M. Azzam

Quantifying the degree graduated elastic compression stockings enhance venous emptying.

OBJECTIVES Graduated elastic compression (GEC) stockings reduce reflux and venous volume but their performance on augmenting venous return is unproven. The aim of this study was to quantify the ability of stockings to increase venous outflow from the leg. DESIGN A prospective study comparing venous emptying without compression, versus class 1 (18-21 mmHg) and class 2 (23-32 mmHg) compression, using air-plethysmography (APG). METHODS The right legs of 20 healthy subjects were studied supine. A 12-cm thigh-cuff was inflated in 10 mmHg steps from 0 to 80 mmHg while the corresponding increase in calf volume was recorded using the APG sensor calf-cuff. At the 80 mmHg plateau, the thigh-cuff was released suddenly to measure the unrestricted venous emptying. Venous return was assessed by: (a) identifying the incremental thigh-cuff pressure causing the maximal incremental increase in calf volume (IPMIV); (b) measuring the percentage reduction in calf volume in 1 second following thigh-cuff release - outflow fraction (OF); (c) time to empty 90% of the venous volume - venous emptying time (VET90). RESULTS Median and inter-quartile range (IQR) baseline values of IPMIV, OF, and VET90 without compression were 20 mmHg (range: 20-30 mmHg), 44% (39-50%) and 13 seconds (8.8-15.9 seconds), respectively. These improved significantly with all stockings. The application of any stocking raised the median IPMIV by 30 mmHg. The change from a class 2 stocking compared with no stocking versus the change from a class 1 stocking to no stocking had a more pronounced effect (p < .005). After sudden thigh-cuff deflation, the venous emptying was 41-45% greater and 9-10 seconds faster with all stockings (p < .005). CONCLUSIONS This is the first study to quantify the venous return of below-knee GEC stockings. Assessments of stockings in augmenting venous return may be of use as a way of optimising compression for individual patients unresponsive to standard conservative treatment.

Venous filling time using air-plethysmography correlates highly with great saphenous vein reflux time using duplex

Objectives: Venous filling time (VFT90) is the time taken to reach 90% of the venous volume in the calf. It is recorded by air-plethysmography (APG®) and is assumed to measure global venous reflux duration. However, this has never been confirmed by duplex. The aim of the study was to compare VFT on APG to venous reflux time/duration (RT) measured simultaneously with duplex on the same patients. Method Twenty-six consecutive patients, M:F = 16:10, age (25–78), C1 = 1, C2 = 4, C3 = 8, C4a = 6, C4b = 4, C5 = 2, C6 = 1, underwent simultaneous APG with duplex. The venous filling index (VFI, mL/second), VFT90 (seconds), great saphenous vein (GSV) RT on duplex, averaged thigh GSV diameter and thigh length (length) between the APG sensor air-cuff and duplex transducer were recorded. The VFT100 was calculated by VFT90/0.9. The additional time taken to fill the thigh was achieved using the VFI, length and deep vein diameter (d), to determine the corrected reflux duration: CRD = VFT100 + (length × πd2/4 (1/VFI)). Results Twenty-five patients are presented. One patient with very mild reflux (VFT90 = 55.9 seconds) had an indeterminate endpoint on duplex and was excluded. The median (range) VFI and GSV diameter was 4.9(1.3–15.5) mL/second and 7(4–17) mm, respectively. The VFT90 and VFT100 both correlated with RT on duplex (Spearman, P < 0.0005) at: r = 0.933, r2 linear = 0.72 and r = 0.933, r2 linear = 0.68, respectively. The median (interquartile range) filling time with VFT90 was less than the duplex RT at 24 (16.9) versus 28 (20) seconds respectively P < 0.0005 (Wilcoxon). The median percentage underestimation improved from 24% to 16% and then 4% using the VFT90, VFT100 and CRD, respectively. Conclusions This is the first study to compare APG parameters with duplex by performing simultaneous measurements. There was an excellent correlation between the VFT90 versus duplex RT, thereby comparing reverse flow in a single superficial vein against the legs overall venous haemodynamic status. These tests can both be used in the quantification of reflux.

