Epidemiology and aetiology of C4-6 disease

Vicious Circle With Venous Hypertension, Irregular Flow, Pathological Venous Wall Remodeling, and Valve Destruction in Chronic Venous Disease: A Review

Substantial advances occurred in phlebological practice in the last two decades. With the use of modern diagnostic equipment, the patients' venous hemodynamics can be examined in detail in everyday practice. Application of venous segments for arterial bypasses motivated studies on the effect of hemodynamic load on the venous wall. New animal models have been developed to study hemodynamic effects on the venous system. In vivo and in vitro studies revealed cellular phase transitions of venous endothelial, smooth muscle, and fibroblastic cells and changes in connective tissue composition, under hemodynamic load and at different locations of the chronically diseased venous system. This review is an attempt to integrate our knowledge from epidemiology, paleoanthropology and anthropology, clinical and experimental hemodynamic studies, histology, cell physiology, cell pathology, and molecular biology on the complex pathomechanism of this frequent disease. Our conclusion is that the disease is initiated by limited genetic adaptation of mankind not to bipedalism but to bipedalism in the unmoving standing or sitting position. In the course of the disease several pathologic vicious circles emerge, sustained venous hypertension inducing cellular phase transitions, chronic wall inflammation, apoptosis of cells, pathologic dilation, and valvular damage which, in turn, further aggravate the venous hypertension.

Mechanochemical ablation for the treatment of superficial venous incompetence: A cohort study of a single centre's early experience

Background

Mechanochemical ablation is an innovative non-thermal method of treating symptomatic axial superficial venous incompetence. This is a single-centre cohort study aiming to investigate the technical efficacy and clinical effectiveness at one year.

Methods

Patients with primary, unilateral, symptomatic axial incompetence were offered treatment with mechanochemical ablation using ClariVein® with 1.5% sodium tetradecyl sulphate. Assessments including clinical examination, duplex ultrasound and patient-reported health-related quality of life were performed at baseline and weeks 1, 6, 26 and 52.

Results

Thirty-two patients were recruited to the study. Complete target vein occlusion at one year was found in 21 (75%) patients. Six patients (21.4%) required secondary procedures, of which three had axial endovenous thermal ablation and three required ambulatory phlebectomy with perforator ligation. There was a significant improvement in the median (interquartile range) Venous Clinical Severity Score from baseline 6 (5–8) to a score of 1 (0–2) at one year (p < 0.001). There was also a significant improvement in health-related quality of life, both generic (p = 0.001) and disease specific (p < 0.001). One patient (3.1%) had a post-procedural non-fatal pulmonary embolus.

Conclusions

Mechanochemical ablation is a feasible and effective treatment for superficial venous incompetence. When using consensus definitions for anatomical closure, results for mechanochemical ablation may be less favourable than previously reported. Further studies are required to compare clinical and technical outcomes following mechanochemical ablation to other methods of endovenous ablation.

Reflection on the cause and avoidance of recurrent venous leg ulcers: An interpretive descriptive approach

AIMS AND OBJECTIVES

To gain insight into the experience of recurrent venous leg ulcers from the individual's perspective and provide knowledge on potential risks of recurrence not previously investigated.

BACKGROUND

Venous leg ulcers are a consequence of chronic venous disease and frequently recur. They are costly and can impact on physical and psychological health. Despite research suggesting the risk can be reduced through compression and lifestyle changes, recurrence rates are often high. This study provides an insight into individual's perceptions of the cause of their ulcers and how they try to avoid them.

DESIGN

A qualitative design guided by the Chronic Illness Trajectory Model and Social Cognitive Theory.

METHOD

A purposive sample of three males and four females were recruited from a community nursing clinic. Participants were ulcer free, had experienced at least two previous venous leg ulcers and could speak and comprehend English. An interpretive descriptive approach was taken using semi-structured interviews and thematic analysis.

