Abstract
Iliac vein interrogation augments venous ulcer healing in patients who have failed standard compression therapy along with pathological venous closure
AY Mousa, M Broce, M Yacoub, et al.
Ann Vasc Surg 2016; Epub ahead of print, DOI: 10.1016/j.avsg.2015.11.036.
The authors conducted a systematic retrospective analysis of a consecutive series of patients who presented with CEAP 6 venous disease. All patients had great saphenous vein ablation, compressive treatment, wound care (including Unna boot compression), and perforator closure using ablation therapy. Iliac vein stenosis was defined as ≥50% stenosis in cross-sectional surface area on intravascular ultrasound. Primary outcomes include time of venous ulcer healing and/or measurable change in the venous clinical severity score (VCSS). Twenty-two patients with CEAP 6 venous disease met the inclusion criteria (active ulcers >1.5 cm in diameter). The average age and BMI were 62.2 ± 9.2 years and 41.7 + 16.7, respectively. The majority were female (72.7%) with common co-morbidities, such as hyperlipidemia (54.5%), hypertension (36.4%), and diabetes mellitus (27.3%). Twenty-nine ulcers with an average diameter of 3.4 ± 1.9 cm and a depth of 2.2 ± 0.5 mm were treated. The majority of the ulcers occurred on the left limb (n = 17, 58.6%). Average perforator venous reflux was 3.6 ± 0.8 s, while common femoral reflux was 1.8 + 1.6. The majority (n = 19, 64.5%) of the perforator veins were located at the base of the ulcer, while the remainder (n = 10, 34.5%) were within 2 cm from the base. Out of 13 patients who underwent iliac vein interrogation (IVI), eight patients (61.5%) had stenosis > 50% that was corrected with iliac vein angioplasty/stenting (IVAS). There was a strong trend toward shorter healing time in the IVI group (7.9 ± 9.5 weeks) than for patients in the NIVI group (20.2 ± 15.3 weeks p = 0.055). The final VCSS was not significantly different (IVI = 7.9 ± 9.5 vs. NIVI = 10.0 ± 6.5; p = 0.578). However, compared to the NIVI group, the healing time for patients who actually received IVAS was marginally lower (5.8 ± 3.6 weeks; p = 0.075), and final VCSS was significantly lower (2.4 ± 2.9; p = 0.031). Veins that received IVI and IVAS remained patent and the associated ulcers were healed (100%). The small sample size and retrospective design limit the strength of the conclusions but the findings suggest further studies are needed to define the exact role of IVI including angioplasty/stenting for patients with chronic venous ulcers.
Less painful tumescent solution for patients undergoing endovenous laser ablation of the saphenous vein
T Gunes, F Altin, B Kutas, et al.
Ann Vasc Surg 2015; 29: 1123–1127
This study aims to investigate the efficacy of lidocaine, prilocaine, and bupivacaine used in tumescent solution during endovenous laser treatment on intraoperative and postoperative pain. Three groups of 30 patients in a prospective randomized study investigating tumescent anesthesia using lidocaine (1), prilocaine (2), and bupivacaine (3) to access venous laser treatment on intraoperative and postoperative pain. Visual analog scale was used for the evaluation of intraoperative and postoperative pain. The mean intraoperative pain score was 2.27 ± 1.53 in group 1, 1.97 ± 1.54 in group 2, and 3.05 ± 0.73 in group 3. On the first day postoperatively, the mean pain score was 2.57 ± 1.7 in group 1, 3.27 ± 1.23 in group 2, and 1.13 ± 0.94 in group 3 (P = 0.0001). Intraoperative and postoperative mean pain scores during first day follow-up were significantly lower in group 3.
The authors concluded that bupivacaine is a better alternative to lidocaine and prilocaine for tumescent anesthesia.
Ultrasonography of skin changes in legs with chronic venous disease
A Caggiati
Eur J Vasc Endovasc Surg 2016; Epub ahead of print, DOI: 10.1016/j.ejvs.2016.03.022.
In legs with venous disorders, sonography refines clinical evaluation of the skin and may reveal changes not highlighted by inspection. US findings from evident skin lesions are comparatively evaluated with those from the surrounding apparently normal skin and from the contralateral leg. Inflammation and dermal edema can be found in the apparently normal skin of C2 legs. Swollen legs show thickening of the subcutaneous layer as a result of diffuse soaking or anechoic cavities, with or without dermal edema. Chronic hypodermitis is characterized by inflammatory edema in initial phases, and by liposclerosis in advanced cases. Recrudescence of inflammation provokes focal rarefactions of the subcutaneous layer, possibly related to ulcer opening. Some of these changes could require further investigation because they have not yet been explained or described. Skin sonography should improve knowledge of the natural history of skin changes, as well as contribute to a better grading of venous diseases severity In particular, US evidence of cutaneous and subcutaneous changes in C2 legs should be considered to stratify the treatment in C2 legs, by identifying those in which varicose veins are not simply a cosmetic problem.