Reflux time estimation on air-plethysmography may stratify patients with early superficial venous insufficiency.

Objectives It has been suggested that quantification of haemodynamic parameters of venous disease may complement clinical assessment and may help identify a group of patients with severe venous disease or alternatively patients with early venous disease. However, there has been very little work to prove this hypothesis. The venous filling index (VFI) of air-plethysmography (APG) can quantify severity and treatment effect but has limited discriminatory value. However, the components of the VFI, total venous volume (VV) and time to reach 90% of VV (VFT90), have never been fully studied. The aim was to investigate the contribution of VV and VFT90 to an elevated VFI and determine their relationship to great saphenous vein (GSV) diameter and clinical severity scoring. Method Ninety-three consecutive patients/legs (22–78 years) with primary GSV reflux (>0.5 seconds) awaiting endovenous treatment were recruited. CEAP (clinical, aetiological, anatomical and pathological elements) assessments were: 33 (35.5%) C2, 14 (15.0%) C3, 29 (31.2%) C4a, 5 (5.4%) C4b, 7 (7.5%) C5 and 5 (5.4%) C6. The median venous clinical severity score (VCSS) was 6 (2–20) and the averaged GSV diameter at three sites was 7.5 mm (4–12). The VFI, VV and VFT90 were recorded using APG. Results There was no correlation between the VV and the VFT90 (r = −0.103, P = 0.324). The VFI, VV and VFT90 significantly correlated (P < 0.0005, Spearman) with the GSV diameter: r = 0.623, r = 0.567, r = −0.432, respectively, and the C of CEAP (P < 0.05): r = 0.4, r = 0.225, r = −0.343, respectively. None of the 25 (26.9%) patients with a VFT90 > 25 seconds were among the 17 (18.3%) patients in categories C4b–6 or with a VCSS > 9 (P = 0.005, Fishers exact test, corrected odds ratio: 17.3). Conclusions The VFT90 complements the VFI as a marker of severe superficial venous insufficiency. However, in contrast to the VFI, it may have discriminatory value in stratifying patients with early disease into two groups based on the severity of haemodynamic impairment.

Saphenous pulsation on duplex may be a marker of severe chronic superficial venous insufficiency

BACKGROUND Pulsatile flow in deep, perforating veins and varicose veins (VVs) has been described previously to support a hypothesis of arteriovenous (AV) fistulae in the pathogenesis of VVs. Its presence has also been suggested as a cause of failure of VV treatments. However, AV communications have never been adequately visualized and direct pressure tracings within leg veins have been inconclusive. The present study was observational aiming to investigate the prevalence and rate of spontaneous pulsation within the great saphenous vein (GSV) in volunteers and patients using color duplex and compare this to reflux and markers of disease severity. METHODS Twenty-seven consecutive patients (32 legs, median Venous Clinical Severity Score (VCSS) = 5 [0-11]) attending the VV clinic and 23 consecutive ambulatory normal volunteers (46 legs) had their GSV assessed at midthigh using color duplex. Subjects were examined standing with the hips resting against an adjustable couch, bearing weight on the contralateral leg, with the test leg touching the ground. The presence of flow and reflux were initially determined using manual calf compression. Saphenous pulsation (SP) was defined as a cyclical change in velocity. The GSV diameter and SP rate were then recorded after 2 minutes of dependency. The number of pulsations was counted from video recordings. RESULTS The resting SP, if present, was discrete, monophasic, of variable amplitude, antegrade, and irregular, irrespective of respiration. Pulsation was detected in 2/44 (4.5%) legs with C(0-1) (C part of CEAP), 9/17 (52.9%) legs with C(2-3), and 16/17 (94.1%) legs with C(4-6) (P < .05, z test of column proportions). Reflux occurred in 8/32 (25%) legs without SP (C(0) = 2, C(1) = 1, C(2) = 3, C(3) = 2). The median GSV diameter was significantly elevated in the presence of SP (no pulse: 3.5 [range, 1.5-8.1] mm; pulse: 7 [range, 4-9.4] mm; P < .0005). The median refluxing GSV diameter in GSV pulsators compared with nonpulsators was 7 (range, 4-9.4) mm; vs 5.1 (range, 2.7-8.1) mm, respectively (P = .003). The median SP rate in refluxing GSVs was 52 (range, 22-95) beats per minute. CONCLUSIONS The high prevalence of pulsatile antegrade saphenous flow is a novel observation in patients with severe superficial chronic venous insufficiency. It is detectable in 75% of patients with GSV reflux and significantly increases with clinical severity and saphenous diameter. It may be a marker of advanced venous disease and, as it is easy to record, it could supplement duplex evaluations of reflux. Further work is needed to establish the clinical relevance of the SP in terms of disease progression, recurrence after treatment, and as a hemodynamic marker of severity.

