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Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, Bush RL, Di Iorio M, Fish J, Fukaya E, Gloviczki ML, Hingorani A, Jayaraj A, Kolluri R, Murad MH, Obi AT, Ozsvath KJ, Singh MJ, Vayuvegula S, Welch HJ. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine. J Vasc Surg Venous Lymphat Disord 2024; 12:101670. [PMID: 37652254 DOI: 10.1016/j.jvsv.2023.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/20/2023] [Indexed: 09/02/2023]
Abstract
The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.
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Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Los Angeles, CA
| | - Suman M Wasan
- Department of Medicine, University of North Carolina, Chapel Hill, Rex Vascular Specialists, UNC Health, Raleigh, NC
| | - Mark H Meissner
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Jose Almeida
- Division of Vascular and Endovascular Surgery, University of Miami Miller School of Medicine, Miami, FL
| | | | - Ruth L Bush
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX
| | | | - John Fish
- Department of Medicine, Jobst Vascular Institute, University of Toledo, Toledo, OH
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University, Stanford, CA
| | - Monika L Gloviczki
- Department of Internal Medicine and Gonda Vascular Center, Rochester, MN
| | | | - Arjun Jayaraj
- RANE Center for Venous and Lymphatic Diseases, Jackson, MS
| | - Raghu Kolluri
- Heart and Vascular Service, OhioHealth Riverside Methodist Hospital, Columbus, OH
| | - M Hassan Murad
- Evidence Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Li C, Jacobowitz GR, Rockman CB, Maldonado TS, Berland TL, Garg K, Barfield M, Sadek M. Superficial venous procedures can be performed safely and effectively in patients with deep venous reflux. J Vasc Surg Venous Lymphat Disord 2023; 11:281-292.e1. [PMID: 36368475 DOI: 10.1016/j.jvsv.2022.09.017] [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: 05/13/2022] [Revised: 09/21/2022] [Accepted: 09/30/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The finding of concurrent deep venous reflux (DVR) when interrogating superficial venous reflux is common and might be a marker of more severe chronic venous insufficiency. However, the safety and clinical and patient-reported outcomes for patients undergoing superficial venous treatment in the presence of DVR remains underreported. Moreover, the factors associated with the persistence and disappearance of DVR after superficial vein treatment have not been evaluated. In the present study, we sought to address these questions. METHODS We performed a review of the institutional vascular quality initiative database from June 2016 to June 2021. Consecutive patient limbs were identified that had undergone a superficial venous intervention and had duplex ultrasound evaluations available. These patients were divided into those with and without DVR. Those with DVR were further reviewed for anatomic details and the persistence or resolution of DVR after the procedure. The primary outcome was the venous clinical severity score (VCSS) at a follow-up >3 months. The secondary outcomes included the incidence of any postoperative deep vein thrombosis or endovenous heat-induced thrombosis, differences in patient-reported outcomes, rate of resolution of DVR, and factors associated with DVR persistence. Both univariate analysis and multivariate logistic regression were applied. RESULTS Of the patients who had undergone superficial venous treatment, 644 patient limbs had had DVR and 7812 had not, for a prevalence of 7.6%. The DVR group was associated with a higher burden of chronic venous insufficiency. On univariate analysis, patient limbs, both with and without DVR, had improved significantly in the VCSS at <3 months of follow-up and were not significantly different. At >3 months of follow-up, the VCSS had again improved significantly compared with the VCSS at <3 months of follow-up. However, the difference between the two groups was statistically significant at the longer interval. The magnitude of improvement in the VCSS between the two groups at the longer follow-up were similar statistically (VCSS, 3.17 ± 3.11 vs 3.03 ± 2.93; P = .739). The HASTI (heaviness, achiness, swelling, throbbing, itching) score had similarly improved significantly in both groups but remained significantly higher in the DVR group during follow-up. On multivariate logistic regression, DVR was not associated with an increased VCSS at >3 months of follow-up. No intergroup difference was found in the incidence of postoperative deep vein thrombosis or endovenous heat-induced thrombosis. Of limbs with DVR, 40.8% no longer had evidence of detectable DVR at the latest follow-up venous duplex ultrasound, and DVR limited to a single segment was more likely than DVR in multiple segments to be no longer detectable. CONCLUSIONS Our results have shown that superficial venous procedures are safe and effective in patients with DVR, leading to improvements in clinical and patient-reported outcomes similar to those for patients without DVR. In a large proportion of the treated limbs, especially those with DVR in a single segment, no evidence of DVR was found after superficial venous intervention. Although patients with DVR will have a higher burden of chronic venous insufficiency, they still appear to derive significant benefit from superficial venous treatment.
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Affiliation(s)
- Chong Li
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY
| | - Todd L Berland
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY
| | - Michael Barfield
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY.
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Kiernan A, Fahey B, Boland F, Aherne T. A systematic review and meta-analysis of concomitant truncal and perforator surgery. J Vasc Surg Venous Lymphat Disord 2023; 11:648-656.e3. [PMID: 36736858 DOI: 10.1016/j.jvsv.2022.12.068] [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: 09/02/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Incompetent perforator veins are encountered frequently during ultrasound assessment of the venous system in chronic venous disease. Some studies have shown that concomitant treatment of truncal and perforator incompetence improves ulcer healing, yet a Cochrane review was unable to determine the potential benefits of perforator surgery in venous ulcer management due to poor quality evidence. This study aims to establish the exact role of concomitant treatment in patients with chronic venous disease. METHODS A search of online databases including MEDLINE, Embase, and Cochrane was performed in March 2022. All studies comparing the outcomes of concomitant superficial venous plus perforator surgery with standard therapy were included. Variables assessed included ulcer healing, time to healing, and ulcer recurrence. Disease severity and quality of life, vein occlusion rates, number of incompetent perforator veins on duplex ultrasound post treatment, and reintervention and complication rates were also analyzed. Data were pooled using a random effects model. RESULTS Seven studies (872 limbs) were included for analysis. Included studies were of reasonable methodological quality. Ulcer healing rates were similar in each group (relative risk [RR], 1.07; 95% confidence interval [CI] 0.96-1.19; P = .23). Two studies reported no difference in mean time (days) to ulcer healing between groups (mean difference, -14.60; 95% CI, -34.57 to 5.38; P = .15; I2 = 0%; P = .56). Ulcer recurrence was significantly lower in the concomitant group (3.7% vs 44%) (RR, 0.21; 95% CI, 0.07- 0.65; P = .007; I2 = 43%; P = .17). Overall, there was no difference in disease severity measured at 12-month follow-up, with a weighted mean difference between groups of -0.88 (95% CI, -2.05 to 0.29; P = .14; I2 = 84%; P = .002). Quality of life was reported in only one study. The total number of perforator veins identified at follow-up duplex ultrasound was significantly lower in the concomitant group (22.4% vs 89%) compared with standard therapy (RR, 0.31; 95% CI, 0.19-0.53; P < .0001; I2 = 88%; P = .0002). There was no difference between groups for occlusion rates of treated great saphenous vein or incompetent perforators (RR, 2.22; 95% CI, 0.10-49.74; P = .61). Reported minor (RR, 0.98; 95% CI, 0.63-1.52; P = .92) and thrombotic complications (RR, 2.04; 95% CI, 0.59-6.99; P = .26) were similar between groups. CONCLUSION Concomitant truncal and perforator surgery is comparable to standard therapy in terms of ulcer healing, safety, and efficacy. Meta-analysis suggests that concomitant treatment could significantly reduce ulcer recurrence rates, but included studies were subject to some biases and short follow-up. Concomitant treatment may be considered to prevent recurrence rather than improve ulcer healing.
