The controversy of managing calf vein thrombosis Masuda, Elna M., MD; Kistner, Robert L., MD; Musikasinthorn, Chayanin, MD ...
Journal of vascular surgery,
02/2012, Volume:
55, Issue:
2
Journal Article
Peer reviewed
Open access
Background Controversy persists as to whether all calf vein thrombi should be treated with anticoagulation or observed with duplex surveillance. We performed a systematic review of the literature to ...assess whether data could support either approach, followed by examination of its natural history by stratifying results according to early clot propagation, pulmonary emboli (PE), recurrence, and postthrombotic syndrome (PTS). Methods A total of 1513 articles were reviewed that were published from January 1975 to August 2010 using computerized database searches of PubMed, Cochrane Controlled Trials Register, and extensive cross-references. English-language studies specifically examining calf deep vein thrombosis (C-DVT) defined as axial and/or muscular veins of the calf, not involving the popliteal vein, were included. Papers were independently reviewed by two investigators (E.M., F.L.) and quality graded based on nine methodologic standards reporting on four outcome parameters. Results Of the 1513 citations reviewed, 31 relevant papers meeting predefined criteria were found: six randomized controlled trials (RCT) and 25 observational cohort studies or case series. There was a single RCT directly comparing anticoagulation with no anticoagulation with compression and duplex surveillance, and they found no difference in propagation, PE, or bleeding in a low-risk population. Based on two studies of moderately strong methodology, C-DVT propagation was reduced with anticoagulation. When treatment was unassigned, moderately strong evidence suggested that about 15% propagate to the popliteal vein or higher. However, based on nonrandomized data but with moderate to high quality (level A and B studies), propagation to popliteal or higher was 8% in those with no anticoagulation treated with surveillance only. Propagation involving adjacent calf veins but remaining in the calf occured in up to one-half of all those who propagate. Major bleeding was an intended endpoint in three RCTs and was reported as 0% to 6%, with a trend toward lower bleeding risk in more recent studies. PE during surveillance in studies with unassigned treatment was strikingly lower than the historical reports of PE recorded at presentation, emphasizing the distinction that must be made between the two entities. Recurrence in C-DVT is lower than thigh DVT, and data suggest that in low-risk groups with transient risk factors, 6 weeks of anticoagulation may be sufficient, as opposed to 12 weeks. Studies of PTS reported that patients with C-DVT had fewer symptoms than their thigh DVT counterparts. Approximately one out of 10 showed symptoms of CEAP Class 4 to 6; however, C5 or C6 with healed or active ulceration were not commonly encountered. Conclusions No study of strong methodology could be found to resolve the controversy of optimal treatment of C-DVT. Given the risks of propagation, PE, and recurrence, the option of doing nothing should be considered unacceptable. In the absence of strong evidence to support anticoagulation over imaging surveillance with selective anticoagulation, either method of managing calf DVT must remain as current acceptable standards.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The CEAP classification for chronic venous disorders (CVD) was developed in 1994 by an international ad hoc committee of the American Venous Forum, endorsed by the Society for Vascular Surgery, and ...incorporated into “Reporting Standards in Venous Disease” in 1995. Today most published clinical papers on CVD use all or portions of CEAP.
Rather than have it stand as a static classification system, an ad hoc committee of the American Venous Forum, working with an international liaison committee, has recommended a number of practical changes, detailed in this consensus report. These include refinement of several definitions used in describing CVD; refinement of the C classes of CEAP; addition of the descriptor n (no venous abnormality identified); elaboration of the date of classification and level of investigation; and as a simpler alternative to the full (advanced) CEAP classification, introduction of a basic CEAP version. It is important to stress that CEAP is a descriptive classification, whereas venous severity scoring and quality of life scores are instruments for longitudinal research to assess outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Primary chronic venous disorders, which according to the CEAP classification are those not associated with an identifiable mechanism of venous dysfunction, are among the most common in Western ...populations. Varicose veins without skin changes are present in about 20% of the population while active ulcers may be present in as many as 0.5%. Primary venous disorders are thought to arise from intrinsic structural and biochemical abnormalities of the vein wall. Advanced cases may be associated with skin changes and ulceration arising from extravasation of macromolecules and red blood cells leading to endothelial cell activation, leukocyte diapedesis, and altered tissue remodeling with intense collagen deposition. Laboratory evaluation of patients with primary venous disorders includes venous duplex ultrasonography performed in the upright position, occasionally supplemented with plethysmography and, when deep venous reconstruction is contemplated, ascending and descending venography. Primary venous disease is most often associated with truncal saphenous insufficiency. Although historically treated with stripping of the saphenous vein and interruption and removal of major tributary and perforating veins, a variety of endovenous techniques are now available to ablate the saphenous veins and have generally been demonstrated to be safe and less morbid than traditional procedures. Sclerotherapy also has an important role in the management of telangiectasias; primary, residual, or recurrent varicosities without connection to incompetent venous trunks; and congenital venous malformations. The introduction of ultrasound guided foam sclerotherapy has broadened potential indications to include treatment of the main saphenous trunks, varicose tributaries, and perforating veins. Surgical repair of incompetent deep venous valves has been reported to be an effective procedure in nonrandomized series, but appropriate case selection is critical to successful outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The purpose of this study was to investigate the blood flow changes and venous wall movements that occur in the perivalvular area during venous flow, to learn how these physiologic events influence ...the movements of the valve cusps, and to learn how the movements of the valve cusps influence the venous flow.
