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Phlebology May 2017Introduction Lower limb venous disease affects up to one half, and obesity up to one quarter, of the adult population. Many people are therefore affected by, and present... (Review)
Review
Introduction Lower limb venous disease affects up to one half, and obesity up to one quarter, of the adult population. Many people are therefore affected by, and present to health services for the treatment of both conditions. This article reviews the available evidence of pathophysiological and clinical relationship between obesity and varicose veins, chronic venous insufficiency and ulceration and deep vein thrombosis. Methods A literature search of PubMed and Cochrane libraries was performed in accordance with PRISMA statement from 1946 to 2015, with further article identification from following cited references for articles examining the relationship between obesity and venous disease. Search terms included obesity, overweight, thrombosis, varicose veins, CEAP, chronic venous insufficiency, treatment, endovenous, endothermal, sclerotherapy, bariatric surgery and deep vein thrombosis. Results The proportion of the population suffering from lower limb venous disease and obesity is increasing. Obesity is an important risk factor for all types of lower limb venous disease, and obese patients with lower limb venous disease are more likely to be symptomatic as a result of their lower limb venous disease. The clinical diagnosis, investigation, imaging and treatment of lower limb venous disease in obese people present a number of challenges. The evidence base underpinning medical, surgical and endovenous management of lower limb venous disease in obese people is limited and such treatment may be associated with worse outcomes and increased risks when compared to patients with a normal body mass index. Conclusion Lower limb venous disease and obesity are both increasingly common. As such, phlebologists will be treating ever greater numbers of obese patients with lower limb venous disease, and clinicians in many other specialties are going to be treating a wide range of obesity-related health problems in people with or at risk of lower limb venous disease. Unfortunately, obese people have been specifically excluded from many, if not most, of the pivotal studies. As such, many basic questions remain unanswered and there is an urgent need for research in this challenging and increasingly prevalent patient group.
Topics: Age Factors; Female; Humans; Lower Extremity; Male; Obesity; Risk Factors; Varicose Veins; Venous Thrombosis
PubMed: 27178403
DOI: 10.1177/0268355516649333 -
Journal of Vascular Surgery. Venous and... May 2022Calcifications in the subcutaneous layer (SCL) have been described by radiographic studies of legs with advanced chronic venous disease (CVD). However, SCL...
BACKGROUND
Calcifications in the subcutaneous layer (SCL) have been described by radiographic studies of legs with advanced chronic venous disease (CVD). However, SCL calcifications have rarely been included among the CVD-related changes. The aim of the present study was to evaluate the prevalence and morphology of SCL calcifications in legs with CVD of all grades of severity determined by ultrasound.
METHODS
A total of 500 legs in 250 patients (148 women and 102 men; mean age, 51 years; range, 18-87 years) referred to our vascular clinic for symptoms and signs of CVD were included. After duplex ultrasound evaluation of the deep, superficial, and perforating veins, the skin and SCL were investigated using duplex ultrasound. Those patients with other possible causes of SCL calcification were excluded.
RESULTS
Using the C component of the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, 43 legs were classified as C1, 189 as C2, 34 as C3, 16 as C4A, 45 as C4B or C, 18 as C5, and 16 as C6. Varicose veins were reported in 273 legs, and lipodermatosclerosis in 79 legs. Subcutaneous calcifications were demonstrated in 35 of 361 legs with CVD in two different locations: the wall of superficial varicose veins and in subcutaneous tissue unrelated to the path of the superficial veins. Superficial veins calcifications were found in 12 of 273 legs with varicose veins (4.4%) and were found in older patients with severe varicose vein disease (grade 3 using the venous clinical severity score and disease duration >30 years). Subcutaneous tissue calcifications (STCs) were found in 24 of 95 legs with a more advanced CVD stage (C4A-C6). No STCs were found in legs with a C1, C2, or C3 class.
CONCLUSIONS
Superficial veins calcifications were found only in the legs with severe and long-lasting varicose veins and seemed to be related to chronic severe inflammation of the venous wall. STCs were independent of the vein wall and were found only in the damaged areas of legs with severe CVD (C4-C6). STCs are possibly related to chronic inflammation of the subcutaneous tissue. Their avulsion from the ulcer bed has been recommended to facilitate ulcer healing and prevent recurrence.
Topics: Aged; Chronic Disease; Female; Humans; Inflammation; Leg; Male; Middle Aged; Ulcer; Varicose Veins; Venous Insufficiency
PubMed: 35217216
DOI: 10.1016/j.jvsv.2022.02.008 -
Phlebology May 2022The aim was to compare the genetic information of varicose vein patients with that of a healthy population attempting to identify certain significant genetic...
