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Kelly D, Scovell S. Standardizing practice patterns for venous insufficiency ultrasound. Phlebology 2024:2683555241276556. [PMID: 39239932 DOI: 10.1177/02683555241276556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Abstract
BACKGROUND This study aimed to evaluate the variability in practice patterns associated with the performance of duplex ultrasound (DUS) for venous insufficiency. METHODS Sonographers participated in a survey regarding patient positioning and method of augmentation as well as the availability of ergonomic equipment for DUS. RESULTS DUS was performed in RT position by 41% of sonographers versus standing position in 40%. In 18% of laboratories, if the RT position did not demonstrate reflux, the study was repeated in the standing position. An automated cuff inflation device was used as the primary method of augmentation in only 22% of practices. CONCLUSIONS There is a lack of standardization for the performance parameters of patient position and method of augmentation in VDU, which may lead to variation in the results between sonographers and institutions.
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Affiliation(s)
- Donna Kelly
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Brigham, Boston, MA, USA
| | - Sherry Scovell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Brigham, Boston, MA, USA
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Wang SH, Shyu VBH, Chiu WK, Huang RW, Lai BR, Tsai CH. An Overview of Clinical Examinations in the Evaluation and Assessment of Arterial and Venous Insufficiency Wounds. Diagnostics (Basel) 2023; 13:2494. [PMID: 37568858 PMCID: PMC10417660 DOI: 10.3390/diagnostics13152494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/11/2023] [Accepted: 07/17/2023] [Indexed: 08/13/2023] Open
Abstract
Arterial and venous insufficiency are two major causes of chronic wounds with different etiology, pathophysiology, and clinical manifestations. With recent advancements in clinical examination, clinicians are able to obtain an accurate diagnosis of the underlying disease, which plays an important role in the treatment planning and management of patients. Arterial ulcers are mainly caused by peripheral artery diseases (PADs), which are traditionally examined by physical examination and non-invasive arterial Doppler studies. However, advanced imaging modalities, such as computed tomography angiography (CTA) and indocyanine green (ICG) angiography, have become important studies as part of a comprehensive diagnostic process. On the other hand, chronic wounds caused by venous insufficiency are mainly evaluated by duplex ultrasonography and venography. Several scoring systems, including Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification, the Venous Clinical Severity Score (VCSS), the Venous Disability Score, and the Venous Segmental Disease Score (VSDS) are useful in defining disease progression. In this review, we provide a comprehensive overlook of the most widely used and available clinical examinations for arterial and venous insufficiency wounds.
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Affiliation(s)
- Szu-Han Wang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung 204, Taiwan; (S.-H.W.); (V.B.-H.S.); (B.-R.L.)
- Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei 110, Taiwan
| | - Victor Bong-Hang Shyu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung 204, Taiwan; (S.-H.W.); (V.B.-H.S.); (B.-R.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Wen-Kuan Chiu
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan;
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Ren-Wen Huang
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
- Division of Trauma Plastic Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Bo-Ru Lai
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung 204, Taiwan; (S.-H.W.); (V.B.-H.S.); (B.-R.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Chia-Hsuan Tsai
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung 204, Taiwan; (S.-H.W.); (V.B.-H.S.); (B.-R.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
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Zalaquett E, Gunabushanam G, Vallejos A, Dahiya N. Ultrasound Evaluation of Chronic Venous Insufficiency. Ultrasound Q 2023; 39:2-9. [PMID: 36651650 DOI: 10.1097/ruq.0000000000000634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
ABSTRACT Chronic venous insufficiency is a common condition caused by valvular incompetence and/or obstruction of the lower extremity venous system. Chronic venous insufficiency presents in a wide range of clinical presentations, ranging from mild pain or edema to the development of varicose veins and nonhealing venous ulcers. Doppler ultrasound is the preferred imaging modality in the assessment of this condition and provides both anatomical and functional information in a noninvasive, cost-effective, and radiation-free manner. Knowledge of the anatomy and nomenclature, pathophysiology, equipment requisites, scanning protocols, relevant findings, and reporting nuances is essential to the creation of an accurate and clinically actionable report. Evaluation of the superficial and deep venous system for degree and extent of reflux is necessary to establish the diagnosis and to institute appropriate treatment.
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Affiliation(s)
| | | | - Antonio Vallejos
- Radiology Residency Program, Universidad de Santiago, Santiago, Chile
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Hemodynamic and neurobiological factors for the development of chronic pelvic pain in patients with pelvic venous disorder. J Vasc Surg Venous Lymphat Disord 2023; 11:610-618.e3. [PMID: 36781107 DOI: 10.1016/j.jvsv.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/18/2022] [Accepted: 01/05/2023] [Indexed: 02/13/2023]
Abstract
OBJECTIVE The study was aimed at the identification of hemodynamic and neurobiological factors for the development of chronic pelvic pain (CPP) in patients with pelvic venous disorder (PeVD) using ultrasound, radionuclide, and enzyme immunoassay methods. METHODS This cohort study included 110 consecutive patients with PeVD and 20 healthy controls. Seventy patients with PeVD had symptoms (CPP in 100% of cases, discomfort in hypogastrium, dyspareunia, vulvar varices, and dysuria), and 40 were asymptomatic. Patients underwent clinical examination, duplex ultrasound study of the pelvic veins and lower extremities, and single-photon emission computed tomography of the pelvic veins with in vivo labeled red blood cells. The prevalence, duration, severity, and pattern of reflux in the pelvic veins, as well as the severity of pelvic venous congestion, were evaluated. Healthy controls underwent only clinical and duplex ultrasound examination. All 130 patients were assessed using enzyme immunoassays to determine plasma levels of calcitonin gene-related peptide (CGRP) and substance P (SP). RESULTS Symptomatic patients with PeVD had a higher prevalence of reflux in the ovarian veins (OVs) than asymptomatic ones (45.7% vs 10%, respectively; P = .001) and a greater reflux duration (4.1 ± 1.7 seconds vs 1.4 ± 0.3 seconds; P = .002), although no differences in the OV diameter were found. Similar results were obtained when comparing the diameters of the parametrial veins (PVs) and the duration of reflux in them. Type II/III reflux (greater than 2 seconds) was identified in 41.4% of symptomatic and in only 5% of asymptomatic patients (P = .001). Among patients with CPP, 24.2% had a combined reflux in the OVs, PVs, and uterine veins, and 45.7% had a combined reflux in the OVs and PVs, whereas 90% of patients without CPP had only an isolated reflux in the PVs. The pelvic venous congestion was moderate or severe in 95.7% of patients with CPP and in only 15% patients without CPP (P = .001). In patients with PeVD, the presence of CPP was associated with higher levels of CGRP and SP compared with asymptomatic patients (CGRP: 0.48 ± 0.06 vs 0.19 ± 0.02 ng/mL, respectively, P = .001; SP: 0.38 ± 0.08 vs 0.13 ± 0.03 ng/mL, P = .001). CONCLUSIONS In patients with PeVD, significant hemodynamic and neurobiological factors for the CPP development were found to be reflux in the pelvic veins greater than 2 seconds, involvement of several venous collectors, and increased plasma levels of CGRP and SP.
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Kokkinidis DG, Ochoa Chaar CI, Mena-Hurtado CI, Attaran RR. Correlation between reflux time and venous clinical severity score in patients undergoing saphenous vein ablation: A prospective study. Phlebology 2023; 38:62-66. [PMID: 36524895 DOI: 10.1177/02683555221146730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES It is unclear whether reflux time independently correlates with severity of symptoms in patients with great saphenous vein reflux. METHODS Eighty patients (mean age 64+/-12.7 years, 56% female) undergoing great saphenous vein (GSV) ablation for symptomatic reflux were assessed prospectively. Fifty-seven underwent ablation with radiofrequency, 23 with cyanoacrylate adhesive. Venous clinical severity score (VCSS) was assessed at, or prior to the time of ablation. The highest reflux time in the GSV was selected. RESULTS VCSS values ranged from 2 to 20 (median 7). Mean reflux time was 5.3 s (+/-3.3). The Spearman rank correlation yielded a value of rs = -0.123, p (2-tailed) = .279, which was not significant. The patients with concomitant deep vein reflux had higher VCSS (p < .05). Analysis of patients with only superficial vein reflux (n = 45) also demonstrated a poor correlation between VCSS and reflux time (rs = -0.051, p (2-tailed) = .741). CONCLUSION This prospective study did not demonstrate a correlation between reflux time and VCSS.
