Abstract
A Population-based Assessment of Mortality in Patients with Varicose Veins
Mayo Clinic
Introduction
Conventional wisdom suggests that varicose veins (VVs) develop because of pathological processes affecting the venous wall and/or valves; these produce changes that lead to vein malfunction and lower extremity pain, swelling, skin changes, and other manifestations of venous disease. If this view is correct, these “degenerative” processes (which could also potentially affect veins throughout the body) might adversely impact other health outcomes, including overall mortality. To explore this possibility, we assessed the impact of VVs on survival in a well-described, well-defined population (Olmsted Co., MN).
Objectives
To assess the impact of varicose veins on survival
Methods
Subjects age 18 or older participating in the Rochester Epidemiology Program between 1979 and 1985 were eligible for inclusion. 3712 subjects were selected; 1856 carried a diagnosis of VVs (based on ICD-9 codes), and 1856 were controls without a diagnosis of VVs. The groups were age- and sex-matched (both groups averaged 54 years of age and 75% females/25% males). All individuals were followed until death or last contact using Kaplan-Meier analysis. Expected survival was based on Minnesota Vital Statistics, and comparisons to observed survival were based on the one-sample log-rank test. Survival was compared between cases and controls using proportional hazards modeling.
Results
When survival is compared to predicted survival for comparable subjects, the observed survival for those with VVs is actually better than the predicted survival for this cohort (one-sample log rank p-value <0.001). The two-sample comparison of survival between cases and controls results in a hazard ratio (HR) of 1.07 favoring VVs subjects, p = 0.14. In a sub-group analysis of younger subjects (those between 18–49 years of age at the start of the study) the beneficial effect of VVs on late survival (after 20 years) is even more dramatic, with an HR of 1.76 (p = 0.003) favoring late survival in subjects with VVs over those without.
Conclusion
Survival is not worse in subjects with VVs; paradoxically, it is actually much better. This observation suggests that the usual pathological explanations for VV formation may be imperfect or wrong. Rather than suffering from a purely destructive process that causes vessel wall “degeneration,” subjects with VVs may have enhanced “pro-angiogenesis” or “pro-vascular remodeling” tendencies that are associated with both negative (VV formation) and positive (better overall survival) effects on health.
The Effect of Obesity on Chronic Venous Insufficiency Treatment Outcomes
Center for Vein Restoration
Introduction
It has been reported that progressive increases in obesity are associated with higher severity of chronic venous disease (CVD) that correlates with CEAP class. It is unclear whether or not obesity affects the outcomes of CVD related treatments and what level of obesity predicts inferior outcomes. The purpose of this investigation is to assess the effectiveness of various CVD related treatments in patients with various categories of obesity and their relationship to CEAP classification.
Objectives
To determine the relationship of obesity and CEAP to post procedure rVCSS score. To determine relationship of obesity to outcomes of various CVD treatments.
Methods
Data were prospectively collected in the Center for Vein Restoration’s (CVR) electronic medical record system (NexGen Healthcare Information System, Irvine, California) and retrospectively analyzed. Patients and limbs were categorized by the following BMI categories: <25, 26–30, 31–35, 36–40, 41–45, >46. The revised venous clinical severity score (rVCSS) was utilized to determine CVD treatment effectiveness in patients who underwent endovenous ablations, ambulatory microstab phlebectomies, and ultrasound guided foam sclerotherapy (UGFS). Outcomes were further assessed by subcategorizing patients by CEAP class for each BMI category. All statistical analyses were performed utilizing Graphpad Prism 7 (GraphPad Software Inc, La Jolla, California) Treatment outcomes were assessed utilizing unpaired t-tests and two way analysis of variance.
Results
From January 2015 to December 2017 64,368 patients (77% female, 23% male) with procedures performed in 39,919 limbs were retrospectively reviewed. The number of patients and limbs in each BMI category were as follows: <25 (16,019/9,240), 26–30 (20,090/12,936), 31–35 (14,105/9,241), 36–40 (7,335/4,613), 41–45 (3,794/2,318), >46 (3025/1571). Patients/limbs who underwent procedures were as follows: Ablations (24,116/37,914), ultrasound guided foam sclerotherapy (14,173/23,098) and micro-stab phlebectomies (11,026/17,537). The degree of improvement in pre and post rVCSS scores was determined by measuring the percent difference between the two. The degree of improvement progressively decreased with increasing BMI (47%, 44%, 42%, 40%, 39%, 36%) in patients who had ablations alone and significantly differed in patients with BMI’s greater than 35 (p ≤ 0.001). Outcomes improved approximately 10% with the addition of microstab phlebectomies (57%, 54%, 53%, 48%, 42%, 44%). Patients who underwent ablations, phlebectomies, and ultrasound guided foam sclerotherapy had no further improvement. In general, differences in outcomes were most noted in patients with BMIs ≥35 and were worse in patients with a BMI ≥ 46 (p ≤ 0.001). Similarly, with progressive increases in BMI, post intervention rVCSS scores were worse in CEAP class 3–6 patients compared to CEAP 2 patients (p ≤ 0.001).
Conclusion
Treatment outcomes for CVD correlate with BMI classification and CEAP. Outcomes progressively worsen with BMIs greater than 35 for patients undergoing ablations alone. The addition of phlebectomies, but not phlebectomies and UGFS, improve outcomes by about 10%. Increased BMI is associated with higher severity of disease and worsening CEAP class. Patients with BMIs greater than 46 demonstrated the poorest outcomes. BMI should be incorporated into discussions with patient’s regarding treatment outcomes and expectations.
Six-year outcome of ultrasound-guided foam sclerotherapy for incompetent great saphenous vein without additional foam injections for varicose tributary veins
Tokyo Women’s Medical University
Introduction
For the treatment of incompetent saphenous veins, endovenous thermal ablation is now considered as a first line treatment option. The treatment of incompetent saphenous veins by sclerotherapy is also a good and cost–effective option. In recent years, ultrasound-guided foam sclerotherapy (UGFS) has become an established method for incompetent saphenous veins, and simultaneous injection of foam into tributary varicose veins is also performed. However, during UGFS, foam produced vasospasm both proximally and distally, including great saphenous vein (GSV) and varicose tributary veins, which may help avoid unnecessary foam injections.
This study presents the long-term results of UGFS for incompetent GSV without additional foam injections for varicose tributary veins.
Objectives
The primary purpose of this study was to evaluate 6-year cumulative competency and success rates after the treatment. The secondary purpose was to define confounding factors associated with development of reflux in the GSV and recurrent varicose veins after treatment. The final purpose was to determine whether the results suggest ways to improve outcomes and indicate directions for future research to evaluate best patient selection and treatment methods.
Methods
From 2011 to 2017, we conducted a retrospective study in a tertiary-care academic hospital. This study included 115 limbs out of 113 patients who had GSV incompetence. The baseline characteristics of the patients included age, gender, body mass index (BMI), CEAP classification, Venous Clinical Severity Score (VCSS), and ultrasound-derived reflux parameters in the GSV, including vein diameter, reflux times, mean reflux velocity, peak reflux velocity, and total refluxed volume.
All patients were placed supine and received ultrasound-guided foam sclerotherapy for refluxing GSV using 3% polidocanol (POL)-foam with their affected leg elevated 30 degrees. Visible varicose tributary veins were not injected. UGFS was the sole treatment modality used in all cases, and repeated UGFS sessions were performed where indicated following serial follow-up ultrasound.
Life table analysis using Kaplan-Meier curves was performed to evaluate 6-year primary and secondary competency and success rates. Univariate Cox regression analysis was used to estimate hazard ratios for confounding covariates that might affect outcomes.
Results
There were 33 males and 80 females with the mean age of 68 years. The mean BMI of the patients was 22.4 kg/m2. The mean VCSS of the study limbs was 6. There were 2 (2%) limbs with CEAP C1, 84 (73%) with C2, 1 (1%) with C3, 19 (16%) with C4a, and 3 with C6. The mean POL-foam volume used was 4.0mL per session. Using Kaplan-Meier life table analysis, primary and secondary cumulative competency rates at 6 years were 29% and 29%, respectively. Similarly, 6-year primary and secondary cumulative success rates were 61.8% and 76.2%. Using univariate Cox regression analysis, pre-treatment age, gender, BMI, CEAP clinical classification, VCSS, ultrasound-derived reflux parameters, and volume of foam were not significantly associated with the development of venous reflux or recurrent varicose veins. Of 15 limbs with recurrent varicose veins, 13 (86%) were due to recanalization via branch inflow, 1 with small saphenous vein reflux, and 1 with anterior accessory saphenous vein.
Conclusion
Although primary and secondary competency rates were low, UGFS for incompetent GSV without additional foam injections gives relative good long-term results. These results were comparable to earlier studies with UGFS combined with simultaneous injection of foam into tributary varicose veins. Development of GSV reflux and recurrent varicose veins after treatment were not associated with patients’ characteristics but branch inflow. These findings provide a basis for further research to explore factors that might affect outcomes.
STUDY TO COMPARE OPEN SURGERY, ENDOVENOUS THERMAL ABLATION (EVTA) AND ULTRASOUND GUIDED (USG) FOAM SCLEROTHERAPY FOR TREAMENT OF VARICOSE VEINS at Annapurna
Annapurna
Introduction
Varicose veins, whether primary or secondary, are common in Nepal. The prevalence has been variously reported. Most of the varicose vein patients present at C5-6 stages. In Nepal available treatment options include open surgery, sclerotherapy, laser ablation & radiofrequency ablation. Open surgery encompasses high ligation, division and stripping of GSV or SSV, combined with excision of segments of varicose veins if required. The underlying goal for all thermal ablation procedures is to deliver sufficient thermal energy to the wall of an incompetent vein segment to produce irreversible occlusion, fibrosis, and ultimately disappearance of the vein. Foam sclerotherapy is the application of a sclerosing agent in the form of foam, guided by ultrasound, in a given insufficient vein, in order to occlude or reduce the vessel diameter. The most utilized sclerosing agents are polidocanol and sodium tetradecyl sulfate. Conventional surgery for varicose veins due to great or small saphenous reflux is associated with high recurrence rates. This prospective audit examines the safety, efficacy, and complications of EVTA in the treatment of varicose veins at one center in Annapurna, Nepal.
Objectives
To compare open surgery, EVTA, USG foam sclerotherapy for primary superficial venous insufficiency with respect to obliteration of superficial venous system at 3 months, clinical outcome and cost. To observe aesthetic results.
Methods
Between January 2015 and Janury 2018, all patients with symptomatic primary venous insufficiency of lower limbs who were willing to undergo definitive management were randomized to open surgery (n = 20), EVTA (n = 360), or USG foam sclerotherapy (n = 20). In the foam sclerotherapy group, review of ultrasound findings was performed at 1 week, and it was determined whether or not re-injection was necessary. The patients in all the groups underwent review ultrasound examinations at three months. Obliteration of superficial venous system, clinical outcome, and costs were registered.
Results
Five patients in foam sclerotherapy group required re-injection at one week. Superficial venous system was obliterated in all the patients of all the groups at 3 months. Improvement in clinical score was similar in all groups. The foam sclerotherapy group had less frequent analgesia intake, earlier return to normal activity, and lower cost. The local complication rate was slightly higher in foam sclerotherapy group.
Conclusion
Foam sclerotherapy is a cheaper alternative to open surgery & EVTA for primary venous insufficiency with respect to early measures of clinical outcome. USG foam sclerotherapy was demonstrated to be a safe and effective procedure for the treatment of chronic venous insufficiency (CVI). The observed complications were minimal and most of the patients reported satisfaction with the treatment outcomes. When comparing open surgery with endovenous thermal ablation, it was determined that EVTA is superior in terms of cosmetic results, less pain, number of incision punctures, early mobilization, and same day discharge.
Patterns of lower extremity reflux in patients with pelvic venous insufficiency
Center For Vein Restoration
Introduction
Women with pelvic venous insufficiency (PVI) often present with lower extremity symptoms and manifestations of chronic venous disorders (CVD). The purpose of this investigation was to determine the incidence of lower extremity CVD and the types and distribution of lower extremity veins involved in patients with a known diagnosis of PVI.
Objectives
To determine the incidence of chronic venous disorders in patients with pelvic venous insufficiency To determine the types of lower extremity veins involved in patients with pelvic venous insufficiency. To determine the extent of lower extremity reflux in pelvic venous insufficiency patients.
Methods
Between January 2012 and December 2015 we retrospectively reviewed the charts of 227 women with PVI, as well as their lower extremity (LE) venous duplex investigations. Presenting symptoms, CEAP class, initial rVCSS, and the types of LE veins with reflux and their locations were noted. Patients were also subcategorized according to their primary pelvic disorder as follows: Entire cohort (PVI), Ovarian vein reflux (OVR), iliac vein stenosis (IVS) or both (OVR+IVS).
Results
Of the 227 patients, complete charts were available on 204. The average age was 44.71 ± 10.2. In decreasing order, patients presented with the following lower extremity symptoms: pain (66%), swelling (32%), heaviness (26%), limb fatigue (13%), itching (13%), leg cramps (10%), skin changes or SVT (2%) and ulceration or bleeding (0.004%). Table 1 outlines the CEAP class for 215 of the 227 patients. For the entire cohort 48% of right and 50% of left limbs demonstrated C0 or C1 disease. Initial rVCSS for the right and left limbs were as follows: PVI (4.48 ± 2.97/4.53 ± 2.95), OVR (4.50 ± 2.93/4.22 ± 3.20), IVS (4.53 ± 2.76/4.29 ± 3.12), OVR+IVS (4.49 ± 2.91/4.58/2.95) (p ≤ 0.99). The incidence and type of symptomatic lower extremity veins were as follows: Any axial vein: 32%, Great Saphenous (GSV): 21%, Small Saphenous (SSV): 11%, GSV and SSV: 5%, Non-saphenous tributaries: 15%, Saphenous tributaries: 12%, Posterior or postero-lateral thigh distribution: 5%, vulvar distribution: 4%, perforators: 4%, deep veins: 2%, and Anterior Accessory Saphenous Veins: 1%. For the GSV and SSV, the following patterns of reflux were observed: Entire GSV: 4%, entire above knee GSV: 2%, entire below knee GSV: 2%, above knee segmental GSV: 20%, below knee segmental GSV: 21%, above and below knee GSV segmental disease 1%, Entire SSV: 4%, SSV segmental disease: 12%.
Conclusion
At least 50% of patients with PVI present with lower extremity venous disease. Initial rVCSS scores are mild across all treatment groups. The majority of symptomatic patients present with segmental axial GSV or SSV disease. Although vulvar and gluteal escape veins are highly associated with PVI, they are infrequently observed. In patients who experience residual or persistent symptoms after treatment for CVD, a pelvic venous ultrasound should be performed to assess for the presence of PVI.
Stability of foam comparing carbon dioxide and Xenon gas phase using 3%STS liquid phase produced by different methods
Fellow Canadian Society of Phlebology
Introduction
Why develop a better foam for echosclerotherapy? What would a better foam ideally achieve?
Presented at:
43rd BIANNUAL CONGRESS
ENRICHING EXPERIENCE FOR A BETTER FUTURE
Objectives
Show how quickly carbon dioxide gas phase STS liquid phase foam, mixed by Tessari method at room temperature, degrades rapidly from foam to froth in 15 seconds and completely degrades by 45 seconds. Show how carbon dioxide gas phase foam is made much more effective using silicone free syringes and a micro filter with cooling. Demonstrate how the same production method using Xenon gas is far more effective than CO2.
Methods
The syringes of foam were illuminated so that one can see the STS 3% draining from the foam in real time as it was filmed.
Photographs were taken at 15 and 45 seconds to measure the rate of STS 3% fluid run off from the foam; the more fluid that runs out of a foam the less stable it becomes. Observations were made of the bubble sizes and variability, demonstrating the transition from foam to froth to complete degradation of the foam over 60 seconds.
This observational technique was applied to foam made from CO2 by Tessari method, then CO2 made in silicone free syringes using a microfilter. Finally, Xenon gas phase was used to make foam to demonstrate its superior stability verses CO2 gas foam
Results
Xenon is the heaviest nonradioactive noble gas obtainable. Xenon is a highly polarized molecule making it fat and serum soluble. It is totally inert. When mixed with oxygen it makes an ideal anesthetic as it is a competitive inhibitor of the serotonin 5-HT3 receptor; in lower concentrations it is both neuro-protective and cardio-protective in ischemia-reperfusion conditions. It is used in MRIs to enhance lung tissue. It induces polycythemia if used repeatedly by activating transcription factor HIF-1-alpha, which increases production of erythropoietin.
Ideal foam for echosclerotherapy has a bubble scale that is a single-ordered scale system of small stable bubbles. The ideal foam sclerosant displaces blood in veins by maintaining a cohesive foam that lasts long enough for the sclerosant to permanently destroy the endothelium and can be absorbed in tissue and serum once the sclerosant has worked.
Foam for echosclerotherapy is traditionally made by the Tessari method using carbon dioxide or air as the gas and using silicone coated syringes at ambient temperature. The angle of the stopcock and the speed of mixing is variable. By using Xenon gas and silicone free syringes via a fine filter all cooled to 10°c produces a far more stable foam.
In a foam small bubbles shrink, and large ones grow, which is called the Ostwald ripening effect. This is thermodynamically-driven; larger particles are more energetically favored than smaller particles as molecules on the surface are energetically less stable than the ones in the interior. This is partly controlled by the gas (CO2 falls apart quickly, air/N2 is slower and Xenon much slower). The sclerosant surfactant acts as a partial barrier to gas diffusion which is affected by the thickness of the film.
Henry’s law states that the amount of dissolved gas is proportional to its partial pressure and temperature in the gas phase
CO2 H = 0.832 diffuses out producing least stable foam
N2 H = 0.015 stable foam but dissolves poorly causing embolization and the bends.
Xenon H = 0.0043 nontoxic stable foam that dissolves well in fat and serum.
C2F6 H = 0.0014 very stable foam, toxic
So, carbon dioxide foam is the least stable; Oxygen could be effective but its great solubility in hemoglobin makes it an unstable foam. As such, the ideal gas for foam echosclerotherapy is Xenon which has a low permeability, dissolves in tissue, dissolves in blood and produces a dense dry cohesive foam
Conclusion
Developing a better foam for echosclerotherapy would make treatments more effective with less sclerosant. Additionally, it would enable phlebologists to treat larger veins with less sclerosant. Xenon microfoam may be a better alternative to CO2 foam created using the Tessari method.
Post-operative anti-coagulation for venous stenting does not improve stent patency
1Center For Vein Restoration
2Center For Vascular Medicine
Introduction
It has been reported that thrombotic versus non-thrombotic iliac vein lesions affects the long term patency of venous stents. To improve stent patency and prevent early stent thrombosis, many clinicians anti-coagulate patients. Whether or not post-operative anti-coagulation improves stent patency, and what types of anti-coagulants provide optimal results, is currently unknown. The purpose of this investigation is to determine whether or not post-operative anti-coagulation improves stent patency.
Objectives
To determine the effect of various anti-coagulation regiments on immediate and late venous stent patency in patients with non-thrombotic iliac vein lesions. To determine the rate of in-stent restenosis after venous stenting in patients with non-thrombotic iliac vein lesions. To determine the re-intervention rate in patients with in-stent restenosis of iliac vein stents in patients with non-thrombotic iliac vein lesions.
Methods
Data were prospectively collected in the Center for Vascular Medicine’s (CVM) electronic medical record system (NexGen Healthcare Information System, Irvine, California) and retrospectively analyzed. Patients were categorized into three anti-coagulation regimens: Clopidogrel alone (CL), Aspirin and Clopidogrel (ASA/CL) or Apixiban or Riveroxiban alone (AP/RX). Patients were assessed at 6, 12, 26 and 52 weeks for stent patency with trans-abdominal ultrasonography. Stent patency was analyzed utilizing life table analyses. Differences in stent patency were analyzed utilizing Graphpad Prism 7 statistical software (GraphPad Software Inc, La Jolla, California) and the Log-Rank (Mantel-Cox) test.
Results
From January 2016 to January 2017, 241 patients (17% male, 83% female) underwent iliac vein stenting for non-thrombotic iliac vein lesions. Stents were placed to treat pelvic venous insufficiency (PVI) in 8%, lower extremity chronic venous disorders (CVD) in 28% and combined disease (PVI/CVD) in 64%. Cumulative primary patencies at 6, 26 and 52 weeks for each anti-coagulation group were as follows: CL (89%, 84% and 77%), ASA/CL (85%,79%,79%) and AP/RX (91%, 88%, 84%). Statistical analysis on these subgroups utilizing the Log-Rank (Mantel-Cox) Test demonstrated no statistically significant difference between treatment groups. There was one acute stent thrombosis and 41 patients demonstrated evidence of in-stent restenosis. 17% patients required re-intervention and six were secondary to in-stent restenosis.
Conclusion
Acute thrombosis is rare in patients stented for non-thrombotic iliac vein stenosis. In stent restenosis is common within the first post-operative year and appears unaffected by the type of anti-coagulation regimen utilized. Based on these data, routine post-operative anti-coagulation for non-thrombotic lesions does not appear to improve stent patency. Larger data sets with longer follow-up, and patients stented for thrombotic lesions, are needed.
An observational study of chronic venous disease in northwest China
1Xijing Hospital
2University of California, Davis, Vascular Center
Introduction
Chronic venous insufficiency (CVI) affects approximately one fifth of the general adult population in the western countries and results in significant psychological, physical and financial burden. The related epidemiologic findings in the northwest region of China are largely scarce.
Objective
This study aims to prospectively evaluate consecutive CVI patients using the VVSymQ VR/HASTI and Venous Clinical Severity Score (VCSS) according to CEAP classification.
Methods
This is an observational study. From September 2017 to April 2018, consecutive patients with CVI symptoms and varicose veins referred for duplex ultrasound exam at Xijing Hospital were evaluated. CEAP classification was applied and the highest C class was used to characterize patients. VVSymQ®/HASTI and VCSS scores were adopted to describe symptom severity and compared between each C class using one-way analysis of variance (ANOVA) via SPSS version 13.0 (SPSS, Chicago, IL, USA). Continuous variables were expressed as means ± standard deviation. A P value less than 0.05 was considered statistically significant.
Results
Conclusion
This is the first observational study on epidemiologic pattern of CVI in northwest China. A positive correlation was observed between VVSymQ®/HASTI, VCSS and increasing C class. Moreover, there appeared to be predominance of more advanced stage disease (C4 and above) according to C class.
Congenital Venous Anomalies Identified by Ultrasound in an Outpatient Vascular Laboratory: Review of 457 Sequential Scans and Description of a Patient with Dual Inferior Vena Cava Presenting with Pelvic Pain
Lake Washington Vascular
Introduction
Duplex ultrasound investigation of the abdominal and pelvic veins is being increasingly utilized by many outpatient vascular laboratories as the recognition of and treatment of pelvic venous disease is becoming more common. Congenital variations of the vena cava and renal veins are uncommon, occurring in between 0.5-3.0% of the population. Duplex ultrasound can identify these anomalies and has the added benefit of being able to evaluate anomalous veins for abnormal flow and reflux.
Objectives
To identify the frequency of congenital venous anomalies identified in a review of outpatient vascular laboratory duplex ultrasounds of pelvic and abdominal veins.
Methods
A retrospective chart review was conducted over a one-year period of time from March of 2017 to March of 2018 at a single institution. Initial pelvic and abdominal duplexes were reviewed. Routine follow-up studies of iliac stents and pelvic embolization were excluded from this analysis. Patient demographics, indications for treatment, and anatomical data were collected.
Results
457 patient studies were reviewed. Eleven congenital venous anomalies (2.5% of the studies reviewed) were found: 4 dual inferior vena cava, one left-sided vena cava, three retro-aortic left renal veins, one circum-aortic left renal vein, one left renal vein arising in the pelvis to a pelvic kidney, and one left ovarian vein originating from the infrarenal inferior vena cava. The anomalies were found in eight female patients and 3 male patients. Indications for the studies included pelvic pain, leg swelling and pain, and venous skin changes. In one case, a young female patient with pelvic pain was found to have antegrade flow in her right vena cava and reflux in her left vena cava leading to dilated, refluxing pelvic veins.
Conclusion
The frequency of congenital venous abnormality of the inferior vena cava and renal veins found on outpatient duplex evaluation was within the range reported historically by other authors. Duplex ultrasound is able to effectively characterize these anomalies. An understanding the embryology of the vena cava and the most common presentations of venous anomalies is important for vascular technologists and physicians evaluating pelvic and abdominal veins.
