Factors associated with lack of clinical improvement after vein ablation in the vascular quality initiative

BACKGROUND

Insurance companies have adopted variable and inconsistent approval criteria for chronic venous disease (CVD) treatment. Although vein ablation (VA) is accepted as the standard of care for venous ulcers, the treatment criteria for patients with milder forms of CVD remain controversial. This study aims to identify factors associated with a lack of clinical improvement (LCI) in patients with less severe CVD without ulceration undergoing VA to improve patient selection for treatment.

METHODS

We performed a retrospective analysis of patients undergoing VA for CEAP C2 to C4 disease in the Vascular Quality Initiative varicose veins database from 2014 to 2023. Patients who required intervention in multiple veins, had undergone prior interventions, or presented with CEAP C5 to C6 disease were excluded. The difference (Δ) in venous clinical severity score (VCSS; VCSS before minus after the procedure) was used to categorize the patients. Patients with a ΔVCSS of ≤0 were defined as having LCI after VA, and patients with ≥1 point decrease in the VCSS after VA (ΔVCSS ≥1) as having some benefit from the procedure and, therefore, "clinical improvement." The characteristics of both groups were compared, and multivariable regression analysis was performed to identify factors independently associated with LCI. A second analysis was performed based on the VVSymQ instrument, which measures patient-reported outcomes using five specific symptoms (ie, heaviness, achiness, swelling, throbbing pain, and itching). Patients with LCI showed no improvement in any of the five symptoms, and those with clinical improvement had a decrease in severity of at least one symptom.

RESULTS

A total of 3544 patients underwent initial treatment of CVD with a single VA. Of the 3544 patients, 2607 had VCSSs available before and after VA, and 420 (16.1%) had LCI based on the ΔVCSS. Patients with LCI were more likely to be significantly older and African American and have CEAP C2 disease compared with patients with clinical improvement. Patients with clinical improvement were more likely to have reported using compression stockings before treatment. The vein diameters were not different between the two groups. The incidence of complications was overall low, with minor differences between the two groups. However, the patients with LCI were significantly more likely to have symptoms after intervention than those with improvement. Patients with LCI were more likely to have technical failure, defined as vein recanalization. On multivariable regression, age (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00-1.02) and obesity (OR, 1.47; 95% CI, 1.09-2.00) were independently associated with LCI, as was treatment of less severe disease (CEAP C2; OR, 1.82; 95% CI, 1.30-2.56) compared with more advanced disease (C4). The lack of compression therapy before intervention was also associated with LCI (OR, 6.05; 95% CI, 4.30-8.56). The analysis based on the VVSymQ showed similar results.

CONCLUSIONS

LCI after VA is associated with treating patients with a lower CEAP class (C2 vs C4) and a lack of compression therapy before intervention. Importantly, no significant association between vein size and clinical improvement was observed.

Serious Adverse Events with Cyanoacrylate Closure of Varicose Veins: An Initial Report from a Large-Scale National Survey in Japan

Objective: Cyanoacrylate closure (CAC) is a minimally invasive technique for the treatment of varicose veins. A recent paper reported serious adverse events (AEs) associated with this use. This triggered an urgent survey to determine the incidence of AEs in Japan. Methods: The CAC-AE survey was sent to all 1,030 institutions authorized for CAC treatments. Cases performed between January 2020 and October 2023 were surveyed. Data on serious AEs and mortality were collected. Results: There were 623 surveys returned. There were 16 cases of proximal deep vein thrombosis, 3 cases of pulmonary embolism (PE), and 0 cases of stroke. Deep vein occlusion due to cyanoacrylate extension was observed in 1 case. Vein resection due to infection was observed in 4 cases. There were 299 cases of localized phlebitis and/or allergic reactions requiring steroid administration. Systemic allergic reactions requiring steroid administration were observed in 66 cases. There was no anaphylaxis associated with cyanoacrylate. There was one postoperative death from PE. Conclusion: This report's intent is to provide real world data on serious AEs following CAC from Japan given current concern over these events. An extensive report investigation of individual complications with analysis including causality will be provided following a full investigation separately.

A comparison of below-knee vs above-knee endovenous ablation of varicose veins

OBJECTIVE

Varicose veins have a significant impact on quality of life and can commonly occur in the thigh and calves. However, there has been no large-scale investigation examining the relationship between anatomic distribution and outcomes after varicose vein treatment. This study sought to compare below-the-knee (BTK) and above-the-knee (ATK) varicose vein treatment outcomes.

METHODS

Employing the Vascular Quality Initiative Varicose Vein Registry, 13,731 patients undergoing varicose vein ablation for either BTK or ATK lesions were identified. Outcomes were assessed using patient-reported outcomes (PROs) and the Venous Clinical Severity Score (VCSS). Continuous variables were compared using the t-test, and categorical variables were analyzed using the χ2 test. Multivariable logistic regression was used to estimate the odds of improvement after intervention. The multivariable model controlled for age, gender, race, preoperative VCSS composite score, and history of deep vein thrombosis.

