Phlebology: The Journal of Venous Disease

Lipedema is a chronic condition that predominantly affects women, leading to painful, disproportionate fat distribution in the limbs. This systematic review and meta-analysis aimed to characterize health-related quality of life (HRQoL) across multiple domains in individuals with lipedema.

We systematically reviewed studies from inception to 3 July 2025 in MEDLINE (via PubMed) and Cochrane Controlled Register of Trials (CENTRAL) that primarily assessed HRQoL in individuals with lipedema. Data were extracted from studies using HRQoL assessment scales. The methodological quality of included studies was assessed using an adapted version of the Newcastle-Ottawa Scale for cross-sectional studies. The review protocol was pre-registered with PROSPERO (CRD42024590792). A random-effects meta-analysis was conducted to compute pooled mean HRQoL scores across various domains.

Fourteen cross-sectional studies involving nine countries and 3851 participants were included. The meta-analysis found significant impairments in multiple HRQoL domains: physical functioning (61.19, 95% CI: 56.77–65.60), pain (51.77, 95% CI: 45.01–58.53), social functioning (63.24, 95% CI: 58.44–68.04), emotional well-being (64.19, 95% CI: 59.86–68.52), and energy/fatigue (43.50, 95% CI: 39.32–47.68).

Lipedema significantly affects HRQoL, with major deficits in physical, emotional, and social functioning. These findings highlight the need for greater clinical awareness and comprehensive management strategies, including both physical and psychological interventions, to improve the quality of life for individuals with lipedema. Further research is needed to explore long-term effects and optimize treatment approaches.

This review evaluates the current evidence for the role of venoactive drugs (VADs) for venous origin chronic pelvic pain (VO-CPP) and provide insights to inform the design of an ideal randomized controlled trial (RCT) for future research.

A search was performed in the following databases: Ovid MEDLINE, Ovid EMBASE, Cochrane Library, and Scopus. Studies retrieved were screened for eligibility using Covidence software following PRISMA reviews’ methodology. The quality of RCTs and cross-over RCTs was assessed using the Cochrane review tools.

Studies were reviewed by 3 physicians, with discrepancies resolved by consensus. A narrative review of the studies was conducted to identify and synthesize clinical outcomes and safety profile of VADs.

Eleven studies (n = 748) were identified: 3 RCTs and 8 open-label prospective studies. Most participants were reproductive-age women with confirmed VO-CPP, diagnosed via imaging or laparoscopy. Micronized Purified Flavonoid Fraction (MPFF) was the most studied VAD.

Pain assessment with VAS scores was the primary endpoint in all studies, with significant benefit in patients consistently demonstrated. Other endpoints included Pelvic Venous Clinical Severity Score (PVCSS) and Pelvic Varicose Vein Questionnaire (PVVQ), with improved symptoms and quality of life. Quantitative outcomes were also reported (reduced pelvic vein diameter; better venous hemodynamics). MPFF was safe, with few adverse events reported. Three RCTs had methodological limitations, with two judged high-risk for bias.

While many identified studies appear to be of low quality, the consistent beneficial effect on VO-CPP scores and the safety profile observed across all reviewed studies suggest that flavonoids have a positive role in the conservative management of pelvic venous disease (PeVD). Future well-designed RCTs are needed to confirm these findings. In the meantime, flavonoids should be considered a therapeutic option for symptomatic patients with PeVD who are not qualified for, not wishing, or are awaiting intervention.

Compression pressure is the key factor determining effectiveness in compression therapy for venous and lymphatic disorders. Despite its clinical importance, few studies report the actual applied pressure, and national standards for compression classes differ. This review aims to identify the optimal compression pressure at different stages of venous disease.

A literature search was conducted in PubMed, Scopus, and Web of Science (January 1980–October 2025) using MeSH terms related to compression therapy and chronic venous disease, edema, thrombosis, post-thrombotic syndrome, lipedema, and lymphedema. Only English-language studies reporting compression pressure or class were included.

