Abstract
Interventions for the treatment of recurrent varicose vein disease arising from the saphenofemoral junction or the great saphenous vein: A systematic review and meta-analysis
Bontinis A, Bontinis V, Koudounas G, Giannopoulos A, Karkos C, Virvilis D, Chorti A, Ktenidis K
Int Angiol. 2024 Oct; 43(5):485-496. doi: 10.23736/S0392-9590.24.05323-9. Epub 2024 Nov 19
The authors investigated the safety and feasibility of the available interventions in the treatment of recurrent varicose vein disease. A systematic search on Medline, Scopus, and Web of Science for articles published by August 2024 was performed. Primary endpoints included duplex ultrasonography (DUS)-identified recurrence and clinical recurrence. Twenty-eight studies, eleven describing endovenous thermal ablation (EVTA), four ultrasound-guided foam sclerotherapy (UGFS), and thirteen surgeries (high ligation with or without stripping) encompassing 2228 limbs, were included. The overall DUS-detected recurrence estimate was 11.84% (95% CI: 7.15–17.40). EVTA displayed the lowest recurrence of 4.27% (95% CI: 0.37–10.75), followed by UGFS 11.19% (95% CI: 6.80–16.42) and surgery 23.27% (95% CI: 15.35–32.19). Statistically significant differences were observed between surgery and both EVTA (p < 0.01) and UGFS (p = 0.01). The overall clinical recurrence estimate was 24.91% (95% CI: 10.40–42.96) with EVTA portraying the lowest clinical recurrence of 2.37% (95% CI: 0.00–16.81), followed by surgery 31.08% (95% CI: 14.43–50.63). Subgroup analysis identified statistically significant differences between EVTA and surgery (p = 0.01). Whereas non statistically significant differences were identified between the included interventions regarding paresthesia and deep vein thrombosis (DVT), surgery exhibited higher wound infection estimates compared to EVTA of 0.00% (95% CI: 0.00–0.80) versus 4.34% (95% CI: 2.21–7.02, p < 0.01). The pooled hematoma and lymphatic complication estimates for surgery were 5.04% (95% CI: 0.50–12.87) and 5.71% (95% CI: 2.91–9.22) respectively.
The authors concluded that this review demonstrated the superior efficacy of EVTA over surgery in treating recurrent varicose vein disease corroborating its use as the preferred treatment, when feasible. Additionally, UGFS displayed comparable outcomes to EVTA. The notable recurrence estimates associated with surgery call into question its suitability within this context.
Efficacy of medical compression stockings class I on the reduction of symptoms in patients with uncomplicated varicose veins
Stücker M, Braß D, Möckel L, Hartmann K
Vasa. 2024 Nov 25. doi: 10.1024/0301-1526/a001163. Online ahead of print
The authors’ aim of this study was to analyze the effect of medical compression stockings (MCS) class I (according to the German classification “RAL-GZ 387”; 18–21 mmHg) on symptoms in patients with uncomplicated varicose veins (C2s-C4a). They conducted a randomized (1:1), controlled, clinical trial enrolling patients with uncomplicated varicose veins (CEAP: C2s-C4a). The study consisted of a 1-week baseline period and a 4-week follow-up period with MCS treatment (compression class I, 18–21 mmHg) in the intervention group and non-treatment in the control group. The frequency and severity of symptoms on the leg including heaviness, pain, swelling, throbbing and itching were measured every evening using an app-based measuring tool. The primary endpoint was the reduction of symptoms during compression therapy, measured by a symptom sum score over a period of 5 weeks ranging from 0 (no symptoms during the day) to 25 (symptoms all day). Patients treated with MCS (n = 25) showed a significant improvement in the overall symptom sum score from 8.90 ± 4.26 at baseline to 6.37 ± 3.55 at follow-up (p = 0.004) whereas for patients in the control group without MCS (n = 25) the overall score remained unchanged (baseline: 7.46 ± 3.71; follow-up: 7.67 ± 4.74; p = 0.293). The intervention group reported significant improvements in symptom frequency scores for pain, leg swelling and feeling of leg heaviness (p ≤ 0.002). In the control group the score for pain significantly increased during the follow-up period. Leg itching was numerically more frequent in patients with MCS.
