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Objective: National guidelines in the United Kingdom have recommended regular exercise for individuals with venous leg ulceration. However, data on the effects of exercise on ulcer healing and recurrence are sparse. In the present study, we aimed to quantify the evidence for exercise regarding venous ulcer healing with respect to the primary outcomes of the proportion of healed ulcers and rate of ulcer recurrence. The secondary outcomes were improvement in ulcer symptoms, ulcer healing time, quality of life, compliance, and adverse events reported. Methods: The review followed PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines using a registered protocol (CRD42021220925). The MEDLINE and Embase databases and Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, European Union Clinical Trials, and International Standard Randomised Controlled Trial Number registries were searched up to April 6, 2022 and included studies comparing exercise therapy and compression vs compression alone. Data for the proportion of healed ulcers were pooled using a fixed effects meta-analysis. Results: After screening 1046 reports, 7 were included, with 121 participants allocated to exercise therapy and 125 to compression alone. All the reports were of randomized controlled trials and had reported ulcer healing at 12 weeks, with a pooled relative risk of ulcer healing of 1.38 for exercise vs compression (95% confidence interval, 1.11-1.71). Only one study had reported on recurrence; thus, data pooling was not performed. No differences between exercise and usual care were demonstrated. Compliance with exercise ranged from 33% to 81%. The included studies demonstrated low enrollment and a high risk of bias. Also, most of the trials had failed to demonstrate any differences in activity completed between the intervention and control arms. Conclusions: A paucity of studies has examined leg ulcer recurrence after exercise programs, with no evidence to show that exercise is beneficial. Furthermore, the quality of evidence supporting exercise as an adjunct to ulcer healing is very low, and the trials demonstrated serious methodologic flaws, chiefly in recording the activity undertaken by the participants in the intervention arm. Future randomized controlled trials should implement activity monitoring and standardize the reporting of key patient, ulcer, and reflux characteristics to enable future meaningful meta-analyses to determine the role of exercise as an adjunct to venous leg ulceration healing.

Objectives Exercise improves haemodynamic parameters in patients with chronic venous disease. There is a paucity of evidence on its effect in post-thrombotic syndrome (PTS). The aim of this systematic review is to assess the impact of exercise in PTS. Methods Adhering to PRISMA guidelines and following PROSPERO registration (CRD42021220924), MEDLINE, Cochrane Library, EMBASE database, and trial registries were searched on 19th May 2022. Results One article met the inclusion criteria and a narrative synthesis was carried out. The included randomised controlled trial reported a between-group mean difference of 4.6 points ( p = .027) in the VEINES-QOL score and −2.0 points ( p = .14) in the Villalta score, in favour of exercise therapy. The statistical significance threshold was not reached. Conclusion Data on exercise in PTS remains sparse but exercise appears to be a safe intervention. In the context of this literature, a potential future trial and outcome reporting measures are suggested.

Groin incision surgical site infections (SSIs) following arterial surgery are common and are a source of considerable morbidity. This review evaluates interventions and adjuncts delivered immediately before, during, or after skin closure, to prevent SSIs in patients undergoing arterial interventions involving a groin incision.MEDLINE, EMBASE, and CENTRAL databases were searched.This review was undertaken according to established international reporting guidelines and was registered prospectively with the International prospective register of systematic reviews (CRD42020185170). The MEDLINE, EMBASE, and CENTRAL databases were searched using pre-defined search terms without date restriction. Randomised controlled trials (RCTs) and observational studies recruiting patients with non-infected groin incisions for arterial exposure were included; SSI rates and other outcomes were captured. Interventions reported in two or more studies were subjected to meta-analysis.The search identified 1 532 articles. Seventeen RCTs and seven observational studies, reporting on 3 747 patients undergoing 4 130 groin incisions were included. A total of seven interventions and nine outcomes were reported upon. Prophylactic closed incision negative pressure wound therapy (ciNPWT) reduced groin SSIs compared with standard dressings (odds ratio [OR] 0.34, 95% CI 0.23 - 0.51; p.001, GRADE strength of evidence: moderate). Local antibiotics did not reduce groin SSIs (OR 0.60 95% CI 0.30 - 1.21 p = .15, GRADE strength: low). Subcuticular sutures (vs. transdermal sutures or clips) reduced groin SSI rates (OR 0.33, 95% CI 0.17 - 0.65, p = .001, GRADE strength: low). Wound drains, platelet rich plasma, fibrin glue, and silver alginate dressings did not show any significant effect on SSI rates.There is evidence that ciNPWT and subcuticular sutures reduce groin SSI in patients undergoing arterial vascular interventions involving a groin incision. Local antibiotics did not reduce groin wound SSI, although the strength of this evidence is lower. No other interventions demonstrated a significant effect.

