The Migrating Stent: A Case Report of a Patient With Circulation Issues Who Experienced Stent Migration to the Right Ventricle of the Heart.

Over the past several decades, percutaneous venous stenting has surfaced as the forefront for addressing symptomatic venous outflow obstruction. Stent migration is a very rare, but serious life-threatening complication that can occur with the placement of iliofemoral stents. Life-threatening complications following stent migration include but are not limited to damaged valves, arrhythmias, endocarditis, tamponade, and acute heart failure. Stent failure is seldom understood, but one can attribute it to the incorrect stent and or vein sizing and or the inherent natural forces of the body during respiration. Intravascular ultrasound (IVUS) should be utilized for proper vein and stent sizing prior to placement and patients should be monitored more closely after the procedure. Stent retrieval can be very difficult, as the procedure must consider the location of the migrated stent and the comorbidities associated with the patient. This case report explains an 81-year-old Caucasian male who presented to the Emergency Department with dizziness and dyspnea on exertion. Upon further evaluation via transesophageal echocardiogram, he was found to have severe tricuspid regurgitation and an iliofemoral venous stent located in the right ventricle of the heart.

Challenging conventions: Reconsidering the indication for endovenous ablation in CEAP 2 patients.

INTRODUCTION: Endovenous ablation may not always be necessary for every patient with chronic venous insufficiency who has an indication for endovenous ablation. This study investigates whether compression stockings and Daflon® can be as effective for some patients with CEAP two in chronic venous insufficiency. METHODS: In this study, 137 patients who had endovenous ablation indication received plethysmographical hemodynamic tests and were divided into two groups. Group 1 had normal venous hemodynamics and received compression stockings and Daflon®. Group 2 had abnormal function and received laser ablation. All patients were reevaluated after 6 months. RESULTS: The study showed that there was no statistically significant difference between Groups 1 and 2 in the 6th month measurements after the treatments. CONCLUSION: As a result, we do not find it appropriate and do not recommend that every patient with complaints of chronic venous insufficiency and an indication for endovenous ablation undergo ablation without evaluating lower extremity venous hemodynamics.

Diagnosis and treatment of venous leg ulcers: S2k Guideline of the German Society of Phlebology and Lymphology (DGPL) e.V.

This S2k guideline on venous leg ulcers was created on the initiative and under the leadership of the German Society of Phlebology and Lymphology (DGPL). The guideline group also consisted of representatives from the German Society for Phlebology and Lymphology, German Dermatological Society, German Society for General Medicine, German Society for Angiology, German Society for Vascular Surgery and Vascular Medicine, German Society for Surgery, German Society for Dermatosurgery, German Society for Wound Healing and Wound Treatment, Professional Association of Phlebologists and Lymphologists and Initiative Chronische Wunden. The aim of this guideline is to combine the different approaches and levels of knowledge of the respective professional groups on the basis of consensus, so that a basic concept for the best possible treatment of patients with venous leg ulcers can be provided. A total of 70 specific recommendations were formulated and agreed upon, divided into the subject areas of diagnostics, therapy, prevention of recurrences, and everyday challenges. The guideline thus reflects the current state of scientific knowledge and is intended to be widely used as the best available document for the treatment of patients with venous leg ulcers in everyday clinical practice.

Demographic and clinical characteristics of patients with varicose veins in Albania: a retrospective, single-centre analysis.

Introduction: Chronic venous disease (CVD) constitutes a frequently underdiagnosed pathological condition that progressively diminishes patients' quality of life and imposes an escalating strain on healthcare resources. This study aims to comprehensively investigate the epidemiological landscape of varicose vein disease, examining age group distributions, gender patterns, residence influences, marital status correlations, weight considerations, educational impacts, and various aspects related to varicose veins. Material and methods: This was a single-centre retrospective analysis, in Albania from May 2018 to September 2023. Data were collected retrospectively through hospital records. Data collection involved administering a structured questionnaire to study participants, categorically organised into three sections. The first section focused on collecting demographic information, the second section involved self-perception of identifying risk factors associated with varicose veins, and the final section included inquiries about the history of variceal surgery. Results: The CEAP classification distribution in our cohort revealed a predominant presence of C2 (varicose veins) in 53.3% of patients, followed by C3 (oedema) at 29.2%, and C4 (changes in skin and subcutaneous tissue secondary to CVD) at 10.5%, whereas C5 (healed venous ulcer) and C6 (active venous ulcer) were less frequent. Based on the body mass index (BMI) scale, data from patients indicated that 9.7% were in the category of underweight, 54.8% had a normal BMI, and 35.5% were categorised as overweight. Conclusions: The study's thorough exploration of patient perspectives, risk factors, and treatment choices contributes to a holistic understanding of varicose vein management, emphasising the importance of personalised approaches that account for demographic variations and individual beliefs.

