Erika Mendoza

Superficial venous reflux duration and cessation with two concurrent duplex probes

BACKGROUNDnVenous reflux is the principal hemodynamic disorder and therapeutic target in patients with superficial venous insufficiency. To date, no studies have identified where or when it stops, anatomically or regionally, along the course of the refluxive conduit. Duplex measurements of reflux are performed invariably with a single probe. Because many anatomic locations are studied, repeated provocation maneuvers are required. However, this fails to appreciate reflux as a circulation. The use of two probes placed concurrently in different regions may address this limitation. The study compared venous reflux duration and cessation, above the knee and below the knee simultaneously, with two duplex probes.nnnMETHODSnSeventeen legs from 17 consecutive patients (12 female, nine left) with great saphenous vein reflux were studied. Their median (range) age was 51 (28-71) years; weight, 76.8 (63.5-189) kg; height, 169 (153-180) cm; and Venous Clinical Severity Score, 5 (1-12). The clinical class of the Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) classification was as follows: C2, 6; C3, 4; C4a, 5; and C4b, 2. After 2 minutes of elevation, the leg was assessed for reflux duration with duplex ultrasound. This occurred when the patient stood up during venous filling. One probe was positioned 10 cm below the saphenofemoral junction over the great saphenous vein (point A) and the other over a refluxive saphenous vein or tributary below the knee (point B). Concurrent images were displayed on adjacent monitors and recorded by a single video camera. Reflux duration was from the onset of dependency, indicated by the start of the video, to the termination of the red color (reflux) on video playback. The probes were swapped to negate for differences in machine sensitivity. Each leg was tested three times. Simultaneous was defined when there was <0.1 second difference between the two sites.nnnRESULTSnThe median (range) vein diameters at points A and B were 6.1 (2.8-9.3) mm and 5.5 (2.5-8.1) mm, respectively, with an intertransducer distance of 41 (23-59) cm. There was no significant difference in reflux duration between point A with 27 (9-150) seconds and point B with 27 (10-149) seconds (P = .943 [Wilcoxon]). The correlation was excellent (r = .986; P < .0005 [Spearman]).nnnCONCLUSIONSnThis is the first study to investigate reflux cessation by introducing a novel two-probe technique. It has demonstrated that reflux may stop simultaneously above and below the knee with use of the elevation to dependency maneuver to provoke reflux. It has shown that either site may be used to measure reflux duration. Furthermore, the two-probe technique confirms the belief that the mechanism of refluxive venous filling is through the descending path of a recirculation circuit.

Gravitational venous drainage is significantly faster in patients with varicose veins

Objectives It has been proposed that varicose veins may be caused by a degree of impeded proximal venous drainage (pelvic venous obstruction) in the same way that biological tubes dilate in response to an obstruction. The venous drainage index (VDI) of air-plethysmography (APG) was used to test this hypothesis. A dependency to elevation manoeuvre was used to provoke gravitational venous drainage. A rapid reduction in calf volume implied good drainage. Methods This was a single centre, proof-of-concept study comparing gravitational venous drainage in varicose vein patients and controls. Leg filling and drainage manoeuvres (elevation to dependency and dependency to elevation) were performed three times per leg in 15 patients (7 male, 8 right) and 16 controls (3 male, 8 right). The VDI was measured in the same way the established venous filling index (VFI) is calculated to quantify filling: VDIu2009=u200990% of venous drainage volume (90VDV)/90% venous drainage time (VDT90). Results The patients were significantly older at 58 (41–75) years versus the controls 47 (18–58), pu2009=u20090.001. There was no significant difference between the groups in weight, height, BMI or common femoral vein diameter. The patients were (C2u2009=u20098; C3u2009=u20091, C4u2009=u20096), VCSS 4 (1–11) with a median refluxing proximal thigh saphenous diameter of 6 (5–11) mm. The median (inter-quartile range) VFI and VDI (both in mL/s) in the control tests (nu2009=u200948) were 1.3 (0.9–1.9) and 33.8 (21.5–55), respectively. The VFI and VDI in the patient tests (nu2009=u200941) were significantly faster at 6.2 (3.5–9.4), pu2009<u20090.0005, and 47.1 (36.1–66.3), pu2009=u20090.002, respectively. Adjusted to a standard mean for each leg, the reproducibility limits (×3) of the VDI was very good at 39.7 (95% CI: 36.5–42.9) in controls and 52.9 (95% CI: 49.7–56.1) in patients. Conclusion The VDI was significantly greater in patients with varicose veins compared to controls. It is unlikely that impeded gravitational drainage is a significant factor in the pathophysiology of varicose veins.

