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Introduction The coronavirus (COVID-19) pandemic continues to affect the NHS. The Vascular and Endovascular Research Network (VERN) COvid Vascular sERvice (COVER) study has prospectively shown the significant global impact of the COVID-19 pandemic on vascular surgery. The aim of this study is to investigate the way in which this second wave has affected surgeons’ ability to treat patients with urgent vascular conditions, using contemporaneous snapshot data from 30 UK vascular centres. Methods This is a contemporary (18–28 January 2021) re-run of the Tier 1 COVER survey. This used closed and open questions, related to centres’ provision of common vascular services, threshold for treatment, imaging, screening, staff and theatre availability, multidisciplinary team input, clinics, personal protective equipment, vaccination policies and case-backlogs. The survey was disseminated to clinicians via email. A service reduction score was calculated. Results Forty-two complete responses were received from 30 vascular centres (England, Northern Ireland, Scotland and Wales). Overall, 56.7% of units are performing only urgent procedures. The threshold for abdominal aortic aneurysm (AAA) repair has increased in the majority of UK centres (60%). One in six AAA screening programmes have stopped all screening activity: 30% having a significantly reduced programme and only half running as normal. Waiting lists are increasing for AAA, lower limb revascularisation and venous disease. Conclusion Overall, these data suggest that vascular care in the NHS is facing unprecedented pressures due to COVID-19. Vascular stakeholders will have to urgently address these issues in the coming months. Study registration number ISRCTN 80453162 (registered prospectively).

As per the World Health Organization, a disaster is defined as “an event that occurs in most cases suddenly and unexpectedly, causing severe disturbances to people or objects affected by it, resulting in the loss of life and harm to the health of the population.” A number of health issues are often reported following disasters, such as physical and psychological trauma, infections, malnutrition, and cardiovascular events. Among these, venous thromboembolism is deemed serious and thus should be taken into consideration. Indeed, its risk has been demonstrated to increase following earthquakes, floods, burns, and intoxications. The recent coronavirus pandemic summarizes some of the main triggering factors involved in acute and chronic venous disease development in a disaster setting: inflammation, infection, lockdown-induced reduced mobility, potential malnutrition, and overweight. Proper venous risk assessment and guideline application have been determined to be essential in disaster management, particularly in the current time in which sheltering could lead to a potential exacerbation of the pandemic, which can only increase the risk for venous thrombotic diseases. Global scientific teamwork is needed to make the recommendations as evidence-based and as homogeneous as possible among continents. In this present review, we focus on how earthquakes impact venous thromboembolism, including an analysis of other disaster-related conditions, such as burns and intoxication. (This is a review article based on the informative seminar of the 40th Annual Meeting of Japanese Society of Phlebology.)

Chronic venous disease (CVD) is a proqgressive and underestimated condition related to a vicious circle established by venous reflux and endothelial inflammation, leading to vein dilation and histology distortion, including loss of media tone. Sulodexide (SDX) is a drug restoring the glycocalyx that demonstrated endothelial protection and permeability regulation, together with anti-thrombotic and anti-inflammatory roles. In the lab it also exhibited vein contractility function. The aim of the present study was to show the possible role of endothelium and nitric oxide pathway on SDX’s veno-contractile effect on human saphenous veins. The remnants of great saphenous vein (GSV) segments (n = 14) were harvested during coronary artery bypass graft surgery. They were dissected as endothelium-intact (n = 8) and denuded rings (n = 6). First, a viability test was carried out in bath with Krebs–Henseleit solution to investigate a control and basal tension value. After this, cumulative doses of SDX were applied to rings and contraction values were studied in endothelium-intact phenylephrine (PheE, 6 × 10−7 M) pre-contracted vein rings. Finally, endothelium-intact PheE pre-contacted vein rings were treated by nitric oxide synthase inhibitor Nω-nitro-L-arginine methyl ester (L-NAME, 10−4 M) for 10 min. Contraction protocol was applied, and contraction values were measured in cumulative doses of SDX. The same protocol was applied to endothelium-denuded vein rings to investigate the effect of SDX. Saphenous vein rings showed an increase in contraction to cumulative doses of SDX. In endothel-intact rings, KCL-induced contraction from 92.6% ± 0.3 to 112.9% ± 0.4 with cumulative SDX doses. However, SDX did not show any veno-contractile effect on endothel-denuded rings. In denuded rings contraction responses measured from 94.9% ± 0.3 to 85.2% ± 0.3 with increasing doses of SDX, indicating no significant change. Nitric oxide synthase inhibitor (L-NAME) prohibited the contraction response of the sulodexide in all dosages, indicating that the contractile function of SDX was mediated by endothelial derived nitric oxide. Results of endothel-intact and denuded rings with L-NAME showed a similar incline with denuded rings with SDX only. The results confirmed SDX’s veno-contractile effect in human samples, by means of nitric oxide synthase pathways involvement.

Chronic venous disease is a worldwide problem associated with significant morbidity and is expected to increase in prevalence as the current population ages. This is a comprehensive review of the anatomy, pathophysiology, genomics, clinical classification, and treatment modalities of chronic venous disease.

Objective: To determine the efficacy (sensitivity, specificity, and accuracy) of the VeinesQol/Sym with metric statements fewer than the EQ5D in detecting the quality of life of patients with Chronic Venous Disease (CVD) before and after treatment. Methods: This is a descriptive-comparative design in collecting the necessary data to arrive at conclusions that respond to the specific questions of the study in 2 private hospitals. The responses gathered from patients through EQ5D and VeinesQol/Sym, before and after they received treatment were utilized in describing and comparing the efficacy of the health questionnaires. Data were further subjected to a comparative analysis to elaborate the efficacy of the VeinesQol/Sym. Results: A total of 114 CVD patients completed the study after the exclusion of 13 patients due to failure to follow up after eight weeks of treatment. The study showed that VeinesQol/Sym and EQ5D has similar efficacy in determining quality of life of CVD patients. However, VeinesQol/Sym has higher accuracy (84.96% vs 76.99%), higher sensitivity (87.85% vs 83.87%), detects greater level of impairment in mobility, anxiety/depression, pain and discomfort, disruptions in usual activity and lower quality of current state of health condition than EQ5D Conclusion: With the responses to the metric statements of the indicators of quality life in both VeinesQol/Sym and EQ5D, VeinesQol/Sym was found to have a greater efficacy in establishing the accurate status of quality of life of patients with CVD than the EQ5D.