Objectives Peripheral artery disease is estimated to affect 237 million individuals worldwide. Critical limb ischaemia, also known as chronic limb threatening ischaemia is a consequence of the progression of peripheral artery disease which occurs in ∼21% of patients over a five-year period. The aim of this systematic review is to assess the use of additional below-the-ankle angioplasty in comparison to the use of above-the-ankle angioplasty alone, and the subsequent rates of amputation, wound healing, restenosis, rest pain, reintervention and complications. Methods This systematic review was undertaken in accordance with PRISMA guidelines following a registered protocol (CRD42019154893). Online databases were searched using a search strategy of 20 keywords. Included articles reported the outcome for inframalleolar (pedal artery, pedal arch, plantar arteries) angioplasty with additional proximal angioplasty in comparison to proximal angioplasty alone. GRADE assessment was applied to assess the quality of the evidence. Results After screening 1089 articles, 10 articles met the inclusion criteria. Comparative performance assessment of below-the-ankle with above-the-ankle versus above-the-ankle angioplasty alone was undertaken in 3 articles, with the remaining 7 articles reporting outcomes of below-the-ankle with above-the-ankle angioplasty with no distinct comparator group. Significant decrease in major lower limb amputation at the last follow-up in the below-the-ankle group when compared with the above-the-ankle angioplasty alone group was observed in a single study (3.45% vs. 14.9%, p Conclusion To date, there is a lack of studies assessing inframalleolar interventions and their use in improving limb salvage, wound healing and symptomatology. Prospective RCTs should be undertaken with adequate participant numbers to be sufficiently powered and report clinically important end-points.

Objective The ambulatory selective variceal ablation under local anesthesia (ASVAL) technique subscribes to the “ascending” theory of varicose vein etiology, which recommends primary ambulatory phlebectomy as a treatment for tributary varicosities and truncal vein incompetence. This systematic review explores the efficacy and safety of the ASVAL technique for the treatment of symptomatic varicose veins. Methods A comprehensive search of the Medline and Embase databases and the Cochrane Register of Controlled Trials in May 2019 revealed 11 original articles that were qualitatively reviewed. The primary outcome was the absence from recurrent varicose veins at 1-year follow-up. Secondary outcomes were resolution of great saphenous vein (GSV) reflux on duplex ultrasound, change in GSV diameter, objective and subjective clinical improvement in chronic venous disease, and patient-reported outcome measures. Results A total of 2106 limbs underwent intervention in 1734 patients reported in two randomized controlled trials, one case control study, three cohort studies, and five case series. Varicosity recurrence at 1 year ranged from 0.5% to 13.5% in patients. Of 1622 limbs with diagnosed GSV incompetence before intervention, 1114 were competent at 1 year (mean, 68.2% [±12.62%]). All studies measuring GSV diameter reported statistically significant reductions in vein size. Conclusions ASVAL may be considered as a minimally invasive treatment for early stages of chronic venous disease in the presence of truncal reflux. The evidence base should be strengthened by prospective randomized controlled trials that follow standardized procedures and report according to recognized measures of quality of life alongside clinical and hemodynamic data.

Introduction: Post-thrombotic syndrome (PTS) is a common lifelong condition affecting up to 50% of those suffering from deep vein thrombosis (DVT). PTS compromises function and quality of life with subsequent venous ulceration in up to 29% of those affected. Areas covered: A literature review of surgical and non-surgical approaches in the prevention and treatment of PTS was undertaken. Notable areas include the use of percutaneous endovenous interventions and the use of graduated compression stockings (GCS) after acute proximal DVT. Expert opinion: In patients with acute iliofemoral DVT, we think it is important to have a frank conversation with the patient about catheter-directed thrombolysis, aiming to reduce the severity of PTS experienced. We advocate ultrasound-accelerated thrombolysis with adjunctive procedures, such as deep venous stenting for proximal iliofemoral DVT. For patients with isolated femoral DVT, we believe that anticoagulation and GCS should be recommended. In patients with established PTS, we recommend GCS for symptomatic relief. We recommend that patients engage in regular exercise where possible with the prospect of gaining symptomatic relief. For those with severe PTS that has a significant effect on quality of life, we discuss the patient’s case at a multi-disciplinary team meeting to plan for endovenous intervention.

Objectives This survey study evaluates current management strategies for venous ulceration and the impacts of the EVRA trial results. Methods An online survey was disseminated to approximately 15000 clinicians, through 12 vascular societies in 2018. Survey themes included: referral times, treatment times and strategies, knowledge of the EVRA trial and service barriers to managing venous ulceration. Data analysis was performed using Microsoft Excel and SPSS. Results 664 responses were received from 78 countries. Respondents were predominantly European (55%) and North American (23%) vascular surgeons (74%). Responses varied between different countries. The median vascular clinic referral time was 6 weeks and time to be seen in clinic was 2 weeks. This was significantly higher in the UK (p ≤ 0.02). 77% of respondents performed surgical/endovenous interventions prior to ulcer healing, the median time to intervention was 4 weeks. 31% of participants changed their practice following EVRA. Frequently encountered barriers to implementing change were a lack of operating space/time (18%). Conclusion Venous ulcers are not managed as quickly as they should be. An evaluation of local resource requirements should be performed to improve service provision for venous ulceration. When interpreting the results of this survey consideration should be given to the response rate.

Background Various guidelines exist worldwide for the diagnosis and management of venous leg ulcers; however, these are difficult to implement resulting in disparate treatment of patients globally. Method An online, 26-question survey was designed to evaluate the current global management of venous leg ulceration and was emailed globally to approximately 15,000 participants (November 2017–February 2018). Results Overall, 799 responses were received from 86 countries, with a 5% response rate. The respondent physicians saw a median of 10 (interquartile range 5–20) patients per month, with a median time to referral from primary to secondary care of six weeks. Of the respondents, 61% arranged an ankle brachial pressure index on first visit and 84% performed a venous duplex, with 95% prescribing compression for those in whom it was not contraindicated. Fifty-nine percent performed endovenous intervention or surgery prior to ulcer healing. Conclusions The survey showed a diversity of treatment pathways. The need to develop a robust, clear pathway for patients with leg ulceration is clearly required.

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.

