[Comparative efficacy of various methods of treatment of chronic venous oedema in real clinical practice]

AIM

The study was aimed at assessing efficacy and safety of micronized purified flavonoid fraction (MPFF, Detralex) in comprehensive treatment of chronic venous oedema induced by lower limb varicose veins.

PATIENTS AND METHODS

We performed a post hoc analysis of the results of treatment of 708 patients included into the observational programme VAP-PRO-C3 (ClinicalTrials.gov. NCT03722836). These patients, depending on the type of treatment, were divided into 8 subgroups: MPFF (n=32); MPFF + compression (n=145); MPFF + compression + topical treatment (n=158); MPFF + compression + topical treatment + endovasal laser coagulation (n=197); MPFF + endovasal laser coagulation (n=3); MPFF + compression + endovasal laser coagulation (n=152), patients not receiving MPFF (n=16); MPFF + topical treatment (n=2). Due to paucity of the participants, from the subsequent analysis we excluded the groups MPFF + endovasal laser coagulation, patients not receiving MPFF (n=16) and MPFF + topical treatment. All further statistical data are shown for the remaining 687 patients.

RESULTS

Comparing the groups of patients undergoing conservative treatment alone and those subjected to surgical intervention demonstrated no statistically significant differences in dynamics of crural oedema. In both groups at every subsequent visit there was a statistically significant decrease in the ankle volume (p<0.001). During the whole period of follow up the crural volume in patients from the group of conservative treatment totally decreased by 0.201±0.158 L and in the operated patients by 0.236±0.189 L (p=0.021). The QOL assessed by the CIVIQ-14 global index score statistically significantly improved in the unoperated patients from 31.5±19.2 to 12.0±10.1 (p<0.001). In the operated patients, the baseline and final values of the QOL of the global index score amounted to 33.4±17.8 and 7.7±9.2, respectively (p<0.001). In the groups with and without topical treatment, the baseline values of the QOL assessed by CIVIQ-14 global index score amounted to 28.5±17.4 and 36.2±18.6, respectively. During the follow-up period, we observed statistically significant positive dynamics of all parameters of quality of life. The final visit demonstrated improvement of the CIVIQ-14 global index score to 9.4±9.2 in patients without topical treatment and 10.1±10.4 in those receiving topical treatment (p=0.367), with the mean value of this parameter during treatment in both groups decreased significantly (p<0.001). A statistically significant decrease in the ankle volume in both groups was registered at every visit, finally amounting to 0.223±0.166 L and 0.248±0.174 L (p=0.118) for patients not receiving and receiving topical treatment, respectively. In groups of patients not receiving and those receiving compression therapy, the baseline values of the QOL assessed by CIVIQ-14 global index score amounted to 21.4±14.2 and 33.1±18.5 (p<0.001), respectively. At the final visit, these indices statistically significantly (p<0.001) decreased to 7.3±9.1 and 9.9±9.9 (p=0.106). Compared with the baseline values, the ankle volume at the final visit in groups of patients with and without compression therapy statistically significantly decreased by 0.187±0.14 L and 0.238±0.17 L respectively (p=0.204). During the study, there were no adverse events related to the administration of MPFF and use of Detragel.

CONCLUSION

MPFF and Detragel appear to be effective and safe components of comprehensive conservative therapy of chronic oedema induced by primary varicose veins of lower extremities.

[Additional possibilities in conservative treatment of patients with post-thrombotic disease of lower limbs]

AIM

This study was undertaken to evaluate efficacy of Actovegin in the composition of comprehensive therapy in patients presenting with post-thrombotic disease of lower extremities free from trophic disorders.

PATIENTS AND METHODS

The study included a total of 60 patients (28 men and 32 women) diagnosed as having post-thrombotic disease of lower limbs without trophic disorders (C1-C3 according to the CEAP classification), induced by previously endured iliofemoral phlebothrombosis. The duration of the disease varied from 1 year to 10 years. All patients for 10 days received Actovegin intravenously in drips at a dose of 1200 mg (30 ml of the drug reconstituted in 400 ml of normal saline) followed by continuing taking the drug orally in a daily dose of 1200 mg for 30 days. During the whole follow up period the patients wore class 2 compression stockings (RAL standard). The results of the carried out treatment in relation to the subjective complaints (pain, feeling of heaviness, convulsions, pruritus and paresthesias) were assessed by the visual analogue scale and based on the CIVIQ-20 questionnaire, with additionally measuring the malleolar circumference.

RESULTS

On the background of the carried out therapy the patients demonstrated a significant decrease in the oedematous syndrome in the area of the ankles. This parameter decreased form 26.88±0.39 cm to 25.02±0.35 cm (p<0.05). The patients' complaints of tingling decreased form 5.73±0.79 to 2.32±0.68 points (p<0.05), the incidence and intensity of convulsions fell from 6.51±1.39 to 3.2±0.98 points (p<0.05). The intensity of the oedematous syndrome (swelling) decreased significantly from 8.11±1.75 to 4.33±1.20 points (p<0.05), the pain syndrome fell from 7.92±1.88 to 3.12±1.45 points (p<0.05), the feeling of heaviness in the lower limbs decreased from 8.52±1.73 to 3.91±1.48 points (p<0.05). Also, improvement of the general quality of life of patients was observed (the integral parameter decreased from 63.27±1.8 to 44.33±1.19 points, p<0.05).