Introduction Superficial venous disease (SVD) is a very common disease and much research has been done towards finding the ideal treatment and discovering the pathophysiology of SVD. Not much is known about the psychological burden of SVD. Current guidelines and scientific publications tend to focus on clinical and physiological aspects of SVD. The aim of this study was to relate the changes in Quality-of-Life (QoL) after SVD treatment to possible changes in psychological distress (PD). Methods A prospective cohort was set up with the assistance of 5 specialized vein clinics in the Netherlands. Inclusion criteria were: 18 years of age or older, fluent in Dutch language, C1 to C6 (CEAP) class intended to be primary treated with either endovenous laser(LA), radiofrequency ablation (RFA) and phlebectomy(PHL) or sclerocompression therapy alone (SCT). Patients were divided in two groups: 1. C1-C3 patients treated by SCT 2. C1-C6 patients treated invasively (LA, RFA and PHL) Outcomes were a disease specific QoL questionnaire (CIVIQ-20) and a questionnaire to assess PD (Hospital Anxiety and Depression Scales (HADS)). This study was approved by the local institutional review board, following the principles outlines in the Declaration to Helsinki. This trial was registered in the ISRCTN registry with study ID ISRCTN12085308 Results 442 patients were included in the study and completed the T0 measurements. Mean age of these patients is 54.4 years (s.d. 12.9, 17-90). Number of females: 349 (79.0%), of males: 93 (21.0%). The mean baseline (T-0) HADS depression (0-3) scale scores is 2.54 (s.d. 0.51, n = 412). The mean one-year difference between T-12 HADS depression (0-3) scale scores and baseline T-0 scores is +0.06. The mean baseline (T-0) HADS anxiety (0-3) scale scores is 2.19 (s.d. 0.5, n = 283). The mean one-year difference between T-12 HADS anxiety (0-3) scale scores and baseline T-0 scores is +0.06. Controlled for baseline scores, gender, age, weight and length(BMI), patients in group 2 (receiving invasive treatment) show significantly higher one-year improvement in the QoL of their psychological state of mind than patients in group 1 (receiving SCT and having C1,2,3) (beta 0.158 p = 0.002). Conclusions The significant improvement in psychological, QoL and clinical scores that we observe after successful invasive treatment compared to no significant improvement after SCT and the lack of psychological distress in patients with “simple” SVD indicates that SCT is mainly performed for cosmetic reasons. One could thus argue that reimbursement of SCT as a stand-alone medical treatment is debatable.

espanolLa enfermedad venosa cronica (EVC) se entiende como el mal funcionamiento del sistema de retorno venoso de los miembros inferiores (MMII), siendo clinicamente diagnosticada por la presencia de venas varicosas. Nos encontramos ante una enfermedad de muy alta prevalencia. Sobre la etiopatogenia, de manera global se diferencia la existencia de dos mecanismos que explican la aparicion de la EVC, el reflujo primario y la obstruccion venosa. El diagnostico de EVC se basa en la clasificacion CEAP, siendo la mas comunmente aceptada y utilizada. Valora aspectos clinicos, etiologicos, anatomicos y patofisiologicos. El tratamiento de la EVC tiene por objeto reducir los sintomas e impedir la evolucion a fases clinicas avanzadas de la enfermedad con sus complicaciones y secuelas. Por otra parte, las varices, una vez que aparecen, no pueden revertirse farmacologicamente, y tan solo puede plantearse su eliminacion mediante un abanico creciente de posibilidades tecnicas. EnglishChronic venous disease (CVD) is understood to be the venous return system of the lower limbs (LL) failing to work effectively, and is clinically diagnosed by the presence of varicose veins. It is a very common disease. In terms of aetiopathogenesis, two mechanisms explain the onset of CVD: primary reflux and venous obstruction. A diagnosis of CVD is based on CAP score, which is the most widely used and accepted. It assesses clinical, aetiological, anatomical, and pathophysiological aspects. Treatment of CVD aims to reduce symptoms and prevent progression to advanced clinical stages of the disease with complications and sequelae. However, once varicose veins appear, they cannot be reversed pharmacologically; there are an increasing range of technical possibilities for their removal.

Objectives: The study aims to investigate the change in postoperative clinic, pain, and general quality of life of patients who were operated on due to chronic venous disease (CVD), according to their body mass index (BMI). Materials and methods: 150 patients (30–45 years) who were treated with cyanoacrylate embolization for CVD between January 2017 and February 2020 were analyzed retrospectively. The clinical (C) category of clinical, etiology, anatomy, and pathophysiology (CEAP) classification venous clinical severity score (VCSS) and visual analog scale (VAS) questionnaires were applied to the patients before and after the operation periodically. The patients were surveyed preoperatively and postoperatively at 1st, 6th, 12th, and 24th months. Results: The patients were divided into three groups according to their BMI. In the comparison between normal and overweight participants, venous reflux, CEAP C categories, and VAS scores were not statistically significantly different in preoperative and postoperative periods. In the comparison between normal and obese participants, CEAP C categories, VCSS, and VAS scores were statistically significantly different in postoperative periods. There was no statistically significant difference in terms of venous reflux preoperatively and postoperatively in all three groups. Conclusions: The study showed that the increase in BMI had negative effects on the CEAP C categories, pain, and quality of life independently of the venous reflux of CVD.

Homocysteine (Hcy) is considered as a modifiable risk factor for vascular disease. This study was aimed to explore the association between serum concentration and the severity of primary chronic venous disease (CVD).Clinical data of 582 patients diagnosed with primary CVD were collected and analyzed retrospectively. The Clinical Etiology Anatomy Pathophysiology classification system was used to grade the severity of chronic venous disease. Patients were divided into 2 groups (group A: C1-C3; group B: C4-C6). The association between serum homocysteine levels and the severity of primary chronic venous disease was investigated using rank sum test and logistic regression.The difference between the level of homocysteine in each grade has statistical significance. Group A has higher median Hcy concentrations than Group B (15.40 μmol/L vs. 14.05 μmol/L, P0.01). Further binary logistic regression showed no statistical significance among the level of Hcy (11.00-14.75 μmol/L [OR 0.66, 95% CI 0.40-1.11, P= 0.12], 14.75-20.38μmol/L [OR 0.97, 95% CI 0.59-1.69, P = 0.89], ≥20.38 μmol/L [OR 0.67, 95% CI 0.41-1.10, P = 0.11]), but age (OR 1.03, 95% CI 1.01-1.04, P0.01) and female (OR 0.41, 95% CI 0.28-0.59, P0.01) are associated with more severe stages of CVD.Higher level of Hcy is associated with more severe stages of CVD, but it not an independent risk factor. However, Advanced age and female are risk factors for CVD development based on logistic regression analysis.