Introduction Evidence regarding ultrasound assessment of left common iliac vein diameter (LCIV) is limited. Extensive work is currently being undertaken worldwide on non-thrombotic iliac vein lesions to identify patients who may benefit from intervention to alleviate symptoms of chronic venous obstruction. Interventions include long-term stent implantation to improve vein diameter stenosis. This study aimed to assess a cohort of symptomatic venous patients and the diameter of the LCIV in these patients. Methods : Retrospective medical records review of all patients attending a tertiary vascular surgery centre who underwent a venous duplex ultrasound assessment between April 2017 and February 2018 were analysed for assessment of LCIV. Medical records of those patients with documented LCIV diameter were assessed over 18 months of follow-up. Results : A total of 672 (271 males, 401 females) LCIV diameter measurements were collected. The age of the patients ranged from 21 to 95 years (mean = 56.38). Median LCIV diameter overall was 7.64 mm (IQR 5.80mm–9.00 mm). 40 patients (6%) were reported to have a LCIV diameter measurement of < 4 mm, 8 (20%) male and 32 female (80%). 17 of these 40 patients (47.5%) were treated conservatively. Median LCIV diameter was 3.4 mm (IQR 2.5–3.7). 21 of these 40 patients (52.5%) underwent superficial venous intervention only, with a median LCIV diameter of 3.5 mm (IQR 3.2–3.7) and 2 out of these 40 patients (5%) underwent deep venous stenting (2/2 female – 100%), with a median LCIV diameter of 2.9 (IQR 2.9–2.9). No patients underwent both superficial and deep venous treatment in this 40 patient cohort. In those undergoing superficial venous intervention, 4 (19%) underwent repeat treatment. The two deep venous stenting patients underwent magnetic resonance venogram and venogram with intravascular ultrasound to allow stent placement, which confirmed a narrowed left common iliac vein. Primary stent patency at 18 months was 100%. Conclusion In this large study cohort of venous duplex assessments the median vein diameter was 7.64 mm and 40 patients out of 672 had a vein diameter smaller than 4 mm. 2 patients underwent deep venous stenting with primary patency of 100%.

Objective: Extended anticoagulation therapy should always be considered after standard treatment of an unprovoked episode of venous thromboembolism (VTE). It can also be considered for selected patients with provoked VTE. However, the evidence-based protocols suggested by some clinical guidelines and risk assessment tools to guide this practice are limited and ambiguous. The goal of the present survey research was to analyze current practices in applying extended anticoagulation therapy for patients with VTE among members of the American Venous Forum (AVF) and European Venous Forum (EVF). Methods: An online survey was created by the AVF Research Committee. The survey consisted of 16 questions to identify the country of practice, specialty, experience of the participating physicians, and their clinical practice patterns in applying extended anticoagulation therapy for VTE patients. The survey was distributed via e-mail to the members of the AVF and EVF. Results: A total of 144 practitioners, 48 AVF members (33%) and 96 EVF members (66%), participated in the survey. Most of the respondents identified themselves as vascular specialists with primary certification in vascular surgery (70%), vascular medicine or angiology (9%), and venous disease or phlebology (3%). Of the 144 respondents, 72% believed that the risk of VTE recurrence will generally overweigh the risk of bleeding for patients with unprovoked VTE. Extended anticoagulation therapy might be used by 97% of providers. Different patterns in real world clinical practice were identified. More than one half of the practitioners estimated the VTE recurrence and bleeding risk subjectively. The antithrombotic drugs most commonly used for secondary prophylaxis were rivaroxaban, apixaban, warfarin, dabigatran, and aspirin, in decreasing order of frequency. Among the reasons selected for not regularly considering extended anticoagulation therapy were the lack of specific clinical practice guidelines (24%), lack of reported evidence (9%), and absence of valid VTE and/or bleeding risk prediction calculators (8%). Twelve participants (8%) stated that extended anticoagulation therapy would not be beneficial for most patients with VTE. Ten participants (7%) indicated that prescribing extended anticoagulation therapy was outside the scope of their specialty. Conclusions: Different practice patterns exist regarding extending anticoagulation therapy beyond the standard treatment for patients with VTE. Major gaps in knowledge remain a serious challenge at least partially explaining the inaccuracy and inconsistency in long-term VTE management. Appropriately designed studies are needed to evaluate risk stratification tools when contemporary best medical therapy is used, accurately predict VTE recurrence and its long-term outcomes, and tailor safe and effective secondary prophylaxis.

Objective Pelvic venous reflux (PVR) can present with symptoms such as chronic pelvic pain, dysmenorrhea, and dyspareunia, resulting in a decreased quality of life among those affected. Percutaneous coil embolization (CE) is a common intervention for PVR; however, the efficacy and safety of its use in isolation has yet to be reviewed. Methods The MEDLINE and EMBASE databases were systematically searched from 1990 to July 20, 2020, for studies reporting on adult patients undergoing isolated CE for PVR. Articles not in English, case reports, studies reporting on pediatric patients, and studies not performing isolated CE were excluded. Search, review, and data extraction were performed by two independent reviewers (S.S. and M.T.). Changes in pain before and after CE was evaluated through a pooled analysis of visual analogue scale scores in seven studies. Results A total of 970 patients (range, 3-218, 100% female) undergoing isolated ovarian vein or mixed veins embolization from 20 studies were included. Pooled analysis revealed mean improvements of 5.47 points (95% CI, 4.77-6.16) on the visual analogue scale. Common symptoms such as urinary urgency and dyspareunia reported significant improvements of 78-100% and 60-89.5% respectively. Complications were rare, with coil migration (n = 19) being the most common. Recurrence rates differed based on the varying symptoms and studies, with recurrence in pain 1-2 years after CE ranging from 5.9-25%. Two randomized controlled trials revealed improved clinical outcomes with CE as compared with vascular plugs and hysterectomy. Conclusions The current data suggests that isolated CE is technically effective and can result in clinical improvement among patients with PVR. However, further trials are required to ascertain its long-term effects.