[Efficacy of micronized purified flavonoid fraction in treatment of chronic venous oedema]

AIM

The purpose of the study was to assess efficacy and safety of using in real clinical practice micronized purified flavonoid fraction (Detralex) in patients with chronic venous oedema.

PATIENTS AND METHODS

The study enrolled a total of 708 patients presenting with chronic venous disease, belonging to C3EpAsPr according to the CEAP classification (chronic venous oedema), who. depending on the accepted clinical practice by expert physicians were prescribed compression and phlebotropic therapy, as well as undergoing surgical interventions. The main criteria for efficacy of the micronized purified flavonoid fraction included the dynamics of chronic venous oedema, vein-specific symptoms, as well as the main parameters of quality of life. Assessment was made using visual analogue scales, the vein-specific questionnaire CIVIQ-14, and the method of discs for measuring the volume of the crus.

RESULTS

The obtained findings demonstrated significant positive dynamics of the main vein-specific symptoms assessed by a visual analogue scale. When comparing between the visits of recruitment into the study and its termination the feeling of heaviness in calves decreased form 5.38±2.19 cm to 1.56±1.56 cm (p<0.001), pain in the calf diminished from 4.24±3.39 cm to 1.12±1.37 cm (p<0.001), feeling of oedema dropped from 5.68±2.44 cm to 1.38±1.59 cm (p<0.001), severity of nocturnal cramps fell from 2.46±2.30 cm to 0.43±1.01 cm (p<0.001), and intensity of skin inching from 1.46±2.06 cm to 0.43±1.01 cm (p<0.001). Positive dynamics of venous-specific symptoms appeared to be accompanied by significant improvement of all dimensions of quality of life according to the CIVIQ-14 scale: by the pain scale from 41.0±19.1% to 12.8±11.6% (p<0.001), by the physical condition scale - from 31.6±23.8% to 11.1±15.4% (p<0.001), by the psychological state scale - from 24.5±21.1% to 5.7±9.0% (p<0.001). The global index of quality of life also improved significantly from 32.4±18.5% to 9.9±9.9% (p<0.001). The results of the intervention along all the examined parameters (external appearance, possibility of wearing various clothes and increasing the quality of the self-performed work, to improve both interactions with surrounding people and the social activity and rest) turned out better than expectations form an intervention. The volume of the crus as the main criterion over the period of follow up averagely by the group decreased from 3.07±0.84 to 2.78±0.80 litres (p<0.001). A significant decrease in the calf volume from 3.03±0.87 to 2.77±0.85 litres was observed in 288 patients who during the follow up period were not subjected to surgical interventions, with no significant differences in the dynamics of chronic venous oedema revealed between the operated patients and those having received conservative treatment alone.

DISCUSSION

According to a meta-analysis, the micronized purified flavonoid fraction (Detralex) turned out to possess better parameters in relation to therapy of chronic venous oedema as compared with other phlebotropic agents. Therefore, it appears absolutely logical to predominantly use the micronized purified flavonoid fraction in real clinical practice in patients with the CEAP C3 clinical class, which was registered in our study. An important result was also the fact that within the specified terms of follow up surgical intervention demonstrated no significant advantage over conservative therapy alone in treatment of chronic venous oedema. Moreover, conservative treatment in the form of a combination of compression and phlebotropic therapy demonstrated a dynamic decrease in the volume of the affected extremity with a probable transition of the CEAP C3 clinical class to C2.

CONCLUSION

The micronized purified flavonoid fraction (Detralex) at a standard daily dose of 1000 mg in a combination with compression therapy irrespective of the surgical intervention performed resulted in a significant dynamic decrease in the volume of the calf in patients with chronic diseases of lower limb veins (C3EpAsPr according to the CEAP classification). An anti-oedematous effect of the micronized purified flavonoid fraction (Detralex) in a combination with compression manifests itself during the entire period of treatment.

[Local drugs in treating and decreasing the incidence of adverse reactions after sclerotherapy of telangiectasia]

AIM

The purpose of the study was to assess efficacy and safety of heparin sodium gel 1000 IU/g and Detragel® in decreasing the incidence and treatment of the most common local adverse reactions in patients after endured sclerotherapy of reticular veins and telangiectasias.

PATIENTS AND METHODS

Our open prospective observational study included a total of sixty 18-to-35-year-old female patients who after undergoing standardized sclerotherapy of reticular veins and telangiectasias on symmetrical portions of lower limbs were given a tube of heparin sodium gel 1000 IU/g or Detragel® to be applied onto the skin of one (left) lower limb in the projection of the sclerotherapy-exposed vessels 2-3 times daily for 10 days followed by putting on a compression class 2 (RAL standard) stocking. The women were allowed to use only the paired stocking on the contralateral extremity. Efficacy and safety of heparin sodium gel 1000 IU/g and Detragel® were evaluated based on the incidence of typical adverse reactions (ecchymoses, phlebitides, hyperpigmentation and neovasculogenesis), as well as on the patient's subjective perceptions.