RESULTS

Three themes each containing three categories emerged: The Increasing Influence of the Recurring Wound on Mind and Body, Reflection on Past Experiences and Optimism in the Face of Adversity. Most participants reported traumatic injury and lower leg surgery triggered ulcer recurrence. Failure to replace compression stockings was also deemed a cause. Compression was reported essential, but some participants were unaware of the level they were wearing and how often it should be replaced. Other preventive activities included avoiding injury and securing immediate assistance if wounding occurred.

CONCLUSION

Clinicians need to be aware that lower leg surgery may trigger recurrent venous ulceration and that individuals require ongoing emotional, physical and financial support throughout the trajectory of venous disease. The continued use of old compression stockings should be avoided and recurrence prevented by adoption of evidence-based practice rather than reflection on past experiences.

RELEVANCE TO CLINICAL PRACTICE

This research raises the awareness of factors from the individual's perspective which can influence the recurrence of venous leg ulcers.

Framing of research question using the PICOT format in randomised controlled trials of venous ulcer disease: a protocol for a systematic survey of the literature

INTRODUCTION

Although venous ulcers have a great social and economic impact, there is a lack of evidence from randomised controlled trials (RCTs) to support appropriate management for this disease. Framing the research question using the Population; Intervention; Comparator; Outcome; Time frame (PICOT) format in RCTs can improve the quality of the research design.

OBJECTIVES

To evaluate how the PICOT format is used to frame a research question in reports of RCTs of venous ulcer disease and to determine the factors associated with better adherence to the PICOT format in framing the research question.

METHODS AND ANALYSES

We will conduct a systematic survey of RCTs on venous ulcers published in the National Institute of Health, PubMed database between January 2009 and May 2016. We will include all RCTs addressing therapeutic intervention for venous ulcer disease involving human subjects, and published in the English language. The selection process will be carried out in duplicate by two independent investigators. First, titles and abstracts will be screened, then full-text articles. We will examine whether the five elements of the PICOT format are used in formulating the research question and give a score between 0 and 5. The primary outcome will be the proportion of studies that have adequately reported all five PICOT elements.

DISSEMINATION

This will be the first survey to assess how the PICOT format is used to frame research questions on the management of venous ulcers in reports of RCTs. On completion, this review will be submitted to a peer-reviewed biomedical journal for publication and the findings will also be presented at scientific conferences.

Differentiation of functional venous insufficiency and leg lymphedema complicated by functional venous insufficiency using subcutaneous tissue ultrasonography

OBJECTIVE

To use subcutaneous ultrasonography to differentiate legs with edema because of obesity-related functional venous insufficiency (FVI_ob), immobility-related FVI (FVI_im), secondary lymphedema (LE), LE complicated by obesity (LE_ob), and LE complicated by immobility (LE_im).

METHODS

Ninety-nine legs with edema (16 FVI_ob, 32 FVI_im, 22 LE, 9 LE_ob, and 20 LE_im), and 10 normal legs were examined. Subcutaneous tissue ultrasonography was performed at eight points (medial, lateral, upper, lower, thigh, and calf) in each leg. Subcutaneous echogenicity (SEG) and subcutaneous echo-free space (SEFS) were assessed, and each graded as 0, 1, and 2 according to their severity.

RESULTS

In normal legs, SEG and SEFS were graded 0 in almost all parts of the leg. SEG was diffusely increased in FVI_ob, whereas SEG was increased in accordance with gravity in FVI_im (upper medial thigh, 0.6 ± 0.5 vs lower medial calf, 1.2 ± 0.4; P < .001). In LE, SEG was increased in the medial side, particularly evident in upper thigh (upper medial thigh, 1.1 ± 0.4 vs upper lateral thigh, 0.6 ± 0.6; P < .01). SEFS was increased in accordance with gravity in all of these legs (FVI_ob: upper medial thigh, 0.2 ± 0.4 vs lower medial calf, 0.7 ± 0.8; P = .05; FVI_im: upper medial thigh, 0.1 ± 0.2 vs lower medial calf, 1.3 ± 0.7; P < .0001; LE: upper medial thigh, 0.4 ± 0.7 vs lower medial calf, 0.9 ± 0.9; P < .05). The increases of SEG and SEFS in legs with LE_ob or LE_im were diffuse and similar. As determined via stepwise logistic regression analyses, the increases in SEG in the upper medial thigh and SEFS in the lower medial thigh in LE cases, the increases in SEG in the upper lateral thigh and SEFS in the lower lateral thigh in cases with obesity-related leg edema (ie, FVI_ob and LE_ob), and the increase in SEFS in the lower lateral calf in cases with immobility-related leg edema (ie, FVI_im and LE_im) were determined to be significant factors to characterize each leg edema.

