Abstract
A new pearl in chronic venous disease pathophysiology-the duplex ultrasound and the elastographic features of lymph nodes varicose veins in the groin
Dulgheriu IT, Solomon C, Timofte S, Ciurea AI, Dudea SM. Diagnostics (Basel) 2026 Mar 18;16(6):905.
The purpose of this study was to provide an ultrasonographic anatomical description of intranodal varicose veins and to assess possible changes in the stiffness of varicose, dilated inguinal lymph nodes. Chronic venous disease (CVD) is a prevalent condition marked by valve dysfunction and increased pressure in lower limb veins. The trans-nodal veins in the inguinal region and Scarpa triangle, which connect the superficial and deep venous systems, provide new insight into venous insufficiency pathways. While they function normally in healthy individuals, they can become dilated in chronic venous disease or following surgery. 92 participants, 69 women and 23 men, underwent Doppler ultrasound examinations of the lower-limb venous system, with a focus on the groin from both a descriptive morphological and an elastographic perspective. The diagnosis of lymph node varices utilized established criteria; its severity was assessed using an original classification system; shear-wave elastography (SWE) values were recorded. Greater than 83% of patients with operated CVD had lymph node varicose veins. Patients with lymph node varicose veins had larger groin lymph node diameters than patients with CVD without lymph node varicose pathology. The mean shear wave elastography values were significantly lower in the group with lymph node varices compared to the group without (12.2 ± 1.1 kPa vs 20.1 ± 2.3 kPa; p < .05). Elastographic values correlate with lymph node diameter (p = .039) and with varicose vein grade (p < .001).
The authors concluded that intranodal varices may indicate disease progression. These vascular abnormalities impact SWE measurements by altering tissue mechanics. To improve patient outcomes in the management of CVD, it is imperative to consider the interactions between the lymphatic and venous systems.
Bleeding risk with apixaban versus rivaroxaban in acute venous thromboembolism
Castellucci LA, Chen VM, Kovacs MJ, Lazo-Langner A, Greenstreet P, Kahn S, Côté B, Schulman S, de Wit K, Douketis J, Suryanarayan D, Wan T, Yeo E, Le Templier G, Tran HA, Willcox A, Crowther HJ, Prasad R, Shivakumar S, Umana E, Ni Ainle F, Tritschler T, Barco S, Galanaud JP, Blondon M, Kreuziger LB, Solymoss S, Kearon C, Thomas E, Ramsay T, Le Gal G, Rodger M; COBRRA Trial Investigators. N Engl J Me.2026 Mar 12;394(11):1051-1060.
The authors’ aim was to define the difference in bleeding risk between Apixaban and Rivaroxaban. In an international trial with a prospective, randomized, open-label, blinded end-point design, the trialists assigned, in a 1:1 ratio, patients with acute symptomatic pulmonary embolism or proximal deep-vein thrombosis to receive apixaban or rivaroxaban for 3 months. Apixaban’s dose was 10 mg twice daily for 7 days followed by 5 mg twice daily, and rivaroxaban was given at a dose of 15 mg twice daily for 21 days followed by 20 mg daily. Primary outcome was clinically relevant bleeding, a composite of major bleeding or clinically relevant nonmajor bleeding, according to the International Society on Thrombosis and Hemostasis, during the 3-months trial period. Secondary outcomes included death from any cause. 2760 patients underwent randomization: 1370 to the apixaban group and 1390 to the rivaroxaban group. A primary-outcome event occurred in 44 of 1345 patients (3.3%) in the apixaban group and 96 of 1355 patients (7.1%) in the rivaroxaban group (relative risk, 0.46; 95% confidence interval [CI], 0.33 to 0.65; p < .001). Death from any cause occurred in 1 patient (0.1%) in the apixaban group and in 4 patients (0.3%) in the rivaroxaban group (relative risk, 0.25; 95% CI, 0.03 to 2.26). Serious adverse events unrelated to bleeding or venous thrombosis occurred in 36 patients (2.7%) in the apixaban group and in 30 patients (2.2%) in the rivaroxaban group.
The authors concluded that among patients with acute venous thromboembolism, the risk of clinically relevant bleeding was significantly lower with apixaban than with rivaroxaban during the 3-months treatment period.
Age-adjusted D-dimer cutoff levels to rule out deep vein thrombosis
Le Gal G, Robert-Ebadi H, Thiruganasambandamoorthy V, Moustafa F, Penaloza A, Catella J, Grenot MC, Visser S, Mazzolai L, Plumacker A, Barco S, Lang E, Tagalakis V, Deroche C, Garnett M, Hulme J, Roy PM, Ghuysen A, Couturaud F, Engelberger R, El Kouri D, Aujesky D, Righini M, ADJUST-DVT Investigators. JAMA. 2026 Feb 3;335(5):416-424.