RESULTS

Patients who received below-knee treatment had a lower preoperative VCSS composite (7.0 ± 3.3 vs 7.7 ± 3.3; P < .001) and lower PROs composite scores (11.1 ± 6.4 vs 13.0 ± 6.6; P < .001) compared with those of patients receiving above-knee treatment. However, on follow-up, patients receiving below-knee intervention had a higher postoperative VCSS composite score (4.4 ± 3.3 vs 3.9 ± 3.5; P < .001) and PROs composite score (6.1 ± 4.4 vs 5.8 ± 4.5; P = .007), the latter approaching statistical significance. Patients receiving above-knee interventions also demonstrated more improvement in both composite VCSS (3.8 ± 4.0 vs 2.9 ± 3.7; P < .001) and PROs (7.1 ± 6.8 vs 4.8 ± 6.6; P < .001). Multivariable logistic regression analysis similarly revealed that patients receiving above-knee treatment had significantly higher odds of improvement in VCSS composite in both the unadjusted (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.28-1.65; P < .001 and adjusted (OR, 1.31; 95% CI, 1.14-1.50; P < .001) models. Patients receiving above-knee treatment also had a significantly higher odds of reporting improvement in PROs composite in both the unadjusted (OR, 1.85; 95% CI, 1.64-2.11; P < .001) and adjusted (OR, 1.65; 95% CI, 1.45-1.88; P < .001) models.

CONCLUSIONS

Treatment region has a significant association with PROs and VCSS composite scores after varicose vein interventions. Preoperatively, there were significant differences in the composite scores of VCSS and PROs with patients receiving BTK treatment exhibiting less severe symptoms. Yet, the association appeared to reverse postoperatively, with those receiving BTK treatments exhibiting worse PROs, worse VCSS composites scores, and less improvement in VCSS composite scores. Therefore, BTK interventions pose a unique challenge compared with ATK interventions in ensuring commensurate clinical improvement after treatment.

Generation of induced pluripotent stem cell line from a patient suffering from arterial calcification due to deficiency of CD73 (ACDC)

Arterial calcification due to deficiency of CD73 (ACDC) is an adult onset, rare genetic vascular disorder signified by calcium deposition in lower extremity arteries and joints of hands and feet. Mutations in NT5E gene has been shown to be responsible for the inactivation of enzyme CD73 causing calcium buildup. Here, we report a iPSC line generated from a patient showing signs of ACDC and carrying a missense mutation in NT5E (c.1126A→G,p.T376A) gene. This iPSC line shows normal morphology, pluripotency, karyotype, and capability to differentiate into three germ layers, making it useful for disease modeling and investigating pathological mechanisms of ACDC.

Variations and inconsistencies in venous ablation coverage policies between single-state and multistate carriers in the United States

BACKGROUND

Vein ablation is a common and effective treatment for patients with chronic venous insufficiency. The overuse of vein ablation despite the existence of evidence-based guidelines has resulted in insurance companies developing restrictive policies for coverage that create barriers to appropriate care. This study compares the insurance coverage by single-state carriers (SSCs) and multistate carriers (MSCs), highlighting the variations and inconsistencies in the various policies.

METHODS

The American Venous Forum Venous Policy Navigator was reviewed for the various policies available in the United States. The policies were divided into SSCs and MSCs. The characteristics of the policies, including the anatomic and hemodynamic criteria for specific veins, duration of conservative treatment, disease severity, symptoms, and types of procedures covered, were compared between the two groups. SAS, version 9.4 (SAS Institute Inc) was used for statistical analysis.

RESULTS

A total of 122 policies were analyzed and divided between SSCs (n = 85; 69.7%) and MSCs (n = 37; 30.3%). A significant variation was found in the size requirement for great saphenous vein ablation. Although 48% of the policies did not specify a size criterion, the remaining policies indicated a minimal size, ranging from 3 to 5.5 mm. However, no significant differences were found between SSCs and MSCs. Similar findings were encountered for the small and anterior accessory saphenous veins. MSCs were more likely to define a saphenous reflux time >500 ms compared with SSCs (81.1% vs 58.8%; P = .04). A significant difference was found between the SSCs and MSCs in the criteria for perforator ablation in terms of size and reflux time. MSCs were significantly more likely to provide coverage for mechanochemical ablation than were SSCs (24.3% vs 8.2%; P = .03). SSCs were more likely to require ≥12 weeks of compression stocking therapy than were MSCs (76.5% vs 48.7%; P = .01). No significant differences were found in the clinical indications between the two groups; however, MSCs were more likely to mention major hemorrhage than were SSCs.

CONCLUSIONS

The results of this study highlight the variations in policies for venous ablation, in particular, the striking inconsistencies in size criteria. MSCs were more likely to cover mechanochemical ablation and require a shorter duration of conservative therapy before intervention compared with SSCs. Evidence-based guidance is needed to develop more coherent policies for venous ablation coverage.

A systematic review on ablation techniques for larger saphenous veins in patients with symptomatic superficial venous disease

OBJECTIVE

The aim of this study was to summarize the existing evidence for the treatment of saphenous veins >10 mm in diameter, to determine whether there were vein size limits for treatment modalities, and to determine if there are specific technical considerations for treatment of large veins.

METHODS

We searched the literature for reports of treatment methods and outcomes for patients with large-diameter saphenous veins treated with various ablation methods between 1993 and 2023. These studies were evaluated for the size of the vein determined as "large diameter," type of ablation method, study type, outcomes, adverse events, and any technical considerations noted. A systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The COVIDENCE software was used for full-text screening and data extraction. Three reviewers reviewed the data, and the content expert served as the tiebreaker.

RESULTS

Seventy-one records were identified, of which 24 studies were deemed appropriate for extraction. Most of the studies identified reported outcomes of endovenous thermal ablation modalities. There were fewer studies on non-thermal, non-tumescent techniques, and these studies reported an overall lower occlusion rate compared with endovenous thermal ablation techniques.

