Postural Diameter Change of the Saphenous Trunk in Chronic Venous Disease.

OBJECTIVE: The aim of this study was to analyze the correlation between the extent of diameter change from standing to supine position ("postural diameter change," PDC), and patient or duplex ultrasound (DUS) characteristics in lower limbs with and without saphenous trunk (ST) reflux. METHODS: Measurements were carried out in 193 limbs with primary great saphenous vein, anterior accessory saphenous vein, or small saphenous vein reflux, and 48 control limbs without ST reflux. The inner diameter of the ST was measured with DUS in the standing and lying positions. The PDC, calculated as a percentage, followed the formula: (standing diameter - lying diameter)/standing diameter × 100. Clinical findings (according to the highest "C" - of the CEAP classification), venous clinical severity score, body mass index (BMI), time of visit, and inside and outside temperature were documented. Limbs were divided into two groups using the median value of PDC as a cut off to increase interpretability of the analysis. RESULTS: The median PDC of the ST was 19% in limbs with ST reflux compared with 24% in control limbs (p = .16). In limbs with and without ST reflux, only older age and increased BMI were independently associated with a low PDC of the ST (R(2) 0.13). In limbs with ST reflux, median PDC was significantly lower in C4-C6 (16%, interquartile [IQR] 8-21) than in C0-C1 (23%, IQR 12-35) or C2-C3 limbs (21%, IQR 11-33; p = .016). In addition, PDC was significantly lower in veins with a large diameter (>7 mm) than in those with a small diameter (p = .003). CONCLUSION: Low PDC of the ST correlates with older age and increased BMI. Whether PDC might become a useful additional DUS tool to classify the severity of chronic venous disease and thereby influence the management strategy should be further investigated.

Predictors of Recanalization of the Great Saphenous Vein in Randomized Controlled Trials 1 Year After Endovenous Thermal Ablation.

OBJECTIVE/BACKGROUND: The objective was to identify predictors to develop and validate a prognostic model of recanalization of the great saphenous vein (GSV) in patients treated with endovenous thermal ablation (EVTA). METHODS: The search strategy of Siribumrungwong was updated between August 2011 and August 2014 using MEDLINE, Embase, and the Cochrane register to identify randomized controlled trials (RCTs), in which patients presenting with GSV reflux were treated with radiofrequency or endovenous laser ablation. Leg level data (n = 1226) of 15/23 selected RCTs were pooled. The primary outcome was recanalization of the GSV; the secondary outcome was change in health related quality of life (HRQoL) measured by the Chronic Venous Insufficiency quality of life Questionnaire or Aberdeen Varicose Vein Questionnaire 1 year post-procedure. Candidate predictors were age, sex, body mass index, clinical class, GSV diameter, saphenofemoral junction reflux, type of device, energy, and length of treated vein. RESULTS: At 1 year, 130 GSVs were recanalized (11%). Clinical class (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.4-3.3) and diameter (OR 1.8, 95% CI 1.2-2.7) of the GSV were the strongest predictors of recanalization. Other predictors included in the final model were sex, type of device, and length of treated vein. The performance of the recanalization model was moderate, with an area under the curve above 0.717. GSV diameter, type of device, and amount of energy delivered were the only predictors of the change of HRQoL. None of the candidate predictors were included in the final HRQoL model (R(2) = .027). CONCLUSION: There are several important prognostic factors for GSV recanalization and change of HRQoL after EVTA. However, the performance of each model was unsatisfactory to allow use in clinical practice yet.

Analysis of 1,338 Patients with Acute Lower Limb Deep Venous Thrombosis (DVT) Supports the Inadequacy of the Term "Proximal DVT".