Anomalous intraosseous venous drainage: Bone perforators?

Objectives Anomalous intraosseous venous drainage is a rare and almost unknown entity; only 14 cases have been reported in the literature and 4 mentioned in textbooks. We report the characteristics of 35 further cases observed in 32 patients. Method After the presentation of two cases at the congress of the French Society of Phlebology in Paris (2013), 12 colleagues joined to present a large series of so-called bone perforators observed in their practice, all identified with at least a duplex investigation. Results Thirty-two patients suffering from varicose veins and/or skin changes (C2−C6) associated with a bone perforator of the tibia (with bilateral anomalies in three) are reported: 19 females and 13 males, average age 56.9. The majority of the affected legs were symptomatic (30/35). Bone perforator was an isolated finding in 27/35 legs. In three cases, the investigations revealed that the venous reflux in the bone originated from an incompetent posterior tibial vein. Conclusions We suggest the name of “bone perforators” for an anomalous tibial intraosseous venous drainage, feeding varicose veins, and in more advanced stages lipodermatosclerosis and leg ulcers. Most of them were successfully treated with surgery or sclerotherapy.

Rationale, design, and methodology of the observational INSIGHTS-SVT study on the current state of care and outcomes of patients with superficial vein thrombosis

OBJECTIVEnSuperficial vein thrombosis (SVT) is a common disease in clinical practice. In terms of pathophysiology and outcomes, the condition is related to venous thromboembolism, bearing a potential for severe thromboembolic complications if it is not treated adequately. A wide range of treatment approaches (including oral and injectable anticoagulants, pain medication, nondrug therapy including compression therapy, and no treatment at all) are applied in clinical practice, but there is sparse information about selection of patients for therapies, current treatment pathways, and drug use as well as outcomes. The INvestigating SIGnificant Health TrendS in the management of Superficial Vein Thrombosis (INSIGHTS-SVT) study aims to close this gap by collecting representative data on the current treatmentxa0of SVT.nnnMETHODSnThe observational prospective study of about 1200 patients is carried out by up to 120 clinical and office-based physicians who regularly treat patients with SVT and are capable of conducting appropriate compression ultrasound diagnostics, such as vascular physicians, phlebologists, internists, vascular surgeons, and general practitioners. Patients are eligible for inclusion if they have ultrasound-confirmed acute, isolated SVT of the lower extremities. Documentation about the characteristics of the patients, diagnostics, comorbidities, and medical and nonmedical treatment is collected at baseline, at 10xa0± 3xa0days or at approximately 45xa0days (depending on treatment), at approximately 3xa0months, and at approximately 12xa0months. Patients are requested to fill in quality of life questionnaires (on pain, Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms [VEINES-QOL/Sym], EuroQol-5 Dimension 5-Level [EQ-5D-5L]) at baseline and at approximately 3xa0months. Interventions are not stipulated by the trial protocol.nnnRESULTSnThe primary efficacy outcome is the incidence of venous thromboembolism at 3xa0months; the primary safety outcome is the combined incidence of major and clinically relevant bleeding events at 3xa0months. As quality measures, plausibility checks at data entry, queries based on statistical analyses that focus on outliers and distribution of values, monitoring visits, and adjudication procedures will be applied.nnnCONCLUSIONSnThis large study is expected to provide a comprehensive picture of patients with SVT under clinical practice conditions in Germany.