Sulodexide Reverses the Decreases in Contraction and Increases in Matrix Metalloproteinase Activity in Veins
Under Increased Wall Tension
1VA Boston HCS, Brigham and Women’s Hospital, Harvard Medical School
2Brigham and Women’s Hospital
3Alfasigma SpA
4Brigham and Women’s Hospital, Harvard Medical School
Introduction
Increased lower extremity venous pressure has been implicated in the pathogenesis of chronic venous insufficiency (CVI) and varicose veins (VV). We have previously demonstrated that prolonged increases in vein wall stretch are associated with decreased contraction and increased matrix metalloproteinases MMP-2 and MMP-9. We have also shown that MMPs cause venous dilation, which is characteristic of VV. Sulodexide (SDX) is a glycosaminoglycan with reported antithrombotic and profibrinolytic properties and clinical benefits in patients with CVI and leg ulcers. However, the effects of SDX on venous function and the underlying mechanisms are not clearly understood.
Objectives
To determine whether SDX restores venous function and improves vein contraction by reducing MMP proteolytic activity in veins under prolonged stretch. To determine whether SDX improves vein contraction under prolonged stretch. To determine whether SDX reduces MMP activity under prolonged stretch.
Methods
Isolated circular rings of rat inferior vena cava (IVC) were incubated in Krebs solution under control 0.5 g basal tension, and isometric contraction to 96 mM KCl and increasing concentrations of phenylephrine (PHE, 10–9 to 10-5 M) was measured using a force transducer and a Grass polygraph. Tissues were then treated with 1 mg/ml SDX or vehicle, and placed under control 0.5 g basal tension or increased 2 g wall stretch for 18 h, and the effect on KCl and PHE contraction was measured. Veins at either 0.5 g, 2 g + vehicle or 2 g + SDX were then collected for measurement of MMP-2 and MMP-9 levels and proteolytic activity using Western blots and gelatin zymography, respectively. Data was presented as means ± SEM, and analyzed using t-test, with significant values set at P<0.05.
Results
In IVC under control 0.5 g basal tension, KCl caused robust contraction (159.4 ± 19.6 mg/mg tissue) and PHE caused concentration-dependent contraction that reached a maximum (56.0 ± 8.4 mg/mg tissue) at 10-5 M. In IVC under prolonged 2 g stretch for 18 h, KCl contraction (112.2 ± 18.4 mg/mg) and maximum PHE contraction (23.4 ± 4.7 mg/mg) were significantly reduced. In IVC under prolonged 2 g stretch and treated with SDX for 18 h, KCl contraction was significantly improved (228.1 ± 36.4 mg/mg) and maximum PHE contraction was enhanced (115.0 ± 17.0 mg/mg) when compared to IVC under the same stretch conditions and nontreated with SDX. MMP-2 and MMP-9 levels and proteolytic activity were significantly increased in IVC under prolonged 2 g stretch and normalized in IVC treated with SDX.
Conclusion
SDX restores venous function and improves contraction in veins under prolonged stretch. The mechanism of SDX-improved venous function appears to involve decreased MMP expression/activity, and may partly mitigate the adverse effects of increased venous pressure on vein contraction and MMPs in CVI and VV.
VENOUS ULCERATION, ANKLE FUSION AND COMPRESSION
Tri-State Vein Center
Introduction
Venous ulcerations account for 70 to 90% of chronic wounds of the lower leg. Treatment is focused on local wound care, compression, and treatment of superficial venous reflux. This case highlights interesting challenges and important considerations when dealing with a chronic venous ulceration.
Objectives
Effective compression is possible even when the patient’s anatomy is challenging. Correction of superficial venous reflux with endovenous ablation should be considered early in the management of venous ulcerations. Range of motion of the ankle joint and calf muscle strength need to be assessed in patients with venous ulcerations.
Methods
The patient is a 71-year-old female presenting with a wound involving the right medial ankle. She reported 6 previous leg ulcerations, each requiring several months of meticulous wound care. The interval between ulcers had been decreasing. Her current wound developed 5 months prior to her visit to a vein specialist and was being treated with medical-grade honey, thought to augment the body’s natural wound cleansing activities through a reduction in pH, maintaining a moist environment, and improved debris removal. Compression was provided by a single layer of elasticated tubular bandage, Tubigrip® (less than 10–15 mm Hg). The ulcer measured 2.6 cm by 1.4 cm (3.64 sq. cm). (Photograph 1)
Her past medical history was remarkable for a traumatic right ankle fracture with soft tissue loss 28 years earlier, treated with right ankle fusion and a latissimus dorsi muscle free flap. Venous duplex ultrasound evaluation of the right leg revealed greater than 500 milliseconds of reflux involving the right great saphenous vein from the saphenofemoral junction through the distal lower leg. There was no evidence of deep vein insufficiency. The patient’s BMI is 35.6.
Results
The patient was placed in an adjustable inelastic compression device (30–40 mm Hg). (Photograph 3) After two weeks in this compression her ulcer size had decreased.
The right great saphenous vein venous reflux was subsequently treated with radiofrequency ablation from the saphenofemoral junction through proximal lower leg. Seven weeks after her initial presentation to the office her venous ulcer was healed.
Discussion
The patient’s recurrent venous ulcerations were felt to be due to superficial venous insufficiency, exacerbated by a nonfunctioning calf muscle pump, secondary to the ankle fusion surgery and inadequate compression. Once adequate compression was applied, the ulcer decreased in size. Full healing occurred following her endovenous ablation procedure, which was carried out both to expedite ulcer healing and extend the time between ulcerations. The ESCHAR Study (Comparison of Surgery and Compression with Compression Alone in Chronic Venous Ulceration: Randomized Controlled Trial) revealed that the 12-month ulcer recurrence was reduced when superficial venous reflux was corrected. The recent EVRA Trial – (A Randomized Trial of Early Endovenous Ablation in Venous Ulceration) report supports the improved patient outcomes from early intervention of superficial reflux and venous ulcerations. The right medial ankle venous ulcer was completely healed 7 weeks after initial presentation to a vein specialist. The patient continues to wear the inelastic compression garment for maintenance. Since the patient had undergone fusion of her ankle, no additional movement of her ankle was possible. For other patients with recurrent venous ulceration, physical therapy assessment and treatment of ankle ROM and calf muscle strength may be adjuvants in their management.
Conclusion
Compression is an essential treatment for venous ulceration but must be applied at an adequate dosage (strength). Effective compression is possible even when the patient’s anatomy is challenging. Correction of the superficial venous reflux with endovenous ablation should be considered early in the management of a patient with venous ulcerations.
Photograph 1
Photograph 2
Photograph 3
ENDOVENOUS ABLATION HEAT INDUCED THROMBOSIS TYPE 2 AND SURGICAL INTERVENTION
Tri-State Vein Center
Introduction
Thermal endovenous ablation of the great saphenous vein revolutionized treatment of venous reflux disease. Thrombus formation within the proximal great saphenous vein extending into the common femoral vein is a phenomenon termed endovenous heat-induced thrombosis (EHIT). The first description of this phenomenon was reported by Dr. Mark Whiteley in 2004. EHIT is categorized as class 1 to 4. Class 2 and 3 EHIT are clinically significant secondary to possible progression to deep venous thrombosis. Treatment of EHIT 2 and 3 has been focused on anticoagulation. The appropriate medication, duration, and outcomes have yet to be clearly defined. This case highlights a surgical approach in treating an EHIT 2.
Objectives
Recognize the complication of heat-induced thrombosis following thermal endovenous ablation. Understand there is controversy considering treatment of a patient with each of the different EHIT classes. Understand that extenuating circumstances with each patient may result in a different treatment approach to decrease the potential of a more serious complication.
Methods
The patient is a 66-year-old female with a several years of leg discomfort, itching, burning, cramping, and restless legs. She is a retired high school teacher. The patient’s BMI is 32.6. She had no prior treatment for varicose veins or venous reflux diseases. The symptoms are exacerbated with prolong standing activities. Knee-high graduated compression stocking (20–30 mm Hg) provided reduction in the degree of cramping. A venous Duplex ultrasound study revealed more than 500 milliseconds of venous reflux involving both great saphenous veins, from the saphenofemoral junction through the knee level, and venous reflux within the anterior accessory saphenous veins. The right great saphenous vein measured 8.6 mm at the saphenofemoral junction. The right anterior accessory saphenous vein measured 3.1 mm at its origin. The deep vein systems were within normal limits.
Results
She underwent radiofrequency ablation of the right great saphenous vein and accessory saphenous vein. She returned for a follow up ultrasound on post procedure day 6. An EHIT 2 was noted. (Photograph 1 & 2) Under real time imaging the lead point of the thrombus appeared to move back and forth and was tethered to the proximal great saphenous vein by a thin thread. The finding was discussed with the patient. Close follow up with a repeat venous ultrasound was recommended. The patient was leaving by car in 24 hours to winter in Arizona for 3 months. The drive was to take 3 to 4 days. Concern for possible embolization of the thrombus during her travels was a major concern.
Discussion
The incidence of EHIT following endovenous ablation ranges from 0 to 16%. The risk factors associated with EHIT formation include vein size, age, and multiple concomitant phlebectomies. This patient developed an EHIT 2 following the endovenous ablation of her right great saphenous vein and right anterior accessory saphenous vein. Generally, heat-induced thrombus resolves in 2 to 4 weeks in the majority of patients. However, the thrombus may worsen in a few patients. The consensus for therapy is that anticoagulation is not necessary for EHIT 1 and is mandatory for EHIT 4. There is disagreement as to what is the best course of action for EHIT 2 and 3, i.e. anticoagulation or close observation.
The concern with this patient was her upcoming trip to Arizona. If she had progression of the thrombus or developed a PE during her travels her health and life could be placed at risk. Under local anesthesia, a 3 cm incision was made over the right saphenofemoral junction. The proximal great saphenous vein was opened, and the thrombus removed. (Photograph 3) The right great saphenous vein was ligated at the saphenofemoral junction. She tolerated the procedure well. Follow up after her return from Arizona, her leg symptoms had improved with complete resolution of lower leg cramping.
Conclusion
EHIT is a known complication following thermal endovenous ablation of truncal veins. Close observation verses anticoagulation therapy depends on the level of the EHIT. Extenuating circumstances that arise with each patient may cause a different course of action to be taken to decrease a more serious problem from occurring.
Photograph 1
Photograph 2
Photograph 3
Five Year Experience of Comprehensive Ultrasound-Guided Foam Sclerotherapy in Varicose Veins
Treatment
Americas Vein Centers
Introduction
Varicose veins are widely distributed in the world population. Prevalence of chronic venous insufficiency varies significantly in different studies from 20% to 50% in women and 10% to 40% in men. Ligations and phlebectomies for varicose vein disease have been performed since ancient times. Ancient Greeks, Romans, and Arabs described the methods approximately 2000 years ago. Unfortunately, due to the invasiveness of procedure and high recurrence rate of varicosities, 20% to 60%, depending on the study, found this method of treatment unsatisfactory.
EVLT has made it possible to treat Great Saphenous Vein (GSV) and Small Saphenous Vein (SSV) insufficiency with high success rates (90% to 98%, respectively), low complications rates, and minimal invasiveness. But treatment of GSV and SSV tributaries still includes wide use of phlebectomies, leading to high reoccurrence rates and scarring.
Sclerotherapy of varicose veins was introduced more than 150 years ago. Sclerosants and sclerotherapy techniques have changed over the years, making this method a safe and minimally invasive alternative to phlebectomies.
Objectives
Report our experience utilizing comprehensive ultrasound-guided foam sclerotherapy (CUSGFS) over a five year period. Compare use of ultrasound-guided foam sclerotherapy and micro-phlebectomy. Report patient satisfaction with ultrasound-guided foam sclerotherapy method.
Methods
Comprehensive ultrasound-guided foam sclerotherapy (CUSGFS) with sodium tetradecyl sulfate (STS) of the large and medium size varicose veins. Ultrasound systems used: MindRay with probes 7L4 and 14L7, ATL 5000 with probe 7L4, Terason 3000 with probe 12L5. Sclerosants: 1% or 3% Sodium Tetradecyl Sulfate foamed in a syringe with air in 1 to 3 ratio.
Technique: Under ultrasound guidance the needle is placed into the varicose vein and STS foam injected into the vein: 0.5-1 ml per injection. The distribution of sclerosant is followed by ultrasound probe: 1 to 30 injections per session.
The progress of the treatment is followed by ultrasound assessment at 1 week, 1, 3, 6 months, and 1 year. Injections for open varicose veins are repeated until vein is closed.
Results
We report 5000 patient encounters with one thousand patients who underwent comprehensive ultrasound-guided foam sclerotherapy with over 50,000 CUSGFS injections performed (5 to 30 injections per patient per session). All patients required more than one session of USGFS. No patients required phlebectomy.
Patients received CUSGFS for tributary reflux following primary endovascular venous laser ablation (EVLT). Over 85% of these cases were either primary greater saphenous vein (GSV) and/or lesser saphenous vein (LSV) EVLT closure. Tributary vein closure was performed for the remainder.
Patient follow-up rate over five years was greater than 98%. Closure rates were over 99%. Complications included four ulcerations, one transient ischemic event (ocular TIA), one deep vein thrombosis (DVT) of the femoral and popliteal vein, and one pulmonary embolus (PE) of un-diagnosed etiology. This is a considerably decreased complications rate comparing with classical vein stripping and ligation associated average rates of 0.5% pulmonary embolism, 0.6-1% of DVT, ∼8% of infection.
The ambulatory microphlebectomy, sufficiently safe procedure with low infection rate 1 in 1000 requiring use of antibiotics, comparable to infectious rate post-sclerotherapy, has the major drawbacks of the necessity of foam and cotton wraps for several days after the procedure, wearing the compression stockings for 2 to 4 weeks following the phlebectomy. Sclerotherapy and microphlebectomy both can lead to brownish skin discoloration that can persist from 1–2 months to 1–2 years, and then gradually disappears; but sclerotherapy does not leave scars, when every micro-incision post phlebectomy leads to skin scar formation.
Patient compliance and satisfaction was very high. Tolerance for numerous sessions was also very high in order to avoid more invasive procedures (phlebectomy). Most patients had extensively researched other treatment options before choosing our method.
Conclusion
Comprehensive ultrasound-guided foam sclerotherapy (CUSGFS) is a very safe and effective method for the treatment of varicose veins, and in our experience has replaced more conventional surgical procedures.
Role of Vitamin D3 in the management of pain in C5-6 chronic venous disease (CVD): need to include as an integral part in the treatment protocol
1Daya Hospital
2First Choice Vascular
3www.roots-simplified.org
Introduction
Vitamin D deficiency prevails in epidemic proportions all over the Indian subcontinent, with a prevalence of 70%-100% in the general population. Despite adequate sunshine, sub-clinical vitamin D deficiency is highly prevalent in both urban and rural settings across all socioeconomic and geographic strata. Vitamin D deficiency affects several aspects of health and its supplementation is known to benefit health. Leg ulcers secondary to chronic venous disease (CVD) are common and prevalent in adult Indians. Non-compliance for treatment and lifestyle measures lead to worsening of the disease, causing significant morbidity. Although the treatment is multi-faceted, it has high recurrence and failure rates often requiring surgical intervention in the most progressed cases. The current available clinical evidence is suggestive of improvement in wound healing in patients with venous leg ulcers with supplementation of micronutrients, vitamin D and folic acid. Vitamin D supplementation for better clinical outcomes in CVD patients was considered as a treatment protocol in an out-patient setting in this study.
Objectives
To evaluate the prevalence of Vitamin D3 deficiency among CVD patients presenting CVD of CEAP C5-6. Evaluation of pain score at baseline and post treatment in CVD patients using Villalta score and patient feedback to the treatment. To evaluate the safety and clinician’s assessment to the treatment.
Methods
This was an open study in an out-patient setting. 400 out-patients of both genders were enrolled in this study during the year 2016-17 and were evaluated for CVD using the CEAP classification system. The treatment protocol was standardized for all patients presenting with pain. The standard treatment included below-knee compression with oral amitriptyline, 5 mg morning & 10 mg evening and micronized purified flavonoid fraction 1 gm daily. Patients with pain at end of 1 week received twice the dose of amitriptyline. Serum Vitamin D3 levels were estimated at baseline and the deficiency was treated with intramuscular injection of Vitamin D3, 600,000 IU once weekly for 4 weeks. Patients were followed up at day 15 and weekly thereafter for clinical examination and pain assessment using Villalta scale (0 to 50). Vitamin D3 levels were estimated after 3 months in all patients.
Results
A quarter of the patients had venous ulcers. Majority patients were female who invariably presented with vitamin D deficiency at the time of enrollment. Patients also presented with other chronic diseases such as thyroid disorders and type 2 DM. All treated patients presented CEAP 5–6. The pain score at admission ranged between 2 to 46 out of 50 (Villalta score) and average pain score was 25.29 ± 10.43. At day 30, patients with corrected vitamin D3 deficiency demonstrated marked pain relief. There was significant reduction in pain in all patients. The pain score ranged from 0 to 31 with average score of 11.37 ± 8.07. (p-value = 0.000). At day 30 two patients had no pain at all. Almost all patients expressed satisfaction to the treatment and resumed normal activities. Vitamin D3 checked at 3 months showed no levels that suggested hypervitaminosis. The levels were within statistical parameters. Patients expressed satisfaction with the treatment and treatment was well-tolerated. Clinician’s expressed satisfaction and the patient outcomes were rated as satisfactory.
Conclusion
Our findings support the available evidence of increased prevalence of Vitamin D3 deficiency in patients with chronic venous diseases. It also supports supplementation of vitamin D3 for earlier recovery and relief of pain in CVD. There is a very strong relationship between Vitamin D3 deficiency in CVD with refractory pain. Correction of Vitamin D3 deficiency via the parenteral route ensured accelerated D3 correction, healing and recovery in almost all patients and must be included in the treatment protocol for all CVD cases. Hypervitaminosis D was not observed. The treatment was well tolerated, and patients expressed satisfaction with the treatment.
Venous Leg Ulcers – What is Agreed?
1Imperial College London
2Istituto Clinico Beato Matteo
Introduction
Various venous leg ulcer (VLU) clinical practice guidelines (CPGs) have been developed by different guideline committee groups for different healthcare professionals involved in VLU care. However, there exists marked heterogeneity between them, particularly with respect to methodology.
Objectives
Determine the methodological quality of current venous leg ulcer clinical practice guidelines using a validated assessment tool. Assist healthcare professionals in selecting an accessible high-quality clinical practice guideline to advise their practice. Identify areas for improvement in future versions of current clinical practice guidelines.
Methods
A systematic review was performed. PubMed, Embase, online CPG databases were searched from 1998 to 31st December 2017. Reference lists of included CPGs were also searched to identify other relevant CPGs. Full text CPGs published no earlier than 1998 reporting evidence-based recommendations on VLU diagnosis and management in English were included. CPGs based on expert consensus, guideline summaries or if only available if purchased were excluded. Two reviewers identified eligible CPGs, extracted data and assessed the quality independently using Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Inter-reviewer reliability was calculated using a two-way mixed model to determine intraclass correlation coefficients (ICCs). Scores of the individual statements in a domain were summed for each of the six domains. Quality score for each guideline was calculated by scaling the raw domain score total as a percentage of the maximum possible score. Significant scoring discrepancies were discussed with a third reviewer. An overall guideline assessment scaled score of ≥80% was considered adequate to recommend use in clinical practice.
Results
Fourteen eligible CPGs were identified (1999–2016). Most CPGs originated from Europe or North America. Overall, there was good inter-reviewer reliability of scores with ICC of 0.986 (95% CI, 0.979 to 0.991). No single CPG achieved the highest score in all six domains, but there were no clear relationships between inter-domain performance of individual CPGs. Significant methodological heterogeneity was observed across VLU CPGs in all domains but consistently, poor performance was noted in domain 5 (mean scaled score 26.9 ± 29.9%) which concerns CPG applicability. In the overall guideline assessment, three CPGs were rated as ≥80% and of adequate quality for recommendation for clinical practice.
Conclusion
While three CPGs were considered adequate for clinical practice, these CPGs still showed areas for improvement. Consolidation of efforts to drive high quality, comprehensive VLU CPGs is necessary to reduce the number and heterogeneity seen in current VLU CPGs. Elements of methodological quality are lacking and a structured approach with use of checklists and CPG creation tools, such as AGREE II or others, may bolster rigor in future VLU CPGs.
Cyanoacrylate closure of perforator veins: initial technical feasibility and safety and presentation of a case of its use in a patient with Ehler’s Danlos syndrome and a non-healing ulcer
Lake Washington Vascular Surgeons
Introduction
Perforator vein treatment (PTV) can be considered in patients with advanced venous disease such as those with active or healed ulcers, or advanced skin changes. Minimally invasive techniques using endothermal ablation or sclerotherapy have been described for perforator vein closure, although long term closure rates are disappointingly low compared to saphenous vein closure rates with similar technologies. Newer non-thermal techniques such as cyanoacrylate closure (CAC) may offer advantages over techniques using tumescent anesthesia, as risk of nerve injury is minimal and visualization of the vein is not obscured by tumescent fluid.
Objectives
To describe a novel method of perforator vein closure using cyanoacrylate adhesive. To assess early technical success and safety for this method. To present a case of the use of cyanoacrylate treatment of incompetent saphenous trunks and pathologic perforator veins in a patient with Ehler’s Danlos syndrome (EDS) and a two-year history of a nonhealing venous ulceration.
Methods
A retrospective review was conducted over a 30-month period from January 2016 to June 2018 at a single institution of patients (n = 246, 314 limbs) undergoing CAC of incompetent saphenous veins, identifying patients who underwent concomitant PVT. Standardized technique for PVT was developed and will be described. After treatment, closure assessed by duplex ultrasound with closure defined as lack of outward flow and an incompressible vessel. Patient demographics, CEAP clinical class, VCSS, number of perforators, and size of veins treated were collected. Follow up data including assessment of perforator closure at the time of the index procedure by duplex scan, and in follow-up (time points variable depending on provider and patient preference) were recorded. Complications as documented in the practice electronic medical record and in-patient phone records were collected. Patient characteristics and complication rates were compared to a patient treated with CAC of the saphenous veins without PVT.
Results
Forty-two perforator veins were treated in 24 patients. All of the patients had additional closure of at least one saphenous vein (great, small and/or accessory) at the same time as the perforator vein treatment. The patients included 16 females and 7 males with a mean age of 65 years (SD 13.5), mean BMI of 27.2 (SD 5.8) and a mean VCSS of 9 (range 4–24). Mean perforator diameter was 5.1 mm (range 3.5-8.8 mm). Compared to the population of patients in whom perforator veins were not treated, the perforator patient cohort was older (C2 65 years, SD 13.5 v/ 52 years, SD 14.4 , P<.001), and had more advanced venous disease (C2 VCSS mean 9, SD 4.9 v. 6, SD 2.6, P = .01) than the population of patients without perforator treatment. Initial technical success for perforator vein closure on the day of the procedure, and within one month of follow-up was 100%. Ten patients (16 perforator veins, 38% of all perforator veins treated) were examined with duplex ultrasound greater than 30 days from the index procedure with a mean follow-up time of 235 days (range 31 to 755 days), and 13/16 (81%) of the perforator veins remained closed in follow-up. There were no infections, deep vein thromboses, or nerve injuries in the perforator treatment group. One patient had a self-limited mild hypersensitivity reaction after treatment along a concomitantly treated great saphenous vein (4.8% of treated patients compared to 7% hypersensitivity reactions in the non-perforator treatment group, P = .698). The patient with EDS had a lateral calf ulcer that remained unhealed after 2 years of standard wound care and compression therapy. Treated perforator vein sizes in the patient with EDS were 6.3, 6.3, and 6.7 mm. Perforator veins in this patient remain closed at 6 months, and his ulcer healed in 5 months.
Conclusion
Perforator vein closure with cyanoacrylate is straightforward with a simple injection technique. Retrospective review of a series of cases at a single center showed excellent initial safety and technical success. Further investigation is warranted to assess both long term closure rates and benefits to patients with advanced venous disease.
Is there a difference in target saphenous vein diameter at the time of endovenous ablation?