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Affiliation(s)
| | - Cassius I Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, 5755Yale University, New Haven, CT, USA
| | - Carlos I Mena-Hurtado
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, 5755Yale University, New Haven, CT, USA
| | - Robert R Attaran
- Section of Cardiovascular Medicine, 5755Yale University, New Haven, CT, USA
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Liu G, Clarke JL, Mohan I. A snapshot of venous ultrasound examinations in Australia and New Zealand: Implications for diagnosis and management of chronic venous disease interventions. ULTRASOUND (LEEDS, ENGLAND) 2022; 30:236-245. [PMID: 35936961 PMCID: PMC9354182 DOI: 10.1177/1742271x211046641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/23/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Chronic venous disease is a common vascular condition, affecting up to 60% of the population worldwide. In Australia and New Zealand, chronic venous insufficiency ultrasound examinations are primarily performed by sonographers. This research aimed to explore how ultrasound examinations are being performed, providing insights into current practices and recommendations for quality improvement. METHOD A questionnaire was distributed to capture demographics, practices of ultrasound, examination techniques, the use of nomenclature and experience of the respondents. RESULTS The analysis of 97 responses showed a heterogeneity in the clinical application of ultrasound. Most sonographers performed less than two scans per day within 30-45 minutes. Deep venous incompetence was routinely excluded by all respondents. The majority used standing, sitting and reverse Trendelenburg position except for a few using supine position. Manual augmentation was the preferred provocation manoeuvre. Anatomical variations at the junctional level were not adequately evaluated. Although Giacomini's vein was assessed by 80%, 57% of those did not evaluate paradoxical reflux. Seventy-five per cent routinely assessed non-saphenous reflux; however, over 50% were unfamiliar with lymph node venous networks. A significant number of out-dated venous terms were still being used. A low participation rate in continuing professional development was identified, which might be attributable to limited education and training programs. CONCLUSION The study is a multi-faceted exploration that identified a need for standardized diagnostic and reporting guidelines. Our results could explain discrepancies in diagnostic findings and inconsistencies in the use of medical terminology, with implications for clinical decision making and assessment of surgical outcome.
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Affiliation(s)
- Gaorui Liu
- Western Sydney Vascular, Westmead, Australia
| | | | - Irwin Mohan
- Western Sydney Vascular, Westmead, Australia
- Westmead Clinical School, University of Sydney, Wentworthville, NSW, Australia
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Galeandro AI, Galeandro C, Scicchitano P, Clima R, Ritacco IA, Dellisanti Fabiano Vilardi M, Di Ponzio E, Annichiarico A, Ciciarello F, Contursi V, Wegierska AE, Ciccone MM. The Application of MEVEC 3D Doppler Ultrasound Technique for a New Classification of Morpho-Functional Phenotypes in Lower Limbs Venous Diseases. Vasc Health Risk Manag 2022; 18:81-87. [PMID: 35250272 PMCID: PMC8892712 DOI: 10.2147/vhrm.s333507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/30/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction MEVEC 2.1 is a novel 3D mapping software dedicated to the evaluation of the venous vascular three of the lower limbs. It has already proven as a sensitive, specific, and accurate technique able to provide better morphologic and functional details of the lower limb venous system than standard reports. The aim of this study was to identify specific morpho-functional graphic phenotypes in lower limb venous diseases by means of MEVEC 2.1. Materials Three-hundred eleven consecutive outpatients underwent lower limb Doppler ultrasound examination by means of the MEVEC 2.1 technique. All of them showed at least one among these pathological findings: venous insufficiency, thrombosis, incompressibility, and/or incompetent. Results We tried to evaluate possible clusters among the different morpho-functional findings from the venous maps in order to outline reproducible phenotypes. Correlation indexes allowed us to provide a classification in morpho-functional phenotypes in order to standardize the data from examinations performed by different physicians. Twelve phenotypes had been proposed. Conclusion The study showed that the MEVEC 2.1 technique provides a standardized classification that allows physicians identifying phenotypes yielded by 3D mapping of the veins of the lower limbs.
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Affiliation(s)
- Aldo Innocente Galeandro
- Unit of Technological Medical Research of the Parco Scientifico-Tecnologico, University of Bari “A. Moro”, Bari, Italy
| | - Cristina Galeandro
- Section of Vascular Surgery, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Pietro Scicchitano
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Correspondence: Pietro Scicchitano, Section of Cardiovascular Diseases, Cardio-Thoracic Department, University of Bari “A. Moro”, Piazza G. Cesare, Bari, 11 – 70124, Italy, Email ;
| | - Rosanna Clima
- BROWSer S.r.l. - Bioinformatics Resource for Omics Wide Services, Dipartimento di Bioscienze, Biotecnologie e Biofarmaceutica, University of Bari “A. Moro”, Bari, Italy
| | - Ilenia Annunziata Ritacco
- Section of Cardiac Surgery, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Egidio Di Ponzio
- Unit of Technological Medical Research of the Parco Scientifico-Tecnologico, University of Bari “A. Moro”, Bari, Italy
| | - Annamaria Annichiarico
- Unit of Technological Medical Research of the Parco Scientifico-Tecnologico, University of Bari “A. Moro”, Bari, Italy
| | - Francesco Ciciarello
- Department of Cardiovascular, Respiratory, Geriatric and Morphologic Sciences of “Umberto I” Polyclinic of Rome, “Sapienza” University, Rome, Italy
| | | | - Angelika Elzbieta Wegierska
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Marco Matteo Ciccone
- Section of Cardiovascular Diseases, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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Lyons O, Walker J, Seet C, Ikram M, Kuchta A, Arnold A, Hernández-Vásquez M, Frye M, Vizcay-Barrena G, Fleck RA, Patel AS, Padayachee S, Mortimer P, Jeffery S, Berland S, Mansour S, Ostergaard P, Makinen T, Modarai B, Saha P, Smith A. Mutations in EPHB4 cause human venous valve aplasia. JCI Insight 2021; 6:e140952. [PMID: 34403370 PMCID: PMC8492339 DOI: 10.1172/jci.insight.140952] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/11/2021] [Indexed: 11/25/2022] Open
Abstract
Venous valve (VV) failure causes chronic venous insufficiency, but the molecular regulation of valve development is poorly understood. A primary lymphatic anomaly, caused by mutations in the receptor tyrosine kinase EPHB4, was recently described, with these patients also presenting with venous insufficiency. Whether the venous anomalies are the result of an effect on VVs is not known. VV formation requires complex "organization" of valve-forming endothelial cells, including their reorientation perpendicular to the direction of blood flow. Using quantitative ultrasound, we identified substantial VV aplasia and deep venous reflux in patients with mutations in EPHB4. We used a GFP reporter in mice to study expression of its ligand, ephrinB2, and analyzed developmental phenotypes after conditional deletion of floxed Ephb4 and Efnb2 alleles. EphB4 and ephrinB2 expression patterns were dynamically regulated around organizing valve-forming cells. Efnb2 deletion disrupted the normal endothelial expression patterns of the gap junction proteins connexin37 and connexin43 (both required for normal valve development) around reorientating valve-forming cells and produced deficient valve-forming cell elongation, reorientation, polarity, and proliferation. Ephb4 was also required for valve-forming cell organization and subsequent growth of the valve leaflets. These results uncover a potentially novel cause of primary human VV aplasia.
