Abstract
Relationship between patient-reported symptoms, limitations in daily activities, and psychological impact in varicose veins
R Mallick, B Kumar Lal, C Daugherty
J Vasc Surg: Venous and Lym Dis 2017; 5: 224–237.
This was a pooled analysis from two studies which evaluated polidocanol injectable foam for the treatment of saphenofemoral junction incompetence: VANISH-1 and VANISH-2. Health outcomes were classified on the basis of the Wilson–Cleary conceptual framework continuum linking CEAP clinical class and great saphenous vein (GSV) diameter, to patient-reported outcomes. Association of clinical and anatomic categories with each of the patient-reported outcomes was assessed using analysis of variance for statistical significance and standardized mean differences for clinical meaningfulness. Hierarchical regression modeling was applied to evaluate the direct association of the VVSymQ symptom score with the m-VEINES-QOL/Sym functional limitations score and the indirect association with the m-VEINES-QOL/Sym psychological impact score, adjusting for clinical, behavioral, and demographic factors. Among 516 patients, approximately three-fourths were women (mean age, 49 years), approximately 70% were overweight or obese, 42% were C2 and 32% were C3, and 88% reported never or only intermittently wearing compression stockings. VVSymQ (symptom) scores did not vary by GSV diameter but were significantly worse for those with severe disease stage, especially C5 or C6. Among m-VEINES-QOL/Sym work-related function items, 47% of patients reported difficulty at work and 31% reported cutting down at work. On nonwork function items, standing for prolonged periods was most affected; 53% were limited a little, and 22% were limited a lot. Concern about appearance and choice of clothing predominated among psychological impact items, with 74% and 65%, respectively, affected all or most of the time. The m-VEINES-QOL/Sym functional limitation and psychological impact scores varied by neither GSV diameter nor CEAP C class, but they varied directly with VVSymQ (symptom) score quartiles. Multivariable regression analysis revealed that VVSymQ symptom scores continued to be associated with m-VEINES-QOL/Sym psychological impact scores, even after adjustment for m-VEINES-QOL/Sym functional limitation scores. The authors concluded that substantial patient-reported functional limitation and psychological impact of varicose veins (VVs) were observed. Limitations on work, standing for prolonged periods, concern about appearance, and clothing choice were most affected. Patient-reported VVSymQ (symptom) score, an objective patient-reported measure of symptom severity in VVs, was the key predictor of patient-reported m-VEINES-QOL/Sym functional limitations. Symptoms and functional limitations led to greater psychological impact. Physicians should routinely ascertain symptoms and functional limitations to enhance quality of care and to document medical necessity.
Blind-sided by cosmetic vein sclerotherapy: A case of ophthalmic arterial occlusion
M Arunakirinathan, RJ Walker, N Hassan, S Ameen, S Younis
Retin Cases Brief Rep 2017; Epub ahead of print, DOI: 10.1097/ICB.0000000000000559.
The authors present the first documented case of ophthalmic artery occlusion resulting in panocular ischemia secondary to intravascular injection of foam sodium tetradecyl sulfate into forehead veins in a young healthy woman. The patient presented with unilateral sudden loss of vision. Funduscopy demonstrated a pale retina, cherry-red spot, and sclerosant visualized directly at the macula. She underwent emergency treatment for central retinal artery occlusion. According to the authors, prior to this report, the only published ocular side effects of foam sclerotherapy are transient visual disturbances or temporary scotomas.
The authors concluded that this side effect is rare; however, patients should be counseled regarding this potential devastating complication.
Postpartum varicose veins: Supplementation with pycnogenol or elastic compression-A 12-month follow-up
G Belcaro, M Dugall, R Luzzi, et al.
Int J Angiol 2017; 26: 12–19.
