Risk factors of venous thromboembolism after incisional ventral hernia repair.

BACKGROUND: The problem of venous thromboembolic events (VTE) after incisional hernia repair remains relevant. According to the literature the frequency of VTE ranges from 0.2 to 4.2%. The data on risk factors of VTE in this cohort of patients are scarce. Aim of our study is to find frequency and risk factors for VTE development in patients who underwent surgery for incisional ventral hernia. MATERIALS AND METHODS: There were 240 patients enrolled in our retrospective study. We included patients, who were operated for incisional hernia in Saveljev University Surgery Clinic from January 2018 to December 2019. Compression duplex ultrasound of lower extremity veins was performed within median 3 days (min 1 day, max 7 days) after surgery for all participants. The primary endpoint was the occurrence of the VTE event, including deep venous thrombosis (DVT) and pulmonary embolism (PE). RESULTS: VTE was detected in 19 patients, which accounted for 7.9% in analyzed cohort. All patients received standard pharmacological prophylaxis. There were 3 (1.3%) proximal, 16 (6.7%) distal DVT, in one patient (0.4%) distal thrombosis was complicated by symptomatic pulmonary embolism. In multivariate Cox proportional hazard model was found that component separation (HR 3.99, 95% CI 1.14-14.0, p = 0.03), duration of operation in hours (HR 1.67. 95% CI 1.13-2.5, p = 0.011) and body mass index (HR 1.13, 95% CI 1.02-1.2, p = 0.02) were statistically significant risk factors. CONCLUSION: The incidence of postoperative VTE in patients after incisional hernia repair is high with a predominant distal DVT as a thrombotic event. Component separation, duration of operation and body mass index are statistically significant factors of VTE in patients undergoing surgery for incisional hernia.

Polymorphism of Matrix Metalloproteinases Genes MMP1, MMP2, MMP3, and MMP7 and the Risk of Varicose Veins of Lower Extremities.

We studied the effects of single nucleotide polymorphisms in the promoter regions of matrix metalloproteinase genes rs1799750 (-1607dupG) MMP1, rs243865 (C-1306T) MMP2, rs3025058 (-1171dupA) MMP3, and rs11568818 (A-181G) MMP7 on the risk of varicose vein of the lower extremities in ethnical Russians, residents of the Russian Federation. We genotyped 536 patients with this pathology and 273 healthy participants without history of chronic venous disease. Association was examined using logistic regression analysis. None of the studied polymorphisms showed statistically significant association with the risk of varicose veins of the lower extremities. Our results provide evidence that these polymorphisms are not involved in the pathogenesis of varicose veins and cannot serve as markers of predisposition to this pathology.

Polymorphic Variants rs13155212 (T/C) and rs7704267 (G/C) in the AGGF1 Gene and Risk of Varicose Veins of the Lower Extremities in the Population of Ethnic Russians.

We analyzed associations between single nucleotide polymorphisms (SNP) rs13155212 and rs7704267 in the AGGF1 gene (angiogenic factor with G patch and FHA domains 1) and the risk of risk of varicose veins of the legs in ethnic Russians. Frequencies of alleles, genotypes, and haplotypes were estimated in the sample of patients with this disease (474 patients) and in the control group of participants (478 volunteers) without a history of chronic venous disease. None of the studied polymorphisms was associated with the risk of this pathology. The whole AGGF1 gene sequence lies in a single block of high linkage disequilibrium, and both studied polymorphic variants are representative of all other SNP within this region. From these results, a conclusion was made that AGGF1 gene polymorphism does not affect the risk of varicose veins of the legs in ethnic Russians, or its contribution is low and can be revealed only after analysis of larger cohorts.

[How real is the prevention of postoperative venous thromboembolic complications].

The article represents the results of the Study "The safety territory of venous thromboembolic complications". 59 surgical hospitals took part in the multi-centered study. The risk assessment of the venous thromboembolic complications and prevention measured were analyzed in 53, 596 patients.

[Lower limb varicose disease in men and women: findings of prospective study SPECTRUM].