RESULTS

The use of heparin sodium gel 1000 IU/g and Detragel® in addition to compression after sclerotherapy of reticular veins and telangiectasias significantly and comparably decreased the incidence and accelerated the resolution of ecchymoses and phlebitides associated with phlebosclerosing treatment. The Detragel® group patients were found to develop hyperpigmentation or neovasculogenesis significantly less often as compared with the heparin sodium gel 1000 IU/g group women. What is more, using Detragel® was not accompanied by hyperkeratosis, pruritus or formation of a sticky film, the events, however, observed while applying heparin sodium gel 1000 IU/g.

CONCLUSION

The use of Detragel® or heparin sodium gel 1000 IU/g for 10 days additionally to compression significantly decreased the incidence of typical undesirable reactions associated with sclerotherapy of reticular veins and telangiectasias. The Detragel® group women turned out to have lower incidence of hyperpigmentation and neovasculogenesis. Besides, Detragel® demonstrated better organoleptic properties.

[Perioperative administration of micronized purified flavonoid fraction in endovascular treatment of varicose disease]

AIM

The study was aimed at assessing efficacy and safety of using a micronized purified flavonoid fraction in the perioperative period in patients scheduled for endovascular surgical intervention for CEAP clinical class C2 lower limb varicose veins.

PATIENTS AND METHODS

This study enrolled a total of 1519 patients with CEAP C2a,sEpAs (primary varicose vein with valvular incompetence of the great and/or small saphenous vein) who were subdivided into two groups. Group One included 1039 patients who in the perioperative period were prescribed a micronized purified flavonoid fraction at a daily dose of 1000 mg and who continued therapy, including visit 4. Group Two was composed of 480 patients taking no venoactive agents. The main criterion for assessing efficacy of the micronized purified flavonoid fraction was the incidence rate of typical adverse events in the compared groups of patients after surgical intervention.

RESULTS

The patients receiving the micronized purified flavonoid fraction were found to have adverse events significantly less often as compared with those in the control group: ecchymosis 7.1 versus 11.0% (p=0.01), haematoma 0.5 vs 1.3% (p=0.1), paresthesia 0.5 vs 1.7% (p=0.02), thrombophlebitis 0.2 vs 0.6% (p=0.2), pigmentation 0.6 vs 3.3% (p=0.001), heat-induced thrombosis 0.3 vs 1.3% (p=0.02). The total incidence rate of adverse events in patients receiving and those not receiving the micronized purified flavonoid fraction amounted to 7.6 vs 15.0%, respectively (<0.001).

DISCUSSION

The micronized purified flavonoid fraction prescribed in the perioperative period, owing to a pluripotent mechanism, adapts the venous system and microcirculatory bed of the lower extremities to operative stress, decreasing the anti-inflammatory response to endovascular intervention, lowering thereby the incidence of undesirable events.

CONCLUSION

Prescription of the micronized purified flavonoid fraction in the perioperative period ensures a significant decrease in the incidence of typical adverse events developing after endovascular surgical treatment for CEAP clinical class C2 varicose veins and may be recommended for real clinical practice.

[Detralex-phlebosclerosing treatment. Results of the national multicenter follow up programme VEIN ACT PROLONGED-C1]

Presented herein are the results of the observational follow up study programme dedicated to the assessment of appropriate use of adjuvant therapy with Detralex while carrying out phlebosclerosing treatment in patients suffering from dilated intradermal veins (clinical class C1 according to the CEAP classification). A conclusion was drawn that administration of Detralex for 60 days decreased the incidence rate of typical undesirable side events after phlebosclerosing therapy, thus making the use of this drug appropriate in routine clinical practice.

[Cryocompression sclerotherapy of reticular veins and teleangiectasias]

Compression serves as an important component for carrying out successful and safe phlebosclerosing treatment. At the same time, the necessity of wearing compression hosiery or bandages is associated with known limitations and objections of patients, especially in a hot season. We comparatively assessed efficacy of usual compression stockings and a short-term pneumatic bandage with cryoelements while carrying out sclerosing treatment of dilated intradermal veins. Our open prospective observational study included a total of fifty 18-to-35-year-old women. After performing standardized sclerotherapy of reticular veins and telangiectasias on the symmetrical portions of the lower limbs, a pneumatic cryocompression bandage with a pressure of 50 mmHg was applied onto one of the limbs for 15 minutes, with a class 2 compression (RAL standard) medical stocking put on the other limb to be worn by the patients at daytime for 10 days. We assessed completeness of obliteration of the target veins, frequency of the development of typical undesirable events (ecchymoses, phlebitides, hyperpigmentation and neovasculogenesis), as well as the composite discomfort score according to an 11-point visual analogue scale. It was determined that using the pneumatic bandage with cryoelements as compared with the traditional compression stockings significantly decreased the frequency of the development of typical undesirable events after phlebosclerosing treatment, such as formation of ecchymoses, phlebitides, hyperpigmentation and neovasculogenesis. Significance of differences was revealed as early as 7 days after sclerotherapy, to be increasing during further dynamic follow up. By convenience for the patients, the use of the short-term pneumatic cryobandage was four times better than wearing the compression stockings. A conclusion was drawn that while carrying out sclerotherapy of reticular veins and telangiectasias short-term pneumatic cryocompression by efficacy and safety was not inferior to the traditional medical stockings (RAL standard) and made it possible to significantly decrease the incidence of the known undesirable events after phlebosclerosing treatment.

