Mustapha Azzam

Compression stockings significantly improve hemodynamic performance in post-thrombotic syndrome irrespective of class or length

BACKGROUNDnGraduated elastic compression (GEC) stockings have been demonstrated to reduce the morbidity associated with post-thrombotic syndrome. The ideal length or compression strength required to achieve this is speculative and related to physician preference and patient compliance. The aim of this study was to evaluate the hemodynamic performance of four different stockings and determine the patients preference.nnnMETHODSnThirty-four consecutive patients (40 legs, 34 male) with post-thrombotic syndrome were tested with four different stockings (Mediven plus open toe, Bayreuth, Germany) of their size in random order: class 1 (18-21 mm Hg) and class II (23-32 mm Hg), below-knee (BK) and above-knee thigh-length (AK). The median age, Venous Clinical Severity Score, Venous Segmental Disease Score, and Villalta scale were 62 years (range, 31-81 years), 8 (range, 1-21), 5 (range, 2-10), and 10 (range, 2-22), respectively. The C of C0-6EsAs,d,pPr,o was C0 = 2, C2 = 1, C3 = 3, C4a = 12, C4b = 7, C5 = 12, C6 = 3. Obstruction and reflux was observed on duplex in 47.5% legs, with deep venous reflux alone in 45%. Air plethysmography was used to measure the venous filling index (VFI), venous volume, and time to fill 90% of the venous volume. Direct pressure measurements were obtained while lying and standing using the PicoPress device (Microlab Elettronica, Nicolò, Italy). The pressure sensor was placed underneath the test stocking 5 cm above and 2 cm posterior to the medial malleolus. At the end of the study session, patients stated their preferred stocking based on comfort.nnnRESULTSnThe VFI, venous volume, and time to fill 90% of the venous volume improved significantly with all types of stocking versus no compression. In class I, the VFI (mL/s) improved from a median of 4.9 (range, 1.7-16.3) without compression to 3.7 (range, 0-14) BK (24.5%) and 3.6 (range, 0.6-14.5) AK (26.5%). With class II, the corresponding improvement was to 4.0 (range, 0.3-16.2) BK (18.8%) and 3.7 (range, 0.5-14.2) AK (24.5%). Median stocking pressure (mm Hg) as measured with the PicoPress in class I was 23 (range, 12-33) lying and 27 (range, 19-39) standing (P < .0005) and in class II was 28 (range, 21-40) lying and 32 (range, 23-46) standing (P < .0005). There was a significant but weak correlation (Spearman) between stocking interface pressure measured directly with the PicoPress and the VFI improvement (baseline VFI-compression VFI) at r = .237; P = .005. Twenty-one patients (legs) changed their preference of compression and 38% of these (8/21 patients, 9/21 legs) preferred an AK-GEC stocking.nnnCONCLUSIONSnCompression significantly improved all hemodynamic parameters on air plethysmography. However, the hemodynamic benefit did not significantly change with the class or length of stocking. These results support the liberal selection of a GEC stocking based on patient preference.

The Aberdeen varicose vein questionnaire may be the preferred method of rationing patients for varicose vein surgery.

Rationing treatment of varicose veins (VVs) is of importance in countries with a public health service and limited funds. This study examines why and how the Aberdeen varicose vein questionnaire (AVVQ) can be used in achieving rationing. Baseline assessments prior to endovenous treatment included the venous clinical severity score (VCSS), venous filling index (VFI), and the refluxing great saphenous vein (GSV) diameter. Absolute change in the AVVQ defined improvement. There was no significant correlation in AVVQ improvement compared to baseline VCSS, VFI, GSV diameter or when patients were divided into mild and severe disease (C2,3 vs C4-6) or laser ablation versus foam sclerotherapy. However, AVVQ improvement significantly correlated at 3 weeks (n = 84) and 3 months (n = 70) with their baseline values (r = .5 and r = .585), P < .0005 (Spearman). In conclusion, patients with an initial poor quality of life may benefit most from endovenous treatment, irrespective of other baseline severity assessments.

Validation of the Villalta scale in assessing post-thrombotic syndrome using clinical, duplex, and hemodynamic comparators.