Should we use platelet-rich plasma as an adjunct therapy to treat “acute wounds,” “burns,” and “laser therapies”: A review and a proposal of a quality criteria checklist for further studies
F Picard, B Hersant, R Bosc, et al.
Wound Repair Regen 2015; 23: 163–170
Platelet-rich plasma seems to help wound healing. The goal of this review is to determine if the nine randomized controlled studies, six prospective controlled studies, and two retrospective controlled studies prove that platelet-rich plasma seems to help wound healing. Regarding acute wounds, three randomized controlled trials found a statistical benefit regarding either the healing time, the return back to work time, the quality of life, or the pain. Three prospective controlled studies found a statistical difference regarding the velocity of healing. Platelet-rich plasma decreased the intensity or duration of erythema after laser therapy in four randomized studies. Regarding the long-term outcome of laser therapies, two studies found a statistical benefit and two others did not.
The authors concluded that platelet-rich plasma speeds up acute wound healing, decreases erythema after laser therapies and no conclusions in the use on burns.
Transjugular liver access cannula as a guiding instrument for the recanalization of chronic venous occlusions
E Dou, RS Winokur, DW Trost, et al.
J Vasc Surg: Venous and Lym Dis 2016; 4: 187–192
This report describes an experience using the transjugular liver access cannula technique in nine patients. A review of patients requiring venous recanalization between May 2012 and October 2014 identified nine cases that required the use of a transjugular liver access cannula as a guiding instrument. Lesion characteristics, technical success, and clinical outcomes were evaluated. The transjugular liver access cannula was used to traverse a total of nine chronic occlusions in both the upper and lower central venous systems in nine patients. The technical success rate was 100%. There were no clinically significant complications. One patient was lost to follow-up. Of the remaining eight patients, seven experienced symptomatic relief within one month of recanalization. The transjugular liver access cannula may serve as a useful adjunctive tool during difficult venous recanalizations, especially when traditional guidewire and catheter techniques fail.
Real-life use of non-vitamin K antagonist oral anticoagulants in patients with cancer associated venous thromboembolism: Data from a prospective cohort
A Mancuso, MC Vedovati, L Pierpaoli, et al.
Thromb Res 2016; 140: S191
In this prospective cohort consecutive patient trial, the authors wished to derive information regarding mortality, recurrent venous thromboembolism (VTE) and bleeding complications with cancer associated thrombosis (CAT) and without cancer receiving direct oral anticoagulants (DOACs). Included in this study were patients with acute objectively confirmed VTE receiving DOACs within one month from diagnosis; 472 patients were included in the study: 78 with CAT (16.5%). Lung, breast, gastrointestinal, and genitourinary cancer was observed in 16%, 24%, 20%, and 24% of patients with CAT, respectively. Thirty-one patients with CAT (40%) were on chronic hormone therapy or radiotherapy. Ten patients with CAT (13%) had at least an additional risk factor for VTE. Pulmonary embolism was index VTE in 152 patients: 24.4% of patients with CAT and in 33.8% of those without cancer (p = 0.10). Deep vein thrombosis (DVT) was only present in 320 patients and 78 had both DVT and pulmonary embolism (PE). Among DOACs patients, 312 (66%) received initial loading dose: 61% of those with CAT and 67% without. Fifty-three (11%) received reduced maintenance doses (10% with CAT, 11% without). Two hundred and seventy-two patients had at least three months of follow-up, the mean follow-up being 8.6 months. Twenty patients died (7.3%): 17 were cancer-related deaths. No fatal bleedings or fatal VTE recurrences occurred.
The authors concluded that patients with CAT receiving DOACs were treated as patients without CAT in terms of use of loading doses and maintenance treatment. Upper arm thrombosis was more frequently involved in CAT patients and proximal lower vein in patients without CAT. Non-cancer-related mortality was higher in CAT patients but no fatal recurrences or fatal bleedings were observed.
Quantifying saphenous recirculation in patients with primary lower extremity venous reflux
CR Lattimer, M Azzam, E Kalodiki, et al.