The authors evaluated the clinical evolution of postpartum varicose veins in 133 healthy women after the second pregnancy in a registry study. The registry included two groups of women: (1) those who used elastic compression stockings and (2) those who used an oral venotonic agent (Pycnogenol, 100 mg/d). The resulting two registry groups were comparable. At three and six months in the Pycnogenol cohort, the number of veins and incompetent sites were lower. At six months, there were 13.3% of patients with edema versus 3.2% in the Pycnogenol group. Spider veins decreased in Pycnogenol patients. Cramps and other minor symptoms were less common in the Pycnogenol group. In both groups, there was a significant improvement at six months; however, the Pycnogenol group showed better results. The overall satisfaction was higher among Pycnogenol patients, and compliance was optimal. Most remodeling appeared to happen within six months after the pregnancy.
The authors concluded that the use of Pycnogenol improves signs/symptoms of postpartum varicose veins; venous function and shape seem to return faster to prepartum.
New diagnostic modalities in the evaluation of lymphedema
TF O’Donnell Jr, JC Rasmussen, EM Sevick-Muraca
J Vasc Surg: Venous and Lym Dis 2017; 5: 261–273.
Literature for each technique is reviewed and discussed, and the evidence for each of these new diagnostic techniques was assessed on several criteria to determine if each could (1) establish whether disease is present, (2) determine the severity of the disease process, (3) define the pathophysiologic mechanism of the disease process, (4) demonstrate whether intervention is possible as well as what type, and (5) objectively grade the response to therapy. Lymphoscintigraphy (LSG) is currently the standard test to confirm lymphedema (LED). Duplex ultrasound (DUS) is a simple, readily available noninvasive test that can identify LED by specific tissue characteristics as well as the response to therapy. Magnetic resonance imaging and computed tomography scans similarly demonstrate the alterations in epidermal and subcutaneous tissue, but the latter can also detect obstructing neoplasms as a cause of secondary LED. Moreover, magnetic resonance lymphangiography details lymphatic vessels and nodes and their function. Newer fluorescence imaging techniques provide opportunities to image lymphatic anatomy and function. Visible microlymphangiography by fluorescein sodium is limited by tissue light absorption to imaging depths of 200 mm. Near-infrared fluorescence lymphatic imaging, a newer test using intradermal injection of indocyanine green, can penetrate several centimeters of tissue and can visualize the initial and conducting lymphatics, the lymph node basins, and the active function of lymphangions (the key module) in exquisite detail. The findings show that the availability and the noninvasive nature of DUS should make this modality the first choice for establishing the diagnosis of LED based on tissue changes. Further studies comparing DUS with LSG, however, are needed. The costs of magnetic resonance imaging and computed tomography limit their adoption as a means to regularly assess the lymphatics. Whereas lymphatic truncal anatomy and transit times can be delineated by the older technique of LSG, near infrared fluorescence lymphatic imaging is rapid, highly sensitive, and repeatable and provides exquisite detail for lymphatic vessel anatomy and function of the lymphangions as well as the response to therapy.
Prevalence of deep vein thrombosis in hospitalized patients with suspected pulmonary embolism ruled out by multislice CT angiography
FJ Vazquez, ML Posadas-Martinez, B Bioetti, et al.
Clin Appl Thromb Hemost 2017; Epub ahead of print, DOI: 10.1177/1076029617696580.
The goal was to determine the prevalence of deep vein thrombosis (DVT) in hospitalized patients who had pulmonary embolism (PE) ruled out by multislice computed tomographic angiography (CTPA). This was a prospective cohort study of patients who developed symptoms indicative of PE, after being admitted to the hospital for any reason other than PE and were evaluated with multislice CTPA. The main outcome was proximal DVT. Between November 2011 and December 2014, 191 hospitalized patients were screened. A total of 99 patients satisfied the inclusion criteria. The average length of hospitalization for this group was 14 days (range: 2–127 days). While hospitalized, 54 (28%) patients underwent a major surgical procedure, and 80 (79%) were receiving thromboprophylaxis. Of the 99 patients included, seven (7.07%; 95% CI: 3.4–13.8) were diagnosed with a proximal DVT. The likelihood of developing a proximal DVT was higher for those with subtle and nonspontaneously reported symptoms of DVT; odds ratio (OR) was 50.93 (95% CI: 5.35-2572) and for those classified as PE likely OR was 37.54 (95% CI: 4.05–186.1). Given the prevalence of DVT in hospitalized patients with suspected PE ruled out by a negative multislice CTPA, this study suggests that compression ultrasonography would, in fact, be justified for patients with these characteristics.