Twenty healthy volunteers (10 male, 10 female, age 18 to 52) were subjects of this study. Each volunteer was examined in semi-recumbent and standing positions at rest and during active foot movements. Ultrasound examinations were performed in the B-flow mode supplemented by B-mode and pulsed-wave Doppler scanning.
Four phases of the valve cycle are described. During the
opening phase (0.27 ± 0.05 s), the cusps move from the closed position toward the sinus wall. After reaching a certain point, the valves cease opening and enter the
equilibrium phase. During this phase (0.65 ± 0.08 s), the leading edges remain suspended in the flowing stream and undergo self-excited oscillations with an amplitude of 0.01 to 0.16 cm. During the
closing phase (0.41 ± 0.07 sec), the leaflets move synchronously toward the center of the vein. The subsequent
closed phase has a duration of 0.45 ± 0.05 seconds when the cusps remain closed. During the equilibrium phase, flow separation occurs at the leading edge of the cusp with reattachment at the wall of sinus. At this point, flow splits into two streams at each valve cusp. Part of the flow is directed into the sinus pocket behind the valve cusp, forming a vortex along the valve cusp before re-emerging in the main stream in the vein. When the valve is maximally open, the two cusps create a narrowing of the lumen about 35% smaller than the vein distal to the valve. In this narrowed area flow accelerates, forming a proximally directed jet.
The valve cusps undergo the four phases constituting the valve cycle. The local hemodynamic events, such as flow separation and reattachment, and vortical flow in the sinus play important roles in the valve operation. In addition to prevention of retrograde flow, the valve acts as a venous flow modulator. The vortical stream behind the valve cusps participates in the operation of the valve, and prevents stasis inside the valve pocket. The central jet possibly facilitates outflow.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Current techniques to treat venous ulcerations and patients with severe lipodermatosclerosis include the elimination of incompetent perforator veins by open surgical ligation and division or by ...subfascial endoscopic perforator surgery. An alternative and less invasive means to obliterate perforator veins is ultrasound-guided sclerotherapy (UGS). We hypothesize that UGS is a clinically effective means of eliminating perforator veins and results in improvement of the clinical state (scores) without the complications associated with other more invasive methods.
Between January 2000 and March 2004, UGS was used to treat chronic venous insufficiency in 80 limbs of 68 patients. This was a clinical series of patients who had perforator incompetence and no previous surgery for venous disease ≤2 years of their UGS procedure. Most had perforator disease without coexisting axial reflux of the saphenous or deep venous systems. Color flow duplex scanning was used to identify incompetent perforator veins in the calf, and duplex guidance was used to inject each perforator with the liquid sclerosant sodium morrhuate (5%). Patients were restudied by duplex scanning up to 5 years after treatment. Clinical results were determined by Venous Clinical Severity Score (VCSS) and Venous Disability Score (VDS) before and after treatment.
Of the 80 limbs treated with UGS, 98% of incompetent perforators were successfully obliterated at the time of treatment, and 75% of limbs showed persistent occlusion of perforators and remained clinically improved with a mean follow-up of 20.1 months. According to the CEAP classification, there were 46.2% with limb ulceration or C6, 1.2% C5, 28.7% C4, 17.5% C3, and 6.2% C2 with pain isolated to the site of the perforator(s). Of those who returned for follow-up, the VCSSs changed from a median of 8 before treatment (95% confidence interval CI, 3 to 15) to a median of 2 after treatment (95% CI, 0 to 7) (
P < .01). Likewise, VDSs dropped from a median of 4 before treatment (95% CI, 1 to 3) to 1 after treatment (95% CI, 0 to 2) (
P < .01). There were no cases of deep vein thrombosis involving the deep vein adjacent to the perforator injected. One patient had skin complications with skin necrosis. Perforator recurrence was found more frequently in those with ulcerations than those without.