1OMNY Vein & Cardiovascular
2Columbia University Medical Center
Introduction
It has been hypothesized that patients presenting for saphenous vein ablation may experience vasospasm observed as reduction of target vein diameter. This has been attributed to procedural anxiety, hydration status, etc. We sought to investigate the existence and magnitude of such a relationship.
Objectives
Is there a difference in target/index saphenous vein diameter on the procedure day compared to the initial measurement performed at the baseline diagnostic sonography testing?
Methods
A total of 226 patients were evaluated between 4/20/16-10/30/16 at our outpatient vascular facility. The great saphenous vein (GSV) and small saphenous vein (SSV) diameters were measured at baseline as part of the initial diagnostic testing (bVd). Patients who needed saphenous vein ablations had their index vein diameter (iVd) measured peri-procedurally by the same sonographer. For both sets of measurements (bVd and iVd) and in order to standardize the measurement location, a distance of 3 cm from both the sapheno-femoral and the sapheno-popliteal junctions was used for GSV and SSV diameters respectively. Room temperature was maintained around 70’F and all patients had the same NPO orders. All procedures were done within 60 days of the baseline ultrasounds. Percentage change was defined as [ (iVd-bVd)/bVd ] X100. Univariate analyses between percentage change and demographics were evaluated using t-test and chi square tests. SAS 9.3 software was used to perform the statistical analysis.
Results
The median age for the group was 58 +/- 12 years with a preponderance of female patients (88.5%). GSV ablations constituted the majority of the procedures at 82.7% vs.17.3% for SSVs. At procedure time there was an overall vein diameter reduction of 8.2%: GSV iVd reduction was 3.4% while SSV iVd reduction was 31.1%. Neither age nor gender had any significance on % change. Anatomical vein location however, was associated with a statistically significant reduction in diameter in favor of SSV vs. GSV when controlled to the other variables: 27.7% difference, 95% CI 17.1-38.3, p < 0.0001.
Conclusion
In this cohort of patients, there appears to be a significant diameter reduction in the SSV territory but not in the GSV group. A myriad of etiologies might have contributed to this observation including compression stockings use, procedural anxiety or dehydration status of patients. Prospective studies might further elaborate on such an observation while controlling for preoperative anxiolytics, standardized hydration protocols and similar.
Frequency and severity of hypersensitivity reaction in patients after cyanoacrylate treatment of superficial venous insufficiency
Lake Washington Vascular Surgeons
Introduction
The VeClose and WAVES trials were the first trials published in the United States to evaluate the use of cyanoacrylate adhesive closure (CAC) of saphenous veins. In these trials, it was noted that some patients post-CAC treatment developed a self-limited but distinctive erythematous cutaneous/dermal reaction within the first few weeks after great saphenous vein (GSV) closure. This erythematous reaction was not typical for a phlebitis seen post-endothermal ablation. The duration of symptoms in these patients was not typically prolonged, and the WAVES trial showed that the development of this reaction did not have a significant impact on time to back to work or normal activities, nor did it impact pain scores at one month. There are no previously published data outside of clinical trials to document the incidence or severity of these reactions, nor outcomes in patients treated with CAC.
Objectives
To assess the frequency of hypersensitivity reactions in patients treated with CAC of saphenous veins To identify factors that are associated with hypersensitivity to CAC To document the severity of hypersensitivity reactions to CAC
Methods
A retrospective chart review was conducted for a 30-month period of time (January 2016 - June 2018) at a single institution of patients (n = 246, 314 limbs) undergoing CAC of incompetent saphenous veins. The study was divided into three “eras”: “early” (during clinical trials), “middle” (after FDA approval), and “late” (after CPT code activation). CAC hypersensitivity was defined as a red, itchy dermal reaction, sometimes painless, but sometimes associated with discomfort and/or localized swelling. Patient characteristics included demographics, CEAP clinical class, and VCSS. Procedure data included number and type of veins treated, mean diameter of the treatment segment, total volume of CA used. The electronic medical record was reviewed for the presence or absence of a hypersensitivity reaction. Time of reaction onset, duration of symptoms (if documented) and severity of reaction were collected. Reaction severity was classified as mild (patient required no treatment or took over the counter medications only), moderate (required prescription medications - steroids), or severe (reaction was prolonged >30days or required vein excision).
Results
Three hundred and fourteen limbs were treated in 246 patients on 263 treatment days. The patients included 191 females and 55 males with a mean age of 53 years (SD 14.3), mean BMI of 25.9 (SD 5.0) and a median VCSS of 6 (SD 2.8). Veins treated included 246 great saphenous veins (GSVs), 64 small saphenous veins (SSVs), 47 accessory saphenous veins (AASVs) and 42 perforator veins. The largest treated segment was 24 mm in diameter. Eighteen hypersensitivity reactions occurred. CEAP clinical classes in the groups that had hypersensitivity v. no hypersensitivity are shown in Table 1. Eighteen hypersensitivity reactions occurred after 263 discrete CAC treatment dates (6.8%). Of these, 13 were mild (4.9%), 4 were moderate (1.5%) and one was severe (0.4%). The frequency of hypersensitivity reactions was not different when comparing the early (4/81 cases, 4.9%), middle (10/134, 7.5%) and late (4/48, 8.3%) time periods (p = .70, X2). There were no patient or procedural factors identified when comparing the cases with and without hypersensitivity reactions as shown in Table 2. Of note, 16 patients (none with a hypersensitivity reaction) had a second limb treated on a later date, and none of these patients had a hypersensitivity reaction with treatment of the second limb. Symptom onset time ranged from 1 to 23 days, with a mean of 13 days (confidence interval (CI) +/- 3.5 days). Duration of symptoms could be ascertained in 13/18 cases and ranged from 3 to 28 days (mean 10.8 CI +/-4.9 days).
Conclusion
Hypersensitivity reactions occurred in 6.8% of patients treated with CAC, but the majority of these cases were mild and self-limited. Severe reactions were uncommon. No predictive patient or procedural factors were found to be associated with hypersensitivity reactions. CEAP Clinical Classes-Hypersensitivity and No Hypersensitivity groups Patient and procedural comparisons between Hypersensitivity and No Hypersensitivity groups 1Standard deviation, 2z-score, 3 t-test, 4chi-square, 5Mann-Whitney
Factors associated with Duplex Ultrasound Identified Iliac Vein Obstructive Lesions in Patients Referred to an Outpatient Vascular Laboratory
Lake Washington Vascular Surgeons
Introduction
Obstruction of central veins has been associated with impact on patient quality of life. Central venous obstruction (CVO) in the lower extremities can be caused by acute thrombosis, post-thrombotic lesions, or non-thrombotic iliac veins. Venous claudication, chronic pain and edema, stasis changes and ulceration can all result when CVO is present. Duplex ultrasound is increasingly being utilized as an initial diagnostic modality in the evaluation of abdominal and pelvic veins by many vascular laboratories, although studies validating its accuracy for CVO testing are limited. The low risk, noninvasive nature of duplex ultrasound makes it an attractive screening tool for CVO, but this perceived lack of risk along with the increased awareness of the role of CVO in causing disease may lead to overutilization. Many other disease states may have signs and symptoms in common with CVO, therefore pretest probability models may help to predict which patients might best benefit from duplex ultrasound testing.
Objectives
To quantify and characterize iliac vein obstructions discovered during duplex ultrasound of the abdominal and pelvic veins To identify patient factors associated with duplex-identified CVOs To create a model of pre-test probability of duplex-identified CVOs
Methods
A retrospective chart review was conducted from March 2017 to March 2018. Routine follow-up studies of iliac stents and pelvic embolizations were excluded from this analysis, as were scans not ordered to evaluate for CVO. Duplex scans were considered positive for possible CVO based on any combination of lack of phasicity and respiratory variation in the ipsilateral common femoral vein, visualization of luminal narrowing or occlusion compared to adjacent normal iliac veins, and/or increased velocity ratio in the narrowed segment. Patient demographics (age, gender, BMI), indications for study, history of previous deep vein thromboses (DVT) and extent of DVT, CEAP clinical class, venous clinical severity score (VCSS) and anatomic data were collected. Univariate analyses were performed to assess for potential associations between patient factors and the presence or absence of iliac or caval obstructive lesions. All factors with a statistically significant association with iliac vein obstruction were then entered into a multivariate logistic regression model to create a formula to predict probability of a duplex identified iliac vein obstruction.
Results
457 patient studies were reviewed, and of these 405 met criteria for evaluation. The mean patient age was 60 (SD+/-16.1), with 230 females and 175 males (56.8% and 43.2% respectively). The mean BMI was 29.8 (range 18-58, SD+/-7.2). Indications for testing included edema alone (n = 135, 33.3%), pain and edema (n = 119, 29.4%), stasis skin change (n = 64,15.8%), pain alone (n = 57, 14.1%), and ulceration (n = 30, 7.4%). Symptom presentation was noted to be bilateral (n = 168, 41.5%), left-sided (n = 160, 39.5%) or right sided (n = 77, 19%), with a mean VCSS of 8.1 (range 0–24, SD+/-4.1). Obstructive vein lesions (ranging from mild compression to complete occlusion) were seen in 171 patient scans (42.2%), with 137 studies showing a lesion in a single anatomic segment and 36 showing lesions in multiple anatomic segments. The locations of the identified iliac and IVC lesions are shown in Table 1. Univariate analysis revealed female gender, younger age, lower BMI, left-sided symptoms, a history of iliofemoral DVT, and presentation with symptoms that were not edema alone were associated with a positive finding of CVO (Table 2). VCSS, CEAP clinical class, and a history of non-iliofemoral DVT were not associated with a finding of CVO. Multivariate analysis revealed age, gender, BMI, side of lesion, history of iliofemoral DVT and a presentation not including edema alone were independently associated with a positive finding of iliac obstruction (Table 3). A mathematical model (Figure 1) to calculate the probability that a duplex ultrasound would be positive for obstruction was created. The ROC curve for this model (Figure 2) had an area under the curve of 0.7944.
Conclusion
Age (younger), gender (female), BMI (thinner), indication for examination (symptoms other than edema alone), side of symptoms (left) and a history iliofemoral DVT are all independent predictors of a duplex ultrasound scan positive for CVO. VCSS, CEAP clinical class, and a history of DVT not including the iliofemoral segment were not predictive of a positive duplex ultrasound scan for CVO. A predictive mathematical model to calculate the probability of a positive duplex ultrasound scan for CVO has been created based on this retrospective review. Future work includes building a simpler predictive scoring system to help guide which patients may benefit from abdominal and pelvic vein duplex scanning from this model and testing the validity of this system prospectively. Further study would be required to determine if this model can also predict CVO with more definitive diagnostic modalities such as venography and intra-vascular ultrasound.
Location of Iliac and IVC lesions
Number of studies with one lesion:137, two: 30, three: 2, four: 2
Univariate analysis of factors associated with a duplex study showing an obstructive vein lesion
1Standard deviation, 2z-score, 3Mann-Whitney, 4chi-square
Multivariate analysis of factors associated with a duplex study showing an obstructive vein lesion
Decrease of number of chemical ablation procedures required to achieve ablation of varicose vein tributaries with ≥3 mm diameter following non-thermal, non-tumescent ablation compared to thermal, tumescent ablation: single-center non-investigational initial experience with non-thermal non-tumescent techniques
St Joseph Mission Heritage Medical Group
Introduction
Experience with thermal, tumescent techniques for ablation of incompetent truncal veins has demonstrated sustained benefit for a high percentage of patients. Supplementation of thermal, tumescent ablation of truncal veins with subsequent chemical foam injections has been reported to be useful. The purpose of this study was to determine if the number of treatment sessions required to treat varicose vein tributary reflux following truncal vein ablation differs between patients who had thermal, tumescent ablation of their truncal vein reflux as compared to those treated with non-thermal, non- tumescent techniques. We routinely measure the diameter of all varicose vein tributaries treated with chemical foam at each treatment session, starting with the largest diameter veins. Therefore, we were able to use the diameter of varicose vein tributaries treated as an objective end-point for comparing the number of chemical foam treatment sessions required to reach an equivalent degree of tributary vein reflux following truncal vein ablation using thermal, tumescent techniques compared to non-thermal, non-tumescent techniques.
Objectives
Compare the number of chemical ablation sessions required to ablate all varicose veins with diameter of 3mm or more following truncal vein ablation with thermal, tumescent compared to non-thermal, non-tumescent techniques. Compare changes of the Venous Clinical Severity Score (VCSS) following truncal vein ablation with thermal, tumescent compared to non-thermal, non-tumescent techniques. Assess the results in regard to the unique technical features of each of the non-thermal, non-tumescent techniques that were used.
Methods
We performed a retrospective review of our initial experience with two non-thermal, non-tumescent techniques for ablation of truncal vein reflux in order to determine if there is a difference in the number of ultrasound-guided chemical ablation sessions required to close all varicose vein tributaries with 3mm or more diameter after thermal, tumescent ablation (EndoVenous Laser Ablation (EVLA) or Radio Frequency Ablation (RFA)) compared to the number of chemical ablations required to achieve that same result following non-thermal, non-tumescent ablation (Mechanical Occlusion Chemically Assisted (MOCA) or Polidocanol Endovenous Microfoam (PEM)). The first MOCA was in September 2017, and the first PEM was in December 2017.
The VCSS was calculated at the time of the truncal vein procedure and re-calculated at each subsequent chemical ablation treatment.
Ultrasound-guided chemical foam injections were performed in order to ablate residual venous reflux with the first chemical injection procedure performed no sooner than 4 weeks after the truncal vein ablation. A maximum of 20 mL of foam was injected at any one session and the diameter of each vein injected was recorded.
Results
These results were observed during our first experience with MOCA and PEM in a clinical setting in our vein lab. We had no prior experience with these techniques as part of any investigational study or protocol. After the first MOCA procedure was performed, MOCA was preferentially used for truncal vein ablation. Following the first PEM procedure, either MOCA or PEM was preferentially used for ablation over the thermal tumescent techniques.
Beginning in January 2017 we performed 29 EVLA, 32 RFA, 13 MOCA, and 9 PEM procedures for which we subsequently achieved ablation of all varicose vein tributaries with diameter of 3 mm or more. EVLA has been used for ablation of incompetent truncal veins in our vein laboratory since 2008 and RFA since 2010. Our first MOCA was performed in September 2017, and the first PEM procedure in December 2017.
For patients treated with EVLA the VCSS score decreased from 7.2 + 3.1 (mean+SD) at baseline to 5.8 + 2.0 (p = .007) at the last chemical ablation session at which there were any varicose vein tributaries with diameter of 3mm or more. The change of VCSS was from 8.6 + 4.5 to 6.2 + 2.1 (p = .0003) after RFA; from 5.5 + 2.0 to 5.2 + 1.4 (p = 0.3) after MOCA and from 7.9 + 2.9 to 4.9 + 4.9 (p = .0007) after PEM.
For patients treated with EVLA the number of chemical ablation sessions required to ablate all varicose vein tributaries with diameter of 3mm or more was 2.6 + 0.7. The number of sessions required to reach the same goal was 3.1 + 0.7 after RFA; 2.7 + 0.6 after MOCA; 1.7 + 0.9 after PEM. The number of sessions was significantly larger after RFA ablation of the truncal vein compared to the other three techniques (p = .02 vs MOCA, .002 vs. EVLA and .0004 vs. PEM). The number of sessions required to reach the goal was least following PEM. The only comparison that did not reach significance was the number of treatment sessions required following EVLA vs. MOCA (p = 0.3).
Conclusion
The routine measurement of the diameter of varicose vein tributaries being treated at each chemical ablation session provided an objective end-point for comparing the impact of the technique of ablation used to treat reflux in truncal veins on subsequent ablations required to treat persisting reflux in varicose vein tributaries. The number of sessions of chemical ablation required for treatment of residual venous reflux in varicose veins with diameter of 3mm or more was greatest following RFA, similar following EVLA and MOCA, and least following PEM. There was a significant decrease of VCSS score from before ablation of truncal vein reflux to the last chemical ablation session required to achieve the goal ablation of tributary vein reflux when truncal vein ablation was performed using EVLA, RFA and PEM, but not after MOCA, although the number of MOCA observations was small. This suggests that elimination of the truncal vein reflux alone usually results in symptomatic improvement independent of technique used. The intermediate results following MOCA in regard to less reduction of the VCSS and larger number of chemical ablation sessions required to achieve the tributary vein ablation goal may be due to the small number of observations and possibly a steeper learning curve with this technique due to the complexity of having a unique non-thermal but contact-based property of the mechanical component combined with the non-foamed liquid chemical sclerosant component. Although the number of PEM observations was the smallest, the appearance of a significant reduction of follow-up chemical ablation sessions required to achieve an equivalent ablation of tributary vein reflux compared to the other techniques is consistent with the unique non-contact, chemical foam based characteristics of this technique, which differentiates it from the others.
Lower extremity venous lesions in patients with chronic thromboembolic pulmonary hypertension who underwent pulmonary endarterectomy
1Yokohama Minami-Kyosai Hospital
2Yokohama City University Medical Center
3Yokohama City University Hospital
Introduction
Chronic thromboembolic pulmonary hypertension (CTEPH) is thought to be caused by unresolved acute pulmonary embolism (APE) arising from deep vein thrombosis (DVT). However, its pathophysiology is still unclear. Because significant numbers of patients with CTEPH have no history of APE or DVT, we investigated the lower extremity venous system in patients with CTEPH who had undergone pulmonary endarterectomy (PEA).
Objectives
To confirm the relationship between the CTEPH and VTE. To investigate the difference in the patient characteristics between DVT-positive group and DVT-negative group. To discuss the cause of CTEPH referring the literatures.
Methods
We retrospectively analyzed 23 consecutive patients (female, 56.5%; median age, 59 years) who underwent PEA at Minami-Kyosai Hospital between April 1995 and October 2016. Patient medical histories including APE/DVT, physical findings, and duplex ultrasonography or CT findings in lower extremities prior to PEA were analyzed. Surgical specimens were classified following the Jamieson classification.
Results
A history of APE was found in only 4 patients (17.4%). Eleven (47.8%) patients had an objectively confirmed history of DVT. Prior to PEA, duplex scan or CT identified DVT in 13 patients, despite 5 of them not having had a history of DVT. Although thrombi disappeared in 4 patients with a history of DVT, 17 (73.9%) patients presented with APE or DVT (proximal DVT, 10 patients; distal DVT, 6 patients) through the course of CTEPH.
PEA surgical findings and their association with DVT sites were as follows: There were 13 Jamieson type I cases (proximal thrombi in pulmonary artery) comprising 8 cases of proximal DVT, 4 cases of distal DVT, and 1 case of no DVT; 7 Jamieson type II cases (intermediate type) comprising 1 case of proximal DVT, 2 cases of distal DVT, and 4 cases of no DVT; and 2 Jamieson type III cases (distal type) comprising 1 case of proximal DVT and 1 case of no DVT. Prevalence of Jamieson type I was significantly higher in the DVT-positive group than the DVT-negative group, although there were no significant relationships between DVT sites and pulmonary artery thrombi.
Prevalence of deep vein thrombosis in patients with chronic thromboembolic pulmonary hypertension who underwent pulmonary endarterectomy.
Conclusion
We found higher prevalence of DVT in patients with CTEPH than previously reported, possibly due to the use of meticulous duplex/CT scan examinations of DVT prior to PEA given the lower detection rate of chronic phase DVT using duplex scanning, most patients with CTEPH appeared to present leg venous pathology. In addition, we found that DVT was associated with central pulmonary artery lesions in CTEPH.
Rapid-Acting Cyanoacrylate Embolization (RACE) for Great Saphenous Vein Reflux: Mid-term results
1Edogawa Hospital
2Juntendo University
3Tokyo Vascular & Vein Clinic
Introduction
FDA-approved cyanoacrylate (CA) embolization has become popular because of minimally invasiveness without thermal adverse effects, because anatomical and clinical outcomes showed no inferiority compared with thermal ablation. Since glue viscosity is honey-like and shows slow polymerization, procedure time takes longer than thermal ablation. Mid-term closure rate is mostly equivalent to thermal ablation and larger vein <20 mm is also included in the indication. Recently, the rapid-acting CA embolization (RACE) systems was launched for saphenous trunk reflux. Since glue viscosity is water-like and shows more rapid polymerization than the conventional CA, RACE is a time-saving procedure. Several studies were conducted for the initial to mid-term outcome, but the maximum vein diameter was limited to less than 15 mm. In the real world, a larger vein diameter of 20 mm or more is relatively common with severe patients, and treatment is challenging with any modality. However, the mid-term outcome and risk for recanalization using RACE, including patients with larger vein diameter, is still not well known.
Objectives
To evaluate the efficacy and safety of RACE, including patients with larger vein diameter < 30 mm of GSV. To evaluate mid-term outcome up to two years. To assess the predictors for recanalization.
Methods
This is a single-center, case control study for the evaluation of safety, efficacy, and performance of RACE for the treatment of 184 great saphenous veins (GSVs) with reflux. 169 patients, 127 female, average age of 65.4 y, 114 patients more than C3 were recorded, from June 2016 to June 2018. CE mark-approved CA vein closure systems (VariClose and VenaBlock) were used in this study. Patients were treated with minimal local anesthesia only for puncture, but no TLA and no compression bandages were used. Anti-inflammatory medication was prescribed for one week. Inclusion criteria were the same as thermal ablation, however, the contraindication included history of CA, multiple drug allergies, and autoimmune disease. For efficacy, anatomical success (occluded or recanalization length <5 cm), clinical success (AVVQ or VCSS improvement) were evaluated. For safety evaluation, phlebitis, pain (VAS score>4), induration, bruising, post-ablation saphenous thrombus extension (PASTE) into deep veins, and skin pigmentation were monitored. Follow-up by serial clinical and duplex examinations was performed at 1 week, 1 month, 6 months, 12 months, and a maximum of 24 months.
Results
A total of 184 legs (169 patients), 15 bilateral patients, 127 female (75%), average age of 65.4 y, 114 patients (62%) who had more than CEAP clinical class 3 venous disease, were included in this study from June 2016 to June 2018. The average GSV trunk diameter in the treatment zone as determined by preoperative ultrasound with the patients in an upright position was 6.9 ± 2.1 mm (range 5.2-29.1 mm), while 18 legs (9.8%) were >20 mm and 43 legs (23.4%) were >15 mm. CAs were performed with VariClose in 164 legs and VenaBlock in 20 legs. All the GSVs were successfully punctured percutaneously and cannulated, and glue injections were at precisely 3 cm from SFJ. The mean procedure time with concomitant ambulatory phlebectomy or perforator ligation was 26.8 ± 16.2 min, however it was 16.6 ± 7.2 min CA alone. Total delivered glue volume of 1.8 ± 1.6 mL and treated vein length of 32.7 ± 9.3 cm were recorded. Recanalization occurred in 16 legs (8.7%); 4 legs at 1 week, 11 legs at 1 month, and 1 leg at 3 months. However, 6 legs later spontaneously occluded. New recanalization did not occur at all after 3 months. Kaplan-Meier analysis showed anatomical success rates were 97.5%, 97.0%, 91.2%, 91.2%, 91.2% at 1 week, 1 month, 3 months, 12 months and 24 months, respectively, after the procedure (Figure 1). After 24 months, all 17 legs were occluded and the glue ultrasound density were apparently reduced. Clinical success rate was 100% because both the AVVQ (7.7 to 1.7) and VCSS (4.8 to 0.9) were significantly improved in all patients (p < 0.001), including patients with recanalization. Of 184 legs, 24 experienced phlebitis (13.0%), 3 induration (1.6%), 4 pain (2.2%), 13 skin discoloration (7.1%), but no PASTE and no bruising were recorded. However, all symptoms were self-limited and disappeared within two weeks. Mean GSV diameter >8.0 mm was the weakly significant approximate relative risk for recanalization (odds ratio 3.8; 95% CI, 1.4–10.9; P = 0.02). On the other hand, the maximum large diameter of >15 mm and >20 mm were not significant relative risk (Table 1).