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Affiliation(s)
- Aoife Kiernan
- Royal College of Surgeons in Ireland, Dublin, Ireland; University of Edinburgh, Edinburgh, Scotland.
| | - Brian Fahey
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Thomas Aherne
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Garavello A, Gilardi S, Fiamma P, Toti V, Tozzi M, Fransvea P. Deep Venous Thrombosis and Ulcers of Lower Limbs: Ultrasound Findings in 156 Patients. Int J Angiol 2022; 31:113-119. [PMID: 35833180 PMCID: PMC9272312 DOI: 10.1055/s-0042-1743408] [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: 10/18/2022] Open
Abstract
Venous ulcers (VUs) of lower limbs affect 1% of Western population. In most cases, ultrasounds show only superficial venous insufficiency (SVI), but a deep venous insufficiency (DVI) may also be present without a history of deep vein thrombosis (DVT). To assess SVI and DVI in DVT-positive and DVT-negative patients with VU, a retrospective cohort of 123 patients entered the study (50 male and 73 female, minimum age 29 years and maximum age 90 years, and mean 70.6 years). In 56 patients (45.5%), ulcer was on the right leg, in 52 (42.3%) on the left leg, and in 15 patients (12.2%), ulcer was bilateral, resulting in a total number of 138 limbs in the study. Sixty-six patients suffered DVT, while in 72 anamnesis was negative. Color duplex ultrasound was performed on both limbs, which revealed insufficiencies of superficial and/or deep veins in 18 limbs which had not been affected by an ulcer or a previous DVT. So the study was on 156 limbs. SVI were substantially overlapping in two groups ( p -value = 0.593), while combined SVI and DVI was 72.5% in DVT positive limbs ( p -value = 0.001). In 70% of cases with a femoral vein insufficiency ( p -value = 0.036) or popliteal vein insufficiency (PVI) ( p -value 0,003), a DVT history was present. Of 18 limbs, although not affected by ulcer or previous DVT, eight were positive for DVI (two femoral veins and six popliteal veins). In the patient with VU, the history of DVT is a strong predictor of DVI insufficiency. In DVT-positive patients with ulcer, the number of "combined superficial and deep insufficiencies" appears to be particularly significant and surgical treatment must take this into account. A previous DVT has a low impact on great and small saphenous insufficiencies in ulcer patients; these were substantially overlapping in DVT-positive and DVT-negative patients. The 18 limbs with DVI and SVI without ulcer and DVT history were unexpected result. We think these patients must have a close follow-up to avoid the onset of a VU.
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Affiliation(s)
- Alberto Garavello
- UOC Chirurgia d'Urgenza e del trauma fondazione Policlinico Universitario A.Gemelli IRCCS - Roma
| | - Stefania Gilardi
- Centro Per la Terapia Dell'ulcera Venosa e Arteriosa, Ospedale San Filippo Neri -ASL RM1, Roma, Italy
| | - Paola Fiamma
- Centro Per la Terapia Dell'ulcera Venosa e Arteriosa, Ospedale San Filippo Neri -ASL RM1, Roma, Italy
| | - Valentina Toti
- Centro Per la Terapia Dell'ulcera Venosa e Arteriosa, Ospedale San Filippo Neri -ASL RM1, Roma, Italy
| | | | - Pietro Fransvea
- Dipartimento di Chirurgia D'urgenza, Policlinico Agostino Gemelli, Roma, Italy
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Gujja K, Kayiti T, Sanina C, Wiley JM. Chronic Venous Insufficiency. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Pannier F, Noppeney T, Alm J, Breu FX, Bruning G, Flessenkämper I, Gerlach H, Hartmann K, Kahle B, Kluess H, Mendoza E, Mühlberger D, Mumme A, Nüllen H, Rass K, Reich-Schupke S, Stenger D, Stücker M, Schmedt CG, Schwarz T, Tesmann J, Teßarek J, Werth S, Valesky E. S2k guidelines: diagnosis and treatment of varicose veins. DER HAUTARZT; ZEITSCHRIFT FUR DERMATOLOGIE, VENEROLOGIE, UND VERWANDTE GEBIETE 2022; 73:1-44. [PMID: 35438355 PMCID: PMC9358954 DOI: 10.1007/s00105-022-04977-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- F Pannier
- Praxis für Dermatologie und Phlebologie, Helmholtzstr. 4-6, 53123, Bonn, Germany.
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The need for perforator treatment after VenaSeal and ClosureFast endovenous saphenous vein closure in CEAP 6 patients. J Vasc Surg Venous Lymphat Disord 2021; 9:1510-1516. [PMID: 34111593 DOI: 10.1016/j.jvsv.2021.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/08/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The authors have previously demonstrated that VenaSeal (Medtronic, Inc, Minneapolis, Minn) adhesive, compared with radiofrequency ablation (RFA, ClosureFast; Medtronic, Inc), in treatment of refluxing saphenous veins in CEAP 6 limbs, results in shorter healing times of venous ulcers. The authors hypothesize that the longer treated length possible with VenaSeal's nonthermal modality may affect the number of critical refluxing perforators contributing to the nonhealing wound. This follow-up study compares the need for follow-up treatment of perforator veins after saphenous vein treatment with either radiofrequency ablation (ClosureFast RFA) or adhesive closure (VenaSeal). METHODS A multi-institutional retrospective review of CEAP 6 patients who had closure of their saphenous veins from 2015 to 2020 was conducted. Patients who underwent follow-up treatment of perforator veins were grouped according to their method of initial management of their saphenous veins. The primary end point was incidence of a perforator procedure after ClosureFast or VenaSeal ablation. Secondary end points included sclerotherapy to facilitate wound healing. Bivariate analysis used the χ2 test, Fisher exact test, t-test, and Wilcoxon rank sum test. A P value of <.05 defined statistical significance. RESULTS There were 119 CEAP 6 patients with saphenous closure: 51 limbs treated with VenaSeal and 68 with RFA. Median follow-up was 105 days (interquartile range: 44, 208). All limbs achieved wound healing during the study period. Mean time to wound healing post index procedure was shorter for VenaSeal than RFA (72 vs 293.8 days, P > .0009), as was median time (43 vs 104 days, P = .001). More limbs treated with RFA had previous known deep vein thrombosis (29% vs 10%, P = .009), deep venous insufficiency (82% vs 51%, P = .0003), and perforator reflux (57% vs 29%, P = .002). Limbs with identified follow-up perforator reflux treated with RFA had a higher prevalence of initially treated saphenous veins with RFA compared with those treated with VenaSeal (49% vs 27%, P = .003). There was no difference between the methods of vein closure and use of concurrent sclerotherapy. CONCLUSIONS ClosureFast and VenaSeal are both effective and safe modalities of saphenous ablation, but VenaSeal treatment was associated with less perforator RFA intervention.
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Palma RGD, Kowallek DL, Barcia TC. New Approaches to an Old and Vexing Problem: Improving the Results of SEPS: an Overview. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2000.12098519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- R. G. De Palma
- From the Departments of Surgery and Radiology, University of Nevada School of Medicine and the VA Sierra Nevada Health Care System, Reno, Nevada
| | - D. L. Kowallek
- From the Departments of Surgery and Radiology, University of Nevada School of Medicine and the VA Sierra Nevada Health Care System, Reno, Nevada
| | - T. C. Barcia
- From the Departments of Surgery and Radiology, University of Nevada School of Medicine and the VA Sierra Nevada Health Care System, Reno, Nevada
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Jain P, Savlania A, Behera A, Gorsi U. Distribution patterns of pathological venous reflux and risk factors in patients with skin changes due to primary venous disease in North India. Phlebology 2020; 36:209-216. [PMID: 32931383 DOI: 10.1177/0268355520957193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the distribution patterns of pathological venous reflux and risk factors in patients with skin changes due to primary venous disease. METHODS Two hundred limbs belonging to C4, C5 & C6 classes were examined with duplex ultrasound to determine the sites of reflux. We also analyzed the correlation of risk factors with patterns and severity of disease. RESULTS Among 200 limbs, superficial system reflux was found in 163 limbs (81.5%), deep system reflux in 10 limbs (5%) and perforator system reflux in 180 limbs (90%). The most common pattern of abnormality was combined superficial and perforator system reflux. Of all the risk factors, prolonged standing, obesity and in the female history of pregnancy preceding varicose occurrence had the highest prevalence. CONCLUSIONS In patients with primary chronic venous disease, lifestyle modification is required to avoid risk associated with obesity and prolonged standing. The higher prevalence of pathological perforator reflux in association with advanced venous disease necessitates careful treatment of this least reported pathology to achieve better treatment results.