The authors’ aim was to prospectively validate whether using an age-adjusted D-dimer cutoff (age × 10 µg/L in patients 50 years or older) allows clinicians to safely rule out deep vein thrombosis (DVT). The trial included a multicenter, multinational prospective management outcome study conducted in 27 centers in Belgium, Canada, France, and Switzerland between January 2015 and October 2022 (last follow-up visit, 30 January 2023) and including outpatients presenting to the emergency department with suspected DVT. Patients were assessed by a sequential diagnostic strategy based on the assessment of clinical pretest probability by the Wells score, a highly sensitive D-dimer test, and leg compression ultrasonography. Patients in whom DVT was ruled out were followed up for a 3-month period. The primary outcome was the rate of adjudicated symptomatic venous thromboembolic events during follow-up in patients in whom DVT was ruled out based on a D-dimer value between the conventional cutoff of 500 µg/L and their age-adjusted cutoff. 3205 patients were included. Median age was 59 years, and 1737 (54%) were female. DVT prevalence was 14%. Among the 2169 patients with a non-high or unlikely clinical probability, 531 (24.5% [95% CI, 22.7%-26.4%]) had a D-dimer level less than 500 µg/L, and 161 additional patients (7.4% [95% CI, 6.4%-8.6%]) had a D-dimer level between 500 µg/L and their age-adjusted cutoff. No failures were identified in patients with a D-dimer level 500 µg/L or greater but below the age-adjusted cutoff (0% [95% CI, 0%-2.3%]). Among patients 75 years or older, using the age-adjusted cutoff instead of the 500-µg/L cutoff increased the proportion of negative D-dimer from 33 of 379 (8.7% [95% CI, 6.3%-12.0%]) to 99 of 379 (26.1% [95% CI, 22.0%-30.8%]), without any false-negative test results.
The authors concluded that the age-adjusted D-dimer cutoff may safely rule out DVT. Moreover, age-adjusted D-dimer cutoff was associated with a larger number of patients in whom DVT could be effectively ruled out.
A novel endovascular thermal ablation technique for pelvic venous disorders via basilic vein access: A prospective descriptive study
Moreno L, Rivero F, Forero Ramirez N, Cabrera Vargas LF. J Vasc Surg Venous Lymphat Disord. 2026 May;14(3):102442. doi: 10.1016/j.jvsv.2026.102442.
The authors evaluated the feasibility, safety, and early efficacy of basilic vein access 1470-nm endovenous laser ablation (EVLA) for refluxing gonadal veins in women with pelvic venous disorders causing pelvic congestion syndrome. In this prospective, single-center descriptive cohort study conducted between January and June 2025, 10 women aged 18 to 50 years with chronic pelvic pain refractory to conservative therapy and Doppler-confirmed pelvic varices, defined by venous diameter >6 mm, low-flow waveforms, or Valsalva-induced reflux, underwent EVLA. When compressive syndrome was suspected, preprocedural computed tomography (CT) venography was obtained. Procedures were performed under local anesthesia with conscious sedation via right basilic vein access using a 400-μm, 1470-nm radial fiber delivering six to 8 W with controlled pullback to the proximal and mid gonadal vein segments. Diagnostic venography of the left renal, left common iliac, and internal iliac veins was performed to exclude compression and map reflux and varices, and the ureter was identified fluoroscopically for safety. The primary endpoints were technical success, defined as cessation of reflux or closure on completion of venography and 3-months CT, and safety, defined by periprocedural complications. Secondary end points included same-day discharge, pain measured using the visual analog scale (VAS), and imaging resolution of pelvic varices. Follow-up consisted of a 48-h clinic visit, a 4-weeks transvaginal Doppler ultrasound, a 3-months venous-phase CT, and a 6-months clinical assessment. The mean patient age was 37 years (range, 28-45 years). Baseline symptoms included pelvic pain in 100%, dysmenorrhea in 77%, dyspareunia in 94%, and postcoital pain in 97%, with a mean baseline VAS score of 7.8 of 10. All procedures were performed as day-case interventions with a hospital stay of 0 days. The mean target vein diameter was 14 mm (range, 10-17 mm), and all patients had left gonadal vein reflux (Symptoms-Varices-Pathophysiology S2V2; nonthrombotic). Procedure time was 45 to 60 min, and the estimated blood loss was approximately 10 mL. No intraoperative or postoperative complications occurred, including perforation, bleeding, ureteral injury, thrombosis, access-related complications, or contrast reactions. Technical success was 100%, with 3-months CT confirming complete occlusion in 10 of 10 patients and Doppler ultrasound showing resolution of pelvic varices. Pain improved rapidly to a VAS score of 1 to 2 of 10 at 24 h and remained low at 0.4 of 10 at 6 months. There was no opioid use, readmission, or reintervention at 30 days, and patient-reported quality of life improved throughout follow-up.
