Phlebology: The Journal of Venous Disease

Low-flow vascular malformations are congenital abnormalities of the veins, capillaries or lymphatic vessels or a combination of the previous. Compressive garments are frequently used as a first-line treatment option for low-flow vascular malformations of the extremities with the purpose of relieving symptoms. Yet, the benefits and harms of compression stockings remain unclear.

A systematic search was performed in MEDLINE, Embase, Cochrane Central Register of Controlled Trials including a hand search for studies measuring the benefits and harms of compression garments in treating low-flow vascular malformations. Two investigators performed study selection, quality assessment and data extraction independently.

Of the 565 studies found, eventually five (totalling 101 patients with venous malformations or Klippel–Trenaunay syndrome receiving compression therapy) observational studies were included in the systematic review. Although the overall quality of these studies was poor, results suggest that compression garments might lessen intravascular coagulation, improve symptoms and appearance, diminish oedema, and protect against minor trauma. None of the studies quantified any harms of compression therapy.

Even though compression therapy is commonly used in the treatment of low-flow vascular malformations, available literature does not provide high-quality evidence to validate its use. We therefore advocate the need for prospective comparative trials with standardised outcome measures to study the benefits and harms of this treatment option.

The therapeutic effectiveness of compression therapy depends on the selection of compression hosiery.

To assess efficacy and tolerability of graduated elastic compression stockings (GECS) and inverse graduated elastic compression stockings (PECS).

Thirty-two healthy volunteers and thirty-two patients with chronic venous insufficiency were analysed; wear period: one week for each stocking type (randomised, blinded). Primary outcome: volume reduction of ‘Lower leg’ (Image3D®) and ‘Distal leg and foot’ (water plethysmography). Secondary outcomes: clinical symptoms of chronic venous insufficiency assessed by the Venous Clinical Severity Score, side effects and wear comfort in both groups.

Volume of ‘Lower leg’: significant reduction in healthy volunteers (mean GECS: −37.5 mL, mean PECS: −37.2 mL) and in patients (mean GECS: −55.6 mL, mean PECS: −41.6 mL). Volume of ‘Distal lower leg and foot’: significant reduction in healthy volunteers (mean GECS: −27 mL, mean PECS: −16.7 mL), significant reduction in patients by GECS (mean: −43.4 mL), but non-significant reduction by PECS (mean: −22.6 mL). Clinical symptoms of chronic venous insufficiency were improved significantly better with GECS than with PECS, p < 0.001. GECS led to more painful constrictions, p = 0.047, PECS slipped down more often, p < 0.001.

GECS and PECS reduce volume of the segment ‘Lower leg’ in patients and healthy volunteers. Patients’ volume of the ‘Distal lower leg and foot’, however, were diminished significantly only by GECS (p = 0.0001). Patients’ complaints were improved by both GECS and PECS, and GECS were superior to PECS.

To study the association of polymorphisms rs699947, rs2010963, rs3025039 in the VEGFA gene region and rs1870377, rs2305949, rs2071559 in the VEGFR2 gene region with the risk of primary varicose veins in ethnic Russians.

Genotypes were determined by real-time PCR allelic discrimination. The case group consisted of 448 patients with primary varicose veins and the control group comprised 609 individuals without a history of chronic venous disease. Association was studied by logistic regression analysis.

Allele rs2010963 C was associated with the decreased risk of varicose veins (additive model of inheritance: odds ratio = 0.73, 95% confidence interval = 0.59–0.91, P = 0.004).

Our results provide evidence that polymorphism rs2010963 located in the 5′ untranslated region of the VEGFA gene can influence genetic susceptibility to primary varicose veins in Russians. Otherwise, it can be in linkage disequilibrium with another functional single nucleotide polymorphism that can alter the level of vascular endothelial growth factor A protein.

Patient compliance is the cornerstone of compression therapy success. However, there has been up to now no tool to assess it other than self-reporting by the patient, which is not reliable.

Forty active females classified C2S were enrolled to wear compression stockings (CS) providing a pressure of 15–20 mmHg at the ankle.

A thermal probe was inserted in the stocking (Thermotrack®), recording the skin temperature every 20 min for four weeks.

The patients were randomized in two groups of 20:

– Group 1: Receiving minimal recommendations by their physician at the office.

– Group 2: Receiving in-depth recommendations by the physician reinforced with SMS message which were repeated once a week for four weeks.

The basic CEAP classification and the quality of life (QoL) were recorded before and after four weeks.

The two groups are similar for age, symptoms and type of CS.

The analysis of the thermal curves showed a significant increase (+33%) in the average wearing time daily in the group 2: 8 h vs. 5.6 h (group1) p < 0.01. The average number of days worn per week is also increased: 3.4 (group 1) vs. 4.8 (group 2), thus improving patient compliance from 48.5% to 70% as a direct result of the physician recommendations (p < 0.001).