[Efficacy of sulodexide in treatment of chronic venous insufficiency. Results of the ACCORD trial]

OBJECTIVE

The purpose of our study was to evaluate both clinical and laboratory efficacy of sulodexide given at a daily dose of 500 lipasemic units (LSU) in patients presenting with class C3-C4 chronic venous insufficiency (CVI) according to the CEAP classification.

PATIENTS AND METHODS

The study included a total of 25 patients diagnosed with C3-C4 CVI and prescribed to receive sulodexide at a daily dose of 500 LSU for 90 days. Efficacy was comprehensively controlled by the following tools: the disease-specific Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ), visual-analogue methods of assessment separate symptoms; the Venous Clinical Severity Score (VCSS), as well as ultrasonographic determination of the thickness of subcutaneous fat and crural fascia. Amongst the key laboratory indices determined by means of the ELISA test were the levels of interleukin-1 alpha (IL-1α), interleukin-1 beta (IL-1β), matrix metalloproteinases-2 and -9 (MMP-2, MMP-9), vascular endothelial growth factor A (VEGF-A), vasopressin and endothelin.

RESULTS AND DISCUSSION

Of the initially enrolled 25 subjects, twenty-two patients completed the study and were taken as 100%. The 90-day treatment yielded favourable results manifesting themselves in complete disappearance of convulsions in the calf muscles detected at the first visit in 22.7% of patients (p=0.0485), a significant reduction in the frequency of complaints of decreased tolerance to static loads from 27.3 to 9.1% (p=0.2404). The volume of the crus of the control lower extremity decreased from 134.18±14. 92 to 128.42±12.46 cm3 (p=0.0006), subcutaneous fat thickness at the fixed point decreased from 1.50±0.53 to 1.32±0.46 cm (p=0.0007), and fascial thickness decreased from 0.14±0.7 to 0.11±0.04 (p=0.0359). Pain syndrome according to the visual analogue scale (VAS) decreased from 36.45±25.60 to 17.50±19.27 mm (p=0.0002). The global index of quality of life (GIQoL) according to the CIVIQ-20 increased by 27.7% compared with the baseline level (p = 0.0001), the VCSS index decreased from 6.00±1.83 to 4.86±2.05 points (p=0.0002). as for the laboratory markers of endothelial dysfunction, there was a significant decrease in the levels of MMP-2 - from 178.53±36.30 to 176.35±36.67 ng/ml (p=0.0152), MMP-9 - from 90.84±20.41 to 89.78±20.32 ng/ml (p=0.0394), and that of endothelin - from 0.42±0.10 to 0.39±0.10 fmol/ml.

CONCLUSION

Sulodexide exerting a statistically significant clinical and endothelium-protecting effect turned out to be an effective drug for treatment of initial forms of chronic venous insufficiency of lower limbs.

[Bioflavonoids and their significance in angiology: focus on diosmin]

The article deals with historical information dedicated to the discovery of bioflavonoids and their effect on the human cardiovascular system, also considering the modern classification of phlebotrophic agents, followed by generalization and analysis of their mechanisms of action, as well as detailed discussion of different forms of diosmin. Summing up contains generalization of the Russian, European, and American guidelines on using phlebotrophic drugs for various forms and stages of chronic venous diseases.

[Efficacy of compression knee-high socks ULCER X in treatment of venous-genesis trophic ulcers]

The study was aimed at comparatively assessing the efficacy of treatment for venous trophic ulcers at stages II-III of the wound process using special compression knee-length socks of the ULCER X kit (Sigvaris AG, St. Gallen, Switzerland) and long-stretch bandages Lauma. Compression therapy was included into the programme of outpatient treatment of forty 31-to-74-year-old patients presenting with trophic ulcers (stage II-III of the wound process) with an average area of 5,36±1,1 cm2. The Study Group consisting of 20 patients used compression knitted fabrics in the form of knee-length socks ULCER X and the comparison group (n=20) used long-stretch bandages Lauma.

RESULTS

The obtained findings (6 months) demonstrated that using compression therapy exerted a positive effect on the process of healing of venous trophic ulcers, also proving advantages of compression therapy with the knee-length socks ULCER X that create an adequate level of pressure on the crus and maintain it in long-term daily use, reliably accelerating the healing of venous trophic ulcers as compared with elastic long-stretch bandages. The use of long-stretch elastic bandages in treatment of venous trophic ulcers turned out to be not only ineffective but fraught with a possibility of the development of various complications. During 6 months of follow up the patients using the special knee-length socks ULCER X were found to have 80 % of ulcers healed (16 patients), mainly within the first 2 months, whereas using elastic bandages resulted in only 30 % of healing (6 patients) by the end of the study. Along with it, we documented a considerable decrease in the malleolar circumference in the study group patients (from 30,05±0,78 to 28,35±0,86 cm) and in the control group from 31,2±30,35 to 30,25±0,75 cm), accompanied and followed by more than a two-fold increase in quality of life of the patients along all the parameters in the study group and a 1.4-fold increase in the control group patients.

[Cardiac pathology and autonomic dysfunction in patients with vertebral and spinal cord injury]

The disturbances of cardiovascular function were examined in 103 patients with vertebral and spinal cord injury. To evaluate myocardial conduction time and regulation of heart rate we used the method of spiroarteriocardiorythmography. Comparative power spectral and time domain analyses of heart rate variability were carried out in patient and healthy individuals. The autonomic nervous system dysfunction revealed in patients result in severe cardiovascular complications and is associated with high risk of heart diseases.