AIM: The study was aimed at comparing peculiarities of varicose disease, its complications, treatment policy in men and women. MATERIAL AND METHODS: The prospective observational study SPECTRUM follows up a total of 866 patients with venous chronic disease. Of these, 615 were found to have varicose disease (VD) (486 (79.0%) women and 129 (21.9%) men). The patients' age varied from 12 to 83 years old (mean age 46.1, median 46). The body weight index ranges from 15.7 to 62.0 (average 27.2, median 26.0). The duration of the disease from the moment of being included into the program ranges from 0.1 to 53 years (mean 14.5, median 11, interquartile range from 5 to 20). RESULTS: No differences by age, body mass index were observed. Men consulted the phebologist averagely at earlier stages of the disease onset (after 10.9 years as compared with 15.5 years for women; p=0.00001). The frequency of detecting subjective symptoms does not differ along the majority of the measures, with men less often reporting the development of pain syndrome (45.7 versus 65.2% for women; p=0.0001). The proportion of patients with class C4-C6 amongst men and women does not differ (29.5% and 24.1%, respectively; p=0.211). No differences in the incidence of varicosephlebitis, external bleeding from the venous node were revealed. Men were found to have more often total reflux along the great saphenous vein on the right leg (35.7% as compared with 25.1 % for women; p=0.017) and insufficiency of perforants (72.9% versus 59.7%; p= 0.006). Women were more often found to have isolated varicosity of inflows-confluents. 47.3% of men had not previously attended presented consulted for VD, amongst women the proportion of such cases was considerably lower (28.6%; p = 0.000001). Only 6.0% of women had previously not undergone any treatment for VD. Amongst men the share of previously not treated amounts to 23.3% (p=0.000001). Women were statistically significantly more often prescribed phleboscleroobliteration the inflows confluents. The recommendations of phlebologists on using compression, pharmacotherapy, surgical methods did not differ in men and women. CONCLUSION: The obtained differences are not principal. The course of VD is similar in patients of different gender, which is confirmed by identity of treatment policy.

[Functional venous insufficiency: diagnosis and treatment (literature review) (Part I)].

UNLABELLED: Reviewed herein are the available literature data concerning functional venous insufficiency (phlebopathies). Part I analyses the data on terminology, epidemiology, effect on quality of life, aetiology and pathogenesis, risk factors, as well as possible methods of diagnosis of this pathological condition. METHOD: search in the MEDLINE database by means of the PubMed system.

[Functional venous insufficiency: diagnosis and treatment (review of the literature)].

UNLABELLED: Reviewed herein are the available literature data concerning functional venous insufficiency (phlebopathies). Part I analyses the data on terminology, epidemiology, effect on quality of life, aetiology and pathogenesis, risk factors, as well as possible methods of diagnosis of this pathological condition. METHOD: search in the MEDLINE database by means of the PubMed system.

Surgical correction of varicose vein disease under micronized diosmin protection (results of the Russian multicenter controlled trial DEFANS).

The paper presents the results of DEFANS trial (Detralex - assessment of efficacy and safety for combined phlebectomy). The study enrolled 245 patients with varicose vein disease, who underwent unilateral combined phlebectomy. The main group (n=200) received micronized diosmin (Detralex, 1000 mg/day) for 2 weeks before and 30 days after the procedure; control group (n=45) did not receive Detralex in pre- and postoperative period. Pain severity by 10-point visual analog scale (VAS), an area of subcutaneous hemorrhage in the zone of femoral great saphenous vein resection (by original 12-point scale) and subjective feelings of limb heaviness and fatigability were evaluated 7, 14 and 30 days after the procedure. Subjective symptoms and the area of subcutaneous hemorrhage were significantly lower in the main group, then in control: 7 days after the procedure VAS score was 2.9 and 3.5, respectively; hemorrhage area - 3.4 and 4.6 points, respectively. The same trend was observed for limb heaviness and fatigability, evidencing the better exercise and orthostatic tolerance among patients of the main group in early postoperative period. Quality of life assessment by CIVIQ failed to reveal statistically significant difference between main and control groups in 4-weeks postoperative follow-up. Micronized diosmin in pre- and postoperative period after plebectomy helps to attenuate pain syndrome, to decrease postoperative haematomas and accelerate their resorption, to increase exercise tolerance in early postoperative period.

[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.

[A relapse of lower-limb varicose disease: definition, diagnosis and causes of pathology (review of literature)].

Current trends are towards a permanent growth of the number of patients presenting with a relapse of lower-limb varicose disease (RVD). According to the data of various investigators, from 5 to 80 % of postoperative patients develop RVD. Despite the close attention paid over decades to this problem by phlebologists of all the world over, there is no common interpretation of the notion "relapse of varicose disease". Recommendations on carrying out examination are of too general character and do not take into consideration the necessity of maximal individualization of therapeutic policy. Attention is attracted by a wide variety of the data concerning the causes of RVD with considerable differences as to the percentage ratio thereof. All this results in various readings when assessing the outcomes of different therapeutic methods, as well as hampers development of a unified therapeutic policy. It is necessary to eliminate terminological ambiguity, to be followed by devising a present-day diagnostic and therapeutic policy in RVD. The structure and classification of the causes leading to development of a relapse should also be studied, especially in the light of using novel, including minimally invasive technologies.