CONCLUSIONS

Differences in the extent and distribution of SEG and SEFS might help in differentiating LE from FVI_ob and FVI_im, although assessment of LE complicated by obesity vs immobility remains difficult.

Risk Factors in Patients with Venous Stasis-Related Skin Lesions without Major Abnormalities on Duplex Ultrasonography

Purpose: To clarify the risk factors for venous stasis-related skin lesions in the legs in patients without major abnormalities on duplex ultrasonography (DUS). Methods: Fifty patients (nine males and 41 females, age 27-93 years) with symptoms of C4 or greater according to the Clinical, Etiological, Anatomical, Pathological (CEAP) classification, but having no abnormalities on DUS were reviewed for known risk factors for chronic venous insufficiency (CVI) such as older age (>70 years), obesity (body mass index [BMI] >30 kg/m²), short walking distance (<200 m/day), reduced ankle range of motion (<20°), and occupation requiring prolonged standing (>8h per day). Results: The risk factor was different between male and female patients; although all patients had at least one of the above risk factors, the most commonly found risk factor in male patients was occupation requiring prolonged standing (63%), while advanced age (78%) and limited walking distance (83%) were risk factors in female patients. Conclusions: Although male and female patients had different risk factors, insufficient walking seemed to be closely related to the development of venous stasis-related skin lesions.

Adherence to and efficacy of different compression methods for treating chronic venous insufficiency in the elderly

Objectives To investigate the adherence to and efficacy of different compression methods in elderly patients. Methods A retrospective review of compression therapy in 120 elderly patients (≥65 years) with chronic venous insufficiency was performed to study the initially preferred compression method, adherence to each method, and its efficacy. Results Initially, an oversize strong stocking (24%), an appropriate size moderate stocking (19%), and bandages (37%) were equally preferred. Adherence at 1 month was 69%, 96%, and 91%, respectively, and they reduced ankle circumferences in C3 patients by 1.8 ± 1.9 cm, 0.3 ± 1.7 cm, and 2.9 ± 1.7 cm, respectively. The improvement rates of C4 symptoms were 79%, 60%, and 91%, respectively. Only three patients (2%) preferred an appropriate size strong stocking. Conclusions In elderly patients, an appropriate size strong stocking was not preferred. The best adherence was achieved by using a moderate stocking, while the best efficacy was achieved by using bandages.

Modulation of matrix metalloproteinases MMP-2 and MMP-9 activity by hydrofiber-foam hybrid dressing - relevant support in the treatment of chronic wounds

Success in chronic wound therapy requires careful selection of appropriate dressing, which enables effective management of wound exudate. According to current knowledge, exudate may contain large quantities of proteases, including matrix metalloproteinases, MMP-2 and MMP-9, which are responsible for delay in wound healing. Therefore, neutralization of MMPs may be beneficial for treatment efficacy. The aim of the study was to test whether AQUACEL Foam, a novel, technologically advanced hydrofiber-foam hybrid dressing (HFHD), may interfere with proteolytic activity of MMPs in vitro. The assessment included in vitro tests of liquid retention and measurement of human recombinant MMP-2 and MMP-9 activity. The MMPs activity was measured before and after their interaction with HFHD, using a fluorescent gelatinase assay kit and Real-Time PCR device. The in vitro tests have shown that the hydrofiber layer of HFHD revealed significant potential to decrease the activity of MMPs in the experimental system. The mentioned modulatory properties of AQUACEL Foam may contribute to a composed mechanism of its beneficial action. Furthermore, our finding may explain clinical effectiveness of HFHD observed in clinical settings.

