Summaries of recent phlebological abstracts

Am J Case Rep 2017; 18: 1194–1197.

Round ligament varices (RLV) are almost exclusively seen in pregnant women. Clinically, this entity can resemble any pathology involving the inguinal canal and round ligament. The diagnosis is made by duplex. Case: A 34-year-old at 34 weeks’ gestation presented with a complaint of a small, painless, reducible right inguinal mass. Sonography showed an asymmetric right inguinal anechoic mass composed of multiple serpentine tubular channels, which became more prominent when the patient performed a Valsalva maneuver. Color Doppler ultrasound imaging showed a hypervascular structure with a venous flow pattern. The patient was treated non-operatively and had an uneventful vaginal delivery. At two weeks postpartum, the round ligament spontaneously regressed and her symptoms completely resolved.

The authors concluded that duplex is the diagnostic imaging procedure of choice as well as for patient follow-up and to exclude possible complications associated with RLV.

J Vasc Surg Venous Lymphat Disord 2018; 6: 13–24.

The goal was to determine the presentation and treatment outcomes in elderly patients compared with a cohort of patients younger than 65 years. From January 2015 to December 2016, prospectively collected data were retrospectively reviewed from 38,750 patients with chronic venous disease (CVD) from the Center for Vein Restoration’s electronic medical record. The patients were divided into two groups; group A patients were younger than 65 years and group B patients were 65 years of age or older. Medical and surgical history, presenting symptoms, treatment modalities, and revised Venous Clinical Severity Score before and after intervention were evaluated. A multivariate logistic regression analysis was performed to determine the predictive value of presenting and associated symptoms. Groups A and B were subdivided by clinical, etiology, anatomy, and pathophysiology class for subgroup analysis. There were 27,536 patients in group A and 11,214 in group B. Women constituted 78% of all patients. Group B demonstrated a higher incidence of chronic diseases compared with group A (P < .003). As initial presenting symptoms, pain, heaviness, fatigue, and aching were more common in group A than in group B (61% vs. 55%, 30% vs. 27%, 27% vs. 24%, and 17% vs. 12%, respectively; P < .001). Swelling, skin discoloration, and venous ulceration were more common in group B than in group A (29% vs. 23%, 12% vs. 6%, and 5% vs. 2%; P < .001). Ablations were more commonly performed in group B patients with C4 to C6 disease (P < .004). The revised Venous Clinical Severity Scores before and one month after intervention were similar between groups. Treatment improvement was statistically significant in both groups (P < .001). Multivariate logistic regression analysis indicated that varices, bleeding, swelling, skin changes, venous ulceration, aching, heaviness, pain, fatigue, cramping, and restless legs were associated with the presence of CVD (P < .001). The authors concluded that Medicare beneficiaries presented with more chronic diseases and more severe disease. Initial and associated symptoms were highly associated with the presence of CVD. Despite requiring more interventions than patients younger than 65 years, Medicare beneficiaries demonstrated the same degree of clinical improvement. Medicare should not develop coverage policy decisions that prevent access to therapies that alleviate CVD-induced symptoms.

J Vasc Surg Venous Lymphat Disord 2017; Epub ahead of print, doi: 10.1016/j.jvsv.2017.10.012.

The authors’ aim for this study was to determine long-term efficacy of endovenous therapy methods for varicose veins compared with conventional surgery (saphenofemoral ligation and stripping of great saphenous vein (GSV) with or without multiple avulsions) in management of GSV-related varicose veins.

The following were searched without date or language restriction for relevant randomized controlled trials (RCTs): MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, Scopus, Cochrane Library, and Web of Science. RCTs comparing conventional surgery and endovenous therapy for treating lower extremity varicose veins with five years or more of follow-up were selected.

The following procedures were included: endovenous laser therapy (EVLT), radiofrequency ablation (RFA), and ultrasound-guided foam sclerotherapy. Nine RCTs qualified. The RCTs included 2185 legs; only 1352 legs were followed up for five years (61.9%). There was no statically significant difference in recurrence rate in comparing EVLT with conventional surgery in treating GSV incompetence (36.6% vs. 33.3%, respectively; pooled risk ratio, 1.35 (95% confidence interval, 0.76–2.37); P = .3). No significant difference was determined for recurrence rate in comparing RFA with surgery or EVLT.