Non Catheter-based Cyanoacrylate Embolization for Tortuous Great Saphenous Veins
1Edogawa Hospital
2Juntendo University
3Tokyo Vascular & Vein Clinic
Introduction
Conventional catheter-based cyanoacrylate (CA) embolization has become a popular modality for saphenous vein reflux. However, tortuosity or segmental large truncal varicosities can be troublesome for catheter-based techniques. In that case, thermal ablation can overcome this challenge because multiple segmental ablations is an alternative technique. On the other hand, since the CA delivery catheter is a single use, several catheters are necessary for multiple segmental CA embolization, which is more costly. To avoid catheter related difficulties, non catheter-based techniques would be recommended using direct injection; ultrasound guided CA embolization (UGCE). Glues were injected by two methods: a single syringe technique and an aliquot technique. Single syringe technique was 0.2-0.3 mL of direct CA injection with a 2.5 mL syringe and 25 G long needles, whereas needles were exchanged at every injection. Aliquot technique was 0.2 mL of bolus injection with 24 G valve built-in catheters and 1.0 mL aliquot syringes, whereas each catheter and syringe were only single use.
Objectives
To evaluate the efficacy and safety of UGCE for tortuous Great Saphenous Veins (GSVs). To evaluate the initial-term outcome for three months.
Methods
This is the single center, case control study of UGCE for tortuous GSV reflux from November 2017 to June 2018. Inclusion criteria were tortuous or inaccessible GSV with reflux. Exclusion criteria were age <18 years, gravid, immobility, deep venous obstruction, or CA with/without multiple allergies, and autoimmune diseases. Two CA were used as adhesive; VariClose or VenaBlock. In addition, Histoacryl mixed with ethiodized oil was added as a filler after incomplete thermal ablation. Single syringe (SS) or aliquot technique was selected according to the proper access. SS technique was used for deep GSVs, while aliquot technique was used for shallow GSVs. After each injection, manual compression was applied for one minute. Anesthesia, wound dressing, and bandaging were not required after UGCE. Anti-inflammatory medication was prescribed for one week. For efficacy evaluation, anatomical success (flow signal disappearance at the UGCE area) and clinical success (AVVQ and VCSS improvement) were recorded. For safety evaluation, moderate pain (VAS score>4), phlebitis, bruising, skin discoloration, and nerve injury were recorded. Patients were followed upto 3 months.
Results
A total of 22 legs (21 patients) were treated. Average age of 67.4, 14 female (63.6%), 16 (72.7%) of CEAP clinical class >3 including class 6, mean AVVQ of 5.1 and VCSS of 4.0 were recorded. Mean proximal GSV diameter of 9.2 mm (range 4.7-12.5), truncal GSV diameter of 6.6 mm (range 4.6-9.0), and the maximum GSV diameter of 11.7 mm (range 8.4-18.5) were measured. SS technique was used in 17 legs and aliquot technique was used in 5 legs. VariClose glue with 13 legs, VenaBlock glue with 5 legs, and Histoacryl glue with 4 legs after failed catheter-based CA embolization or radiofrequency ablation were used. Mean CA volume used was 1.8 mL and mean procedure time was 27.7 min (range 5–70). Concomitant procedures were 2 phlebotomies and 2 perforator ligations. Procedures were carried out without complications. In UGCE, phlebitis in 1 leg (4.5%), temporary skin discoloration in 3 legs (13.6%), and self-limited moderate pain in 1 leg (4.5%) were recorded. However, there were no incidences of bruising or nerve injury. Maximum GSV diameter was significantly reduced to 8.7 mm (P<0.01), however GSV trunk diameter was not significantly changed (Figure1). AVVQ (5.1 to 1.5, p < 0.001) and VCSS (4.0 to 0.5, p < 0.001) were significantly improved (Figure 2 and 3). All patients (100%) showed complete embolization after 3 months, and visible varicose veins were not noticeable in all patients.
AVVQ was significantly improved at
3 months.
VCSS was significantly improved at 3 months.
Conclusion
The present study explores the feasibility of UGCE for tortuous or inaccessible GSV. Previous studies of ultrasound guided CA adhesive perforator embolization (CAPE) showed a 76% occlusion rate of incompetent perforating veins without serious complications leading to the conclusion that further investigation with a dedicated delivery device in a larger patient population is warranted. CAPE is still using catheters and only one kit is allowed for each perforator, which is costly. The basic idea of UGCE is to repeat CA delivery with cost-effective material: needles, inexpensive valve built-in catheters and syringes. This procedure technique utilizes ultrasound guided foam sclerotherapy, which is familiar to phlebologist. VariClose and VenaBlock glue is likely to adhere to the vein wall, while Histoacryl glue is likely to fill the residual channel of vein lumen. If the catheter-based CA adhesive embolization appears to be incomplete, additional Histoacryl embolization can be used in the same session. There was no significant difference in adverse effects with those three glues. Although GSV trunk diameter did not change up to 3 months follow-up, the maximum GSV diameter was significantly reduced at 3 months. This means glue ablation makes slow progress to become inflamed in the vein wall even with a larger vein, and finally the vein would shrink. In conclusion, this study indicates UGCE is efficient and safe, and initial outcomes shows 100% of anatomical and clinical success rate up to 3 months. Since UGCE requires no anesthesia, no wound dressing, and no compression bandage, it could be recommended as an alternative to catheter-based CA, especially for tortuous or catheter-inaccessible GSV.
Venous Leiomyosarcoma of Vena Cava and Non-Vena Cava Origin: a Review of the Literature for Better Characterization and Description of the Disease
Northside Regional Medical Center
Introduction
Soft tissue sarcomas are very rare tumors, representing less than 1% of all malignancies. Leiomyosarcomas (LMS) are malignant tumors of smooth muscle, which account for about 6% of all soft tissue sarcomas. A small percentage of this sarcoma subset may originate from the smooth muscle of vessel walls, most of which are of venous origin. If we consider large blood vessel tumors such as primary malignant tumors of the vena cava (VC), LMS is the most frequently encountered, which originate from the smooth muscle within the VC wall. They are seen mainly in older women. There is limited information focused on non-VC LMS derived from large veins.
Objectives
This study serves to provide a thorough review of venous leiomyosarcoma of VC and non-VC origin based on historic data. The purpose is to discuss the epidemiology, clinical presentation, diagnosis, imaging, and outcomes for leiomyosarcoma. An additional objective is to provide a consensus on the latest therapeutic and surgical modalities.
Methods
The study was focused on retrospectively reviewing the previously published data of all LMS of venous origin, available as case studies and small case series, to better characterize and describe this disease process. A literature search was performed by using the online search engine PubMed (http://www.pubmed.org/) and searching for the term ‘leiomyosarcoma vein.’ This search yielded 869 articles, which then were filtered individually to categorize them as VC or non-VC origin. Cases were classified on the basis of patient demographics, clinical presentations, metastasis at the time of diagnosis, anatomic location, tumor size, surgical treatment, whether chemotherapy or adjuvant radiotherapy was provided, and patient outcome. As most of the information collected was taken from individual case reports, data analysis was limited to descriptive statistics.
Results
Only a few hundred patients with vascular leiomyosarcoma have been reported in the literature. Classification of LMS can be divided into 3 major groups: soft tissue, cutaneous, and vascular. Major vessel leiomyosarcomas are extremely rare, making up less than 2% of all leiomyosarcomas, and occur in veins nearly 5 times more than in arteries. Vascular leiomyosarcomas most often arise from the inferior vena cava (IVC), representing approximately 35-60% of the cases. Less frequently they have been described in the renal, mesenteric, hepatic and saphenous veins, portal veins, or very rarely in arteries.
Conclusion
The accumulated experience about venous LMS in the literature consists of mainly scattered case reports, small series, and an international registry published in 1996. Based on the data gathered, several inferences can be made. Women are far more commonly affected by venous LMS, with nearly four times as many cases in VC and twice as many cases in non-VC LMS compared to men. Venous LMS affects the older population more than the younger population, most commonly in the sixth decade of age. Chief complaints were largely dictated by the anatomic location of the tumor. For example, in pulmonary vein cases, the most common complaint was shortness of breath, which is most likely due to tumor growth and subsequent pulmonary vascular congestion or increased dead space. Aggressive resection of primary leiomyosacoma of the VC or non-VC can be performed safely and result in long-term survival. Patients who are treated with complete surgical resection have a significantly better prognosis and survival rate compared with other forms of treatment. A collaborative approach from surgical oncologists and vascular surgeons ensures adequate resection with functional reconstruction to achieve the best patient outcomes. Despite high recurrence rates, no consensus yet exists regarding adjuvant treatment.
Endovenous chemically induced thrombosis classification post mechanochemical saphenous vein ablation
1OMNY Vein & Cardiovascular
2Columbia University Medical Center
Introduction
Mechanochemical endovenous ablation (MOCA) has been utilized as a tumescentless option for saphenous vein ablation in the past several years. Limited information exists on the frequency of deep venous thrombosis and/or the potential of liquid sclerosant or its associated thrombus proximal migration into or towards the deep venous system. We sought to categorize and quantify this phenomenon based on our experience of 712 cases.
Objectives
Determine the frequency of occurrence of proximal migration of the liquid sclerosant or its associated thrombus into or towards the deep venous system. Evaluate the proximal migration and whether or not it can be quantified in order to guide therapy for such a complication. Identify how to manage each subcategory.
Methods
A retrospective review of all consecutive MOCA cases performed between August 25, 2016 and December 27, 2017 was done. Procedures were performed at our outpatient facility utilizing the standard MOCA protocol on patients with advanced venous insufficiency. The sclerosant used was 1.5% liquid sodium tetradecyl sulfate (Sotradecol-STS). Patients’ demographics and procedure-related parameters were collected, including anatomical subsets i.e. great, small and accessory saphenous veins (SV); sapheno-femoral and sapheno-popliteal junction diameters; distance of the intravenous MOCA catheter tip to that junction; SV diameter standardized at 3cm distal to such a junction; length of the index SV treatment segment, and the volume of STS infused (see Table).
Endovenous chemically induced thrombosis (ECIT) was defined as any sclerosant or associated thrombus proximal migration beyond the STS delivery point. Subcategories included ECIT I: any forward migration short of the junction; II: migration reaching the junction; III: deep venous involvement but <50% of its lumen; IV ≥ 50% lumen or acute deep venous thrombosis.
All post op ultrasounds were performed within 2–3 weeks.
Results
A total of 712 subjects were included in this study with a preponderance of females representing 68.4% of the cohort. The mean age was of 61.4 +12.5 years and majority of the procedures were great saphenous (GSV) vs. small saphenous veins (SSV) (73.7% vs. 23.2%). A small percentage of procedures were performed on accessory saphenous veins (3.1%).
The table below depicts procedural related parameters described previously.
At a follow up of 10.01 ± 9.68 days post operatively, venous ultrasound showed no proximal migration in 64.2% of patients’ procedures regardless of the anatomic vein type (ECIT 0). The remaining 46.8% were distributed mainly among ECIT I - observed in 22.9% and ECIT II in 9.3%. Those 2 subcategories were managed conservatively with low dose aspirin with no clinical sequela.
On the other hand, ECIT III was documented in 3.2% and ECIT IV in 0.4%. Those 2 subcategories were treated with full anticoagulation for a mean of 28.77 + 9.01 days with reduction of ECIT to 1.27 + 0.45.
Conclusion
Endovenous chemically induced thrombosis classification post MOCA ablation stratified patients into subcategories that guided therapy and follow up.
In addition, this cohort of patients’ procedures demonstrated sustained safety profiles of mechanochemical ablation given the low deep venous thrombosis rates. Prospective trials might further elaborate on such a categorization proposal specifically while utilizing an ultrasound core lab and multi-center platforms.
Association of rheumatoid arthritis and osteoarthritis of the knee with states of chronic venous insufficiency of the lower extremities
Clinica Vanguardia
Introduction
The venous disease is the results of different facts, (genetic, environmental, etc.). The clinical presentation ranges from telangiectasias to venous ulcers. The etiology is a hemodynamic phenomenon with damage to the vein wall, venous hypertension, stasis, and thromboembolism risk.
In this study we used the vein insufficiency to refer to the abnormal function (using ultrasound) and CEAP nomenclature. Different components work for a joint effort. The osteoarthritis and the rheumatic arthritis are chronic inflammatory diseases related to joint pathologies and have the common element affecting the regular movement of the knee, activity of muscles, and higher venous pressure, all of which present in venous insufficiency. Clinically present edema, pain and in some cases, ankylosis.
Osteoarthritis is considered one of the most debilitating joint function diseases in population more than 50 years old. Additionally, arthritis in a minor number. We see more in Native American populations. Both pathologies share risk factors, such as female sex and genetics. Overweight and obesity are also included in arthrosis. These conditions are common in venous insufficiency too.
Objectives
Describe the possible association between the rheumatoid arthritis (RA) and osteoarthritis (OA) affecting the knees with chronic venous insufficiency (CVI) of the lower extremities (LE). Investigate the association of obesity with chronic venous insufficiency. Demonstrate the impact of the absence of regular exercise on venous return.
Methods
It’s a transversal, analytic, retrospective study in patients with arthritis diagnosis in a clinic from 2006 through 2018. The inclusion criteria were 18 years old or more, rheumatoid arthritis or arthrosis diagnosis based in ACR/EULARD criteria, one or more knees involved. The exclusion criteria were previous surgery of the knees and previous diagnosis of venous insufficiency. The venous insufficiency diagnosis was considered after an ultrasound study related to the non-invasive guide. The overweight was measured and established more than IMC30%. The exercise included 45 minutes at least 3 times a week.
The categorical variable statistics were analyzed by chi square with a limit 0.05 for statistical significance.
For the association variables of interest, the bivariate logistic regression with OR and a confidence interval of 95% were used. We used Excel spreadsheet and a statistic software SPSS 20.
Results
The statistical average age was 60 years old. The age range was from 32 to 83 years old. The median age was 59,3 +/- 12.1 years old.
The data distribution according the phlebology and rheumatology diagnosis represented a significant relation between the presence of rheumatic pathologies and the development of venous insufficiency in the lower limbs. chi square IC95% p = 0,001
The study also concluded the presence of epifascial veins, telangiectasias and lymphatic insufficiency in some cases, but the results were not important to be associated.
The results in chi square represents an unimportant association between obesity and the venous insufficiency in this group of patients in the study. OR 1,89 IC 95% 0,42-8,41. The indifferent risk is related to the few numbers of patients with body mass index (IMC) 30kg/m2 in this population.
We could relate the absence of regular exercise with the development of venous pathologies. OR 2,85 IC 95% 1,11-7,41. The patients have 2,87 times more possibilities to have venous problems, data in accordance with the muscle’s activity and the pump function.
There are no other regional studies related with rheumatic diseases and venous pathologies; In fact, only few Asian and European studies could be founded.
Nevertheless, there is an increase interest in venous physiology and the functioning of the calf pump. The muscle pump of the calf is a fundamental element for venous return.
The regular function of this element guarantees the efficiency of the muscle to work with the adequate joint movement to his ascendant aspirate return.
The osteoarthritis and arthritis are inflammatory diseases that affect the joint function severely, then the groups of neighbor muscles are affected and the hypertension of the venous develop chronic venous insufficiency of the lower limbs. This condition is particularly important when the joint affected are in the lower limbs.
In our study first, the osteoarthritis and then arthritis were associated with venous insufficiency according with the diminution of exercise, as expected.
Our results are compared to a Russian study, Patients with osteoarthritis develop venous insufficiency more than the general population (p = 0,36). In this study the obesity was a risk factor but the association of the knee osteoarthritis and venous insufficiency was independent.
Tabla de contingencia para el cálculo de asociación de Actividad física con Insuficiencia Venosa Crónica. Asunción, Paraguay 2018
Conclusion
Rheumatoid arthritis and osteoarthritis are related to venous insufficiency with statistically significant results. Lack of exercise was related to the development of venous insufficiency. This investigation has the limits of being a retrospective and transversal study. A prospective longitudinal study is necessary in the future.
INVESTIGATION OF THE VENOUS INGUINAL LINFOGANGLIONAR NET BY MULTISLICE 3D FLEBOTOMOGRAPHY
1Hospital italiano regional del sur
2Hospital Penna
Introduction
The linfoganglionar net is a complex venous network that connects the veins and lymph nodes in the groin. A constant lymph node is located between the magna saphenous vein and its accessory vein. To demonstrate that the insufficiency in linfoganglionar net is involved in primary superficial insufficiency and varicose vein recurrence.
Objectives
Demonstrate usefulness of Multislice 3D scan in complex venous pathology of lower limbs, evaluating the superficial and deep venous system in primary and recurrent venous insufficiency. Its utility in difficult diagnosis. Demonstrate that insufficiency in linfoganglionar net is involved in primary superficial insufficiency and varicose vein recurrence. To diagnosis abnormal circuits of linfoganglionar net insufficiency and its importance to decide a choice of treatment.
Methods
Analysis of 120 Multislice 3D Tomographies performed on patients with primary venous insufficiency and complex recurrences in the lower limbs over a 48-month period with contrast injection in the arm and back of the foot. All patients were studied with venous color doppler and evaluated prospectively and observationally considering the following variables: clinical according to stage CEAP, surgical history, diagnosis of leakage points, flow bypass circuits and re-entry points.
Results
The 3D anatomical study as a complement to color Doppler ultrasound allowed a detailed study of the complex venous pathology of the lower limbs, determining statistically greater complexity in the inguinal lymphogranglionar vein net and popliteal fossa.
In 21(17,5%) patients the linfoganglionar net was involved in varicose pathology. 6 had primary disease and 15 patients had recurrence.
Perforating veins of atypical location were identified with their bypass circuits and reentry points. Its study in the leg determined its correlation with venous ulcers.
Double ganglionar reflux to Magna saphenus vein
Ganglionar reflux
Inguinal Linfoganglionar net
Conclusion
The MCT is an excellent way to study the complex venous pathology of the lower limbs, especially in cases of recurrences and areas of difficult evaluation such as the popliteal fossa and the inguinal lymphogranglionar vein net, providing a more complete anatomical information and hemodynamic data not available with doppler. This study was essential for therapeutic planning in complex patients, reducing the rate of recurrence. It is also a great educational and research tool to learn the anatomy of the venous system.
Inferior Vena Cava Filter Placement: retrospective analysis of single center experience compared to international guidelines and standards
1King Abdulaziz Medical City, MNGHA
2Ministry of National Guard Health Affairs
3Colchester Hospital University
Introduction
Objectives
Review our practice in regard to indication for IVC filter insertion Identify and study our periprocedure complications Compare our practice outcomes to international standards
Methods
Retrospective chart review was conducted for 411 patients who underwent IVC filter insertion between 2011 and 2016, with an average 60 filters insertion per year. Patient demographics, filter duration, indication for insertion, filter type, filter insertion and retrieval complications were investigated. Complications were compared with international Guidelines of Society of Interventional Radiology (SIR) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE).
Results
97.32% (n = 399) of the IVC were placed infrarenally, 2.2% (n = 9) suprarenally, and 0.49% (n = 2) were inserted in the common iliac vein. Mean duration of filter in situ was 91.91 days. More than two thirds 83.90% (n = 344) of the patients did not have any immediate complications, whereas filter tilting was noticed in 13.66% (n = 56) of patients.
Retrieval was successful in 84.97% (n = 153) patients. One patient died during filter retrieval 0.24%. IVC thrombus complicated retrieval in 1.97% (n = 8) patients, and failure to retrieve due to other comorbidities and implications was found in 1.48% (n = 6). Among patients who had follow up; thrombosis was found as a late complication in 9.38% (n = 38). 40.25% (n = 163) did not encounter any complication.
However, there was loss of follow up in 49.38% (n = 200) patients due to death 27.90% (n = 113), other causes 21.48% (n = 87).
Conclusion
Compared to the international standards considered by our institution, our sample had comparable thresholds since no immediate complications occurred in most of the patients and IVC filter placement and retrieval has minimal complications.
Investigation on diameters of the GSV: A study from the SFP- French Society of Phlebology (Diagraves study)
1Hôpital Privé Saint Martin, Ramsay Générale de Santé
2Department of Dermatology
3Médecine Vasculaire et Phlebologie
4Clinique Saint Charles
5CENBIOTECH
Introduction
Chronic venous disorders (CVDs) caused by superficial venous pathology are a frequent reason for medical consultation. In France, between 20% and 35% of the general population suffers from varices in the lower limbs, i.e. 18-20 million individuals. In 30% to 50% of these patients with CVDs i.e. about 8 million people, saphenous veins are involved, in particular the great saphenous vein (GSV).
In Europe, treatments for saphenous vein incompetence offered most frequently are: endovenous thermal ablation (TA), endovenous non-thermal, non-tumescent ablation techniques (NTNT) including ultrasound-guided foam sclerotherapy (UGFS) and, still to a considerable extent, surgery.
There are currently few data available on the distribution of GSV diameters in large cohorts of patients presenting with venous symptoms and clinical signs of CVDs. Therefore, the French Society of Phlebology (Société Française de Phlébologie-SFP) decided to set up a large observational study to assess the distribution of GSV diameters in patients with CVDs and reflux, presenting at phlebology clinics in France.
Objective
To evaluate the distribution of the diameters of the great saphenous vein (GSV) at mid-thigh level, in patients presenting with chronic venous disorders in daily phlebological practice in France.
Methods
35 vascular physicians included consecutive patients presenting with symptoms and/or signs of uni-or bilateral chronic venous disorders (CVDs, CEAP classification C0S-C6), without previous GSV treatment. Duplex ultrasound was performed with the patient standing to detect reflux in the GSV and to measure the inner diameter of the GSV at mid-thigh.
Results
More than 1200 patients (>2400 limbs) were included; a large majority of the patients had venous symptoms in one or both legs and C2 and C1 classes were more frequent. In the case of a reflux of the GSV (40% of limbs), the average diameter was 5.6mm and the distribution was: 62%<6mm, 30% between 6 and 8 mm and 8%>8 mm. The study showed a clear correlation between clinical class and GSV diameters, between venous symptoms and diameters and between proximal extent of reflux and diameters.
Conclusion
This study demonstrated that, in patients consulting for CVDs in France, more than half of the incompetent GSVs had a diameter smaller than 6 mm, while large diameters were relatively infrequent This should be kept in mind when considering management strategies in patients with CVDs.
Hypnosis is not (enough) widely used in Phlebology
Clinic Saint Charles
Introduction
Hypnosis is an effective way to reducing pain and anxiety.
The widespread of non-surgical procedures for treating varicose vein without general anesthesia or epidural analgesia, should remind that pain and anxiety must be always managed but differently.
Objectives
Description of what is medical hypnosis, background, how to learn it, how to perform it. Evaluate the pain during an endovenous thermal ablation with patients who received intraoperative hypnotic relaxation.
Methods
Non-consecutive monocentric observational study. The patient had to be voluntary. The usual protocol was applied for the endovenous thermal treatment. We asked the patients rated their anxiety and pain at the end of the procedure (scale 0–10; 10 max).
All patients were treated with endovenous thermal ablation of the great saphenous vein. A hypnotic induction was performed at the operating room followed by maintenance of the hypnotic state during all the procedure.
Results
10 Patients were included. The 10 patients did not report any anxiety (0/10), the mean pain score was 1.5/10. Hypnotic trans has often been considered comfortable.
Conclusion
This study aims at demonstrating that with a minimum of knowledge it is possible to achieve an induction and retention of hypnotic state in order to considerably improve comfort. A randomized controlled study is needed in order to compare endovascular procedures with or without hypnosis and the effects on anxiety, pain, discomfort and adverse event.
C1 sclerotherapy failure – augmented reality and 18 MHz ultrasound in the complex approach to the sclerotherapy resistive C1 pathology
1European Centre of Phlebology, Department of Vascular Surgery Medical University of Silesia
2European Centre of Phlebology
Introduction
Sclerotherapy remains one of major treatment method of C1 pathology. Despite the high success rate and common use of the sclerotherapy, the local treatment complications as well as the possibility of the treatment failure implicate the research dedicated to the C1 sclerotherapy improvement. One of the significant problem related to the C1 treatment is the proper feeding vein identification and treatment.
Objectives
In the study, the efficacy of the augmented reality and functional vein assessment based on the 18 MHz US in the treatment of the C1 pathology resistive to the previous sclerotherapy was investigated. The usefulness of the 18MHz ultrasound in the skin and subcutaneously located feeding vein reflux identification was assessed Additionally, the efficacy of the 18MHz ultrasound guided sclerotherapy of the subcutaneous feeding veins in the C1 sclerotherapy resistive lesions was investigated
Methods
50 C1 lesions resistive to the previous sclerotherapy in 35 patients were identified. In the primary treatment 0.5% polidocanol foam for reticular veins and 0.5% liquid polidocanol sclerotherapy was used. In all the cases the qualification to the primary sclerotherapy was based on the standard venous Doppler US and the lack of the presence of the major vessel reflux – during primary procedure, for reticular vein identification, intraoperatively, transillumination was used. In all the cases the repeated venous Doppler US was performed with an implementation of 18 MHz US probe to identify the perpendicular and horizontal feeding vein reflux located in the skin, subcutaneous tissue or dipper compartment. In all the cases for horizontally located feeding vein identification (not visible or difficult to identified in 18 MHz US), the augmented reality (Veinviewer) was also used. In all cases, as a first step of the re-do procedure the repeated sclerotherapy was performed based on the feeding vein obliteration under 18MHz US or augmented reality control.