BACKGROUND
The aim was to compare the genetic information of varicose vein patients with that of a healthy population attempting to identify certain significant genetic associations.
METHOD
Patients' clinical characteristics and demographics were collected, and their genetic samples were examined. The results were compared to the genetic information of one thousand sex-matched healthy controls from Taiwan Biobank database. The Clinical-Etiology-Anatomy-Pathophysiology classification was applied for further subgroup analysis.
RESULTS
After comparison of genetic information of ninety-six patients to that of healthy controls, two significant single nucleotide polymorphisms (SNPs) were identified. One was in DPYSL2 gene, and the other was in VSTM2L gene. A further comparison between C2-3 patient subgroup and C4-6 subgroup identified another four significant SNPs, which were located in ZNF664-FAM101A, PHF2, ACOT11, and TOM1L1 genes.
CONCLUSION
Our preliminary result identified six significant SNPs located in six different genes. All of them and their genetic products may warrant further investigations.
Topics: Adaptor Proteins, Signal Transducing; Genetic Predisposition to Disease; Genome-Wide Association Study; Homeodomain Proteins; Humans; Polymorphism, Single Nucleotide; Varicose Veins
PubMed: 35099328
DOI: 10.1177/02683555211069248 -
European Journal of Medicinal Chemistry Aug 2019The term varicose vein refers to the twisted and swollen vein visible under the skin surface which occurs most commonly in the leg. Epidemiological studies report a... (Review)
Review
The term varicose vein refers to the twisted and swollen vein visible under the skin surface which occurs most commonly in the leg. Epidemiological studies report a varying percentage of incidences from 2 to 56% in men and <1-60% in women. Venous insufficiency is most often caused by the damage to the valves and walls of the veins. The mechanism of varicose vein formation is complex. It is, however, based on hypotensive blood vessels, hypoxia, and other mechanisms associated with inflammation. This work describes mechanisms related to the formation and development of the varicose vein. It discusses risk factors, pathogenesis of chronic venous disease, markers of the epithelial and leukocyte activation, state of hypoxia and inflammation, reactive oxygen species (ROS) generation, and oxidative stress. Additionally, this paper describes substances of plant origin used in the treatment of venous insufficiency. It also considers the structure of the molecules, their properties, and their mechanisms of action, the structure-activity relationship and chemical properties of flavonoids and other substances. The flavonoids include quercetin derivatives, micronized purified flavonoid fraction (Daflon), natural pine bark extract (Pycnogenol), and others such as triterpene saponine, extracts from Ruscus aculeatus and Centella asiatica, Ginkgo biloba extract, coumarin dereivatives that are used in chronic venous insufficiency. Flavonoids are natural substances found in plants, including fruits, vegetables, flowers, and others. They are important to the circulatory system and critical to blood vessels and the blood flow. Additionally, they have antioxidant, antiinflammatory properties.
Topics: Antioxidants; Biological Products; Chronic Disease; Flavonoids; Humans; Inflammation; Oxidative Stress; Reactive Oxygen Species; Varicose Veins; Venous Insufficiency
PubMed: 31096120
DOI: 10.1016/j.ejmech.2019.04.075 -
Journal of Vascular Surgery. Venous and... Mar 2022Technical errors are the most common preventable cause of recurrence after high ligation and stripping procedures for the treatment of great saphenous vein incompetence.... (Comparative Study)
Comparative Study Randomized Controlled Trial
Ultrasound-assisted varicose vein surgery and endovenous laser ablation using 1470-nm laser for treatment of great saphenous vein incompetence has similar outcomes at 1 year in a single-center prospective randomized study.
BACKGROUND
Technical errors are the most common preventable cause of recurrence after high ligation and stripping procedures for the treatment of great saphenous vein incompetence. Ultrasound-assisted varicose vein surgery (UAVS) uses intraoperative ultrasound during high ligation and stripping to minimize such failures, although no data have been reported regarding its use during open surgery. The present study compared the short-term outcomes of UAVS and endovenous laser ablation (EVLA) with a 1470-nm laser.
METHODS
The present prospective randomized study was conducted from January 2019 to December 2019. We compared 40 patients who had undergone UAVS under regional anesthesia with an equal number of patients who had undergone EVLA under tumescent anesthesia. Both groups received 1 week of standardized postoperative analgesia. The improvements in the pain score, venous clinical severity score, and recurrence at 6 months and 1 year were studied.