Klippel-Trenaunay syndrome is a rare vascular disorder which includes leg swelling, or lower extremity deep venous reflux/thrombosis as a presenting symptom. May-Thurner syndrome is also a rare pathology involving compression of the left common iliac vein, usually by the right common iliac artery. The incidence of concomitant occurrence of these entities is unknown and not well reported. This case series describes 3 patients who underwent evaluation of symptomatic left lower extremity venous disease. All 3 suffered symptomatic Klippel-Trenaunay initially, and were subsequently diagnosed with concomitant May-Thurner Syndrome. They were successfully treated with left common iliac vein stents with symptomatic improvement.

Background To review long-term outcomes and saphenous vein (SV) occlusion rate after endovenous ablation (EVA) for symptomatic varicose veins. Methods A review of our EVA database (1998–2018) with at least 3-years of clinical and sonographic follow-up. The primary end point was SV closure rate. Results 542 limbs were evaluated. 358 limbs had radiofrequency and 323 limbs had laser ablations; 542 great saphenous veins (GSV), 106 small saphenous veins (SSV) and 33 anterior accessory saphenous veins (AASV) were treated. Follow-up was 5.6 ± 2.3 years; 508 (74.6%) veins were occluded, 53 (7.8%) partially occluded and 120 (17.6%) were patent. On multivariable Cox regression analysis, male sex (HR 1.6, 95% CI [0.46–018], p = 0.012) and use anticoagulation (HR 2.0, 95% CI [0.69–0.34], p = 0.044) were predictors of long-term failure. On Kaplan-Meier curve, we had an 86.3% occlusion rate. Conclusion Our experience revealed a 5-year closure rate of 86.3%. Ablations have satisfactory occlusion rate.

Introduction: To study the efficiency of internal compression therapy (ICT), a new and promising method of treatment for deep venous insufficiency, how that efficiency is achieved, and its potential side-effects, in a porcine model. Material and Methods: The femoral vein diameters of 4 pigs were first measured. ICT was then applied such as to reduce the diameter of these veins by 50%. The femoral vein diameters of 2 pigs were re-measured after 1 month. The femoral vein and its surrounding tissue were excised for immunohistopathological and genetic examination. The same procedures were applied to the remaining 2 pigs 3 months subsequently. Collagen I and IV immunohistochemical staining and Masson’s trichrome and Alcian blue histochemical staining were applied during immunohistopathological examination. Collagen I, III, and IV and connective tissue growth factor (CTGF) mRNA expressions were examined for genetic examination. Results: The femoral vein diameters decreased by approximately 50% after ICT application. This decrease persisted after the first and third months. Histopathological examination revealed loose connective tissue around the venous tissue after the operation, particularly in the third month, together with perivascular fibrosis and increased collagen in connective tissue. No difference was observed between regions with and without ICT application in terms of mucinous degeneration, an indicator of tissue injury, during Alcian blue staining. Genetic examination revealed an increase in collagen I and IV and CTGF mRNA expression in perivascular tissue resulting from ICT application. Conclusion: ICT is effective both in terms of creating a durable tissue around the vein and of increasing collagen tissue and stimulating fibrosis, and has no deleterious side-effects on tissue.

Chronic Venous Disease is estimated at 83.6% of the global population. Patients experience pain, discomfort and severe complications with few effective therapies being available. Current strategies for the treatment of malfunctioning venous valves are invasive with a high recurrence rate. A prosthetic venous valve replacement is imminent, possibly providing better outcomes and improved general quality of life. In this review, prosthetic venous valves history is presented and assesses the advantages and disadvantages of developed venous valves. Articles that discussed potential designs of prosthetic venous valves were examined. A systematic search produced thirty-five papers fitting the inclusion criteria. Our understanding of the ideal abilities required in prosthetic valves has evolved. Developed valves are reported for regurgitation, migration and leakage. Issues have been resolved, but we are still away from the ideal valve. Improvements within the last eight years provided information on the importance of sinuses and prosthetic to venous wall-size mismatch.

Objectives To determine the distribution patterns of pathological venous reflux and risk factors in patients with skin changes due to primary venous disease. Methods Two hundred limbs belonging to C4, C5 & C6 classes were examined with duplex ultrasound to determine the sites of reflux. We also analyzed the correlation of risk factors with patterns and severity of disease. Results Among 200 limbs, superficial system reflux was found in 163 limbs (81.5%), deep system reflux in 10 limbs (5%) and perforator system reflux in 180 limbs (90%). The most common pattern of abnormality was combined superficial and perforator system reflux. Of all the risk factors, prolonged standing, obesity and in the female history of pregnancy preceding varicose occurrence had the highest prevalence. Conclusions In patients with primary chronic venous disease, lifestyle modification is required to avoid risk associated with obesity and prolonged standing. The higher prevalence of pathological perforator reflux in association with advanced venous disease necessitates careful treatment of this least reported pathology to achieve better treatment results.

Objective To describe the mid-term outcome after inferior selective crossectomy in a subset of patients with symptomatic chronic venous disease and both great saphenous vein and suprasaphenic valve incompetence. Methodsː Retrospective analysis of prospectively collected data was conducted. During an eight-year period, 1095 ligations of all saphenofemoral junction inferior tributaries and great saphenous vein stripping were performed in 814 Clinical, Etiology, Anatomy, Pathophysiology C2–C6 patients. Duplex ultrasound follow-up examinations were performed after 30 days, 6 months, and 2 years, and saphenofemoral junction hemodynamic patterns and varicose veins recurrence rates were evaluated. Results Two hundred and twenty patients completed the two-year follow-up period. At the 30-day Duplex ultrasound evaluations, two different hemodynamic patterns were described. Type 1, with physiological drainage of saphenofemoral junction superior tributaries, was observed in 214 patients. Type 2, without flow in saphenofemoral junction superior tributaries, was observed in six patients. Overall varicose vein recurrence rates were 0, 2.3, and 2.7% at the 30-day, 6-month, and 2-year follow-up examinations, respectively. At the two-year follow-up, Type 1 patients showed 0% varicose vein recurrence, while Type 2 patients showed 100%. Conclusionsː Inferior selective crossectomy seems to be a valid and safe option in case of both suprasaphenic valve and great saphenous vein incompetence. Duplex ultrasound evaluation, according to our protocol, allows us to identify two different saphenofemoral junction hemodynamic patterns that could predict varicose vein recurrence at mid-term. An optimal stump washing after inferior selective crossectomy, warranted by patency and large caliber saphenofemoral junction superior tributaries, seems to be the key point in preventing varicose vein recurrence in this context. However, large prospective studies regarding saphenofemoral junction modifications and varicose vein recurrence are needed to confirm these preliminary observations.