Introduction: The Villalta scale (VS) was developed by Prandoni and introduced as an abstract in 1994 as a diseasespecific assessment questionnaire to diagnose and classify the severity of post-thrombotic syndrome (PTS). While validation using quality-of-life assessments and reproducibility have been reported as good, limited data exist as how the VS compares against generalized assessment tests in defining the severity of PTS. The aim of this study was to compare the VS against the Venous Clinical Severity Score (VCSS), the C of the CEAP classification, the Venous Segmental Disease Score (VSDS), and the Venous Filling Index (VFI) of air plethysmography. Methods: Baseline data generated from a recent single-center prospective clinical trial comparing graduated elastic compression stocking performance on 40 legs in 34 patients with PTS were analyzed. Ancillary data from this study were used to assess the measurement properties of the VS. All the legs had PTS defined as persisting leg symptoms/signs at least 6 months after a deep vein thrombosis with evidence of deep venous obstruction and/or deep venous reflux on duplex ultrasound. Unadjusted VS scores were used so patients with ulceration with a VS <15 were not automatically upgraded to a score of 15.

Haemodynamic Performance of Low Strength Below Knee Graduated Elastic Compression Stockings in Health, Venous Disease, and Lymphoedema ☆

OBJECTIVEnTo test the inxa0vivo haemodynamic performance of graduated elastic compression (GEC) stockings using air-plethysmography (APG) in healthy volunteers (controls) and patients with varicose veins (VVs), post-thrombotic syndrome (PTS), or lymphoedema. Responsiveness data were used to determine which group benefited the most from GEC.nnnMETHODSnThere were 12 patients per group compared using no compression, knee-length Class 1 (18-21xa0mmHg) compression, and Class 2 (23-32xa0mmHg) compression. Stocking/leg interface pressures (mmHg) were measured supine in two places using an air-sensor transducer. Stocking performance parameters, investigated before and after GEC, included the standard APG tests (working venous volume [wVV], venous filling index [VFI], venous drainage index [VDI], ejection fraction [EF]) and the occlusion plethysmography tests (incremental pressure causing the maximal increase in calf volume [IPMIV], outflow fraction [OF]). Results were expressed as median and interquartile range.nnnRESULTSnSignificant graduated compression was achieved in all four groups with higher interface pressures at the ankle. Only the VVs patients had a significant reduction in their wVV (without: 133 [109-146] vs. class1: 93 [74-113] mL) and the VFI (without: 4.6 [3-7.1] vs. class1: 3.1 [1.9-5] mL/s), both at p <.05. The IPMIV improved significantly in all groups except in the PTS group (p <.05). The OF improved only in the controls (without: 43 [38-51] vs. class1: 50 [48-53] %) and the VVs patients (without: 47 [39-58] vs. class1: 56 [50-64] %), both at p <.05. There were no significant differences in the VDI or the EF with GEC. Compression dose-response relationships were not observed.nnnCONCLUSIONnPatients with varicose veins improved the most, whereas those with PTS improved the least. Performance seemed to depend more on disease pathophysiology than compression strength. However, the lack of responsiveness to compression strength may be related to the low external pressures used. Stocking performance tests may have value in selecting those patients who benefit most from compression.