Results
During the follow up of 6 months, 45 out of 50 C1 lesions (90%) were successfully obliterated. Among these 45 lesions, in 13 cases (28%), to obtain the positive final result, the redo-procedures were required within 4–8 weeks after primary re-do treatment. No major complications (skin necrosis or permanent severe hyperpigmentation was reported).
Conclusion
An implementation of the combined approach based on the augmented reality and 18 MHZ functional feeding vein identification improves the C1 sclerotherapy efficacy in the treatment of the pathology resistive to the primary treatment based on the standard approach.
Incorporating new technology for ambulatory compression: An intelligent pressure device applies pressures appropriate for each postural position
1Clinica MD Barbantini
2Head Angiology Department, MD Barbantini Clinic
3ACI Medical
Introduction
Medical elastic compression stockings (MECS) apply reasonably good pressure to limbs with chronic venous insufficiency in the supine position but insufficient pressure with dependent limbs that have higher intravenous pressures than stockings can apply. Non-elastic wraps are more easily applied by the patient but have less than ideal pressure increases between supine and standing positions. Inelastic bandages overcome many of these problems, but they are usually very poorly applied. In addition, they are known to lose pressure and to slip over time becoming less effective.
Objectives
Applying newly available microelectronic technologies (IntelliPress®; ACI Medical, Ca, USA) to create a more ideal compression device that may determine the postural position, the activity of the patient and the changes of limb size with reduced swelling to automatically apply the programmed pressures. A miniature pump inflates a bladder that is within an easily applied wrap made of short stretch material. The device, not for commercial sale, incorporates technologies to: A. identify the postural position of patients, and B. apply posture and leg size changes-appropriate pressures to the limb over both short- and long-term usage.
Methods
In 16 patients with Great Saphenous Vein incompetence (C3 to C6) and candidates for venous ablation, the pressures applied by an IntelliPress® device were measured at the calf segment of the affected limb using a repeatedly published compression pressure measuring system (Picopress®, MicrolabItalia, Padua Italy). Measurements were made in the supine and standing positions with class II knee length MECS and with IntelliPress® devices applied, one with a more elastic (El. device) and one with a stiffer cuff (Stiff dev.) The IntelliPress® pump was programmed to deliver 35 mmHg when the supine position was detected and 65 mmHg when the standing position was detected.
Results
As shown in the table, the median pressure measured was 35 mmHg in the supine position and 68 mmHg in the standing position using the stiff IntelliPress device. Median pressures measured withMECS applied are approximately those expected for that class.
Conclusion
These data validate that the IntelliPress® device was able to accurately identify patients’ postural position and that the appropriate programmed pressures were delivered. The median applied pressure increased by 33 mmHg when the patients’ posture changed from supine to standing. In contrast, the class II MECS increased median pressure by about 3 mmHg during that same change in postural position. Further testing during exercise showed how the device’s applied pressure improve calf muscle pump function to efficiently expel venous blood from the limb to essentially normalize the ejection fraction. Patients can self-apply and remove the device which precludes the need for clinic visits with trained bandaging clinicians. Tolerability is ensured due to the controlled pressures.
Variability in venous thromboembolism (VTE) risk assessment tools
St Mary’s Hospital
Introduction
As a result of the significant mortality attributable to Hospital Acquired VTE, the use of venous thromboprophylaxis is common in the UK with some healthcare trusts prescribing thromboprophylaxis for up to 90% of patients admitted into hospital. The National Institute for Health and Care Excellence (NICE) recommends the Department of Health (DoH) VTE risk assessment tool for medical and surgical inpatients. A number of additional tools also exist. It is unclear how well these tools correlate with each other and how accurately they are able to predict those at high risk of VTE.
Objective
To assess the concordance between different VTE risk assessment tools in stratifying inpatients at high risk of developing VTE who may therefore require thromboprophylactic measures
Methods
This is a single centre, retrospective cohort study of 100 patients admitted to a single centered hospital between 27/03/2018 to 17/05/2018. A random number generator was used to select a sample of patients from each ward; the sample size from each ward was relative to the ward size. 39 surgical patients were retrospectively risk assessed using the Department of Health (DoH) and the Modified Caprini VTE risk assessment tools. 61 medical patients were risk assessed using the DoH, Modified Caprini, Padua and Improve VTE risk assessment tools. For each tool, the risk of VTE was graded as either low, moderate or high in each patient.
Results
All 39 surgical patients were at high risk of VTE according to DoH risk assessment tool (score >1). According to the Caprini VTE risk assessment tool, 2 patients were at low risk (score 0–2), 3 patients were at moderate risk (score 3–4) and 34 patients were at high risk (score >4). Moderate agreement between the two tests is demonstrated through measurement of an intraclass correlation coefficient (Cronbach’s alpha) (0.618, p < 0.002).
Of the 61 medical patients, 60 were considered high risk of VTE according to the DoH risk assessment tool. Using the Caprini VTE risk assessment tool, 4 patients were at low risk, 12 patients were at moderate risk and 45 patients were at high risk. According to the Improve VTE risk assessment tool, 39 patients were at low risk (probability of symptomatic VTE 0.2-0.6%), 12 patients were at moderate risk (0.6-1.5%) and 10 patients were at high risk (>1.5%). According to the Modified PADUA VTE risk assessment tool, 10 patients were at low risk (score <4), 9 patients were at moderate risk (score = 4) and 42 patients were at high risk (score >4).
The inter-rater reliability, as measured by Cohen’s Kappa, was 0.456 (p < 0.001) between the Caprini and Pauda scores; this suggests moderate agreement between these two scores. No significant agreement was found between the other scoring systems when assessing the VTE risk in medical inpatients.
Conclusion
Amongst patients being admitted to hospital, the DoH risk assessment tool doesn’t provide clear stratification of different VTE risk levels; most inpatients are considered high risk. Agreement between the Caprini and Padua VTE risk assessment tools is evident in this analysis. Disagreement between these tools and IMPROVE may be due to due to a disparity in the weighting of important risk factors such as obesity, age and immobility in addition to inclusion/exclusion of other risk factors such as medical comorbidities. Unclear risk stratification may lead to suboptimal allocation of thromboprophylaxis. In order to optimize the use of thromboprophylaxis and formulate clear guidance on when it should be used, a large, multicenter study should be considered.
Objective Improvement in Response to Treatment of Lymphatic Dysfunction with Comprehensive Decongestive Therapy Using Calf Muscle Pump Training and Manual Lymphatic Drainage and Automated Lymphatic Drainage in Patients With and Without Venous Reflux
1St Joseph Mission Heritage Medical Group
2OC Sports & Rehab
Introduction
Symptoms and signs associated with chronic venous reflux may be due to concomitant lymphatic dysfunction and as a result they may persist despite successful ablation of the venous reflux. We have also noted similar symptoms and signs in patients referred to our Vein Clinic, in the absence of significant venous reflux. Improvement of symptoms that are presumed due to lymphatic dysfunction has been observed following treatment with a program of Comprehensive Decongestive Therapy (CDT) that may include calf muscle pump training, Manual Lymphatic Drainage (MLD) and Automated Lymphatic Drainage (ALD) using a Sequential Pneumatic Compression (SPC) device. The symptom improvement is presumed due to a reduction of leg edema and, possibly, decreased inflammation with both reflecting improvement of lymphatic flow. The purpose of this study was to determine if improvement of objective measures in response to CDT treatment could be documented. Measurements of leg circumference were obtained as a surrogate for leg swelling and measurement of skin temperature as a surrogate for inflammation.
Objectives
Measure the response of leg swelling to treatment with CDT by comparing measurements of leg circumference before the first CDT session with measurements before the last CDT session. Measure the response of skin temperature to treatment with CDT by comparing measurements at the talo-crural joint before the first CDT session with measurements before the last CDT session. Assess the relationship of changes in these objective measures with previous observations of symptomatic improvement in response to Comprehensive Decongestive Therapy of lymphatic dysfunction.
Methods
This is a retrospective analysis of measurements made on patients that we referred to our Physical Therapy/Lymphedema Clinic for treatment with CDT. The decision to refer was based on symptoms and signs of lymphatic dysfunction that were either persistent following successful ablation of venous reflux or that were present in the absence of any venous reflux. Referral of patients began on March 30, 2016, and the symptomatic improvement, based on reduction of the Venous Clinical Severity Score (VCSS) was previously reported. (3) Leg circumference was measured at the bi-malleolar level and at 10, 20 and 30 cm above the ankle both before the first CDT session and before the last session. Skin temperature was measured at the anterior talo-crural joint at the same time points. The number of CDT sessions and the timing of the last session was determined by patient preference.
Results
Paired results were available for 24 patients for both circumference measurements and skin temperatures. A significant decrease of leg circumference at the bi-malleolar measurement was observed. (Table 1). Reduction of circumference was present in 18 of 24 patients with the decrease being bilateral, when present. No significant changes of circumference were detected at the measurements at 10, 20 or 30 centimeters above the ankle.
The temperature measurements were 89.8 + 2.5 degrees Fahrenheit pre-CDT and 89.2 + 2.5 degrees post CDT on the right (p = NS) and 89.2 + 3.3 degrees pre- and 89 + 2.9 degrees post, on the left (p = NS).
Conclusion
Reduction of leg circumference measured at the bi-malleolar level, but not higher up the leg, may be useful as an objective measure of response to comprehensive decongestive therapy of the lower extremity. Measurement of skin temperature did not change in response to comprehensive decongestive therapy. These findings document the difficulty of objective measurements of response to decongestive therapy for treatment of lymphatic dysfunction.
Stationary blood particle aggregates at the valve sinus: Markers of venous stasis, indicators of damage stage, predictors of venous insufficiency
Angioclinic vein centers
Introduction
Using novel high-resolution ultrasound systems (HRU), valvular structures and low-flow microaggregates may be depicted today in a more detailed way. We recently reported the existence of particle aggregations within valve sinus which are neither sludge nor thrombus, detected by high resolution ultrasound (>14 MHz) 1. This study is about the analysis of 180 saphenous vein valves showing motion-resistant aggregates (MRA),
Objectives
To compare valve structures, cusp motility and extent of aggregates. To distinguish different stages of vein valve damage. To determine the number of potential locations of onset of disease.
Methods
In 100 consecutive patients (68 f, 32 m; 42 - 64 yr/o.) presenting with proven or suspected unilateral epifascial venous insufficiency, a total of 180 great saphenous vein valves showing MRA were selected for closer ultrasound analysis (14–16 MHz, peak up to 40 MHz, Vevo MD). Videos were reviewed by the performing physician and two independent investigators.
Results
Six different stages of valve changes could be determined: A. Alteration of sinus hemodynamics (reduction of flushed sinus volume, but no other pathology) was present in 102/180 valves (56.7%). B. Restriction of cusp function (limited motility) correlating with aggregates while maintaining closure was seen in 64/180 valves (35.6%). 6/180 valves (3.3%) showed fixation of cusps (> 2/3 of length without motility) but yet without reflux. C. whereas in 8/180 valves (4.5%) there was fixation of cusps as cause of diastolic gap and reflux (Figure 1). D. In segments with significant reflux (> 1000 ms, > 10 cm/s), E. regression and finally F. loss of valve structures with less or no valvular aggregates was the typical finding. Saphenous disease had a single location of potential onset of disease in 93/100 (93.0%) of the cases.
Conclusion
Stationary blood cell aggregates at the valve sinus seem to indicate successive stages of venous insufficiency, correlating with specific relations of sinus shape and flow. Analysis of valves and aggregate allows “to read” the individual history of disease. This insight might become a basis for a more differentiated therapeutical approach.
Varicose veins and thyroid pathology: often present never seen
1Ippocrate Vein Clinic
2UNIVERSITY OF BRESCIA
Introduction
During the clinical and duplex examination of patients with varicose veins usually we check the carotid wall thickness and thyroid gland.
The arterial endothelium represents an important feature of the age and wellness of our vascular system, so we believe that the measurement of the thickness of the carotid artery, despite a plaque or stenosis, is an important detail about the “inflammatory pattern” of the whole body. The thyroid gland is sometimes involved in patients with chronic venous and lymphatic disorders particularly in hypothyroidism, but we couldn’t find data in literature about the anatomical condition of an asymptomatic thyroid in VV disease. During a neck echo check for carotid study, it’s easy to see occasional pathologies of the thyroid or lymphnodes.
Aim of this observational study to check the thyroid gland with echography in patients with VV.
Objectives
To show the importance of thyroid gland analysis in patients with Varicose veins 88% of patients with Varicose veins are affected by thyroid solid or cystic nodules This pattern is more evident in patients with recurrence of varicose veins
Methods
A series of 100 consecutive patients with primitive or recurrent symptomatic varicose veins (c2-c3-c4) of CEAP classification were submitted simultaneously at echography of the thyroid gland checking the structure, size and the presence of cysts or solid asymptomatic and unknown nodules.
The patients were 69 female and 21 male, median age of 57 (18–72) and 78% with primitive varicose veins and 22% with recurrent VV and previously operated of surgical or endovascular ablation of the great saphenous vein, and precisely of 22 patients 20 submitted to classical stripping with high ligation of the junction and 2 to EVLA from 4 to 18 years before.
In all patients the VV presented with skin troubles (c4) in 5%, with swollen (c3) in 10% and c2 in the rest of the group (75%).
Results
In 82 patients we found asymptomatic thyroid pathology and in 4% the patients were previously surgically treated with thyroid ablation or in 2% were treated or in treatment with thyroid hormone. A total of 88 patients/100 presented thyroid nodules with varicose veins.
In all the patients with recurrence (22–100%) the thyroid gland was affected. In 50% of affected glands the nodules were bilateral and from 3 to 10mm. In 25% monolateral solid nodules more than 1 cm. And in 4 cases a needle biopsy was necessary and in 2 patients a carcinoma was detected and operated. In patients with thyroid pathology including solid nodules more than 1 cm, the thickness of the carotid wall was more than 1 mm. In 89% of cases.
Conclusion
This observational study introduces a new pathway of analysis if VV are present and particularly in patients with recurrence. In all your patients you should include a test of the carotid arteries and of the thyroid gland even if more extensive studies should begin from now to demonstrate the biochemistry and the biological reasons of this strange but significative clinical feature, a new Syndrome?
Beware of Testosterone: An Under-Recognized Risk Factor
1University of Cincinnati College of Medicine
2Good Samaritan TriHealth Hospital
3Beacon Orthopaedics & Sports Medicine
4TriHealth Cancer Institute
Introduction
Testosterone has been advocated for energy, libido, and muscle building. Unfortunately, “low T” treatment and supplements may be associated with an increased risk of deep vein thrombosis (DVT), much like estrogen in women, especially in the perioperative period.
Objective
We present a case of undisclosed testosterone use associated with a DVT after anterior cruciate ligament (ACL) repair.
Methods
Patients frequently do not consider supplements and over-the-counter agents as medications.
Results
This patient did not reveal testosterone use until after he developed a DVT. He had no other familial risks for thrombosis.
Conclusion
Perioperative history taking must include specific questions about supplements and hormones, even in men, and especially in power builders. A complete review of testosterone effects and literature will be presented.
Phlebolymphedema: Unrecognized and Undertreated
Brennan School of Innovative Lymphatic Studies
Introduction
Phlebolymphedema is a condition of mixed venous and lymphatic insufficiency. It is usually not recognized. Furthermore, it is not treated. The lymphatic and venous systems are intimately interrelated. In the presence of venous hypertension, which is characteristic of most venous disorders, the increase in lymphatic flow becomes much greater than the lymph transport capacity. The diagnosis of phlebolymphedema is based on a detailed history and physical examination. Patients with phlebolymphedema have skin changes of venous insufficiency, which are easy to recognize. Treatment for chronic phlebolymphedema consists of treating the venous abnormality and watching regression of the lymphatic problem.
Objectives
Understand the mechanisms of lymphatic failure which is responsible for all forms of peripheral edema Recognize contemporary management of chronic edema based on Decongestive Lymphatic Therapy Integrate this knowledge in the practice of phlebology
Methods
Case Studies
2016
Phlebolymphedema
Patients referred for decongestive lymphatic therapy
Outpatient lymphedema clinic Decongestive lymphatic therapy Volume
QOL measures
Results
Symptoms reduced and QOL improved. Management strategies for self-care shifts burden of care from the healthcare professional to the patient.
Conclusion
The view that venous capillaries are normally in a state of sustained absorption is widely taught as an established fact. This view has been disproved. There is no net reabsorption of the interstitial fluid by venous microvessels. Tissue fluid balance depends on lymph flow. Venous insufficiency maintains an increased filtration and permeability of blood capillaries. Thus, venous insufficiency is a continuous source of excess interstitial fluid, which overfills and in the end damages lymphatic vessels. Lymphatics may frequently fail in venous disease, especially in chronic venous insufficiency. Conservative treatment, utilizing decongestive lymphedema therapy including compression therapy is recommended for phlebolymphedema. Autonomous handling of ACW seemed to improve the clinical outcome and is a promising step toward self-management involving effective compression. Therefore, phlebolymphedema, when recognized, is a treatable condition.
Incidence of Segments with Complete or Partial Compressibility and of Extension of Thrombus into a Deep Vein at Early Follow-up Ultrasound Examination Following Ablation Using Non-Thermal Non-Tumescent Techniques
St Joseph Mission Heritage Medical Group
Introduction
We observed on routine post ablation ultrasound follow-up studies that some segments within a truncal vein ablated using either Mechanical Occlusion Chemically Assisted (MOCA) or Polidocanol Endovenous Microfoam (PEM) injection techniques were either completely or partially compressible during our early experience with these techniques. The reported incidence of partial obliteration of the treated vein at 8 weeks after MOCA is 3.3% and these were all successfully treated with ultrasound-guided foam sclerotherapy.(1) To determine the incidence of similar ultrasound findings in our early experience using MOCA and PEM, we reviewed the ultrasound findings for all patients at 2–7 days after their truncal (great saphenous vein (GSV), small saphenous vein (SSV), anterior or posterior accessory GSV (AAGSV or PAGSV) vein ablation We compared the number of veins with such findings to the total number of veins treated for each technique. We also compiled the number of thrombus extensions into the deep veins for each technique (EHIT equivalent) and the number of veins we treated with foam chemical ablation at their first procedure following truncal vein ablation.
Objectives
Calculate the incidence of complete or partial compressibility within truncal veins ablated using non-thermal non-tumescent techniques at early ultrasound follow-up. Document the incidence of thrombus extension into deep veins following non-thermal non-tumescent ablation of truncal vein reflux during our initial experience with MOCA and PEM. Document the number of truncal veins ablated with non-thermal non-tumescent techniques that we treated with subsequent ultrasound-guided foam injections.
Methods
This is a retrospective review of the findings on routine early ultrasound follow-up after truncal vein ablation using either MOCA or PEM beginning with our first procedure using either technique.
Between our first vein ablation using MOCA on 9/21/2017 and our most recent on 5/30/2018 we ablated 20 veins (14 GSV, 4 SSV, 2 AAGSV) in 14 patients, 9F/5M, age 70 + 14 (mean + SD) years, Between our first PEM procedure on 12/11/2017 and our most recent on 3/30/2018, we ablated 44 veins (27 GSV, 8 SSV, 8 AAGSV, 1 PAGSV) in 31 patients, 21F, 10M, age 70 + 9 years.
The mean length of vein ablated using MOCA was 30 + 14 cm (minimum = 3cm; maximum = 62 cm) and using PEM, the mean length ablated was 29 + 15 cm (minimum = 1cm; maximum = 54 cm). The ratio of sotradecol infused per length of vein ablated was 0.26 + 0.13 ml/cm and the volume of polidocanol microfoam infused per length of vein treated was 0.31 + 0.25 ml/cm.
The early follow-up ultrasound was performed between day 2 and day 7 post-ablation.
Chemical foam sclerosant was injected into a previously ablated truncal vein when there was complete compressibility, partial compressibility, or an echo-lucent center within a visible thrombus
Results
Complete or partial compressibility was detected in at least 1 segment of the ablated truncal vein in 9/20 veins (45%) treated with MOCA and in 12/44 (27%) treated with PEM. When the treated vein was compressible, there was full compressibility observed in 3/9 (33%) and partial compressibility in 6/9 (66%) when the technique was MOCA; among the veins with compressible segments observed, complete compressibility was present in 5/12 (42%) and partial compressibility in 7/12 (58%) when the treatment was PEM.
Compressibility at the proximal end of the ablated vein overlying the proximal-most segment of ablation was detected in none of the MOCA-treated veins and in 5 of the PEM-treated veins. Of the 5 veins treated with PEM with this finding, which was associated with spontaneous reflux flow in all 5, 3 were in the first 3 veins treated with PEM and these were also in the first 2 PEM procedures we performed. Of the remaining 2, 1 involved the proximal GSV and the other the proximal SSV. Full or partial compressibility bounded at either end by non-compressible vein was associated with less than 1 second inducible flow in all cases.
Thrombus extension into the deep veins was observed in none of the veins treated with MOCA and in 3 of the veins treated with PEM. Of the 3 with thrombus extension, 1 extension of thrombus into what appeared to be a duplicated segment of femoral vein through a competent perforator vein resulted in total occlusion (equivalent of an EHIT 4) that did not resolve after 4 weeks of treatment with rivaroxaban and that was not associated with symptoms (the other femoral vein branch remained normal). The second was a non-occlusive thrombus extension also through a competent perforator vein into the femoral vein resulting in the equivalent of an EHIT 3. This was also without symptoms and resolved with absence of residual thrombus in the femoral vein after 2 weeks of treatment with rivaroxaban. The third was thrombus extension into the popliteal vein at a sapheno-popliteal junction that was not recognized prior to the thrombus extension due to the very small size of the vein connecting the SSV with the junction. This thrombus extension was non-occlusive to an equivalent of an EHIT 2, was without symptoms and resolved with no residual thrombus extension into the popliteal vein after 2 weeks of treatment with rivaroxaban.
At the first ultrasound-guided chemical foam ablation procedure after the non-thermal non-tumescent truncal vein procedure, injection of foam into a previously ablated truncal vein was performed in 15 veins previously treated with MOCA and in 38 veins previously treated with PEM.
Conclusion
Our findings suggest the following:
Full compressibility or partial compressibility of segments of truncal veins ablated using non-thermal non-tumescent techniques at early ultrasound follow-up was a not uncommon finding during our early experience with either the MOCA or PEM technique. No significant flow (<1 second with compression and release) was detected in compressible segments bounded by non-compressible vein; spontaneous reflux flow was only detected at segments of compressibility at the proximal (cranial) end of the ablated truncal vein and this only occurred in veins treated with PEM and was not observed in veins ablated with MOCA. Although we routinely injected these fully or partially compressible segments of truncal vein with chemical foam, our criteria for chemical injection of truncal veins after prior truncal vein ablation resulted in treatment of more veins than those having some degree of compressibility. There is no data suggesting that this is necessary or that it will improve outcomes especially since we could not demonstrate significant flow in these segments. Thrombus extension into the deep venous system was observed in 3 veins that were ablated with the PEM technique and the specific anatomical findings in these cases emphasize the importance of obtaining an accurate understanding of the venous anatomy prior to ablation using PEM As experience with these techniques increases the incidences of these early post-procedure ultrasound findings may change.
FOUR-STEP PLAN FOR AN EFFICIENT VENOUS ULCER TREATMENT
Glomach Medic
Introduction
Venous ulcer is the final stage of Chronic Venous Insufficiency (CVI); its main cause is venous reflux. In our specialized practice we receive a high rate of patients with this complication. After 30 years of experience we have stablished a four-step plan to achieve ulcer healing with low cost for our patients.
Objective
(1) To demonstrate that it is possible to achieve efficient ulcer healing with low cost to our patients.
Methods
Descriptive Study
Conducted from January 2016 -July 2018
We studied Patients with venous ulcer, regardless of its size, that comes to our private practice.