Background Endovenous thermal ablation for chronic venous disease treatment is recommended over traditional surgery. The present investigation compares endovenous laser ablation (EVLA) with radiofrequency (RF) for segmental endovenous sapheno–femoral junction ablation. Methods This is a retrospective study in which 79 patients underwent a 6 cm great saphenous vein ablation by RF or by EVLA. Primary outcome was occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score, peri-procedural pain, aesthetic satisfaction. Results At 12 ± 1 months recanalization of shrunk tract was recorded in 5/85 (5.8%) cases (2 RF, 3 EVLA) [OR: 1.6; 95%CI: 0.2–10.4; P = 0.6689]. Two cases (1/44 RF group and 1/38 EVLA group) also showed reflux recurrence [OR: 1.0; 95%CI: 0.06–17.8; P = 1.0000]. No significant differences between groups were found in AVVQ, VCSS, peri-procedural pain, or aesthetic satisfaction. Conclusion Saphenous sparing is feasible and effective by means of both EVLA and RF, representing a possible alternative to surgery.

We herein report the case of a young patient who presented with premature thromboembolic venous disease secondary to combined heterozygous G20210A prothrombin mutation, dual homozygosity for Factor V Leiden, and severe protein S deficiency. This association has never been reported to date and is likely to be exceptional, even in populations wherein these thrombophilia traits are more common. Long-term antithrombotic prophylaxis with rivaroxaban has proven successful in preventing clinical recurrence under prolonged treatment.

ObjectivesMedical compression therapy is used for non-invasive treatment of venous and lymphatic diseases. Medical compression therapy-associated adverse events and contraindications have been reported, although some contraindications are theoretically based. This consensus statement provides recommendations on medical compression therapy risks and contraindications.MethodsA systematic literature search of medical compression therapy publications reporting adverse events up until November 2017 was performed. A consensus panel comprising 15 international experts critically reviewed the publications and formulated the recommendations.ResultsSixty-two publications reporting medical compression therapy adverse events were identified. The consensus panel issued 21 recommendations on medical compression therapy contraindications and adverse event risk mitigation, in addition to reviewing medical compression therapy use in borderline indications. The most frequently reported non-severe medical compression therapy-associated adverse events included skin irritation, discomfort and pain. Very rare but severe adverse events, including soft tissue and nerve injury, were also identified.ConclusionThis consensus statement summarises published medical compression therapy-associated adverse events and contraindications, and provides guidance on medical compression therapy. Severe medical compression therapy-associated adverse events are very rarely encountered if compression is used correctly and contraindications are considered.

Chronic venous outflow obstruction is a significant cause of chronic venous disease and therefore chronic morbidity. When conservative measures fail, intervention through deep venous reconstructive techniques should be considered. Referral should be considered in all patients with features of chronic venous disease that are life-affecting. Imaging relies primarily on duplex ultrasonography, supplemented by computed tomographic and magnetic resonance venography, and intraoperatively by intravascular ultrasonography. Intervention is primary endovenous, using angioplasty and stenting. Open surgical procedures are used in very select patients.

Aim The aim of the present study was to show that an increase in weight leads to the aggravation of limited joint mobility. Method One hundred sixteen patients with varicose veins of the lower limbs and body mass index (BMI) higher than 30 kg/m2 were evaluated at the Belczak Clinic in Maringá, Brazil. All patients were evaluated by the same physician, and the goniometric readings were performed on all patients by a physiotherapist. The participants were then divided into three groups based on BMI: Group I—BMI between 30 and 40. Group II—BMI between 40 and 50, and Group III—BMI > 50. Results There is a significant difference between the groups detected. Conclusion The present findings show that an increased BMI in obese individuals with chronic venous disease is associated with a progressive limitation of ankle mobility.

Objective Current minimally invasive techniques for ablation in superficial venous reflux are limited to thermal based systems requiring tumescent anesthesia, non-thermal chemical sclerosants and permanent glue implantation. The aim of this feasibility study was to determine the safety and efficacy of a novel mechanical-only ablation (MOA) device called EnVena, in a recognised large animal model with chronic follow up. Methods Venous ablation of six lateral saphenous veins in three sheep was performed using the EnVena device. Luminal patency and vein wall fibrosis were evaluated by histologic analysis at 51 and 89 days. Results All treated veins demonstrated fibrotic occlusion in contiguous segments at 51 and 89 days on histological analysis. From 45 consecutive segments spanning the treatment length across the six treated veins, 26 (57%) were fully occluded, 7 (16%) were impinged or partially occluded and 12 (27%) were open. There were no device related complications during the follow up period. Conclusions A purely mechanical approach to superficial venous ablation demonstrated safety and efficacy in a recognized large animal model based on histological findings.

Compression therapy is used to treat leg symptoms arising from chronic venous disease and lymphoedema. Heart failure, which is traditionally regarded as a contraindication for compression therapy, is prevalent among patients with such leg symptoms. This article aims to assess the evidence on the safety and effectiveness of compression therapy, as well as recommending the assessment and measures required when initiating compression therapy in patients with heart failure. Recent evidence suggests that initiating compression therapy in patients with stable and compensated heart failure is safe if appropriate precautionary measures are undertaken. However, there is still insufficient evidence to support the safety of compression therapy in patients with severe and decompensated heart failure. A standardised, evidence-based guideline on compression therapy in patients with heart failure will help medical and nursing professionals and improve informed consent for the patients.

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.

Contemporary interventional treatment of primary chronic venous disease (CVD) is mainly focused on the treatment of venous reflux. The long-term results of endovenous ablation (EVA) and high ligation and stripping are not different with respect to varicose vein recurrence, and this recurrence appears to be a manifestation of disease progression. Since inflammation is one of the key mechanisms of CVD development and progression, efforts to minimize inflammation and angiogenic potential in endovenous and surgical procedures are worthwhile. As techniques continue to be refined, surgery remains a valid option; in particular, the techniques that minimize trauma can be beneficial regarding recurrence. Medical treatment with venoactive drug therapy such as micronized purified flavonoid fraction (MPFF; Daflon®), which has proven clinical benefits in patients with CVD, can be used before and after EVA or surgery to minimize inflammation, pain, hemorrhage, and reduce CVD symptoms.

Chronic venous disease (CVD) is one of the most prevalent diseases worldwide. The health condition of most patients with early stage CVD will worsen over time, and this progression increases the burden as well as the costs of treatment and reduces patient quality of life (QoL). This highlights the importance and the likely cost-effectiveness of treatment of patients with early stage CVD. Options for managing the early stages of CVD include lifestyle changes together with venoactive drugs (VAD); VADs may be used alone or in conjunction with interventional treatment of varices such as sclerotherapy, surgery, or endovenous treatments. Micronized purified flavonoid fraction (MPFF; Daflon®) is a well-studied VAD which has anti-inflammatory activities, reduces endothelial activation and leukocyte adhesion, and increases capillary resistance and integrity, to eventually improve venous tone, CVD symptoms and QoL. This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by the author.