Background/Objective Sport-related vascular trauma is an important consequence of increased physical activity. Repetitive, high-intensity movements predispose athletes to vascular disease, including arterial pathology, by exerting increased pressure on neurovascular structures. This is an important source of morbidity in an otherwise young and healthy population. Arterial pathology associated with repetitive trauma is often misdiagnosed as musculoskeletal injury. This article increases awareness of sport-related arterial disease by reviewing the symptomatology, investigation, and treatment modalities of this pathology. In addition, prognostic outcomes specific to the athlete are discussed. Results Arterial thoracic outlet syndrome and vascular quadrilateral space syndrome are associated with athletes involved in overhead throwing exercises. Sport-related arterial pathology of the lower limb include external iliac artery endofibrosis (EIAE), popliteal artery entrapment syndrome (PAES), and adductor canal syndrome. Vascular stress and kinking secondary to vessel tethering are important contributors to pathology in EIAE. Chronic exertional compartment syndrome must also be considered, presenting with clinical features similar to PAES. In addition, athletes are predisposed to blunt mechanical trauma. Hypothenar hammer syndrome is one such example, contributing to a high burden of morbidity in this population. Conclusions In arterial thoracic outlet syndrome and vascular quadrilateral space syndrome, surgery is advocated in symptomatic individuals, with postoperative outcomes favorable for the athlete. Acute limb ischemia may occur as a result of secondary thrombosis or embolization, often without preceding claudication. PAES and adductor canal syndrome are associated with functional entrapment in the athlete, secondary to muscular hypertrophy. Surgical exploration may be indicated. Poorer outcomes are noted when this process is associated with vascular reconstruction. Surgical treatment of EIAE follows failure of conservative management, with limited data available on postoperative prognosis. Investigations for all these conditions should be targeted based on clinical suspicion. A delay in diagnosis can have severe consequences on return to competition in these high-functioning individuals.

Objective/background The aim was to summarise the evidence for the relationship between vein diameters and clinical severity, and elucidate the relationship between diameters and health related quality of life (HRQoL) Methods A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The MEDLINE and Embase databases were searched from 1946 to 31 August 2018. Reference lists of included studies were searched for further relevant papers. Full text studies in English reporting the relationship between great and small saphenous vein diameters and clinical severity and/or HRQoL scores measured using validated instruments were included. All study designs were included. Studies that did not include relationships between these parameters, non-English studies, and studies focusing on non-truncal veins were excluded. Two reviewers independently performed the study selection, data extraction, and risk of bias assessment. Results Eleven eligible studies were identified, reporting on 2,732 limbs (range 22–681). Four studies correlated truncal vein diameter with both clinical severity and HRQoL, while seven reported only on clinical severity measures. Multiple instruments were used to quantify HRQoL and clinical severity. Seven studies assessed the relationship with CEAP class, with the majority observing a positive correlation between vein diameter and disease severity. Four studies found weak correlations with VCSS, with one showing correlations with VCSS components. No significant relationship between diameters and HRQoL scores was reported. One study also revealed no correlation with Aberdeen Varicose Vein Questionnaire improvements post-treatment. The majority of studies failed to include C0 and C1 participants. Conclusions While further studies are required to improve the level of evidence, the existing literature suggests that truncal vein diameters correlate with clinical severity. Diameters are a poor predictor of HRQoL, with no relationship to patients’ perceived impact of chronic venous disease. As such, vein diameter should not be used as a measure to decide who needs venous intervention.

Objective The development of a venous leg ulcer (VLU) represents the most severe clinical manifestation of a chronic venous disease. Despite major progress, our understanding of the VLU pathogenesis and wound healing biology has remained limited. Treatment of VLUs remains a serious challenge for physicians of different specialties. In the present review, we focused on describing the rationale and scientific basis for topical wound care in the management of VLUs. Methods A literature review was performed to summarize the methods with proven efficacy in VLU management. A systematic search was also performed to identify new evidence from the randomized controlled trials reported from 2014 to 2021. The scientific challenges, clinical practice concerns, economic obstacles, and possible directions for further research have been discussed. Results Hundreds of topical products have been advertised for the treatment of VLUs. However, the reported data on the topical treatment of venous ulcers are insufficient, scattered, and weak, with significant methodologic flaws. A total of 43 randomized controlled trials on the topical treatment of VLUs were reported from 2014 to 2021. Thus, the clinical practice guidelines require updating. We identified major gaps in knowledge and have provided suggestions for future research directions. Conclusions The American Venous Forum Research Committee would like to bring attention to the use of topical wound care for VLUs as a critical gap in knowledge and to encourage scientists, practitioners, and industry to collaborate to fill this gap.