Effects of a Dietary Supplement Composed of Baicalin, Bromelain and Escin for Venous Chronic Insufficiency Treatment: Insights from a Retrospective Observational Study.

Chronic venous insufficiency (CVI) represents a risk factor for cardiovascular events. The first-line treatment includes the use of compression stockings and lifestyle changes. Natural products, such as flavonoids, could be used to improve the effects of compression therapy due to their anti-inflammatory and anti-oxidant properties. This study aims to evaluate the effects of a dietary supplement containing baicalin, bromeline and escin in CVI patients. A retrospective cohort study was performed by using the medical records of CVI affected outpatients. Patients treated with the dietary supplement were defined as "users". A modified Venous Clinical Severity Score (VCSS) was calculated, including pain, inflammation, vessels induration and skin pigmentation. All clinical variables were evaluated at baseline (T0), after 30 (T1) and 90(T2) days in "users" and "non-users". Out of 62 patients, 30 (48.4%) were "users". No difference was observed between groups at baseline. A lower VCSS value was recorded in "users" than that observed in "non-users" at T2 (7.0 (4.0-9.0) vs. 9.0 (5.0-10.0); p = 0.025). Vessels' induration and pain significantly reduced in 53.3% and 43.3% of "users" and in 18.8% and 9.4% of "non-users". Only "users" (33.3%) showed a reduction of the inflammatory signs as well as a decrease in malleolar circumference, from 29.0 (26.5-30.0) to 27.5 (26.0-28.5) (p < 000.1). A reduction of C-reactive Protein levels was found in "users" compared to "non-users" at T2 (1.0 (0.9-1.2) vs. 1.3 (1.0-1.5); p = 0.006). These findings suggest that implementation of a dietary supplement could improve the clinical outcomes of CVI patients.

Compression therapy after endovenous laser ablation: Patient compliance and impact on clinical outcome.

OBJECTIVES: This study aimed to investigate the impact of post-interventional compression therapy on clinical outcomes after endovenous laser ablation (EVLA) of incompetent saphenous veins. METHODS: This prospective, controlled, multicenter study in Germany involved 493 varicose vein patients followed-up for 6 months. RESULTS: Compression therapy significantly reduced symptoms compared to no compression (VCSS: 1.4 ± 1.6 vs 2.2 ± 2.2; p = .007). Post-interventional therapy duration of up to 14 days was found to be most effective for improving patient-reported disease severity (p < .001) and higher quality of life (p = .001). Patient compliance was high (82%), and non-compliance was linked to worse disease severity (VCSS 1.4 ± 1.5 vs 2.1 ± 2.3, p = .009). CONCLUSION: In conclusion, post-interventional compression therapy is beneficial by reducing symptoms and improving quality of life. High patient compliance with the therapy is observed, and non-compliance is associated with worse disease severity.

Safety of synchronous prophylactic ablation of the anterior saphenous vein in patients undergoing great saphenous vein thermal ablation- 6 months follow-up data of the SYNCHRONOUS study.

BACKGROUND: The SYNCHRONOUS-study investigates simultaneous ASV-ablation with great saphenous vein (GSV) treatment in endovenous laser ablation (EVLA) for preventing varicose vein recurrence. This sub-study examines complication rates associated with prophylactic ASV-ablation. METHODS: Among 1173 patients with refluxing GSV, 604 underwent GSV-ablation only, and 569 received additional ASV-ablation. Complication rates were compared over 6 months. RESULTS: Approximately 80% of patients were complication-free with minor bruising and dysesthesia being most common complications. After 6 months, additional prophylactic ASV-ablation did not increase the rate of complications compared to GSV-only treatment. CONCLUSION: The 6-months follow-up data suggests that prophylactic ASV-closure, alongside GSV-treatment, is safe, with similar complication rates to GSV-only EVLA.