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Affiliation(s)
- Oliver Lyons
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Research Excellence, King’s College London, St. Thomas’ Hospital, London, United Kingdom
| | - James Walker
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Research Excellence, King’s College London, St. Thomas’ Hospital, London, United Kingdom
| | - Christopher Seet
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Research Excellence, King’s College London, St. Thomas’ Hospital, London, United Kingdom
| | - Mohammed Ikram
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Research Excellence, King’s College London, St. Thomas’ Hospital, London, United Kingdom
| | - Adam Kuchta
- Department of Ultrasonic Angiology, Guy’s & St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Andrew Arnold
- Department of Ultrasonic Angiology, Guy’s & St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Magda Hernández-Vásquez
- Rudbeck Laboratory, Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | - Maike Frye
- Rudbeck Laboratory, Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | - Gema Vizcay-Barrena
- Centre for Ultrastructural Imaging, King’s College London, London, United Kingdom
| | - Roland A. Fleck
- Centre for Ultrastructural Imaging, King’s College London, London, United Kingdom
| | - Ashish S. Patel
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Research Excellence, King’s College London, St. Thomas’ Hospital, London, United Kingdom
| | - Soundrie Padayachee
- Department of Ultrasonic Angiology, Guy’s & St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Peter Mortimer
- Molecular and Clinical Sciences Research Institute, St. George’s University of London, London, United Kingdom
| | - Steve Jeffery
- Molecular and Clinical Sciences Research Institute, St. George’s University of London, London, United Kingdom
| | - Siren Berland
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Sahar Mansour
- Molecular and Clinical Sciences Research Institute, St. George’s University of London, London, United Kingdom
- South West Thames Regional Genetics Service, St. George’s Hospital, London, United Kingdom
| | - Pia Ostergaard
- Molecular and Clinical Sciences Research Institute, St. George’s University of London, London, United Kingdom
| | - Taija Makinen
- Rudbeck Laboratory, Department of Immunology, Genetics and Pathology, Uppsala University, Sweden
| | - Bijan Modarai
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Research Excellence, King’s College London, St. Thomas’ Hospital, London, United Kingdom
| | - Prakash Saha
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Research Excellence, King’s College London, St. Thomas’ Hospital, London, United Kingdom
| | - Alberto Smith
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Research Excellence, King’s College London, St. Thomas’ Hospital, London, United Kingdom
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Stratification of pelvic venous reflux in patients with pelvic varicose veins. J Vasc Surg Venous Lymphat Disord 2021; 9:1417-1424. [PMID: 34023538 DOI: 10.1016/j.jvsv.2021.04.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/15/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE We investigated the association between the pattern and duration of pelvic venous reflux (PVR) and pelvic pain severity in patients with pelvic varicose veins (PVVs). METHODS The present retrospective study included 600 female patients with PVVs. Of the 600 patients, 453 had had PVVs and pelvic congestion syndrome (group 1) and 147 had had an asymptomatic disease course (group 2). Pelvic venous pain (PVP) was assessed using a visual analog scale. All the patients had undergone duplex ultrasound of the left and right renal veins, external, internal, and common iliac veins, and parametrial, uterine, gonadal, and vulvar veins (PV, UV, GV, and VV, respectively), with an assessment of their patency and diameter and the presence and duration of reflux. Reflux in the pelvic veins was considered pathologic if it lasted for >1 second. RESULTS In group 1, PVR type I (1-2 seconds), II (3-5 seconds), and III (>5 seconds or spontaneous reflux in the absence of a loading test) was found in 31%, 58%, and 11% of the patients, respectively. Moderate and severe reflux (types II and III) was associated with severe PVP (mean score, 8.3 ± 0.5) in 69% of the group 1 patients. A combination of reflux in the GV, PV, UV, and internal iliac vein was associated with severe PVP (mean score, 8.1 ± 0.3) in 51% of these patients. A combination of reflux in the PVs, UVs, and VVs was associated with moderate pain (mean score, 5.3 ± 0.2) in 49.2% of group 1. In group 2, PVR type I, II, and III was present in 95%, 4%, and 1% of the patients, respectively, and was observed in the PV only in patients with type I; in the GVs, PVs, UVs, and internal iliac veins in those with type II; and in the PVs and GVs in the patients with type III reflux. Reflux in the GVs and UVs was significantly more prevalent in group 1 than in group 2 (GVs, 51% vs 6%; P = .0001; UVs, 57% vs 7%; P = .0001). A combination of reflux in the GVs and UVs was a predictor of severe PVVs (odds ratio, 19.7; 95% confidence interval, 11.3-34.6). CONCLUSIONS In patients with PVVs, the presence and severity of pelvic pain will be determined by the type of PVR and its distribution in the pelvic veins. The combination of moderate to severe reflux (types II and III) in the PVs, UVs, and GVs was a predictor of severe PVP. Patients with asymptomatic PVVs were characterized by mild reflux (type I) in the PVs, with rare involvement of the GVs and UVs.
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Lurie F. Even the best guess is not as good as a measurement. J Vasc Surg Venous Lymphat Disord 2020; 8:840. [DOI: 10.1016/j.jvsv.2019.12.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/16/2019] [Indexed: 11/16/2022]
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11
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Tauraginskii RA, Simakov S, Borsuk D, Mazayshvili K, Lurie F. The immediate effect of physical activity on ultrasound-derived venous reflux parameters. J Vasc Surg Venous Lymphat Disord 2020; 8:640-645. [DOI: 10.1016/j.jvsv.2019.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 11/03/2019] [Indexed: 10/25/2022]
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12
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Dawson DL. Moving toward consensus for the best method to test for venous reflux in the vascular laboratory. J Vasc Surg Venous Lymphat Disord 2020; 8:501-502. [PMID: 32553649 DOI: 10.1016/j.jvsv.2020.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 03/31/2020] [Indexed: 11/29/2022]
Affiliation(s)
- David L Dawson
- Department of Surgery, Baylor Scott & White Health System, Temple, Tex.
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13
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Comparison of hand-held acoustic Doppler with point-of-care portable color Doppler ultrasound in the assessment of venous reflux disease. J Vasc Surg Venous Lymphat Disord 2020; 8:831-839.e2. [PMID: 32184080 DOI: 10.1016/j.jvsv.2019.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 11/23/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Diagnostic-quality portable color Doppler ultrasound (PCD) offers convenient point-of-care venous reflux disease (VRD) diagnosis. Philips Lumify (Philips N.V., Best, The Netherlands), a high-fidelity broadband linear array transducer (4-12 MHz frequency), connects through a web-enabled smartphone or tablet to cloud software and offers B-mode and color Doppler imaging without pulsed wave Doppler capability. The aims of the study were to compare hand-held acoustic Doppler (HHD) vs PCD diagnostic performance using conventional duplex ultrasound (DUP) as the "gold standard" for VRD assessment, to assess effects of body mass index (BMI) and disease severity on diagnostic performance of HHD and PCD, and to determine whether PCD offers any diagnostic improvement over HHD in VRD assessment. METHODS There were 241 patients (65 male, 176 female; mean age, 55.5 ± 15.5 years; mean BMI, 32.2 ± 7.9 kg/m2). DUP (447 legs), PCD (262 legs), and HHD (217 legs) studied the great saphenous vein at above-knee (AK) and below-knee (BK) levels. A phlebologist performed HHD, whereas PCD and DUP were performed sequentially (PCD first) by an experienced technologist and interpreted independently. PCD was done blinded to DUP results. DUP findings were analyzed blinded to HHD and PCD results. Venous reflux was dichotomously assessed as <2 seconds and >2 seconds. RESULTS HHD improves from moderate to good sensitivity from AK level (68%) to BK level (94%) but suffers poor specificity that declines significantly from AK level (50%) to BK level (12%; P < .05). HHD positive predictive value exceeds its negative predictive value (NPV) and remains unchanged from AK level (71%) to BK level (72%). HHD NPV remains consistently poor at AK (48%) and BK (42%) levels. PCD has similar sensitivity from AK level (69%) to BK level (74%), better AK level (79%) vs BK level (58%) specificity (P < .05), similar positive predictive value for AK (76%) and BK levels (78%), and better NPV for AK level (72%) vs BK level (53%; P < .05). BMI range (<30 kg/m2 vs ≥ 30 kg/m2) did not influence diagnostic performance of HHD and PCD significantly. HHD and PCD specificity was higher for Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class <4 compared with CEAP class ≥4 (P < .05). CONCLUSIONS The relative diagnostic performance of HHD and PCD is highly dependent on insonation level. PCD advantages compared with HHD are marginally greater specificity at AK and BK levels and better NPV at AK level. Compared with HHD, PCD's disadvantage is lower sensitivity at BK level. Both HHD and PCD have higher specificity at AK level than at BK level. Overall, PCD offers only moderate sensitivity and specificity, making it inadequate for exclusion of significant venous reflux. Neither obesity nor CEAP class significantly influenced the general diagnostic performance of PCD or HHD.
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14
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Masuda E, Ozsvath K, Vossler J, Woo K, Kistner R, Lurie F, Monahan D, Brown W, Labropoulos N, Dalsing M, Khilnani N, Wakefield T, Gloviczki P. The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology. J Vasc Surg Venous Lymphat Disord 2020; 8:505-525.e4. [PMID: 32139328 DOI: 10.1016/j.jvsv.2020.02.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Stimulated by published reports of potentially inappropriate application of venous procedures, the American Venous Forum and its Ethics Task Force in collaboration with multiple other professional societies including the Society for Vascular Surgery (SVS), American Vein and Lymphatic Society (AVLS), and the Society of Interventional Radiology (SIR) developed the appropriate use criteria (AUC) for chronic lower extremity venous disease to provide clarity to the application of venous procedures, duplex ultrasound imaging, timing, and reimbursements. METHODS The AUC were developed using the RAND/UCLA Appropriateness Method, a validated method of developing appropriateness criteria in health care. By conducting a modified Delphi exercise and incorporating best available evidence and expert opinion, AUC were developed and scored. RESULTS There were 119 scenarios rated on a scale of 1 to 9 by an expert panel, with 1 being never appropriate and 9 being appropriate. The majority of scenarios consisted of symptomatic indications were deemed appropriate for venous intervention. For scenarios with anatomically short segments of reflux and/or no symptoms, the indications were rated less appropriate. For the indication of edema, a wide dispersion of ratings was observed especially for short segments of saphenous reflux or stenting for iliac/ inferior vena cava disease, noting that there are multifactorial causes of edema, some of which could coexist with venous disease and possibly impact effectiveness of treatment. Several scenarios were considered never appropriate, including treatment of saphenous veins with no reflux, iliac vein or inferior vena cava stenting for iliac vein compression as an incidental finding by imaging with minimal or no symptoms or signs, and incentivizing sonographers to find reflux. CONCLUSIONS The AUC statements are intended to serve as a guide to patient care, particularly in areas where high-quality evidence is lacking to aid clinicians in making day-to-day decisions for common venous interventions. This may also prove useful when applied on a population level, such as practice patterns, and not necessarily to dictate decision making for individual cases. As a product of a collaborative effort, it is hoped that this could be utilized by physicians and multiple stakeholders committed toward improving patient care and to identify and stimulate future research priorities.