BACKGROUND: The COVIDSurg collaborative was an international multicenter prospective analysis of perioperative data from 235 hospitals in 24 countries. It found that perioperative COVID-19 infection was associated with a mortality rate of 24%. At the same time, the COVER study demonstrated similarly high perioperative mortality rates in vascular surgical patients undergoing vascular interventions even without COVID-19, likely associated with the high burden of comorbidity associated with vascular patients. This is a vascular subgroup analysis of the COVIDSurg cohort. METHODS: All patients with a suspected or confirmed diagnosis of COVID-19 in the 7 days prior to, or in the 30 days following a vascular procedure were included. The primary outcome was 30-day mortality. Secondary outcomes were pulmonary complications (adult respiratory distress syndrome, pulmonary embolism, pneumonia and respiratory failure). Logistic regression was undertaken for dichotomous outcomes. RESULTS: Overall, 602 patients were included in this subgroup analysis, of which 88.4% were emergencies. The most common operations performed were for vascular-related dialysis access procedures (20.1%, N.=121). The combined 30-day mortality rate was 27.2%. Composite secondary pulmonary outcomes occurred in half of the vascular patients (N.=275, 45.7%). CONCLUSIONS: Mortality following vascular surgery in COVID positive patients was significantly higher than levels reported pre- pandemic, and similar to that seen in other specialties in the COVIDSurg cohort. Initiatives and surgical pathways that ensure vascular patients are protected from exposure to COVID-19 in the peri-operative period are vital to protect against excess mortality.

Funder: Actergy Health, 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

Objective Determine standards of referral and management of patients with venous leg ulceration in primary care after the release of the EVRA (A Randomized Trial of Early Endovenous Ablation in Venous Ulceration) study results. Methods An online questionnaire was disseminated over four months to professionals working within primary care. Results The survey received 643 responses. Of respondents, 90 (14%) had heard of the EVRA trial and 51 (8%) were familiar with the results. Of those who answered the following questions, 410 (69.1%) stated that referral to a vascular specialist must be made by the General Practitioner and 13 (2.2%) reported that they would always refer patients for secondary care assessment before the publication of EVRA. Considering the EVRA results, 128 (29%) reported that they would change practice regarding referral and would experience no barriers and 198 (45%) reported that they would like to refer earlier but is not their decision. Barriers to changing practice included local referral policies, training and time restrictions, 266 (59%) had heard of the NICE guideline (CG168) and 194 (43%) were aware of the recommendations for referral to a vascular service within two weeks for patients with an open or healed ulcer. Conclusion There is a considerable variation in local referral pathways for venous leg ulceration, and despite clinicians wanting to refer promptly, many primary care professionals are unable to. Unfortunately, the EVRA study alone may not change the overall practice, and work is needed to overcome barriers faced by primary care professionals.

Objectives Venous thromboembolism is a potentially fatal complication of superficial endovenous treatment. Proper risk assessment and thromboprophylaxis could mitigate this hazard; however, there are currently no evidence-based or consensus guidelines. This study surveyed UK and Republic of Ireland vascular consultants to determine areas of consensus. Methods A 32-item survey was sent to vascular consultants via the Vascular and Endovascular Research Network (phase 1). These results generated 10 consensus statements which were redistributed (phase 2). ‘Good’ and ‘very good’ consensus were defined as endorsement/rejection of statements by >67% and >85% of respondents, respectively. Results Forty-two consultants completed phase 1. This generated seven statements regarding risk factors mandating peri-procedural pharmacoprophylaxis and three statements regarding specific pharmacoprophylaxis regimes. Forty-seven consultants completed phase 2. Regarding venous thromboembolism risk factors mandating pharmacoprophylaxis, ‘good’ and ‘very good’ consensus was achieved for 5/7 and 2/7 statements, respectively. Regarding specific regimens, ‘very good’ consensus was achieved for 3/3 statements. Conclusions The main findings from this study were that there was ‘good’ or ‘very good’ consensus that patients with any of the seven surveyed risk factors should be given pharmacoprophylaxis with low-molecular-weight heparin. High-risk patients should receive one to two weeks of pharmacoprophylaxis rather than a single dose.

Background Compression after sclerotherapy is commonly used, although the evidence base for this practice is unclear. This study aims to summarize and assess the evidence for compression therapy after sclerotherapy to inform clinical practice. Methods A systematic review was performed according to PRISMA guidelines via Medline and EMBASE databases (1946 to December 31, 2019) by two reviewers. Full-text, English-language studies comparing compression type and/or duration in adult chronic venous disease patients undergoing liquid or foam sclerotherapy were included. Results Nine studies were identified: five using liquid sclerotherapy, three foam sclerotherapy and one using both. Studies had short follow-up periods (6-24 weeks) and reported on clinical outcomes, quality of life, side effects and complications. In C1 patients undergoing liquid sclerotherapy, any duration of stocking use significantly decreased telangiectasia and reticular vein number and size compared with no compression. No significant difference in clinical symptoms or quality of life was seen when comparing compression duration after liquid or foam sclerotherapy in tributary or truncal veins in C2 to C6 patients. Greater superficial vein resolution was seen with stockings compared with bandages in C2 patients undergoing liquid sclerotherapy to tributary veins. A comparison of stockings vs bandaging revealed differing thrombophlebitis rates but no significant difference in pigmentation. In C2 to C6 patients undergoing foam sclerotherapy, use of 35 mm Hg stockings significantly improved post-treatment symptoms compared with 23 mm Hg stockings. This review was limited by heterogeneity of outcome measurements and the variety of comparisons between compression types and durations. Conclusions Postsclerotherapy compression may have beneficial clinical outcomes at short-term follow-up; however, evidence is lacking regarding its type, class, length, and duration. Further trials are required to guide the optimal management of postsclerotherapy patients.