Impact of anticoagulation in elderly patients with pulmonary embolism that undergo IVC filter placement: A retrospective cohort study
JM Falatko, B Dalal, L Qu
Heart Lung Circ 2017; Epub ahead of print, DOI: 10.1016/j.hlc.2017.01.011.
Patients ≥60 years of age, that had an inferior vena cava (IVC) filter placed between 1 January 2008 and 2 February 2013, with a primary diagnosis of pulmonary embolism, were included. Patients that died during index hospitalization, were discharged to hospice, or had active malignancy were excluded. The primary endpoint was overall survival. Patients were divided depending on whether they were treated with an approved anticoagulant for VTE or had no anticoagulant. Of the 152 patients identified, 55 were not anti-coagulated after IVC filter placement. The incidence of death was 0.4 per 1000 filter days and 0.7 per 1000 filter days in the anti-coagulated and untreated groups, respectively (p-value = 0.06). After statistical correction for co-morbid conditions, the effect of anticoagulation was not significant (HR 0.82, CI 0.49–1.37, p-value 0.46). Age was a significant confounder that was associated with death. Increased BMI was protective. Indications for IVC filter placement were numerous, but similar between the two groups. The investigators concluded that treatment with an approved anticoagulant is recommended after IVC filter placement for prevention of recurrent PE; however, its effect may be attenuated by advanced age. In elderly patients that have undergone IVC filter placement for prevention of recurrent PE, survival may be more dependent on age and co-morbid conditions than exposure to anticoagulation.
Catheter-directed, ultrasound-assisted thrombolysis is a safe and effective treatment for pulmonary embolism, even in high-risk patients
KA Lee, A Cha, MH Kumar, et al.
J Vasc Surg Venous Lymphat Disord 2017; 5: 165–170.
The authors studied the early success and safety of catheter-directed ultrasound-assisted (CDUA) pulmonary thrombolysis in 91 patients in a retrospective manner for a duration of 39 months. All patients presented with acute pulmonary embolism (PE) as diagnosed by computed tomography angiography. Standard thrombolysis protocol was followed (1 mg of tissue plasminogen activator per hour per catheter after an initial 2-mg bolus per catheter). All patients had PE and pulmonary hypertension (pulmonary artery pressures (PAP) >25 mmHg); 19% of patients were deemed to be at high risk for bleeding. The high-risk patients in the study were noted to have higher right ventricle (RV):left ventricle (LV) ratios and lower oxygen saturations on admission (P < .05). On computed tomography angiography, the mean pretherapy RV axial:LV axial ratio was 1.5 ± 0.4. The mean pretherapy PAP was 56.2 ± 15.2 mmHg. After 18.5 ± 3.5 h of thrombolysis, the mean post-therapy PAP was 34.3 ± 10.4 mmHg, with a pressure drop of 21.9 ± 4.8 mmHg (39% decrease; P < .001); 8% of the patients had bleeding complications that required intervention. Three of the seven complications occurred in the high-risk group (3/17) and the other four in the general population of patients (4/74; P = .118); 15% of the patients had minor bleeding complications. Regarding bleeding complications, increasing RV axial:LV axial ratio was a predictor of any bleeding complication, independent of all risk factors (P = .005).
The authors concluded that CDUA pulmonary thrombolysis for the management of acute submassive PE appears has an acceptable risk profile and effective in decreasing right-sided heart strain.