A randomised controlled trial of neuromuscular stimulation in non-operative venous disease improves clinical and symptomatic status.

BACKGROUND: This randomised controlled trial investigates the dosing effect of neuromuscular electrical stimulation (NMES) in patients with chronic venous disease (CVD). METHODS: Seventy-six patients with CEAP C3-C5 were randomised to Group A (no NMES), B (30 minutes of NMES daily) or C (60 minutes of NMES daily). Primary outcome was percentage change in Femoral Vein Time Averaged Mean Velocity (TAMV) at 6 weeks. Clinical severity scores, disease-specific and generic quality of life (QoL) were assessed. RESULTS: Seventy-six patients were recruited - mean age 60.8 (SD14.4) and 47:29 male. Six patients lost to follow-up. Percentage change in TAMV (p<0.001) was significantly increased in Groups B and C. Aberdeen Varicose Veins Questionnaire Score (-6.9, p=0.029) and Venous Clinical Severity Score (-4, p-0.003) improved in Group C, and worsened in Group A (+1, p=0.025). CONCLUSIONS: Daily NMES usage increases flow parameters, with twice daily usage improving QoL and clinical severity at 6 weeks in CVD patients.

Cyanoacrylate glue embolisation for varicose veins - A novel complication.

BACKGROUND: Non-thermal non-tumescent methods for varicose vein treatment have rapidly gained popularity in recent years due to clinical efficacy comparable to other endovenous methods, but with a superior safety and tolerability profile. Cyanoacrylate is an adhesive that rapidly polymerises during endovenous treatment to cause rapid occlusion of veins and initiate vein fibrosis. METHOD: Cyanoacrylate glue treatment is known to cause complications such as phlebitis, cellulitis and deep vein thrombosis in rare instances. We present the first reported case of cyanoacrylate extravasation with chronic foreign body reaction in a patient nine months after initial treatment. RESULTS: We discuss the aetiology of this complication, its treatment, patient outcome and its significance to both clinicians and patients. CONCLUSION: Cyanoacrylate glue embolisation can, in rare instances, lead to extravasation and chronic foreign body reaction, necessitating surgical intervention. The relative novelty of cyanoacrylate glue embolisation in the treatment of varicose veins requires clinicians to monitor for rare complications during its use in clinical practice. Patients should be aware of the rare risk of glue extravasation and foreign body reaction for fully informed consent prior to treatment.

Neuromuscular electrical stimulation for the prevention of venous thromboembolism.

Objective Venous thromboembolism, encompassing deep vein thrombosis and pulmonary embolism, is a significant cause of morbidity and mortality, affecting one in 1000 adults per year. Neuromuscular electrical stimulation is the transcutaneous application of electrical impulses to elicit muscle contraction, preventing venous stasis. This review aims to investigate the evidence underlying the use of neuromuscular electrical stimulation in thromboprophylaxis. Methods The Medline and Embase databases were systematically searched, adhering to PRISMA guidelines, for articles relating to electrical stimulation and thromboprophylaxis. Articles were screened according to a priori inclusion and exclusion criteria. Results The search strategy identified 10 randomised controlled trials, which were used in three separate meta-analyses: five trials compared neuromuscular electrical stimulation to control, favouring neuromuscular electrical stimulation (odds ratio of deep vein thrombosis 0.29, 95% confidence interval 0.13-0.65; P = .003); three trials compared neuromuscular electrical stimulation to heparin, favouring heparin (odds ratio of deep vein thrombosis 2.00, 95% confidence interval 1.13-3.52; P = .02); three trials compared neuromuscular electrical stimulation as an adjunct to heparin versus heparin only, demonstrating no significant difference (odds ratio of deep vein thrombosis 0.33, 95% confidence interval 0.10-1.14; P = .08). Conclusion Neuromuscular electrical stimulation significantly reduces the risk of deep vein thrombosis compared to no prophylaxis. It is inferior to heparin in preventing deep vein thrombosis and there is no evidence for its use as an adjunct to heparin.

The Future of Phlebology in Europe.