A study of leg edema in immobile patients

BACKGROUND

Our objectives were to elucidate the pathophysiology of leg edema in immobile patients and to discuss reasonable management of this condition.

METHODS AND RESULTS

The 30 patients with leg edema had visited our clinic between April 2009 and March 2013; they suffered from severe gait disturbance, had no significant venous abnormalities detected using duplex ultrasound, and did not have any systemic diseases that could cause leg edema. Here, we review their symptoms, examinations, and treatments. Among 59 edematous legs of the 30 patients, 30 legs (51%) had symptoms that indicated advanced chronic venous insufficiency. The ankle range of motion and calf : ankle circumference ratio were abnormal in only 3 (5%) and 10 (17%) of the legs, respectively. The severity of edema and subcutaneous inflammation, which was confirmed using ultrasonography, was significantly influenced by gravity. Air plethysmography and lymphangioscintigraphy were completed in 15 and 10 patients, respectively, neither of which revealed any significant abnormalities. Reasonable success for all patients was achieved by compression therapy and physical therapy without medications.

CONCLUSIONS

It was assumed that leg edema in these immobile patients was mainly caused by venous stasis because of the immobility itself, not because of anatomical problems. The patients were successfully managed by compression and physical therapy alone.

Association between Thrombophilia and the Post-Thrombotic Syndrome

The post thrombotic syndrome (PTS) is a chronic condition that develops in 20%–40% of deep vein thrombosis (DVT) patients. While risk factors that predispose to the development of venous thromboembolism (VTE) are widely known, factors that influence the development of PTS after DVT have not been well elucidated. Over 10% of the general population is affected by one or more identifiable inherited thrombophilias which have been shown to underlie at least 1/3 of cases of VTE. The various thrombophilias are important risk factors for VTE, but it is unknown whether they also increase the risk for development of PTS. We performed a review of studies that have reported on the association between thrombophilia and the development of PTS in populations of patients with DVT and with chronic venous ulcers. Studies vary with regards to the definition of PTS, study design, follow-up period, and present conflicting results. Based on these results, the question of whether thrombophilia predisposes to the development of PTS remains unanswered.

Obesity and worsening of chronic venous disease and joint mobility

OBJECTIVE

The aim of this study was to investigate a possible relationship between obesity and decreased mobility of the talocrural joint and in turn chronic venous disease.

SUBJECTS AND METHODS

One hundred obese patients recruited at Hospital Santa Casa de Maringa, Parana were enrolled by order of arrival at the hospital in a randomized quantitative cross-sectional study. Inclusion criteria were patients with a body mass index above 30 kg/m(2) and the exclusion criteria were infectious conditions that would interfere with the assessment. Patients were graded according to the clinical, etiological, anatomical and pathophysiological classification. Talocrural goniometry was performed to assess the degree of mobility of the legs. The Kolmogorov-Smirnov normality test, Kruskal-Wallis test, Dunn's Multiple comparison test and analysis of variance were used for statistical analysis tests with an alpha error of 5% being considered acceptable.

RESULTS

The increase in body mass index is correlated to the reduction in joint mobility (Kruskal-Wallis test: p-value <0.0001) and increase in clinical, etiological, anatomical and pathophysiological classification is correlated to a decrease in joint mobility and the increase in age is associated with an increase in clinical, etiological, anatomical and pathophysiological classification (Kruskal-Wallis test: p-value <0.0001).

CONCLUSION

Obesity is associated with deterioration in joint mobility and worsening of chronic venous disease.