Venous leg ulcers (VLUs) are the most severe manifestation of chronic venous disease (CVD). Due to their chronic nature, high recurrence rate and slow healing time, VLUs account for 80% of all leg ulcers seen in patients with CVD. VLUs impose a heavy burden on patients that reduces their quality of life; VLUs also represent a major socioeconomic impact due to the cost and duration of care. The primary medical approach to treating VLUs is local compression therapy in combination with venoactive drug (VAD) pharmacotherapy to promote the reduction of the inflammatory reaction initiated by venous hypertension. Micronized purified flavonoid fraction (MPFF; Daflon®) is the most widely prescribed VAD. MPFF counteracts the pathophysiologic mechanisms of CVD and ulceration and has proven to be an effective adjunct to compression therapy in patients with large and chronic VLUs. Two other non-VAD drugs, pentoxifylline and sulodexide, have also been shown to improve VLU healing and are also recommended in addition to compression therapy. However, MPFF is the only VAD with the highest strength of recommendations in the 2018 guidelines for the healing of VLUs.

ObjectivesTo define a consensual approach for the conservative treatment of patients C0s-C3.MethodThe project was structured into two phases. The first one involved a group of Italian specialists in angiology and/or vascular surgery with the aim to compare their therapeutic choices in the management of patients in CEAP C0s-C3. The second phase used a Delphi consensus in order to elaborate practical statements on the conservative management of these patients.ResultsThe first phase involved a group of 166 Italian specialists while the second phase involved a Steering Committee of 6 specialists and a panel of 20 specialists. At the end of the third round, a consensus >80% was reached on seven assertions.ConclusionSeven statements have been drafted by a group of Italian specialists to provide physicians with practical guidance for the conservative treatment of C0s-C3 patients. Outstanding issues on the management of these patients were identified, confirming the urgent need of further research.

Objectives To describe saphenous reflux patterns in patients classified as CEAP C2 by analysis of 2027 vascular ultrasound examination reports. Methods A total of 2027 venous mapping studies were reviewed and 1196 patients classified as CEAP C2 were selected. Patients were classified according to patterns of reflux for the great saphenous vein and for the small saphenous vein, and rates of great saphenous vein and small saphenous vein reflux were analyzed for both sexes. Results The overall prevalence of saphenous vein reflux was 45%. Males had significantly higher great saphenous vein reflux prevalence than females ( p Conclusions Saphenous vein reflux is common in C2 patients and is more frequent in males. Standardization of classifications of reflux patterns is very important for correct management of the disease.

Objective Stenting of the iliac veins is increasingly considered in the presence of symptomatic obstructive chronic lesions in the iliac vein segment. However, it is often necessary to extend the stented zone into the inferior vena cava, increasing the risk of contralateral iliac vein thrombosis. This study aims to review the current literature concerning the incidence of contralateral deep vein thrombosis after stenting across the iliocaval confluence. Methods A systematic review from potentially relevant published articles reporting contralateral deep vein thrombosis after iliac venous stenting between January 2007 and February 2019 was performed. Results A total of 764 references were retrieved initially. Twelve studies reporting events of contralateral deep vein thrombosis were selected for review, with a total of 1864 patients. Contralateral deep vein thrombosis incidence varied between 0% and 15.6%. The post-interventional and follow-up anticoagulation regimens were heterogeneous between studies. The decision to maintain patients on anticoagulation and the duration of treatment was based on the presence of comorbidities, hypercoagulable states, post-thrombotic syndrome and history of recurrent deep vein thrombosis. Patients with non-thrombotic iliac vein lesions were either anticoagulated for three or six months after stenting or received no anticoagulation. Patients with post-thrombotic syndrome were anticoagulated for longer periods. Most studies (eight studies) used an oral vitamin K antagonist agent. The data on compliance with anticoagulation treatment is scarce and few references present data on whether contralateral deep vein thrombosis occurred during anticoagulation treatment. The use of antiplatelet agents in addition to the anticoagulant treatment in the follow-up period was also variable. Conclusion The incidence of contralateral deep vein thrombosis due to iliac vein jailing is not negligible and reported being as high as 15.6%. Large-scale studies on the ideal antithrombotic treatment and its impact are necessary. It is possible that patients with stent crossing the iliocaval confluence might benefit from long-term antithrombotic treatment.

Symptoms of chronic venous insufficiency have been known since antiquity. The prevalence of chronic venous insufficiency in Western Europe and the USA has been reported within the range from from 1 to 40% in women and from 1 to 17% in men [1]. As reported by the European authors, the average prevalence of chronic venous insufficiency with class C2-C6 (according to the CEAP classification) among the European population reaches 30% [2]. Edema syndrome remains one of the leading manifestations of chronic venous disease. Compression therapy is one of the main ways to combat edema. The arsenal of devices for the treatment of edematous syndrome is steadily expanding with the development of medical science. Today, in addition to inelastic compression wrap and elastic compression garments, brand-new compression products, circaid adjustable inelastic compression wraps are available.

Objective Hypersensitivity reaction presenting as a distinctive erythematous rash has been reported following VenaSeal™ cyanoacrylate adhesive closure. We report the frequency of hypersensitivity reactions, time to onset, duration, and severity of symptoms in patients treated with cyanoacrylate adhesive closure at a single institution. Patient and procedural factors associated with hypersensitivity reactions were evaluated. Methods A combined retrospective/prospective review of cyanoacrylate adhesive closure-treated patients was conducted over five years. Data collected from electronic medical records were reviewed for the presence of hypersensitivity reactions along with the time of onset, duration of symptoms, and severity of reaction. Severity was classified as mild if no treatment or over the counter medication was provided, moderate if steroids were required, and severe if the reaction lasted >30 days or required vein excision. Results Three hundred and seventy-nine limbs were treated in 286 patients (313 treatment days). Hypersensitivity reactions occurred in 18 patients (5.8% treatments, 6.3% patients). Thirteen were mild (4.2%), four were moderate (1.3%), and one was severe (0.3%). No patient or procedural predictive factors for hypersensitivity reaction were identified other than a trend towards decreased hypersensitivity reactions in patients with Clinical, Etiologic, Anatomic, Pathophysiologic (CEAP) clinical class C4–C6 (p = .06). Second limb treatment on a subsequent day was performed in 27 patients, and no hypersensitivity reactions occurred. Symptom onset time ranged from 1 to 23 days, with a mean of 13 days (confidence interval (CI) ±3.5 days). Duration of symptoms ranged from 3 to 28 days (mean 10.8 CI ±4.9 days). Conclusions Hypersensitivity reactions occurred in 6.0% of patients treated with cyanoacrylate adhesive closure, but most were mild and self-limited. Severe reactions were uncommon. No predictive patient or procedural factors were found to be associated with hypersensitivity reactions other than a trend towards decreased risk in patients with advanced CEAP clinical class. Previous cyanoacrylate adhesive closure treatment was not a predictive factor for hypersensitivity reaction in patients undergoing treatment at a later date.