Objective Our aim was to assess the methodologic quality of clinical practice guidelines (CPGs), which inform the diagnosis and management of chronic venous disease (CVD), using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Methods A systematic review was performed through the Medline and Embase databases to identify CPGs relevant to CVD. The included articles were evidence-based CPGs available in English and reported in the past 20 years. Consensus documents, expert opinions, and studies providing guidance for diagnosis or treatment alone were excluded. Four independent reviewers assessed the CPGs using the AGREE II tool across six domains. Overall quality scaled scores were calculated for each guideline, and the interrater reliability was measured using an intraclass correlation coefficient. SPSS, version 25 (IBM Corp, Armonk, NY) was used for statistical analysis. Results Six CPGs reported from 2004 to 2018 were identified; all were of European and North American origin. The interrater reliability when scoring each CPG was high, with an intraclass correlation coefficient of >0.8 (P ≤ .002) for all six CPGs. One CPG had an average score of 95.83% across all domains, qualifying as a high quality CPG. The remaining five CPGs had scores ranging from 29% to 71%. The CPGs generally performed poorly in outlining stakeholder involvement and evaluating the applicability of the guideline to clinical practice. Conclusions Scores from the AGREE II tool were reproducible when different users evaluated the CPGs. We identified one CPG for CVD of high methodologic quality. The AGREE II appraisal tool can be used to identify aspects of CPGs that can be developed to improve their methodologic quality.

Objective Acute deep venous thrombosis (DVT) can be complicated by post-thrombotic syndrome, which is associated with significant morbidity and healthcare costs. The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) was the largest and most controversial randomized controlled trial evaluating the use of pharmacomechanical catheter-directed thrombolysis (CDT) for the prevention of post-thrombotic syndrome after acute DVT. This study aimed to evaluate clinicians' opinion on the ATTRACT trial and its impact on clinical practice. Methods An online survey consisting of 10 core multiple choice items and a maximum of five follow-up open-ended questions was delivered to vascular surgeons, interventional radiologists, hematologists, and interventional cardiologists affiliated with 10 international societies between April 23 and July 1, 2019. Clinicians' views on the main limitations of the ATTRACT trial, its impact on patient selection for thrombolysis and the need for a new trial were evaluated. Results Out of 15,650 contacted clinicians, 451 (3%) completed the survey, with 74% vascular surgeons, 24% interventional radiologists, 2% hematologists, and 0.2% interventional cardiologists. The majority of respondents (79%) were aware of the results of the ATTRACT trial before completing the survey and routinely performed pharmacomechanical CDT (PCDT) in their centers (70%). Only 20% of clinicians considered ATTRACT to be a well-designed and well-performed trial. The inclusion of femoropopliteal DVT was reported as the main limitation of the trial by 55% of respondents. Despite half of the participating clinicians reporting no change in their clinical practice, equal number of clinicians (14%) were encouraged and discouraged from treating iliofemoral DVT. More than one-half of the respondents thought that the use of PCDT would be defensible in a court of law despite the increased risk of bleeding reported in the study. Nearly two-thirds of participating clinicians recommended performing a trial limited to iliofemoral DVT, with a follow-up period of 5 years, quality of life as the primary outcome measure, and standardization of thrombolysis protocol across the trial sites. Conclusions ATTRACT failed to provide the long-awaited indisputable evidence on the use of PCDT. Surveyed clinicians were aware of the limitations of this trial and the need for further evidence on the subject.

Objective This review aims to assess the evidence supporting the impact of patient foot care education on self efficacy, self care behaviour, and self care knowledge in individuals with diabetes. Methods This systematic review was registered prospectively on the PROSPERO database (CRD42019106171). Ovid EMBASE and MEDLINE databases were searched from 1946 to the end of March 2019, using search terms related to the domains diabetic foot, patient education, self efficacy, self care behaviour, and self care knowledge. All included studies were prospective, randomised controlled trials that assessed foot care education interventions in individuals with diabetes and recorded an outcome related to self efficacy, self care behaviour, and/or self care knowledge. Results Thirteen randomised controlled trials were included, reporting on a total of 3948 individuals. The risk of bias was high or unclear in 11 of the 13 included studies, and low in two studies. Both the education interventions delivered, and the outcome assessment tools used were heterogenous across included studies: meta-analysis was therefore not performed. Eight of 11 studies identified significantly better foot self care behaviour scores in individuals randomised to education compared with controls. Self efficacy scores were significantly better in education groups in four of five studies reporting this primary outcome. Foot care knowledge was significantly better in intervention vs. control in three of seven studies. In general, studies assessing secondary endpoints including quality of life and ulcer/amputation incidence tended not to identify significant clinical improvements. Conclusion The available evidence is of inadequate quality to reliably conclude that foot care education has a positive impact on foot self care behaviour and self efficacy in individuals with diabetes. Quality data supporting accompanying benefits on quality of life or ulcer/amputation incidence are also lacking and should be considered as an important outcome measure in future studies.