CONCLUSIONS

Large head-to-head trials or randomized controlled that compare all the modalities over a long follow-up duration are yet to be performed. In the existing literature, there is considerable heterogeneity in terms of the study size, design, definition of large veins, site of vein measurement, and follow-up periods, making it challenging to make fair comparisons and draw firm conclusions. Currently available evidence supports the use of endothermal ablation techniques for the treatment of veins >10 mm in diameter as they have a more favorable efficacy and safety profile and have a larger body of evidence available compared with non-thermal, non-tumescent techniques or surgery.

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

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.

Varicose Veins: Approach, Assessment, and Management to the Patient with Chronic Venous Disease

Varicose veins are tortuous and dilated veins commonly seen in chronic venous disease. This article will review chronic venous disease, including its differential diagnosis, workup, and treatment.

A Nurse-Led Care Delivery App and Telehealth System for Patients Requiring Wound Care: Mixed Methods Implementation and Evaluation Study

BACKGROUND

Innovative solutions to nursing care are needed to address nurse, health system, patient, and caregiver concerns related to nursing wellness, work flexibility and control, workforce retention and pipeline, and access to patient care. One innovative approach includes a novel health care delivery model enabling nurse-led, off-hours wound care (PocketRN) to triage emergent concerns and provide additional patient health education via telehealth.

OBJECTIVE

This pilot study aimed to evaluate the implementation of PocketRN from the perspective of nurses and patients.

METHODS

Patients and part-time or per-diem, wound care-certified and generalist nurses were recruited through the Stanford Medicine Advanced Wound Care Center in 2021 and 2022. Qualitative data included semistructured interviews with nurses and patients and clinical documentation review. Quantitative data included app use and brief end-of-interaction in-app satisfaction surveys.

RESULTS

This pilot study suggests that an app-based nursing care delivery model is acceptable, clinically appropriate, and feasible. Low technology literacy had a modest effect on initial patient adoption; this barrier was addressed with built-in outreach and by simplifying the patient experience (eg, via phone instead of video calls). This approach was acceptable for users, despite total patient enrollment and use numbers being lower than anticipated (N=49; 17/49, 35% of patients used the app at least once beyond the orientation call). We interviewed 10 patients: 7 who had used the app were satisfied with it and reported that real-time advice after hours reduced anxiety, and 3 who had not used the app after enrollment reported having other resources for health care advice and noted their perception that this tool was meant for urgent issues, which did not occur for them. Interviewed nurses (n=10) appreciated working from home, and they reported comfort with the scope of practice and added quality of care facilitated by video capabilities; there was interest in additional wound care-specific training for nonspecialized nurses. Nurses were able to provide direct patient care over the web, including the few participating nurses who were unable to perform in-person care (n=2).

CONCLUSIONS

This evaluation provides insights into the integration of technology into standard health care services, such as in-clinic wound care. Using in-system nurses with access to electronic medical records and specialized knowledge facilitated app integration and continuity of care. This care delivery model satisfied nurse desires for flexible and remote work and reduced patient anxiety, potentially reducing postoperative wound care complications. Feasibility was negatively impacted by patients' technology literacy and few language options; additional patient training, education, and language support are needed to support equitable access. Adoption was impacted by a lack of perceived need for additional care; lower-touch or higher-acuity settings with a longer wait between visits could be a better fit for this type of nurse-led care.

Cyanoacrylate glue reactions: A systematic review, cases, and proposed mechanisms

OBJECTIVE

Cyanoacrylate glue closure was first used in humans 10 years ago to treat venous reflux of the axial veins. Studies have since shown its clinical efficacy in vein closure. However, great need exists to elucidate further the types of specific adverse reactions that cyanoacrylate glue can cause for better patient selection and to minimize these events. In the present study, we systematically reviewed the literature to identify the types of reported reactions. In addition, we explored the pathophysiology contributing to these reactions and proposed the mechanistic pathway with inclusion of actual cases.

METHODS

We searched the literature for reports of reactions following cyanoacrylate glue use in patients with venous diseases between 2012 and 2022. The search was performed using MeSH (medical subject headings) terms. The terms included cyanoacrylate, venous insufficiency, chronic venous disorder, varicose veins, vein varicosities, venous ulcer, venous wound, CEAP (clinical, etiologic, anatomic, pathophysiologic), vein, adverse events, phlebitis, hypersensitivity, foreign body granuloma, giant cell, endovenous glue-induced thrombosis, and allergy. The search was limited to the literature reported in English. These studies were evaluated for the type of product used and the reactions noted. A systematic review, in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) method, was performed. Covidence software (Melbourne, VC, Australia) was used for full-text screening and data extraction. Two reviewers reviewed the data, and the content expert served as the tiebreaker.

RESULTS

We identified 102, of which, 37 reported on cyanoacrylate use other than in the context of chronic venous diseases and were excluded. Fifty-five reports were determined appropriate for data extraction. The adverse reactions to cyanoacrylate glue were phlebitis, hypersensitivity, foreign body granuloma, and endovenous glue-induced thrombosis.

CONCLUSIONS

Although cyanoacrylate glue closure for venous reflux is generally a safe and clinically effective treatment choice for patients with symptomatic chronic venous disease and axial reflux, some adverse events could be specific to the properties of the cyanoacrylate product. We propose mechanisms for how such reactions can occur based on histologic changes, published reports, and case examples; however, further exploration is necessary to confirm these theories.

