Phlebology: The Journal of Venous Disease

Endovenous thermal ablation has revolutionised varicose vein treatment. New non-thermal techniques such as mechanical occlusion chemically assisted endovenous ablation (MOCA) allow treatment of entire trunks with single anaesthetic injections. Previous non-randomised work has shown reduced pain post-operatively with MOCA. This study presents a multi-centre randomised controlled trial assessing the difference in pain during truncal ablation using MOCA and radiofrequency endovenous ablation (RFA) with six months’ follow-up.

Patients undergoing local anaesthetic endovenous ablation for primary varicose veins were randomised to either MOCA or RFA. Pain scores using Visual Analogue Scale and number scale (0–10) during truncal ablation were recorded. Adjunctive procedures were completed subsequently. Pain after phlebectomy was not assessed. Patients were reviewed at one and six months with clinical scores, quality of life scores and duplex ultrasound assessment of the treated leg.

A total of 170 patients were recruited over a 21-month period from 240 screened. Patients in the MOCA group experienced significantly less maximum pain during the procedure by Visual Analogue Scale (MOCA median 15 mm (interquartile range 7–36 mm) versus RFA 34 mm (interquartile range 16–53 mm), p = 0.003) and number scale (MOCA median 3 (interquartile range 1–5) versus RFA 4 mm (interquartile range 3–6.5), p = 0.002). ‘Average’ pain scores were also significantly less in the MOCA group; 74% underwent simultaneous phlebectomy. Occlusion rates, clinical severity scores, disease specific and generic quality of life scores were similar between groups at one and six months. There were two deep vein thromboses, one in each group.

Pain secondary to truncal ablation is less painful with MOCA than RFA with similar short-term technical, quality of life and safety outcomes.

This is a single-center clinical study for the evaluation of safety, efficacy, and performance of endovenous cyanoacrylate (Sapheon Venaseal Closure System, now Medtronic Medical) for the treatment of great saphenous vein (GSV) reflux.

Primary outcome measures included the GSV obliteration, with clinical recurrence on follow up as detected by serial clinical and duplex examinations of patients at 1 week, 1 month, 6 months, and 1 year. Venous clinical severity score (VCSS), Aberdeen varicose vein questionnaire (AVVQ), Short Form Health Survey 36 Item (SF-36) questionnaires were used at clinical follow up. Diameter of the GSV, treatment length of the GSV, and pretreatment clinical severity of the varicose vein were analyzed to predict recanalization using Cox regression analysis.

Fifty-seven legs in 29 patients with primary varicose veins were included. One week follow-up duplex showed successful obliteration of the GSV in all except one of the legs. Two legs had minimal extension of thrombus to deep vein. None of the patients had deep venous thrombosis. All the patients were discharged the same day of operation. Median time to return to work was 1 day (range 1–16 days). Our VCSS, AVVQ, and the SF-36 physical and mental scores changed from a mean of 6.91, 23.66, 44.24, 54.26 at baseline to 2.43, 6.10, 43.85, 52.50 at 1 month post operation, respectively. Kaplan–Meier analysis showed that the GSV closure rates were 98.2%, 94.3%, 89.7%, and 78.5% at post-op 1 week, 1 month, 6 months, and 1 year, respectively. With median follow-up period of 9 months (range 1–13 months), no clinical recurrence of varicosity was observed. Mean GSV diameter ≥8 mm was a significant predictor for recanalization (hazard ratio 6.92, 95%CI 1.34–35.67, p = 0.021).

This study showed that the use of endovenous cyanoacrylate in the treatment of the GSV reflux was safe. All patients had symptomatic improvement as shown by the VCSS and AVVQ.

To develop a new pretest probability score for deep vein thrombosis (DVT) in unselected population of outpatients and inpatients.

The new score was developed using independent factors from 500 patients clinically suspected of leg DVT. The new score was validated in a second group of 315 patients.

The score consists of four components: unilateral leg pain, confinement to bed, calf enlargement >3 cm compared with the other side, and previous venous thromboembolism. A score ≥2 indicated a high probability while a score <2 indicated low probability. The sensitivity and specificity of the new score were 71.60% and 79.49%, respectively. The area under the receiver operating characteristic curve for the new score was 0.79. The combination of a new score <2 and D-dimer level <500 µg/L had a negative predictive value of 96.43%.

Our new score was valid in an unselected population of outpatients and inpatients.

Varicocele is characterized by dilatation and tortuosity of the internal spermatic vein. Sonic hedgehog plays an important role in angiogenesis and vascular remodeling under hypoxic stress. We studied the relationship and distribution of SHH and vascular endothelial growth factor in internal spermatic vein in patients diagnosed with varicocele.

Specimens of 1 cm were taken from the internal spermatic vein during left varicocele repair (N = 20). The control samples of ISV were obtained from eight male patients who underwent left inguinal herniorrhaphy. We analyzed the sonic hedgehog and vascular endothelial growth factor expression and distribution by immunoblotting, immunohistochemistry, immunofluorescent staining, and confocal laser scanning microscopy. The data were analyzed using the Student’s t test.