BACKGROUND: Median arcuate ligament syndrome (MALS) describes the clinical presentation associated with direct compression of the celiac artery by the median arcuate ligament. The poorly understood pathophysiologic mechanism, variable symptom severity, and unpredictable response to treatment make MALS a controversial diagnosis. METHODS: This review summarizes the literature pertaining to the pathophysiologic mechanism, presentation, diagnosis, and management of MALS. A suggested diagnostic workup and treatment algorithm are presented. RESULTS: Individuals with MALS present with signs and symptoms of foregut ischemia, including exercise-induced or postprandial epigastric pain, nausea, vomiting, and weight loss. Consideration of MALS in patients' diagnostic workup is typically delayed. Currently, no group consensus agreement as to the diagnostic criteria for MALS exists; duplex ultrasound, angiography, and gastric exercise tonometry are used in different combinations and with varying diagnostic values throughout the literature. Surgical management involves decompression of the median arcuate ligament's constriction of the celiac artery; robotic, laparoscopic, endoscopic retroperitoneal, and open surgical intervention can provide effective symptom relief, but long-term follow-up data (>5 years) are lacking. Patients treated nonoperatively appear to have worse outcomes. CONCLUSIONS: MALS is an important clinical entity with significant impact on affected individuals. Presenting symptoms, patient demographics, and radiologic signs are generally consistent, as is the short-to medium-term (

Background Athletes are generally young, high-functioning individuals. Pathology in this cohort is associated with a decrease in function and consequently has major implications on quality of life. Venous disorders can be attributed to a combination of vascular compression with a high burden of activity. Objective This article promotes increased awareness of these uncommon conditions specific to the athlete by summarizing pathophysiology, clinical features, investigation, and treatment protocols for use in clinical practice. Prognostic outcomes of these management regimens are also discussed, allowing for clinicians to counsel these high-functioning individuals appropriately. With the aim of providing an overview of sport-related venous pathology, a literature review was undertaken identifying articles that were independently reviewed by the authors. Results Lower limb venous thrombosis has been identified in young, high-functioning athletes attributed to both compression-related venous trauma, associated with repetitive movements resulting in intimal damage, and blunt trauma. The diagnosis and treatment follow the same protocols as for the general population. Of note, early ambulation is advocated, with an aim to return to premorbid (noncontact) function within 6 weeks. Athletes performing high-intensity repetitive upper limb movement, such as baseball players, are predisposed to upper limb deep venous thrombosis (DVT). Diagnosis follows the same protocols as for lower extremity DVT; however, the optimal treatment strategy remains debated. Current guidelines advocate the use of anticoagulation alone. A specific subset of primary upper limb DVT is effort thrombosis, where there is compression at the level of the thoracic outlet. Thrombolysis with first rib resection is indicated in the acute setting within 14 days. In cases of complete occlusion, surgical decompression with venous reconstruction may be required. Popliteal vein entrapment syndrome is also discussed. This entity has been identified as an overuse injury associated with popliteal vein compression. Duplex ultrasound examination is indicated as a first-line investigation, with conservative noninvasive options considered as an initial management strategy. Chronic venous insufficiency or persistent symptoms may require subsequent surgical decompression. Conclusions Key conditions including upper extremity and lower extremity venous thrombosis, venous aneurysms, Paget-Schroetter syndrome (effort thrombosis), and popliteal vein entrapment syndrome are discussed. Further studies evaluating long-term outcomes on morbidity for current treatment regimens in upper extremity DVT, effort thrombosis, venous thoracic outlet syndrome, and popliteal venous entrapment syndrome are required.

Objective The objective of this review was to determine the methodologic quality of current lymphedema clinical practice guidelines (CPGs) to assist health care professionals in selecting accessible, high-quality guidance and to identify areas for improvement in future CPGs. Methods MEDLINE, Embase, online CPG databases, and reference lists of included guidelines were searched up to January 31, 2020. Full-text CPGs reporting on evidence-based recommendations in lymphedema diagnosis or management in English were included. CPGs based on expert consensus, CPG summaries, or CPGs that were not freely available were excluded. Two reviewers identified eligible CPGs, extracted data, and assessed their quality independently using the Appraisal of Guidelines for Research and Evaluation II instrument. Significant scoring discrepancies were discussed with a third reviewer. An overall scaled quality score of ≥80% was the threshold to recommend guideline use. Results Six relevant CPGs were identified. One was subsequently excluded as its full text could not be obtained. Overall, there was very good inter-reviewer reliability of scores with intraclass correlation coefficient of 0.952 (95% confidence interval, 0.921-0.974). No single CPG scored highest in all domains, with methodologic heterogeneity observed. Poor performance was noted in domain 5 (mean scaled score, 23.8% ± 17.1%) and domain 6 (22.9% ± 26.7%). No CPG achieved an overall scaled quality score of ≥80%, with the top CPG scoring 79.2%. Conclusions According to the defined threshold, no lymphedema CPG was considered adequate for use in clinical practice. All current lymphedema CPGs have areas for improvement with elements of methodologic quality lacking, particularly with respect to rigor of development. A structured approach, guided by the use of CPG creation tools and checklists such as the Appraisal of Guidelines for Research and Evaluation II instrument, should help CPG development groups in improving the quality of future CPGs. This is of particular importance in a complex, multidisciplinary condition such as lymphedema.

Superficial venous disease (SVD) is a common condition in the Western world, with recognized, negative effects on mood and quality of life (QoL) in those affected. Numerous tools exist to assess QoL in patients with SVD. The aim of this article is to review the literature on the role of QoL assessment tools in this disease group, describing the most commonly used instruments and their relevance, assessing the relationship between clinical and functional assessment tools, delineating the correlation among physician and patient reports and discussing the importance of translation.