VIEW-VLU observational study of the effect of Varithena on wound healing in the treatment of venous leg ulcers

OBJECTIVE

Chronic venous hypertension, triggered by venous reflux and/or obstruction, leads to skin changes and venous leg ulcers (VLUs). Compression therapy is the standard of care, but many wounds remain unhealed. The objectives of this study were to observe the effects of endovenous chemical ablation with commercially available 1% polidocanol injectable microfoam on VLU healing and recurrence rates.

METHODS

The VIEW VLU study was a multicenter, open-label, phase IV registry of patients with active VLUs resulting from venous insufficiency of the great saphenous vein and/or anterior accessory saphenous vein systems who underwent ablation with 1% polidocanol microfoam. Primary outcomes included wound healing rate (change in wound perimeter), wound closure at 12 weeks after treatment, and time to wound closure. Secondary outcomes included VLU recurrence, numeric pain score at the ulcer location, EuroQol five-dimension five-level questionnaire quality-of-life index, and the Venous Clinical Severity Score. Patients were followed for 12 months.

RESULTS

We enrolled 76 patients (80 ulcers) from 14 sites across the United States and Canada (mean age 63.6 ± 13.7 years, 39.5% female, mean body mass index 36.3). Of the enrollees, 96.3% presented with great saphenous vein incompetence. The mean baseline wound perimeter was 117.2 ± 107.4 mm and 26.3% of wounds (21/80) were circumferential. The mean ulcer age was 34.8 ± 51.8 weeks at first presentation and the mean compression therapy duration was 26.4 ± 35.9 weeks. The median wound perimeter decreased by 16.3% from baseline in the first 2 weeks after the procedure and by 27.0% at 12 weeks. By 12 weeks, 53.8% of wounds (43/80) were healed. The median time to ulcer closure by Kaplan-Meier analysis was 89 days (95% confidence interval, 62.0-117.0). In a Kaplan-Meier analysis of initially healed wounds, 88.9% (95% confidence interval, 76.9-94.8) remained closed at 12 weeks after closure. The mean numeric pain scores (ulcer site) improved by 41.0% and 64.1% at 12 weeks and 12 months after the procedure, respectively. The health-related quality-of-life index (scale of 0-1) improved from 0.65 ± 0.27 at baseline to 0.72 ± 0.28 at 12 weeks and 0.73 ± 0.30 at 12 months. By 12 weeks after treatment, the mean target leg Venous Clinical Severity Score had significantly decreased by 5.8 points, and by 12 months it had decreased by 10.0 points.

CONCLUSIONS

Treatment with 1% polidocanol microfoam was associated with promising wound healing rates and low recurrence rates for VLUs, despite a challenging patient population with recalcitrant ulcers, a large percentage of which were circumferential, in patients with high body mass indexes.

The potential of chatbots in chronic venous disease patient management

Objective

Health care providers and recipients have been using artificial intelligence and its subfields, such as natural language processing and machine learning technologies, in the form of search engines to obtain medical information for some time now. Although a search engine returns a ranked list of webpages in response to a query and allows the user to obtain information from those links directly, ChatGPT has elevated the interface between humans with artificial intelligence by attempting to provide relevant information in a human-like textual conversation. This technology is being adopted rapidly and has enormous potential to impact various aspects of health care, including patient education, research, scientific writing, pre-visit/post-visit queries, documentation assistance, and more. The objective of this study is to assess whether chatbots could assist with answering patient questions and electronic health record inbox management.

Methods

We devised two questionnaires: (1) administrative and non-complex medical questions (based on actual inbox questions); and (2) complex medical questions on the topic of chronic venous disease. We graded the performance of publicly available chatbots regarding their potential to assist with electronic health record inbox management. The study was graded by an internist and a vascular medicine specialist independently.

Results

On administrative and non-complex medical questions, ChatGPT 4.0 performed better than ChatGPT 3.5. ChatGPT 4.0 received a grade of 1 on all the questions: 20 of 20 (100%). ChatGPT 3.5 received a grade of 1 on 14 of 20 questions (70%), grade 2 on 4 of 16 questions (20%), grade 3 on 0 questions (0%), and grade 4 on 2/20 questions (10%). On complex medical questions, ChatGPT 4.0 performed the best. ChatGPT 4.0 received a grade of 1 on 15 of 20 questions (75%), grade 2 on 2 of 20 questions (10%), grade 3 on 2 of 20 questions (10%), and grade 4 on 1 of 20 questions (5%). ChatGPT 3.5 received a grade of 1 on 9 of 20 questions (45%), grade 2 on 4 of 20 questions (20%), grade 3 on 4 of 20 questions (20%), and grade 4 on 3 of 20 questions (15%). Clinical Camel received a grade of 1 on 0 of 20 questions (0%), grade 2 on 5 of 20 questions (25%), grade 3 on 5 of 20 questions (25%), and grade 4 on 10 of 20 questions (50%).

Conclusions

Based on our interactions with ChatGPT regarding the topic of chronic venous disease, it is plausible that in the future, this technology may be used to assist with electronic health record inbox management and offload medical staff. However, for this technology to receive regulatory approval to be used for that purpose, it will require extensive supervised training by subject experts, have guardrails to prevent "hallucinations" and maintain confidentiality, and prove that it can perform at a level comparable to (if not better than) humans. (JVS-Vascular Insights 2023;1:100019.).

