Phlebology: The Journal of Venous Disease

Objectives: The nutcracker syndrome (NS) may lead to insufficient perirenal collaterals as well as incompetence of the left ovarian vein with consecutive ovarian vein insufficiency.

Methods: A female patient with NS and severe genital varicosis was treated with dilation of the renal vein and coiling of a left perirenal collateral vein feeding an insufficient left ovarian vein (LOV) with pelvic vein varicosity.

Results: In re-evaluation 18 month later with left renal vein (LRV) and LOV phlebography, a widely patent LRV was found. The embolized LRV to LOV collateral was occluded. However, left hypogastric phlebography showed incompetent branches of the left hypogastric vein feeding the genital varicose veins. These were successfully embolized with coils and the genital varicosity decreased on follow-up.

Conclusions: In our patient a combined therapeutic approach with balloon dilation of the NS and embolization of the genital varicose veins by left hypogastric vein coil was performed.

Objective: Endovenous laser ablation of saphenous veins is an alternative in treating symptomatic varicose veins. Deep venous thrombosis (DVT) has been reported in up to 7.7% of patients undergoing such procedure. We sought to establish clinical risk factors that predict DVT post-endovenous laser ablation.

Method: Patients who underwent endovenous laser ablation were prospectively followed. Clinical data and post-interventional duplex ultrasound were analysed. A P value <0.05 was accepted as representing a significant difference.

Results: From 2007 to 2008, 360 consecutive patients were followed. Nineteen DVTs were found on follow-up ultrasound. Eighteen cases involved either the saphenofemoral or saphenopopliteal junctions; only one case involved the deep venous system. Age >66 (P = 0.007), female gender (P = 0.048) and prior history of superficial thrombophlebitis (SVT) (P = 0.002) were associated with increased risk of DVT postprocedure.

Conclusion: Age >66, female gender and history of SVT were significant predictors of DVT post-endovenous laser ablation of saphenous veins.

Objective: The purpose of this study was to compare the activation of haemostasis and inflammatory response after three different methods of treatment of great saphenous vein (GSV) incompetence.

Material and methods: Forty-five patients with GSV incompetence were assigned to one of the three types of treatment: high ligation and stripping (HL&S), radiofrequency ablation with ClosureFast (RFA) and endovenous laser ablation (EVLA) with 810 nm diode laser with miniphlebectomy if required. Peripheral blood samples were obtained in the morning before the surgery and 24 hours and 10 days after the procedure. The concentrations of C-reactive protein (CRP), D-dimer, prothrombin fragment 1+2 (F1 + 2), antigen of tissue plasminogen activator (t-PA) and von Willebrand factor (vWF) antigen and activity of plasminogen activator inhibitor (PAI-1) were determined. The results were statistically analysed with SPSS for Windows 15.0.

Results: Thirty-eight patients completed the study: 13 from RFA, 14 from EVLA and 11 from HL&S group. The baseline data did not differ among groups. There was a significant increase of D-dimer in HL&S group after 24 hours (P = 0.002). The changes in RFA and EVLA groups did not show statistical significance (P = 0.092). PAI-1 decreased in RFA patients after 24 hours (P = 0.02), did not change in EVLA patients, and tended to increase after HL&S (P = 0.08). The highest CRP increase was observed in HL&S group (P = 0.003). No significant changes in F1 + 2, t-PA and vWF were observed in any group of patients at 24 hours. At 10 days, a further significant increase of D-dimer (P = 0.04) and CRP (P = 0.018) concentrations in HL&S but not RFA and EVLA patients was observed.

Conclusions: Endovenous thermal ablation is associated with significantly less activation of haemostasis and inflammatory response when compared with HL&S.

Introduction: To investigate the morphological changes in the walls of thrombophlebitic saphenous veins.

Methods: Fifty-four specimens were made into slices for haematoxylin and eosin and Masson trichrome staining; ultrathin slices were also created. Slices were observed under light microscopy and electron microscopy.

Results: Under light microscopy, the tunica intima of venous wall in the thrombophlebitic saphenous veins group was obviously thickened and incomplete; intravascular papillary endothelial hyperplasia was observed. Hyperplasia of collagenous fibres in the tunica media was observed. Elastic fibres in the tunica externa became fewer, whereas nourishing vessels were significantly increased in number. Infiltration of many inflammatory cells was observed. Under electron microscopy, Auer bodies with high electron density and round granules could be seen in endothelial cells in the thrombophlebitic saphenous veins group. Smooth muscle cells had an irregular karyotype, with blurred cristae in some mitochondria. Myofilaments basically disappeared.

Conclusion: Thrombus formation might aggravate re-modelling of the walls of varicose veins.

Objectives: The purpose of these experiments was to simulate thrombus formation during endovenous laser closure by measuring coagulum formation of in vitro laser exposures in porcine blood and investigate the role of procedures and equipment in thrombus formation.

Methods: Continuous wave 810, 940, 980, 1310 and 1470 nm lasers and microsecond pulsed wave 1064 nm Nd:YAG (neodymium-doped yttrium aluminium garnet), 1320 nm Nd:YAG and 2100 nm THC:YAG (thulium holmium chromium-doped yttrium aluminium garnet) lasers were tested with standard fibres with diameters of 365, 550 and 600 μm as well as two prototype modified tip fibres.