The pernicious cycle of VLUs in Brazil: epidemiology, pathogeny and auxiliary healing methods

Venous leg ulcers (VLUs) represent the most advanced stage of chronic venous insufficiency. Despite the large body of knowledge available regarding the risk factors and aetiopathogeny of the condition, patients referred to public health care systems in developing countries often do not receive adequate diagnosis or early treatment, leading to clinical evolution and disease recurrence. This review collates updated information about the epidemiology, risk factors, aetiopathogeny, diagnosis, ulcer healing methods and determinant factors of the pernicious cycle of VLUs in developing countries, with a focus on the Brazilian setting.

The use of ultrasound in the evaluation of the efficacy of calf muscle pump function in primary chronic venous disease

OBJECTIVES

To evaluate popliteal vein blood flow during calf muscle contraction in chronic venous disease (CVD) patients and healthy controls using ultrasound imaging and to investigate the relationship between venous blood flow and gastrocnemius muscle (GM) morphology.

METHODS

Thirty-one subjects participated in this study (mean age: 40.3 [11.8] years), 15 healthy controls and 16 with CVD (clinical classification: C₁₋₄). Popliteal vein cross-sectional area and venous blood flow velocity (FV) were evaluated by Doppler ultrasound at baseline and during three sets of 10 tip-toe movement repetitions. Muscle thickness, muscle fascicle length and pennation angle of both medial and lateral GM were measured by ultrasound. Measures were repeated a week later in 17 participants in order to assess reproducibility with intraclass correlation coefficient (ICC) and Bland-Altman analysis.

RESULTS

Peak FV was lower in CDV group compared with Control group for both first (40.6 [11.8] versus 62.4 (22.1) cm²/second; P = 0.021) and last (30.4 [9.1] versus 49.5 (22.7) cm²/second; P = 0.024) contraction. In CVD group, peak FV during first contraction increased with GM's muscle fascicle length (r = 0.63; P = 0.041). Popliteal FV also increased with rising range of muscle fascicles pennation change between ankle dorsiflexion and plantar flexion (r = 0.70; P = 0.025). No associations were found between haemodynamics and medial or lateral GM thickness. Calf muscular architecture was similar in both CVD and control participants. Test-retest reliability of FV measured in the same session was high (ICC≈0.70) for measures taken in the first contraction of the set but lowered when using the last contraction (ICC<0.50). Reproducibility of ultrasound evaluation of calf pump is acceptable within the same session but is unsatisfactory when testing in separate days.

CONCLUSION

Patients with moderate CVD have lower FV during calf muscles contraction but similar muscle anatomical characteristics compared with healthy controls. Changes in calf muscles flexibility and fatigue resistance may be investigated as possible causes of calf pump dysfunction.

Healing rates following venous surgery for chronic venous leg ulcers in an independent specialist vein unit

Objectives

This is a retrospective study over 12 years reporting the healing rates of leg ulcers at a specialist vein unit. All patients presented with active chronic venous leg ulcers (clinical, aetiological, anatomical and pathological elements [CEAP]: C6) and had previously been advised elsewhere that their ulcers were amenable to conservative measures only.

Method

Seventy-two patients (84 limbs) were treated between March 1999 and June 2011. Patients were contacted in August 2011 by questionnaire and telephone. Of 72 patients, two were deceased and two had moved location at follow-up, so were not contactable. Fifty patients replied and 18 did not (response rate 74%), representing a mean follow-up time of 3.1 years.

Results

Ulcer healing occurred in 85% (44 of 52 limbs) of which 52% (27) limbs were no longer confined to compression. Clinical improvement was achieved in 98% of limbs.

Conclusions

This study shows that a significant proportion of ulcers currently managed conservatively can be healed by surgical intervention.

Venous leg ulcer in the context of chronic venous disease

Objectives

Chronic venous disease (CVD) is a frequent disorder with a high socioeconomic impact. Little is known about the possible differences between healed ulcer (C5 group) and active ulcer (C6 group) in terms of disease severity and quality of life (QoL). Our aim was to determine the possible differences in severity disease and QoL between the C5–C6 and C1 (control) group.