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Affiliation(s)
- Prashant Jain
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Savlania
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunanshu Behera
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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O'Donnell TF. The SeCure trial-The quest for the White Whale and a better harpoon. J Vasc Surg Venous Lymphat Disord 2020; 8:704-705. [PMID: 32800258 DOI: 10.1016/j.jvsv.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/03/2020] [Indexed: 11/17/2022]
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Nicolaides A, Kakkos S, Baekgaard N, Comerota A, de Maeseneer M, Eklof B, Giannoukas A, Lugli M, Maleti O, Mansilha A, Myers KA, Nelzén O, Partsch H, Perrin M. Management of chronic venous disorders of the lower limbs. Guidelines According to Scientific Evidence. Part II. INT ANGIOL 2020; 39:175-240. [PMID: 32214074 DOI: 10.23736/s0392-9590.20.04388-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | | | | | | | | | - Bo Eklof
- American Venous Forum, Hoffman Eastates, IL, USA
| | | | | | | | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Department of Angiology and Vascular Surgery, S. João Hospital, Porto, Portugal
| | | | - Olle Nelzén
- Vascular Surgery Unit, Skaraborg Hospital, Kärnsjukhuset, Skövde, Sweden
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de Moraes Silva MA, Flumignan RLG, Miranda F, Cardoso RS, Silva SGDJ, Guedes HJ, Nakano LCU. Protocol for a systematic review and meta-analysis of interventions for pathologic perforator veins in chronic venous disease. BMJ Open 2019; 9:e024088. [PMID: 31048426 PMCID: PMC6502043 DOI: 10.1136/bmjopen-2018-024088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 03/04/2019] [Accepted: 03/08/2019] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Perforator veins (PVs) play an important role in the development of chronic venous insufficiency and ulceration. Procedures to eliminate incompetence and reflux in PV may include open surgery, subfascial endoscopic surgery, intravenous ablation techniques and sclerotherapy. With the aim of filling the evidence gap, this is a protocol for a systematic review that will assess the effects of any form of intervention for the treatment of pathologic PVs of the lower limbs in patients with chronic venous disease. METHODS AND ANALYSIS Systematic searches will be carried out in MEDLINE, EMBASE, Cochrane CENTRAL, IBECS and LILACS databases at a minimum without date or language restrictions for relevant randomised controlled trials (RCTs) and quasi-RCTs (trials in which the method of allocation is not truly random). In addition, a search will also be carried out in the WHO International Clinical Trials Registry Platform, in the clinical trial registries of ClinicalTrials.gov and in the grey literature source OpenGrey.eu. The RCT and quasi-RCT comparison techniques isolated or in combination for treating PVs will be considered. Three review authors will independently perform data extraction and quality assessments of data from included studies, and any disagreements will be resolved by discussion. The primary outcomes will be wound healing and pain. Secondary outcomes will include oedema, adverse events, recurrence or recanalisation, quality of life and economic aspects. The Cochrane handbook will be used for guidance. If the results are not appropriate for a meta-analysis in RevManV.5 software (eg, if the data have considerable heterogeneity and are drawn from different comparisons), a descriptive analysis will be performed. ETHICS AND DISSEMINATION Ethics committee approval is not necessary. We intend to update the public registry used in this review, report any important protocol amendments and publish the results in a widely accessible journal. PROSPERO REGISTRATION NUMBER CRD42018092974.
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Affiliation(s)
- Melissa Andreia de Moraes Silva
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Division of Vascular and Endovascular Surgery, Hospital de Clínicas de Itajubá, Itajubá, MG, Brazil
| | - Ronald Luiz Gomes Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Fausto Miranda
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Rodolfo Souza Cardoso
- Division of Vascular and Endovascular Surgery, Hospital de Clínicas de Itajubá, Itajubá, MG, Brazil
| | | | - Henrique Jorge Guedes
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Luis Carlos Uta Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Melikian R, O'Donnell TF, Suarez L, Iafrati MD. Risk factors associated with the venous leg ulcer that fails to heal after 1 year of treatment. J Vasc Surg Venous Lymphat Disord 2018; 7:98-105. [PMID: 30558732 DOI: 10.1016/j.jvsv.2018.07.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/19/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Despite regular treatment of venous leg ulcers (VLUs), some fail to heal. Although several risk factors have previously been identified to be associated with the failure of VLUs to heal, the majority of studies are limited to <24-week follow-up. METHODS A retrospective cohort study was performed at an academic vascular and wound center. A total of 65 patients with VLUs who were observed for a year or more were identified. These patients underwent a variety of treatments following the Society for Vascular Surgery and American Venous Forum VLU guidelines. Risk factors, which were based on previously defined elements for failure of VLUs to heal after a period of treatment, were examined. Both univariate (unadjusted) and multivariate (adjusted) logistic regression analyses were used to assess the magnitude of effect that a given risk factor had on healing. RESULTS Of 65 patients treated for a minimum of 52 weeks, 19 (29%) remained unhealed. By univariate analysis, deep venous disease (P = .01; odds ratio [OR], 5.82; 95% confidence interval [CI], 1.49-22.72), history of deep venous thrombosis (P < .001; OR, 14.06; 95% CI, 3.77-52.39), and depression (P = .04; OR, 3.89; 95% CI, 1.10-13.80) were all shown to be significant risk factors for nonhealing. The patient's race (ie, being nonwhite; P = .02; OR, 103.45; 95% CI, 1.94-5.53 × 103), deep venous disease (P = .05; OR, 37.0; 95% CI, 1.05-1.31 × 103), and history of deep venous thrombosis (P = .01; OR, 122.4; 95% CI, 3.09-4.84 × 103), however, were all shown to be significant for nonhealing under multivariate analysis. In addition, identification of an incompetent perforator (P = .02; OR, 0.006; 95% CI, 9.27 × 10-5-0.44) was conversely shown to be a good prognostic factor for healing. CONCLUSIONS This study confirmed that risk factors known to be associated with the failure of a VLU to heal-deep venous disease and post-thrombotic etiology-were significant at 52 weeks, whereas depression and race (nonwhite) are novel risk factors. An analysis of markers of access to care showed no difference between white and nonwhite, suggesting other factors as a cause. The predominance of deep venous disease in the unhealed vs healed cohort (84% vs 48%) highlights the need for a viable treatment option for deep venous disease due to reflux. Overall, this study emphasizes the need to consider all risk factors when evaluating a patient for VLU to coordinate an effective treatment plan and to identify gaps in our treatment.