RESULTS
No significant differences were found in either clinical or radiologic great saphenous vein recurrence after UAVS compared with EVLA at 1 year. The mean pain score at 8 hours after the procedure was higher in the UAVS group (3.7 ± 1.2 vs 2.9 ± 1.0; P = .03). At 1 week, the score was higher in the EVLA group (1.8 ± 0.7 vs 1.4 ± 0.5; P = .01). At 6 months, the venous clinical severity score had improved from 9.2 ± 3.7 to 2.4 ± 1.4 in the UAVS group and from 9.3 ± 3.2 to 2.1 ± 0.8 in the EVLA group (P = .64). At 1 year, the corresponding scores were 1.3 ± 0.7 and 1.4 ± 0.6 (P = .21).
CONCLUSIONS
UAVS has high technical success, making it a suitable alternative to EVLA using a 1470-nm laser.
Topics: Adult; Aged; Female; Humans; India; Laser Therapy; Ligation; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Predictive Value of Tests; Prospective Studies; Recurrence; Saphenous Vein; Time Factors; Treatment Outcome; Ultrasonography, Interventional; Varicose Veins; Vascular Surgical Procedures; Venous Insufficiency; Young Adult
PubMed: 34438089
DOI: 10.1016/j.jvsv.2021.08.013 -
Value in Health : the Journal of the... Aug 2018To analyze the cost-effectiveness of current technologies (conservative care [CONS], high-ligation surgery [HL/S], ultrasound-guided foam sclerotherapy [UGFS],... (Review)
Review
OBJECTIVES
To analyze the cost-effectiveness of current technologies (conservative care [CONS], high-ligation surgery [HL/S], ultrasound-guided foam sclerotherapy [UGFS], endovenous laser ablation [EVLA], and radiofrequency ablation [RFA]) and emerging technologies (mechanochemical ablation [MOCA] and cyanoacrylate glue occlusion [CAE]) for treatment of varicose veins over 5 years.
METHODS
A Markov decision model was constructed. Effectiveness was measured by re-intervention on the truncal vein, re-treatment of residual varicosities, and quality-adjusted life-years (QALYs) over 5 years. Model inputs were estimated from systematic review, the UK National Health Service unit costs, and manufacturers' list prices. Univariate and probabilistic sensitivity analyses were undertaken.
RESULTS
CONS has the lowest overall cost and quality of life per person over 5 years; HL/S, EVLA, RFA, and MOCA have on average similar costs and effectiveness; and CAE has the highest overall cost but is no more effective than other therapies. The incremental cost per QALY of RFA versus CONS was £5,148/QALY. Time to return to work or normal activities was significantly longer after HL/S than after other procedures.
CONCLUSIONS
At a threshold of £20,000/QALY, RFA was the treatment with highest median rank for net benefit, with MOCA second, EVLA third, HL/S fourth, CAE fifth, and CONS and UGFS sixth. Further evidence on effectiveness and health-related quality of life for MOCA and CAE is needed. At current prices, CAE is not a cost-effective option because it is costlier but has not been shown to be more effective than other options.
Topics: Ablation Techniques; Conservative Treatment; Cost-Benefit Analysis; Elective Surgical Procedures; Humans; Laser Therapy; Markov Chains; Sclerotherapy; Varicose Veins
PubMed: 30098668
DOI: 10.1016/j.jval.2018.01.012 -
Phlebology Nov 2015To review the literature related to the management of reticular varices and telangiectases of the lower limbs to provide guidance on the treatment of these veins. (Review)
Review
AIM
To review the literature related to the management of reticular varices and telangiectases of the lower limbs to provide guidance on the treatment of these veins.
FINDINGS
Very few randomised clinical trials are available in this field. A European Guideline has been published on the treatment of reticular varices and telangiectases, which is largely based on the opinion of experts. Older accounts written by individual phlebologists contain extensive advice from their own practice, which is valuable in identifying effective methods of sclerotherapy. All accounts indicate that a history should be taken combined with a clinical and ultrasound examination to establish the full extent of the venous disease. Sclerotherapy is commenced by injecting the larger veins first of all, usually the reticular varices. Later in the same session or in subsequent sessions, telangiectases can be treated by direct injection. Following treatment, the application of class 2 compression stockings for a period of up to three weeks is beneficial but not used universally by all phlebologists. Further sessions can follow at intervals of 2-8 weeks in which small residual veins are treated. Resistant veins can be managed by ultrasound-guided injection of underlying perforating veins and varices. Other treatments including RF diathermy and laser ablation of telangiectases have very limited efficacy in this condition.
CONCLUSIONS
Sclerotherapy, when used with the correct technique, is the most effective method for the management of reticular varices and telangiectases.
Topics: Europe; Humans; Laser Therapy; Lower Extremity; Sclerosing Solutions; Sclerotherapy; Stockings, Compression; Telangiectasis; Ultrasonography; Varicose Veins
PubMed: 26556703
DOI: 10.1177/0268355515592770 -
Medicine Jul 2022Ectopic varices are the collateral circulation of portal vein located anywhere in the gastrointestinal tract other than the esophageal and gastric regions. Rupture of...