Responsiveness of individual questions from the venous clinical severity score and the Aberdeen varicose vein questionnaire.

Objectives The venous clinical severity score (VCSS) and the Aberdeen varicose vein questionnaire (AVVQ) improve after treating chronic venous insufficiency (CVI). The aim was to examine how and why they improve by evaluating the change in each individual question. Methods This was an analysis on prospectively collected data from a clinical study on 100 patients (58% female) with CVI (C2 = 34, C3 = 14, C4a = 29, C4b = 9, C5 = 7, C6 = 7) who were randomized to endovenous laser ablation (n = 50) or foam sclerotherapy (n = 50). The change scores (performance) of each question of the VCSS (questions 1–10) and the AVVQ (questions 1–13) were calculated by subtracting the score at three weeks, and three months, from the pre-treatment score. Results Both the median, interquartile range (IQR), VCSS and the AVVQ scores improved from 6 (4) and 21.4 (15.1) at baseline to 3 (4) and 18.6 (12.1) at three weeks (P < 0.0005, P = 0.031) to 2 (3) and 8.8 (13.6) at three months, (P < 0.0005, P < 0.0005), respectively. The performance of the first three questions of the VCSS (pain, extent of varicosities, oedema) were the most contributory to the overall score. Questions 5, 7, 8, 9 on ulceration improved the most individually but did not contribute significantly to the overall score. Questions 5, 9 of the AVVQ on stocking use and ulceration failed to contribute statistically to the overall improvement at three months. Conclusion The majority of the individual questions of the VCSS and AVVQ responded to change. However, the cause of a poor response was multifactorial with statistical dilution playing a significant role. Stratification of patients according to ulceration may allow better comparisons.

Validation of a New Duplex Derived Haemodynamic Effectiveness Score, the Saphenous Treatment Score, in Quantifying Varicose Vein Treatments☆

OBJECTIVES To evaluate a duplex-derived score for varicose vein treatments using numerical values of haemodynamic effectiveness. DESIGN The saphenous treatment score (STS) was developed prospectively to compare the effect of endovenous treatments on reflux within saphenous segments. PATIENTS Sixty-six patients were randomised to endovenous laser ablation (EVLA) or ultrasound-guided foam sclerotherapy (UGFS) to the great saphenous vein (GSV). METHODS Assessments included the Aberdeen varicose vein severity score (AVVSS), the venous clinical severity score (VCSS), the venous filling index (VFI) and the STS. RESULTS A mean STS of 5.70 decreased to 3.30, P < .0005, post-treatment. The median (IQR) AVVSS, VCSS and VFI (ml/sec) decreased from 21.52(15.48) to 18.86(11.27), P = .14, from 6(4) to 3(4), P < .0005 and from 7.1(6.9) to 1.9(.9) P < .0005, respectively. In 15 patients requiring additional UGFS the mean STS values decreased from 5.8 to 4.13 and then to 2.6 P < .0005, respectively. The individual above and below knee mean treatment differences in STS on 38 EVLA and 28 UGFS patients were 1.92 and .87 (EVLA) compared to 1.57 and .29 (UGFS) P = .001, respectively. CONCLUSIONS The STS has been shown to grade the haemodynamic effects of different treatments as well as ongoing treatments on the GSV.