OBJECTIVE/BACKGROUND: For decades acute lower limb deep venous thrombosis (DVT) has been subdivided into distal DVT (isolated to the calf veins) and proximal DVT (extending above calf vein level). The aim of this study was to analyse the anatomical site and extent of thrombus in a large cohort of patients with acute DVT. METHODS: A retrospective analysis of all patients aged >18 years, presenting with unilateral DVT according to duplex ultrasound investigation was performed at the University Hospital of Antwerp, Belgium (1994-2012). The anatomical site and extent of thrombus was registered and subdivided into five segments: calf veins (segment 1), popliteal vein (segment 2), femoral vein (segment 3), common femoral vein (segment 4), and iliac veins, with or without inferior vena cava (segment 5). RESULTS: The median age of the 1,338 patients (50% male) included was 62 years (range 18-98 years). Left sided DVT was predominant (57%). DVT was limited to one segment in 443 patients, of whom 370 had DVT isolated to the calf veins (28% of total cohort). In 968 patients with what was previously called "proximal DVT", the median number of affected segments was three (range 1-5 segments). In this group iliofemoral DVT (at least involving segment four and/or five) was present in 506 patients (38% of total cohort), whereas the remaining patients had femoropopliteal DVT (at least in segment two and/or three but not in four or five). Iliofemoral DVT without thrombus in segments one and two was present in 160 patients (12% of total cohort). CONCLUSION: This study illustrates the large diversity of thrombus distribution in patients previously described as having "proximal DVT". Therefore, this term should be abandoned and replaced with iliofemoral and femoropopliteal DVT. Patients with iliofemoral DVT (38%) could be considered for early clot removal; 12% of all patients with DVT would be ideal candidates for such intervention.

Randomized clinical trial of 940- versus 1470-nm endovenous laser ablation for great saphenous vein incompetence.

BACKGROUND: The independent effect of wavelength used for endovenous laser ablation (EVLA) on patient-reported outcomes, health-related quality of life (HRQoL), treatment success and complications has not yet been established in a randomized clinical trial. The aim was to compare two different wavelengths, with identical energy level and laser fibres, in patients undergoing EVLA. METHODS: Patients with great saphenous vein incompetence were randomized to receive 940- or 1470-nm EVLA. The primary outcome was pain at 1 week. Secondary outcomes were: patient satisfaction, duration of analgesia use and time without normal activities assessed at 1 week; HRQoL after 12 weeks; treatment success after 12 and 52 weeks; change in Venous Clinical Severity Score (VCSS) after 12 weeks; and adverse events at 1 and 12 weeks. RESULTS: A total of 142 legs were randomized (940-nm EVLA, 70; 1470-nm EVLA, 72). Patients in the 1470-nm laser group reported significantly less pain on a visual analogue scale than those in the 940-nm laser group: median (i.q.r.) score 3 (2-7) versus 6 (3-8) (P = 0.004). Duration of analgesia use was significantly shorter after 1470-nm EVLA: median (i.q.r.) 1 (0-3) versus 2 (0-5) days (P = 0.037). HRQoL and VCSS improved equally in both groups. There was no difference in treatment success rates. Complications were comparable in both groups, except for more superficial vein thrombosis 1 week after 1470-nm EVLA. CONCLUSION: EVLA using a 1470-nm wavelength fibre was associated with improved postoperative pain and a reduction in analgesia use in the first week after surgery compared with use of a 940-nm fibre. Treatment success and adverse event rates were similar. REGISTRATION NUMBER: NCT01637181 (http://www.clinicaltrials.gov).

Multiple venous aneurysms in a patient with hypereosinophilic syndrome.

Hypereosinophilic syndrome (HES) is a diverse group of rare disorders, defined by persistent peripheral blood eosinophilia (>1500 per mm(3)), the absence of a primary cause of eosinophilia (such as parasitic or allergic disease), and evidence of eosinophil-mediated end-organ damage. Arterial aneurysms have been previously reported in these patients. This is the first report of a patient with HES and multiple venous aneurysms, causing recurrent pulmonary thromboembolism. Venous aneurysms can represent eosinophil-mediated, potentially fatal end-organ damage in patients with HES.

Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins.