RATIONALE
Ectopic varices are the collateral circulation of portal vein located anywhere in the gastrointestinal tract other than the esophageal and gastric regions. Rupture of these varices often results in life-threatening hemorrhage. Management guidelines for ectopic variceal bleeds are not yet standardized because cases are rare and treatment approaches described in the literature vary considerably.
PATIENT CONCERNS
A 53-year-old woman with a 20-year history of chronic hepatitis C cirrhosis came to our hospital for treatment due to intermittent black stools for 4 days. After admission, the patient developed hemorrhagic shock, with hemodynamic instability.
DIAGNOSIS
Postoperative histological examination confirmed the diagnosis of sigmoid varicose veins.
INTERVENTION
Emergency colonoscopy showed that a varicose vein mass in the sigmoid colon wall 30 cm from the anus was ruptured and bleeding. Percutaneous transhepatic inferior mesenteric venography revealed the presence of a varicose mass of sigmoid colon veins. After embolization of the sigmoid varicose veins with spring coils, angiography showed that the hemorheology of the distal varicose vein mass was slow but not completely blocked. Three days after embolization, the patient had hematochezia again. Splenectomy and sigmoid colon resection were performed immediately.
OUTCOMES
Follow-up computed tomography showed no residual varices were observed after sigmoid colon resection.
LESSONS
Ectopic varices, which are rare sequelae of portal hypertension, need to be taken seriously because bleeding from these varices can be catastrophic. We report a case of isolated sigmoid variceal rupture and hemorrhage due to portal hypertension in cirrhosis. The patient experienced failure of endoscopic hemostasis and sigmoid colon venous coil embolization. She was eventually successfully brought to hemostasis by surgery.
Topics: Colon, Sigmoid; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Liver Cirrhosis; Middle Aged; Portal Vein; Rupture; Varicose Veins
PubMed: 35905227
DOI: 10.1097/MD.0000000000030024 -
Annals of Vascular Surgery Jan 2017
Topics: Humans; Male; Varicocele; Varicose Veins
PubMed: 27989727
DOI: 10.1016/j.avsg.2016.09.004 -
The British Journal of Surgery Jan 2023Standardization of access to treatment and compliance with clinical guidelines are important to ensure the delivery of high-quality care to people with varicose veins....
BACKGROUND
Standardization of access to treatment and compliance with clinical guidelines are important to ensure the delivery of high-quality care to people with varicose veins. In the National Health Service (NHS) in England, commissioning of care for people with varicose veins is performed by Clinical Commissioning Groups (CCGs) and clinical guidelines have been developed by the National Institute for Health and Care Excellence (NICE CG168). The Evidence-Based Intervention (EBI) programme was introduced in the NHS with the aim of improving care quality and supporting implementation of NICE CG168. The aim of this study was to assess access to varicose vein treatments in the NHS and the impact of EBI.
METHODS
CCG policies for the delivery of varicose vein treatments in the NHS in England were obtained from 2017 (before EBI introduction) and 2019 (after EBI introduction) and categorized by two independent reviewers into levels of compliance with NICE CG168. Hospital Episode Statistics data were compared with the NICE commissioning model predictions. A quality-adjusted life-year was valued at £20 000 (Euro 23 000 15 November 2022).
RESULTS
Despite the introduction of the EBI programme, CCG compliance with NICE CG168 fell from 34.0 per cent (64 of 191) to 29.0 per cent (55 of 191). Some 33.0 per cent of CCG policies (63 of 191) became less compliant and only 7.3 per cent (14 of 191) changed to become fully compliant. Overall, 66.5 per cent of CCGs (127 of 191) provided less than the recommended intervention rate before EBI and this increased to 73.3 per cent (140 of191) after EBI. The overall proportion of patients estimated to require treatment annually who received treatment fell from 44.0 to 37.0 per cent. The associated estimated loss in net health benefit was between £164 and 174 million (Euro 188 million and 199 million 15 November 2022) over 3 years. A compliant policy was associated with a higher intervention rate; however, commissioning policy was associated with only 16.8 per cent of the variation in intervention rate (R2 = 0.168, P < 0.001).
CONCLUSION
Many local varicose vein commissioning policies in the NHS are not compliant with NICE CG168. More than half of patients who should be offered varicose vein treatment are not receiving it, and there is widespread geographical variation. The EBI programme has not been associated with any improvement in commissioning or access to varicose vein treatment.
Topics: Humans; State Medicine; England; Varicose Veins; Surveys and Questionnaires; Quality of Health Care
PubMed: 36448204
DOI: 10.1093/bjs/znac392