Phlebology : the official journal of the Venous Forum of the Royal Society of Medicine and Societas Phlebologica Scandinavica 34(7), 459-465 (2019). doi:10.1177/0268355518819398, Published by Sage, London

BackgroundThe purpose of the guideline was to achieve consensus in the care and treatment of patients with chronic venous disease, based on current evidence.MethodA systematic literature search was performed in PubMed, Embase, Cinahl, and the Cochrane library up until 1 February 2019. Additional relevant literature were added through checking of references. Level of evidence was graded through the GRADE scale and recommendations were concluded.ResultsFor the treatment of great and small saphenous vein reflux, endovenous ablation with laser or radiofrequency was recommended in preference to surgery or foam sclerotherapy. If tributaries are to be treated it should be done in the same procedure. Treatment with mecanicochemical ablation and glue can be used but we still need long term follow up results.ConclusionFor the treatment of truncal varicosities, endovenous ablation with laser or radiofrequency combined with phlebectomies is recommended before surgery or foam.

Objectives: The study aimed to investigate risk factors for venous symptoms in Russian patients with chronic venous disease (CVD).Methods: Data on 487 patients with CVD aged 18 years and more were ...

Chronic venous disease (CVD) is a multifactorial condition affecting an important percentage of the global population. It ranges from mild clinical signs, such as telangiectasias or reticular veins, to severe manifestations, such as venous ulcerations. However, varicose veins (VVs) are the most common manifestation of CVD. The explicit mechanisms of the disease are not well-understood. It seems that genetics and a plethora of environmental agents play an important role in the development and progression of CVD. The exposure to these factors leads to altered hemodynamics of the venous system, described as ambulatory venous hypertension, therefore promoting microcirculatory changes, inflammatory responses, hypoxia, venous wall remodeling, and epigenetic variations, even with important systemic implications. Thus, a proper clinical management of patients with CVD is essential to prevent potential harms of the disease, which also entails a significant loss of the quality of life in these individuals. Hence, the aim of the present review is to collect the current knowledge of CVD, including its epidemiology, etiology, and risk factors, but emphasizing the pathophysiology and medical care of these patients, including clinical manifestations, diagnosis, and treatments. Furthermore, future directions will also be covered in this work in order to provide potential fields to explore in the context of CVD.

Katherine J Williams, Hayley M Moore, Mary Ellis, Alun H Davies Academic Section of Vascular Surgery, Imperial College London, London, UKCorrespondence: Alun H DaviesAcademic Department of Vascular Surgery, 4th Floor, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UKTel +44 20 3311 7320Email a.h.davies@ic.ac.ukIntroduction: Neuromuscular stimulation (NMES) has been shown to improve peripheral blood flow in healthy people. We investigated the effect of bilateral leg NMES on the symptoms of chronic venous disease.Methods: Forty subjects were recruited from four groups: healthy, superficial insufficiency, deep insufficiency, and deep obstruction. Haemodynamic venous measurements were taken from the right femoral vein with ultrasound, laser Doppler fluximetry from the left hand and foot. Devices were then worn for 4– 6 hours per day, for 6 weeks. Haemodynamic measurements were repeated at week 6. Quality of life questionnaires were taken at week 0, 6 and 8.Results: The mean age was 48.7, BMI 28.6kg/m2, and maximum calf circumference 39.0 cm. Twenty-four subjects were men. NMES increased femoral vein peak velocity, TAMV and volume flow by 55%, 20%, 36% at 20 minutes (all p< 0.05), which was enhanced at week 6 (PV and TAMV p< 0.05). Mean increases in arm and leg fluximetry were 71% and 194% (both p< 0.01). Leg swelling was reduced by mean 252.7 mL (13%, p< 0.05) overall; 338.9 mL (16%, p< 0.05) in venous disease. For those with venous pathology, scores for disease specific and generic quality of life questionnaires improved. Those with C4-6 disease benefitted the most, with improvements in VDS score of 1, AVVQ of 6, and SF-12 of 10.Conclusion: NMES improves venous haemodynamic parameters in chronic venous disease, which is enhanced by regular use. NMES reduces leg oedema, improves blood supply to the skin of the foot, and may positively affect quality of life.Clinical Trials: This trial was registered with www.clinicaltrials.org.uk (NCT02137499).Keywords: neuromuscular, electrical, stimulation, venous disease, venous insufficiency

Objective To assess the clinical efficacy of sulodexide, including a comparison with venoactive drugs (VAD) (micronized purified flavonoid fraction, MPFF; hydroxy-ethyl-rutosides, HR; calcium dobesilate;Ruscus extract combined with hesperidin methyl chalcone and vitamin C, Ruscus+HMC+VitC; horse chestnut seed extract, HCSE) and pentoxifylline in patients with chronic venous disease. Methods We performed a literature search in MEDLINE, Embase, and Cochrane Library for randomized controlled trials (RCTs) and observational studies. Proportion of patients with complete venous ulcer healing was the primary outcome and lower leg volume, foot volume, ankle circumference and symptoms were the secondary outcomes. Bayesian network meta-analysis (NMA) was perfomed with random effects models using only RCTs. A meta-analysis of observational studies was performed for sulodexide because no RCT could be included in NMA for symptoms or signs. Results Forty-five RCTs and eighteen observational studies were identified. Sulodexide was included only in a single NMA for the proportion of patients with complete ulcer healing and it showed to have the highest probability of being the best treatment (48%) compared with pentoxifylline (37%) and MPFF (16%). MPFF was the most effective treatment in reducing lower leg volume, CIVIQ-20 score and pain VAS scale while calcium dobesilate and Ruscus+HMC+VitC were the most effective in reducing foot volume and ankle circumference respectively. Meta-analyses of observational studies for sulodexide showed that it improves significantly the scoring of pain, feeling of swelling, heaviness and parasthesiae measured by Likert scales. Conclusions Sulodexide is at least as effective as pentoxifylline and more effective than MPFF in improving the rate of ulcer healing in patients with CVD. VADs are effective in improving venous symptoms and signs, as was also shown by sulodexide in the meta-analysis of observational studies. The relative effectiveness of sulodexide and VADs needs to be evaluated by an RCT in order to better inform clinical practice.