Hemodynamic changes at the saphenofemoral junction during the application of a below-knee graduated compression stocking.

BACKGROUND It is strongly recommended that patients wear compression after foam sclerotherapy, but pulling up a stocking may inadvertently flush foam into the femoral vein, which may increase the risk of systemic side effects and reduce great saphenous vein (GSV) occlusion rates. OBJECTIVE The hypothesis was that a stocking pull‐up maneuver would increase flow in the GSV. The aim was to quantify this using duplex ultrasound. METHODS AND MATERIALS Twelve consecutive patients with primary varicose veins were studied. A below‐knee 23‐ to 32‐mmHg graduated elastic compression stocking was placed over the foot, leaving a cuff of redundant stocking around the ankle. Duplex ultrasound over the saphenofemoral junction was used to measure peak velocity (PV) and volume flow (VF) before and while the stocking was being pulled up. RESULTS The pull‐up maneuver caused a median 17.7 times increase in PV (interquartile range (IQR) 14.2–23.9), from 7.6 cm/seconds (IQR 6.4–9.8 cm/seconds) to 150.5 cm/seconds (IQR 110–187 cm/seconds) and a 9.4 times increase in VF (IQR 7.7–10.3), from 50.9 mL/minutes (IQR 33.8–78.9 mL/minutes) to 458.7 mL/minutes (IQR 292.1–593 mL/minutes) (p = .002). CONCLUSION A stocking causes significant hemodynamic changes within the GSV. These forces could be avoided by the partial application of a stocking to knee level before foam injection. Further work may establish the implication of these findings in patients treated with foam sclerotherapy.

Pneumatic thigh compression reduces calf volume and augments the venous return

Objectives Reactive hyperaemia following thigh compression increases arterial inflow and venous outflow. The net effect can be measured by changes in calf volume quantified using air-plethysmography. The objective was to investigate the effect of thigh compression on venous return. Method The right legs of 19 consecutive volunteers (14 male), median age 31 (25–56) years, were studied in the supine position using air-plethysmography. The clinical, etiological, anatomical, pathophysiological (CEAP) class was C0. A thigh-cuff, 12 cm wide, was inflated in increments of 10 mmHg, from 0 to 80 mmHg. After each inflation step, the calf volume increased to a plateau and was recorded. At 80 mmHg, the thigh-cuff was deflated suddenly with the calf volume decreasing until baseline. Calf volume changes were recorded and stored for analysis. Results There was a stepwise increase in the venous volume of the calf with each incremental rise in thigh-cuff pressure up to 80 mmHg (p < .0005, Friedman). The median (interquartile range) increase in venous volume from 0 to 80 mmHg was 87 (65–113) mL (p < .0005, Wilcoxon). The volume change below the original baseline following thigh-cuff release was −16 (−12 to −25) mL (p < .0005, Wilcoxon). Conclusions Once optimised, intermittent pneumatic compression of the thigh may have a therapeutic role in augmenting the venous return and reducing leg swelling in patients.

Regional and Systemic Prothrombotic Biomarkers in Varicose Vein Patients and Healthy Controls.

Arm vs leg Arm vs leg Patient vs control Patient vs control P-Selectin Inhibition Therapeutically Promotes Thrombus Resolution and Prevents Vein Wall Fibrosis Better than Enoxaparin and an Inhibitor to von Willebrand Factor J.A. Diaz, S.K. Wrobleski, A.R. Pechota, A.E. Hawley, K.J. Roelofs, N.K. Doornbos, J.E. Gabriel, G. Reynolds, P. Lester, F. Londy, S. Lowe, P.K. Henke, R.G. Schaub, T.W. Wakefield, D.D. Myers. University of Michigan, Ann Arbor, Mich; 4NKT Therapeutics, Inc, Waltham, Mass