J Vasc Surg: Venous and Lym Dis 2016; 4: 179–186
The aim of this study was to measure the antegrade and retrograde great saphenous vein (GSV) volume displacements during calf compression and release maneuvers. This was used to quantify harm over benefit with a recirculation index (RCI); 16 legs (nine right) from 16 patients (nine male) with primary superficial venous insufficiency were scanned standing with duplex ultrasound, at the upper thigh GSV, 10 cm below the saphenofemoral junction. The clinical, etiological, anatomical, pathophysiological class was C2 = 3, C3 = 2, C4a = 6, C4b = 4, C5 = 1. The median age (range), venous clinical severity score, and refluxing GSV diameter were 63 (21–79) years, 8 (4–16), and 7 (5–10) mm, respectively. A manual calf compression and release (MCCR) maneuver was performed once, and a cyclical calf compression and release (CCCR) three times for repeatability. With the CCCR maneuver, the calf-cuff and inflation–deflation pump provided a cyclical compression pressure of 120 mm Hg (3 s) with a release time of 16.4 s to standardize venous refilling time. The results are expressed as median [interquartile range]. The CCCR compared with the MCCR resulted in longer reflux duration (16.4 [8.2–16.4] s vs. 5.7 [3.7–6.8] s; P < 0.0005), higher time-averaged mean velocities in reflux (23.5 [14.9–27.9] cm/s vs. 14.1 [9–17.6] cm/s; P < 0.0005), and greater reflux volume displacements (81.7 [38.8–152.8] mL vs. 27.3 [16.4–53.4] mL; P < 0.0005). There were significant correlations between increasing antegrade volume measurements and increasing reflux volume measurements irrespective of whether CCCR (r = 0.841; P < 0.0005) or MCCR (r = 0.762; P = 0.001) was used. This implies that the displaced antegrade volume might have a causal effect on the resulting reflux volume. The ratio of reflux volume/antegrade volume (RCI) was 2.14 [1.58–2.74] with the CCCR. This supports the recirculation phenomenon. Adjusted to a standard median for each leg, the repeatability limits (three times) of the RCI was excellent at 2.14 (95% confidence interval, 2.09–2.21). In this study, we measured the behavior of the GSV in terms of harmful reflux over beneficial drainage using the RCI. We recognize that reflux values depend on the type of provocation test and the amount of displaced antegrade volume. This limitation might be overcome by factoring reflux as an expression of antegrade flow using the RCI. When standardized, a test for quantifying saphenous recirculation might have many clinical applications. The next step should be a prospective study to validate the RCI with clinical and quality of life parameters.
Use of statins and reduced risk of recurrence of venous thromboembolism in an older population. A population-based cohort study
V Tagalakis, M Eberg, S Kahn, et al.
Thromb Haemost 2016; Epub ahead of print, https://dx-doi-org.web.bisu.edu.cn/10.1160/TH15-10-0775.
This three year follow-up (mean) study which included 25,681 patients 65 years or older with incident venous thromboembolism (VTE) were used to determine in older patients if statin use was associated with a decreased risk of recurrent VTE. There were 2343 recurrent VTE events (rate: 3.1 per 100 person-years). Compared with non-use, current use of statins was associated with a decreased risk of VTE recurrence (rates: 1.55 vs. 3.47 per 100 per year, respectively; HR: 0.74, 95% CI: 0.61–0.89), while no association was observed with past use (HR: 0.98, 95% CI: 0.76–1.25). In a secondary analysis, longer durations of statin use were associated with greater risk reductions (0–6 months, HR: 0.82, 95% CI: 0.67–1.01; 6–12 months, HR: 0.62, 95% CI: 0.43–0.90; ≥12 months, HR: 0.50, 95% CI: 0.33–0.74; p value for trend ≤0.001).
The authors concluded that the use of statin in older patients was associated with a decreased risk of recurrent VTE. This study supports the need for randomized controlled trials to assess the efficacy and safety of statins in the long-term treatment of VTE.
Efficacy of topical local anesthesia to reduce perioperative pain for endovenous laser ablation of varicose veins: A double-blind randomized controlled trial
S Saha, A Tiwari, C Hunns, et al.
Ther Adv Cardiovasc Dis 2016; Epub ahead of print, DOI: 1753944716644140.
Tumescent local anesthesia via multiple injections in the perivenous space leads to intraoperative and postoperative pain during endovenous laser ablation (EVLA). We considered whether the application of topical local anesthesia reduces pain caused by these injections. The authors’ primary outcome objective was to evaluate whether topical anesthesia reduces needle pain during tumescent anesthesia for laser ablation (EVLA); 44 patients undergoing local anesthetic EVLA were randomized to either application of topical local anesthesia or water-based gel (placebo) to the inner thigh over the marked great saphenous vein. Secondary outcome measures were extra analgesia requirement during or immediately postoperatively. There were two groups. Group 1 consisted of 24 patients who received topical anesthesia; group 2 consisted of 20 placebo patients. There was no statistical difference in age, gender distribution, or the severity of varicose veins assessed preoperatively by the clinician (CEAP classification score, median = 2 in both groups) and patient (AVVQ, mean placebo = 21.59, local anesthesia = 17.53, p = 0.264) between the two groups. There was no statistical difference in pain scores between the placebo and topical local anesthetic group at baseline (23.0 vs. 20.44, p = 0.57), immediately postoperatively (23.35 vs. 19.75, p = 0.44) or predischarge (20.9 vs. 13.75, p = 0.68).
The authors concluded that topical anesthesia is of no benefit in EVLA.