Neuropathy in a Patient With Congenital Absence of the Inferior Vena Cava.

Neuropathic pain is a frequent complaint in the neurology clinic. We present a case of a 31-year-old male with congenital absence of the inferior vena cava (AIVC) resulting in venous hypertension who complained of lower extremity pain interfering with his daily activities. His AIVC was thought to be incidental rather than causative of his pain complaints. His examination was consistent with peripheral neuropathy. Simple lifestyle adaptations, such as restriction of physical activity and leg elevation, were sufficient to relieve his symptoms. Recognition of the role of AIVC may have prevented additional invasive procedures in our patient.

Drug Reaction with Eosinophilia and Systemic Symptoms Induced by Diosmin and Hesperidin: A Case Report.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse reaction which exhibits a diverse range of presentations. We described a 48-year-old man diagnosed with acute generalized exanthematous pustulosis (AGEP)-like DRESS following the administration of diosmin and hesperidin. To our knowledge, diosmin and hesperidin-induced DRESS are exceptionally rare. This aims to raise awareness of potential severe cutaneous side effects in patients taking these agents.

EndoVenous-assisted invaginated stripping of the great saphenous vein: A pilot and feasibility study.

Objective: By incorporating an endovascular component into Great Saphenous Vein stripping, EndoVenous-assisted Invaginated Stripping (EVIS) aims to make the procedure minimally invasive. A study was conducted to investigate the surgical intervention. Methods: Sketches and videos were used to illustrate the technical aspects of EVIS. A prospective cohort study included 20 patients with chronic venous insufficiency (CVI). Results: EVIS is performed as a day-surgery. Technical success was 100%, and no complications were recorded. The mean operative time was 45 minutes, intraoperative pain score was 4.8, post-operative pain was 2.5, 1.8, 1.2, 0.5 at 48 hours, 1, 4, and 12 weeks, respectively. The mean blood loss was 15 mL, and the mean length of the GSV strapped was 19 cm. The follow-up duplex showed a reduction in the diameter of the residual GSV stump. Conclusions: EVIS is a combination of standard techniques that may prove valuable in managing CVI.

[Varicosis-Current treatment concepts]. / Varikosis ­ aktuelle Therapiekonzepte.

Varicosis is a chronic progressive disease characterized by varicose veins of the lower extremities. Pain, swelling and heaviness of the legs are typical symptoms. These symptoms are caused by a pathological venous reflux, arising from a weakness of the vein wall and progressive venous insufficiency. The indications for invasive surgery are the symptomatic clinical, etiological, anatomical, pathophysiological (CEAP) stages C2s-C6. Compression therapy and venoactive drugs can be recommended for conservative therapy. When it comes to surgical treatment conventional open vein surgery is associated with the best long-term results. Endovenous thermal ablation is associated with few postoperative complications and favors earlier mobilization of the patient. Sclerotherapy has become established with good clinical results for the ablation of reticular and telangiectatic veins, for recurrences and complicated vein anatomy.

Radiofrequency ablation for the treatment of great saphenous venous insufficiency using a newly developed VENISTAR catheter: A preliminary study.

OBJECTIVES: This study was aimed to assess the preliminary outcomes of radiofrequency ablation (RFA) using a newly developed catheter (VENISTAR) for the treatment of incompetent great saphenous veins (GSVs). METHODS: In this prospective observational study, endovenous RFA using a VENISTAR catheter was performed on 16 saphenous veins in 12 patients between August and November 2019. Patients' pre- and post-procedural data were recorded. Doppler ultrasound imaging and clinical evaluation were performed at 1 week and 1, 3, and 6 months to determine the efficacy and safety of the treatment. RESULTS: Technical success and complete closure of the targeted GSVs immediately after the procedure were observed in all 16 limbs (100%). However, one patient (one limb) was found to have partial occlusion without significant reflux after 1 week of follow-up. Kaplan-Meier analysis yielded a complete occlusion rate of 93% at 6 months of follow-up. The Venous Clinical Severity Scores at the time of all follow-up were significantly lower than those at baseline (3.3 ± 1.1 at baseline to 0.6 ± 0.6, 0.3 ± 0.6, 0.1 ± 0.4, and 0.2 ± 0.4 at 1 week and 1, 3, and 6 months, respectively) (p < .001). Mild post-procedural pain was noted in 7 and 4 limbs at 1 week and 1 month, respectively. Grade 1 ecchymosis over the ablated segment was noted in 5 (35.7%) of 14 limbs at 1-week follow-up. CONCLUSIONS: Endovenous treatment of GSV insufficiency using a new VENISTAR radiofrequency catheter has been shown to be feasible, effective, and safe throughout the 6-month follow-up.