Low pressures (10–21 mmHg) are enough to relieve symptoms in CEAP C0s–C1. For uncomplicated varicose veins (C2), 18–32 mmHg offers optimal symptom control. In venous edema (C3), pressures of 15–21 mmHg help prevent edema, while around 40 mmHg is more effective for treatment. Lipodermatosclerosis (C4) requires about 40 mmHg, and healed ulcers (C5) benefit from pressures greater than 30 mmHg to prevent recurrence, although compliance decreases with higher pressures. Active ulcers (C6) heal fastest under 40–50 mmHg, preferably with short-stretch materials or adjustable wraps. For lymphedema, effective reduction occurs at more than 50 mmHg (up to 120 mmHg briefly), while in the maintenance phase, 23–32 mmHg with flat-knit garments may be enough. Data on thrombosis, post-thrombotic syndrome, and post-procedure compression remain inconsistent.

Optimal compression pressure depends on disease severity. Early CVD stages and lipedema benefit from a compression pressure <30 mmHg, while severe venous or lymphatic disease requires ≥40 mmHg. Standardized reporting and pressure-based recommendations are essential to improve therapeutic consistency and patient outcomes.

Pelvic venous compression syndromes (PVCS) are often underdiagnosed causes of chronic venous disease and deep vein thrombosis. This study evaluates whether duplex ultrasound and venography predict significant pelvic vein compression confirmed by intravascular ultrasound (IVUS).

Retrospective cohort of 237 adults with lower extremity symptoms undergoing duplex ultrasound including continuous spectral doppler waveform identification without volumetric flow, venography, and IVUS. Patients were classified by presence of ≥50% stenosis on IVUS. Logistic regression identified predictors.

Reduced compressibility of the common femoral vein predicted ≥50% stenosis on venography bilaterally (left p = .025; right p = .014). The presence of thrombosis predicted ≥50% stenosis bilaterally (left p = .015; right p = .009), and abnormal spontaneity on the right also predicted ≥50% stenosis (p = .033). On duplex ultrasound, the absence of reflux (p = .008) and normal valvular competency (p = .008) on the left were associated with ≥50% stenosis on IVUS. Conversely, continuous phasicity (p = .036) and continuous flow (p = .035) on the left predicted <50% stenosis on IVUS.

Certain duplex ultrasound features may serve as early noninvasive markers of PVCS, aiding timely IVUS referral and intervention. Prospective studies are warranted.

This study aimed to assess the relationship between wall shear stress (WSS), the curvature of the iliac vein, and iliac venous in-stent restenosis (ISR) using computational fluid dynamics (CFD) analysis.

Nine limbs in nine patients were enrolled, in which patients received stent placement for a de novo iliac venous lesion and developed non-occlusive ISR. Initial follow-up computed tomographic venography (CTV) occurred within 1 year after stent placement. Two venous models were created from the CTV: one based on the lumen visualized on CTV (ISR-included stenosis model) and one based on the underlying iliac vein stent free of any ISR (ISR-removed, virtual healthy model). CFD analysis was performed to obtain WSS on each model. WSS was assessed on the greater curve, lesser curve, a healthy stent wall (HS wall), and an intimal hyperplasia/mural thrombus-attaching stent wall (IH/MT wall).

The median (interquartile) WSS on the greater curve was significantly higher than on the lesser curve: 0.179 (0.0686–0.266) versus 0.121 (0.0434–0.167) in the virtual healthy model, and 0.274 (0.153–0.557) versus 0.193 (0.116–0.367) in the stenosis model (both p < .001).

The WSS on the IH/MT wall and on the HS wall were 0.106 (0.0358–0.164) and 0.161 (0.0804–0.248) in the virtual healthy model and 0.253 (0.114–0.501) and 0.226 (0.131–0.432) in the stenosis model, respectively. The WSS was significantly lower on the IH/MT wall than on the HS wall in the virtual healthy model (p < .001), but it demonstrated no significant differences in the stenosis model (p = .838).

The iliac venous stent curvature could be a morphological risk factor of ISR, and WSS analysis could help predict future ISR. In the stenosis model, there were no significant differences in WSS between the IH/MT wall and the HS wall, implying that ISR builds up to a point of WSS equilibration.