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Affiliation(s)
- Elna Masuda
- Straub Medical Center, Hawaii Pacific Health, Honolulu, Hawaii.
| | | | | | - Karen Woo
- Department of Surgery, University of California, Los Angeles, Los Angeles, Calif
| | | | | | | | - William Brown
- William Beaumont Hospital and Wayne State University School of Medicine, Bingham Farms, Mich
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15
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Lurie F, Passman M, Meisner M, Dalsing M, Masuda E, Welch H, Bush RL, Blebea J, Carpentier PH, De Maeseneer M, Gasparis A, Labropoulos N, Marston WA, Rafetto J, Santiago F, Shortell C, Uhl JF, Urbanek T, van Rij A, Eklof B, Gloviczki P, Kistner R, Lawrence P, Moneta G, Padberg F, Perrin M, Wakefield T. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord 2020; 8:342-352. [PMID: 32113854 DOI: 10.1016/j.jvsv.2019.12.075] [Citation(s) in RCA: 326] [Impact Index Per Article: 81.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/22/2019] [Indexed: 12/26/2022]
Abstract
The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification is an internationally accepted standard for describing patients with chronic venous disorders and it has been used for reporting clinical research findings in scientific journals. Developed in 1993, updated in 1996, and revised in 2004, CEAP is a classification system based on clinical manifestations of chronic venous disorders, on current understanding of the etiology, the involved anatomy, and the underlying venous pathology. As the evidence related to these aspects of venous disorders, and specifically of chronic venous diseases (CVD, C2-C6) continue to develop, the CEAP classification needs periodic analysis and revisions. In May of 2017, the American Venous Forum created a CEAP Task Force and charged it to critically analyze the current classification system and recommend revisions, where needed. Guided by four basic principles (preservation of the reproducibility of CEAP, compatibility with prior versions, evidence-based, and practical for clinical use), the Task Force has adopted the revised Delphi process and made several changes. These changes include adding Corona phlebectatica as the C4c clinical subclass, introducing the modifier "r" for recurrent varicose veins and recurrent venous ulcers, and replacing numeric descriptions of the venous segments by their common abbreviations. This report describes all these revisions and the rationale for making these changes.
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Affiliation(s)
- Fedor Lurie
- Jobst Vascular Institute, Toledo, Ohio; Division of Vascular Surgery, University of Michigan, Ann Arbor, Mich.
| | - Marc Passman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Mark Meisner
- Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Michael Dalsing
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Elna Masuda
- Department of Surgery, University of Hawaii, Honolulu, Hi
| | - Harold Welch
- Vascular Surgery, Lahey Hospital and Medical Center, Burlington, Mass
| | - Ruth L Bush
- University of Houston College of Medicine, Houston, Tex
| | - John Blebea
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, Mich
| | | | | | | | | | - William A Marston
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Joseph Rafetto
- Harvard Medical School, Uniformed Services University of the Health Sciences, VA Boston HCS, Brigham and Women's Hospital, Boston, Mass
| | | | - Cynthia Shortell
- Department of Surgery, Duke University Medical Center, Durham, NC
| | | | | | - André van Rij
- Dunedin School of Medicine, University of Otago, Otago, New Zealand
| | - Bo Eklof
- Department of Surgery, University of Hawaii, Honolulu, Hi
| | | | - Robert Kistner
- Department of Surgery, University of Hawaii, Honolulu, Hi
| | | | | | | | - Michel Perrin
- Service de Chirurgie Vasculaire, Clinique du Grand Large, Décines, France
| | - Thomas Wakefield
- Division of Vascular Surgery, University of Michigan, Ann Arbor, Mich
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16
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Domagalska-Szopa M, Szopa A, Puchner M, Schreiber L, Siwiec A, Hagner-Derengowska M, Ziaja D. Leg Venous Properties in Children With Myelomeningocele. Front Pediatr 2020; 8:531. [PMID: 32984225 PMCID: PMC7492545 DOI: 10.3389/fped.2020.00531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/27/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction: The vascular properties of individuals with myelomeningocele (MMC) are an underestimated problem, as evidenced by the lack of relevant research. Therefore, this study was conducted to assess the venous properties of the leg in children with MMC. This study compared the duration of retrograde flow (RF) of the distal and proximal sites of the great saphenous vein (GSV) in children with MMC and typically developing (TD) children. Additionally, the impact of MMC clinical features, such as the anatomical level of the spinal cord defect, muscle strength of the lower limbs, and level of gross motor functional abilities on the of GSV sufficiency were assessed. Methods: Thirty ambulant children between 7 and 12 years with MMC and an age- and sex-matched sample of thirty children with typical development (TD) were included in the study. All participants underwent a complete physical examination that included gross motor assessment, manual muscle testing, and duplex ultrasound examination of the GSV reflux. The duration of retrograde flow (RT) in the GSV was evaluated at four sites: P1: proximal thigh; P2: medial thigh; P3: upper leg; and P4: lower leg. The measurements were performed in two body positions: horizontal position (HP) and vertical position (VP). Results: Children with MMC showed increased duration of RT of both the proximal and peripheral sites of GSV, as compared with the TD peers. The prevalence of GSV reflux in peripheral segments was significantly higher than in the proximal segments. The severity of MMC (expressed by higher level of the spinal cord defect), deficit of thigh and leg muscle strength, and lower functional independence negatively influenced the GSV sufficiency in patients with MMC. Gravity directly influenced GSV reflux occurrence and reflux hemodynamic parameters in MMC. Conclusion: These findings may help better understand aspects concerning the risk of developing venous insufficiency in children with MMC and determine better screening, prevention, and treatment algorithms for venous insufficiency in patients with SB.
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Affiliation(s)
- Małgorzata Domagalska-Szopa
- Department of Medical Rehabilitation, School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Andrzej Szopa
- Department of Physiotherapy, School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Maximilian Puchner
- Department of Neurosurgery, Klinikum Vest, Academic Teaching Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lutz Schreiber
- Department of Neurosurgery, Klinikum Vest, Academic Teaching Hospital, Ruhr University Bochum, Bochum, Germany
| | - Andrzej Siwiec
- Pediatrics Center John Paul II in Sosnowiec, Sosnowiec, Poland
| | | | - Damian Ziaja
- Department of Physiotherapy, School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
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Gianesini S, Obi A, Onida S, Baccellieri D, Bissacco D, Borsuk D, Campisi C, Campisi CC, Cavezzi A, Chi YW, Chunga J, Corda D, Crippa A, Davies A, De Maeseneer M, Diaz J, Ferreira J, Gasparis A, Intriago E, Jawien A, Jindal R, Kabnick L, Latorre A, Lee BB, Liew NC, Lurie F, Meissner M, Menegatti E, Molteni M, Morrison N, Mosti G, Narayanan S, Pannier F, Parsi K, Partsch H, Rabe E, Raffetto J, Raymond-Martimbeau P, Rockson S, Rosukhovski D, Santiago FR, Schul A, Schul M, Shaydakov E, Sibilla MG, Tessari L, Tomaselli F, Urbanek T, van Rijn MJ, Wakefield T, Wittens C, Zamboni P, Bottini O. Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019. Phlebology 2019; 34:4-66. [PMID: 31495256 DOI: 10.1177/0268355519870690] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.
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Affiliation(s)
| | - Andrea Obi
- 2 University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Denis Borsuk
- 6 Clinic of Phlebology and Laser Surgery, 'Vasculab' Ltd, Chelyabinsk, Russia
| | | | | | - Attilio Cavezzi
- 9 Eurocenter Venalinfa, San Benedetto del Tronto (AP), Italy
| | - Yung-Wei Chi
- 10 University of California, Davis Vascular Center, Sacramento, CA, USA
| | | | | | | | | | | | - Josè Diaz
- 15 Vanderbilt University Medical Center, Nashville, TN, USA
| | - Julio Ferreira
- 16 Instituto Brasilerio de Flebologia, Sao Paulo, Brazil
| | | | | | - Arkadiusz Jawien
- 19 Collegium Medicum, University of Nicolaus Copernicus, Bydgoszcz, Poland
| | | | | | | | | | - N C Liew
- 24 Putra University, Serdang, Malaysia
| | - Fedor Lurie
- 25 Jobst Vascular Institute, Toledo, OH, USA
| | | | | | | | | | | | | | | | - Kurosh Parsi
- 32 St. Vincent's Hospital, University of NSW, Sydney, Australia
| | | | | | | | | | - Stanley Rockson
- 37 Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Cees Wittens
- 44 Maastricht University Medical Center, Maastricht, Netherlands.,45 Uniklinik Aachen, Aachen, Germany
| | | | - Oscar Bottini
- 46 Universidad de Buenos Aires, Buenos Aires, Argentina
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18
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Kovač A, Janić M, Nuredini D, Kozak M. The influence of May-Thurner syndrome on post-thrombotic syndrome in young women. VASA 2019; 48:393-398. [DOI: 10.1024/0301-1526/a000776] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Summary. Background: The mechanism for post-thrombotic syndrome (PTS), the most important long-term sequelae of deep venous thrombosis, is not entirely known. It is probably caused by venous hypertension due to venous insufficiency and venous obstruction. Venous hypertension could also be a consequence of the May-Thurner syndrome (MTS), i.e. the obstruction of the common iliac vein. The aim of the present study was to explore if women with untreated MTS and a history of proximal DVT develop PTS more frequently. Patients and methods: A cohort of 68 female patients with a history of proximal left-sided DVT in the past were evaluated. According to Villalta score, they were segregated in two groups – with and without PTS (Villalta score ≥ 5 or < 5 points, respectively). For the diagnosis of MTS, magnetic resonance venography was performed. Results: Out of 68 patients, 25 developed PTS (36.8 %). Recurrent DVT, older age, pre-existent chronic venous insufficiency, and shorter compression stockings wearing time were statistically related to PTS. Deep and superficial valve incompetence was also significantly related to PTS, while incomplete thrombus removal showed only a trend towards PTS development. On the other hand, MTS per se turned out not to be linked to PTS. Conclusions: Our study suggests that women with MTS might not develop PTS more often, which puts aggressive treatment of MTS under question. More clinical trials are warranted to further examine this yet not fully explained field.