Methods

Data from a national, multicentre, observational and cross-sectional study ( n = 1598) were used to compare three groups of CVD: C1 ( n = 243), C5 ( n = 136) and C6 ( n = 70). CVD severity was assessed with the Venous Clinical Severity Score (VCSS) and QoL with the Short Form 12 Health Survey (SF-12) and Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ-20).

Results

Patients with active ulcers had a higher mean total VCSS than patients with healed ulcers ( P < 0.05). Both SF-12 and CIVIQ-20 QoL questionnaires indicated a poorer QoL in patients with ulcers than in those with C1 ( P < 0.05). Compared with the C5 group, patients with active ulcers (C6) had lower QoL scores, but the differences were not statistically significant.

Conclusions

Patients with venous leg ulcers (C5–C6) are associated with high severity and poor QoL. However, the healing of a leg ulcer did not contribute to improvement of QoL.

Negative impact of deep venous thrombosis on chronic venous disease

INTRODUCTION

There are several conditions that may cause chronic venous disease (CVD). It is not known whether the aetiology of CVD can predict disease severity and quality of life (QoL). Our objective is that the severity and QoL of patients with CVD secondary to DVT is different from those without prior DVT.

MATERIAL AND METHODS

We compare patients with CVD caused by DVT (n=125) and patients with non-DVT CVD (n=1435) with respect to disease severity (CEAP and Venous Clinical Severity Score-VCSS) and quality of life (Health Survey Short-Form-SF12 y Chronic Lower Limb Venous Insufficiency Questionnaire-CIVIQ20).

RESULTS

Regarding to non-thrombotic CVD, patients with CVD due to DVT showed more severe disease [C6 grade (14.4% vs 3.6%) (p<0.05); score VCSS (1,33±0,65 vs 0,84±0,49) (p<0.05)] and poorer QoL [global score CIVIQ-20 (57,84±15,57 vs 65,75±14,07) (p<0.05); global score SF-12 (45,98±18,79 vs 57,79±19,64) (p<0.05).]. These differences remained statistical significant in all parameters - attributed measured at each severity score and QoL questionnaires.

CONCLUSION

A history of DVT leads to worse clinical severity and quality of life in CVD patients. These data support even more the need to implement programs to prevent DVT and/or its evolutionary consequences.

Oral doxycycline with topical tacrolimus for treatment of stasis dermatitis due to chronic venous insufficiency: A pilot study

Objectives:

Chronic venous insufficiency (CVI) in lower limbs manifest as stasis dermatitis. The anti-collagenase, anti-inflammatory and immunomodulatory effects of doxycycline and the T-cell inhibitory effects of tacrolimus could theoretically modify the disease pathophysiology. This study was undertaken to evaluate the efficacy and safety of four weeks combination therapy of oral doxycycline 100 mg with topical tacrolimus 0.1% for stasis dermatitis associated with CVI.

Materials and Methods:

A single-arm, interventional pilot study was conducted on subjects with CVI of C4 to C6 category (CEAP classification: clinical, etiology, anatomical, pathophysiology). Treatment duration was four weeks with fortnightly follow-ups. Primary efficacy was assessed as changes from baseline of pigmentation, erythema, edema, itching and hair loss of the affected area evaluated on Likert scale scores. Secondary efficacy parameters were percentage improvement of the dermatitis area and changes in ulcer dimensions (maximum length and breadth), if present. Safety evaluation included all treatment emergent clinical signs and symptoms reported by the patients and/or observed by the physician.

Results:

Out of 19 recruited subjects, 15 completed the study for analysis. Significant (P<0.01) improvement in pain, edema, pigmentation, erythema and exudation were observed. Reduction of ulcer dimensions was also statistically significant (P<0.01). 86.6% showed improvement of the dermatitis area, 6.7% patients failed to show any improvement and 6.7% showed worsening. Adverse effects were observed in only two subjects.

Conclusion:

This pilot study suggests efficacy of this combination therapy in controlling features of stasis dermatitis but further studies are needed for validation.