Vivak Hansrani

Trans-venous occlusion of incompetent pelvic veins for chronic pelvic pain in women: a systematic review.

Chronic pelvic pain (CPP) affects 24% of women worldwide; the cause cannot be identified in 40% despite invasive investigations. Dilated, refluxing pelvic veins may be a cause of CPP and treatment by trans-venous occlusion is increasingly performed when gynecological causes are excluded, but is it effective? A systematic review of the literature published between 1966 and July 2014 was conducted. Two authors independently reviewed potential studies according to a set of eligibility criteria, with a third assessor available as an arbiter. Thirteen studies including 866 women undergoing trans-venous occlusion of pelvic veins for CPP were identified (Level of evidence: one study grade 2b, 12 studies grade four). Statistical significant improvements in pelvic pain were reported in nine of the 13 studies. Technical success was reported in 865 of 866 (99.8%) with low complication rates: coil migration in 14 women (1.6%), abdominal pain in ten women (1.2%) and vein perforation in five (0.6%). In a study on varicose veins of the legs, recurrence was seen in 13% of 179 women 5-years following coil embolization. Subjective improvements in pain were seen in all 13 studies after treatment by trans-venous occlusion. All 13 studies were of poor methodological quality. Complication rates were low and no fatalities occurred. Well-designed studies are essential to determine whether pelvic vein incompetence (PVI) is associated with CPP, and to explore whether trans-venous occlusion of PVI improves quality of life for these women.

The Diagnosis and Management of Early Deep Vein Thrombosis

The diagnosis and management of an acute DVT is difficult and mistakes are often made. The cost to the National Health Service (NHS) of litigation arising from failure to diagnose and treat DVT early is substantial. Clinical diagnosis alone is often unreliable and a large proportion of DVT occurring in hospital are asymptomatic. In the United Kingdom, clinical scoring systems, D-dimer and ultrasound (US) imaging have all been adopted to aid diagnosis via DVT pathways. These pathways aim to exclude DVT only and often fail to actually address the cause of the symptoms once DVT is eventually cleared.

Is pelvic vein incompetence associated with symptoms of chronic pelvic pain in women? A pilot study.

OBJECTIVE Pelvic vein incompetence (PVI) affects 15-20% of all women, yet we know little about how it affects sufferers. The aim of this prospective pilot study was to explore symptoms experienced by women with PVI, and determine its impact on quality of life and NHS costs. STUDY DESIGN Case-control study at a UK University teaching hospital conducted over an eight-month period. Cases were 40 premenopausal women aged 18-49 years with PVI and varicose veins (VV). There were two age-matched controls groups: (i) 40 healthy women with no PVI but with VV, and (ii) 40 healthy women with no PVI and no VV. Subjects were asked to complete a structured questionnaire on disease specific outcomes, health status and use of healthcare resources. RESULTS Mean age (range) was 39.8 (24-47) years for cases, 39.1 (24-49) for VV controls and 38 (25-49) for healthy controls. Pelvic pain was reported by 38 of 40 (95%) PVI cases, compared with 25 of 40 (62%) VV controls, and 26 of 40 (65%) healthy controls (p=0.001). The median (range) EQ-5D utility score for PVI cases was 0.80 (0.29-1.0) compared with 0.80 (0.09-1.0) for VV controls and 1.0 (0.62-1.0) for healthy controls (p=0.002). Of the 40 PVI cases, 35 (88%) visited a consultant in the previous 12 months compared with 12 of 40 (30%) VV controls, and 14 of 40 (35%) healthy controls (p<0.001). CONCLUSIONS Women with PVI report a greater frequency of pelvic pain with reduced health status and increased use of healthcare resources compared with matched controls.

The role of compression in the management of soft tissue ankle injuries: a systematic review

BackgroundAnkle sprains are very common injuries which can lead to long-term pain, swelling and instability. Compression is often used in the treatment of these common injuries but is it effective and how best is it delivered?MethodsMEDLINE (1966-current), EMBASE (1980-current), Cochrane Library (2011:1) and MEDION were included in our search. Studies evaluating compression in the treatment of ankle sprains were included. Two authors independently reviewed potential studies according to a set eligibility criteria.ResultsTwelve studies including 1,701 patients with ankle sprains were identified (level of evidence: four grade 1b; five grade 2b; three grade 4). Intermittent pneumatic compression (IPC), elastic tubular bandage and compression bandaging were all evaluated. Five of the 12 studies reported that compression therapy improves recovery after ankle injury, of which one evaluated IPC, and the remaining four elastic bandages (Elastoplast, class II elastic stockings, wool and crepe, focal compression with air stirrup). Five studies evaluating Tubigrip in ankle sprains concluded that Tubigrip has no positive effect on functional recovery and may increase the requirement for analgesia compared with no intervention.ConclusionCompression may be an effective tool in the management of ankle injuries and has been shown to reduce swelling and improve quality of life in single studies. Definitive conclusions are hampered by the poor quality of evidence and the variety of treatments used. The most effective form of compression to treat ankle sprains or is yet to be determined. Adequately designed randomized control trials are clearly needed.

The Prevention of Venous Thromboembolism in Surgical Patients

Patients undergoing surgery are at an increased risk of VTE. Since the early 1990s the prevention of VTE has been dominated by the administration of low-molecular weight heparin during admission. New oral anticoagulants have been extensively researched and have increased in popularity. This chapter reviews why surgical patients are at increased risk of VTE and summaries both the pharmacological and mechanical methods of prophylaxis available.