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Affiliation(s)
- Ana Kovač
- Department of Cardiology, University Medical Centre Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Slovenia
| | - Miodrag Janić
- Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia
| | - Dašmir Nuredini
- Institute of Radiology, University Medical Centre Ljubljana, Slovenia
| | - Matija Kozak
- Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia
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19
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Gravity force is not a sole explanation of reflux flow in incompetent great saphenous vein. J Vasc Surg Venous Lymphat Disord 2019; 7:693-698. [PMID: 31281101 DOI: 10.1016/j.jvsv.2019.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/11/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study aimed to evaluate the impact of gravity, reservoir size, and competence of the ostial valve on venous reflux in different body positions. METHODS Our study included 61 lower limbs with primary incompetence of the great saphenous vein (GSV). The diameter of the GSV and its cross-sectional area, time-averaged mean velocity (TAMEAN), and reflux time (RT) were measured with duplex ultrasound with pulsed wave Doppler. Reflux volume (RV) and reflux volume flow rate (Q) were calculated. The measurements were carried out in three body positions: horizontal, A; seated upright with stretched legs, B; and vertical, C. Distal automatic cuff compression-decompression (120 mm Hg) was used as a provocation maneuver. RESULTS There was 100% occurrence of reflux in the patient positions B and C. Reflux was observed in 91.8% of cases in position A. All reflux parameters (TAMEAN, RT, Q, RV) and the size of the vein were significantly different in the three studied positions. The patient's height did not influence the magnitude of change in reflux parameters. All reflux parameters increased more significantly when the position changed from A to B than from B to C (TAMEAN, +103% and +37%; GSV diameter, +33% and +5%; RV, +408% and +65%, respectively). CONCLUSIONS Observed positional changes in reflux parameters suggest that gravitational forces are not a sole explanation for reflux flow in incompetent GSV. It is likely that the gravitational effect on venous flow is mediated by the changes in vein diameter and the total volume of the venous reservoir of the leg.
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20
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Mervis JS, Kirsner RS, Lev-Tov H. Protocol for a longitudinal cohort study: determination of risk factors for the development of first venous leg ulcer in people with chronic venous insufficiency, the VEINS (venous insufficiency in South Florida) cohort. BMJ Open 2019; 9:e023313. [PMID: 30610020 PMCID: PMC6326300 DOI: 10.1136/bmjopen-2018-023313] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 11/02/2018] [Accepted: 11/05/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Chronic venous insufficiency (CVI) affects up to one-third of the adult population yet venous leg ulcers (VLU), a significant complication of CVI, only affect 1%-2% of adults in the USA. Why some develop VLU and others do not is unclear. VLU have a significant impact on quality of life and are extremely costly and difficult to treat. Moreover, VLU prevalence is increasing, doubling in the last 20 years. In order to characterise the differences between people with CVI and those who ultimately develop VLU, we aim to set up the unique venous insufficiency in South Florida cohort. METHODS AND ANALYSIS Subjects will be recruited from the University of Miami Hospital and Clinic's vascular laboratory database, which began in July 2011. Any adult age 18-95 who has had venous reflux detected on duplex ultrasound of the lower extremities is included. Approximately 2500 patients are already in the database that meet these criteria, with an estimated 2500 additional potential subjects to be recruited from the vascular laboratory database over the next 5 years. Subjects with a history of VLU prior to the duplex study date will be excluded. Data will be collected via review of the Doppler study report, patient phone interview and review of the electronic medical record. Subjects will be contacted for follow-up every 3 months for at least 5 years until the study endpoint, development of first VLU (fVLU), is reached. In order to estimate the time from reflux documentation to fVLU, Kaplan-Meier survival curves will be constructed. Cox proportional hazard regression models will be constructed to investigate possible risk factors. ETHICS AND DISSEMINATION This study is approved by the University of Miami's Institutional Review Board. We hope to present the results of this study to the scientific community at conferences and in peer-reviewed journals.
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Affiliation(s)
- Joshua S Mervis
- Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Robert S Kirsner
- Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Hadar Lev-Tov
- Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Florida, USA
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Stapler SJ, Zurales K, Mazurek A, Otemuyiwa B, Knol M, Wakefield TW, Coleman DM. A pilot study of venous duplex ultrasound parameters in healthy children. J Vasc Surg Venous Lymphat Disord 2018; 6:347-350. [PMID: 29292113 DOI: 10.1016/j.jvsv.2017.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The spectrum of chronic venous disease (CVD) in adults is well documented, whereas there is a paucity of data published commenting on pediatric CVD. We previously identified that there is often venous reflux present in cases of pediatric lower extremity edema despite an alternative confirmed diagnosis. To further assess the clinical significance of this venous reflux, this study aimed to elicit venous parameters in healthy pediatric controls. METHODS Healthy pediatric volunteers aged 5 to 17 years were recruited for venous reflux study. A comprehensive venous reflux study was performed with the patient standing. Vein diameter, patterns of valvular reflux, and accessory venous anatomy were examined in the deep and superficial venous systems. RESULTS Eighteen children including 10 boys and 8 girls were studied. Five volunteers were aged 5 to 8 years, six volunteers were aged 9 to 12 years, and seven volunteers were aged 13 to 17 years. Great saphenous vein (GSV) diameter at the saphenofemoral junction significantly increased with age. Deep vein valve closure time (VCT) did not differ significantly between groups, whereas GSV VCT was significantly higher in the 9- to 12-year age group. Incidental venous insufficiency was identified in 60% of children aged 5 to 8 years (n = 3), 50% of children aged 9 to 12 years (n = 3), and 57% of children aged 13 to 17 years (n = 4). All superficial venous reflux was confined to the GSV; there were no cases of isolated deep venous reflux. Reflux was identified at multiple GSV stations in 60% of children. There was no significant difference in incompetent GSV VCT in comparing children with and without deep venous reflux. Accessory superficial veins were identified in 20% of children aged 5 to 8 years (n = 1), 50% of children aged 9 to 12 years (n = 3), and 43% of children aged 13 to 17 years (n = 3). The presence of an accessory saphenous vein was not associated with deep venous reflux in any patient, and only 29% of those with accessory saphenous venous anatomy had evidence of superficial venous (GSV) reflux. CONCLUSIONS The GSV continues to grow in diameter through the teenage years. Incidental valvular incompetence and GSV reflux are common. The presence of accessory saphenous veins is similarly common and not associated with venous reflux. The clinical significance and natural history of this incidental venous reflux remain unclear. Future research should determine whether these changes seen in the pediatric age group lead to CVD during later years of life.
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Affiliation(s)
| | - Katie Zurales
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Alyssa Mazurek
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | | | - Meghan Knol
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | | | - Dawn M Coleman
- Department of Surgery, University of Michigan, Ann Arbor, Mich.