BACKGROUND: A variety of techniques exist for the treatment of patients with great saphenous vein (GSV) varicosities. Few data exist on the long-term outcomes of these interventions. METHODS: Patients undergoing conventional surgery, endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS) for GSV varicose veins were followed up for 5 years. Primary outcome was obliteration or absence of the treated GSV segment; secondary outcomes were absence of GSV reflux, and change in Chronic Venous Insufficiency quality-of-life Questionnaire (CIVIQ) and EuroQol - 5D (EQ-5D™) scores. RESULTS: A total of 224 legs were included (69 conventional surgery, 78 EVLA, 77 UGFS), 193 (86.2 per cent) of which were evaluated at final follow-up. At 5 years, Kaplan-Meier estimates of obliteration or absence of the GSV were 85 (95 per cent c.i. 75 to 92), 77 (66 to 86) and 23 (14 to 33) per cent in the conventional surgery, EVLA and UGFS groups respectively. Absence of above-knee GSV reflux was found in 85 (73 to 92), 82 (72 to 90) and 41 (30 to 53) per cent respectively. CIVIQ scores deteriorated over time in patients in the UGFS group (0.98 increase per year, 95 per cent c.i. 0.16 to 1.79), and were significantly worse than those in the EVLA group (-0.44 decrease per year, 95 per cent c.i. -1.22 to 0.35) (P = 0.013). CIVIQ scores for the conventional surgery group did not differ from those in the EVLA and UGFS groups (0.44 increase per year, 95 per cent c.i. -0.41 to 1.29). EQ-5D™ scores improved equally in all groups. CONCLUSION: EVLA and conventional surgery were more effective than UGFS in obliterating the GSV 5 years after intervention. UGFS was associated with substantial rates of GSV reflux and inferior CIVIQ scores compared with EVLA and conventional surgery. REGISTRATION NUMBER: NCT00529672 (http://www.clinicaltrials.gov).

Management strategies for patients with varicose veins (C2-C6): results of a worldwide survey.

OBJECTIVES: This study evaluated how patient characteristics and duplex ultrasound findings influence management decisions of physicians with specific expertise in the field of chronic venous disease. METHODS: Worldwide, 346 physicians with a known interest and experience in phlebology were invited to participate in an online survey about management strategies in patients with great saphenous vein (GSV) reflux and refluxing tributaries. The survey included two basic vignettes representing a 47 year old healthy male with GSV reflux above the knee and a 27 year old healthy female with a short segment refluxing GSV (CEAP classification C2sEpAs2,5Pr in both cases). Participants could choose one or more treatment options. Subsequently, the basic vignettes were modified according to different patient characteristics (e.g. older age, morbid obesity, anticoagulant treatment, peripheral arterial disease), clinical class (C4, C6), and duplex ultrasound findings (e.g. competent terminal valve, larger or smaller GSV diameter, presence of focal dilatation). The authors recorded the distribution of chosen management strategies; adjustment of strategies according to characteristics; and follow up strategies. RESULTS: A total of 211 physicians (68% surgeons, 12% dermatologists, 12% angiologists, and 8% phlebologists) from 36 different countries completed the survey. In the basic case vignettes 1 and 2, respectively, 55% and 40% of participants proposed to perform endovenous thermal ablation, either with or without concomitant phlebectomies (p < .001). Looking at the modified case vignettes, between 20% and 64% of participants proposed to adapt their management strategy, opting for either a more or a less invasive treatment, depending on the modification introduced. The distribution of chosen management strategies changed significantly for all modified vignettes (p < .05). CONCLUSIONS: This study illustrates the worldwide variety in management preferences for treating patients with varicose veins (C2-C6). In clinical practice, patient related and duplex ultrasound related factors clearly influence therapeutic options.

Randomized clinical trial of endovenous laser ablation versus steam ablation (LAST trial) for great saphenous varicose veins.