Meta-analysis and meta-regression analysis of iliac limb occlusion after endovascular aneurysm repair

Objective: Our objective was to investigate the incidence, interventions and outcomes of iliac limb occlusion after endovascular aneurysm repair (EVAR). Methods: We performed a systematic review that conformed to the Preferred Reporting Items for Systematic Reviews and Meta‐analysis guidelines using a registered protocol (CRD42017064375). We considered studies reporting patients with iliac limb occlusion after EVAR. We interrogated electronic information sources and bibliographic reference lists using a combination of free text and controlled vocabulary searches. We conducted a proportion meta‐analysis of outcomes applying a random effects model. We used mixed effects (methods of moments) regression models to investigate whether the incidence of iliac limb occlusion changed over time. Results: We identified 13 studies reporting a total of 5454 patients who underwent EVAR from 1995 to 2014. The pooled incidence estimate of primary iliac limb occlusion was 5.6% (95% confidence interval [CI], 4.0‐7.8). The incidence of iliac limb occlusion was more pronounced in old studies and declined in more recently published studies (slope P = .022; Q=5.279). Forty‐four percent (95% CI, 36%‐52%) had an acute presentation. One‐half of the patients (48%; 95% CI, 41%‐56%) presented within 30 days of EVAR. Seventeen percent (95% CI, 13%‐23%) underwent endovascular treatment, 8% (95% CI, 5%‐13%) received hybrid procedures, and 61% (95% CI, 54%‐67%) had open surgery. The 30‐day mortality was 0.036 (95% CI, 0.018‐0.070; heterogeneity: P = .999, I2 = 0%). The rate of limb loss within 30 days and during follow‐up was 0.031 (95% CI, 0.015‐0.063; heterogeneity: P = .999; I2 = 0%) and 0.045 (95% CI, 0.024‐0.083; heterogeneity: P = .978; I2 = 0%), respectively. Reintervention was undertaken in 0.080 (95% CI, 0.048‐0.130; heterogeneity P = .919; I2 = 0%) over a follow‐up ranging from 7 to 39 months. The mortality during follow‐up was 0.056 (95% CI, 0.031‐0.099; heterogeneity: P = .866; I2 = 0%). Conclusions: Iliac limb occlusion occurred in 5.6% of patients after EVAR. One‐half of these patients presented early. Even though surgical treatment has been used more frequently, there is insufficient evidence to suggest its superiority over endovascular/hybrid repair. A considerable number of patients will require reintervention. Future research is needed in identifying patients at risk of iliac limb occlusion.

Pelvic vein incompetence: clinical perspectives

Chronic pelvic pain (CPP) affects 24% of premenopausal women, accounts for 20%–30% of UK gynecology outpatient appointments, and has an annual pan-European economic cost of €3.8 billion. Despite extensive investigation, often including laparoscopy, up to 55% of women do not receive a diagnosis and endure persistent symptoms. In these patients, clinical management focuses on symptom control rather than treatment. It is possible that pelvic vein incompetence (PVI) is a cause of CPP, although the quality of studies investigating an association is generally low. PVI may develop during and after pregnancy, as uterine blood flow increases significantly, pushing venous valve leaflets apart, and enabling retrograde venous flow. Analogies with varicose veins of the lower limb are helpful, and symptoms are similar. Women with symptomatic PVI report a dull pelvic ache that is worse on standing and sitting and persists throughout the day. It can be relieved by lying down. Early treatments for PVI included laparoscopic ligation; however, since the advent of endovascular occlusive techniques, treatments have lower risk and lower cost, and can be undertaken without sedation or anesthetic. However, there have been no high-quality randomized controlled trials of interventions and, therefore, the evidence is limited to single-center case series.

Diagnosing of pelvic vein incompetence using minimally invasive ultrasound techniques

Background Pelvic vein incompetence is a cause for pelvic pain and recurrent varicose veins in women. The gold standard diagnostic method is reflux venography involving radiation, nephrotoxic contrast and jugular puncture. Trans-vaginal ultrasound (TVU) is increasingly being used as a diagnostic tool for pelvic vein incompetence. Methods Fifty women with clinical suspicion of pelvic vein incompetence and aged between 18 and 55 years were recruited prospectively over two years at a large UK University Teaching Hospital. Trans-vaginal ultrasound was performed using a standardised protocol which included assessment of the ovarian and internal iliac veins bilaterally in the supine and semi-standing position with provocative manoeuvres. Diagnostic readability and inter-observer variability was determined. Results Mean (range) age of 43 (23–51). Visibility of all four pelvic veins was better in the supine position compared with semi-standing position (76% vs 64%). Pelvic vein incompetence was identified in 34 of 50 (68%) women in the supine position compared with 38 of 50 (76%) women in the semi-standing position. Pelvic vein incompetence was demonstrated in 35 of 50 (70%) women with Valsalva manoeuvre. Inter-observer variability was 0.84 (kappa, very good agreement, p = 0.001). Conclusion Trans-vaginal ultrasound is effective at demonstrating pelvic vein incompetence. All trans-vaginal ultrasound protocols should include assessment of pelvic veins in the supine and semi-standing position with Valsalva manoeuvre.