An Alternate Explanation

A 48-year-old man with long-standing type 2 diabetes mellitus (recent glycated hemoglobin level, 6.5%) and chronic kidney disease (baseline creatinine level, 3.3 mg per deciliter [292 μ mol per liter]; glomerular filtration rate, 24 ml per minute per 1.73 m2 of body-surface area) presented to his primary care physician with a 3-month history of numbness, tingling, and faint violaceous discoloration of the tips of multiple fingers and toes. His physical examination showed reduced light-touch sensation in a glove-and-stocking distribution; the radial and pedal pulses were palpable. The vitamin B12 level was 260 pg per milliliter (192 pmol per liter; normal range, 190 to 950 pg per milliliter [140 to 701 pmol per liter]). He did not smoke tobacco, drink alcohol, or use illicit drugs. One month later, a nontraumatic wound developed on the left foot. The ankle–brachial index (ABI) was 1.2 on both sides (normal range, 0.91 to 1.3). Wound care was initiated for a presumed neuropathic ulcer.

Characteristics of venous leg ulcer patients at a tertiary wound care center

OBJECTIVE

The objective of this study was to assess patient, wound, care, and reflux characteristics of venous leg ulcers (VLUs) to update and improve knowledge of disease etiology, identify barriers to healing, and improve treatment.

METHODS

Patients diagnosed with VLUs treated at the Stanford Advanced Wound Care Center between 2018 and 2019 were identified from the Healogics iHeal database. We identified 327 VLU entries, of which 133 were patients who had multiple or recurring wounds. An additional 27 patients were labeled as misdiagnosis, resulting in a final patient sample of 167. Patient demographics, wound, care, and ultrasound data for these patients were extracted from the Stanford electronic medical records regarding characteristics. The initial data analysis suggested possible differences in VLU characteristics depending on patient age and body mass index (BMI), which was then further analyzed.

RESULTS

Of the 167 VLU patients assessed, 53.9% were male and 46.1% were female. The mean age was 74.7 years, and the average BMI was 30.2 kg/m2, including 41.1% of patients with a BMI over 30 kg/m2. Approximately 50% of wounds were presented in multiples, had cellulitis, or were recurring, and 39.5% were caused by trauma. Most common venous reflux patterns on duplex ultrasound examination were below-knee great saphenous vein reflux and calf perforator reflux, which was identified in 37.7% and 29.3% of the patients, respectively. Axial great saphenous vein reflux was detected in 14.4% of patients. When looking at the patient sample under 60 years of age, 67.7% were male, 61.3% presented with venous skin changes, and 51.6% had diabetes. In the patients older than 60, only 51.9% were male, 37.6% presented with venous skin changes, and 31.6% had diabetes. BMI was greater in the patients under age 60, with an average of 39.2 kg/m2, compared with 28.2 kg/m2 in those above 60. Of the patients with a BMI ≥30 kg/m2, 64.3% had multiple wounds, 61.4% had recurring wounds, and 56.5% had venous skin changes. In contrast, in patients with BMI <30 kg/m2, 47.4% had multiple wounds, 39.2% had recurring wounds, and 32.0% had venous skin changes.

CONCLUSIONS

VLU pathology appears to differ depending on patient demographics and characteristics. Different drivers may influence disease cause, progression, and prognosis, making a standard approach to VLUs difficult. Our findings suggest that identifying different subtypes of VLUs and adapting an algorithm of care with a personalized treatment may help optimize management of these patients.

The 2022 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 I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology

The Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society collaborated to update the 2011 Society for Vascular Surgery/American Venous Forum clinical practice guidelines and provide new evidence-based recommendations on critical issues affecting the care of patients with varicose veins. Each recommendation is based on a recent, independent systematic review and meta-analysis of the diagnostic tests and treatments options for patients with lower extremity varicose veins. Part I of the guidelines includes evidence-based recommendations for the evaluation of patients with CEAP (Clinical Class, Etiology, Anatomy, Pathology) class 2 varicose vein using duplex ultrasound scanning and other diagnostic tests, open surgical treatment (ligation and stripping) vs endovenous ablation techniques, thermal vs nonthermal ablation of the superficial truncal veins, and management of incompetent perforating veins in CEAP class 2 disease. We have also made recommendations on the concomitant vs staged treatment of varicose tributaries using phlebectomy or liquid or foam sclerotherapy (with physician-compounded foam or commercially prepared polidocanol endovenous microfoam) for patients undergoing ablation of incompetent superficial truncal veins.

Varicose Veins and Chronic Venous Disease

Chronic venous disease is a worldwide problem associated with significant morbidity and is expected to increase in prevalence as the current population ages. This is a comprehensive review of the anatomy, pathophysiology, genomics, clinical classification, and treatment modalities of chronic venous disease.

Epidemiology and Genetics of Venous Thromboembolism and Chronic Venous Disease

Venous disease is a term that broadly covers both venous thromboembolic disease and chronic venous disease. The basic pathophysiology of venous thromboembolism and chronic venous disease differ as venous thromboembolism results from an imbalance of hemostasis and thrombosis while chronic venous disease occurs in the setting of tissue damage because of prolonged venous hypertension. Both diseases are common and account for significant mortality and morbidity, respectively, and collectively make up a large health care burden. Despite both diseases having well-characterized environmental components, it has been known for decades that family history is an important risk factor, implicating a genetic element to a patient's risk. Our understanding of the pathogenesis of these diseases has greatly benefited from an expansion of population genetic studies from pioneering familial studies to large genome-wide association studies; we now have multiple risk loci for each venous disease. In this review, we will highlight the current state of knowledge on the epidemiology and genetics of venous thromboembolism and chronic venous disease and directions for future research.