The authors concluded that the analysis showed that EVLT and RFA are as effective as conventional surgery in treating saphenous venous insufficiency. However, the number of patients available for analysis was too small for definitive conclusions to be drawn.

J Vasc Surg Venous Lymphat Disord 2018; 6: 31–40.

The objective of this study was to compare long-term effectiveness of great saphenous vein (GSV) thermal ablation and postprocedural recovery using radiofrequency-powered segmental ablation (RPSA) or 1470-nm EVLA with radial-tip fibers (EVLA-RTF). In a comparative prospective monthly altering-treatment cohort study of 311 patients (346 treated legs), each leg with incompetence of the GSV was treated with either RPSA (158 patients, 175 legs) or EVLA-RTF (153 patients, 171 legs). The primary outcome was anatomic occlusion of the GSV, assessed at 12, 24, 36, 48, and 60 months using Kaplan-Meier statistics and compared using the log-rank test. Secondary outcomes included freedom of varicose vein recurrence, clinical success measured by VCSS, disease-specific quality of life determined using the AVVQ, postoperative pain scores, and time to return to work. The total primary obliteration rate after 36 and 60 months was 96.2% with RPSA and 96.7% with EVLA-RTF (P = .81). Freedom of symptomatic anterior accessory vein recurrence after five years was 85% after RPSA and 87% after EVLA-RTF (P = .50). VCSS and AVVQ score presented similar and durable improvements in both groups between 6 weeks and 60 months. There was no difference in postoperative pain scores after both treatments during the first 14 days (mean visual analog scale score, 0.54–2.19). The median time for return to work was one day after both treatments. No severe adverse events were observed. In conclusion, RPSA and EVLA-RTF have similarly high GSV obliteration rates in the long term, and the treatments are equally effective clinically. Both treatments are associated with similar minimal postprocedural pain scores and short recovery times.

Semin Thromb Hemost 2018; Epub ahead of print, doi: 10.1055/s-0037-1621716.

We investigated the clinical presentation and outcomes of patients with deep vein thrombosis (DVT)-based on thrombus sidedness. The authors used the data from the Registro Informatizado Enfermedad TromboEmbólica (RIETE) database (2001–2016) to identify patients with symptomatic proximal lower-extremity DVT. Main outcomes included cumulative 90-day symptomatic pulmonary embolism (PE) and one-year mortality. Overall, 30,445 patients were included. The majority of DVTs occurred in the left leg (16,421 left-sided, 12,643 right-sided and 1390 bilateral; p < 0.001 for chi-squared test comparing all three groups). Comorbidities were relatively similar in those with left-sided and right-sided DVT. Compared with those with left-sided DVT, patients with right-sided DVT had higher relative frequency of PE (26% vs. 23%, p < 0.001) and one-year mortality (odds ratio (OR): 1.08; 95% confidence interval (CI): 1.00–1.18). This difference in mortality did not persist after multivariable adjustment (OR: 1.01; 95% CI: 0.93–1.1). Patients with bilateral DVT had a greater burden of comorbidities such as heart failure, and recent surgery compared with those with unilateral DVT (p < 0.001), and higher relative frequency of PE (48%), and one-year mortality (24.1%). Worse outcomes in patients with bilateral DVT were attenuated but persisted after multivariable adjustment for demographics and risk factors (OR: 1.64; 95% CI: 1.43–1.87). Patients with bilateral DVT had worse outcomes during and after discontinuation of anticoagulation. There is a left-sided preponderance for proximal lower-extremity DVT. Compared with those with left-sided DVT, patients with right-sided DVT have slightly higher rates of PE. Bilateral DVT is associated with markedly worse short-term and one-year outcomes.

Objective: To evaluate the safety and efficacy of retrograde endovenous laser ablation (EVLA) and to compare it with the conventional antegrade EVLA for incompetent small saphenous vein (SSV).

Materials and methods: Small saphenous vein was cannulated via two approaches under ultrasound guidance. One method involved puncturing the SSV cranially at mid-calf (the antegrade group). If the antegrade puncture into the SSV failed twice, the other approach for puncture was selected that involved puncturing the SSV toward the ankle (the retrograde group). Patients were evaluated in terms of technical and clinical success, closure rates of the SSV, and complications including pain, bruising, or paresthesia at all follow-up visits.