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Affiliation(s)
| | - Thomas F O'Donnell
- Tufts University School of Medicine, Boston, Mass; The CardioVascular Center at Tufts Medical Center, Boston, Mass
| | - Luis Suarez
- Tufts University School of Medicine, Boston, Mass; The CardioVascular Center at Tufts Medical Center, Boston, Mass
| | - Mark D Iafrati
- Tufts University School of Medicine, Boston, Mass; The CardioVascular Center at Tufts Medical Center, Boston, Mass
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14
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Montminy ML, Jayaraj A, Raju S. A systematic review of the efficacy and limitations of venous intervention in stasis ulceration. J Vasc Surg Venous Lymphat Disord 2018; 6:376-398.e1. [DOI: 10.1016/j.jvsv.2017.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/20/2017] [Indexed: 11/27/2022]
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15
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Stacey M. Combined Topical Growth Factor and Protease Inhibitor in Chronic Wound Healing: Protocol for a Randomized Controlled Proof-of-Concept Study. JMIR Res Protoc 2018; 7:e97. [PMID: 29703712 PMCID: PMC5948413 DOI: 10.2196/resprot.8327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 12/17/2022] Open
Abstract
Background Leg ulcers due to venous disease are chronic wounds that can take 6 or more months to heal. Growth factors have been used to try and improve this healing; however, many such studies have failed, and that is thought to be due to enzymes in the wound that degrade the growth factors and prevent them from working. Objective This is a proof-of-concept study that will evaluate the treatment of chronic leg ulcers with topically applied growth factors that are combined with a therapy to prevent their inactivation in the wound. This combined therapy has the potential to speed up the healing of these wounds and thereby improve the quality of life of patients and reduce the costs to the health system. Methods This will be a double-blind, placebo-controlled, randomized controlled proof-of-concept study comparing growth factor with protease inhibitor wound dressings to growth factors with standard wound dressings. Results The project was funded by the Canadian Institutes for Health Research and enrollment is expected to be initiated in 2018. It is expected that results will be available in 2021. Conclusions It is expected that the results of this trial will inform as to whether modifying the wound environment through the use of protease inhibitors increases the effectiveness of topically applied growth factors in the healing of chronic wounds. Trial Registration ClinicalTrials.gov NCT02845466; https://clinicaltrials.gov/ct2/show/NCT02845466 (Archived by WebCite at http://www.webcitation.org/6yOPhSBUA)
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Affiliation(s)
- Michael Stacey
- Division of Vascular Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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16
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Sureshkumar S, Vignesh N, Venkatachalam J, Vijayakumar C, Sudharsanan S. Clinical Tests Combined with Color Doppler Versus Color Doppler Alone in Identifying Incompetent Perforator Veins of the Lower Limb: A Prospective Analytical Study. Cureus 2018. [PMID: 29531879 PMCID: PMC5837254 DOI: 10.7759/cureus.2026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background The color Doppler, a better investigation to identify the perforators objectively has replaced the clinical examination for the same. However, this has led to a significant number of negative explorations and cosmetic disfigurement. Objective To compare the efficacy of the clinical tests combined with the color Doppler versus color Doppler alone to identify the perforator incompetence during the surgery for primary varicose veins of the lower limb. Methods This was a prospective analytical study, including 61 lower limb varicose vein patients who belonged to the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class four-six, planned for the surgical treatment for perforator incompetence, excluding those requiring additional vascular or nonvascular procedure, recurrent varicose veins and those who had injection sclerotherapy prior to the surgery. The clinical tests, including Trendelenburg's test, multiple tourniquet tests and, the Fegan's tests were performed and incompetent perforators were marked on a template as 'C' to indicate the clinically positive perforator incompetence. The patients were then examined with the color Doppler ultrasound and the pathological incompetent perforators were marked as 'D'. The surgical management of the perforator incompetence was done by stab ligation. The incision was made in the color Doppler 'D' marked sites as it has been the standard protocol. The number of incompetent perforators identified during the surgical exploration were categorized as 'D' positive or 'C' and 'D' positive and were recorded in the specified proforma. Results It was found that the mean number of the perforator incompetence identified by the color Doppler alone was 8.2 whereas during the surgery, only a mean of six perforators was identified, leading to 20 unnecessary explorations per 10 patients (8.2 vs. 6; mean difference 2.229; P <0.001). The mean number of the perforator incompetence identified by the color Doppler combined with the clinical tests was 4.5 and during the surgery, a mean of four perforators was identified (4.5 vs. 4; mean difference 0.377; P <0.001). The color Doppler combined with the clinical examination lead to only four unnecessary explorations per 10 patients. Conclusion A combination of both the clinical tests and the color Doppler ultrasound has a higher accuracy in detecting perforator incompetence and can reduce the number of negative explorations by the rate of 16 unnecessary explorations per 10 patients.
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Affiliation(s)
- Sathasivam Sureshkumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Narayan Vignesh
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - J Venkatachalam
- Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Chellappa Vijayakumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sundaramurthi Sudharsanan
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Kusagawa H, Haruta N, Shinhara R, Hoshino Y, Tabuchi A, Sugawara H, Shinozaki K, Matsuzaki K, Nagata H, Niihara H, Kohno K, Takeda R. Surgical methods and clinical results of subfascial endoscopic perforator surgery in Japan. Phlebology 2018; 33:678-686. [DOI: 10.1177/0268355517750523] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objectives To clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan. Methods This study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively. Results Preoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 ( P < .0001) postoperatively. The primary ulcer healing rate was 96.2% (332/345 C6 limbs) at an average follow-up of 47.7 months, and the ulcer recurrence rate was 12.0% (49/393 C5, C6 limbs) at the average follow-up of 46.0 months after the ulcer healed. Conclusion These results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome.
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Affiliation(s)
- Hitoshi Kusagawa
- Department of Thoracic and Cardiovascular Surgery, Matsusaka Chuo General Hospital, Matsusaka, Japan (Presently, Matsusaka Ohta Clinic, Matsusaka, Japan)
| | - Naoki Haruta
- Department of Vascular Surgery, Takanobashi Central Hospital, Hiroshima, Japan
| | - Ryo Shinhara
- Department of Vascular Surgery, Mitsubishi Mihara Hospital, Mihara, Japan
| | - Yuji Hoshino
- Department of Vascular Surgery, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Atsushi Tabuchi
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Hiromitsu Sugawara
- Department of Surgery, Sendai Hospital of East Japan Railway Company, Sendai, Japan
| | - Koji Shinozaki
- Department of Surgery, Kobe Ekisai-kai Hospital, Kobe, Japan
| | - Kenji Matsuzaki
- Department of Cardiovascular Surgery, NTT Sapporo Hospital, Sapporo, Japan
| | - Hidetoshi Nagata
- Department of Surgery, Fujita Health University Banbuntane-hotokukai Hospital, Nagoya, Japan
| | - Hiroyuki Niihara
- Department of Dermatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Kunie Kohno
- Center for Community-Based Health Research and Education (COHRE), Organization for the Promotion of Project Research, Shimane University, Izumo, Japan
| | - Ryoji Takeda
- Department of Vascular Surgery, Rakuwakai Otowa Hospital, Kyoto, Japan
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Lin YN, Hsieh TY, Huang SH, Liu CM, Chang KP, Lin SD. Management of venous ulcers according to their anatomical relationship with varicose veins. Phlebology 2017; 33:44-52. [DOI: 10.1177/0268355516676124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Adequately excising varicose and incompetent perforating veins is necessary for reducing their recurrence rate of venous ulcer. Method In total, 66 venous ulcers (C6) in 1083 legs with primary varicose veins were managed through endoscopic-assisted surgery. In an endoscopic operative view, the nonvaricose, varicose, and incompetent perforating veins were clearly visualized and precisely dissected. The varicose and incompetent perforating veins were divided and completely excised. Result The varicose veins were traced to the base or periphery of the 55 ulcers. Moreover, 89.4% of the ulcers healed within 14 weeks. Kaplan–Meier analysis revealed a five-year recurrence rate of 0.0%, and the satisfaction mean score was 4.6. Conclusion Endoscopic-assisted surgery can be used to radically excise varicose veins complicated with venous ulcers; the surgery yields low recurrence and high satisfaction rates.
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Affiliation(s)
- Yun-Nan Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tung-Ying Hsieh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Hung Huang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Ming Liu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Yuan’s General Hospital, Kaohsiung, Taiwan
| | - Kao-Ping Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sin-Daw Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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19
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Kishore R, Sankar TB, Anandi A, Nedunchezhian S, Murugan V. A Prospective Study in Comparison of Ambulatory Phlebectomy and Duplex Guided Foam Sclerotherapy in the Management of Varicosities with Isolated Perforator Incompetence. Indian J Surg 2016; 78:356-363. [PMID: 27994330 DOI: 10.1007/s12262-016-1481-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 04/11/2016] [Indexed: 11/30/2022] Open
Abstract
Perforators are those which connect the superficial and deep venous system either directly to main veins or indirectly through the muscular and soleal venous plexus. The emergence of minimally invasive techniques like ambulatory phlebectomy (AP) and foam sclerotherapy (FS) has led to increasing interest about the appropriate therapy for the treatment of isolated perforator incompetence. There have been no studies which have compared the effectiveness of these in-office procedures in isolated perforator incompetence due to the low prevalence of cases. The primary goal of this study is to compare the clinical parameters (return to normal activity, primary symptom relief), functional parameters (procedure time, change in disease severity, course of venous ulcer), and duplex parameters (recurrence in treated veins, complete occlusion of treated veins) in the management of leg varicosities having isolated primary perforator incompetence by ambulatory phlebectomy and duplex guided foam sclerotherapy. Though the procedure time was shorter with FS than AP, the other parameters of primary symptom relief such as change in disease severity, faster healing of venous ulcer, complete occlusion of treated veins in follow-up duplex examination, and lower recurrence of treated veins are better with AP than FS. In conclusion, the interruption of perforators is effective in decreasing the symptoms of chronic venous insufficiency and for the rapid healing of ulcers. The interruption of the incompetent perforating veins appears to be essential to decrease ambulatory venous hypertension. It is apparent from this study that ambulatory phlebectomy stands distinct with enormous benefits and serves as a superior alternative to foam sclerotherapy in treating patients with isolated perforator incompetence.