[On advisability of perioperative phleboprotection in endovascular treatment of lower in varicose disease: first initial results of the decision study]

Presented in the article are the results of the DECISION multicenter study dedicated io assessment of efficacy and feasibility of using the phlebotropbic drug detralex in the perioperative period in patients undergoing endovascular treatment of lower limb varicose discase. The study comprised a total of 230 patients presenting with chronic venous disease. (CVD) C2-4s according the CEAP classification, each of these had not less than three CVD- related symptoms. All patients were randomly assigned to the Study Group (126 people) and the Control Group (104 subjects). The Study Group patients 2 weeks prior to endovascular treatment and during 4 weeks thereafter took the phlebotrophic drug detralex at a standard daily dose of 1,000 mg. The Control Group patients received conventional compression thernpy using compression bandages or medicinal knitted fabric. The findings of the statistically processed results in the both groups demonstrated a significant decrease in the CVD severity score according to the VCSS scale and an increase in the quality of life parameters according to the disease-specilic questionnaire CIVIQ-14. While so doing, more pronounced dynamics was observed in patients taking detralex during the perioperative period. Besides, there was synergism between the results of the endovascular intervention and therapeutic effects from detralex. Based on the findings obtained in the present study, the authors made a conclusion on feasibility of using the drug detralex as an agent for nonspecific pharmacological protection in endovascular treatment of varicose disease.

[Participation of leucocytes in pathogenesis of primary forms of lower limb chronic venous disease]

AIM

The purpose of the study was to test the hypothesis on participation of WBCs in damaging the venous wall in patients presenting with primary forms of lower limb chronic venous diseases LLCVD .

MATERIAL AND METHODS

The study included a total of fifteen consecutively selected patients (13 women and 2 men) diagnosed as having grade C2-C-4 LLCVD according to the CEAP classification. Static loading (30 minutes in the sitting position) was followed by simultaneous sampling of blood from the varicose vein of the cms and ulnar vein. The total blood count including determination of both the absolute values and percentage of blood formed elements was performed using the automated haematological counter «Advia 7» («Bayer», USA). The obtained findings were statistically processed using the Microsoft Office Excel software by means of the pared two-sample τ-test for the average values.

RESULTS

The number of leukocytes and their subpopulations in blood samples obtained from the crural varicose veins turned out to be significantly less as compared with that in blood sampled from the ulnar vein. Thus, blood sampled from the crural varicose veins demonstrated a decrease in the counts of WBC by 9.6% in fourteen (93.3%) patients, that of neutrophils by 4.9% in twelve (80%) patients, that of lymphocytes by 16,8% in fifteen (100%) patients, and that oi monocytes by 24% in twelve (80%) patients. The mentioned differences were statistically significant at a = 0.05. The eosinophilic counts in blood sampled from the upper and lower extremities appeared similar in 66.7% of the examined subjects. In 33.3% of cases the eosinophilic count in blood samples from crural varicose vein was by 16.7% lower than that for blood samples form the ulnar vein. No differences for the rest parameters of the clinical blood count were revealed.

CONCLUSION

The absolute lymphocytic count in the blood samples taken after the 30-minute static loading from the crural varicose veins was significantly lower as compared with that in blood sampled form the cubital vein. The counts for RBCs and blood platelets, as well as other qualitative haematological indices (haemoglobin, haematocrit, average volume of the RBC, erythrocytic diameter, etc.) in blood sampled form crural and ulnar veins in the same patient were identical, thus strongly suggesting the lack of either haemodynamic or haemorheological phenomena capable of leading to redistribution of the blood formed elements in varicose veins. Hence a decrease in the counts of leukocytes and their subpopulations in blood sampled from crural varicose veins might be associated with the «leukocytic trap» phenomenon.

[Review of the proceedings of the 11th Conference of the European Venous Forum (June 24-26, 2010, Antwerp, Belgium)]

The authors reviewed herein the proceedings of the 11th Conference of the European Venous Forum held under the badge of a more and more significant effect of the positions and principles of evidence-based medicine on the life of the European Phlebological Community. This concerned both the representative reports and special subject lectures dedicated to the statistical analysis in surgery and phlebology, as well as assessment of the remote outcomes of surgical management of venous chronic diseases. Also analysed herein are the materials devoted to the modern minimally invasive techniques aimed at obliterating major veins and used in randomized studies. Presented at the Congress were initial results of employing a novel technique of thermoregulation using steam. Also analysed are the reports concerning interrelationship between phlebology as a science and mass media including the World Wide Web.

[Pharmacotherapy of chronic venous diseases in the light of the Russian and International Guidelines]

The article reviews present-day data on pathogenesis of chronic venous diseases, as well as formulates the strategic missions of treatment, with an emphasis placed on the criteria ol evidence-based medicine, followed by critically analysing the standards of pharmacotherapy of chronic venous diseases, reflected in the European, American and Russian clinical guidelines. A conclusion is drawn on the necessity and advisability, from the point of view ol evidence-based medicine, of using phlebotropic drugs in patients suffering from various forms of chronic venous diseases.

