Selected phlebological abstracts

Internist (Berl) 2020; 61: 1230–1237. doi: 10.1007/s00108-020-00899-6

Patients with chronic venous disorders may be asymptomatic, have subjective symptoms, or have objective alterations such as edema, cutaneous alterations, and venous leg ulcers. This ultimately results in chronic venous insufficiency (CVI). Varicose veins are a progressive degenerative disease of the venous walls in the superficial venous system of the legs, which can decisively impair the quality of life of those affected. The classification of chronic venous diseases is carried out with the CEAP classification according to clinical, etiological, anatomical, and pathophysiological criteria. Instruments such as the venous clinical severity score are used for assessment of the severity. The treatment of chronic venous diseases targets the improvement of the subjective complaints and objectifiable alterations. In addition, complications such as phlebitis and formation of ulcers should be avoided. Invasive procedures, compression treatment, and pharmaceutical treatment are complementary, and a combination of these procedures can be meaningful. General physical measures, such as propping up the legs and frequent walking, are part of the basic measures for every patient with venous diseases. Compression therapy with medical compression stockings is the gold standard in the noninvasive treatment of symptomatic venous diseases, possibly supplemented by anti-inflammatory drugs. A varicose vein should be eliminated whenever possible. Stripping operations and the less invasive endovenous thermal ablation show comparable results for saphenous vein varices. Foam sclerotherapy and percutaneous phlebectomy are the methods of choice for elimination of side branch varices; however, recurrences of varicose veins are frequent.

J Vasc Interv Radiol 2020; S1051-0443(20)30699-0. Epub ahead of print, doi: 10.1016/j.jvir.2020.08.019

The authors, in this study, wanted to evaluate feasibility, safety, and results of endovenous mechanochemical ablation (MOCA) for treatment of persistent embryonic and dysplastic veins in pediatric patients with Klippel-Trénaunay syndrome (KTS). 13 MOCA (ClariVein catheter plus liquid sodium tetradecyl sulfate) procedures were performed under general anesthesia in 11 patients (age range 4–16 years) with KTS and symptomatic persistent embryonic or dysplastic veins during a two year period. All patients were evaluated with duplex ultrasound (DUS), contrast-enhanced MR imaging, and venography to assess the anatomy of the target vessels and patency of the deep venous system. DUS and fluoroscopic guidance were used in all cases. Clinical and radiological controls were performed at 1 day, 7 days, 1 month, and 6 months after the procedure and once a year thereafter, with a mean follow-up of 16 months (range, 6–25 months). Technical success and primary occlusion were achieved in 100% of all patients with no adverse events. In the follow-up period, partial recanalization and symptom recurrence occurred in 2 patients (18%), 14 and 18 months postoperatively. These 2 patients had a second ablation procedure with no recanalization or symptom recurrence during the subsequent follow-up period.

The authors concluded that MOCA is feasible and appears to be a safe and effective technique for treatment of varicose veins in pediatric patients with KTS.

J Vasc Surg Venous Lymphat Disord 2020; S2213-333X(20)30559-X. Epub ahead of print, doi: 10.1016/j.jvsv.2020.10.014

In a systematic review, the authors explore the efficacy and safety of “the ambulatory selective variceal ablation under local anesthesia” (ASVAL), “ascending” theory of varicose vein etiology. This theory recommends ambulatory phlebectomy as an initial treatment for tributary varicosities and truncal vein incompetence. In May 2019, Medline, Embase, and the Cochrane Register of Controlled Trials databases revealed 11 original articles that were qualitatively reviewed. The primary outcome was absence of recurrent varicose veins at one-year follow-up. Secondary outcomes were resolution of great saphenous vein (GSV) reflux on duplex ultrasound, change in GSV diameter, objective and subjective clinical improvement in chronic venous disease (CVD), and patient-reported outcome measures. 2,106 limbs underwent intervention in 1,734 patients reported in two randomized controlled trials (RCTs), one case control study, three cohort studies, and five case series. Varicosity recurrence at one year ranged from 0.5% to 13.5% in patients. Of 1,622 limbs with diagnosed GSV incompetence prior to intervention, 1,114 were competent at one year (mean 68.2% [+/− 12.62%]). All studies measuring GSV diameter reported statistically significant reductions in vein size.

The authors conclude that ASVAL may be considered as a minimally-invasive treatment for early stages of CVD in the presence of truncal reflux; however, the evidence base should be strengthened by prospective RCTs that follow standardized procedures and report according to recognized measures of quality of life together with clinical and hemodynamic data.