3-year clinical outcomes of A Singapore VenaSeal™ real world post-market evaluation Study (ASVS) for varicose vein ablation.

INTRODUCTION: Medium-term clinical outcome data are lacking for cyanoacrylate glue (CAG) ablation for symptomatic varicose veins, especially from the Asian population. OBJECTIVES: Aim was to determine the 3-year symptomatic relief gained from using the VenaSeal™ device to close refluxing truncal veins from the Singaporean ASVS prospective registry. METHODS: The revised Venous Clinical Severity Score (rVCSS) and three quality of life (QoL) questionnaires were completed to assess clinical improvement in venous disease symptoms along with a dedicated patient satisfaction survey. 70 patients (107 limbs; 40 females; mean age of 60.9 ± 13.6 years) were included at 3 years. RESULTS: At 3 years, rVCSS showed sustained improvement from baseline (5.00 to 0.00; p < 0.001) and 51/70 (72.9%) had improvement by at least 2 or more CEAP categories. Freedom from reintervention was 90% and 85.7% patients were extremely satisfied with the treatment outcome. No further reports of further hypersensitivity reactions after one year. CONCLUSION: The 3-year follow-up results of the ASVS registry demonstrated continued and sustained clinical efficacy with few reinterventions following CAG embolization in Asian patients with chronic venous insufficiency. TRIAL REGISTRATION: ClinicalTrials.gov Registration: NCT03893201.

Comparative effectiveness of non-compounded polidocanol 1% endovenous microfoam (Varithena) ablation versus endovenous thermal ablation utilizing a systematic review and network meta-analysis.

OBJECTIVE: We compared the effectiveness and safety of polidocanol 1% endovenous microfoam ablation vs endovenous thermal ablation with radiofrequency or laser energy for treatment of venous insufficiency caused by lower extremity truncal vein incompetence via network meta-analysis of published comparative evidence. METHODS: We conducted a systematic literature review following best practices, including a prospective protocol. We screened studies published in English from 2000 to 2023 for randomized and nonrandomized studies reporting direct or indirect comparisons between polidocanol 1% endovenous microfoam and endovenous thermal ablation. Thirteen studies met our eligibility criteria for the network meta-analysis. The co-primary effectiveness outcomes were the closure rate ≥3 months after procedure and the average change in the Venous Clinical Severity Score. For the subgroup of venous ulcer patients, the ulcer healing rate was the primary effectiveness outcome. The secondary outcomes included safety and patient-reported outcomes. Network meta-analyses were conducted on outcomes having sufficient data. Categorical outcomes were summarized using odds ratios (ORs) with 95% confidence intervals (CIs). Sensitivity tests and estimates of network inconsistency were used to investigate the robustness of our meta-analysis. RESULTS: We found that polidocanol 1% endovenous microfoam was not significantly different statistically from endovenous thermal ablation for venous closure (OR, 0.65; 95% CI, 0.36-1.18; P = .16). Although not the primary aim of the study, the network meta-analysis also provided evidence to confirm our supposition that polidocanol 1% endovenous microfoam was significantly differentiated statistically from physician-compounded foam, with higher odds for vein closure (OR, 2.91; 95% CI, 1.58-5.37; P < .01). A sensitivity analysis using the longest available time point for closure in each study, with a minimum of 12 months of follow-up (median, 48 months; range, 12-72 months), showed results similar to those of the main analysis. No association was found between the risk of deep vein thrombosis and the treatment received. The available data were insufficient for a network meta-analysis of Venous Clinical Severity Score improvement and ulcer healing rates. CONCLUSIONS: Polidocanol 1% endovenous microfoam was not significantly different statistically from endovenous thermal ablation for venous closure and deep vein thrombosis risk for chronic venous insufficiency treatment, based on a network meta-analysis of published evidence. Polidocanol 1% endovenous microfoam was significantly differentiated statistically from physician-compounded foam, with higher odds of vein closure. A sensitivity analysis found venous closure findings were robust at follow-up intervals of 12 months or greater and for up to 6 years. New evidence meeting the inclusion criteria for this review will be incorporated at regular intervals into a living network meta-analysis.