[Pain and other symptoms of chronic venous diseases: pathophysiology and therapeutic principles]

The literature review presented herein analyses the mechanism of the development of pain and othersubjective signs and symptoms in chronic venous diseases. Also discussed are numerous findings suggesting a pivotal role played by the leukocytic-endothelial inflammatory reaction as the main stimulator of the nociceptors of the venous wall and paravasal tissue, resulting information of the pain syndrome. This is followed by substantiating the necessity of early initiation of comprehensive conservative therapy making it possible to block the molecular and cellular mechanisms damaging the venous wall and microcirculatory bed in patients presenting with various stages of venous chronic diseases.

[Surgical pathology of lower limb veins: from pathogenesis to prevention and management]

The paper reviews modern epidemiological, experimental and clinical data on chronic diseases of lower limb veins. In particular the latest data on pathogenesis of variceal disease and chronic venous insufficiency are discussed along with their relation to leukocytic-endothelial interactions.

[What was interesting at the World Congress of the International Union of Phlebology. Kyoto, 18-20 June, 2007]

Asian Chapter Meeting of the International Union of Phleboiogy (UIP) was held in Kyoto (Japan), 18?-?20 June, 2007. Participants of this important forum have discussed some actual problems concerning epidemiology, pathogenesis, diagnosis and treatment of venous diseases.

Trophic venous ulcers and their relationship with the immune status

This paper describes the results of an original study into the systemic and local immunity in 25 patients with trophic venous ulcers. The authors discovered a number of significant parameters demonstrating the influence of the immune status on the formation of venous ulcers and tempo of their healing. They revealed previously unknown relationships between the immune status, clinical manifestations arid natural history of venous ulcers. Presented herein are the first results of the local use of the immunomodulator gepon and evidence for its efficacy in the treatment of chronic trophic venous ulcers.

[Peculiarities of ultrasonographic anatomy of the small saphenous vein]

The authors studied the prevalence and peculiarities of lesions of the small saphenous vein (SSV), having performed ultrasonographic mapping of this vessel on 223 lower limbs. We revealed three major variants of localization of the SSV's terminal portion. In 36.3 % of cases, the SSV merged with the popliteal vein in the zone from the projection of the knee-join line and not above 7 cm from this level (type I). In 29.6% of cases, the SSV flowed into the femoral vein at a height of 8-20 cm from the knee-joint line (type II). In 31,3 % of cases, the SSV's terminal portion had no direct connection with the deep veins. In the upper third of the femur, the vessel flowed into the confluents of the large saphenous vein, or into the system of the gluteal veins (type III) The largest by the calibre are type I veins. Valvular insufficiency of the SSV was revealed in 16 (7.2 %) cases. The majority of the veins with incompetent valves (12) belonged to type I In the group of 143 veins with the diameter of not more than 0.4 cm at the level of the knee-joint fissure in the standing position, no pathological venous reflux was registered. We also examined the extent of the reflux along the SSV. Only in one case blood shunt to the lower third of the crus was registered. A combination of venous insufficiency of the SSV and the large saphenous vein on the same extremity was revealed only in 2 cases (1.6%). The obtained results give occasion to reconsider certain diagnostic and therapeutic approaches in varicose disease in the SSV's basin.

[Phlebology today and tomorrow. Review of the materials presented at the 15th World Congress of the Phlebologists (IUP)]

In addition to reviewing the traditionally presented printed matter, the article contains the information about the most interesting events including lectures, symposia, round tables and master-classes held within the framework of the 15th World Congress of the International Union of Phlebologists.

[Remote outcomes of endoscopic dissection of crural perforating veins in chronic venous insufficiency]

We studied the long-term results following endoscopic dissection of crural perforating veins (EDCPV) in chronic venous insufficiency. The study comprised a total of 36 patients (41 lower limbs) who had endured the intervention concerned. The term having passed from the time of the operation till the moment of assessing the obtained outcomes varied from I to 10 years. Ultrasonographic angioscanning within the zone of the previous intervention revealed 38 perforating veins on 3.1 of the postoperative lower limbs (75.6 %). Amongst the veins revealed, most frequently encountered were Cockett's perforants (the so-called Cockett II) in the typical place - the lower third along the medial surface of the crus (29 cases). In five cases, perforants were revealed in the middle third of the crus, which located in the close proximity from the edge of the tibia (Cockett III). Perforants on the posterior crural surface were revealed on four extremities. Only 22 veins on 20 lower limbs (48.8%) turned out incompetent. The median access to perform EDPCV was used in 28 cases (68.3%); within the zone of the operative intervention performed we found 24 perforating veins, with 15 of these being incompetent. After EDPCV performed from the posterior or posterior-medial approaches on 13 limbs (317%), we revealed 14 perforating veins (of these, 7 - incompetent). Despite this, the patients regarded the effect obtained as either good or satisfactory in 79% of cases. The obtained findings suggest that thorough diagnosis of perforating reflux and improvement of the technique of endoscopic dissection thereof should be required. Along with it, it is also necessary to attentively examine the problem of the true role of the low vein-venous shunt in the pathogenesis of vein chronic diseases.