We performed a clinical examination and then apply our plan: Sclerotherapy as the sole method to eliminate varicose veins, elastic compression, hygiene and physical rehabilitation. Main outcome is ulcer healing and ulcer size reduction.
Variables: gender, age, wound size, time of evolution, time of ulcer healing.
Results
Successful ulcer healing, in 80% of the cases in an average of 10 weeks. More than half of the remains were large ulcers but decreased at least 60% of its size by the time we close this study. The average weekly expense for the patient is 60.00 dollars.
Conclusion
It is possible to achieve a successful venous ulcers healing at low cost by the right use of effective resources and education of the patient.
Venous Insufficiency as a Cause of Chronic Foot Pain
1Texas Vein & Aesthetics
2Univ. of Texas Dallas
Introduction
This study was done to see if venous insufficiency is a cause of plantar foot pain, and if treating the venous reflux could relieve that pain.
Objectives
To evaluate whether venous insufficiency could cause chronic or recurrent plantar fasciitis or foot pain. If treating underlying venous insufficiency would effectively relieve the pain.
Methods
Patients were evaluated based on initial complaints of plantar fasciitis. Many of these patients had been treated for plantar fasciitis by traditional methods (NSAIDs, physical therapy, orthotics, etc.) During work-up, they underwent a foot and ankle MRI. In the selected group, the MRI showed enlarged or varicose veins in the tarsal sheath. These patients then underwent a full doppler ultrasound. The majority of these patients were found to have venous insufficiency.
For the purpose of this study, only patients with foot pain and mild to no edema were selected. Patients with tradition venous insufficiency symptoms were not selected.
The study was conducted from 11/16 to current date. Study is ongoing, but all subjects were followed to at least 6 months post-treatment. Study has been conducted in a clinical outpatient setting. These patients underwent radiofrequency ablation (RFA) and ultrasound guided sclerotherapy of incompetent saphenous veins and tributaries per normal treatment protocol. No direct treatment was performed on the feet.
Our initial findings are that treating venous insufficiency provides partial to complete relief these select patients.
Results
Patients’ pain was measured on a traditional 10-point scale at the time of initial ultrasound, 6 weeks post treatment and 6 months post treatment. A 64 and a 62-year-old male, as well as 49 and 52- year-old female were presented with having foot pain, particularly fascial pain and mild to no edema. Initial pain ratings ranged from a 3–6 before treatment, with an average of 4.25.
The above four patients had RFA performed to 15 total veins as well as ultrasound guided sclerotherapy. No sclerotherapy or treatment was done below the ankle. Patients were evaluated with ultrasound at 2 weeks and 6 weeks post treatment. No complications were seen in the study group.
At 6 weeks post treatment scores on the pain scale ranged from 0–2 with an average of 0.75. At 6 months the pain scores ranged from 0–1, with an average of 0.25. Only one patient reported still having mild discomfort when standing for long periods at 6 months.
Conclusion
This study was started to evaluate if venous insufficiency could be a cause of chronic or recurrent foot pain or plantar fasciitis. Patients found to have enlarged tarsal sheath veins on MRI underwent a complete venous doppler. Those patients found to have venous reflux were then treated with RFA and sclerotherapy. Results were followed out for at least 6 months. Findings show that by treating the incompetent saphenous veins, these patients were relieved or cured of their foot pain. Based on these findings, venous insufficiency should be in the differential for chronic plantar pain. This has also held true for patients showing more typical symptoms of venous reflux along with plantar foot pain.
CLINICAL APPROACH FOR PATIENTS WITH CHRONIC VENOUS DISEASE
Glomach Medic
Introduction
Chronic Venous Disease (CVD) includes a wide spectrum of abnormalities of the venous system that manifest through different signs and symptoms that require investigation and/or treatment. CVD prevalence varies from 10% to 73%. CEAP classification is used for its study. CVD has a large impact on the society, economy and quality of life of patients. In our specialized practice, with a high flow of patients, in 30 years of experience, we have established a clinical approach to diagnose and treat successfully all patients with CVD.
Objective
To demonstrate that a clinical approach of the patient with CVD is possible and applicable in a center with a high flow of patients.
Methods
Descriptive study
From January to December 2016
Patients with CVD, regardless of its stage, that comes to our private practice. We register all the data in our own clinical record format and perform the anamnesis, a traditional physical examination and then conclude with our treatment plan.
Results
1377 patients evaluated and registered successfully over the course of one year. 72% were women; mean age was 57.61 ± 14.9; 58.9% were between 40 and 80 years old, predominates the clinical stage C2, C3 and C4 of CEAP classification; 60.09% have chronic venous insufficiency (CVI) and 11.47% are in C6 stage.
Conclusion
A clinical approach of the patient with CVD is possible and applicable in a center with a high flow of patients.
STUMP EVOLUTION AFTER GSV STRIPPING WITHOUT CROSSECTOMY OR GSV LASER OR CLOSURE ABLATION
1Ippocrate Vein Clinic
2AZIENDA OSPEDALIERA DI PADOVA UOC DAY SURGERY
Introduction
The aim of the present observational study is to show the evolution of great saphenous vein (GSV) stump in two different periods of follow up and after different ablation procedures: stripping, EVLA and Closure
Objectives
Present observational study is to classify 4 stump models Present observational study is to show the evolution of stumps in time Present observational study is to show that the crossectomy is always an overtreatment
Methods
From 2004 to 2017 7500 legs with VV were treated with surgery or endovascular techniques. A group of 200 consecutive and homogeneous legs were examined with GSV insufficiency and terminal valve incompetence and operated on with invaginating stripping without crossectomy (n - 120) or EVLA and / or Closure Fast (n - 80) were followed. Duplex examination was performed at 1 year and 3 years after the procedures to check the sapheno-femoral stump (early and midterm FU)
Results
The hemodynamic examination of residual stumps showed 4 different types: S1) draining and competent terminal valve; S2) thrombosis and fibrosis; S3) turbulence under Valsalva maneuver and normal antegrade flow at rest; S4) turbulence with reflux at rest: refluxing terminal valve. Early: the most common finding was S1 (64%), then S2 (18%), S3 (12%) and S4 (6%); S1-S3 patterns were considered as good evolution (94%), whereas S4 were considered recurrence. Mid-term phase: the most common finding was again S1 (67%), then S3 (15%), S4 (10%) and S2 (8%). S1 evolution: out of 319 legs in S1 group at early phase, 294 (92%) remained still in S1 at mid-term follow up; 25 (8%) worsen to S3. S2 evolution: out of 92 legs in S2 at early phase, 42 (46%) improved to S1, 40 (43%) did not change pattern across time and 10 legs (11%) worsen to S4. S3 evolution: almost the legs in S3 (51, 86%) remained unchanged at mid-term, whereas 8 (14%) worsen to S4. S4 evolution: all the patients in S4 class at early follow up were still in the same class at mid-term. The evolution of GSV stump can be classified in 4 different patterns, where only S4 should be considered failure.
Conclusion
The evolution of the GSV stumps can be classified in four different patterns, where only S4 (incompetent TV at rest) should be considered failing outcome of saphenous ablation without treatment of the junction and periodically treated with foam under echo-guide. In S3 cases, a strict follow up is mandatory.
Diagnosis and therapy of vein insufficiency in children
Angioclinic vein centers
Introduction
Venous insufficiency of the lower extremities is usually regarded to be a genetically determined, long-term acquired disease. Children have rarely been examined for vein disease, if not symptomatic. In earlier studies, performed with doppler or duplex of that time, e.g. preclinical saphenous insufficiency was said to be just 2.5%. For the “Berlin kinds vein study” we used high resolution ultrasound systems built 2017 to determine preclinical vein valve damage in children and adolescents.
Objectives
To determine the frequency of vein valve damage; To determine patterns of vein disease; To determine the type of valve damage.
Methods
In an ongoing study, until 5/2018 a total of 170 legs in 85 children of angioclinic C2 vein patients, aged 6–18 (38 m, 47 f) were examined with high frequency ultrasound (Siemens X 700, Mindray M9, 14–16 MHz; Vevo MD, 16–32 MHz). Investigation time was limited to 15 minutes. In case of visible vein changes (protruding, more intense colour, increased diameter), ultrasound started here. Otherwise, systematic screening of saphenous veins and medial perforators was performed.
Results
In 47/85 children (55.3%), resp. 59/170 legs (34.7%) relevant venous pathology was found. Focal valvular defects of the GSV: 20/85 (7.6%), segmental GSV reflux without varices: 15/170 (8.8%), same but with varices: 11/170 (6.5%), GSV side branch reflux only: 3/170 (7.6%), total GSV reflux 3/170 (1.8%), focal SSV valve lesion: 2/170 (1.2%), segmental SSV reflux: 1/170, 0.6%, medial perforator reflux: None. In the subgroup of 6–8 y/o kids, 9/30 legs (30.0%) already showed pathology (Fig. 1, tab. 1). Among the cases allowing diagnosis of lesion type (n = 53), unilateral commissural mismatch was the most frequent pattern (24/53, 45.3%).
6/47 kids with vein pathology (12.8%), all > 16 y/o, were selected for treatment: Side branch foam sclerotherapy (n = 2), perforator + reticular vein sclerotherapy (n = 1) and GSV perivenous hyaluronan valve repair (n = 2, study), all successful with a single puncture.
Example of a refluxing saphenous side branch, just about to induce reflux in the GSV, in a 6-year-old girl. Asymptomatic, normal outer appearance.
Conclusion
The surprising high incidence of detected valve lesions in children, in particular in the younger ones, should be best explained by congenital disease. It is a merit of todays ultrasound systems that these lesions now can be detected. There might be bias by selecting families with vein disease. However, about 25% of western populations belong to that group so there is a big number of potential young patients. New strategies for systematic early detection, coaching and cost-effective therapy have to be developed.
AN ANALYSIS OF CLINICAL CARE GUIDELINES FOR LYMPHEDEMA
1Tufts Medical Center
2Tufts School of Medicine
Introduction
Lymphedema (LED) affects more than 5 million in the USA and a staggering 140–200 million people worldwide, yet Lymphedema is the forgotten disease of the vascular system. While the diagnosis and treatment of arterial and venous diseases has been strengthened by the development of clinical care guidelines (CCG), few CCGs appear available for LED. Moreover, for CCGs to have their greatest impact they should be both of high quality and have been developed using rigorous evidence-based methods.
Objective
We performed a systematic review of the available “guidelines” for LED to assess their breadth of content, contemporary relevance and methodological strength.
Methods
To identify Lymphedema Clinical Care Guidelines a systematic review was conducted for the years 2000-2017 from multiple sources: National Guideline Clearinghouse (www.guidelines.gov), BMJ Clinical Evidence (http://clinicalevidence.bmj.com), and National Institute for Health and Clinical Excellence (http://www.nice.org.uk); as well as MEDLINE and Google. The resultant documents were analyzed for inclusion of key elements for diagnosis and treatment. The important process of guideline development and reporting was assessed by the
Results
Following an abstract review of 258 documents, 13 potential LED “guideline” documents underwent full review. Four were eliminated as not CCGs (2 consensus statements; 1 position statement and another Systematic Review). Of the 9 remaining an additional 5 were not suitable - 3 were limited in scope (rehab or compression only) and 2 were limited to LED post breast cancer, which resulted in four CGGs for LED: Lymphedema Framework (LED F); Clinical Resource Efficiency Support Team (CREST), Japan Lymphedema Study Group (J LED); American Venous Forum Guidelines (AVF). The table below shows that 3/4 were published over 7 years ago, thus only one CCG was based on contemporary literature. Lymphoscintigraphy (LSG) was the diagnostic test of choice, but Duplex was barely mentioned. While Manual Lymphatic Drainage (MLD) was favored, Intermittent Pneumatic compression (IPC) and surgery were less fully discussed and received low evidence grades. The AGREE II analysis of the four CCGs showed low scores (<50%) in the rigor of development and scope domain, the key domains influencing overall CCG quality.
Conclusion
This systematic review shows a lack of robust high-quality clinical care guidelines for lymphedema. This results from both methodological issues in available reports as well as limits based on the underlying primary scientific literature. It is therefore imperative that our vascular societies develop contemporary evidence-based Clinical Care Guidelines for lymphedema, as they have for other vascular diseases.
INNOVATIVE SIMULTANEOUS EMISSION OF 532 AND 808 NM TRANSDERMAL DIODE LASER FOR TELEANGECTASIA TREATMENT
1Crippa Vein Clinic
2University of Ferrara
Introduction
Telangiectasia treatment represents an as common as potentially challenging act in Phlebology. Sclerotherapy is not always feasible in the smallest telangiectasia for which the use of a neodymium‐doped yttrium aluminum garnet (Nd:YAG) transdermal laser is usually preferred.
Previous literature show a superiority of Nd:Yag compared to 810 nm diode lasers in this field.
A new alternative has been recently introduced into the market in the form of an innovative combination of 532 and 808 nm pulsed transdermal diode laser (Spectrum™, Eufoton).
Objectives
To evaluate the safety of an innovative transdermal multiple wavelength diode laser in telangiectasia treatment. To evaluate the effectiveness of an innovative transdermal multiple wavelength diode laser in telangiectasia treatment. To provide new data in human tissue photomodulation
Methods
85 females (mean age 42 + 9 yo; Fitzpatrick II) affected by lower limb telangiectasia (0.1-1 mm caliber), with negative ultrasound screening for venous reflux, underwent treatment by means of a multiple wavelength laser.
All the cases were treated using a 1 mm spot and a non-uniform pulse sequence mode: 532 nm pulse at 2.5 W (30 msec ON) with simultaneous 808 nm pulse at 25 W (80 msec ON). OFF time was 100 msec. A total of 3 cycles were performed in the same spot (total fluence 28 J/cm2 at 532 nm and 763 J/cm2 at 832 nm). All the cases were treated in one session by the same physician, without pharmacological anesthesia, using a polarized light for visualization and a skin contact cooling device.
At 4 months the physician, the patient and a blind assessor scored the aesthetic outcome in a range from 0 (no change) to 10 (100% disappearance) by evaluating pre and post-treatment pictures. Side effects were reported by the handling physician while pain was scored from 0 (no pain) to 10 (most painful experience ever) by the patient. Short-stretch single bandage was applied for 24 hours. All the patients wore 23-30 mmHg thigh-high graduated compression stockings for 3 weeks.
Results
At 4 months neither skin necrosis nor infection was reported.
The following side effects were observed: depigmentation (3/85; 3.5%), hyperpigmentation (2/85; 2.3%), transient erythema (14/85; 16.5%), transient edema (11/85; 12.9%), matting (1/85; 1.2%). Mean aesthetic outcome was scored as 8.1 + 1.3 by the physician, 7.6 + 2.2 by the independent assessor and 7.3 + 2.7 by the patient (P: ns). Patients reported a mean peri-procedural pain of 3.4 + 1.6
Conclusion
The simultaneous application of 532 nm and 808 nm laser emission is safe and effective in 0.1-1 mm telangiectasia treatment for Fitzpatrick phenotype II.
As in previous studies conducted with Nd:Yag 1064 nm laser, the identification of specific protocols of non-uniform pulse emission can enhance the performance and safety of also diode lasers (Fig. 1 and 2).
In particular, in the herein evaluated device, 532 nm pulse is responsible for the transformation of oxy-hemoglobin into meta-hemoglobin, which is then hit by the 808 nm pulse so maximizing the ablative effect, while minimizing the damage to the surrounding tissue.
The simultaneous emission of 505 and 832 nm diode laser demonstrates to be well tolerated by the patients in terms of pain. Further research is needed in the different phototypes and in the side effect rates associated with a variable fluence. The present investigation paves the way not only for new investigations comparing the performance of different types of lasers for telangiectasia, but, being the first data collection dealing with the simultaneous emission of two different wavelengths, it also provides evidence for a deeper insight into the biology of the tissue photo-modulation.
Superficial Venous Insufficiency prevalence CEAP class increases with age
1USA Vein Clinics
2Vascular Laboratory Jobst Vascular Institute
Introduction
Populational studies demonstrated progressive nature of chronic venous disease. We hypothesized that older patient tend to be treated later, in more advanced stages of the disease compared to younger patients.
Objectives
Older patients with chronic venous insufficiency are treated for the disease in more advanced stages of the disease compared to younger patients. Older patients present with a severe disease according to CEAP classification (C4 - C6) and do not seek medical attention attributing their symptoms to “old” age, where younger patients seek medical attention earlier Patient education about venous insufficiency is important to prevent development of severe disease with CEAP C5 and C6, which represent venous ulcers
Methods
Prospectively collected data of 6,206 patients treated for symptomatic venous insufficiency in this multi-center study (from July 1, 2015 through June 30, 2017) was gathered and used to analyze the highest Clinical class (“C” of CEAP classification) during each patient’s initial visit. The prevalence of the heights Clinical Class was compared between the three age groups: younger than 40 years old, 40 to 65 years old and older than 65 years old. Classes C5 and C6 were combined to better represent the prevalence of venous ulcers.
Results
When seeking treatment, percentage of patients with higher CEAP Class is increasing with advanced age. While comparing age groups 40 and below with group 65 and above, CEAP 2 prevalence on presentation decreased from 31.23% to 15.81%, CEAP 3 decreased only slightly from 43.41% to 39.44%, CEAP 4a increased from 23.64% to 35.24%, CEAP 4b increased from 0.86% to 5.88%, CEAP 5 from 0.14% to 1.89%, CEAP 6 increased from 0.72% to 1.46%
Conclusion
Venous insufficiency is clearly a progressive disease. With higher age prevalence of CEAP classes 2 and 3 is decreasing and prevalence of CEAP classes 4a, 4b, 5 and 6 is increasing.
Experience of endovenous ablation therapy for hyperflow vein
1Murayama Clinic
2Kannai Medical Clinic
3Yokohama Municipal Citizen’s Hospital
4Sato Vascular Surgery Clinic
5Yokohama City Minato Red Cross Hospital
Introduction
As cause of varicose vein, involvement of arteriovenous anastomosis (AVA) has been discussed for a long time. Meanwhile in daily clinical works, we often meet the cases with any symptoms seem to be due to hyperflow vein or pulsatile vein. Nevertheless, they are with or without reflux. But the clear definition of this pathology is still unknown.
Objectives
Report 100 cases with this hyperflow vein which were treated effectively by endovenous ablation therapy. Determine hyper flow vein by ultrasound examination and CT angiography. Investigate blood gas analysis and venous pressure in those hyper flow vein.
Methods
We did retrospective study for the 100 cases from last 2 years. Preoperative conservative therapies by elastic stocking and medication were not successful for these 100 patients. All operation was achieved by only puncture without surgical cuts. Anesthesia was performed by local anesthesia including TLA and sedation. We often used 1470nm diode laser and radiofrequency ablation as combination. The targets of ablation mainly were hyperflow vein on below knee and foots. We classified symptoms. And as preoperative examinations, measurement of circumference of legs on the site of below knee and ankle, ultrasound, CT angiography (CTA), Blood gas analysis was performed. Measurement of venous pressure was performed during operation. All patients were followed by ultrasound and measurement of circumference of legs on the site of below knee and ankle
Results
Mean age of patients is 66.8, male: female is 34: 67. As symptoms swelling and pain were most observed, and especially the ’smarting’ pain was thought characteristic. Symptoms were improved by operation in almost 80% patients. No severe complication after surgery was observed. 95% patients had past history of big operation and injury, or autoimmune disease, chemotherapy, radiation therapy. Ultrasound and CTA were useful for diagnosis. Especially ultrasound revealed hyperflow in vein and location which hyperflow starts. At first, we thought venous hyper pressure should be cause of this pathology. But hyperflow was more significant than pressure.
Conclusion
Endovenous ablation therapy was effective and safe for the hyperflow vein symptoms, and at the same time, we can say that hyperflow vein can cause those kinds of symptoms. The mechanism of this pathology is thought as below. AVA which physiologically exists on legs can be opened by chance of stress from big operations or diseases. Then if this open AVA situation is fixed and chronic, symptoms can appear as phlebitis. It’s difficult to find the location of AVA, but careful observation by ultrasound examination can reveal that. AVA often exist multiply on the below knee legs and foots. Therefor it’s important that treatment should be not for small part, but systematically.
Results of management of Lesser Saphenous Vein (LSV) Insufficiency with Thermal or Chemical Ablation and the relationship with Insufficient Venous Diseases (IVC) in a series of Salvadorian Patients
Varicentro El Salvador
Introduction
The role of Lesser Saphenous Vein reflux and its relationship with chronic venous insufficiency has been a topic ignored and unexplored for many years. This study aims to present the current panorama of the role of the lesser saphenous vein insufficiency in the clinical condition of patients in El Salvador.
In Central American, studies published on the approach to venous insufficiency of the lesser saphenous vein are either not published or have not been performed, which is why it is important to know demographic characteristics of the population, identify the anatomical pattern and determine the classification and severity before and after treatment with thermal or chemical ablation. There is also no information about the improvement in functionality, the pain after carrying out the procedures and the repercussions of the treatments on symptoms such as edema of the limbs.
In the absence of regional (Central América) data to guide the management of patients with venous insufficiency of the lesser saphenous vein, it is necessary to gather information from the experience so far in specialized care centers for patients with this disease.
Objectives
Evaluate the clinical cases of patients with venous insufficiency of the lesser saphenous vein managed with thermal or chemical ablation in the Varicentro Clinic. Describe the main demographic characteristics and anatomical variants of the lesser saphenous vein present in population treated. Determine the classification and severity of venous insufficiency of the lesser saphenous vein in the patients studied before and after treatment.
Methods
Methodology: Retrospective longitudinal study, observational type.
Universe: Salvadorean patients diagnosed with venous insufficiency of the lesser saphenous vein.
Sample: Salvadorean patients who underwent thermal ablation or chemical ablation procedures at the Varicentro Clinic in San Salvador during the period from January 2014 to December 2016. A non-probabilistic sampling was used for convenience.
Analysis unit: Instrument for data collection based on the clinical record of each patient and the VCSS scale.Inclusion criteria:
Patients diagnosed with venous insufficiency of the lesser saphenous vein who undergo thermal or chemical ablation at the Varicentro Clinic. Age over 18 years with consent
Exclusion criteria:
Patients diagnosed with venous insufficiency of the lesser saphenous vein secondary to deep vein thrombosis. Pregnant woman or breast-feeding. Retirement during the study
All the data were consigned in a file per patient and later tabulaste in a Microsoft Excel database, the subsequent arrangements were made in SPSS and GraphPad Prism. The data will be subjected to descriptive and inferential statistics
Results
An average age of 57 years was found, a mode of 69 years and a predominantly female population (98%). At the time of being treated, 63.3% of the population was overweight or obese. Anatomically, the most common patterns of the lesser saphenous vein were types A and B, with 35.4% representativeness each; in 54.2% the opening of the lesser saphenous vein was found in relation to the interatrial line above the popliteal fossa.
Of the patients who presented saphenous vein insufficiency, 48.8% (CEAP 3–6) presented criteria to classify them with chronic venous insufficiency. Of the treated limbs, 16.6% presented with active ulcer, with an effectiveness of closing the ulcer in a period between 15 to 22 weeks of 100% after intravenous ablation.
The total occlusion of the treated veins at the observation period was 91.6% in the thermal ablation and 66.6% in the chemical ablation. There was only one case of total vein permeabilization and it was observed after treatment with chemical ablation.
A significant reduction was observed in relation to the Venous Clinical Severity Score (specifically pain, varicose size and edema reduction) and the CEAP Classification after treatment. We consider that the most important clinical sign of follow-up for comparison before and after treatment is the diameter of the affected leg, since there was a statistically significant decrease in the average diameter of 2.2 cm at the ankle, 1.22 cm at the level of the middle third and 1.19 cm at the level of the upper third (p <0.0001).
Conclusion
Complications of the reported treatments are more frequent if complementary treatments are added at the surgical time to the ablation treatment. The most frequent adverse effects when pure treatments were carried out were: in the thermal ablation ecchymoses (50%) and paresthesia (25%); in the chemical ablation thrombophlebitis (66.6%) and thrombosis of other veins (50%).