Hemodynamic changes in the femoral vein with increasing outflow resistance

INTRODUCTIONnIn post-thrombotic and May-Thurner syndromes, the iliac veins may be scarred, compressed, or obstructed. Obesity and increased intra-abdominal pressure may also hamper the venous return. Therefore, measurements of outflow resistance (OR) impeding venous return may be helpful to select patients for intervention and to assess the impact of intervention. A proof-of-concept study is presented in healthy volunteers where OR is quantified using duplex assessment of the femoral vein (FV) at mid-thigh following predetermined inflation pressures with a high thigh tourniquet.nnnMETHODSnTwenty-two consecutive subjects (15 male) without evidence of venous disease by clinical and duplex examination were studied. Two male exclusions were due to bifid FVs. Median (range) baseline characteristics were age 30xa0years (24-57xa0years), height 173xa0cm (158-197xa0cm), weight 72xa0kg (50-97xa0kg), leg length 80xa0cm (74-94xa0cm), and FV diameter 11.2xa0mm (6.8-14.8xa0mm). Subjects were examined standing with the test leg nonweight-bearing, resting gently on the floor. A 26-cm-wide calf cuff was attached to an intermittent pneumatic compression device that delivered three compressions per minute at 120xa0mm Hg. A high thigh cuff, 12xa0cm wide, was inflated just before each calf compression in multiples of 20xa0mm Hg, from 0 to 120xa0mm Hg, to provide a standard OR. FV waveform parameters were recorded using duplex beneath each thigh-cuff inflation pressure and repeated three times. OR was calculated using change in pressure (P2-P1)/Flow (Q). Pressure P2 was 120xa0mm Hg minus the additional height to the duplex transducer. P1 was assumed toxa0be zero. Flow was cross-sectional area (πxa0× diameter [d](2)/4)xa0× velocity. The velocity parameters chosen were peakxa0velocity (PV), time-averaged mean velocity (TAMV), andxa0TAMV from start to peak.nnnRESULTSnPeak velocity, TAMV, and TAMV to peak all decreased significantly (Pxa0< .0005; Friedman) with increasing thigh cuff pressure with Pxa0< .0005 correlations (Spearman) of rxa0= .842, rxa0= .488, and rxa0= .744, respectively. Furthermore, increasing thigh cuff pressure at 0, 20, 40, 60, 80, 100, and 120xa0mm Hg also caused a gradual and significant increase in median (interquartile range) OR at 27 (19-34), 30 (21-42), 30 (23-44), 40 (26-47), 46 (32-51), 61 (38-71), and 79 (45-134) resistance units, respectively (Pxa0< .0005; Friedman, and rxa0= .516; Spearman). Higher baseline (innate) OR values were found in taller (Pxa0= .002) and heavier (Pxa0= .043) subjects.nnnCONCLUSIONSnHemodynamic velocity parameters in the femoral vein attenuate progressively with increasing venous obstruction. Outflow resistance (OR) can be quantified using duplex measurements when they are substituted into equations of fluid mechanics. Optimization of this novel technique, which requires an IPC outflow challenge test, may provide useful information in the assessment and treatment of patients.

Quantifying saphenous recirculation in patients with primary lower extremity venous reflux.

BACKGROUNDnThe great saphenous vein (GSV) in patients with superficial venous insufficiency might act as a beneficial conduit for antegrade venous drainage and also as a harmful conduit for promotion of reflux and/or recirculation and subsequent skin changes. The aim of this study was to measure the antegrade and retrograde GSV volume displacements during calf compression and release maneuvers. This was used to quantify harm over benefit with a recirculation index (RCI).nnnMETHODSnSixteen legs (nine right) from 16 patients (nine male) with primary superficial venous insufficiency were scanned standing with duplex ultrasound, at the upper thigh GSV, 10 cm below the sapheno-femoral junction. The clinical, etiological, anatomical, pathophysiological class was C2 = 3, C3 = 2, C4a = 6, C4b = 4, C5 = 1. The median age (range), venous clinical severity score, and refluxing GSV diameter were 63 (21-79) years, 8 (4-16), and 7 (5-10) mm, respectively. A manual calf compression and release (MCCR) maneuver was performed once, and a cyclical calf compression and release (CCCR) three times for repeatability. With the CCCR maneuver, the calf-cuff and inflation-deflation pump provided a cyclical compression pressure of 120 mm Hg (3 seconds) with a release time of 16.4 seconds to standardize venous refilling time.nnnRESULTSnThe results are expressed as median [interquartile range]. The CCCR compared with the MCCR resulted in longer reflux duration (16.4 [8.2-16.4] seconds vs 5.7 [3.7-6.8] seconds; P < .0005), higher time-averaged mean velocities in reflux (23.5 [14.9-27.9] cm/s vs 14.1 [9-17.6] cm/s; P < .0005) and greater reflux volume displacements (81.7 [38.8-152.8] mL vs 27.3 [16.4-53.4] mL; P < .0005). There were significant correlations between increasing antegrade volume measurements and increasing reflux volume measurements irrespective of whether CCCR, (r = 0.841; P < .0005) or MCCR (r = 0.762; P = .001) was used. This implies that the displaced antegrade volume might have a causal effect on the resulting reflux volume. The ratio of reflux volume/antegrade volume (RCI) was 2.14 [1.58-2.74] with the CCCR. This supports the recirculation phenomenon. Adjusted to a standard median for each leg, the repeatability limits (three times) of the RCI was excellent at 2.14 (95% confidence interval, 2.09-2.21).nnnCONCLUSIONSnIn this study we measured the behavior of the GSV in terms of harmful reflux over beneficial drainage using the RCI. We recognize that reflux values depend on the type of provocation test and the amount of displaced antegrade volume. This limitation might be overcome by factoring reflux as an expression of antegrade flow using the RCI. When standardized, a test for quantifying saphenous recirculation might have many clinical applications. The next step should be a prospective study to validate the RCI with clinical and quality of life parameters.

