two years were 57%, 88%, and 96%, respectively. Pain grade (visual analog scale, 0–10) improved from median 5 (0–9) to 3 (0–8) after stenting (P  < 03); 12% were completely relieved of pain. Cumulative improvement in pain (>3 of 10 on the visual analog scale) was 87% at two years. Median swelling (grade 0, none; grade 1, pitting; grade 2, ankle edema; grade 3, gross) improved from median 3/3 (0–3) to 2/3 (0–3) (P = 09, NS). Among 22 of 39 limbs (56%) with grade 3 swelling before stenting, 7 of 22 limbs (32%) with grade 3 swelling improved (>1 grade) after stent placement. In the 15 of 22 limbs (68%) with residual grade 3 swelling after stenting, subjective improvement was reported by all. Four of seven active ulcers (54%) healed. There were no obstructive sequelae after concurrent saphenous ablation. Saphenous flow in the erect position was not different from that of controls with patent femoral veins. The group concluded tercutaneous stenting of associated iliac vein obstruction in symptomatic limbs with femoral vein occlusion yields satisfactory clinical relief. The saphenous vein has little collateral role in this pathologic process and can be safely ablated if it is refluxive, in line with prior observations.