Micronized diosmin (Detralex) for vein-related trophic ulcers: European experience

The paper presents a meta-analysis of 5 large European studies (N - 723) on the micronized diosmin administration to patients with venous trophic ulcers (CEAP class VI). With the use of evidence-based approach, it was shown that micronized diosmin has a statistically significant clinical effect on middle-sized trophic ulcers (5 - 10 cm(2)) that persisted for 6 - 12 months. The study concludes that polyvalent venotonics are an appropriate and valuable addition to complex therapy of complicated chronic venous insufficiency.

[The treatment of trophic ulcers of venous etiology from the standpoint of evidence-based medicine. Review of literature]

Presented herein is a review of the modern world literature devoted to the pressing problem of phlebology--the treatment of trophic ulcers. In the given review all the available data on the modern treatment methods for trophic ulcers, resting on the criteria of evidence-based medicine (EBM), are systematized. Proceeding from these data we have evaluated the efficacy and safety of different approaches to the treatment of trophic ulcers and created the diagnostic and treatment algorithm for patients suffering from the pathology in question. The literature review, resting on the general criteria of evidence-based medicine, has demonstrated that the main current trends in the management of venous ulcers are moist healing, compression therapy, and surgical treatment. However, despite this fact there is a number of unsolved problems concerned first of all with the creation of the integral diagnostic and treatment program for patients with venous ulcers, based on the significant statistical data.

[Semisynthetic Diosmin (Phlebodia 600) for therapy of lower limb chronic venous insufficiency]

The study was held to assess clinical effectiveness of coaggregated semisynthetic Diosmin (Phlebodia 600) for patients with II-III CEAP classes of chronic venous insufficiency (CVI), caused by lower limb variceal diseases. In 30 cases Phlebodia 600 demonstrated positive effect on CVI symptoms, edematous and convulsive syndromes. The authors conclude that Phlebodia 600 is highly effective and safe for patients with CVI.

[Phlebosclerosing treatment of lower extremity varicosity using the 'foam-form' technique]

This paper presents an experience gained with the treatment of 39 patients with lower extremity varicosity using a novel method of phlebosclerosing treatment, named the foam-form technique. The authors give a detailed description of the treatment modality, analyze the short- and long-term results. The conclusion is drawn that the given method is safe and effective. The emphasis is laid on the necessity of an objective evaluation of the collective experience with the use of the foam-form technique.

Chronic diseases of lower extremity veins in industrial workers of Moscow (results of the epidemiological survey)

This paper describes the results of the study into the prevalence of chronic venous diseases among industrial workers of Moscow. It has been established that chronic venous diseases are fairly prevalent among industrial workers. They affect the people of both sexes (67.5% of women and 50.4% of men), varying age and occupation. With age their incidence rises. The most significant risk factors of the onset of chronic venous diseases include hereditary predisposition, pregnancy and birth, overweight, and intake of hormonal contraceptives. The study has demonstrated that in most cases, such patients are not rendered medical assistance.

Endovasal laser obliteration of the greater saphenous vein in patients with varicosis

This paper describes the first results of endovasal laser obliteration of the greater sephenous vein in two patient groups (n=40) math varicosis. In 15 cases (control group), laser obliteration was employed during routine operation as an alternative to phlebectomy according to Babcock following crossectomy. In 25 patients (the main group), operation was performed without ligation of the saphenofemoral anastomosis. After puncture and catheterization according to Seldinger the greater saphenous vein was exposed to thermal action over the length from the osteal valve to the upper third of the leg. The follow up of the patients amounted to 12 months. The results obtained in the main patient group seem most interesting. Stable elimination of truncal varicosis could be attained in more than 90% of cases, which was associated with quick medicosocial rehabilitation, the minimal number of complications and an excellent cosmetic effect.

Shave therapy for non-healing venous trophic ulcers

Venous trophic ulcers comprise an important social and medical problem. Conventional therapy includes initial healing of ulceration with consequent surgical intervention. Persistent or recurrent venous ulcers elicit irreversible changes in skin, subcutaneous fat and fasciae making impossible complete success of standard autodermoplasty. We present our experience in shave therapy with autodermoplasty and simultaneous correction of hemodynamic disturbances for this cohort of patients. Study results have demonstrated that in patients with chronic venous trophic ulcers and manifested lipodermatofasciosclerosis shave therapy suggests an optimal volume of intervention.

[The drug therapy of chronic venous insufficiency (a trial of the clinical use of the preparation Detralex)]

76 patients with severe venous insufficiency (CVI) entered the study. All the patients received 500 mg of Detralex twice daily for 2 months. The drug was well tolerated and relieved CVI symptoms in the majority of cases.

[The ultrasonic diagnosis of acute thrombophlebitis of the vena saphena magna]

A total of 321 patients with suspected acute thrombophlebitis were examined. There were 92 men (30%) and 229 women (70%). For control 15 patients without lower limb vein abnormalities and 19 ones with uncomplicated varicose disease were examined. Ultrasonic examinations using Ultramark-8 (Medata, Sweden) device were carried out in all the patients. Of the 313 cases (in 8 patients the diagnosis of acute thrombophlebitis was not confirmed by ultrasonic examination) ultrasonography results were erroneous in only 6 cases when assessing the proximal borderline of the great subcutaneous femoral vein thrombosis. Hence, the accuracy of duplex scanning in assessment of the proximal border of thrombosis in acute thrombophlebitis was 98.6% in our study. Ultrasonic angio-scanning in patients with superficial thrombophlebitis give reliable and valuable information about the presence, type, and extension of the pathologic process. This helps to optimally solve the therapeutic policy problems and adequately plan surgical intervention.