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22
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Martini D, Rossi S, Biasini B, Zavaroni I, Bedogni G, Musci M, Pruneti C, Passeri G, Ventura M, Di Nuzzo S, Galli D, Mirandola P, Vitale M, Dei Cas A, Bonadonna RC, Del Rio D. Claimed effects, outcome variables and methods of measurement for health claims proposed under European Community Regulation 1924/2006 in the framework of protection against oxidative damage and cardiovascular health. Nutr Metab Cardiovasc Dis 2017; 27:473-503. [PMID: 28434807 DOI: 10.1016/j.numecd.2017.01.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 01/30/2017] [Accepted: 01/31/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS The high number of negative opinions from the European Food Safety Authority (EFSA) to the requests for authorization of health claims is largely due to the design of human intervention studies, including the inappropriate choice of outcome variables (OVs) and of their methods of measurement (MMs). The present manuscript reports the results of an investigation aimed to collect, collate and critically analyse the information in relation to claimed effects, OVs and MMs, in the context of protection against oxidative damage and cardiovascular health compliant with Regulation 1924/2006. METHODS AND RESULTS Claimed effects, OVs and the related MMs were collected from EFSA Guidance documents and applications for authorization of health claims under Articles 13.5 and 14. The OVs and their MMs were evaluated only if the claimed effect was sufficiently defined and was considered beneficial by EFSA. The collection, collation and critical analysis of the relevant scientific literature consisted in the definition of the keywords, the PubMed search strategies and the creation of databases of references. The critical analysis of the OVs and their MMs was performed on the basis of the literature review and was aimed at defining the appropriateness of OVs and MMs in the context of the specific claimed effects. CONCLUSIONS The information provided in this document could serve to EFSA for the development of further guidance on the scientific requirements for health claims, as well as to the stakeholders for the proper design of human intervention studies aimed to substantiate such health claims.
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Affiliation(s)
- D Martini
- The Laboratory of Phytochemicals in Physiology, Department of Food and Drug, University of Parma, Parma, Italy
| | - S Rossi
- The Laboratory of Phytochemicals in Physiology, Department of Food and Drug, University of Parma, Parma, Italy
| | - B Biasini
- The Laboratory of Phytochemicals in Physiology, Department of Food and Drug, University of Parma, Parma, Italy
| | - I Zavaroni
- Department of Medicine and Surgery, Division of Endocrinology, University of Parma, Italy; Azienda Ospedaliera Universitaria of Parma, Parma, Italy
| | - G Bedogni
- Clinical Epidemiology Unit, Liver Research Center, Basovizza, Trieste, Italy
| | - M Musci
- Department of Food and Drug, University of Parma, Parma, Italy
| | - C Pruneti
- Department of Medicine and Surgery, Clinical Psychology Unit, University of Parma, Medical School Building, Parma, Italy
| | - G Passeri
- Department of Medicine and Surgery, Building Clinica Medica Generale, University of Parma, Parma, Italy
| | - M Ventura
- Department of Chemistry, Life Sciences and Environmental Sustainability, Laboratory of Probiogenomics, University of Parma, Parma, Italy
| | - S Di Nuzzo
- Department of Medicine and Surgery, Section of Dermatology, University of Parma, Parma, Italy
| | - D Galli
- Department of Medicine and Surgery, Sport and Exercise Medicine Centre (SEM), University of Parma, Parma, Italy
| | - P Mirandola
- Department of Medicine and Surgery, Sport and Exercise Medicine Centre (SEM), University of Parma, Parma, Italy
| | - M Vitale
- Department of Medicine and Surgery, Sport and Exercise Medicine Centre (SEM), University of Parma, Parma, Italy
| | - A Dei Cas
- Department of Medicine and Surgery, Division of Endocrinology, University of Parma, Italy; Azienda Ospedaliera Universitaria of Parma, Parma, Italy
| | - R C Bonadonna
- Department of Medicine and Surgery, Division of Endocrinology, University of Parma, Italy; Azienda Ospedaliera Universitaria of Parma, Parma, Italy
| | - D Del Rio
- The Laboratory of Phytochemicals in Physiology, Department of Food and Drug, University of Parma, Parma, Italy.
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Abstract
Stasis dermatitis commonly occurs in older age. It is caused by venous hypertension resulting from retrograde flow due to incompetent venous valves, valve destruction, or obstruction of the venous system. Further tissue changes arise from an inflammatory process mediated by metalloproteinases, which are up-regulated by ferric ion from extravasated red blood cells. Stasis dermatitis presents initially as poorly demarcated erythematous plaques of the lower legs bilaterally, classically involving the medial malleolus. It is one of the spectrum of cutaneous findings that may result from chronic venous insufficiency. Its mimics include cellulitis, contact dermatitis, and pigmented purpuric dermatoses. Duplex ultrasound is useful in demonstrating venous reflux when the clinical diagnosis of stasis dermatitis is inadequate. Conservative treatment involves the use of compression therapy directed at improving ambulatory venous pressure. Interventional therapy currently includes minimally invasive techniques such as endovenous thermal ablation and ultrasound-guided foam sclerotherapy, which have supplanted the use of open surgical techniques.
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Zollmann P, Zollmann C, Zollmann P, Veltman J, Kerzig D, Doerler M, Stücker M. Determining the origin of superficial venous reflux in the groin with duplex ultrasound and implications for varicose vein surgery. J Vasc Surg Venous Lymphat Disord 2017; 5:82-86. [DOI: 10.1016/j.jvsv.2016.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Andraska EA, Horne DC, Campbell DN, Eliason JL, Wakefield TW, Coleman DM. Patterns of pediatric venous disease. J Vasc Surg Venous Lymphat Disord 2016; 4:422-5. [PMID: 27638996 DOI: 10.1016/j.jvsv.2016.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 06/03/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The spectrum of chronic venous disease (CVD) is well documented in adults; clinical guidelines standardize diagnosis and treatment. There is a paucity of data published commenting on pediatric CVD exclusive of Klippel-Trénaunay syndrome (KTS) and post-thrombotic syndrome. METHODS This study aimed to define patterns of pediatric venous disease. All venous reflux studies performed on patients <18 years of age between January 2012 and June 2014 were reviewed. Study indication, patient history, clinical examination, and duplex ultrasound results were queried and described. Venous reflux parameters were compared using one-way analysis of variance. RESULTS Twenty patients were evaluated. All presented through the vascular surgery or multidisciplinary venous clinic at a tertiary academic medical center. Indications for referral included swelling (n = 10), varicose veins (n = 9), and rubor/acrocyanosis (n = 3); two patients carried a diagnosis of KTS. Mean age at study was 13 years (range, 5-17 years). Clinical examination revealed the following: dependent rubor (n = 3); edema (n = 9); and varicose veins or venous abnormality concerning for venous malformation (n = 9). There were no stigmata of chronic inflammation, hyperpigmentation, or ulceration; 90% of patients (n = 18) demonstrated venous reflux by duplex ultrasound interrogation. Mean right great saphenous vein (GSV) diameter was 0.49 cm (range, 0.31-0.66 cm); mean left GSV diameter was 0.55 cm (range, 0.24-0.93 cm). Adjunctive studies were often used (including magnetic resonance venography and lymphoscintigraphy). Despite the presence of venous reflux on imaging, an alternate diagnosis was made in 8 of 18 children (44%), including postural orthostatic hypotension syndrome (n = 2), vascular malformation (n = 2), lymphedema (n = 2), complex regional pain syndrome (n = 1), and acrocyanosis of disuse (n = 1). An additional case of KTS was identified. Three cases referred for varicose veins were diagnosed with venous malformation. Maximum GSV diameter and venous reflux time were compared across patients with isolated CVD, KTS, or an alternate diagnosis (as before). Whereas there was no significant difference in maximum GSV diameter, superficial venous reflux time was significantly increased in the patients with primary CVD and KTS (P = .0394). CONCLUSIONS The differential diagnosis for pediatric lower extremity edema and varicosities is broad; workup often requires adjunctive studies to secure the appropriate diagnosis. Often there is venous reflux present despite an alternative clinical diagnosis. Superficial venous reflux time may aid in the diagnosis of primary CVD. Whereas the clinical significance of pediatric venous reflux remains unclear, ongoing work to expand on venous parameters in healthy pediatric controls is warranted, as is additional follow-up to assess the natural history of pediatric venous disease.
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Affiliation(s)
- Elizabeth A Andraska
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Danielle C Horne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Danielle N Campbell
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Jonathan L Eliason
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Thomas W Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Dawn M Coleman
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
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Shepherd J. Progressive compression versus graduated compression for the management of venous insufficiency. Br J Community Nurs 2016; 21 Suppl 9:S13-S18. [PMID: 27594309 DOI: 10.12968/bjcn.2016.21.sup9.s13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Venous leg ulceration (VLU) is a chronic condition associated with chronic venous insufficiency (CVI), where the most frequent complication is recurrence of ulceration after healing. Traditionally, graduated compression therapy has been shown to increase healing rates and also to reduce recurrence of VLU. Graduated compression occurs because the circumference of the limb is narrower at the ankle, thereby producing a higher pressure than at the calf, which is wider, creating a lower pressure. This phenomenon is explained by the principle known as Laplace's Law. Recently, the view that compression therapy must provide a graduated pressure gradient has been challenged. However, few studies so far have focused on the potential benefits of progressive compression where the pressure profile is inverted. This article will examine the contemporary concept that progressive compression may be as effective as traditional graduated compression therapy for the management of CVI.
