Phlebology: The Journal of Venous Disease

Livedo vasculopathy is a cutaneous thrombotic microangiopathy favouring the lower legs characterised by an intense reticulate pigmentation, atrophie blanche and recurrent painful stellate ulcerations. There is a strong association with antiphospholipid syndrome, thrombophilic abnormalities, factor V Leiden mutation and more recently, lipoprotein A. Thrombotic occlusion of the dermal venules is the key pathology in livedo vasculopathyand there is no associated vasculitis. Anticoagulation and other currently recommended conservative therapies do not influence the rate of ulcer healing.

Concurrent venous hypertension was treated with endovenous ablative methods. In addition, vessels deemed to be involved in the process of vasculopathy, irrespective of their reflux status were identified on duplex ultrasound or by sight and ablated using endovenous laser and/or sclerotherapy.

Five patients received endovenous intervention while two patients did not undergo any procedures. One patient requested a delay in interventions due to her circumstances and the other patient had multiple contraindications and comorbidities. On long-term follow-up, the intervention achieved complete ulcer healing and resolution of pain without any recurrence in four treated patients.

We recommend ablative venous interventions in suitable patients with livedo vasculopathy to prevent recurrent ulcerations. Compression should be considered as an adjunct treatment.

Venous thromboembolism is rare following varicose vein ablation procedures, but uncertainty about its incidence combined with a lack of evidence-based clinical guidelines regarding thromboprophylaxis has led to debate about best practice. We conducted a national survey to investigate current practice among Irish vascular surgeons.

An anonymous online questionnaire was emailed to all members of the Irish Association of Vascular Surgeons and the Northern Ireland Vascular Society.

Response rate was 60%. With regard to procedure type, 36.7% of respondents use only endovenous techniques and 53% use a combination of open and endovenous. Formal duplex imaging on all patients is obtained by 53.3%. With regard to VTE prevention, 73.3% always give thromboprophylaxis. For those who give it selectively, a variety of factors were considered as risks. Pharmacological agents used are enoxaparin in 73.3% of cases or tinzaparin, and 71.4% use a single dose (either 20/40 mg or 3500/4500 IU respectively). If patients are already taking anticoagulation, this is continued by 46.7% of respondents. Routine post procedure duplex imaging is carried out by 23.1% of recipients, either by the surgeon or formally and 80% review patients clinically. Moreover, 43.3% of respondents claim to know their post-operative VTE rate and this varies from 0 to 1% with one mortality reported.

The majority of respondents use single-dose thromboprophylaxis periprocedurally for varicose vein ablation procedures. VTE rates are low but the true incidence may be unknown.

Comparison of a flush sapheno-popliteal junction ligation versus a mini-invasive foam sclerotherapy-assisted ligation.

Forty-eight chronic venous disease patients underwent sapheno-popliteal junction flush ligation (group A). Forty-one patients underwent small saphenous vein ligation by means of mini-invasive incision with foam sclerotherapy of the popliteal stump (group B).

At 4.1 ± 3.3 years mean follow-up, sapheno-popliteal junction recurrence was detected in four patients of group A (4/48; 8.3%) and in two cases of group B (3/41; 7.3%) (P=ns). Mean procedural time was 36 ± 11 minutes versus 21 ± 6 minutes (p<0.0001). A mild post-operative paresthesia lasting more than 24 h was reported in 6.3% (3/48) of group A versus 2.4% (1/41) (p<0.009) of group B.

At one-year check-up, Aberdeen Varicose Vein Questionnaire significantly improved in both groups with no significant difference between group A and B.

Foam-assisted mini-invasive sapheno-popliteal ligation represents a time and clinical-effective option, associated with a decrease in post-operative paresthesia risk.

To evaluate the efficacy, safety and acceptability of an innovative two-component versus a well-established four-component compression systems in the management of venous leg ulcer.

Multicentre randomized controlled trial in patients with active venous leg ulcer. Patients were followed-up monthly for a maximum of 16 weeks. The primary endpoint was the complete healing rate at 16 weeks.

Ninety-two patients were randomized to either the two-component BIFLEX® Kit group (n = 49) or the four-component PROFORE® group (n = 43). In the full analysis set (n = 88), a complete healing rate of 48.9% and 24.4% was reported in BIFLEX® Kit versus PROFORE® groups, respectively (i.e. a superiority of 24.5%, p = 0.02). Acceptability of BIFLEX® Kit was higher from both the patients’ and physicians’ perspectives.

The BIFLEX® Kit represents a valid alternative therapy in the management of venous leg ulcer according to its clinical efficacy, safety and acceptability with potential positive impacts on healthcare costs.

