Assessment of causes and patterns of recurrent varicose veins after surgery

The sonographic features of lymph node venous networks and flow patterns in patients with primary chronic venous disease

BACKGROUND

Our study aims to enhance the understanding of lymph node venous networks (LNVNs) by summarising their anatomical, sonographic features, and reflux patterns.

METHOD

We examined 241 legs from 141 patients with primary chronic venous disease (CVD) using duplex ultrasound.

RESULTS

The findings indicated variations in the shape, size, vascularity, and echogenicity of LNVN. The superficial inguinal lymph node with reflux appeared slightly larger, exhibiting higher velocities in the hilar artery. Regarding connections, venous flow within LNVN was predominantly drained through the saphenofemoral junction (SFJ), anterior accessory great saphenous vein (AAGSV), and great saphenous vein (GSV). A significant number of LNVNs were observed to be associated with anterolateral thigh tributaries. The study also identified valve cusps within LNVN.

CONCLUSION

This study revealed a 12% prevalence of primary LNVN. Understanding the anatomical and haemodynamic features of LNVN informs treatment strategies and potentially helps prevent the recurrence of varicose veins.

Mechanoresponsive ETS1 causes endothelial dysfunction and arterialization in varicose veins via NOTCH4/DLL4 signaling

Varicose veins are the most common venous disorder in humans and are characterized by hemodynamic instability due to valvular insufficiency and orthostatic lifestyle factors. It is unclear how changes in biomechanical signals cause aberrant remodeling of the vein wall. Our previous studies suggest that Notch signaling is implicated in varicose vein arterialization. In the arterial system, mechanoresponsive ETS1 is a transcriptional activator of the endothelial Notch, but its involvement in sensing disrupted venous flow and varicose vein formation has not been investigated. Here, we use human varicose veins and cultured human venous endothelial cells to show that disturbed venous shear stress activates ETS1-NOTCH4/DLL4 signaling. Notch components were highly expressed in the neointima, whereas ETS1 was upregulated in all histological layers of varicose veins. In vitro microfluidic flow-based studies demonstrate that even minute changes in venous flow patterns enhance ETS1-NOTCH4/DLL4 signaling. Uniform venous shear stress, albeit an inherently low-flow system, does not induce ETS1 and Notch proteins. ETS1 activation under altered flow was mediated primarily by MEK1/2 and, to a lesser extent, by MEK5 but was independent of p38 MAP kinase. Endothelial cell-specific ETS1 knockdown prevented disturbed flow-induced NOTCH4/DLL4 expression. TK216, an inhibitor of ETS-family, prevented the acquisition of arterial molecular identity and loss of endothelial integrity in cells exposed to the ensuing altered shear stress. We conclude that ETS1 senses blood flow disturbances and may promote venous remodeling by inducing endothelial dysfunction. Targeting ETS1 rather than downstream Notch proteins could be an effective and safe strategy to develop varicose vein therapies.

Ultrasound-guided cyanoacrylate injection for the treatment of incompetent perforator veins

Objective

The use of cyanoacrylate products (CA) in incompetent perforator vein (IPV) treatment has not been thoroughly examined. The primary objective of this study is to describe the technique of ultra sound guided direct injection of IPV with CA, and secondarily to determine early closure rates and safety of this technique.

Methods

A retrospective analysis of patients undergoing IPV injection at two centres between 2015-2018 was conducted. Demographics, CEAP classification and IPV location were collected. Outcomes were assessed at two follow-up appointments.

Results

A total of 83 perforator vein injections were completed. CEAP classifications include C2 – C6 classes. Location of perforators were posteromedial (6%), femoral canal (9%), paratibial (14%), and posterior-tibial (71%). IPV closure rates were 96.3% at initial follow-up (16 ± 2 days). Closure rates decreased to 86.5% at second follow-up (72 ± 9 days). There were no deep vein thromboses during follow-up. One patient developed septic thrombophlebitis that was successfully managed with antibiotics.

Conclusion

Ultrasound-guided CA glue injection is a simple and low risk procedure that effectively closes incompetent perforator veins.

One-year outcomes of radiofrequency ablation of incompetent perforator veins using the radiofrequency stylet device: Cohort study from East Asia

OBJECTIVES

The present study was designed to assess outcomes of patients undergone radiofrequency ablation (RFA) for their incompetent perforator veins (IPVs) with ClosureFast stylets.

METHODS

Data of 165 IPVs in 138 limbs of 117 consecutive patients between July 2017 to Nov. 2019 were retrospectively reviewed. Primary endpoints (technical success rate, complications) and secondary endpoints (VCSS) were analyzed.

RESULTS

The immediate technical success rate was 100%. There were no major complications. The rate of ecchymosis and induration was 5.8%. 129/165 IPVs in 79.5% (93/117) patients had achieved sonographic evaluation at 1 year followed-up, in which 3 perforators were recanalized. VCSS scores at pre-operation and 1-year follow-up were 5.77 ± 1.88 and 2.70 ± 1.39, respectively (t= 29.644, P= .000).