BACKGROUND: The aim was to compare endovenous laser ablation (EVLA) and endovenous steam ablation (EVSA) for great saphenous varicose veins in a non-inferiority study. METHODS: Patients with primary great saphenous vein reflux were randomized to EVLA (940 nm) or EVSA (SVS™). Primary outcomes were treatment success (vein obliteration or abolition of reflux) [corrected] at 52 weeks, and Venous Clinical Severity Score (VCSS) at 12 weeks. Secondary outcomes were pain, satisfaction with treatment, duration of analgesia use and days lost from daily activities, changes in Aberdeen Varicose Vein Questionnaire (AVVQ) and EQ-5D™ scores after 12 weeks, and complications at 2 and 12 weeks. RESULTS: A total of 227 legs were treated (EVSA, 117; EVLA, 110); 36 legs treated with EVSA received a low dose and the remaining 81 a higher dose. At 1 year, the treatment success rate after high-dose EVSA was not inferior to that of EVLA: 92 (95 per cent confidence interval (c.i.) 86 to 98) versus 96 (92 to 100) per cent respectively. Changes in VCSS after 12 weeks were similar: -2·69 (95 per cent c.i. -2·34 to -3·04) and -2·51 (-2·10 to -2·93). AVVQ, EQ-5D™ and EQ VAS scores improved equally 12 weeks after both treatments. Patients treated with EVSA reported less postprocedural pain, fewer days of analgesia use, were more satisfied with therapy, and had a shorter convalescence. Complication rates were comparable. CONCLUSION: The 1-year treatment success of high-dose EVSA was not inferior to that of EVLA. Several secondary outcomes were in favour of EVSA. Registration number NCT02046967 (http://www.clinicaltrials.gov).

Neovascularisation after surgery for recurrent saphenofemoral incompetence: does surgical dissection technique matter?

BACKGROUND: The effect of the type of surgery on neovascularisation in the groin is unknown. The aim of the present study was to compare three different surgical techniques used for recurrent saphenofemoral incompetence in view of their effect on neovascularisation in the groin at short- and long-term follow-up after surgery. PATIENTS AND METHODS: 36 consecutive patients undergoing surgery for recurrent saphenofemoral incompetence were randomised. 12 patients underwent sharp dissection with knife or scissors and excision and ligation of scar tissue using absorbable suture material; 12 had dissection with electrocoagulation and 12 dissection with ultrasound (Ultracision Harmonic Scalpel). Clinical outcome was assessed using the venous clinical severity score and venous disability score, and the saphenofemoral junction was evaluated by means of duplex sonography three months and seven years after the operation respectively. If neovascularisation was present, the maximal diameter of new refluxing veins in the groin was measured. RESULTS: There was no statistically significant difference between the three surgical techniques. Duplex ultrasound showed neovascularisation with an average maximal diameter (± standard error) of the newly formed refluxing vessel of respectively 2.00 (± 0.63) mm, 1.00 (± 0.45) mm and 0.50 (± 0.50) mm after three months and 4.29 (± 1.41) mm, 3.32 (± 0.90) mm and 3.00 (0.83) mm after seven years (no significant difference between groups). After seven years no reflux was detected in 8/36 patients, no varicose veins were found in 14/36 patients. The patients were less symptomatic than before our redo operation and no one needed reoperation within the seven years. CONCLUSIONS: Dissection techniques in the groin did not influence the clinical and sonographic result at 3 months and at 7 years after redo surgery for recurrent varicose veins.

Anatomical patterns of the above knee great saphenous vein and its tributaries: implications for endovenous treatment strategy.

OBJECTIVE: The aim of the present study was to analyse the anatomical patterns of the above knee great saphenous vein (GSV) and its tributaries in limbs with varicose veins in view of potential suitability for endovenous treatment. METHODS: Limbs of a consecutive series of new patients with varicose veins presenting at the phlebologic clinic during a 4 month period were studied. In 73 limbs of 56 patients with varicose veins and both saphenofemoral junction and GSV reflux, anatomical patterns of the above knee GSV were defined as: --'complete' GSV: main trunk visualised within the saphenous compartment from the groin to the knee; --'incomplete' GSV: main trunk partially visualised from the groin to mid thigh with a non-refluxing mostly hypoplastic distal GSV and a superficial tributary vein (STV) parallel to the GSV. RESULTS: 51 limbs (70 %) had a 'complete' GSV. In 4 of these 51 limbs reflux passed from the main GSV trunk to a STV at mid thigh level leaving a non-refluxing part of the GSV from mid thigh to the knee. CONCLUSION: In only 64% of limbs with varicose veins the entire above knee GSV was involved in the disease. This may have implications for endovenous treatment strategy.