The study investigated the association between varicocele, lower extremity venous insufficiency and hemorrhoidal disease.

The study included 62 patients with varicocele and 60 voluntary subjects with no varicocele. Patients who were diagnosed as having varicocele on physical examination and Doppler ultrasonography were included in the study group. Examination of lower extremity venous insufficiency was performed by physical examination and Doppler ultrasonography. Examination of hemorrhoidal disease was performed by a general surgery specialist.

The patients with varicocele had a statistically significant (p < 0.05) higher rates of venous insufficiency of the lower extremities and had a borderline significant difference of higher hemorrhoidal disease rates (p = 0.05). Therewithal incidences of hemorrhoidal disease and lower extremity venous insufficiency were significantly higher in body mass index > 25 and age > 30 years of varicocele patients.

There is a statistically significant relation between varicocele, lower extremity venous insufficiency, and hemorrhoidal disease. In particular, varicocele patients who are aged over 30 years and overweight are at higher risk.

Endovenous mechanochemical ablation (MOCA) is an increasingly popular non-thermal non-tumescent technique used to treat axial reflux in patients with superficial venous incompetence. However, the optimal management of varicose tributaries following this technique is unknown and may impact on patient outcomes. This study compares MOCA with concomitant phlebectomy (MOCAP) versus ablation with sequential phlebectomy if required (MOCAS).

Patients with symptomatic Comprehensive Classification System for Chronic Venous Disorders (CEAP C2–C6) unilateral axial reflux were studied. Patient choice determined whether concomitant treatment of varicosities was carried out. The primary outcome was the Aberdeen Varicose Veins Questionnaire (AVVQ) at one year. Secondary outcomes included: Venous Clinical Severity Scores (VCSS), EuroQol 5-Domain quality of life scores, complications, procedure duration, procedural and post-operative pain scores and need for secondary procedures. Outcomes were assessed at baseline and then one week, six weeks, six months and one year post intervention.

Fifty patients underwent MOCAP and 33 patients MOCAS. The two groups were comparable at baseline. MOCAP was associated with lower (better) AVVQ scores at six weeks (3.4 (0.5–6.0) vs. 6.1 (1.8–12.1); P = 0.009) and at six months (1.6 (0.0–4.5) vs. 3.34 (1.8–8.4); P = 0.009) but by one year the difference was no longer statistically significant (1.81 (0.0–4.5) vs. 3.81 (0.2–5.3); P = 0.099). MOCAP was associated with longer procedural duration (45 min (36–56) vs. 30 min (25–37); P < 0.001) and higher maximal periprocedural pain (31 (21–59) vs. 18 (7–25); P = 0.001). VCSS at all time points were lower in favour of MOCAP (0 (0–1) vs. 1 (0–3); P < 0.001). MOCAP was associated with fewer episodes of clinically significant thrombophlebitis (6 of 50 (12%) vs. 10 of 33 (30%); P = 0.039) and lower numbers of secondary procedures (2 (4%) vs. 6 (18%); P = 0.032).

Concomitant treatment of tributary varicosities following MOCA improves quality of life and clinical severity, while reducing rates of re-intervention and post-operative thrombophlebitis compared to sequential treatment. The penalty is a modest increase in procedural duration and discomfort. Further evidence from longer-term follow-up is needed.

To assess the inter-observer agreement of color duplex ultrasound of central vein stenosis in hemodialysis patients.

This prospective study was conducted on 35 hemodialysis patients with suspected central vein stenosis. All patients underwent color flow duplex examination of the subclavian, internal jugular and brachiocephalic veins in hemodialysis patients. Image analysis was performed by two reviewers for diameter reduction, peak venous velocity ratio, post-stenotic turbulent flow, waveform changes, and thrombus formation.

There was no significant difference between both observers for diameter reduction (p = 0.105) and for the mean peak systolic velocity ratio (p = 0.515). The overall inter-observer agreement of color duplex ultrasound of central vein stenosis was excellent (k = 0.84, percent agreement = 89.7%, P = 0.001). There was excellent inter-observer agreement of both reviewers for diameter reduction (k = 0.928, percent agreement = 97.14%), peak venous velocity ratio (k = 0.7, percent agreement = 85.7%), waveform changes (k = 0.62, percent agreement = 77.14%), post-stenotic turbulent flow (k = 0.866, percent agreement = 88.6%), thrombus formation (k = 1, percent agreement = 100%).

We concluded that color duplex ultrasound is a reliable and reproducible method for diagnosis of central vein stenosis in hemodialysis patients.