Incentivizing physical activity through activity monitoring interventions in PAD - a pilot study

Background: There is ample evidence to show that supervised exercise is efficacious and cost effective for improving claudication symptoms in patients with peripheral artery disease (PAD). Home based exercise therapy can be an effective alternative to supervised exercise however, the results of this is variable depending on the level of motivation and engagement of the patient. Patients and methods: We performed a pilot study in 41 patients to determine whether a home based exercise program with the use of an activity tracking device with personalized feedback and financial incentives can increase daily activity, improve walking and sustain engagement in the exercise regimen in patients with PAD. In this randomized pilot study, the patients in the study group were fitted with an activity monitoring device and given behavioral monitoring, motivational updates and feedback regarding their exercise program. This study group was further divided in to two groups. One half of these patients in the study group were also given financial incentives if they reached their set targets. The control group wore the device with no feedback or ability to see their number of steps walked. Results: Results showed that at the end of the 12 week period, patients in the study groups walked more compared to the controls and the financial incentive structure resulted in an additional 38-63% increase in average daily steps. Conclusions: This pilot study revealed that a home-based exercise program with activity monitoring, feedback and financial incentives resulted increased daily steps, 6-minute walking distance and overall compliance with the program in PAD patients with claudication.

Clinical and Genetic Determinants of Varicose Veins

BACKGROUND

Varicose veins are a common problem with no approved medical therapies. Although it is believed that varicose vein pathogenesis is multifactorial, there is limited understanding of the genetic and environmental factors that contribute to their formation. Large-scale studies of risk factors for varicose veins may highlight important aspects of pathophysiology and identify groups at increased risk for disease.

METHODS

We applied machine learning to agnostically search for risk factors of varicose veins in 493 519 individuals in the UK Biobank. Predictors were further studied with univariable and multivariable Cox regression analyses (2441 incident events). A genome-wide association study of varicose veins was also performed among 337 536 unrelated individuals (9577 cases) of white British descent, followed by expression quantitative loci and pathway analyses. Because height emerged as a new candidate risk factor, we performed mendelian randomization analyses to assess a potential causal role for height in varicose vein development.

RESULTS

Machine learning confirmed several known (age, sex, obesity, pregnancy, history of deep vein thrombosis) and identified several new risk factors for varicose vein disease, including height. After adjustment for traditional risk factors in Cox regression, greater height remained independently associated with varicose veins (hazard ratio for upper versus lower quartile, 1.74; 95% CI, 1.51-2.01; P<0.0001). A genome-wide association study identified 30 new genome-wide significant loci, identifying pathways involved in vascular development and skeletal/limb biology. Mendelian randomization analysis provided evidence that increased height is causally related to varicose veins (inverse-variance weighted: odds ratio, 1.26; P=2.07×10^-16).

CONCLUSIONS

Using data from nearly a half-million individuals, we present a comprehensive genetic and epidemiological study of varicose veins. We identified novel clinical and genetic risk factors that provide pathophysiological insights and could help future improvements of treatment of varicose vein disease.

Bioimpedance and New-Onset Heart Failure: A Longitudinal Study of >500 000 Individuals From the General Population

Background

Heart failure constitutes a high burden on patients and society, but although lifetime risk is high, it is difficult to predict without costly or invasive testing. We aimed to establish new risk factors of heart failure, which potentially could enable early diagnosis and preemptive treatment.

Methods and Results

We applied machine learning in the UK Biobank in an agnostic search of risk factors for heart failure in 500 451 individuals, excluding individuals with prior heart failure. Novel factors were then subjected to several in‐depth analyses, including multivariable Cox models of incident heart failure, and assessment of discrimination and calibration. Machine learning confirmed many known and putative risk factors for heart failure and identified several novel candidates. Mean reticulocyte volume appeared as one novel factor and leg bioimpedance another, the latter appearing as the most important new marker. Leg bioimpedance was lower in those who developed heart failure during an up to 9.8‐year follow‐up. When adjusting for known heart failure risk factors, leg bioimpedance was inversely related to heart failure (hazard ratio [95% confidence interval], 0.60 [0.48–0.73] and 0.75 [0.59–0.94], in age‐ and sex‐adjusted and fully adjusted models, respectively, comparing the upper versus lower quartile). A model including leg bioimpedance, age, sex, and self‐reported history of myocardial infarction showed good discrimination for future heart failure hospitalization (Concordance index [C‐index]=0.82) and good calibration.

Conclusions

Leg bioimpedance is inversely associated with heart failure incidence in the general population. A simple model of exclusively noninvasive measures, combining leg bioimpedance with history of myocardial infarction, age, and sex provides accurate predictive capacity.

Abstract 052: Clinical and Genetic Determinants of Varicose Veins: a Prospective, Community-Based Study of ~500,000 Individuals

Background: Varicose veins are a common problem with no approved medical therapies. While it is believed that varicose vein pathogenesis is multifactorial, there is a limited understanding of the genetic and environmental factors that contribute to their formation. Large-scale studies of risk factors for varicose veins may highlight important aspects of pathophysiology and identify groups at increased risk for disease.