Results: The results show that pulsed lasers with high-peak power densities form less coagulum. Fibre specifications were found not to influence coagulum formation, and prototype modified tip fibres designed to prevent contact between the fibre tip and the vein wall did not eliminate coagulum formation.

Conclusion: Microsecond-pulsed wave lasers with high-peak power densities may be a better choice to minimize soft thrombus formation during endovenous laser ablation treatments.

Objectives: Complex venous malformations (VMs) may extensively involve the soft tissue. The treatment remains a challenge till now. Here we introduce a combinational therapy of copper wires and pingyangmycin (bleomycin A5, PYM).

Methods: Copper wires were retained in VMs by repeated penetration with a straight needle. Subsequently, PYM solution was injected into the lesion. Eight to 10 days later, copper wires were removed. The dressing was changed every day until the puncture pores healed. Magnetic resonance imaging scanning was performed to observe the change of VMs.

Results: From January 2001 to December 2011,56 patients were treated. During the follow-up period, most of the VMs shrunk obviously. The symptoms were relieved or disappeared. The complications included local pain, temporary paraesthesia and moderate fever, which disappeared quickly after the removal of copper wires.

Conclusions: This combinational therapy is a safe and effective approach for the complex VMs in soft tissue.

Objectives: To determine the prevalence, distribution and extent of phlebosclerosis in an outpatient population referred to vascular clinic.

Design: Prospective cohort study.

Patients and Methods: Seven hundred and forty consecutive patients, 302 (41%) men with a cohort median age of 49 (range, 18–84), were referred to the vascular clinic for detection of lower extremity acute or chronic venous disease. A total of 1000 limbs were assessed using duplex ultrasonography. Deep veins were not assessed. Characteristics of venous wall and lumen were studied. Phlebosclerosis was diagnosed based on the increased echogenicity and thickness or calcification of the venous wall. Patients with known trauma or any surgery in the lower extremities were excluded. Two control groups were used for comparison, one of consecutive patients undergoing vein mapping (n = 100) and the other of younger volunteers free of any vein disease (n = 25).

Results: Of the 1000 limbs (right: 458, left: 542) studied by duplex ultrasound, 21 limbs had intense brightness of the venous wall. Fifteen of them had also calcifications and 61 wall thickening. The prevalence of phlebosclerosis was significantly higher in the patient group when compared with control groups 1 (P = 0.019) and 2 (P = 0.011). The mean age of patients with phlebosclerosis was higher compared with the whole patient group (57 versus 49 years, P < 0.0001). Phlebosclerosis affected all superficial veins with greater prevalence in the small saphenous vein (SSV). The mean length of the phlebosclerotic lesion was 2 cm (range 1–7 cm).

Conclusion: The prevalence of phlebosclerosis in the lower extremities appears to be low with no significant sex differences. Age and chronic venous disease are important factors for its development. It may be present in the absence of thrombosis or reflux. A greater prevalence of phlebosclerotic lesions was found in the SSV.

Objective: While chronic cerebrospinal venous insufficiency (CCSVI) can be characterized using cervical plethysmography, much remains unknown about the haemodynamics associated with this procedure. The aim of the study was therefore to gain a deeper understanding of the observed haemodynamics.

Method: Forty healthy controls and 44 CCSVI patients underwent cervical plethysmography, which involved placing a strain-gauge collar around their necks and tipping them from the upright (90^°) to supine position (0^°) in a chair. Once stabilized, they were returned to the upright position, allowing blood to drain from the neck. A mathematical model was used to calculate the hydraulic resistance of the extracranial venous system for each subject in the study.

Results: The mean hydraulic resistance of the extracranial venous system was 10.28 (standard deviation [SD] 5.14) mmHg.s/mL in the healthy controls and 16.81 (SD 9.22) in the CCSVI patients (P < 0.001).

Conclusions: The haemodynamics of the extracranial venous system are greatly altered in CCSVI patients.

Chronic cerebrospinal venous insufficiency (CCSVI) is a syndrome characterized by stenoses of the internal jugular veins (IJVs) and/or azygos veins and formation of collateral venous channels. A case of a 57-year-old patient with CCSVI in whom the venous outflow from the left IJV to the right atrium occurred through a venous anomaly, the persistent left superior vena cava (PLSVC), is reported. PLSVC is caused by persistence of the left anterior cardinal vein that drains blood from the limb effluent from the left and the left side of head and neck into coronary sinus (Type a), or in the left atrium (Type b). PLSVC can be associated either with innominate vein hypoplasia or other congenital heart abnormalities. Because of evidence of left innominate vein hypoplasia, angioplasty was not performed using the ordinary route but passing with the balloon directly through the PLSVC up to the left IJV. Finally, angioplasty was carried out in a standard manner in the right IJV as well as in the azygous vein. Confirmation angiogram revealed complete reopening of all treated vessels with no evidence of peri- and postoperative complications. The patient was discharged home the following day in good general conditions. PLSVC is a rare congenital vein anomaly but in case of concomitant innominate vein hypoplasia may prove to be a valuable alternative to treat patients with IJV diseases.