Korean J Thorac Cardiovasc Surg 2020; 53: 381–386. doi: 10.5090/kjtcs.20.027

The authors conducted a retrospective study of 34 patients over 15 years, all of whom were diagnosed with varicose veins in association with Behçet disease, a chronic inflammatory disorder with varying etiology. The authors reviewed the clinical manifestations, treatment choices, and complications of these patients. Deep vein thrombosis (DVT) was observed in 24 patients (70.59%) and varicose veins in 19 (52.94%). Immunosuppressive treatment was administered to all patients due to the pathological feature of vein wall inflammation; in patients with DVT, anticoagulation therapy was also used; however, post-thrombotic syndrome was observed in all patients along with chronic luminal changes. 11 patients with isolated varicose veins underwent surgery; although symptoms and lesions recurred in 50% of these patients, no cases of secondary DVT occurred.

The authors concluded that when DVT was diagnosed in patients in association with Behçet disease, ultrasonographic abnormalities were observed in all patients, and post-thrombotic syndrome remained to varying degrees. In cases of isolated varicose veins in patients with Behçet disease, DVT did not occur after surgical treatment. If the activity of Behçet disease is controlled, surgical correction of varicose veins is preferable.

Semin Thromb Hemost 2020; 46: 777–780. doi: 10.1055/s-0040-1712155

The authors reviewed the pathophysiology of COVID-19 in the pulmonary circulation. When patients were initially presented to the intensive care units, it was presumed that infection associated inflammation resulted in a cytokine storm. The most common abnormality was elevated D-dimer in 70% of patients admitted. Fibrinogens were found to be markedly raised as well. This led to the recognition of COVID-19 associated hemostasis abnormality (CAHA) causing localized thrombosis in the lungs and was confirmed by post-mortem studies. All patients admitted to the hospital with COVID-19 received anticoagulation. Patients in self isolation who had a prothrombotic tendency were identified as possibly benefitting from anticoagulation. Patients whose symptoms were worsening upon receiving anticoagulation were identified as possibly benefitting from antiplatelet agents. Patient populations that may be protected from CAHA include patients already receiving anticoagulation for other medical reasons, patients with underlying bleeding disorders, and patients who are on immunosuppresants.

The authors concluded that antiplatelet agents may be additionally helpful to COVID-19 infected patients. Additionally, the points they raised are important to manage patients with microembolic pulmonary disease due to infection with COVID-19.

J Vasc Access 2020; 21: 411–418. doi: 10.1177/1129729819867547

The authors studied the use of the Surfacer System to place hemodialysis catheters in dialysis patients with thoracic central venous obstruction involving one or more of the central veins. Nine consecutive patients underwent the procedure. Successful central venous access was obtained in 8 patients. Efficacy and safety has been shown in several studies to date.

The authors conclude that the Surfacer System is a simpler, lower-risk, more time-efficient method for gaining right-side central venous access in patients whose thoracic veins are obstructed.

N Engl J Med 2020; 382: 1916–1925. doi: 10.1056/NEJMoa1913808

The authors, in this international, parallel group, randomized, double-blind noninferiority trial, randomly assigned patients who were thought to be at risk for venous thromboembolism after nonmajor orthopedic surgery to receive either rivaroxaban or enoxaparin. A total of 3,604 patients underwent randomization. Major venous thromboembolism occurred in 4 of 1,661 patients in the rivaroxaban group. In the group of patients receiving enoxaparin 1.1% had major venous thromboembolism. Bleeding complications did not differ between the two groups.

The authors concluded that Rivaroxaban was more effective than enoxaparin in the prevention of venous thromboembolic events during the postoperative period after nonmajor orthopedic surgery of the lower limbs.

Diagn Interv Imaging 2020; 101: 15–23. doi: 10.1016/j.diii.2019.03.014

The authors studied 42 patients with post thrombotic syndrome (PTS) presenting with femoro-iliac venous obstructive lesions who were treated from 2012 to 2017. The procedures the patients underwent included recanalization, predilatation, and stenting of the segment. Severity and quality of life were assessed at presentation and at 3 months using the Villalta score and Chronic Venous Insufficiency Questionnaire Scale. Duplex ultrasound and computed tomography were used to evaluate stent patency in follow up. In 97.6% of the patients, immediate technical success was achieved. Primary patency (66.7%), primary assisted patency (78.6%), and secondary patency (88.1%) were observed at 18.1 months. There was a significant decrease in the severity of PTS and improvement in the quality of life.

The authors concluded that endovascular stenting in patients with PTS confirms high clinical efficacy and favorable mid-term outcomes.