Recognizing the implications of lesser saphenous vein insufficiency in the development of CVI, demographic characteristics of each population, ultrasonographic anatomical pattern and the risks and benefits of current endovascular treatments allow the specialist greater levels of effectiveness at low cost and with lower risks to the patient
Do characteristics of Superficial Vein Thrombosis predict progression? A venous duplex ultrasound study
University of Toronto
Introduction
Superficial vein thrombosis (SVT) is recognized as a venous thromboembolism equivalent with a risk of progression to deep vein thrombosis (DVT). Characteristics of the SVT that have been identified as potential predictors of progression include location near junctions or length > 6 cm. A history of malignancy may be associated with a higher risk of progression. Where a high risk of progression is anticipated, guideline recommendations for management favor intervention with anticoagulant even without documented DVT. Intermediate risk situations may be best monitored for progression with repeat imaging. There is no comprehensive correlation of SVT characteristics, such as distribution, location, combination and length, with risk factors and the progression rate.
Venous duplex ultrasound (VDU) can accurately characterize SVT and serve as a tool for surveillance. The findings on the first study and the risk factors may relate to progression and guide surveillance protocols and management options.
A comprehensive correlation of risk factors and SVT characteristics may help to predict progression and guide therapy.
Objectives
To identify characteristics, such as distribution, location, length and combinations of SVT by venous duplex ultrasound. To correlate characteristics on initial study with changes on surveillance venous duplex ultrasound. To correlate risk factors with SVT characteristics and surveillance findings to predict progression.
Methods
All patients who presented to our community-based vascular center between September 2017 and March 2018 with an SVT on initial VDU were entered in this study. All patients underwent a comprehensive VDU that studied the superficial and deep venous systems from the iliac veins to the ankle bilaterally. The extent, distribution and length of the SVT were entered in a standard recording sheet at the initial and subsequent VDU studies. Patients had an initial study and follow-up surveillance VDU at 3–4 weeks and 3 months. Patients with incomplete studies or those that did not complete follow-up were excluded.
The findings were correlated with risk factors for venous thromboembolism obtained from a standardized detailed history. The assessment of the extent, distribution and length of SVT was correlated with progression of the SVT or development of DVT.
Results
250 patients satisfied the inclusion criteria. Risk factors for venous thromboembolism included varicose veins (190), obesity (98), recent travel (62), previous SVT (25), malignancy (12) and coagulation abnormality (7). The extent of SVT included minimal (42), localized (28), bilateral (66) and multi-segmental (117). The length of SVT included short < 2 cm (20), medium 2–6 cm (150) and long > 6 cm (80). The locations included great saphenous vein (GST) above knee (35), below knee (110) and both (25) and small saphenous vein (SSV) (45) and combined GSV and SSV (62). The SVT was noted to be at the junction (8), < 2cm (12) and 2–5 cm (15).
Progression of SVT, including extension into DVT, occurred in 16% of patients. Correlations with risk factors showed greater likelihood of progression in patients’ malignancy (75%), previous SVT (48%) and coagulation abnormality (42%). Patients with SVT at or within 2 cm of the junction (40%), long segment (25%) and multi-segmental (28%) disease showed progression.
Conclusion
Patients with SVT are at risk of progression; VDU is an appropriate tool to identify and monitor patients with SVT. Specific risk factors (malignancy, previous SVT and coagulation abnormalities) are predictive of progression. Specific characteristics of the SVT itself also correlate with progression (long length, multi-segmental disease and proximity to the junctions). Consideration of these factors may be helpful in guiding therapy in these patients. Intensive surveillance or initiation of anticoagulation may be appropriate in higher risk patients. Further study with larger numbers over a longer period of time may provide more insight into this.
Laser treatment of the Giacomini vein
1société francaise de phlébologie
2clinique pasteur
Introduction
The safety and effectiveness of endovenous laser treatment for varicose veins are evaluated for approximately fifteen years. The vein of Giacomini is an intersaphenous anastomosis that was first described in 1873.
The thigh extension branch, also known as the vein of Giacomini in many patients, may also contribute to venous pathology.
Objectives
Evaluatate if endovenous laser ablation with a 1470-nm wavelength is an effective and safe procedure for treating an incompetent vein of Giacomini. Evaluate the pain during the procedure
Methods
EVLA (1470 nm diode laser-radial fibre) was performed under local tumescent anesthesia. The refluxing vein of Giacomini was entered under ultrasound guidance. Tumescent anesthesia was administered under ultrasound guidance. During tumescent anesthesia and under ultrasound guidance, the position of the nerves, previously identified, determines a safe puncture area, which is located a certain distance away from the nerves. The patient is only under local anesthesia.
The fiber was pulled back continuously at a rate corresponding to 80 J/cm (power setting 11 w)
Results
In the 5 limbs, the technical success rate was 100%. Continued closure of the vein of Giacomini was seen in 5 of 5 limbs after 6 months. No recanalization of the vein and no major complications occurred (thrombosis, paresthesia, steppage). Average pain: 2
Conclusion
Endovenous laser ablation with a 1470nm wavelength seems an effective and safe procedure for treating an incompetent vein of Giacomini.
Duplex Ultrasound Features in Chronic Venous Disease – A Single Centre Experience
Imperial College London
Introduction
Chronic venous disease (CVD) represents a significant societal and financial burden to the healthcare system. Patient assessment comprises of clinical, quality of life and imaging assessment. Venous duplex ultrasound (DUS) is the gold standard imaging tool and is employed to guide further CVD management. While quality of life scores clearly correlates with disease severity, the relationship with duplex features is less clear. Previous work has shown a weak correlation between CEAP stage, venous clinical severity score (VCSS) and Aberdeen Varicose Vein Questionnaire (AVVQ).
Objectives
Determine whether the extent of venous reflux was associated with reduced quality of life (QoL) or increased disease severity by assessment of extent of reflux in a truncal vein Determine whether the extent of venous reflux was associated with reduced quality of life (QoL) or increased disease severity by assessment of the presence of pathological, incompetent
Methods
Patients with symptomatic CVD were recruited prospectively over 4 years (2013–2017). Healthy, asymptomatic volunteers were recruited to act as CVD controls. Both patients and controls provided informed consent for imaging of their lower limb(s) with DUS, recording presence of deep and superficial reflux, presence of above-knee (AK) and below-knee (BK) superficial great saphenous vein (GSV) reflux, small saphenous vein (SSV) reflux, number of trunks affected, and number of incompetent thigh and calf perforators. The AVVQ result, CEAP class and VCSS were also recorded. All statistical analysis was performed using SPSS Statistics (Version 24, IBM®). Participants were stratified into groups based on having isolated AK, isolated BK or both above- and below-knee (ABK) GSV reflux. Students’ t-test was then performed to determine if clinical and quality of life scores differed significantly between groups. Spearman’s correlation was also employed to explore the relationship between perforator number and disease specific data.
Results
621 participants were included: 516 symptomatic patients (57.9% female) with a mean age of 54.1 years (SD ± 16.6; range 19-96) and 105 asymptomatic controls (C0-1) (62.9% female) with a mean age of 36.2 years (SD ± 12.3; range 21-88). A total of 916 limbs were assessed, with reflux seen in 590 GSVs and 199 SSVs.
258 right and 281 left lower limbs were included in the analysis. ABK reflux was seen in 232 limbs, isolated AK reflux in 192 limbs and isolated BK reflux in 115 limbs. ABK reflux was shown to result in significantly higher CEAP class when compared to isolated AK (2.83 ± 1.11 v.s. 3.15 ± 1.35, p = 0.008) and BK (2.83 ± 1.35 v.s. 3.15 ± 1.35, p = 0.044) reflux, but not between isolated AK and BK reflux (2.83 ± 1.11 v.s. 2.83 ± 1.35, p = 0.960). For VCSS, ABK reflux only showed significantly higher scores when compared to isolated BK reflux (4.65 ± 3.52 v.s. 5.57 ± 4.04, p = 0.036). No significant difference was seen for AVVQ scores.
Across this cohort, presence of pathological perforators was weakly associated with AVVQ (Spearman coefficient rs = 0.324, p < 0.01), CEAP (rs = 0.294, p < 0.01) and VCSS (rs = 0.221, p < 0.01). Additionally, incompetent perforator number was also weakly associated with AVVQ (rs = 0.242, p < 0.01), CEAP (rs = 0.236, p < 0.01) and VCSS (rs = 0.186, p < 0.01).
Aberdeen Varicose Vein Questionnaire scores for isolated above-knee, isolated below-knee and both above- and below-knee reflux
Clinical, Etiological, Anatomical, Pathological class for isolated above-knee, isolated below-knee and both above- and below-knee reflux
Venous Clinical Severity Score results for isolated above-knee, isolated below-knee and both above- and below-knee reflux
Conclusion
In a large cohort of CVD patients and healthy controls, having ABK reflux was shown to result in significantly higher CEAP class than isolated AK or BK reflux, and higher VCSS scores than isolated BK reflux. This relationship was not seen for AVVQ scores. Weak correlation was observed between AVVQ, CEAP and VCSS and presence and number of incompetent perforators, suggesting limited utility in the assessment of CVD patients.
HEMODINAMICAL AD ANATOMICAL PATTERNS FOR GREAT SAPHENOUS SPARING IN VARICOSE VEIN TREATMENT
Ippocrate Vein Clinic
Introduction
The treatment of varicose veins is usually characterized by the suppression of the saphenous trunks with or without crossectomy. For the most of vascular surgeons crossectomy and saphenectomy is still the gold standard, for many others physicians the so called endovascular procedures, thermal or chemical, are better, but in any case the poor saphenous trunk is definitely damaged. Other physicians tried to introduce a hemodynamic way of thinking (Chiva), but also in these cases the groin is surgically treated, and the saphenous flow inverted. In all these cases the reflux theory is from top to bottom, but we have seen in many years of phlebological activity that in most of cases the reflux begins at mid leg. So, the theory could be totally different, from bottom to top, creating a new philosophy in phlebology. The removal of the varicose tissue (varicose veins) leaving the GSV has been published and the results seems to be interesting. In this study are presented the anatomical and hemodynamical reasons of a conservative choice, the technique and the results with 18-month follow-up in 250 legs.
Objectives
Aim of this study to demonstrate that in more than 80% of great saphenous vein reflux with terminal valve incompetence the great saphenous vein chemical or terminal disruption or stripping can be avoided There are three hemodynamic models able to give the possibility to treat GSV insufficiency without an ablation Great saphenous vein reflux with terminal valve incompetent can be saved from destruction with a quick recovery, local anesthesia and 1/2 mm skin incisions and discharge in 1 hour and return to normal activity in 12 hours.
Methods
From a series of 728 varicose legs examined and operated for VV, 250 were chosen for GSVSS (Great Saphenous Vein Sparing Surgery). All legs presented great saphenous vein reflux and terminal valve (TV) incompetence; they were mapped and digitally reordered and divided in three groups depending on hemodynamical and anatomical features. Group A: presence of reentry Dodd perforator; Group B: absence of reentry perforator but more than 3 draining thigh veins; Group C: hypoplasia of great saphenous vein. In all patients the GSV was saved. The surgical procedure is described. During mapping the diameter of GSV was recorded, the TV was examined and the number and size of thigh draining tributaries was noted. The presence, the size and number and hemodynamic of thigh perforators was precisely described. An extensive phlebectomy was performed in all patients.
Results
The analysis of the results has been divided in clinical and with color duplex study after 1 month, 6 months, 12/18 months. 124 (50%) legs completed the FU at 18, while 96% experienced 12 months FU. The duplex analysis in the groups A, B, C, D take note of the residual great saphenous vein with: a) diameter, b) presence of reflux c) presence of thrombus d) absence of reflux and draining flow. In 9% of cases the GSV was thrombosed, and in these patients the reentry perforator was very thin or non-present. In 94% of cases the GSV diameter was reduced and in 67% of cases the GSV was still refluent but draining in a perforator, in 42% of cases the GSV was without reflux. In 98% of cases there was improvement in clinical status and no varices were present, in 2% of cases there were residual varices and worsening of previous status (due to acute thrombosis of the residual axis). In 100% of patients at 6 months follow-up all the symptoms disappeared.
Conclusion
More than 80% of great saphenous vein reflux with terminal valve incompetence the great saphenous vein chemical or terminal disruption or stripping can be avoided
SIMULATOR FOR SCLEROTHERAPY TRAINING
UNIFESP-ESCOLA PAULISTA MEDICINA
Introduction
Sclerotherapy is the main treatment of telangiectasias. The physician should receive adequate training to perform the intravascular application. Currently the training is done directly on the patient causing serious ethical problem. The search for better teaching methods should guide the precepts of good medicine and ensure access to new techniques for all. The increasing use of simulators in medical education is notorious worldwide, but the high cost often prevents use in less favored countries.
Objectives
The objective of this work was to develop a realistic simulator for the training of sclerotherapy, having as its scope: easy reproduction, low cost and easily manipulated, allowing wide diffusion of the method. Create a training protocol. Results of the training
Methods
The project was developed in two phases:
Phase 1 - Simulator development
The simulator was developed from easily found materials such as colored and transparent silicone and copper wires. In the transparent silicone were included 20 copper wires of 0.24 mm that simulated the telangiectasias.
After 48 hours, the copper wires were removed one by one and in its place remained the path simulating a venule. For better contrast of the routes blue ink was used that occupied the spaces left by the wires reaching a similar aspect to telangiectasias. Fifty simulators were used in the protocol.
Phase 2 - Training and Certification Protocol
The protocol consisted of theoretical classes and a practical part in the simulator. After the theoretical class was provided to the resident a kit containing: 1 simulator; 1 bottle with ink, 1 bottle with liquid for injection; 1–3 ml syringe; 1 needle 30 G ½; instruction manual. After completing the sessions, the student was examined by 3 experienced examiners. In order to be certified that he was fit, the resident had to present an accuracy of more than 70% of the attempts with the 3 examiners.
Results
Phase 1 - Simulator
We were able to create a simulator that met all the requirements: low cost, reproducible and easy manipulation. The cost per training kit was estimated at $5.
Phase 2
Fifty students from the last year of medical school were evaluated, with 30 men and 20 women with a mean age of 26 years ranging from 24 to 29. All students completed the protocol, which consisted of 10 sessions with 10 applications per session. The mean score in the first session was 4, ranging from 3 to 6, in the last session the mean score was 8.8, ranging from 7 to 10. In the final evaluation of the 3 examiners, all the students achieved a score above 7, showing good performance in the procedure after starting treatment.
Novel, High Containment, Circular Knit Garment Provides Improved Edema Management for Lymphedema
1ILWTI
2SIGVARIS
Introduction
There are statistically significant differences in capillary filtration rate and development of edema between elastic versus stiffer compression garments with same amount of ankle pressure. Most circular knit garments do not have adequate stiffness to contain chronic edema including lymphedema. A novel Compression and Containment Hybrid Garment (CCHG) is the first hybrid, thin, cosmetically appealing, circular knit garment, that delivers containment for robust edema management.
Objectives
Design and test a circular knit product capable of meeting the chronic edema patient need for graduated compression and containment while providing improved cosmesis and ease of use Study product properties using laboratory testing techniques Study product efficacy by wear testing with participants with Stage I Lymphedema
Methods
Tests were conducted to capture CCHGs unique characteristics. Both compression and stiffness values were verified at the foot, ankle, calf, and thigh. Textile stiffness was defined as the increase in compression per centimeter increase in the circumference, expressed in mmHg/cm. Comparative testing was conducted on traditional, circular knit compression garments. Preliminary, clinical wear tests were conducted by participants classified as having Stage I Lymphedema. Participants wore the CCHG for 5–10 days, and circumferential measurements of each participants’ ankle, calf and thigh were taken before and after the wear testing by the treating lymphedema therapist or by an experienced participant managing their lymphedema following decongestive therapy.
Results
CCHG designed with dosages of 20-30mmHg, 30–40mmHg, and 40-50mmHg compression pressures at the ankle were found to be accurate and consistently reproducible within the sizing ranges. Graduated compression was achieved, with more even distribution of compression from the metatarsal heads to the thigh, compared to traditional circular knit stockings. The CCHG distribution of compression, relative to the compression at the ankle, is an average of 71%, 68%, 43% across the foot, calf and thigh, respectively. Comparatively, traditional medical grade circular knit garments averaged <20%, 50%, 30% at the foot, calf and thigh, respectively.
Average stiffness at the ankle for the CCHG was double that of traditional circular knit. Low garment fatigue was achieved for wear cycles out to 6 months of usage.
All 8 wear test participants reported that the garments were comfortable and relatively easy to don and doff. CCHG effectively contained the edema in all patients, with no statistically significant increase in limb size, p>0.05 (Table 1).
Conclusion
Effectiveness of compression garments does vary based on compression and containment properties. As the science of edema management evolves, and our understanding of the different presentations of edemas deepens, new constructs for compression garment selection must be developed such as the CCHG. With a host of compression garments available to patients, effectiveness and concordance to compression does vary. Most circular knit garments do not have adequate stiffness to contain chronic advanced edema including lymphedema. In 2009, van de Wegen-Franken showed that in 12 Different Class II Garments, including both circular and flat knit, static stiffness varied dramatically. According to this study, a dramatic difference in static stiffness between medical grade compression garments can exist. Dramatic differences were also seen in garment fatigue, with one garment dropping over the course of the day by 44.8% to a mere 6.24mmHg at the ankle. Until now, clinicians may have not been aware of critical parameters of garments necessary to make appropriate selection for patients. These parameters include not only the compression at the ankle, but the distribution of compression and stiffness at the foot, ankle, calf and thigh.
The CCHG is a novel, cosmetically appealing, stiffer, circular knit compression garment that provides more containment than traditional circular knit garments for edema management and meets the needs of clinicians and patients.
Beware of “Blue Bumps” in the Elderly
1University of Cincinnati College of Medicine
2Good Samaritan TriHealth Hospital
3TriHealth Hatton Research Institute
Introduction
We present a case of a 75-year-old white female with a complicated medical history of recurrent right hip infections starting in 2004. She received a total hip replacement followed by removal and reinsertion with multiple subsequent infections.
Methods
She presented to the office complaining of new “blue bumps” across her lower abdomen and gave a history of lower extremity lymphedema not responding to therapy. A venous duplex scan showed asymmetry of her common femoral vein sizes and loss of spontaneous and phasic flow with a heterogeneous mass and continuous Doppler signals. A CT scan confirmed iliac vein occlusion and abdominal wall varicosities. Additionally, a mixed fluid collection arising from the right hip joint and measuring 11cm x 12cm x 9 cm was identified.
Results
The patient has declined further intervention due to the risk of infection. However, she is using compression and massage therapy to ease her symptoms.
Conclusion
Delayed complications are common in the elderly after orthopedic surgery. A complete investigation of new symptoms and complaints is warranted in these patients. Vascular complications of orthopedic interventions, both acute and long term will be discussed.
Foam – short track to ulcer healing
Practice for Internal Medicine and Vascular Diseases. Halle, Germany
Introduction
Thermal and non-thermal endovenous procedures, stripping/HL and ultrasound-guided foam sclerotherapy (UGFS) can all be used to treat varicose veins. Although there is a very high primary success rate for all of the procedures, up to 65% of patients experience a relapse within 10 years. It should be noted that the most severe form of the disease, the venous leg ulcer (stages C6 and C5), also has a similarly high recurrence rate. Various studies have shown that surgical or ablative treatment of varicosis is superior to conservative wound dressing and compression therapy alone. Nevertheless, relapsing ulcers can also occur in nearly every second patient receiving surgical or interventional treatment. This often requires repeated procedures and can lead to significant costs.
Objective
The presentation highlights the importance of ultrasound-guided foam sclerotherapy in treating ulcers and demonstrates the workflow for treating the feeder veins and the perforator veins involved.
Methods
Demonstration of a recorded case.
Results
In ulcer treatment, modern wound dressings aim to cleanse the ulcer, combat biofilm and stimulate the proliferation of regenerated tissue. Compression therapy is intended to decongest the edema and improve tropism.
However, the main cause of the skin defect can only be treated by eliminating ambulatory venous hypertension. The principle measures include the removal or occlusion of refluxing saphenous veins and, if necessary, the recanalization of obstructed deep veins.
A special situation is found in the vicinity of a venous ulcer, which is located distally to the refluxing saphenous veins on the inner ankle. The feeder veins have a diffuse, often bed-like course and can be closely connected to the Cockett perforators, which connect the deep vein system with the posterior arch vein. These perforators have a special significance in the context of post thrombotic syndrome.
The guidelines recommend treating the perforators only if the ulcer is active or has healed, however the data on this are weak (grade 2C recommendation). Thermal ablative procedures (EVLT/RFA) and sclerotherapy are preferred to endoscopic surgical therapy. In contrast to the results obtained when treating the saphenous vein, the superiority of thermal treatment over sclerotherapy in treating the perforators is significantly less pronounced. In a study by Hager et al. 73% of the treated perforators were closed after 2 weeks following RFA, 61% after EVLT, but also 57% after UGFS. On the one hand, it can be concluded that UGFS effectively interrupts the reflux, which leads to an acceleration of the healing process. At the same time it can be deduced that, when treating the perforator veins, repeated interventions should be more frequently expected regardless of the method used.
The Cockett perforators can be thermally treated using an RF stylet® (Medtronic™, Minneapolis, U.S.A.) or a radial slim fiber. One major challenge is to avoid puncturing the perforator in supine patients who often have indurated or atrophic skin. Since this is not a routine intervention, the learning curve is steep. The special advantage of ultrasound-guided sclerotherapy is that the perioperative venous plexus can also be treated in the same session.
In accordance with German guidelines, polidocanol is used exclusively for the sclerotherapy carried out at the author’s treatment center. The maximum volume approved for treatment is 10 ml. According to the treatment protocol, the Cockett perforators are first treated through direct puncture or a flexible cannula. For this purpose, small volumes no greater than 3 mL but in stronger concentrations (2%) are applied to the posterior arch vein under ultrasound guidance, whereby the perforator vein is closed tangentially. In order to prevent thrombosis of the posterior tibial vein, the patient is requested to move his or her feet after the foam is applied in order to accelerate outflow from the deep vein as it is impossible to avoid transferring foam through the perforator into the deep vein system. The periulcerous varicose veins are subsequently treated through direct puncture under ultrasound guidance. In this case larger volumes are used (up to 4 mL), but generally at weaker concentrations (0.5–1%). Early mobilization helps to prevent thrombosis. If the patient has a history of thrombosis, a low molecular weight heparin is administered for one week for thrombosis prophylaxis.
The success of the therapy is assessed in a follow-up consultation after approx. 7–10 days. The sclerotherapy is repeated if necessary.
Cockett perforator pre- (left) and post procedure (right) using 2.5 mL of 2% polidocanol foam
Under ultrasound guidance the foam is applied directly into the feeder veins and tangentially into the perforator (via the arch vein).
Conclusion
Ultrasound-guided foam sclerotherapy of periulcerous varicose vein bundles and perforator veins is a fast, cost-effective and low-risk method for treating ulcers. It is characterized by the fact that it can be repeated in a small consultation setting without anesthesia and does not additionally burden the integrity of the skin. The somewhat higher recurrence rate compared to thermal procedures is compensated by the fact that ulcer patients have to repeatedly visit the practice for debridement anyway.
Endovenous Laser, Sclerotherapy and Vein Gluing Combined as a Single Catheter Procedure for Saphenous Veins. Initial experience
Angioclinic vein centers
Introduction
Gluing of veins is discussed as being superior to thermo-occlusive methods or sclerotherapy as it may achieve immediate and permanent vein closure. Furthermore, no tumescent anesthesia is required. However, approved gluing methods use continuous placement of aggressive and hardly resorbable cyanoacrylate (VenaSeal, VariClose, VenaBlock) while for safety reasons sparing the junction. Segmental glue application is preferred by some investigators meanwhile, but this leaves native endothelium and thus a source of relapse. All these drawbacks could be overcome by a new modality which combines endovenous laser for the junction, followed by segmental or pointwise gluing and catheter sclerotherapy.
Objectives
To evaluate feasibility, safety and effectivity of the proposed method; To evaluate the morphology of the saphenofemoral junction after treatment; To compare vein regression effects of the three used modalities.
Methods
22 patients (16 f, 6 m, 42–72 yr.) with GSV insufficiency and diameters of 8 - 22 mm Ø (mean: 9.2 mm), length 43–62 cm (mean 55.1 cm) underwent endovenous laser (980–1470 nm) for an 8 cm long junction segment ("laser crossectomy"), followed by a Scleroglue® procedure, comprising sclerotherapy (Aethoxysklerol 1%, 1 + 4 with air) and cyanoacrylate spot gluing, using a single coaxial catheter access (prototype, Swiss VX). No external compression media were used post treatment except a film bandage for superficial varicosities. Follow up was performed next day and after 2–6–12 months.