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Affiliation(s)
- R Kishore
- Institute of General Surgery, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, 600003 Tamilnadu India
| | - T Bavani Sankar
- Institute of General Surgery, Rajiv Gandhi Government General Hospital, Chennai, 600003 Tamilnadu India
| | - A Anandi
- Institute of General Surgery, Rajiv Gandhi Government General Hospital, Chennai, 600003 Tamilnadu India
| | - S Nedunchezhian
- Institute of General Surgery, Rajiv Gandhi Government General Hospital, Chennai, 600003 Tamilnadu India
| | - Valarmathy Murugan
- Institute of General Surgery, Rajiv Gandhi Government General Hospital, Chennai, 600003 Tamilnadu India
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20
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Affiliation(s)
- Karthik Gujja
- The Zeta and Michael A. Weiner Cardiovascular Institute; Icahn School of Medicine at Mount Sinai; New York NY USA
| | | | - Jose M. Wiley
- Albert Einstein College of Medicine; Montefiore Einstein Center for Heart & Vascular Care; Bronx NY USA
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21
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Abstract
Venous reflux is the most common cause of venous hemodynamic disorders. In this paper 2 issues are discussed: how and where does reflux arise and what are the hemodynamic consequences of retrograde flow. Pressure gradient and incompetent vein connecting both poles of the gradient are the prerequisite for venous reflux to arise. Ambulatory pressure gradient occurs during the activity of the calf muscle venous pump between deep veins of the thigh and the lower leg. Thus the incompetent reflux-carrying vein must connect the popliteal, femoral, profunda femoris, or iliac vein with 1 of the deep veins of the lower leg. Reflux can be considered as shunting of blood from thigh veins into the lower leg veins. The most frequently found incompetent veins are the long and short saphenous veins and perforators communicating with deep veins of the thigh. On the other hand, calf perforators emptying into the deep veins of the lower leg, where the lower pole of the pressure gradient is located, cannot be the feeding source of reflux. A physiological bidirectional flow takes place in calf perforators connecting superficial and deep veins of the lower leg and making them conjoined vessels. Venous reflux produces ambulatory venous hypertension. The quantity of reflux volume and not the localization of retrograde flow in superficial or deep veins is the most important hemodynamic factor. Reflux in superficial veins, when large enough, can cause the most serious symptoms of chronic venous insufficiency including leg ulcers. Plethysmographic findings have shown that incompetence of the femoral and calf perforating veins is hemodynamically unimportant. Large incompetent calf perforators are not the cause of venous abnormality but are the consequence of saphenous retrograde flow.
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22
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Chapter 5 - Invasive treatment. J Eur Acad Dermatol Venereol 2016. [PMID: 27558990 DOI: 10.1111/jdv.6_13848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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23
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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: 30] [Impact Index Per Article: 3.8] [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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Mozes G, Gloviczki P. New Discoveries in Anatomy and New Terminology of Leg Veins: Clinical Implications. Vasc Endovascular Surg 2016; 38:367-74. [PMID: 15306956 DOI: 10.1177/153857440403800410] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advances in diagnosis and in endovascular and surgical treatments of both acute and chronic venous diseases have focused attention on several, previously clinically less important, details of venous anatomy. The time has come to standardize venous nomenclature so that general practitioners and specialists in the United States and abroad speak the same language. There is a need to adopt a universal terminology for the saphenous veins, to avoid the myriad of eponyms of perforators and, most importantly, to omit once and for all, the term “superficial” femoral vein when talking about a deep vein of the thigh. New anatomic names, such as the saphenous fascia and saphenous subcompartment, have to gain better recognition. To achieve the desired consensus on venous nomenclature, an international meeting was held in Rome, Italy, in 2001, under the auspices of the International Union of Phlebology. In this review on venous anatomy, we describe the most important previously published clinical recommendations from this conference, and suggest modifications based on their clinical experience using the new terminology.
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Affiliation(s)
- Geza Mozes
- Division of Vascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN 55905, USA
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25
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Labropoulos N, Patel PJ, Tiongson JE, Pryor L, Leon LR, Tassiopoulos AK. Patterns of Venous Reflux and Obstruction in Patients With Skin Damage Due to Chronic Venous Disease. Vasc Endovascular Surg 2016; 41:33-40. [PMID: 17277241 DOI: 10.1177/1538574406296246] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease ( P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group ( P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls ( P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.
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Affiliation(s)
- Nicos Labropoulos
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA.
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Abstract
The history of surgery is rich with accomplishments in wound care, a legacy that recently has been abandoned by many surgeons only to be taken up by nonsurgical providers. When dealing with advanced wounds at the end of life, such as pressure ulcers or venous stasis ulcers, goals of treatment are relief of pain, elimination of odor, and control of wound exudates and infection. Benefits and risks of surgical intervention must be discussed with the patient and family in terms of the patient's perceived prognosis, extent of tissue necrosis and infection, the rate of deterioration, and the underlying wound pathogenesis. When appropriate, the role of surgery looms large in the treatment of chronic, advanced wounds, especially when minimally invasive surgical techniques are used.
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Affiliation(s)
- K Francis Lee
- Midwestern University, Association for the Advancement of Wound Care, Comprehensive Wound and Disease Management Center, Olympia Fields, Illinois, USA.
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Abstract
Objective: To review the recent medical literature with regard to the use of compressive therapy in healing and preventing the recurrence of venous ulceration. Methods: Searches of Medline and Embase medical literature databases. Appropriate non-indexed journals and textbooks were also reviewed. Synthesis: Elastic compression therapy is regarded as the ‘gold standard’ treatment for venous ulceration. The benefits of elastic compression therapy in the treatment of venous ulceration may be mediated through favourable alterations in venous haemodynamics, micro-circulatory haemodynamics and/or improvement in subcutaneous Starling forces. Available data indicate compressive therapy is highly effective in healing of the large majority of venous ulcers. Elastic compression stockings, Unna boots, as well as multi-layer elastic wraps, have all been noted to achieve excellent healing rates for venous ulcers. In compliant patients it appears that approximately 75% of venous ulcers can be healed by 6 months, and up to 90% by 1 year. Non-healing of venous ulcers is associated with lack of patient compliance with treatment, large and long-standing venous ulceration and the coexistence of arterial insufficiency. Recurrence of venous ulceration is, however, a significant problem after healing with compressive therapy, even in compliant patients; approximately 20-30% of venous ulcers will recur by 2 years. Conclusions: Compressive therapy is capable of achieving high rates of healing of venous ulceration in compliant patients. Various forms of compression, including elastic, rigid and multi-layer dressings, are available depending on physician preference, the clinical situation and the needs of the individual patient. Compressive therapy, while effective, remains far from ideal. The future goals are to achieve faster healing of venous ulceration, less painful healing and freedom from ulcer recurrence.
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Affiliation(s)
- G. L. Moneta
- Department of Surgery, Division of Vascular Surgery, Oregon Health Sciences University and Veterans Affairs Medical Center, Portland, Oregon, USA
| | - A. D. Nicoloff
- Department of Surgery, Division of Vascular Surgery, Oregon Health Sciences University and Veterans Affairs Medical Center, Portland, Oregon, USA
| | - J. M. Porter
- Department of Surgery, Division of Vascular Surgery, Oregon Health Sciences University and Veterans Affairs Medical Center, Portland, Oregon, USA
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Elias S, Peden E. Ultrasound-Guided Percutaneous Ablation for the Treatment of Perforating Vein Incompetence. Vascular 2016; 15:281-9. [DOI: 10.2310/6670.2007.00068] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recent advances in catheter-based endovenous interventions have broadened our understanding in the pathophysiology and therapeutic strategies of chronic venous insufficiency, a condition that can be caused by abnormality of various lower extremity venous structures, including superficial or deep vein reflux or incompetent perforating veins. This article reviews the history and therapeutic principles of percutaneous ablation of perforators (PAPs). Discussions related to treatment strategies and procedural techniques of PAPs using radiofrequency ablation, laser energy, and sclerosant injection are provided. Current clinical results of PAPs with radiofrequency and laser energy ablation as a treatment modality of chronic venous insufficiency are also discussed.