Bacterial Species Involved in Venous Leg Ulcer Infections and Their Sensitivity to Antibiotherapy-An Alarm Signal Regarding the Seriousness of Chronic Venous Insufficiency C6 Stage and Its Need for Prompt Treatment.

BACKGROUND: Venous leg ulcers (VLUs) are a common chronic wound condition susceptible to infection by various bacterial species. Understanding bacterial presence and antibiotic sensitivity is crucial for effective treatment. Methodsː Medical records of 60 patients diagnosed with the C6 chronic venous insufficiency stage were analyzed retrospectively. The patients were divided into an active recurrent VLU group (33 cases) and a first-onset active VLU group (27 cases). Bacterial identification, antibiotic sensitivity, and laboratory markers were assessed. Resultsː Pseudomonas aeruginosa was the most prevalent bacterial species in both the study (72.72%) and control (37.03%) groups, along with other common bacteria such as Proteus mirabilis, Enterococcus sp., Staphylococcus aureus, Acinetobacter baumannii, Klebsiella spp., and Escherichia coli. Furthermore, uncommon bacteria, including Providencia rettgeri, Group B Streptococcus, and Salmonella Paratyphi B, and a fungal infection with Candida albicans, were identified only in the study group, while Morganella morganii was found exclusively in the control group. Pseudomonas aeruginosa showed significant sensitivity to several antibiotics, particularly Amikacin and Meropenem. Nonspecific laboratory markers, such as CRP, fibrinogen, ESR, WBC, CK, neutrophils, and lymphocytes, revealed statistically significant differences between groups, indicating their potential as biomarkers for monitoring recurrent VLUs. Conclusionsː These results highlight the need for comprehensive diagnostic approaches to effectively manage VLU infections and improve patient outcomes. Further research is warranted to explore factors influencing the presence of uncommon bacteria and to develop targeted interventions for VLU management.

Effectiveness of herbal drug Terminalia Arjuna in chronic venous insufficiency - A prospective observational study.

INTRODUCTION: Chronic venous insufficiency (CVI) manifests in various clinical presentations ranging from asymptomatic but cosmetic problems to severe symptoms, such as lower limb edema, skin trophic changes, and ulceration. CVI substantially affects the quality of life and work productivity of the patients. Ayurveda, an ancient traditional medicine in India, evaluates the various pathological stages of CVI with a wide range of pathological conditions such as Siragranthi (venous abnormalities), Raktavaritavata (disorders of vata occluded by rakta ∼ blood), ApanaVaigunya (vitiated apanavayu), Arsha (hemorrhoids), VataRakta (rheumatism due to rakta), Kushtha (integumentary disease) and Dushta Vrana (putrefied wound) depending upon the presentations of the patient. Ayurvedic texts mention Terminalia arjuna as a potential herb for treating various conditions related to the circulatory system. The drug is an effective anti-inflammatory, anti-oxidant, and anti-hypertensive and has a definite role in improving cardiovascular hemodynamics and wound healing. These attributes suggest that the potential of Terminalia arjuna needs to be explored as a promising venoactive drug. METHODS: This prospective observational study included 25 patients (31 limbs) with CVI who were treated with Tab Terminalia arjuna (Bark extract of Terminalia arjuna in a dose of 500 mg, given twice a day) and were observed on two visits on day 30 and day 90. Follow-up was carried out for three months to evaluate post-treatment complications or adverse effects. The clinical outcome assessment was done using Venous Clinical Severity Score (VCSS), and clinical grading was performed using clinical classification (C0 - C6) of CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification. RESULTS: The median VCSS score (of both limbs) during the third visit was comparatively lower than the first, with a statistically significant improvement at 0.05 level. Further, there was a substantial positive improvement in the clinical classification of CEAP among the patients in pre and post treatment phase. CONCLUSION: The prospective observational study shows that Tab Terminalia arjuna is safe and effective in CVI, reducing the symptoms like pain, edema, inflammation, pigmentation, induration and also expediting ulcer healing.