Although venous duplex ultrasonography (USG) is reliable for diagnosing lower extremity venous disease (LEVD), cross-sectional imaging studies were usually required before intervention or surgery. Patients of LEVD with renal insufficiency usually restrict the use of contrast-enhanced imaging modalities. In seeking an alternative imaging solution for these patients, we explore the clinical utility of triggered angiography non-contrast-enhanced magnetic resonance imaging (TRANCE-MRI) in the assessment of LEVD. We collected data from patients presenting to a tertiary wound-care center with symptoms of LEVD from April 2017–November 2019. Each participant underwent baseline USG followed by TRANCE-MRI on a 1.5T MR scanner (Philips Ingenia, Philips Healthcare, Best, The Netherlands). Inter-rater reliability was measured using Cohen's kappa (κ). All 80 participants (mean age, 61.9 ± 14.8 years; 35 males, 45 females) were assessed and were classified into one of five disease groups, deep vein thrombosis (n = 38), venous static ulcer (n = 16), symptomatic varicose veins (n = 18), recurrent varicose veins (n = 3), and lymphoedema (n = 5). The inter-rater reliability between TRANCE-MRI and doppler USG showed substantial agreement (κ, 0.73). The sensitivity, specificity, and accuracy of TRANCE-MRI were 90.5%, 88.1%, and 88.8%, respectively. In 59 (73.8%) USG-negative patients, we were able to diagnose positive findings (deep venous thrombosis, n = 7; varicose veins, n = 15; lymphedema, n = 10; iliac vein compression with thrombosis, n = 6; external venous compression, n = 5; vena cava anomaly, n = 2; occult peripheral artery disease, n = 5; ccluded bypass graft, n = 1) by using TRANCE-MRI. Of these, 9 (15.3%) patients underwent additional vascular surgery based on positive TRANCE-MRI findings. TRANCE technique provides the limb's entire venous drainage in clear images without background contamination by associated arterial imaging. Additionally, simultaneous evaluation of bilateral lower extremities can help determine the lesion's exact site. Although TRANCE-MRI can provide MR arteriography and MR venography, we recommend performing only MR venography in symptomatic LEVD patients because the incidence of occult arterial disease is low.

To evaluate the efficacy of a micronized purified flavonoid fraction in patients with primary venous disease. The study enrolled 31 patients, with varicose veins observed in a total of 47 lower extremities which were divided into 3 groups depending on the CEAP clinical class. The group of class C2 included 19 limbs, with the groups of C3 and C4 comprising 14 limbs each. The patients received a micronized purified flavonoid fraction (Detralex) in a daily dose of 1000 mg for 1 month. The venous function of the lower extremities was examined using venous photoplethysmography before and after the course of pharmacotherapy. Venous refilling time and venous half-refilling time were measured as indicators of total venous reflux. In the overall sample of patients with clinical class C2-C4, a significant increase in venous photoplethysmography parameters was found after the course of administration of the micronized purified flavonoid fraction. Thus, the venous refilling time increased from 15.5 (11; 19) s to 19.3 (13; 25) s, the venous half-refilling time increased from 6.5 (5; 7) s to 7.5 (5; 9) s. At the same time, in the group of patients with clinical class C2 and C3, a significant increase in the venous refilling time was found, and in patients with C4, the increase was not significant. There was an inverse correlation between the increase in venous refilling time after drug exposure and the clinical class of venous insufficiency according to the CEAP, as well as the patient's age. Thus, the administration of the micronized purified flavonoid fraction for 1 month in primary venous disease led to a decrease in the total venous reflux. The effect of the micronized purified flavonoid fraction on the total venous reflux was higher in younger patients and in patients with a lower clinical class of the disease.Целью исследования была оценка эффективности микронизированной очищенной флавоноидной фракции у больных с варикозной болезнью. В исследование включен 31 пациент, варикозное расширение вен наблюдалось на 47 нижних конечностях, которые разделялись на 3 группы в зависимости от клинического класса по СЕАР. В группу с классом С2 вошли 19 конечностей, в группу С3 и группу С4 – по 14 конечностей. Пациенты получали в течение 1 месяца микронизированную очищенную флавоноидную фракцию (Детралекс) в суточной дозе 1000 мг. Венозную функцию нижних конечностей исследовали с помощью венозной фотоплетизмографии до и после курса фармакотерапии. Измеряли время венозного кровенаполнения и время половины венозного кровенаполнения как показателей суммарного венозного рефлюкса. В общей выборке больных с клиническим классом С2–С4 обнаружено значимое увеличение показателей венозной фотоплетизмографии после курса приема препарата. Так, время венозного кровенаполнения повысилось от 15,5 (11; 19) с до 19,3 (13; 25) с, время половины венозного кровенаполнения – от 6,5 (5; 7) с до 7,5 (5; 9) с. При этом в группе пациентов с клиническим классом С2 и С3 зафиксирован значимый прирост времени венозного кровенаполнения, а у пациентов с С4 – прирост был незначимым. Была отмечена корреляционная обратная связь прироста времени венозного кровенаполнения после лекарственного воздействия с клиническим классом венозной недостаточности по СЕАР и с возрастом пациента. Таким образом, назначение микронизированной очищенной флавоноидной фракции в течение 1 месяца при первичном венозном заболевании приводит к уменьшению суммарного венозного рефлюкса. Влияние микронизированной очищенной флавоноидной фракции на суммарный венозный рефлюкс выше у более молодых больных и у пациентов с меньшим клиническим классом заболевания.

Objectives Venous stenting of the lower extremities has grown in popularity and is now considered a key component of the primary treatment strategy for the management of pathologically obstructive or stenotic lesions of the deep venous system. This review aims to provide an overview of the role of venous stenting in the management of chronic conditions affecting the deep venous system of the lower limbs. Methods An overview of venous stents design and current role of stenting procedure in individuals presenting with Chronic Venous Insufficiency (CVI) and presenting the current trials of dedicated venous stenting in management of chronic deep venous lesions. This review provides a focused insight on venous stent design, physical properties and the available dedicated venous stents selected studies with their related patency outcome based on selective literature search of the PubMed database and Cochrane library. Conclusions Dedicated venous stent technology is advancing at a rapid pace alongside the increased undertaking of endovascular deep venous stent reconstruction in the management of iliocaval vein pathologies. The ideal design(s) for venous stents remain unknown, although it is hoped that the presence of new dedicated venous stents in clinical practice will allow the generation of experience and data to advance our understanding in this area.

The venous system is responsible for bringing blood from the lower limbs to the heart. To achieve this, various mechanisms are activated that work against gravitational force. A very important mechanism is the function of the venous valves. A family history of venous disease is most commonly associated with valve dysfunction, which can lead to venous hypertension, amongst several other risk factors, thus activating a cascade of events characterized by venous dilation and leukocyte migration. Chronic complications can be very expensive in relation to quality of life and the health system. At present, venous disease studies include several diagnostic methods that, together with a wide range of therapeutic tools, have achieved excellent results in the quality of life of patients.