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Affiliation(s)
- Steve Elias
- *Division of Vascular Surgery, Mount Sinai School of Medicine, New York, NY, and Center for Vein Disease, Englewood Hospital and Medical Center, Englewood, NJ; †Division of Vascular Surgery, The Methodist Physician Organization, Houston, TX
| | - Eric Peden
- *Division of Vascular Surgery, Mount Sinai School of Medicine, New York, NY, and Center for Vein Disease, Englewood Hospital and Medical Center, Englewood, NJ; †Division of Vascular Surgery, The Methodist Physician Organization, Houston, TX
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Martis G, Laczik R. The role of radical surgery in the management of CEAP C5/6 and lipodermatosclerosis. Phlebology 2016; 31:753-768. [PMID: 27257053 DOI: 10.1177/0268355516652011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim Analysis of the radical removing of the dermatosclerotic tissues and ulcer(s) with perforator veins dissection as well as local wound and standard compression treatment of CEAP C5/6 stage in a prospective comparative cohort study. Primary endpoint is to compare the results of the one-year follow-up regarding quality of life, vein clinical severity score, and ulcer healing process. Secondary endpoint is the precise presentation of the surgical technique. Tertiary endpoint is to demonstrate the photo-documented results of the postoperative wound treatment protocol. Method Clinical and statistical comparison of radical surgery versus solely wound care and compression in a cohort of 15 patients in each group (Groups 1, 2). In Group 1, radical removing of the dermatosclerotic pannicule and leg ulcer, perforator vein dissection, great saphenous vein, or small saphenous vein was performed. Quality of life , pain intensity, vein clinical severity score and patients' load capacity were compared. The tissue oxygen saturation changes were monitored via near infra-red spectroscopy. Results Both groups were statistically comparable. Wound healing in the operated group was 100% versus 60% in the second one, the difference was significant, p = 0.006. The quality of life: 45.33 versus 36.8, p < 0.001, intensity of leg restless and pain: 2.28 versus 5.3, p < 0.001, changes of vein clinical severity score: 5.27 versus 20.93, p < 0.001, changes of tO2sat: 19.00 versus 6.07 in the upper third of the leg p < 0.001, proved significantly better in group 1 compared to 2. Load capacity was significantly better in group 1 than 2 at the end of the study. The average wound healing time was 113 days in group 1. Conclusion The radical surgery provides significantly better results, considering quality of life, vein clinical severity score, load capacity than the conservative treatment in this study.
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Affiliation(s)
- Gábor Martis
- 1 Department of Vascular Surgery, Clinical and Health Science Centre, Institute of Surgery, University of Debrecen, Debrecen, Hungary
| | - Renáta Laczik
- 2 Department of Angiology, Clinical and Health Science Centre, Institute of Medicine, University of Debrecen, Debrecen, Hungary
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A new option for endovascular treatment of leg ulcers caused by venous insufficiency with fluoroscopically guided sclerotherapy. Wideochir Inne Tech Maloinwazyjne 2015; 10:423-9. [PMID: 26649090 PMCID: PMC4653258 DOI: 10.5114/wiitm.2015.54059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/02/2015] [Accepted: 06/06/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Ulcers of lower legs are the most bothersome complication of chronic venous insufficiency (CVI). AIM To assess the effectiveness of endovascular fluoroscopically guided sclerotherapy for the treatment of venous ulcers. MATERIAL AND METHODS Thirty-eight limbs in 35 patients with crural venous ulcers were treated with guided sclerotherapy under the control of fluoroscopy. Patients with non-healing ulcers in the course of chronic venous insufficiency, with and without features of past deep vein thrombosis, were qualified for the study. Doppler ultrasound and dynamic venography with mapping of venous flow were performed. Ambulatory venous pressure measurements, leg circumference and varicography were performed just before and following the procedure. RESULTS In 84% of cases, ulcers were treated successfully and healed. Patients with post-thrombotic syndrome (n = 17) healed in 13 (76.5%) cases, whereas patients without post-thrombotic syndrome (n = 21) healed in 19 (90.5%) cases. The mean time of healing of an ulcer for all patients was 83 days (in the first group it was 121 days and in the second group 67 days). Recurrence of an ulcer was observed in 10 limbs: 6 cases in the first group and 4 cases in the second group. Occurrence of deep vein thrombosis associated with the procedure was not observed. Temporary complications were reported but none giving a serious clinical outcome. CONCLUSIONS Endovascular fluoroscopically guided sclerotherapy can be an alternative method of treatment of venous ulcers, especially in situations when surgical procedures or other options of treatment are impossible.
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Clinical Experience of the Klippel-Trenaunay Syndrome. Arch Plast Surg 2015; 42:552-8. [PMID: 26430625 PMCID: PMC4579165 DOI: 10.5999/aps.2015.42.5.552] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 05/20/2015] [Accepted: 05/26/2015] [Indexed: 01/19/2023] Open
Abstract
Background The Klippel-Trenaunay syndrome (KTS) is characterized by three clinical features, namely cutaneous capillary malformations, venous malformations, and soft tissue and/or bony hypertrophy of the extremities. The varied manifestations are attributed to the unpredictable clinical nature and prognosis of the syndrome. To elucidate the clinical characteristics of this disease, we reviewed a relatively large number of KTS patients who presented to our vascular anomalies center. Methods We conducted a retrospective study with 19 patients who were diagnosed with KTS and treated in our vascular anomalies clinic between 2003 and 2014, and examined their demographic characteristics, their clinical features, and the treatments administered. Results The sex distribution was balanced, with 9 (47%) males and 10 (53%) females. The mean follow-up period was 4.1 years (range, 7 months-9 years). Most of the patients received conservative treatments such as medication or physiotherapy. Compression therapies such as wearing of elastic garments/bandages were also administered, and surgical interventions were considered only when the patients became excessively symptomatic. Other treatments included laser therapy and sclerotherapy, and all the treatments were adjusted according to each case, tailored to the conditions of the individual patients. Conclusions KTS is an extremely rare, multifactorial disorder that induces widely varied symptoms. Because of this unique feature, plastic surgeons, when not careful, tend to attach a one-sided importance to typical symptoms such as limb hypertrophy or capillary malformation and thus overlook other symptoms and clinical features. KTS can be suspected in all infants who show capillary malformations or limb hypertrophy and require a multi-disciplinary approach for comprehensive management.
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Lloret P, Redondo P, Cabrera J, Sierra A. Treatment of venous leg ulcers with ultrasound-guided foam sclerotherapy: Healing, long-term recurrence and quality of life evaluation. Wound Repair Regen 2015; 23:369-78. [DOI: 10.1111/wrr.12288] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 03/27/2015] [Indexed: 01/19/2023]
Affiliation(s)
| | | | - Juan Cabrera
- Phlebology Unit, University Clinic of Navarra; Pamplona Spain
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Hedayati N, Carson JG, Chi YW, Link D. Management of mixed arterial venous lower extremity ulceration: A review. Vasc Med 2015. [DOI: 10.1177/1358863x15594683] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mixed arterial venous disease is estimated to affect up to 26% of patients with lower extremity ulcerations. However, its clinical significance and pathophysiology are incompletely understood. Furthermore, there is no consensus on the optimal treatment modality, whether conservative or operative. In this review paper, we describe the current understanding of the pathophysiology of mixed arterial venous lower extremity ulcers. Guidelines for diagnostic tests for patients with mixed arterial venous diseases are discussed. We review some of the newer biological skin substitutes for conservative wound care. Finally, we propose a treatment algorithm based on current available data.
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Affiliation(s)
- Nasim Hedayati
- Division of Vascular and Endovascular Surgery, University of California, Davis Medical Center, Sacramento, California, USA
| | - John G Carson
- Division of Vascular and Endovascular Surgery, University of California, Davis Medical Center, Sacramento, California, USA
| | - Yung-Wei Chi
- Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, California, USA
| | - Daniel Link
- Department of Radiology, University of California, Davis Medical Center, Sacramento, California, USA
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Abstract
Management of venous ulceration has evolved tremendously during the last 2 decades. There has been considerable progress in our understanding of the pathophysiology, hemodynamics, venous imaging, and therapeutic options for venous ulcers, including endovenous ablation, iliac vein stenting, and vein-valve repair techniques. Details of these procedures are described in this issue of Seminars. With so many permutations and combinations of venous disease, including superficial and deep vein abnormalities, that produce venous ulceration, as well as a plethora of diagnostic and therapeutic tools at our disposal, it is important to have an algorithm for venous ulcer management. Also important is knowledge about risk factors that can influence poor outcomes, despite interventions for venous ulcers. In the end, authors also discuss the gray areas of venous ulcer management, which do not have common consensus and that treatment could be individualized based on patient needs.