Prominent or bulging veins on the temple or around the eyes are usually treated with extra-corporeal laser. However, when too big for laser to be effective, other techniques need to be used. The aim of this study was to evaluate the potential of using an endovenous approach to treat these small veins – a technique that we call “micro-EVLA” (micro-endovenous laser ablation).

We decided to use a 272 µm bare laser fibre, which we could pass through a 21G “green” hypodermic needle. In addition, we used a 1940 nm diode laser, as we have previously shown that the increased affinity of water to this wavelength results in a reduced thermal spread in biological tissues at low powers. We performed two sequential studies. The first measured the thermal spread in the porcine liver model using 1W, 2W and 3W, with a pull-back rate of either 5 s/cm or 10 s/cm. Two blinded observers measured the total width of the ablation tract and the spread of tissue ablation from the edge of the fibre. The second assessed the temperature of the liver surface using an infrared camera, above the laser fibre during treatment, with and without cold air cooling.

Increased power resulted in significantly increased thermal spread, as did the slower pull-back compared to the faster. We found that 2W at 5 s/cm (LEED 10 J/cm) appeared to give the optimal ablation with 0.20 mm (SD: 0.073) thermal spread from the edge of the fibre. When these settings were used with the fibre positioned 1.0-2.0 mm under the surface of the liver, cold air stopped any significant heating of the overlying liver surface.

Our micro-EVLA technique produced a controlled ablation tract, which appears to avoid the risk of skin burns. Clinical studies are required to confirm this conclusion.

This study explores the effectiveness of High Intensity Focused Ultrasound (HIFU) in treating incompetence of the small saphenous vein (SSV).

Patients diagnosed with SSV incompetence received HIFU treatment. The primary outcome measured was the rate of SSV competent shrinkage or closure after 1 year.

Among the 292 legs treated with HIFU for chronic venous disease, 15 (5.1%) were for SSV incompetence. Quality of life, assessed using the CIVIQ-20, showed a significant improvement at 3 months post-treatment, decreasing from 38.9 ± 9.1 to 24.3 ± 2.0 (p < .01). The rVCSS also improved, declining from 6.5 ± 1.7 to 5.0 ± 1.0, although this change was not statistically significant (p = ns). All SSVs were closed or competent with evidence of shrinkage at 1 week, 3 months, 6 months, and 1 year following HIFU. No recurrent varicose veins were identified during the follow-up period.

These initial findings indicate that HIFU may be an effective option for addressing SSV incompetence. Additional studies are necessary to compare this method with other treatments and to evaluate long-term results with a more robust patient cohort.

The pathogenesis of primary varicose veins (PVVs) is multifactorial and remains incompletely understood; however, venous valve dysfunction is recognized as a key factor. Previous studies have suggested racial differences in the prevalence and distribution of venous valves in the proximal femoral vein; however, no data are available for the Japanese population. This study aimed to clarify the prevalence and number of venous valves in the proximal femoral vein and great saphenous vein (GSV) in Japanese individuals and determine whether patients with PVVs have fewer venous valves than healthy individuals.

A cadaveric study of 59 individuals (median age, 87 years) and an ultrasound study involving 52 healthy volunteers (median age, 26 years) and 106 patients with PVVs (median age, 72 years) were conducted. Venous valves were assessed in segments A (from the confluence of the inferior epigastric vein to the saphenofemoral junction [SFJ]) and B (GSV within 4 cm distal to the SFJ).

In cadavers and volunteers, venous valves were identified in approximately 60% of segment A and nearly all of segment B, with no significant differences between the two groups. Conversely, patients with PVVs had significantly fewer venous valves in both segments A (right, 0.22 vs 0.54, p < .001; left, 0.31 vs 0.56, p = .005) and B (right, 1.29 vs 1.50, p = .034; left, 1.32 vs 1.52, p = .028) than volunteers. In several PVVs, only the venous sinus without valve leaflets was detectable by ultrasonography.

Patients with PVVs had significantly fewer venous valves in the proximal femoral vein and GSV than healthy subjects, suggesting that valve deficiency, possibly including congenital factors, may contribute to PVV development. This study provides the first detailed data on venous valve distribution in Japanese individuals. More studies are needed to confirm these findings and clarify clinical implications.