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Affiliation(s)
- Jan Shepherd
- Service Integration Manager, Clinic Based Services, BwD Locality, Lancashire Care NHS Foundation Trust
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Evidence-based (S3) guidelines for diagnostics and treatment of venous leg ulcers. J Eur Acad Dermatol Venereol 2016; 30:1843-1875. [PMID: 27558268 DOI: 10.1111/jdv.13848] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 06/17/2016] [Indexed: 11/29/2022]
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Chapter 2 - Diagnostics. J Eur Acad Dermatol Venereol 2016. [PMID: 27558780 DOI: 10.1111/jdv.3_13848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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29
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Mousa AY, Broce M, Yacoub M, Hanna P, Baskharoun M, Stone PA, Bates MC, AbuRahma AF. Validation of venous duplex ultrasound imaging in determining iliac vein stenosis after standard treatment of active chronic venous ulcers. J Vasc Surg Venous Lymphat Disord 2016; 4:307-12. [DOI: 10.1016/j.jvsv.2016.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
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The value of hemodynamic measurements by air plethysmography in diagnosing venous obstruction of the lower limb. J Vasc Surg Venous Lymphat Disord 2016; 4:313-9. [DOI: 10.1016/j.jvsv.2016.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 01/14/2016] [Indexed: 11/21/2022]
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Menzinger G. Moderne Diagnostik der CVI. Wien Med Wochenschr 2016; 166:275-7. [DOI: 10.1007/s10354-016-0475-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 06/09/2016] [Indexed: 11/29/2022]
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Lattimer CR, Azzam M, Kalodiki E, Geroulakos G. Quantifying saphenous recirculation in patients with primary lower extremity venous reflux. J Vasc Surg Venous Lymphat Disord 2016; 4:179-86. [DOI: 10.1016/j.jvsv.2015.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 09/15/2015] [Indexed: 11/16/2022]
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Gulcu A, Ozutemiz C, Ugurlu B, Kose T. Duplex ultrasonography findings are not related to menstrual cycle phases in women with early symptoms of lower extremity chronic venous disease. JOURNAL OF CLINICAL ULTRASOUND : JCU 2016; 44:85-91. [PMID: 26178614 DOI: 10.1002/jcu.22287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/11/2015] [Accepted: 06/27/2015] [Indexed: 06/04/2023]
Abstract
PURPOSE To investigate if duplex ultrasonography findings change according to the menstrual cycle phases in women with early symptoms of lower extremity chronic venous disease. METHODS Thirty women (60 extremities) aged 18-50 years with regular menstrual cycles who presented with complaints of telangiectasia and/or trunk varices with accompanying leg pain were evaluated prospectively by duplex ultrasonography at three different times of a single menstrual cycle. Previous DVT or menstrual irregularities were exclusion criteria. All exams were performed by the same radiologist, under the same conditions. Reflux was provoked in the deep veins, great saphenous vein (GSV), and small saphenous vein (SSV) using the Valsalva maneuver. Reflux times in each vein and average diameters of the GSV and SSV were recorded. RESULTS Reflux times showed no significant differences in any of the vein segments and the diameters of GSV and SSV were similar in the different menstrual phases (p > 0.05). Reflux was not predominant at any specific phase, and its presence was independent of menstrual phase. CONCLUSIONS Reflux was not specific to a particular phase of menstrual cycle in women with early symptoms of chronic venous disease.
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Affiliation(s)
- Aytac Gulcu
- Department of Radiology, Dokuz Eylul University, Izmir, Turkey
| | - Can Ozutemiz
- Department of Radiology, Dokuz Eylul University, Izmir, Turkey
| | - Baran Ugurlu
- Department of Thoracic and Cardiovascular Surgery, Dokuz Eylul University, Izmir, Turkey
| | - Timur Kose
- Department of Biostatistics and Medical Informatics, Ege University School of Medicine, Izmir, Turkey
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Transforming the best care into the standard for care. J Vasc Surg Venous Lymphat Disord 2016; 4:106-13. [DOI: 10.1016/j.jvsv.2015.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 10/06/2015] [Indexed: 11/16/2022]
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35
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Shaydakov ME, Comerota AJ, Lurie F. Primary venous insufficiency increases risk of deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2015; 4:161-6. [PMID: 26993861 DOI: 10.1016/j.jvsv.2015.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/21/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Varicose veins have been recognized as a risk factor for deep vein thrombosis (DVT). However, venous reflux has not carried the same correlation. This study evaluated the association between primary valvular reflux and DVT. METHODS We performed a nested case-control study with enrollment of outpatients presenting to the vascular laboratory with signs and symptoms of DVT. All patients had a complete bilateral venous duplex examination evaluating for DVT and superficial and deep venous valvular reflux. Eighty-seven patients with confirmed DVT on venous duplex were selected for the study group. The control group was randomly selected from the same cohort in a 4:1 ratio matched by age and gender (n = 348). Groups were compared for the prevalence of deep and superficial reflux. RESULTS DVT outpatients were 4.7-times more likely to have primary valvular reflux than symptomatic controls (65.5% vs 29.0%; 95% confidence interval [CI], 2.8-7.7; P < .000001). Deep reflux was 2.1-times more prevalent (36.8% vs 21.6%; odds ratio, 2.12; 95% CI, 1.28-3.51; P = .005) and superficial reflux was 4.6-times more prevalent (43.7% vs 14.4%; odds ratio, 4.62; 95% CI, 2.75-7.77; P < .0000001) in DVT patients than in controls. DVT patients were also 2.1-times more likely to have combined deep and superficial reflux than non-DVT patients (13.8% vs 6.6%, 95% CI, 1.08-4.75; P = .044). CONCLUSIONS The prevalence of primary valvular reflux in patients with DVT is significantly higher than expected. Reflux may be considered as a novel risk factor for DVT. Two-thirds of patients with DVT have pre-existent primary chronic venous disease, which is likely to contribute to post-thrombotic morbidity.
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Affiliation(s)
| | | | - Fedor Lurie
- Jobst Vascular Institute, ProMedica Toledo Hospital, Toledo, Ohio.
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36
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Chronic venous disease and venous leg ulcers: An evidence-based update. JOURNAL OF VASCULAR NURSING 2015; 33:36-46. [DOI: 10.1016/j.jvn.2015.01.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/17/2015] [Accepted: 01/21/2015] [Indexed: 01/10/2023]
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38
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Birn J, Vedantham S. May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery. Vasc Med 2014; 20:74-83. [PMID: 25502563 DOI: 10.1177/1358863x14560429] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Acute and chronic venous disorders of the lower extremities affect millions of people and cause substantial disability. Long ago, surgeons and pathologists identified the presence of 'spur-like' abnormalities of the left common iliac vein; these abnormalities were hypothesized to result from compression and/or irritation from the adjacent crossing right common iliac artery. In the 1990s, physicians, starting to perform catheter-directed thrombolysis to treat extensive deep vein thrombosis (DVT), observed that about 50% of patients had an iliac vein stenosis. Vascular physicians have become aware of the occasional patient with otherwise-unexplained extremity swelling and/or pain but without a DVT history who is subsequently found to have an iliac vein abnormality. These 'lesions' have been hypothesized to elevate ambulatory venous pressures and thereby produce lower-extremity symptoms, increase the risk of initial and recurrent DVT episodes, and increase the risk of treatment failure with medical and endovascular therapies for thrombotic and non-thrombotic venous conditions. As a result, many practitioners now actively seek iliac venous obstructive 'lesions' when evaluating patients with known or suspected venous disease. However, for many patients, it continues to be unclear what degree of obstruction to venous blood flow is being caused by such lesions, how clinically significant they are, how much emphasis should be placed on identifying them, and when they should be treated. This article seeks to improve the knowledge base of vascular practitioners who make clinical decisions about the diagnosis and treatment of obstructive iliac vein lesions.
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Affiliation(s)
- Jeffrey Birn
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Suresh Vedantham
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
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Konoeda H, Yamaki T, Hamahata A, Ochi M, Sakurai H. Quantification of superficial venous reflux by duplex ultrasound-role of reflux velocity in the assessment the clinical stage of chronic venous insufficiency. Ann Vasc Dis 2014; 7:376-82. [PMID: 25593622 DOI: 10.3400/avd.oa.14-00047] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 08/07/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study we compare the duplex-derived parameters of reflux in patients with early and advanced superficial venous insufficiency (SVI) to identify parameters reflecting this. METHODS Two thousand and one hundred sixty limbs with primary reflux, categorized according to the CEAP (clinical, etiologic, anatomic and pathophysiologic) classification, and the patients were divided into two groups (group I [C1-3, Ep, As, Pr]; group II [C4-6, Ep, As, Pr]) were studied. The vein diameter, reflux duration(s), mean reflux velocity (MRV; cm/s), peak reflux velocity (PRV; cm/s), and total reflux volume (TRV; ml/s) were determined at the sapheno-femoral junction (SFJ), great saphenous vein (GSV) and sapheno-popliteal junction (SPJ). RESULTS Age and the proportion of males were greater in group II. MRV, PRV and TRV were greater in group II at the SFJ, SPJ and in GSV (p <0.01 for all), although the duration of SPJ reflux was non-discriminatory (p = 0.78). From receiver operating characteristic (ROC) curve, optimal cut-off points of 27.8, 47.8, and 36.2 cm/s for the PRV at the SFJ (p <0.01), GSV (p <0.01), and SPJ (p <0.01) discriminated between the two groups. CONCLUSION PRV and MRV improved discrimination between early and advanced SVI compared to reflux duration.