[The current diagnostic procedure in chronic pathology of the veins of the lower extremities]

Stepwise (out- and inpatient) examination forms the basis of diagnostic examination tactics in chronic abnormalities of the veins. Noninvasive ultrasonic methods of studying the venous system are preferred. With the gradual formation of groups of patients with an affection of the veins, invasive isotope and angiographic methods are supplemented. The authors emphasize that such examination of patients in stages raises the efficacy and the quality of diagnosis in individuals with chronic venous abnormalities.

[Ultrasonic examination in the diagnosis of chronic diseases of the veins of the lower extremities]

Noninvasive diagnosis of chronic diseases of the lower limb venous system is an urgent problem of modern phlebology. Ultrasonic examination (USE) makes it possible to judge adequately the condition of the deep and surface veins and, consequently, to improve significantly the management of varicose and post-thrombophlebitic diseases. The authors elaborated an original method for the diagnosis and appraisal of the condition of the lower limb venous system by means of ultrasonic scanning and various functional tests for determining the character of affection of the venous valvular apparatus. Examination of more than 200 patients with primary varicosities and post-thrombophlebitic disease, the use of highly-resolving ultrasonic equipment, and comparison of the results of USE with the findings of radiocontrast phlebography (agreement in 99.8% of cases) allow the conclusion that noninvasive ultrasonic methods must be used widely in appraising the venous status in patients with chronic diseases of the venous system of the lower limbs.

[Surgical anatomy of the posterior tibial veins]

An investigation of the posterior tibial vascular plexus has established certain specific features of its structure both in normality and in patients with postthrombotic disease. The alterations found require an individual approach to choice of surgical measures which is finally determined intraoperatively. At the present time surgical interventions on the posterior tibial veins in patients with postthrombotic disease are thought to be of three types: extended resection, extravasal correction and plasty of the posterior tibial veins.

[A present-day approach to surgery for the formation of crossed femoro-femoral shunts in unilateral occlusions of the ilio-femoral venous segment (indications, principles of the surgical technique)]

As distinct from the classical Palme-D'Esperon operation in which the anastomosis is established with the common femoral vein, the authors prefer to form the anastomosis in the region of the saphenofemoral communication in inadequate drainage in the iliofemoral segment in patients with the postthrombotic disease. Seven variants of crossed femorofemoral shunting (CFFS) were carried out. The anastomoses were formed by means of precision techniques; an operating microscope was used when the anastomosis measured less than 5 mm in diameter. The CFFS was found to be patent in follow-up periods of up to 2.5 years in all cases. From analysis of the late-term results of CFFS, the authors claim that functional block of venous drainage from the femoro-iliac segment, rather than anatomical occlusion, is the indication for this operation.

[Embedding of the deep dorsal vein into the duplication of the tunica albuginea--a new method for the surgical treatment of venous insufficiency of the corpora cavernosa penis]

The methods to block the venous drainage of the spongy bodies (ligation, arterialization and embolization of the venous system in the penis) used in the treatment of vascular erectile impotence lead to spongy tissue sclerosis. The pathogenetic unfoundedness of the above methods prompted the authors to develop better methods for treating the venous insufficiency of the spongy bodies. Nineteen patients with erectile impotence were examined by using drug (papaverin), induced erection, dynamic spongiography, cavernography, and spongiobiopsy. The examination provided a classification of venous insufficiency in the spongy bodies, which included 3 types of the disease: distal, proximal, and mixed. For the treatment of the distal pattern, a new surgical method was developed, namely, immersion of the deep dorsal vein of the penis into the duplication of the tunica albuginea in the spongy bodies. The method partially blocks the venous drainage only in the erected penis, thus avoiding persistent venous hypertension in the erected penis, thus avoiding persistent venous hypertension in the spongy bodies. Five patients were operated on. The follow-up of 3 months to 1 year showed an improvement of penis erectility. Lower venous drainage in the spongy bodies was evidenced by Doppler sonography and perfusion artificial erection. Thus, the proposed operation is an effective tool to correct venous drainage in the spongy bodies.

[Doppler echographic diagnosis in postthrombotic syndrome]

On the basis of rich experience and the elaborated techniques of study, the authors claim that ultrasonic doppler echography is a highly informative and safe method for the diagnosis of the postthrombotic syndrome of the lower limbs yielding all the necessary data on the condition of the superficial and deep veins. The introduction of this method into the wide practice of out-patient clinics will make it possible to recognize the disease in time and determine its stage and form as well as the indications for operative or nonoperative treatment. The use of highly sensitive apparatuses will allow phlebography, which is still a necessary diagnostic procedure, to be rejected as a more hazardous and costly method.

[Ultrasonic diagnosis of post-thrombotic disease of the lower extremities]

On the basis of a rich experience and developed techniques of examination the authors claim that ultrasonic scanning is a highly informative and safe method for the diagnosis of postthrombotic disease of the lower limbs which yields all the necessary data on the condition of the deep main veins. With the introduction of this method into wide clinical practice the disease will be diagnosed in time, its stage and form determined, and the performance of phlebography, which is still necessary, will be less frequent.