Investigating low rates of compliance to graduated compression therapy for chronic venous insufficiency: A systematic review.

Chronic venous insufficiency (CVI) is a chronic lower limb progressive disorder with significant burden. Graduated compression therapy is the gold-standard treatment, but its underutilisation, as indicated in recent literature, may be contributing to the growing burden of CVI. The aim of this systematic review is to determine the reasons for poor compliance in patients who are prescribed graduated compression therapy in the management of chronic venous insufficiency. A systematic review of the literature was conducted to identify the reasons for non-compliance in wearing graduated compression therapy in the management of chronic venous insufficiency. The keyword search was conducted through Medline, PubMed, CINAHL, Cochrane library, AMED, and Embase databases from 2000 to April 2023. Qualitative and quantitative studies were included with no study design or language limits imposed on the search. The study populations were restricted to adults aged over 18 years, diagnosed with chronic venous insufficiency. Of the 856 studies found, 80 full-text articles were reviewed, with 14 being eligible for the review. Due to the variability in study designs, the results were summarised rather than subjected to meta-analysis. There are five main overarching themes for non-compliance, which are physical limitations, health literacy, discomfort, financial issues, and psychosocial issues with emerging sub-themes. Graduated compression therapy has the potential to reduce the burden of chronic venous insufficiency if patients are more compliant with their prescription.

Valvar bypass surgery to ameliorate persistent lower limb edema caused by post-thrombotic syndrome: a case report and literature review.

Obstruction and/or reflux compromise during venous emptying can facilitate different pathophysiologies in chronic venous insufficiency (CVI). We present a patient with persistent lower limb CVI edema caused by post-thrombotic syndrome (PTS), who responded well to femoral vein valve therapy via axillary vein bypass after unsuccessful valvuloplasty, and led a normal life. During a 12 month observation period, bridging vessels completely restored original anatomical structures. In a literature study, no similar surgeries were reported, but we show that this operation may be feasible in selected patients.

Plethysmography: A game changer for chronic venous insufficiency diagnosis, treatment, and follow-up.

OBJECTIVE: Chronic Venous Insufficiency (CVI) presents a various clinical symptoms and treatment options. Although it is generally known which treatment option is more appropriate in which situations in CVI, it is even more difficult to find the right option in some uncertain situations. In this study, we aimed to evaluate the potential contribution of Digital Photoplethysmography (D-PPG) in the diagnosis of CVI and especially in the selection of treatment options. PATIENTS AND METHOD: This retrospective study was conducted at Bursa Heart and Arrhythmia Hospital, involving 721 consecutive patients diagnosed with CVI and with Endovenous Laser Ablation (EVLA) indication. The patients were divided into 2 groups according to the extent of the failure in Doppler USG. In Group 1, the insufficiency ended above the knee, and in Group 2, the insufficiency progressed to below the knee. Patients were evaluated based on anamnesis, physical examination, Doppler USG, and D-PPG. Clinical classification, Venous Clinic Severity Score (VCSS), Quality of Life (QoL) assessment, venous pump capacity (VPC), and venous refill time (VRT) were measured. RESULTS: The study included 263 male and 458 female patients with a mean age of 52.37 ± 12.26 years. Significant differences were observed between Group 1 (above knee reflux) and Group 2 (below knee reflux) patients in terms of VCSS, QoL, VPC, and VRT values. The mean values of VCSS, patient complaints, VPC, and VRT were higher in Group 2 patients. Similar findings were observed within the CEAP 2 subgroup. CONCLUSION: D-PPG shows potential as a valuable tool in the diagnosis and treatment of CVI. By providing information about venous hemodynamics and volume changes, it can assist in optimizing treatment decisions, including saphenous vein preservation. Combining D-PPG with Doppler USG may improve the comprehensive assessment of CVI and change the treatment option, especially for CEAP 2 patients. More research is needed to confirm these findings and explore wider applications of plethysmographic methods in the management of CVI.