BACKGROUND: Worldwide superficial and deep venous diseases are common and associated with significant individual and socioeconomic morbidity. Increasing burden of venous disease requires Phlebology to define itself as an independent specialty representing not only patients but the multidisciplinary physicians involved in venous care. METHODS & RESULTS: In this article the scope of venous disease in Europe and subsequent future governance for treatment in the region is discussed. Superficial venous disease is common with 26.9-68.6% of European populations reported to have C2-C6 disease according to the CEAP (Clinical severity, Aetiology, Anatomy and Pathophysiology) scoring system. However, a significant disparity is observed in the treatment of superficial venous disease across Europe. Post thrombotic syndrome (PTS) after deep vein thrombosis (DVT) contributes to the increasing burden of deep venous disease. Aggressive thrombus removal for acute ileofemoral DVT provides a cost-effective 14.4% risk reduction in the development of PTS. Additionally, deep venous lesions requiring endovascular intervention are being increasingly performed to prevent recurrent thrombosis. The European College of Phlebology (ECoP) has been formed to provide a responsible body for the care of the European patient with venous disease. The role of the ECoP includes unifying European member states through standardised guideline production, identification of research strategy and provision of training and accreditation of physicians. CONCLUSION: Creation of a European venous disease specific speciality will provide a patient centred approach through understanding of the impact of disease in the region and delivery of high quality diagnostics and treatment from an appropriately certified Phlebologist.

Comparison of disease-specific quality of life tools in patients with chronic venous disease.

OBJECTIVES: This work was presented as a poster in the American Venous Forum 25th Annual Meeting; 28 February 2013; Phoenix, Arizona, USA. Quality of life (QoL) is an important outcome measure in the treatment for chronic venous disease. The Aberdeen Varicose Vein Questionnaire (AVVQ) and the ChronIc Venous Insufficiency quality of life Questionnaire (CIVIQ-14) are two validated disease-specific QoL questionnaires in current use. The aim of this study is to evaluate the relationship between the AVVQ and the CIVIQ-14 to enable better comparison between studies and to compare these disease-specific QoL tools with generic QoL and clinician-driven tools. METHODS: Adults attending our institution for management of their varicose veins completed the AVVQ, CIVIQ-14 and EuroQol-5D (EQ-5D). Clinical data, CEAP classification and the Venous Clinical Severity Score (VCSS) were collected. The relationship between the AVVQ and CIVIQ-14 scores was analysed using Spearman's correlation. The AVVQ and CIVIQ-14 scores were also analysed with a generic QoL tool (EQ-5D) and a clinician-driven tool, the VCSS. RESULTS: One hundred patients, mean age 57.5 (44 males; 56 females), participated in the study. The median AVVQ score was 21.9 (range 0-74) and the median CIVIQ-14 score was 30 (range 0-89). A strong correlation was demonstrated between the AVVQ and CIVIQ-14 scores (r = 0.8; p < 0.0001). Strong correlation was maintained for patients with C1-3 disease (r = 0.7; p < 0.0001) and C4-6 disease (r = 0.8; p < 0.0001). The VCSS correlated strongly with the AVVQ and CIVIQ-14 scores (r = 0.7; p < 0.0001 and r = 0.7; p < 0.0001, respectively). Both the AVVQ and CIVIQ-14 scores correlated well with the EQ-5D score (r = -0.5; p < 0.0001 and r = -0.7; p < 0.0001, respectively). CONCLUSIONS: This study demonstrates that there is good correlation between two widely used varicose vein specific QoL tools (AVVQ and CIVIQ-14) across the whole spectrum of disease severity. Strong correlation exists between these disease-specific QoL tools and generic and clinician-driven tools. Our findings confirm valid comparisons between studies using either disease-specific QoL tool.

Carbon monoxide poisoning in a patient with carbon dioxide retention: a therapeutic challenge.

We present the case of a 70 year-old man with carbon monoxide poisoning following a house fire. A significant smoking history and likely underlying chronic lung pathology complicated treatment, as due to symptomatic retention of carbon dioxide we were unable to use high-flow oxygen to facilitate the elimination of carbon monoxide. We suggest that patients with risk factors for obstructive lung disease be monitored extremely carefully during treatment for carbon monoxide toxicity.