Objective This study assessed the improvement in Quality of Life (QoL) of Chronic Venous Disease (CVD) patients in Sri Lanka following treatment. Methods This was a prospective observational study of 58 newly or previously diagnosed CVD patients. QoL was assessed by the 14-item ChronIc Venous dIsease quality of life Questionnaire (CIVIQ-14) at 4 and 8 weeks after treatment. Results At 8 weeks, the improvement in Global score from baseline was greatest in the surgical group with adjusted least squares mean of 23.5 (p Conclusion Both surgical and non-surgical treatments improved QoL of CVD patients.

Background Balneotherapy has been considered beneficial in patients with chronic venous disease due to patient-reported positive outcomes on improvement of symptoms and quality of life. Study aim: Assessing the effects of prolonged water immersion (WI) on leg edema and epifascial thickness and to compare these data with those achieved after continuous walking on ground. Material and methods On three consecutive days, 14 otherwise healthy volunteers (9 females, 5 males, mean age 53 ± 10 years) affected by occupational edema (OE), defined as the edema developing during the time period of the working day and disappearing overnight, stayed standing immobile in a swimming pool for 30 minutes (30’), continuously walking again for 30’ in the same pool and walking on ground for 30’ without interruptions in a randomized sequence. Leg volume, ankle circumference and epifascial thickness of both legs were assessed each day before and after each intervention. Results Leg volume showed a median reduction by 4.20% (IQR 5-3.6) (p = 0.0002) after 30’ of immobile standing immersion and by 6.50% (IQR 7.30-5.61) (P Conclusions This study showed that 30’ of WI, especially when associated with walking, reduced leg volume in otherwise heathy subjects with OE and that walking outside the water did not.

ObjectiveExternal jugular vein (EJV) aneurysm is an extremely uncommon clinical condition. We have studied the clinical profile and need for surgery in this present seven case series of primary external jugular vein aneurysms.MethodOver the past three years, we have diagnosed and managed aneurysms of external jugular vein in seven patients, who presented with swelling in the posterior triangle of the neck. Venous duplex was obtained in all the patients, followed by computed tomography (CT) in three patients and one patient reported with magnetic resonance (MR) venography from another hospital. Three patients had symptoms ranging from mild intermittent discomfort to moderate pain underwent excision of aneurysm after ligation of both ends of EJV. Four patients had swelling on the lateral side of the neck due to EJV aneurysm, with no other associated symptoms. They were kept on six monthly follow-ups.ResultWe operated three patients, as they were symptomatic, of which only two had thrombus in the aneurysmal sac. All three symptomatic patients had aneurysm of size >5 cm. Post-surgery and on subsequent follow-ups they were asymptomatic. The four asymptomatic patients kept on conservative management did not develop any thrombosis of aneurysm sac in follow up.ConclusionSurgical excision is indicated for symptomatic patients with EJV aneurysm, preferably for size > 5 cm because of their higher association with thrombosis or symptoms. Asymptomatic patients can be managed non-operatively with regular surveillance by clinical examination and venous duplex or can be treated if patients insist due to cosmetic reasons.

Background: We thank Franceschi et al for their letter entitled “Transmural pressure for conceptualisation of chronic venous insufficiency management” regarding our paper wherein we have repurposed a Guytonian model of systemic venous return to explain the hemodynamic changes that occur in lower limb venous disease.1,2 This model was developed using the non-thrombotic iliac vein lesion (NIVL) as the basis for the hemodynamic response. Franceschi et al have raised queries in their communication that in our model, we have suggested venous stenting, compression therapy and superficial ablation as treatment options for the NIVL. Their concern is that superficial venous ablation will raise transmural pressures within the deep venous compartment, with a worsening of venous compliance, transmission of the higher pressures to the microcirculation leading to trophic changes of venous stasis, as well as recurrences. It is important to state at the outset that we do not advocate superficial venous ablation as a treatment for an NIVL. The NIVL has been used by us purely to develop the model for venous return, not to suggest one form of therapy or another for superficial venous disease. A detailed explanation of the responses to different interventions for superficial venous disease based on our model is now presented to address the issues raised.

Background: Lipodermatosclerosis (LDS) is a severe skin change accompanied by the development of chronic venous disease of the lower extremities. Its main clinical manifestations are erythema, induration, hyperpigmentation, and rough and thickened skin. It may also eventually lead to refractory ulcers, skin necrosis and even cancer. Conventional treatment methods mainly include the intake of oral anabolic hormones or androgen and pressure therapy. However, patients often refuse due to their drug resistance and intolerance. As a clinical irreplaceable treatment method for LDS, traditional Chinese medicine (TCM) has not been compared of the safety and effectiveness so far. Therefore, we cannot wait to use a method to compare the efficacy of TCM for LDS systematically, such as network meta-analysis (NMA). Methods: We will retrieve the relevant Chinese and English databases comprehensively. All the randomized controlled trials of TCM for LDS from January 2015 to September 2020 will be included. Under the guidance of inclusion criteria, 2 researchers will screen the literature, then assess the risk of bias and extract data. We will use Bayesian NMA to evaluate all available evidence in STATA 14.0 and WinBUGS software. Results: This study will use Bayesian NMA to evaluate the efficacy and safety of TCM for LDS. Conclusion: This study provide a reliable theoretical basis for the clinical application of TCM in the treatment of LDS, and contribute to the formulation of treatment guidelines for LDS.

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

Leg ulcers caused by venous diseases are effectively assessed by Doppler ultrasonography. The examination provides clear anatomical and physiological information for the diagnosis, treatment planning, and real-time guiding during the surgical treatment. Diagnostic Doppler ultrasonography assesses deep, superficial, and perforator veins, starting from patency assessment by direct visualization and simply compression test. The internal flow can be assessed by pulse wave analysis, which is used for rule out downstream flow obstruction and valvular incompetence. The venous valve function of deep, superficial, and perforator systems can be evaluated by measuring the time of the retrograde flow after flow augmentation performing in the upright position. At the end of the study, the venous map will be obtained and this map will guide clinicians to target treatment where the culprit is. The ultrasound technology has made a big shift in the treatment in the venous disease. In recent years, after the evolution and wide availability of ultrasound, newer treatment modalities have emerged for venous treatment. These include endovenous thermal ablation, endovenous adhesive closure, and ultrasound-guided foam sclerotherapy. Patients no longer require general anesthesia or hospitalization. Therefore utilization of duplex ultrasound has also surged and played an essential role in both diagnosis and therapy in venous ulcer. This article has dedicated to reviewing basic anatomy, the technique in diagnosis, and treatment.