UGS is an effective and durable method of eliminating incompetent perforator veins and results in significant reduction of symptoms and signs as determined by venous clinical scores. As an alternative to open interruption or subfascial endoscopic perforator surgery, UGS may lead to fewer skin and wound healing complications. Perforator recurrence occurs particularly in those with ulcerations, and therefore, surveillance duplex scanning after UGS and repeat injections may be needed.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective This prospective multicenter investigation was conducted to define the repeatability of duplex-based identification of venous reflux and the relative effect of key parameters on the ...reproducibility of the test. Methods Repeatability was studied by having the same technologist perform duplicate tests, at the same time of the day, using the same reflux-provoking maneuver and with the patient in the same position. Reproducibility was examined by having two different technologists perform the test at the same time of the day, using the same reflux-provoking maneuver and with the patient in the same position. Facilitated reproducibility was studied by having two different technologists examine the same patients immediately after an educational intervention. Limits of agreement between two duplex scans were studied by changing three elements of the test: time of the day (morning vs afternoon), patient's position (standing vs supine), and reflux initiation (manual vs automatic compression–decompression). Results The study enrolled 17 healthy volunteers and 57 patients with primary chronic venous disease. Repeatability of reflux time measurements in deep veins did not significantly differ with the time of day, the patient's position, or the reflux-provoking maneuver. Reflux measurements in the superficial veins were more repeatable ( P < .05) when performed in the morning with the patient standing. The agreement between the clinical interpretations significantly depended on a selected cut point (Spearman's ρ, −0.4; P < .01). Interpretations agreed in 93.4% of the replicated measurements when a 0.5-second cut point was selected. The training intervention improved the frequency of agreement to 94.4% (κ = 0.9). Alternations of the time of the duplex scan, the patient's position, and the reflux-provoking maneuver significantly decreased reliability. Conclusions This study provides evidence to develop a new standard for duplex ultrasound detection of venous reflux. Reports should include information on the time of the test, the patient's position, and the provoking maneuver used. Adopting a uniform cut point of 0.5 second for pathologic reflux can significantly improve the reliability of reflux detection. Implementation of a standard protocol should elevate the minimal standard for agreement between repeated tests from the current 70% to at least 80% and with more rigid standardization, to 90%.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
To analyze patient-reported quality of life (QOL) and symptoms in a prospective cohort of CVD patients who was managed within the framework of existing policies.
Prospective cohort study of 150 ...patients with C2-C4 clinical class of primary chronic venous disease (CVD). Management consisted of initial conservative measures, following which, the patients were given a choice of continuing conservative therapy, or surgical treatment. Patients completed Specific Quality of Life and Outcome Response--Venous (SQOR-V) tool before initial visit, after completion of conservative treatment, and at 1 and 12 month follow up visits after surgical treatment. Management consisted of initial conservative measures. QOL score and symptom score (SS) part of this instrument was analyzed separately.
Conservative treatment resulted in improvement of symptom score in 85(57%) patients, and the QOL in 111(74%) patients. Despite this improvement, the majority of patients (121) chose surgical option. At the 1-month follow up after surgical treatment 97 (80%) patients reported significant improvement of their symptoms and 114 (94%) in the QOL compare to their status after conservative therapy. The QOL improvement was due mainly to improvement in symptom score. Patients who improved after conservative therapy were more than 15 times more likely to have symptoms relief at 1 month (RR = 15.6, 95% CI 4.3-56.5), and 21 times higher at 1 year after surgery (RR = 21.3, 95% CI 4.7-96.9) compared with those who did not change the SS.
Surgical treatment resulted in a better relief of symptoms compare to conservative therapy. The relief of symptoms after conservative therapy predicts better outcomes of surgical treatment. These findings suggest that success of conservative therapy should be considered as an indication, and the failure of conservative therapy should not be an indication to surgical treatment.
Objective To assess whether the measurement error, and recall bias can reach magnitudes comparable to minimally important difference (MID) in symptoms scores used in chronic venous disease-specific ...quality of life QOL instruments, such as Specific Quality of Life & Outcomes Response-Venous (SQOR-V) questionnaire. Methods Prospective non-randomized study of 150 patients with primary chronic venous disease. SQOR-V questionnaire was administered prior to clinical visit (in 32 patients twice), and 1 month post-treatment. Patients were asked to recall their symptoms 12 months later. Measurement error (SEM) was calculated from repeated baseline measurements. MID was derived from change in the symptom score (SS) part of the SQOR-V questionnaire at 1 month. Recall bias was calculated from 12-month recall data. Results SEM was 1.91, the recall bias was –3.16 (95% CI from –4.08 to –2.24), and the MID was 3.7. In the treatment group the recall bias was negative (recall more severe symptoms than they actually were at the baseline), patients in the observation group had positive recall bias. SS change moderately correlated with transition rating index (Spearman rank-order correlation 0.526, P < 0.0001), and strongly correlated with the baseline value (Pearson r = 0.84). Conclusion The measurement error of patient-reported symptoms scores included in disease-specific QOL instruments is small, but recall bias is close in magnitude to MID.
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BFBNIB, CEKLJ, DOBA, EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, INZLJ, IZUM, KILJ, KISLJ, MFDPS, NLZOH, NMLJ, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UILJ, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ, ZRSKP
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