CONCLUSIONS

In conclusion, RFA is safe and effective for the treatment of IPVs. At the 1-year follow-up, the RFA of IPVs showed a low recanalization rate and had a satisfactory improvement on VCSS.

Endovenous Thermal Ablation of Recurrent Varicose Veins due to Residual Great Saphenous Venous Insufficiency After Saphenous Venous Surgery: A Comparative Study

BACKGROUND

Redo surgery for recurrent varicose veins of the great saphenous vein (GSV) is technically more challenging than the initial surgery.

OBJECTIVE

To compare 980 and 1,470-nm endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) for the treatment of residual GSV insufficiency after saphenofemoral ligation ± stripping.

MATERIALS AND METHODS

Thirty-seven limbs in 29 patients with recurrent varicose veins were retrospectively evaluated. Patients were divided into 3 groups: 980-nm EVLA (group A), 1,470-nm EVLA (group B), and RFA (group C). Duplex ultrasonography, Venous Clinical Severity Score (VCSS), and adverse events were examined at intervals of 1 week, 1, 3, 6, and 12 months.

RESULTS

Complete closure was achieved in 35 (94.6%) limbs at 12 months. Venous Clinical Severity Score decrease in group C (3.6 ± 0.5) was significantly (p < .017) greater compared with that of group A (2.6 ± 0.9). Ecchymosis grade was significantly (p < .017) lower in group C (0.1 ± 0.3) than that in group A (1.6 ± 1.5).

CONCLUSION

Endovenous thermal ablation using EVLA or RFA is safe and effective for treatment of recurrent varicose veins resulting from residual GSV insufficiency after saphenous venous surgery. The RFA is superior to 980-nm EVLA in terms of postprocedural ecchymosis and improvement in VCSS.

Anatomic variations of lower extremity venous system in varicose vein patients: demonstration by three-dimensional CT venography

Background Understanding the anatomy of the lower extremity veins is essential for successful varicose vein treatment. Computed tomography (CT) venography may be used to obtain a comprehensive overview and detailed information regarding this. Purpose To describe anatomic variations of the lower extremity venous system in patients with varicose veins, using three-dimensional (3D) CT venography. Material and Methods A total of 810 limbs in 405 patients with suspected varicose veins were prospectively referred to undertake CT venography and included in our study population retrospectively. The CT venography images were evaluated by consensus of two cardiovascular radiologists. Anatomical variations of the lower extremity venous system and their incidence were analyzed. Specifically, the number of tributaries at saphenofemoral junction, relative location of the great saphenous vein (GSV) with respect to the common femoral artery bifurcation, pattern of saphenopopliteal junction, and end of thigh extension from the small saphenous vein (SSV) were assessed. Results The most frequent number of tributaries joining the GSV was four (44.4%, 360/810). Only 0.7% (6/810) of the limbs demonstrated unusual location of the GSV between the bifurcated superficial and deep femoral arteries. The most common pattern of veins at the saphenopopliteal junction was a larger caliber of saphenopopliteal junction than thigh extension from SSV (43.8%, 355/810), end of which joining the femoral vein directly (41.0%, 288/703). Conclusion CT venography with 3D reconstruction can be used to understand the anatomy of lower extremity veins and how their variations contribute to varicose veins.

Treatment of incompetent perforators in recurrent venous insufficiency with adhesive embolization and sclerotherapy

Recurrent lower limb venous insufficiency is often a challenge in clinical practice and is most commonly due to incompetent perforators. Many of these patients do not have adequate symptom relief with compression and require some form of treatment for incompetent perforator interruption. Various treatment methods have been tried with different efficiencies.

Objective

To evaluate the feasibility, efficiency and safety of an outpatient combined cyanoacrylate adhesion–sodium tetradecyl sulphate sclerotherapy for treatment of patients with symptoms of persistent or recurrent lower limb venous insufficiency secondary to incompetent perforators.

Methods

Eighty-three limbs of 69 patients with symptoms of persistent or recurrent lower limb venous insufficiency secondary to incompetent perforators were treated with cyanoacrylate embolization of incompetent perforators and sclerotherapy of dilated collateral veins (surface branch varicose veins). Technical success, procedural pain, perforator occlusion, venous occlusion, clinical improvement and ulcer healing were assessed. Follow-up was done three- and six-month post-procedure.

Results

Procedure could be successfully performed in all patients. One hundred and ninety-one perforators were treated in total. Perforator and varicose veins occlusion rate was 100%. Deep venous extension of cyanoacrylate occurred in four (4.8%) patients, with no adverse clinical outcome. Venous clinical severity score improved from a baseline of 8.18 ± 3.60 to 4.30 ± 2.48 on three-month follow-up and 2.42 ± 1.52 on six-month follow-up (p < 0.0001). All ulcers showed complete healing within three months. Significant prolonged thrombophlebitis occurred in 38.5% of limbs.

Conclusion

Combined cyanoacrylate adhesion and setrol sclerotherapy is technically easy, has a lot of advantages including being an outpatient procedure and highly efficacious but with a guarded safety profile.

Algorithm-based approach to management of venous leg ulceration

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.