This is the first study assessing the real compliance in CVD patients of using compression. It shows that better and repeated recommendations by the practitioner result in an increase in time the compression is used by 33%. The study also suggests that the number of days the compression stocking is worn is a good criterion of patient compliance.

Adequately excising varicose and incompetent perforating veins is necessary for reducing their recurrence rate of venous ulcer.

In total, 66 venous ulcers (C6) in 1083 legs with primary varicose veins were managed through endoscopic-assisted surgery. In an endoscopic operative view, the nonvaricose, varicose, and incompetent perforating veins were clearly visualized and precisely dissected. The varicose and incompetent perforating veins were divided and completely excised.

The varicose veins were traced to the base or periphery of the 55 ulcers. Moreover, 89.4% of the ulcers healed within 14 weeks. Kaplan–Meier analysis revealed a five-year recurrence rate of 0.0%, and the satisfaction mean score was 4.6.

Endoscopic-assisted surgery can be used to radically excise varicose veins complicated with venous ulcers; the surgery yields low recurrence and high satisfaction rates.

Standard treatment for deep venous thromboembolism involves parenteral anticoagulation overlapping with a vitamin K antagonist, an approach that is effective but associated with limitations including the need for frequent coagulation monitoring. The direct oral anticoagulant rivaroxaban is similarly effective to standard therapy as a single-drug treatment for venous thromboembolism and does not require routine coagulation monitoring. The aim of this analysis was to project the long-term costs and outcomes for rivaroxaban compared to standard of care (tinzaparin/warfarin).

A total of 184 patients who were under anticoagulant therapy with warfarin or rivaroxaban for extended deep venous thromboembolism were retrospectively evaluated; 59 received rivaroxaban and 125 received warfarin therapy. Assessments were made on age, gender, place of residence, the duration of anticoagulation, mean international normalized ratio value, the effective rate of international normalized ratio (time in the therapeutic range), bleeding-related complication rate, duration of hospitalization due to complications, the number of annual outpatient department admission, cost for drug, cost for hospitalization, cost for outpatient department admission and international normalized ratio measurements.

The annual outpatient cost is higher in warfarin group (147.09 ± 78 vs. 62.32 ± 19.79 USD p < 0.001). But annual drug cost is higher in rivaroxaban group (362.6 vs. 71.55 ± 31.01 USD p < 0.001). Overall cost of rivaroxaban group is higher than warfarin group (476.25 ± 36.78 vs. 364.82 ± 174.44 USD). Warfarin is not cost-effective when non-drug costs (342.5 ± 174.44 vs. 113.65 ± 36.77) and hospital costs (173.85 ± 122.73 vs. 64.9 ± 23.55 USD) were analyzed.

This analysis suggests that rivaroxaban has lower costs than warfarin in terms of outpatient department admission and hospital costs due to complications; however, warfarin was more economic when all cost parameters were considered. Time in the therapeutic range was found as 56% for warfarin that should be taken into account while analyzing costs and benefits.

Venous ulcers carry psychological and high financial burden for patients, causing depression, pain, and limitation of mobility. The study aimed to identify factors associated with an increased risk of venous ulceration in patients with varicose veins in Armenia.

A case-control study design was utilized enrolling 80 patients in each group, who underwent varicose treatment surgery in two specialized surgical centers in Armenia during 2013–2014 years. Cases were patients with varicose veins and venous leg ulcers. Controls included patients with varicose veins but without venous leg ulcers. Data were collected using interviewer-administered telephone interviews and medical record abstraction. Multiple logistic regression analysis was used to identify the risk factors of venous ulceration.

There were more females than males in both groups (72.5% of cases and 85.0 % of controls). Cases were on average older than controls (53.9 vs. 39.2 years old, p ≤ 0.001).

After adjusting for potential confounders, the estimated odds of developing venous ulcer was higher in patients with history of post thrombotic syndrome (odds ratio = 14.90; 95% confidence interval: 3.95–56.19; p = 0.001), with higher average sitting time (odds ratio = 1.32 per hour of sitting time; 95% confidence interval: 1.08–1.61; p = 0.006), those with reflux in deep veins (odds ratio = 3.58; 95% confidence interval: 1.23–10.31; p = 0.019) and history of leg injury (odds ratio = 3.12; 95% confidence interval: 1.18–8.23; p = 0.022). Regular exercise in form of walking (≥5 days per week) was found to be a protective factor from venous ulceration (odds ratio = 0.26; 95% confidence interval: 0.08–0.90; p = 0.034).

We found that reflux in deep veins, history of leg injury, history of post thrombotic syndrome, and physical inactivity were significant risk factors for venous ulceration in patients with varicose veins, while regular physical exercise mitigated that risk. Future studies should investigate the relationships between the duration and type of regular exercise and the risk of venous ulceration to make more specific recommendations on preventing ulcer development.