Results
All cases (22/22) showed immediate saphenous occlusion and reflux elimination. Day one examinations showed the saphenofemoral junction closed without any stump (22/22). Procedural time from first puncture to access closure was 9:30–15:30 min. (mean: 11:45 min). At one-year follow-up, all cases showed total occlusion, including the junction. While at 2 months FU glue spots showed the smallest lumen, at one-year FU laser- or foam-treated segments showed better regression, due to the slow resorption of acrylate glue. There were no adverse events.
Conclusion
Combining laser crossectomy and ScleroGlue® in the reported technique is well feasible, safe and effective. Morphological results were clearly superior to any single technique. However, the procedure will hardly be suitable for clinical routine application as long as there is no cost-effective (e.g. < 400 USD) manufactured device.
The venoarteriolar reflex is abnormal in the legs of women with Stage 2 and 3 lipedema compared to controls
1UTEP
2University of Arizona
Introduction
Blood flow to the limbs remains stable despite changes in posture. When venous transmural pressure increases by lowering a limb, there is a reduction in blood flow by 50%. This reduction in flow is termed “the venoarteriolar reflex (VAR).” The VAR exists in all tissues of the limbs, including fat. Blood pools in the lower body on standing, therefore the VAR is an important vasoregulatory mechanism preventing loss of fluid to the extravascular space. Women with lipedema develop increased and painful fat tissue and fluid on the lower abdomen, hips, buttocks, thighs and calves sparing the feet; the arms are less affected. Fluid and fibrosis occur in the interstitium in fat in women with lipedema. Women with Stage 3 lipedema tend to have more fat and fluid than women with Stage 2 lipedema.
Impairment of the VAR may be a cause of unexplained leg swelling. We postulate an abnormal VAR may add to swelling in lipedema as suggested previously. The aim of this study was to assess the VAR in the arms and legs of women with lipedema and controls.
Objectives
Perform venoarteriolar measurements for the fingers and toes of women with Stage 2 and 3 lipedema compared to controls. Determine if the function of the blood vessel venoarteriolar reflex in women with lipedema is altered compared to controls. Link abnormalities in in VAR and pulse volume that may result in leakage of fluid into the interstitium to the pathophysiology in lipedema.
Methods
During the Fat Disorders Research Conference in Dallas, Texas April 27-29, 2018, we recruited 48 women with lipedema, and processed data on 21 and 7 controls. A validated iPhone® app called iPhysioMeter (http://iphysiometer.com/app/?lang = en) was used to measure pulse volume. The subject sat down for measurements. The iPhone was placed on the tip of the index finger with the arm at the level of the heart to completely cover both the LED flash and the camera lens. The measurement of pulse volume was obtained over an average of 60 seconds. The arm was lowered and allowed to hang at the subject’s side and the 60 second measurement was repeated. These steps were repeated for the toe. The VAR was calculated as the pulse volume of the dependent limb (down) over the pulse volume of the neutral limb (up). Data was calculated on a limited data set due to time. Additional analyses will occur before the ACP meeting in Nashville in November 2018. Differences between pulse volume values on the same limb were by paired t-tests. Unpaired t-tests were used to compare between limbs or groups. Alpha of <0.05 was considered significant.
Results
The VAR was abnormal (>1) in the toe of women with lipedema Stage 2 (1.37 +/- 0.6) but not for the finger (0.7 +/- 0.3). The VAR was normal in the toe (0.8 +/- 0.7) and finger (0.4 +/- 0.3) in Stage 3 lipedema and in the toe (0.8 +/- 0.5) and finger (0.3 +/- 0.1) in Controls (Figure 1).
Pulse volume was appropriately and significantly higher in the finger when up compared to when down in controls (P = 0.0073) and trended up in Stage 3 lipedema (P = 0.056) and Stage 2 lipedema (P = 0.063; Figure 2). The foot when down pulse volume (0.0032 +/- 00.13 mNPV) was significantly lower than the foot up pulse volume (0.0066 +/- 0.0038 mNPV) in women with Stage 3 lipedema (P = 0.0043). The down pulse volume of the toe in lipedema Stage 3 was also significantly lower (P = 0.029) than foot down pulse volume in Stage 2 lipedema (0.007 +/- 0.001 mNPV).
Venoarteriolar reflex (VAR) in fingers and toes of women with lipedema and controls (top). VAR > 1 demonstrates dysfunction and risk for fluid leakage into the legs. Pulse Volume in the feet (middle) and hands (hands) in up and down positions of women with lipedema compared to controls.
Conclusion
The VAR was found to be abnormal in the legs of women with Stage 2 lipedema suggesting that there is a deficiency in the function of the vessels in the legs of these women which may contribute to leakage of fluid into the interstitium. Lymph fluid induces fat growth; therefore the abnormal VAR may contribute to the excess fat in lipedema. The VAR was normal in Stage 3 and controls, but the sample size was small and additional samples may allow for more definitive conclusions.
The pulse volume in the hands was appropriately higher or trended higher in the hands of women with lipedema Stages 2 and 3 and controls but there was no significant difference in the pulse volume for the toes for lipedema Stage 2 and controls, suggesting that the VAR may be generally weaker in the legs of women. Additional studies in men would be interesting.
The pulse volume for the toe in the down position was significantly lower for women with Stage 3 lipedema compared to the toe in the up position and was also significantly lower than the toe in the down position for lipedema Stage 2. These data suggest that the vasculature is altered in women with Stage 3 lipedema reducing pulse volume and possibly contributing to poor oxygenation of the fat tissue (hypoxia).
Additional data, currently under review, will allow us to determine if the VAR in women with lipedema is abnormal, and therefore contributes to excess fluid in the interstitium, contributing to the pathophysiology of fluid accumulation and risk for lymphedema in this disease. Additional data will help us determine if the pulse volume is significantly and detrimentally decreased in women with Stage 3 lipedema.
Standardization of compression stocking for disaster
Niigata University
Introduction
Venous thromboembolism (VTE) is frequently occurred in Japanese disaster. Particularly, car shelter induces it widely. In Middle Niigata Prefecture Earthquake 2014 and Kumamoto Earthquake, many evacuees in car shelter occurred pulmonary embolism (PE) and at least 12 died from it.
Objectives
Compression stocking (CS) are used for preventing PE all over the world. PE after surgery in Japan was decreased by it, too. Since Mid Niigata Prefecture Earthquake, we have delivered CS to evacuee after disaster. Most CS after disaster were donated by manufactures of CS. However, about half of donated CS could not use after Kumamoto Earthquake. Since the type, the pressure and the size of it was not adequate for preventing PE after disaster.
Methods
The type of it is high socks, the pressure of it is the same as graduate stocking for prevention DVT in hospital (21.3 - 29.3 hPa in ankle and 9.9 - 23.0 hPa in calf) and size of it has more than 4 (S, M, L, XL). The size is measured by diameter of ankle and calf.
Compression stocking for disaster
(Japanese)
Results
We recommend that local government in Japan should storage it against disaster. Because small compact car will use for private shelter in Japan after earthquake. Many calf DVT were detected after the quake in Modena where compact car used for shelter after Emilia Earthquake.
Conclusion
Compression stocking may be needed all over the world after earthquake or natural disaster.
Case report: Severe infection of left leg with secondary lymphedema after the Radio Frequency
Ablation for the varicose vein
Yokohama Minami Kyosai Hospital
Introduction
The Radio Frequency Ablation (RFA) for the varicose vein is common. It is better for patient condition and cost performance. Therefore it is easy to choose as treatment for the disease of a lower extremity without the discussion about etiology in detail. The case was reported as severe infection of left leg with secondary lymphedema after the RFA for the varicose vein.
Objectives
Complication of RFA Secondary lymphedema Group G of streptococcal species
Methods
Case
79 years old, female. Her chief complaint was edema of the left lower extremity. Present illness was Hepatitis B it has been treated, postoperative cervical cancer and hyperlipidemia. Slightly dilatation and reflux of the left small saphenous vein (SSV) was pointed out by ultrasonography. Her diagnose was edema from varicose vein, then the RFA with stub avulsion for the left SSV was performed. After 2 weeks, she came our outpatients with swelled, red and painfully left leg. Some abscess in subcutaneous area were detected along the avulsion area. The emergency operation to drain them was performed.
Results
The group G of streptococcal species was checked out. Antibiotics like penicillin was chosen. We diagnosed the cellulitis from secondary lymphedema caused by thrombophlebitis after varicose vein operation. 4 months later, the cavity on the left foot was closed in natural.
Conclusion
Differential diagnosis is important to choose the method of operation.
How to use Nd:YAG 1064 transdermal laser to treat telangeactasias step by step
PONTIAC CATHOLIC UNIVERSITY OF RIO GRANDE DO SUL
Introduction
Telangiectasias also known as spider veins are small dilated blood vessels near to the surface of the skin measuring between 0.5 and 1 millimeter in diameter, which can develop anywhere on the body but are commonly seen on the legs, face around the nose, cheeks, and chin.
With a high incidence (60 - 80%), this disease is more common in women and it is a frequent complain at the phlebologist and vascular surgeon’s office, becoming a challenge to the specialist. Traditional treatment of this problem is performed with sclerotherapy, but in some cases, lasers are indicated.
Objectives
To show indications advantages and problems of transdermal laser treatments of telangiectasias. To show how to perform these treatments step by step To show the safety guidelines adopted by our group to perform these treatments
Methods
Using a ND:YAG 1064 transdermal laser source with different fluences and spot sizes alone or combined with sclerosants and with skin cooling, the author show how to set the laser equipment to treat the different kind of telangiectasias (Reds, blues or violets) in all Fitzpatrick skin types.
Results
Using the safety guidelines adopted by our group these treatments have excellent results as we will show on several pictures
Conclusion
Although lasers are expensive equipment, they are an effective and safe way to treat telangiectasias, reticular and feeder veins with the employment of advanced technology free of allergic reactions, anaphylaxis or embolism, and if possible, they should be incorporated as an important tool in phlebologists offices because of their excellent results. On the other hand, they have a difficult learning curve and for this reason training is absolutely necessary.
Thermal Imaging with particular reference to venous disease
1None
2Soffer Health Institute
Introduction
Thermal imaging as a technique has been known for several decades however it has not been used on a regular basis. In the last few years the quality of thermal imaging has improved greatly and at the same time the cost has reduced, and sensitivity has increased. Thermal imaging for breast disease has been over used and relied on to an extent which is not justified leading to bringing the technique into disrepute.
In venous insufficiency blood flows from deep to superficial and from proximal to distal. This results in relatively warm blood filling the veins close to the skin, the heat warms the overlying skin which warms in comparison with adjacent skin. Thermal imaging clearly identifies linear patterns of warm skin which conform to the pattern of superficial veins in the leg, a map of the incompetent veins only is created. Thermal images are maps of surface temperature thus, deeper vessels such as the great saphenous vein are not seen. Conventional duplex ultrasound is required to confirm the deep sources refluxing blood.
Objectives
To develop a method for use of thermal imaging in venous practice To validate thermal imaging To demonstrate it offers additional information compared to duplex ultrasound
Methods
The current experience is based on FLIR E60 and FLIR One Pro cameras. They have a wide range of temperature which includes human clinical temperature range, and can have a sensitivity of 0.1°C. Most recent thermal imaging cameras are little more than the size of a matchbox, have thermal resolution of 0.1°C and image 400 x 800 pixels and are compatible with android and Apple devices.
Thermal images are created by focusing photons in the infra-red spectrum onto a temperature sensitive chip. The differing temperatures are depicted as either colored or black and white spectra relating to temperature, which can easily be interpreted by the observer. Many camera systems have automatic temperature ranging and spot temperature capabilities.
Results
In the leg the skin temperature in normal room conditions is between 28-33°C. Areas of increased heat are typically seen over the anterior tibial surface and form distinctive large areas of increased temperature. In individuals without venous disease there are no other areas of elevated temperature nor specifically elevated temperatures in a linear (but not straight) pattern that follows the superficial venous network (fig 1). In contrast, blood that fills normal superficial veins has already been through the capillary network of the skin and so is at skin temperature and so is not differentiated on the thermal image (fig 2). In individuals with known varicose veins these veins are very readily seen as areas of significantly elevated temperature typically 3–4°C above the background skin temperature. The linear patterns correspond to superficial veins but do not show the incompetent trunk veins, and so thermal imaging is unsuitable as a sole method of diagnosis. If linear patterns of elevated temperature are interrogated by with duplex ultrasound retrograde blood flow can invariably be detected. Along the length of the refluxing vein there is also a thermal gradient, until ultimately the vein is seen to terminate as it re-enters the deep vein system through a perforating vein and the linear thermal track abruptly disappears. The thermal pattern is only created by the abnormal refluxing of blood rather than inflammation as assumed by others.
The venous thermal pattern neither comes nor goes quickly and is not a function of immediate refluxing blood but steady heating over a period of time, thus the thermal pattern which represents nothing more than hot subcutaneous tissue and skin takes time to cool down and so the pattern remains for many minutes once the leg is in the supine position and reflux no longer persists, similarly it takes minutes to return after the upright position is resumed.
The leg is best observed in the erect position, it is imperative that no liquids or gels are applied to the skin before imaging as temperature differences are great and are likely to obscure the true signal.
Optimal camera settings are temperature range 28-37°C, for full scale, colour or grey scale is not important, but it is helpful to keep this constant so comparison between images is facilitated.
The camera is pointed at the whole leg from a distance of approximately 50cm. and the limb thermal image viewed live, there is a small but important time lag. When an optimal image is obtained it is recorded and stored. Spot temperatures may be taken as reference points. Three images at 120° apart around the leg can capture the full extent of disease. Infrequently the thermal pattern suggests an atypical origin of incompetence from gluteal, pelvic or lateral thigh complex which may have been overlooked on ultrasound. Confirmatory duplex ultrasound is performed to identify the origin of reflux, saphenofemoral, saphenopopliteal junctions or incompetent perforator veins. Other atypical sources can be traced back along the thermal track to their origin.
Images may be printed to form a permanent record to aid subsequent therapy and for comparison with post treatment images to confirm the completeness of therapy. Images should be stored and catalogued in a systematic and HIPAA compliant manner.
Conclusion
With the increased availability and performance, a new era where thermal imaging can be helpful in a multiplicity of disease states, each requires systematic evaluation to develop reliable disease specific methodology so consistent data can be gathered and the clinical value can be determined.
For superficial vein disease thermal imaging creates an accurate and complete map of incompetent superficial veins, it acts as an adjunct to duplex ultrasound speeding scanning while improving completeness.
Patient and referring physicians’ understanding of treatment options for venous disease: An opportunity for education
University of Toronto
Introduction
Modern management of venous insufficiency and varicose veins allows for an expanding list of therapeutic options. An understanding of the basics of these options allow for better patient care. Previous studies have shown that the referring physician and patient often do not appreciate the options. It is not known if recent publicity of the expanded options of care has also increased patient and physician understanding.
Objectives
To identify awareness of therapeutic options by referring physicians and patients. To correlate the understandings by the physician and the patient with the specialists’ care path. To consider if education programs may be helpful to understanding venous disease.
Methods
200 patients referred to a community-based venous clinic for management of venous insufficiency and varicose veins were entered in this study between January and March 2018. All patients were referred by a physician with a question of appropriate management. All patients underwent venous ultrasound and a clinical assessment. Treatment was offered based on standard practice models. All patients were asked to relate their understanding of possible treatment options.
Results
Patients were referred for varicose veins (122) or spider veins (78). Complications of venous disease included bleeding (2), ulceration (18), superficial vein thrombosis (SVT) (22) and deep vein thrombosis (DVT) (19). Based on the presenting findings, 185 patients and 118 referring physicians considered the patient to have varicose veins and 15 and 82 considered the findings to be spider (intracuticular) veins. Patients were unaware of the complications of SVT 75%, DVT 100% and ulceration 16%. All patients recognized bleeding as related to the veins.
Compared to the specialist’s advice, management options were recognized by the referring physician and patient as follows: support stockings (40%, 25%), weight loss (10%, 0%), increased activity (12%, 5%), phlebotonics (5%, 0%), injection sclerotherapy (35%, 25%), venous ablation (30%, 40%), operative intervention (84%, 75%).
Conclusion
This study showed that patients and referring physicians have a low level of understanding of venous disease, its complications or its treatment. In particular, patients failed to distinguish varicose veins from spider veins and did not connect SVT and DVT with varicose veins.
Both patients and referring physicians had a poor understanding of both general and interventional options for treatment. In particular, weight loss, increased activity and the use of phlebotonics were not understood.
This study suggests opportunities for focused education to referring physicians and patients with venous disease.
Hypnosis and endovenous thermal treatments: a preliminary prospective study
Clinique pasteur
Introduction
Hypnosis have been suggested as efficient safe means in reducing discomfort and adverse effects during medical procedures. We tested this assumption for patients undergoing percutaneous endovenous thermal procedures in a prospective, single-center study.
Objective
Is hypnosis efficient safe means in reducing discomfort and adverse effects during endovenous procedures
Methods
20 patients were selected a row to receive intraoperative hypnotic relaxation (mean age 54 years; 55% woman).
Patients rated their pain and anxiety on 0–10 scales before and after the procedures.
No patients knew in advance that they would have a self-hypnotic relaxation
Results
The mean pain score was only 2.2 for the procedure itself (VASP 0–10; 10 max). Before the treatment the mean anxiety score was 3.95 (scale 0–10; 10 max), and decrease to 0 for all patients during the procedure except one who gave 1. All patients were very satisfied to receive intraoperative hypnotic relaxation
Conclusion
It’s interesting to note:
That anxiety is reduced in all cases and the patients are very satisfied by the presence of the hypnotherapist; the patient’s comfort is greatly improved as well as the doctor.
A randomized study would be very interesting to carry out in order to compare endovascular procedures with or without hypnosis and the effects on pain, anxiety and discomfort.
A new technology significantly more effective in improving venous pumping function than compression stockings
1Clinica MD Barbantini
2Wien University
3ACI Medical
Introduction
Duplex and MRI studies in the upright position have demonstrated that compression stockings will only lead to some minor degree of venous narrowing in the upright position which is the reason for their restricted effectiveness in improving the venous calf pump in patients with Chronic Venous Insufficiency (CVI). Strongly applied, inelastic bandages are much more effective, but they have the disadvantage to be usually poorly applied by not well-trained staff to lose pressure overtime. IntelliPress® (ACI Medical, CA, USA) is a new device made up of an adjustable compression sleeve and a compression pump able to adjust the compression pressure according to the body position: low in supine position and strong in standing position when it is necessary to counteract the strong intravenous pressure.
Purpose
to compare, in patients with CVI, the effects on the calf pump of compression stockings (23–32 mmHg) with that of two version of the compression sleeve, one more and the other less stiff connected to the IntelliPress pump.
Objectives
Venous calf pump was assessed in 16 patients with Great Saphenous Vein (GSV) incompetence (C3-C6) and candidates to GSV ablation by measuring ejection fraction (EF) with a strain gauge plethysmographic method. By strain gauge plethysmography we could measure venous volume (VV) and ejected volume (EV) during a simple movement (walking on spot). Ejection fraction was calculated by the simple formula 100xEV/VV.
Methods
Examinations were performed on the same day, consecutively without compression, with knee length compression stockings and with two more or less stiff IntelliPress sleeves, applied in randomized order to the affected leg.
The compression pressure exerted by the three compression devices at the calf segment was simultaneously registered using air-filled Picopress® (MicrolabItalia, Padua, Italy) transducers.
Results
EF (normal range: >60) is usually significantly decreased in patients with CVI. The median value in our case series was 36,8% without compression and increased to 46,9% with the compression stockings (+29%, n.s.), to 64,8% with the less stiff IntelliPress® sleeve (+82%,***), and to 75,5% with the stiffer IntelliPress sleeve (+110%, ****). Median interface pressures in the supine position were 23, 31, 35 mm Hg respectively for compression stockings, less stiff and stiffer device. Compression pressure increased in standing position to 26, 56 and 68 mmHg, respectively. Median static stiffness index (SSI), that is the difference between standing and supine position, was 3, 24, 31.5 mm Hg respectively. The walking pressure amplitudes (WPA), the differences between diastolic and systolic pressure during movement were 2, 13.5 and 28.5 with compression stockings, less stiff sleeve and stiffer sleeve respectively.
Conclusion
As consistently reported by many others, stiff devices are able to increase EF significantly more than elastic material due to their stiffness as reflected by SSI and WPA. The massaging effect produced by the great difference between standing and supine pressure and between diastolic and systolic pressure is able to expel a greater blood amount pooled in the calf from the lower leg of patients with CVI. In our CVI patients both IntelliPress sleeves were able to significantly increase the reduced EF into the normal range with the stiffer sleeve more effective (n.s.). Both the IntelliPress® devices are significantly more effective than compression stockings that only achieved a mild, not significant EF increase. The advantage of IntelliPress® over other compression devices is that it does not require any expertise to be applied. It automatically increases the pressure when moving from the supine to the standing position and exerts a strong or very strong pressure starting from a very comfortable low pressure in supine position thus hopefully increasing the patient comfort and, maybe, compliance. Last, but not least, it does not lose pressure overtime due to continuous pressure re-adjustment by the pump.
Treating veins with EVRF monopolar radiofrequency - 5 years follow-up results and new method for percutaneous perforator treatment
VP-Med Health Centre
Introduction
EVRF is a monopolar radiofrequency system for the endothermal treatment of telangiectasias, tributaries, perforators and truncal veins. We evaluated the effectiveness of endovenous EVRF treatment and analyzed the 5 years results using the EVRF device. We also made a comparative study using EVRF with segmental pullback vs continuous pullback mode. EVRF with the new CR40i catheter is excellent in the percutaneous treatment of perforator veins.
Objectives
Evaluate the effectiveness of endovenous EVRF treatment and analyze the 5 years results using the EVRF device Compare the results using EVRF with segmental pullback vs continuous pullback mode Analyze the results of EVRF percutaneous perforator treatment
Methods
From July 2011 to June 2017 we treated patients (49 years of average age, 330 men, 980 women) with saphenous reflux and varicosity using EVRF. The procedures were performed on 1310 limbs - 1070 GSV, 202 SSV, 38 GSV+SSV; 1208 patients belonged to CEAP 2,3, 102 patients to CEAP 4–6. The mean diameter of the GSV was 7 and of the SSV 5,2 mm consequently. The length of the treated vein segment ranged from 15 cm to 82 cm, using an amount of 7200 Joules total energy emitted on average.
After completing the first study we compared the results of 30-30 patients treated with endovenous EVRF using segmental pullback and continuous pullback mode. All other settings were completely identical.
We have just started the treatments of enlarged, insufficient perforators with the new CR40i catheter. Through a 18G veinflow the RF catheter is inserted in the treatable perforator. The treatment happens in local anesthesia and can be clearly seen on ultrasound. The procedure is very simple, safe and can be performed ambulatory.
Results
Complete occlusion was found in 99% at the one-month ultrasound control, 1-year ultrasound control showed 97,2%, 3 years data proved 96,8% occlusion rate and after 5 years 94,9% of the treated veins are occluded. Postoperative pain reported by the patients on a visual analogue scale was under 2,3/10, VCSS scores showed significant improvement of the QOL of the patients after 1 and 12 months. There were no cases of deep vein thrombosis, skin burns, neuritis or bleeding, we found minimal bruising at the treatment site of the tributaries in some cases, 5 patient had mild inflammation, treatable conservatively. In the last 2 years we treated the enlarged tributaries with foam sclerotherapy immediately after the RF ablation or a few month later – the omission of physical varicectomy resulted in lower pain scores, less bruising and hematomas.
Comparing the two pullback modes we found 100% primary occlusion in both groups and there were no significant differences in any compared data.
Conclusion
The CR45i EVRF catheter is excellent until 8–10 mm of vein diameter with the standard endovenous closure procedure, more energy must be used in case of bigger veins or heavy weight patients. Both segmental and continuous pullback provide excellent results with minimal complications.
The EVRF endovenous ablation is a safe, painless procedure for the treatment of the GSV and/or SSV, enlarged tributaries and perforators - high patient acceptance and minimal postoperative discomfort allows the quick return to work and normal life. The procedure under local tumescent anesthesia is simple, the disposable devices are easy to use. In our practice the EVRF treatment with CR45i and CR40i catheters was superior to conventional varicectomy or to laser ablation using a 808 nm device with bare laser fiber.