Methods: We applied machine learning to agnostically search for risk factors of varicose veins in 493,519 individuals in the UK Biobank. Predictors were further studied using univariable and multivariable Cox regression analysis. A genome-wide association study (GWAS) of varicose veins was also performed among 337,536 individuals (9,577 cases) of white British descent, followed by eQTL and pathway analyses. Because height emerged as a new candidate predictor, we used LD score regression to estimate the genetic correlation between height and varicose veins. Finally, we performed Mendelian randomization analyses to assess for a causal role for height in varicose vein disease.

Results: Machine learning confirmed several known (age, gender, obesity, pregnancy, history of deep vein thrombosis) and identified several new risk factors for varicose vein disease. The most important novel predictors were leg bioimpedance (HR: 0.44, 95% CI: 0.39-0.50, P < 0.0001) and height (HR: 1.74; 95% CI: 1.51-2.01, P < 0.0001), which both remained independently associated with varicose veins after adjusting for traditional risk factors in Cox regression. A GWAS identified 30 new genome-wide significant loci, identifying pathways involved in vascular development and skeletal/limb biology. Mendelian randomization analysis provided evidence that increased height is causally related to varicose veins (IVW: beta = 0.266, P = 1.28 x 10 -16 ).

Conclusions: Using data from nearly half a million individuals, we identified novel clinical and genetic risk factors which provide pathophysiological insights and could help future improvements of treatment of varicose vein disease.

Impact of pocket ultrasound use by internal medicine housestaff in the diagnosis of dyspnea

BACKGROUND

Recent reports demonstrate high diagnostic accuracy of lung ultrasound for evaluation of dyspnea. We assessed the feasibility of training internal medicine residents in lung ultrasound with a pocket ultrasound device.

METHODS

We performed a prospective, observational trial of residents performing lung ultrasound with a pocket ultrasound. Training consisted of two 90-minute sessions of didactics and supervised bedside performance. Two residents received an additional 2 weeks of training. Residents recorded a clinical diagnosis based on admission data. Following lung ultrasound performance, an ultrasound diagnosis was recorded integrating clinical and sonographic findings. Using receiver operating curve analysis, the area under the curve was calculated for both clinical diagnosis and ultrasound diagnosis using attending physician's final discharge diagnosis as the gold standard.

RESULTS

Five residents performed 69 exams. The AUC for ultrasound diagnosis was significantly higher than that for clinical diagnosis (0.87 vs 0.81, P < 0.01). AUCs increased using lung ultrasound for diagnoses as follows: chronic obstructive pulmonary disease (0.73-0.85, P = 0.06), acute pulmonary edema (0.85-0.89, P = 0.49), pneumonia (0.77-0.88, P = 0.01), and pleural effusions (0.76-0.96, P < 0.002).

CONCLUSIONS

Lung ultrasound performed by residents with a pocket ultrasound improved the diagnostic accuracy of dyspnea. Two residents undergoing extended training showed a total increase in diagnostic accuracy.

Peripheral arterial disease, prevalence and cumulative risk factor profile analysis

BACKGROUND

The primary aim of the present study was to determine the cumulative effect of a set of peripheral artery disease (PAD) risk factors among age, gender and race/ethnicity groups in the United States.

METHODS

We examined data from a nationally representative sample of the US population (National Health and Nutrition Examination Survey [NHANES], 1999-2004). A total of 7058 subjects 40 years or older that completed the interview, medical examination and had ankle-brachial index (ABI) measurements were included in this study.

RESULTS

The age- and sex-standardized prevalence of PAD was 4.6 % (standard error [SE] 0.3%).The highest prevalence of PAD was observed among elderly, non-Hispanic Blacks and women. In a multivariable age-, gender- and race/ethnicity-adjusted model hypertension, diabetes, chronic kidney disease, and smoking were retained as PAD risk factors (p ≤ 0.05 for each). The odds of PAD increased with each additional risk factor present from a non-significant 1.5-fold increase (O.R 1.5, 95% confidence interval [CI] 0.9-2.6) in the presence of one risk factor, to more than ten-fold (OR 10.2, 95% CI 6.4-16.3) in the presence of three or more risk factors. In stratified analysis, non-Hispanic Blacks (OR 14.7, 95% CI 2.1-104.1) and women (OR 18.6, 95% CI 7.1-48.7) were particularly sensitive to this cumulative effect.

CONCLUSION

In a large nationally representative sample, an aggregate set of risk factors that included diabetes mellitus, chronic kidney disease, hypertension and smoking significantly increase the likelihood of prevalent PAD. A cumulative risk factor analysis highlights important susceptibility differences among different population groups and provides additional evidence to redefine screening strategies in PAD.

Granular cell tumor of the suprasternal space

A case of granular cell tumor (GCT) was reported. We encountered a 33-year-old woman with a painless, elastic, hard mass in the soft tissue of the suprasternal space. The tumor was excised with several millimeters margin of normal tissue above the deep cervical fascia and the wound was closed primarily. Histological examination on hematoxylin-eosin stain showed a tumor growth in the mid- to deep dermis and eosinophilic small granules that were consistent with granular cell tumors. Immunohistochemical studies showed positive staining for S-100 protein. We experienced a case of a granular cell tumor occurring in the suprasternal space and report the importance of including it in the differential diagnosis of subcutaneous soft tissue tumors.