Closure of the cribriform fascia: an efficient anatomical barrier against postoperative neovascularisation at the saphenofemoral junction? A prospective study.

BACKGROUND: Neovascularisation at the sapheno-femoral junction (SFJ) ligation site in the groin may occur within one year after great saphenous vein (GSV) surgery. Several anatomical and prosthetic barrier techniques have been proposed to prevent this evolution. OBJECTIVE: A prospective study examined whether closing the cribriform fascia could reduce the incidence of postoperative neovascularisation in the groin. PATIENTS AND METHODS: Patients with primary varicose veins and incompetence at the level of the SFJ were included. After SFJ ligation in 235 limbs of 193 patients an anatomical barrier was constructed by closing the cribriform fascia. Postoperative duplex scanning was performed after 2 and 12 months. Results were compared with historical control groups in which either a silicone patch saphenoplasty or no barrier technique had been performed. RESULTS: After one year, 10 limbs had developed recurrent thigh varicose veins and duplex scan showed neovascularisation at the SFJ ligation site in 15 of 223 re-examined limbs (6.7%). This was comparable to the group of 191 limbs with silicone patch saphenoplasty (5.2%) (P=0.526) and superior to the group of 189 limbs without barrier (14.8%) (P<0.01). CONCLUSION: Interposition of an anatomical barrier by closing the cribriform fascia after SFJ ligation reduced ultrasound detected neovascularisation at the SFJ after one year. In primary varicose vein operations application of an anatomical barrier technique (without prosthetic patch) is an alternative option to prevent postoperative neovascularisation.

Accuracy of duplex evaluation one year after varicose vein surgery to predict recurrence at the sapheno-femoral junction after five years.

OBJECTIVE: To investigate whether the results of duplex examination 1 year after sapheno-femoral junction (SFJ) ligation might be helpful in predicting long-term results after 5 years. PATIENTS AND METHODS: Follow-up data concerning patients operated on for primary or recurrent varicose veins of the great saphenous vein were studied 1 year and 5 years after surgery, focusing on the thigh and groin region. Clinical examination was undertaken to detect recurrent thigh varicose veins. The site of SFJ ligation was carefully screened for any signs of neovascularisation by duplex ultrasound. Sensitivity, specificity, positive and negative predictive value of the 1-year duplex scan were calculated, based upon the outcome of a further duplex scan 5 years following surgery. RESULTS: A total of 100 limbs were studied: 50 limbs operated on for primary varicose veins and 50 limbs for recurrent varicose veins. The 1-year duplex ultrasound of the SFJ ligation site had a sensitivity of 80%, a specificity of 91%, a positive predictive value of 70% and a negative predictive value of 95% in assessing the 5 year recurrence rate. CONCLUSION: A postoperative duplex scan of the SFJ 1 year after varicose vein surgery to the great saphenous vein predicts which patients are most likely to have a good outcome 5 years after surgery. The 1-year duplex scan is a reliable diagnostic tool for future studies evaluating the effect of new methods of treating sapheno-femoral incompetence.

Current management of spontaneous pneumothorax.

Spontaneous pneumothorax is divided into primary, when there is no underlying lung disease, and secondary, mainly caused by chronic obstructive pulmonary disease. A variety of different non-invasive and invasive treatment options exist. Due to the lack of large randomised controlled trials no level A evidence is present. A first episode of a primary spontaneous pneumothorax is treated by observation if it is < 20% or by simple aspiration if it is > 20%, but recurrences are frequent. For recurrent or persisting pneumothorax a more invasive approach is indicated whereby video-assisted thoracic surgery provides a treatment of lung (resection of blebs or bullae) and pleura (pleurectomy or abrasion). In patients with a secondary spontaneous pneumothorax related to chronic obstructive pulmonary disease, there is an associated increased mortality and a more aggressive approach is warranted consisting of initial thoracic drainage followed by recurrence prevention by thoracoscopy or thoracotomy in patients with a low or moderate operative risk. Talc instillation by the thoracic drain is preferred for patients with a high operative risk.