The authors concluded that medical compression stockings class I (according to the German classification “RAL-GZ 387”; 18–21 mmHg) significantly improve the frequency and severity of symptoms in patients with uncomplicated varicose veins (CEAP: C2s-C4a).
Relationship between internal diameter and vasoconstriction in human varicose veins
Yokota A, Matsumoto T, Nagano T, Kuwabara M, Nakamura E, Yamamoto R, Tanaka-Totoribe N
J Smooth Muscle Res. 2024:60:31-38. doi: 10.1540/jsmr.60.31
Varicose veins are common lower extremity venous disorders characterized by dilated veins and incompetent valves. Although maintaining the required vein wall tone for adaptive responses depends on a proper contractile function of the human saphenous smooth muscle, the contractile properties of varicose veins are mostly unknown. The authors investigated the relationship between contractile responses and the internal diameter of human saphenous varicose veins. The absolute contractile forces induced by potassium chloride (KCl, 60 mmol/l), serotonin (5-hydroxytryptamine [5-HT], 10 µmol/l), and noradrenaline (NAd, 10 µmol/l) were similar between normal saphenous veins (control) and varicose veins. When the contractile forces were normalized to the internal diameter in each preparation, the contractile responses to these stimuli were significantly lower in varicose veins than in the control veins. Furthermore, varicose veins were divided into three groups according to their internal diameter (group 1, 3–4.5 mm; group 2, 4.5–6 mm; group 3, >6 mm). The contractile responses induced by KCl, 5-HT, and NAd did not differ between groups 1 and 2 and the control group, while the contractile responses in group 3 were significantly lower than those in the control group. Moreover, the contractions induced by KCl and NAd in Group 3 were smaller than those in group 1 or group 2. This trend was also observed in 5-HT-induced contractions, although the results were not statistically significant.
The authors concluded that contractile responses in varicose veins may be altered by an increase in internal diameter, although adequate contractile responses are preserved in some diameters.
Editor’s Choice - management of lower extremity venous outflow obstruction: Results of an international Delphi consensus
Black SA, Gohel M, de Graaf R, Gagne P, Silver M, Fleck B, Hofmann LV, International Venous Delphi Consensus Study Group
Eur J Vasc Endovasc Surg. 2024 Feb;67(2):341-350. doi: 10.1016/j.ejvs.2023.09.044. Epub 2023 Oct 4
The endovascular treatment of venous obstruction has expanded significantly in recent years. Best practices for optimal patient outcomes are not well established and the evidence base is poor. The purpose of the authors’ study was to obtain consensus on management criteria for patients with lower extremity venous outflow obstruction. The study was conducted as a two round Delphi consensus. Statements addressed imaging, symptoms and other baseline measures, differential diagnosis, treatment algorithm, indications for stenting, inflow and outflow assessment, successful procedural outcomes, post-procedure therapies and stent surveillance, and clinical success factors. Statements were prepared by six expert physicians (round 1, 40 statements) and an expanded panel of 24 physicians (round 2, 80 statements) and sent to a pre-identified group of venous experts who met qualifying criteria. A 9 point Likert scale was used and consensus was defined as ≥70% of respondents rating a statement between 7 and 9 (agreement) or between 1 and 3 (disagreement). Round 1 results were used to guide rewording and splitting compound statements for greater clarity in round 2. In round 1, 75 of 110 (68%) experts responded, and 91 of 121 (75%) experts responded in round 2. Round 1 achieved consensus in 32/40 (80%) statements. Consensus was not reached in the treatment algorithm section. Round 2 achieved consensus in 50/80 (62.5%). Statements reaching consensus were imaging (2/3, 66%), symptoms and other baseline measures (12/24, 50%), differential diagnosis (2/8, 25%), treatment algorithm (10/17, 59%), indications for stenting (10/10, 100%), inflow and outflow assessment (2/2, 100%), procedural outcomes (2/2, 100%), post-procedure therapies and stent surveillance, (5/7, 71%), and clinical success factors (5/7, 71%).