Examination of Superficial Veins in the Presence of Deep Venous Disease

Deep venous disease may lead to secondary pathologies in the superficial veins and vice versa. A patient with existing incompetence in a superficial vein may also develop deep vein thrombosis and deep venous reflux. In this case two pathologies can occur in the same leg, namely, the aftermath of a deep vein thrombosis plus pre-existing disease in the superficial system. Regardless of the chronological order of disease and the mechanisms giving rise to them, special care must be taken when examining the superficial vein system in the presence of deep venous pathology. This is of particular importance when choosing the appropriate surgical treatment.

The current status of air-plethysmography in evaluating non-thrombotic iliac vein lesions:

Ever since they were published in 1908 by the pathologist McMurrich, non-thrombotic iliac vein lesions (NIVLs) are increasingly recognised as a cause of venous obstruction. Treatment with a stent is successful in the majority of patients with relief of symptoms and improvement of skin changes. However, many patients have no clinical benefit despite the successful deployment of a stent of adequate calibre. Interestingly, iliac vein compression on computerised tomography (CT) of >50% occurs in 25% of the normal population. This casts doubt whether the finding is a true pathological entity or just an indentation of a collapsible tube by an overlying artery. Furthermore, intrinsic lesions occur often within a normal calibre lumen and may be revealed using intra-venous ultrasound, which is invasive. Valsalva manoeuvres add a dynamic component to these investigations and may help to evaluate a true obstructing lesion, in some cases. The limitations of imaging in assessing flow impairments are also apparent when there are several lesions, collaterals which may (or may not) be of haemodynamic benefit, and tortuosity. Furthermore, chronic venous insufficiency (CVI) is multi-factorial in haemodynamic pathophysiology. Since leg drainage, contrary to most other drainage systems is upward, the remaining four components of drainage insufficiency are: reflux encouraging downward flow, poor pump function of the heart and calf hampering upward flow, poor venous tone facilitating pooling, and physiological inactivity like prolonged standing or sitting promoting dependency. Correcting only the obstructive component of the insufficiency may have less impact if the other four components of insufficient drainage are not also corrected. Air-plethysmography (APG) is a non-invasive test which may quantify venous obstruction. The concept is simple. The air sensor-cuff wrapped around the calf records merely a change in calf volume. This is reported as a volume change in mL or a rate of volume reduction in mL/s. It is intuitive that when a dependent leg is elevated suddenly the veins collapse, the venous blood drains and the calf reduces in volume. The amount and rate of this reduction may be related to the degree of obstruction. It is noticeable in daily practice that rapid venous guttering on elevation of the leg is a feature of a healthy unobstructed leg. This was known by the observations of Trendelenburg using his elevation drainage manoeuvre. The function of APG is to support these clinical observations with a numerical value, termed the venous drainage index (VDI) in mL/s. In health, the drainage tracing is a straight line down at a constant rate. This can be likened to a falling column of fluid unimpeded by external forces, without a pressure– volume relationship and with zero resistance. In short, a ‘‘waterfall’’ drainage. The original paper describing the use of elevation drainage with APG on a tilt-table was published in 1964 by Allan. He noted that the volume of the leg decreased with elevation but the rate of this decrease was not quantified. His work was largely forgotten until recently with the introduction of the VDI as a measurement of obstruction. This technique has now been validated in three different ways. First, using a proximal thigh-cuff to simulate known obstruction pressures in healthy volunteers. In this study, the VDI decreased significantly with higher inflation pressures confirming its responsiveness to obstruction. Second, using rapid Trendelenburg tilting on a tilt-table. Here, the VDI was significantly lower in the post-thrombotic obstructed patients with duplex evidence of groin collaterals versus controls with a cut-off point of 10.8mL/s. Finally, in a small study comparing a heterogeneous group of NIVL patients before and after stent deployment. Here, the VDI improved significantly as a result of stenting.

Ultrasound-Based Classifications of Varicose Veins

Varicose disease presents a remarkable variety of forms and clinical expressions. The morphological expression of the disease especially in patients with very large, visible tributaries seldom correlates with their clinical significance. Similarly, ulceration can occur without any visible varicose veins and just a refluxing saphenous trunk.