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Affiliation(s)
- Hisato Konoeda
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takashi Yamaki
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Atsumori Hamahata
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Masakazu Ochi
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroyuki Sakurai
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
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40
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O'Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, Lurie F, Henke PK, Gloviczki ML, Eklöf BG, Stoughton J, Raju S, Shortell CK, Raffetto JD, Partsch H, Pounds LC, Cummings ME, Gillespie DL, McLafferty RB, Murad MH, Wakefield TW, Gloviczki P. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014; 60:3S-59S. [PMID: 24974070 DOI: 10.1016/j.jvs.2014.04.049] [Citation(s) in RCA: 387] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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41
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Dunic I, Vlajinac H, Marinkovic J, Maksimovic M, Radak D. Management of chronic venous disease by general practitioners in Serbia: a cross-sectional study. Postgrad Med 2014; 126:134-40. [PMID: 24685977 DOI: 10.3810/pgm.2014.03.2749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chronic venous disease (CVD) is one of the most prevalent medical conditions in the general population worldwide. OBJECTIVE To evaluate the management of CVD provided by general practitioners (GPs). METHODS AND MATERIALS The 2-center cross-sectional study comprised 2284 patients with CVD diagnosed and treated by GPs. Demographic and clinical data were obtained by physical examinations and standardized interviews. RESULTS Patients were counseled about different types of therapy; lifestyle advice was recommended to 88.8%, venoactive drugs to 90.8%, compression therapy to 44.0% of patients, anticoagulants to 16.7%, surgical treatment to 8.3%, and other types of therapy were recommended to 7.8% of patients. The most common types of treatment were dual and triple therapies recommended to 39.5% and 33.1%, respectively. The number of therapies recommended to patients increased with CVD progression. Treatment was not recommended to < 1% of patients. Only 8.4% of patients were referred to a vein specialist. CONCLUSIONS Although GPs had undergone special medical training about CVD before they were included in the study, some patients did not receive complete management of their condition. Continuous training of GPs and clinical guidelines for the management of CVD may help GPs to make adequate decisions.
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Affiliation(s)
- Ivana Dunic
- City Service of Dermatology and Venereology, Department for Prevention and Treatment Peripheral Vascular Diseases, Belgrade, Serbia.
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42
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Abstract
The advent of duplex ultrasound (DU) has changed vascular practice over the years. Venous anatomy, valve function and obstruction can be evaluated in real time using DU. It is a low cost, portable, non-invasive, safe and operator-friendly device that can be used for diagnosis, treatment guidance and follow-up. This paper defines the patterns, location and characteristics of venous reflux and also provides insightful information on acute and chronic venous obstruction.
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Affiliation(s)
- R D Malgor
- Division of Vascular Surgery, Stony Brook Medical Center, Stony Brook, NY 11794-8191, USA
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Perrins S, Cha A, Qaqish R, Plummer D, Hsu R, Dietzek AM. Clinical and anatomic outcomes of endovenous radiofrequency ablation performed on symptomatic small-diameter great saphenous veins. J Vasc Surg Venous Lymphat Disord 2013; 1:245-9. [PMID: 26992582 DOI: 10.1016/j.jvsv.2012.10.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 10/16/2012] [Accepted: 10/18/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The efficacy of radiofrequency ablation (RFA) for symptomatic varicose veins is well established. Alternatively, there is less consensus and little data on outcomes when treating great saphenous veins (GSV) of small diameter (≤5 mm). The purpose of this study is to assess clinical and anatomical outcomes of RFA on symptomatic patients with small GSV. METHODS A retrospective analysis was performed on our symptomatic patients who received RFA of incompetent GSV without any concomitant adjunctive procedures between January 2008 and December 2011. Limbs with GSV thigh diameter ≤5 mm and >5 mm on duplex while standing were subject to review. Clinical success was defined as an improvement in Venous Clinical Severity Score (VCSS) at 3 months. Anatomic success was defined as absence of venous flow ≤3 cm distal to the saphenofemoral junction on duplex ultrasound examination. Changes in CEAP class were noted. RESULTS In 307 patients, 55 limbs in 44 patients met inclusion criteria. Baseline median VCSS was 4 (interquartile range [IQR], 4, 5) for those patients with diameter ≤5 mm. Clinical success was seen in 83% of limbs at 3 months with a median VCSS change of -2 (IQR, -3, -1). None of the treated limbs had phlebectomy for symptomatic refluxing GSV varicosities prior to 3-month follow up. One phlebectomy was performed for cosmesis at 78 days postprocedure. Anatomic success was achieved in 96% of limbs at 3 months. Baseline median CEAP was 2 (IQR, 2, 2). The median CEAP change at 3 months was 0 (IQR, -1, 0). One patient experienced thrombus extension into the saphenofemoral junction at 4 days. CONCLUSIONS In our experience, RFA of symptomatic small-diameter GSV provides comparable clinical and anatomic outcomes to that of current published data. Our findings suggest that these patients benefit clinically from RFA.
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Affiliation(s)
- Steven Perrins
- Department of Vascular Surgery, Danbury Hospital, Danbury, Conn
| | - Andrew Cha
- Department of Vascular Surgery, Danbury Hospital, Danbury, Conn
| | - Robert Qaqish
- Department of Vascular Surgery, Danbury Hospital, Danbury, Conn
| | - Dahlia Plummer
- Department of Vascular Surgery, Danbury Hospital, Danbury, Conn
| | - Richard Hsu
- Department of Vascular Surgery, Danbury Hospital, Danbury, Conn
| | - Alan M Dietzek
- Department of Vascular Surgery, Danbury Hospital, Danbury, Conn.
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Rabe E, Guex JJ, Morrison N, Ramelet AA, Schuller-Petrovic S, Scuderi A, Staelens I, Pannier F. Treatment of chronic venous disease with flavonoids: recommendations for treatment and further studies. Phlebology 2013; 28:308-19. [PMID: 23395842 DOI: 10.1177/0268355512471929] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES A variety of studies have suggested that flavonoids are effective for the treatment of CVD. However, many questions remain about their mechanism of action and when, how, and for what signs and symptoms they should be used. METHOD A panel of experts in CVD met in Budapest, Hungary in December 2011 to discuss the current state of knowledge of CVD and the role of flavonoids in its treatment. The discussion was based on a literature search in the current databases. The goals of this paper are recommendations for further studies on the use of flavonoids in the treatment of CVD. RESULTS There is good evidence to recommend the use of flavonoids in the treatment of CVD. However, because of the poor quality of some older clinical trials, inadequate reporting, and insufficient information, much work is still needed to firmly establish their clinical efficacy and to determine when and how they should be employed. In particular, long-term randomized, placebo-controlled, double-blind studies are needed to establish the efficacy and safety of flavonoids. Additional studies are also needed to establish their mechanism of action, pharmacokinetics, toxicity, and cost-effectiveness. CONCLUSIONS Aside from good evidence for the use of flavonoids in CVD further studies are indicated to establish long term treatment in this indication.
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Affiliation(s)
- E Rabe
- Department of Dermatology, University of Bonn, Bonn, Germany.
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Perosi NA, Johnson MG, Berkmen T. Fluoroscopic-guided approaches to radiofrequency vein ablation. J Vasc Interv Radiol 2012. [PMID: 23182940 DOI: 10.1016/j.jvir.2012.09.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Ultrasound-guided antegrade access during endovenous lower-extremity vein ablation may be problematic. This study describes fluoroscopic-guided retrograde access to the target veins in cases in which antegrade access proved unfeasible. MATERIALS AND METHODS The retrograde technique was used to treat a total of 38 legs in 33 patients in whom antegrade access failed. This approach was selected because of small caliber or spasm of the proximal (ie, lower) great saphenous vein (GSV; n = 22), proximal (ie, lower) GSV spasm during access (n = 2), previous incomplete vein ablation (n = 7), skin disease over the proximal GSV (n = 6), and tortuous proximal GSV anatomy (n = 1). Thirty-two legs were treated with an ipsilateral retrograde approach and six were treated with a contralateral retrograde approach. Radiofrequency ablation with or without sclerotherapy was then performed. RESULTS The technical success rate for retrograde access and subsequent ablation was 100%. No procedural complications occurred. At 1 month, five patients with active ulcers exhibited ulcer healing (100%). CONCLUSIONS The fluoroscopic retrograde approach can be used to treat GSV reflux when traditional antegrade access is not feasible.
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Affiliation(s)
- Nicholas A Perosi
- Department of Diagnostic and Interventional Radiology, Yale New Haven Hospital, Saint Raphael Campus, New Haven, CT 06511, USA.
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