Objective The aim was to assess the early and mid-term safety and clinical outcomes of a modified sandwich-graft technique (MSGT) that employed the Aorfix and Viabahn stent-grafts to preserve hypogastric flow in cases of complex aortoiliac and isolated common iliac artery (CIA) aneurysms including internal iliac artery (IIA) ostium who were not suitable for an iliac branch device (IBD). Methods A review of prospective collected data of all consecutive cases of treatment of complex aortoiliac or isolated CIA aneurysms including IIA ostium using the MSGT to preserve the hypogastric flow in three European centres between April 1, 2010, and December 31, 2013, was performed. All patients included were unfit for open repair and not suitable for an IBD. Results During the study period, 21 patients met the study criteria and had 25 MSGTs. The mean follow-up duration was 17.2 months. The technical success rate was 100%, with no perioperative mortality and stent-graft or MSGT-treated IIA occlusions. There were two cases with Type Ib endoleaks and one Type III endoleaks intraoperatively that were successfully managed. There was also no reported early and late pelvic ischaemia. The primary patency rate was 90.5%, and two cases of MGST treated IIA occlusions with no reported symptoms of pelvic ischaemia during follow-up. Conclusions MSGT was a safe and feasible strategy to preserve hypogastric flow in cases of complex aortoiliac and isolated CIA aneurysms including IIA ostium and who were not suitable for IBD, with encouraging early and mid-term outcomes.

Varicose veins are a common, progressive condition in the UK, with significant negative effects on patients’ quality of life. Despite their prevalence, access to secondary care for the assessment and treatment of varicose veins can be variable throughout the country. The National Institute of Health and Care Excellence guidelines developed in 2013 provide evidence-based guidance on the referral, assessment, and management of the patient with venous disease. In this article, we review the development of the guidelines for the management of varicose veins over the last 15 years, highlighting the latest changes in referral criteria.

Chronic venous disease (CVD) is a highly prevalent condition with significant effects on patients’ quality of life. Despite this, the underlying pathophysiology of venous disease still remains unclear. Two schools of thought exist, explaining the development and propagation of venous disease as an “ascending” and “descending” process, respectively. The descending theory, stating that CVD is secondary to proximal disease (e.g. saphenofemoral/saphenous incompetence), is the most widely accepted when planning treatment aiming to remove or destroy the junction or truncal veins. The ascending theory, describing the disease process as developing in the lower most part of the leg and propagating cranially, aims to re-route the venous circulation via minimally invasive interventions. Classically, superficial venous insufficiency has been treated with the removal of the incompetent trunk, via open surgery or, increasingly, with endovenous interventions. Minimally invasive treatment modalities aiming to preserve the saphenous trunk, such as CHIVA and ASVAL, may also play an important role in the treatment of the patient with varicose veins.

Objective The aim was to evaluate the quality of current venous leg ulcer (VLU) clinical practice guidelines (CPGs) to assist healthcare professionals in choosing an accessible high quality CPG to advise their practice, and to identify areas for improvement in future versions of current CPGs. Methods A systematic review of PubMed, Embase, online CPG databases, and reference lists of included CPGs was carried out. Full text CPGs published no earlier than 1998 reporting evidence based recommendations on VLU diagnosis and management in English were included. CPGs that were only available if purchased were excluded. Two reviewers identified eligible CPGs, extracted data, and assessed the quality independently using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Significant scoring discrepancies were discussed with a third reviewer. Results Fourteen eligible CPGs were identified (1999–2016). The majority of CPGs originated from Europe or North America. Overall, there was good inter-reviewer reliability of scores with an intraclass correlation coefficient of 0.986 (95% confidence interval 0.979–0.991). No single CPG achieved the highest score in all six domains. Significant methodological heterogeneity was observed across VLU CPGs; however, consistently, poor performance was noted in domain 5, concerning CPG applicability. Conclusion Four CPGs were considered of adequate quality for clinical use. Consolidation of efforts to drive high quality, comprehensive VLU CPGs is necessary to reduce the number of and heterogeneity seen in currently published guidelines. Elements of methodological quality are lacking and a structured approach with use of checklists and CPG creation tools, such as AGREE II or others, may bolster rigour in future VLU CPGs.

Chronic venous disease is a common condition, bearing significant morbidity to patients. It is predicted that the population suffering from this disease will significantly increase in the coming years, with a growing demand for specialists in the field of phlebology. Training and delivery of services are highly heterogeneous in the European Union. The establishment of the European College of Phlebology marks the opportunity to address these differences from a European perspective, with the aim of providing all patients with standardised, high-quality, accessible medical care. In this paper, we review the current status of phlebology from a European and an international perspective, as well as highlighting the current and future roles of the European College of Phlebology.

Chronic venous disease is highly prevalent in the Western world, with varicose veins being the most common form of clinical manifestation. With recent developments in sequencing technology, clinicians and geneticists alike are embarking on a journey to identify and unravel the genetic candidates of chronic venous disease. There is now currently substantial evidence to suggest the presence of genetic influences in the aetiology and pathology of venous disease. Despite this, the precise nature and profile of the genes involved in chronic venous disease remain a poorly understood entity. Moreover, it is strikingly apparent that the majority of venous genetic studies conducted over the past decade do not adhere to fundamental research principles. The emergence of high-throughput genotyping platforms permits a more systematic search for inherited components of venous disease. Pursuing a genome-wide frontier has the potential to reveal novel critical metabolic pathways and explain the genetic susceptibility of chronic venous disease. An expedited knowledge of the genetic factors in the aetiology of venous disease may translate into better prevention or treatment, which would benefit patients suffering from its clinical sequelae. Researchers should be urged to foster collaborative links and design a genome-wide case-control association study as an international consortium to provide a statistically robust paradigm in the field of chronic venous disease genetics. This will carry promise for clinically relevant progress and represent a first step towards better understanding of the genetics of chronic venous disease aetiology.