Results: The 1470-nm endovenous laser was used in all limbs. Technical success was seen in all limbs in both groups (100%). Closure rate in both groups showed about 95%, without significant difference (p = 0.685). Similar linear endovenous energy density was supplied during the EVLA in both groups (p = 0.876). Three frequent complications, including bruising, pain, and paresthesia did not show statistical significance between groups (p = 0.465, 0.823, 1.000, respectively). Major complications were absent in both groups.

Conclusion: The EVLA for the incompetent SSV using a retrograde approach is safe and effective and should be considered the alternative method if the antegrade access fails due to vasospasm or small SSV diameter.

BMJ 2017; 359: j5157.

The authors studied the effect of low-dose aspirin versus placebo on healing of venous leg ulcers in a parallel group, double blind, randomized controlled trial comprising five community nursing centers in New Zealand. A total of 125 venous ulcer patients were randomized to 150 mg of aspirin daily and 126 venous ulcer patients to placebo. The treatment lasted up to 24 weeks and included compression therapy. The primary outcome was time to complete healing of the reference ulcer (largest ulcer if more than one ulcer was present). Secondary outcomes included proportion of participants healed, change in ulcer area, change in health-related quality of life, and adverse events. Analysis was by intention to treat. No difference in groups in ulcer healing with regard to the median number of days – ASA 77 vs. placebo 69 (hazard ratio: 0.85, 95% confidence interval: 0.64 to 1.13, P = 0.25). The percentage of healed ulcers was the same for both groups – 80% (risk difference: −9.8%, 95% confidence interval: −20.4% to 0.9%, P = 0.07). There was no difference in in ulcer area change or adverse events.

The authors concluded that there study does not support low-dose aspirin as adjuvant therapy for venous leg ulcers.

Korean J Radiol 2017; 18: 828–834.

Eleven consecutive patients (age range: 2–79 years) underwent portal stenting between 2009 and 2015. Preoperative medical history and the postoperative clinical course were reviewed.

All patients underwent hepatobiliary-pancreatic cancer surgery except two children with liver transplantation for biliary atresia. Portal occlusion was caused by benign postoperative change (n = 6) and local tumor recurrence (n = 5). Postoperatively, variceal bleeding occurred at 27 months (4–72 months) and portal stenting was performed at 37 months (4–121 months). Technical success, treatment efficacy, and clinical success rates were 90.9, 100, and 81.8%, respectively. The primary patency rate of portal stent was 88.9% during the mean follow-up period of nine months. Neither procedure-related complication nor mortality occurred.

The authors concluded that portal stenting is an effective treatment for delayed jejunal variceal bleeding due to portal occlusion after hepatobiliary-pancreatic surgery.

Thromb Res. 2018; 163: 6–11.

The aim was to assess whether treatment of deep vein thrombosis (DVT) with rivaroxaban would reduce the rate of subsequent PTS and improve health-related quality of life (HRQoL) as compared to conventional anticoagulation with low-molecular-weight heparin (LMWH)/warfarin. Consecutive patients with an objectively confirmed DVT diagnosed between 2011 and 2014 and treated with either rivaroxaban or warfarin were included in this study 24 (±6) months after DVT. PTS was assessed using the Patient-Reported Villalta scale. HRQoL was assessed using the EQ-5D-3L and VEINES-QOL/Sym questionnaires. A total of 309 patients were included, 161 (52%) treated with rivaroxaban and 148 (48%) with warfarin. Rivaroxaban-treated patients had a lower rate of PTS (45%: 95% CI: 37 to 52) compared to those treated with warfarin (59%: 95% CI: 51 to 66, absolute risk difference: 14%: 95% CI: 3 to 25, OR 0.6, P = .01). The adjusted OR for development of PTS was 0.5 (95% CI: 0.3 to 0.8, P = .01) in patients treated with rivaroxaban. HRQoL was significantly better in the rivaroxaban-treated patients. HRQoL measured by EQ-VAS (P = .002) and VEINES-QOL/Sym (P = .005/P = .003) remained significantly better after adjustment. The investigators concluded that patients treated with rivaroxaban had lower rate of PTS and better HRQoL after DVT compared to patients treated with warfarin. However, these results should be interpreted with caution due to the limitation imposed by study design.