[Unadequate ostial ligation of the great saphenous vein as the cause of varicose disease reccurence].

Authors investigated the frequency of varicose disease recurrence after crossectomy, classified clinical types and proposed the tactics of treatment of this group of patients. 258 patients with varicose disease recurrence were examined and operated. In 179 cases (69,4%) there were found differ pathological changes in the place of saphenofemoral junction, which were collected in several groups. Pathological stump of the great saphenous vein was in 155 lower limbs (60,1%). 12 patients (4,7%) had not ligated saphenofemoral junction. And in 12 patients (4,7%) there were found signs of neoangiogenesis. We proposed the scheme of tactical actions in cases of pathological changes in the place of saphenofemoral junction. The absolute indication for surgery is present saphenofemoral junction and trunk of the great saphenous vein. Furthermore, recection of vein's stump is necessary if its length is more 3 cm, that always combined with varicose tranformation of the varicosities. If the linear size of stump is from 1 to 3 cm its resection have to be done only in case of considerable varicosities. In not severe lesions of varicosities it is enough to perform sclerotherapy or mini-phlebectomy of involved vessels. There is not necessary to surgery if the stump is short (less 1 cm). In this case the phlebosclerotherapy or mini-phlebectomy of varicosities are expedient. The method of choice for removal of neoangiogenesis is phlebosclerotherapy. Our results showed that treatment of patients with varicose disease recurrence is in special phlebological centers or vascular departments and improvement of technique of Troyanov-Trendelenburg operation.

[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.

[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.

[Risk factors of chronic venous insufficiency of the lower extremities and possibilities of its medication in therapeutic practice].

AIM: To verify incidence of risk factors of chronic venous insufficiency (CVI) of the lower limbs and efficacy of outpatient treatment. MATERIALS AND METHODS: A total of 4388 patients were examined by questioning and examination of the lower limbs. 1209 patients with CVI stages C1, C2 and C3 were included in the study. They received recommendations to use elastic compression, topic modalities, physiotherapy. Patients of the study group were given, in addition, detralex for 8 weeks. RESULTS: Characteristic symptoms of CVI were seen in 68% males and 84% females but only 17.5 and 20%, respectively, had complaints. The risk was highest in history of CVI in the patient's mother, sitting or standing job, hard physical labour, obesity and constipation, two or more labours in women. The effect was achieved in the detralex group. CONCLUSION: Many outpatients had symptoms of chronic venous insufficiency but had no complaints. Detralex therapy proved highly effective in outpatient practice.

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.

[Elimination of major trunk reflux as a basis for surgical management of lower limb varicosity].

The article reviews the available literature data related to the problem of eliminating the blood reflux along the trunks of saphenous veins in lower limb varicosity. The authors have herein classified the literature-proposed interventions depending on the underlying principle, to have also carried out a detailed analysis of the data contained in the available Russian and foreign publications, as well as having considered technical peculiarities concerning different methods of removing veins, i. e., phlebectomy according to the Babcock technique, inversion venectomy, and cryophlebectomy. The article also deals with comparing therapeutic outcomes and a wide variety of postoperative complications involved. The role of the trunk catheter sclerosing therapy in comprehensive management of varicose disease is also discussed herein. Special attention is paid to the present-day techniques aimed at removing the trunk reflux, i. e., with the help of radio-frequency and laser-mediated obliteration. The currently available information about both advantages and disadvantages of these methods necessitates further studies aimed at searching for an optimal method (or a combination of methods) of removing one of the most important links of pathogenesis of varicosity.

Radionuclide assessment of the treatment by compression of patients with chronic venous insufficiency.

A study was made of the efficacy of the compression medical tricot in the treatment of chronic venous insufficiency (CVI). To evaluate the treatment by compression, the authors, in addition to the clinical examination, used radionuclide techniques such as examination of the regional blood volumes and phleboscintigraphy. The results of the given work have shown that the compression products under test are effective agents for the treatment of CVI by compression which improves venous return and the patients' quality of life. The data obtained point out that in addition to the lowering of blood filling, the medical tricot influences the interstitial element of the edematous syndrome, leading to the elimination of the latter one. The use of elastic bandages creates the known difficulties (the necessity of the patient training in bandaging, complexity of creating an adequate bandage, quick depreciation). In view of this fact the use of the compression tricot which possesses the fixed grade of compression for a concrete form and stage of CVI is preferable in the therapy of chronic venous diseases.

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.