Neuromuscular electrical stimulation reduces sludge in the popliteal vein

BACKGROUNDnThe common peroneal nerve stimulator (CPNS) is a UK-approved device for reducing venous thromboembolism (VTE) risk. It resembles a wrist watch and is placed over the common peroneal nerve, discharging electricity at a rate of 1 impulse/s. It has been presumed that as blood flow slows, erythrocytes aggregate into ultrasound-detectable echogenic particles, described as venous sludge. The aim of the study was to determine whether the CPNS reduces venous sludge by using an ultrasound-derived gray-scale (0-255) venous sludge index (VSI).nnnMETHODSnTwenty-five healthy volunteers had their right popliteal vein video recorded using B-mode ultrasound at 22xa0frames/s in longitudinal and transverse views, standing and lying. This was performed first with the CPNS off and then with the CPNS on. The CPNS impulse intensity used was set from 1 to 7 for each individual, and the level was sufficient to cause an outward jerking movement of the foot. A single frame of the possible 154 frames, lasting 7xa0seconds, was selected using a random number generator for the image analysis. The brightness of the erythrocyte aggregates (pixels) within a circular sampling area was quantified using the VSI. The brighter the sample, the greater the sludge.nnnRESULTSnValues are expressed as median (interquartile range). On standing with the device off, there was a significantly higher VSI (Pxa0< .0005) compared with lying (longitudinal view, 27.7 [18.8-41.4] vs 11.7 [5.5-17.5]; transverse view, 20.7 [13.6-32.2] vs 11.4 [6.3-15.9]). Activation of the CPNS significantly reduced all the VSI values (Pxa0< .0005) shown (longitudinal view, 2 [1.1-3.2] and 1.5 [0.5-3.1]; transverse view, 1.1 [0.6-2.7] and 0.8 [0.5-2.1]).nnnCONCLUSIONSnThe CPNS device significantly reduces venous sludge within the popliteal vein irrespective of whether the subject is standing or lying down or of the longitudinal or transverse position of the ultrasound transducer. The principal mode of action of the device in the claim that it may reduce venous thromboembolism risk may be through a reduction of venous sludge. However, the relationship between erythrocyte aggregation, venous stasis, and venous thromboembolism risk requires more investigation.

The Discord Outcome Analysis (DOA) as a Reporting Standard at Three Months and Five Years in Randomised Varicose Vein Treatment Trials

OBJECTIVESnTreatment success for chronic superficial venous insufficiency could be defined as an improvement in three domains: (i) disease specific quality of life, (ii) clinical severity, (iii) reflux. The aim was to report these at five years using a Venn diagram to profile the outcomes: a discord outcome analysis (DOA).nnnMETHODSnPatients (nxa0=xa050 patients/legs in each treated group) were randomised to endovenous laser ablation (EVLA) with concurrent phlebectomies vs. ultrasound guided foam sclerotherapy (UGFS). Outcomes were assessed using three domains: (i) Aberdeen varicose vein questionnaire (AVVQ), (ii) venous clinical severity score (VCSS), (iii) venous filling index (VFI) of air plethysmography. Change scores were calculated by subtracting the final score after treatment from the baseline score before treatment to quantify the improvement. This was followed by a DOA profile for each patient where a discord was defined as the percentage of patients with a numerical deterioration in one or two domains.nnnRESULTSnThe median [interquartile range] follow up was 68 [64-72] months. Follow up in all three domains was EVLA: 45/50, UGFS: 42/50. On ultrasound examination, GSV occlusion at some point above the knee was 93% for EVLA and 64% for UGFS (pxa0=xa0.001). There was no significant difference in improvement between the two treatment groups in the VCSS and the VFI. However, the EVLA group had a statistically significant AVVQ improvement (pxa0=xa0.004). Using a DOA, only 76% EVLA versus 60% UGFS had success in all three domains. Using improvement thresholds, this reduced to 54% and 39%, respectively. The commonest discord pattern was an improvement in the VCSS and VFI but deterioration in the AVVQ.nnnCONCLUSIONSnA DOA demonstrated that the definition of success is reduced if deterioration in one or two domains is taken into account. A DOA should be considered as a reporting standard for comparative analyses.