The authors concluded that basilic vein access 1470-nm EVLA of refluxing gonadal veins is feasible, safe, and associated with high early technical and clinical success, same-day discharge, and no complications in this pilot cohort, although larger multicenter randomized trials with longer follow-up, blinded imaging review, standardized patient-reported outcomes, and cost-effectiveness analyses are needed.
Endovascular therapy for post-thrombotic syndrome: A randomized trial
Vedantham S, Kahn S, Marston W, Weinberg I, Sista A, Magnuson E, Cohen D, Wasan S, Razavi M, Goldhaber S, Sanfilippo K, Comerota A, Azene E, Chaar C, Leung D, Kolli K, Kalva S, Rostambeigi N, Desai A, Desai K, Tafur A, Khalsa B, Majerus E, Wang B, Wang Y, Nieters P, Derfler M, Oliver A, Hardy C, Bashir R, Winokur R, Weger N, Khaja M, Sharma A, Mani N, Kavali P, Thukral S, Lake L, Mikkelsen K, Parpia S, C-TRACT Investigators. New England Journal of Medicine. 2026; epub April 13. PMID: 41972998
The authors’ objective in this study was to determine whether endovascular therapy improves outcomes in post-thrombotic syndrome. This randomized controlled trial enrolled 225 patients with chronic venous obstruction. Endovascular therapy reduced venous obstruction and improved symptom severity scores compared with standard therapy. Procedure-related complications revealed that bleeding was more common in the endovascular-therapy group.
The authors concluded that, compared to standard care, endovascular therapy resulted in less severe post-thrombotic syndrome and improved health-related quality of life during a 6-months follow-up, although it was associated with an increased risk of bleeding.
Analysis of clinical improvement at 90 days after varicose vein surgery using machine learning
Bakhouche A, Creton O, Lareyre F, Goffart S, Balelli I, Delingette H, Raffort J. Angiology. 2026; 77:33197261416661. PMID: 41619181
In this study, the authors developed machine-learning models to predict 90-days clinical improvement after varicose vein surgery. This retrospective multicenter study included 4015 patients treated between 2014 and 2024. Clinical improvement was defined as any decrease in CEAP stage. Overall, 87.6% of patients improved at 90 days. Random forest modeling achieved 80% accuracy in predicting non-improvement. Key predictors included baseline CEAP class, VCSS, age, and body mass index.
The authors concluded that machine-learning models demonstrated modest predictive ability and identified factors associated with poorer short-term outcomes.
The cardiovascular impact of chronic venous disease: A systematic review and meta-analysis
Del Río-Solá ML, Cenizo-Revuelta N, Saiz Viloria L, Martin Pedrosa M, González-Fajardo JA. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2026;14(1):102,310. PMID: 40912305
The authors’ objective in this study was to evaluate the association between chronic venous disease (CVD) and cardiovascular morbidity and mortality. This systematic review and meta-analysis followed PRISMA guidelines and included 20 observational studies encompassing 393,875 individuals. Study designs included cohort, cross-sectional, and case-control analyses. A pooled meta-analysis of six studies reported a significant association between CVD and cardiovascular events, with an adjusted odds ratio of 2.50 (95% CI 1.15–5.44). Moderate to severe CVD was consistently associated with increased cardiovascular risk. Considerable heterogeneity was present (I2 = 98%), the results included in the meta-analysis varied widely from each other, though no publication bias was detected.
The authors concluded that chronic venous disease is independently associated with increased cardiovascular risk, highlighting the importance of early CV screening in patients with CVD.
Outcomes of lymphovenous anastomoses and vascularized lymph node transplant in the combined surgical treatment of lymphedema
Zeltzer AA, Nistor A, Adriaenssens N, Deleuze J, Giunta G, Hamdi M. Plastic and Reconstructive Surgery. 2026;157(1):163-175. PMID: 40707214
The authors’ objective in this study was to compare surgical and conservative management of breast cancer-related lymphedema. This prospective controlled cohort study included 92 patients assigned to lymphovenous anastomosis, vascularized lymph node transfer, combined surgery, or complex decongestive therapy alone. Mean limb volume reduction ranged from −6.21% to −9.61% in surgical groups versus +3.23% in complex decongestive therapy (p < .0001 for all comparisons).
The authors concluded that in patients with breast cancer-related lymphedema surgical interventions combined with decongestive therapy significantly reduced limb volume compared with conservative therapy alone.