Immunoblotting showed higher expression of sonic hedgehog and vascular endothelial growth factor proteins in varicocele veins than in the control group (P < 0.05) which located over muscle layer and endothelium was demonstrated by immunohistochemical staining. Both proteins with co-localization in the muscle layer and especially distributed in endothelium of varicocele veins were revealed under confocal microscopy.

These findings showed the upexpression of sonic hedgehog and vascular endothelial growth factor with co-localization in varicocele veins which imply that the reducing hypoxia or using sonic hedgehog antagonists may be helpful for this vascular disease.

To describe a new ultrasound marker of the Great Saphenous Vein at the groin.

An ultrasound marker of the Great Saphenous Vein was identified as follows: the Great Saphenous Vein was tracked in cross-sectionally starting from the Sapheno Femoral Junction and optimally visualized where it crosses the Adductor Longus muscle, i.e., 3–5 cm below the junction. This marker, corresponding to a very superficial position of Great Saphenous Vein, was named “E Point,” where E means easy to find. The search for the E point was performed on 230 limbs of 126 subjects with or without chronic venous insufficiency (training population) and the method was validated in 58 subjects (testing population).

The E point was successfully recorded in 128/144 (89%) pathologic and in 85/86 (99%) healthy limbs. Being free from other structures, at the E point the Great Saphenous Vein was always easily calibrated. In 17 cases, the E point could not be identified due to an hypoplasic Great Saphenous Vein; in such instances, the Anterior Accessory Saphenous Vein was well evident and substituted for the Great Saphenous Vein as the main draining vein at the groin.

The E point identifies the Great Saphenous Vein in healthy and varicose patients. Failure to identify the E point indicates Anterior Accessory Saphenous Vein dominance over a hypoplasic Great Saphenous Vein.

To assess the relationship between cross-sectional area of internal jugular veins and brain volumes in healthy individuals without neurologic disease.

A total of 193 healthy individuals without neurologic disease (63 male and 130 female; age > 20 to < 70 years) received magnetic resonance venography and structural brain magnetic resonance imaging at 3T. The internal jugular vein cross-sectional area was assessed at C2–C3, C4, C5–C6, and C7–T1. Normalized whole brain volume was assessed. Partial correlation analyses were used to determine associations.

There was an inverse relationship between normalized whole brain volume and total internal jugular vein cross-sectional area (C7–T1: males r = −0.346, p = 0.029; females r = −0.301, p = 0.002). After age adjustment, association of normalized whole brain volume and normalized gray matter volume with internal jugular vein cross-sectional area became positive in males (normalized whole brain volume and right internal jugular vein cross-sectional area (C2–C3) changed from r = −0.163 to r = 0.384, p = 0.002), but not in the females.

Sex differences exist in the relationship between brain volume and internal jugular vein cross-sectional area in healthy individuals without neurologic disease.

This study was aimed to investigate the prevalence of venous thromboembolism in patients with chronic venous disease and the impact of some intrinsic and extrinsic risk factors.

A retrospective study on 641 outpatients (489 women) with primary chronic venous disease (C₀–C₆). The prevalence of venous thromboembolism was evaluated according to sex, age, BMI, the presence of ≥1 first-degree siblings diagnosed with venous thromboembolism, CEAP clinical class, smoking and the use of hormone therapy.

Venous thromboembolism episodes occurred in 32 patients (5%) with no gender predominance (OR 1.49, 95% CI = 0.90–2.45; p = 0.146). There was no increased RR of venous thromboembolism in the age group 46–69 years compared with patients aged ≤45 years (p = 0.350). In persons aged ≥70 years, the risk of venous thromboembolism was 3.2 times higher than in patients aged 46–69 years and 4.78 times higher than in patients aged ≤45 years. The risk of venous thromboembolism rose very significantly in obese compared with normostenic patients (p = 0.002). There were significantly more venous thromboembolism episodes in patients with chronic venous insufficiency (55.3%) than patients with varicose veins (44.7%) (p < 0.001). A family history of venous thromboembolism (p = 0.12), smoking (p = 0.905) and hormone therapy (p = 0.326) were not associated with increased risk of venous thromboembolism. Smoking was a risk factor in obese patients (p = 0.033), but the combination of obesity, smoking, estrogens in women did not increase the risk of venous thromboembolism.

The 5% prevalence of venous thromboembolism episodes in patients was comparable with the prevalence of venous thromboembolism in the general European population. Age ≥70 years and obesity were strongly associated with an occurrence of venous thromboembolism. Obese patients with chronic venous disease were at higher risk for venous thromboembolism than obese people in the general population. A family history of venous thromboembolism, smoking and estrogens alone or in combination were not revealed as significant risk factors.