Magnetic resonance angiography to evaluate septocutaneous perforators in free fibula flap transfer

BACKGROUND

In harvesting free fibula composite flaps, preoperative knowledge of the lower limb vascular anatomy is essential to prevent ischaemic complications or flap failure. Magnetic resonance angiography (MRA) allows imaging of the septocutaneous perforators (< or = 1-2mm diameter) of the peroneal artery used in the free fibula flap.

METHODS

We investigated seven patients undergoing the free fibula flap preoperatively with high-resolution MRA images to study the following: 1) tibio-peroneal anatomy, 2) peripheral artery disease, 3) the positions of the perforator vessels on the peroneal artery and their course in the posterolateral intermuscular septum and 4) the cutaneous distribution of the perforators, and to compare them to surgical findings.

RESULTS

MRA demonstrated tibio-peroneal anatomy in sufficient detail to exclude anatomic variants and significant peripheral vascular disease, detected septocutaneous perforators arising from the peroneal artery coursing in the posterolateral intermuscular septum and determined the skin terminus of the septocutaneous perforators. All septocutaneous perforators found during surgery were detected prospectively on high-resolution MRA.

CONCLUSION

Lower leg vascular anatomy assessment with high-resolution MRA determined the location of the septocutaneous perforators of the peroneal artery preoperatively with accuracy and precision. This anatomical knowledge provides for a safer procedure and the opportunity to plan surgical details preoperatively.

HBO and gas embolism

Gas embolism, which occurs with the entry of gas into the circulatory system from the vein, artery or both, is a potentially serious even fatal condition. The two main causes of gas embolism are iatrogenic and diving. The site of entry and the signs and symptoms distinguish between arterial and venous embolism. The entering gas may be air, but may also be CO(2) or other gases, especially in iatrogenic embolism. Supportive care is the primary therapy for venous gas embolism, while hyperbaric oxygen therapy in addition to supportive care is the first line of treatment for arterial gas embolism. In this article, we will review the pathophysiology, etiology, diagnosis and treatment of gas embolism.

Monitoring the Changes in Intraparenchymatous Venous Pressure to Ascertain Flap Viability

BACKGROUND

Disruption of venous outflow can lead to tissue necrosis. Thrombosis of a venous channel at the coaptation site in instances of free tissue transfer could cause death of the transplanted tissues. Although various techniques have been used to monitor the viability of transferred tissues, there has been no technique designed specifically to check the flow within and the patency of the venous channel. The authors have devised an approach with which to monitor the changes in venous pressure in a composite tissue transferred by means of microsurgical technique for bodily reconstruction.

METHODS

The status of the venous system in various composite tissue grafts was monitored at the time of surgery or for 3 days after the completion of surgery by placing a small-caliber catheter in the vein within the transferred tissue. A total of 52 patients participated in the study.

RESULTS

The venous pressure noted in grafts with a patent venous channel remained constant within a range between 0 and 35 mmHg. Venous insufficiency was detected in three of the 52 cases, with unmistakable findings of an elevated venous pressure of over 50 mmHg.

CONCLUSIONS

The technique of measuring the venous pressure by means of an indwelling venous catheter to monitor changes was found to accurately assess the patency of the venous channel and, by inference, the viability of the transferred tissue. No morbidity was associated with the technique.

Magnetic Resonance Angiography for Free Fibula Flap Transfer

Recent refinements of magnetic resonance angiography (MRA) allow imaging vessels as small as the septocutaneous perforators (< or = 1 to 2 mm diameter), but a Medline review reveals no report of septocutaneous vessel imaging for free flap surgery. Challenges in fibula free flap preparation include knowledge of: (1) tibioperoneal anatomy, (2) the positions of the perforator vessels on the peroneal artery and their course in the posterolateral intermuscular septum, and (3) the cutaneous distribution of the perforators. Questioning whether high-resolution MRA could image these, we studied the lower extremities of nine healthy volunteers. MRA demonstrated tibioperoneal anatomy in sufficient detail to exclude anatomic variants and significant peripheral vascular disease and showed septocutaneous perforators arising from the peroneal artery and coursing in the posterolateral intermuscular septum to the skin. High-resolution MRA provided anatomic and clinical information that conventionally has been impossible to obtain preoperatively or has required multiple tests, often of an invasive nature.

Takayasu's arteritis in a 69 year-old woman

Takayasu's arteritis and temporal arteritis share many clinical and pathological features. The most discriminatory feature between the two diseases is the age at onset; the mean age at onset of the disease was reported as being 26 years for Takayasu's arteritis and 69 years for temporal arteritis. Here we report a 69-year-old woman who presented with a weak right radial artery pulse. The ethnic background and the presence of vascular insufficiency of the right upper extremity and the absence of clinical signs such as shoulder stiffness and tender scalp indicate that her diagnosis is Takayasu's arteritis. It must be emphasized that the two conditions could be differentiated based on the clinical findings even in a patient as old as 69 years old.

Two patients with polymyositis or dermatomyositis complicated with massive pleural effusion

Two patients with polymyositis (PM) or dermatomyositis (DM) complicated with massive pleural effusion are reported here. Both patients presented a high-grade fever, pleural effusion prominent on the right, and good response to steroid therapy. In a 50-year-old woman with PM, combined process of pleural inflammation, cardiomyopathy and coexisting hypothyroidism were considered to be responsible for the accumulation of the massive pleural effusion. However, in a 34-year-old man with DM, pleural inflammation associated with interstitial pneumonia or pleural microvasculopathy in DM was considered to be responsible for the accumulation of the massive pleural effusion.