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Affiliation(s)
- Himanshu Verma
- Narayana Institute of Vascular Sciences, Level I, B Block, NH-Mazumdar Shaw Medical Centre, Narayana Healthcare, 258-A, Bommasandra Industrial Area, Hosur Road, Bangalore 560099, India
| | - Ramesh K Tripathi
- Narayana Institute of Vascular Sciences, Level I, B Block, NH-Mazumdar Shaw Medical Centre, Narayana Healthcare, 258-A, Bommasandra Industrial Area, Hosur Road, Bangalore 560099, India.
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Surgical treatment of large vascular leg ulcers: a retrospective review evaluating risk factors for healing and recurrence. Dermatol Surg 2014; 40:1240-8. [PMID: 25310752 DOI: 10.1097/dss.0000000000000137] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Superficial reflux ablation and revascularization improve the long-term prognosis of venous and arterial leg ulcers but do not solve the problem of protracted healing of large chronic wounds. Skin grafting has been shown to successfully heal chronic leg ulcers. OBJECTIVE To identify risk factors for ulcer healing and recurrence after shave therapy and split-skin grafting in patients with large ulcers treated surgically for venous insufficiency. METHODS Single-center retrospective cohort study involving 72 chronic leg ulcers with a mean area of 77 ± 132 cm. Healing and recurrence rates were determined using life-table analysis. Clinical, demographic, and hemodynamic parameters were correlated with healing and recurrence using Cox regression analysis. RESULTS Sixty ulcers (83%) healed after a mean of 1.9 months and 15 ulcers (25%) recurred after a mean of 12.7 months. Healing was positively associated with compression treatment (hazard ratio [HR]: 2.02, 95% confidence interval [CI]: 1.14-3.59) and negatively associated with ulcer duration (HR: 0.99, 95% CI: 0.98-1.0). Male sex, ulcer duration, and deep venous reflux were identified as significant risk factors for ulcer recurrence (HR: 0.14, 95% CI: 0.03-0.73; HR: 1.02, 95% CI: 1.0-1.04; and HR: 5.4, 95% CI: 1.30-22.31). CONCLUSION Early surgical intervention improves healing and reduces the risk of ulcer recurrence.
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Kahn SR, Comerota AJ, Cushman M, Evans NS, Ginsberg JS, Goldenberg NA, Gupta DK, Prandoni P, Vedantham S, Walsh ME, Weitz JI. The Postthrombotic Syndrome: Evidence-Based Prevention, Diagnosis, and Treatment Strategies. Circulation 2014; 130:1636-61. [DOI: 10.1161/cir.0000000000000130] [Citation(s) in RCA: 349] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Varicose veins are a common manifestation of chronic venous disease and affect approximately 25% of adults in the western hemisphere. The historical standard treatment has been surgery, with high ligation and stripping, combined with phlebectomies. In the past decade, alternative treatments such as endovenous ablation of the great saphenous vein (GSV) with laser, radiofrequency ablation, and ultrasonography-guided foam sclerotherapy have gained popularity. Performed as office-based procedures using tumescent local anesthesia, the new minimally invasive techniques have been shown in numerous studies to obliterate the GSV, eliminate reflux, and improve symptoms safely and effectively.
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Affiliation(s)
- Robert T. Eberhardt
- From the Cardiovascular Medicine Center, Boston Medical Center, Boston, MA (R.T.E.); Boston University School of Medicine, Boston, MA (R.T.E.); Vascular Surgery, Boston VA Health Care System, Boston, MA (J.D.R.); and Harvard Medical School, Boston, MA (J.D.R.)
| | - Joseph D. Raffetto
- From the Cardiovascular Medicine Center, Boston Medical Center, Boston, MA (R.T.E.); Boston University School of Medicine, Boston, MA (R.T.E.); Vascular Surgery, Boston VA Health Care System, Boston, MA (J.D.R.); and Harvard Medical School, Boston, MA (J.D.R.)
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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: 376] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Taking up subfascial endoscopic perforator surgery for patients of lower limb varicose veins with below knee perforators, in a government medical college-a review of eleven cases. Indian J Surg 2014; 75:473-7. [PMID: 24465105 DOI: 10.1007/s12262-012-0542-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 05/31/2012] [Indexed: 10/28/2022] Open
Abstract
Varicose veins are the most common manifestation of chronic venous insufficiency (CVI) worldwide. They interfere with the patients' daily activities and hamper their professional endeavors, and therefore need to be addressed at the earliest with the best tools. Eleven patients of varicose veins of the lower limb with below knee perforators underwent subfascial endoscopic perforator surgery (SEPS) from October 2010 to December 2011 in our institute. The procedure was successfully completed in all 11 patients. The mean operating time was 78 min (60-96 min). The results showed a favorable outcome for the patients in terms of faster recovery and less morbidity.
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van Gent WB, Wittens CHA. Influence of perforating vein surgery in patients with venous ulceration. Phlebology 2013; 30:127-32. [DOI: 10.1177/0268355513517685] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives The exact role of perforating vein surgery is still unclear. The aim of this study is to analyze the influence of perforating vein surgery in patients with venous ulceration. Methods This study was part of a randomized controlled trial in which conservative and surgical treatment of venous ulceration was compared. It is a secondary analysis of prospectively gathered data. Ninety-seven active leg ulcers were surgically treated with a subfascial endoscopic perforating vein surgery (SEPS) procedure. Concomitant superficial venous incompetence was treated with flush saphenopopliteal ligation and/or saphenofemoral ligation and limited stripping of the great saphenous vein. All patients were also treated with ambulatory compression therapy. Ulcer healing and recurrences are described in detail. To measure the completeness of the SEPS procedure duplex ultrasonography was performed on each patient before and 6 weeks and 12 months after surgery. Also newly formed perforators after surgery were scored and their influence was analyzed. Results Analyses were performed on 94 ulcerated legs with a mean follow-up of 29 months. In all treated legs, only 45% all perforators were treated. In 55% one (29%) or more (26%) perforators were missed. Healing was not significantly influenced by the number of remaining incompetent perforating veins, but recurrence was significantly higher in patients who had incomplete SEPS procedure ( p = 0.007 log-rank). New incompetent perforating veins did not affect ulcer healing or recurrence. The plotted location of new perforators did not show a pattern. Deep vein incompetence and treatment of superficial venous incompetence had no significant influence on healing or recurrence rates in a complete or incomplete SEPS procedure. Conclusion In this series a well-performed SEPS procedure lowers the venous ulcer recurrence rate significantly, indicating the clinical importance of incompetent perforating veins in patients with an active venous ulcer.
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Affiliation(s)
- WB van Gent
- Department of Vascular Surgery, Groene Hart Hospital, Gouda, The Netherlands
| | - CHA Wittens
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Vascular Surgery, Universitätsklinikum Aachen, Aachen, Germany
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Reeder SW, Eggen C, Maessen-Visch MB, de Roos KP, Martino Neumann H. Recurrence of venous leg ulceration. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.rvm.2013.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Jibiki M, Inoue Y, Terasaki H, Igari K, Uchiyama H, Miyai M, Kagayama T. The effect of short saphenous vein stripping in patients with deep venous reflux. Ann Vasc Dis 2013; 6:612-6. [PMID: 24130617 DOI: 10.3400/avd.oa.13-00014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 06/01/2013] [Indexed: 11/13/2022] Open
Abstract
OBJECT We assessed whether or not deep venous reflux (DVR) improved after short saphenous vein (SSV) stripping was performed in patients with SSV reflux and DVR. MATERIALS AND METHODS Sixty-eight patients with SSV reflux who underwent SSV striping every Monday between 2008 and 2011 at Ryougoku Ashino Clinic were enrolled in this study. Forty-six of the 68 patients were selected for the analysis because they underwent duplex ultrasound examinations before and after the operation. The DVR was classified into four categories: type 0, no reflux; type I, reflux in popliteal vein; type II, reflux from popliteal vein to the middle of the superficial femoral vein (SFV) and type III, reflux from the popliteal vein to the SFV. RESULTS There were 23, 13, 2 and 8 patients with type 0, I, II, III before operation, respectively. There were 33, 8, 1, 4 patients with type 0, I, II, III after operation, respectively. There were no changes in 29 patients, improvement in 15 and new DVR in three (type 0 to I). CONCLUSION SSV stripping is feasible in patients with DVR and the DVR might not be deteriorated even though that is performed.