The authors concluded that considerable consensus was achieved between venous experts on the optimal management of lower extremity venous outflow obstruction. There were multiple domains where consensus is lacking, highlighting important areas for further investigation and research.
Various therapies for lymphedema and chronic venous insufficiency, including a multimodal at-home nonpneumatic compression treatment
Barnhart H, Maldonado T, Rockson SG
Adv Skin Wound Care 2024 Feb 9;37(4):212–215
The authors reviewed treatment modalities in the treatment of lymphedema and chronic venous insufficiency. These treatments include elevation, exercise, static compression, gradient sequential compression and active pneumatic compression devices (APCDs). The authors point out that the APCDs provide non-mobile sequential gradient devices that use air to inflate and deflate chambers. Nonpneumatic compression treatments delivers both static compression and gradient sequential compression. These devices enable the necessary muscle and joint contractions to increase lymphangion action.
The authors concluded that using a nonpneumatic compression device that combines multiple treatment modalities allows patients to remain mobile and active which adds to their quality-of-life benefits.
Cumulative incidence of venous thromboembolic events in-hospital, and at 1, 3, 6, and 12 months after metabolic and bariatric surgery: Systematic review of 87 studies and meta-analysis of 2,731,797 patients
El Ansari W, El-Menyar A, El-Ansari K, Al-Ansari A, Lock M
Obes Surg 2024 Jun;34(6):2154-2176
The authors conducted a systematic review and meta-analysis of the incidence of venous thromboembolic events (VTE) post metabolic and bariatric surgery. Pooled in hospital venous VTE in 4,991,683 patients who underwent laparascopic surgery, the incidence was 0.15% at 30 days, 0.51% at 3 months, 0.72% at 6 months, and 0.78% at 12 months. Those patients undergoing open surgery had a higher incidence compared to the laparascopic approach.
The authors recommend extended surveillance of VTE after metabolic and bariatric surgery.
The role of clinicians’ self-efficacy in exercise promotion for adults with venous leg ulcers: A cross-sectional study
O'Brien J, McCann D, Parker CN, Finlayson K, Jull A
Int J Low Extrem Wounds 2025 Feb 25:15347346251321550
The authors developed an online questionnaire to assess clinician’s familiarity with physical active guidelines, their confidence in recommending physical activity, and the barriers encountered. A total of 141 clinicians, predominantly nurses (99%) completed the survey with 83% reporting awareness of venous leg ulcer clinical guidelines. Only 25% regularly recommended increase in physical activity, 27% recommended calf strengthening, and 38% recommended ankle joint mobility exercises. Barriers included insufficient training to recommend exercises, lack of evidence based information to provide to patients, and limited exercise specialists for referrals.
The authors suggest that gaps in knowledge must be addressed.
The role of direct oral anticoagulants in the treatment of cancer-associated venous thromboembolism: Review by middle east and north African experts
Bazarbashi S, El Zawahry HM, Owaidah T, AlBader MA, Warsi A, Marashi M, Dawoud E, Jaafar H, Sholkamy SM, Haddad F, Cohen AT
J Blood Med. 2024 Apr 25:15:171-189
The authors reviewed anticoagulation in cancer patients. They summarize the increased incidence of major gastrointestinal bleeding observed for edoxaban and rivaroxaban, but no apixaban when compared with low molecular weight heparin (LMWH) dalteparin. Most guidelines recommend direct oral anticoagulants (DOACs) for the treatment of cancer associated venous thromboembolism (VTE) in patients without gastrointestinal or genitourinary cancer, with consideration of renal impairment and drug interactions.
The authors suggest that apixaban may be the preferred DOAC, however in patients with unresected gastrointestinal tumors, thought should be given, and LMWH may be the better option.