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Affiliation(s)
- Masatoshi Jibiki
- Department of Vascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan ; Department of Vascular Surgery, Ryougoku Ashino Clinic, Tokyo, Japan
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Hua WR, Yi MQ, Jun WX, Xing J, Xuan LZ, Bo L. Causes of recurrent lower limb varicose veins after surgical interventions in 141 limbs – Five-year retrospective analysis of two centers. Vascular 2013; 22:267-73. [PMID: 23929418 DOI: 10.1177/1708538113484023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim The purpose of this study was to explore the causes of recurrent lower limb varicose veins after surgical interventions. Methods A retrospective five-year survey was conducted on patients who underwent second surgery due to recurrent lower limb varicose veins after surgical interventions. A total of 141 limbs (112 cases), including 72 cases of left lower limbs, 47 of right lower limbs and 22 of both limbs, were involved in the study. All patients underwent lower limb venography (141 limbs were anterograde and 28 cases were retrograde), and then examined with color-Doppler ultrasound. Results The major causes that urged patients to undergo second surgery are clinical changes graded above CEAP IV (93.6%), limb edema without changes on skin (5%), and single varicosity (1.4%). Up to 127 (83%) limbs exhibited perforating venous reflux, 67 (47.5%) limbs had varied degrees of deep venous insufficiency and 68 (48.2%) limbs had through or above-the-knee great saphenous vein trunk residual. Conclusions Preoperative venography before operation is indispensible in confirming the diagnosis and operation strategies. Patients with severe primary deep venous reflux and symptoms up to C3 may need simultaneous repair of the deep venous valves.
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Affiliation(s)
- Wang Rui Hua
- Department of Vascular Surgery, Shandong Provincial Hospital, Shandong University, Shandong Province, China
- Department of Vascular Surgery, Jinan Central Hospital, Shandong University, Shandong Province, China
| | - Meng Qing Yi
- Department of Vascular Surgery, Jinan Central Hospital, Shandong University, Shandong Province, China
| | - Wu Xue Jun
- Department of Vascular Surgery, Shandong Provincial Hospital, Shandong University, Shandong Province, China
| | - Jin Xing
- Department of Vascular Surgery, Shandong Provincial Hospital, Shandong University, Shandong Province, China
| | - Liu Zhao Xuan
- Department of Vascular Surgery, Jinan Central Hospital, Shandong University, Shandong Province, China
| | - Li Bo
- Department of Vascular Surgery, Jinan Central Hospital, Shandong University, Shandong Province, China
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Sreekar H, Dawre S, Petkar KS, Shetty RB, Lamba S, Naik S, Gupta AK. Diverse manifestations and management options in Klippel-Trenaunay syndrome: A single centre 10-year experience. J Plast Surg Hand Surg 2013; 47:303-7. [DOI: 10.3109/2000656x.2013.766201] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Baldwin MJ, Moore HM, Rudarakanchana N, Gohel M, Davies AH. Post-thrombotic syndrome: a clinical review. J Thromb Haemost 2013; 11:795-805. [PMID: 23433231 DOI: 10.1111/jth.12180] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 02/14/2013] [Indexed: 02/03/2023]
Abstract
Up to half of patients with proximal deep vein thrombosis (DVT) will develop post-thrombotic syndrome (PTS) despite optimal anticoagulant therapy. PTS significantly impacts upon quality of life and has major health-economic implications. This narrative review describes the pathophysiology, risk factors, and diagnosis, prevention and treatment of PTS, to improve our understanding of the disease and guide treatment. Relevant articles were identified through systematic searches of the PubMed, EMBASE and Cochrane databases between 1966 and November 2011. Studies were included for detailed assessment if they met the following criteria: published in English, human study participants, study population aged > 18 years, and lower limb post-thrombotic syndrome. All non-systematic reviews and single patient case reports were excluded. Recurrent thrombosis, thrombus location and obesity are major risk factors, whereas the importance of gender and age remain uncertain. The diagnosis of PTS is based on clinical findings in patients with a known history of DVT. Several clinical scales have been described, with the Villalta Score gaining increasing popularity. Adequate anticoagulation and use of elastic compression stockings (ECS) following DVT can reduce the incidence of PTS. Catheter-directed thrombolysis and mechanical thrombectomy of acute DVT may preserve valvular function. Studies to date of these techniques are encouraging, and have reported improved hemodynamics and a reduced incidence of PTS. The management of established PTS is challenging. Compression therapy, aimed at reducing the underling venous hypertension, remains the mainstay of treatment. This is despite a paucity of high-quality evidence to support its use. Pharmacologic and surgical treatments have also been described, with a number of studies citing symptomatic improvement.
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Affiliation(s)
- M J Baldwin
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, UK
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Raju S, Kirk OK, Jones TL. Endovenous management of venous leg ulcers. J Vasc Surg Venous Lymphat Disord 2013; 1:165-72. [PMID: 26992338 DOI: 10.1016/j.jvsv.2012.09.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 09/12/2012] [Accepted: 09/16/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Compression is the current "standard" in the treatment of venous leg ulcers, and corrective surgery is ancillary. The emergence of safe and effective minimally invasive corrective techniques prompts a reappraisal of this paradigm. METHODS Among 192 consecutive limbs with venous leg ulcers, 189 were treated by (1) endovenous laser ablation (n = 30), (2) iliac vein stent placement (n = 89), or (3) both (n = 69). Residual deep reflux was not treated. No specialized wound care was used, and 38% of patients did not use stockings. Outcome measures were time to heal the ulcer and cumulative long-term healing. RESULTS Sixty percent of the limbs were post-thrombotic. The median reflux segment score was 3 (range, 0-7). Thirty-seven percent had deep axial reflux. Median intravascular ultrasound-detected stenosis was 70% (range, 0%-100%) in stented patients. Sensitivity of venography to iliac vein obstruction was 52%. Postprocedural mortality was 0%, and 2% had deep venous thrombosis (<30 days). By 14 weeks, 81% of the small ulcers approximately ≤1 inch in diameter had healed. Larger ulcers were slower in healing (P < .001). Post-thrombotic etiology, presence of uncorrected deep reflux, demographic factors, or stocking use had no bearing on healing time. Long-term cumulative healing at 5 years overall was 75%. Healing was better in nonthrombotic limbs compared with post-thrombotic limbs (87% vs 66% at 5 years; P < .02) but was similar among the various demographic subsets, procedures, and whether or not patients used compression. Quality-of-life measures improved significantly. Cumulative long-term healing was unaffected by residual axial reflux and was unrelated to hemodynamic severity (air plethysmography, ambulatory venous pressure). However, long-term ulcer healing was inferior in limbs with reflux segment score of ≥3 (P < .03). Post-thrombotic limbs with a reflux score of ≥3 had the lowest cumulative healing among cohorts, but even in this category, 60% of limbs had durable healing with very few recurrences. CONCLUSIONS Most venous leg ulcers in this consecutive series achieved long-term healing with the described minimally invasive algorithm. Uncorrected residual reflux was not an impediment to ulcer healing. Ulcers sized ≤1 inch required no specialized or prolonged wound care. Compression was not necessary to achieve or maintain healing after interventional correction.
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Affiliation(s)
| | | | - Tamekia L Jones
- Department of Biostatistics, University of Florida, Gainesville, Fla
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Alden PB, Lips EM, Zimmerman KP, Garberich RF, Rizvi AZ, Tretinyak AS, Alexander JQ, Dorr KM, Hutchinson M, Isakson SL. Chronic Venous Ulcer: Minimally Invasive Treatment of Superficial Axial and Perforator Vein Reflux Speeds Healing and Reduces Recurrence. Ann Vasc Surg 2013; 27:75-83. [DOI: 10.1016/j.avsg.2012.06.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 06/07/2012] [Accepted: 06/29/2012] [Indexed: 10/27/2022]
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