Chronic venous disease (CVD) is a prevalent condition that tends to worsen with age. Patients initially seek treatment to relieve symptoms of leg pain, discomfort, heaviness and swelling, all of ...which impact their quality of life. As the disease increases in severity to include varicose veins, skin changes, and venous ulcer, the demand for treatment increases while the quality of life further diminishes. The prevalence of CVD is highest in Western countries where it already consumes up to 2% of healthcare budgets. With the aging of the global population, the prevalences of CVD and severe CVD are projected to increase substantially, foretelling unsustainably large increases in the healthcare resources and costs needed to treat CVD patients in the coming decades. Effective venoactive drug treatments and ablation procedures are available that provide symptom relief, improve quality of life, slow disease progression, and promote ulcer healing. In addition, venoactive drug treatments may be highly cost-effective. However, there is evidence that physician awareness of CVD is suboptimal and that many patients with CVD are not being treated or referred to specialists according to established guidelines. To decrease this treatment gap and prevent unnecessary disease progression, international guidelines are available to help physicians consider CVD treatment options and refer patients when warranted. Improved disease awareness and appropriate early treatment may help reduce the coming burden of CVD.
Funding
: Servier.
Venous disease is the most common cause of leg ulceration. Although compression therapy improves venous ulcer healing, it does not treat the underlying causes of venous hypertension. Treatment of ...superficial venous reflux has been shown to reduce the rate of ulcer recurrence, but the effect of early endovenous ablation of superficial venous reflux on ulcer healing remains unclear.
In a trial conducted at 20 centers in the United Kingdom, we randomly assigned 450 patients with venous leg ulcers to receive compression therapy and undergo early endovenous ablation of superficial venous reflux within 2 weeks after randomization (early-intervention group) or to receive compression therapy alone, with consideration of endovenous ablation deferred until after the ulcer was healed or until 6 months after randomization if the ulcer was unhealed (deferred-intervention group). The primary outcome was the time to ulcer healing. Secondary outcomes were the rate of ulcer healing at 24 weeks, the rate of ulcer recurrence, the length of time free from ulcers (ulcer-free time) during the first year after randomization, and patient-reported health-related quality of life.
Patient and clinical characteristics at baseline were similar in the two treatment groups. The time to ulcer healing was shorter in the early-intervention group than in the deferred-intervention group; more patients had healed ulcers with early intervention (hazard ratio for ulcer healing, 1.38; 95% confidence interval CI, 1.13 to 1.68; P=0.001). The median time to ulcer healing was 56 days (95% CI, 49 to 66) in the early-intervention group and 82 days (95% CI, 69 to 92) in the deferred-intervention group. The rate of ulcer healing at 24 weeks was 85.6% in the early-intervention group and 76.3% in the deferred-intervention group. The median ulcer-free time during the first year after trial enrollment was 306 days (interquartile range, 240 to 328) in the early-intervention group and 278 days (interquartile range, 175 to 324) in the deferred-intervention group (P=0.002). The most common procedural complications of endovenous ablation were pain and deep-vein thrombosis.
Early endovenous ablation of superficial venous reflux resulted in faster healing of venous leg ulcers and more time free from ulcers than deferred endovenous ablation. (Funded by the National Institute for Health Research Health Technology Assessment Program; EVRA Current Controlled Trials number, ISRCTN02335796 .).
Graduated compression stockings Lim, Chung Sim; Davies, Alun H
CMAJ. Canadian Medical Association journal,
2014-Jul-08, 2014-07-08, 20140708, Letnik:
186, Številka:
10
Journal Article
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Figure 2 summarizes the mechanisms of action of graduated compression stockings. The stockings work by exerting the greatest degree of compression at the ankle, with the level of compression ...gradually decreasing up the garment. The pressure gradient ensures that blood flows upward toward the heart instead of refluxing downward to the foot or laterally into the superficial veins. The application of adequate graduated compression reduces the diameter of major veins, which increases the velocity and volume of blood flow.2 Graduation compression can reverse venous hypertension, augment skeletal-muscle pump, facilitate venous return and improve lymphatic drainage.3 It also initiates complex physiologic and biochemical effects involving the venous, arterial and lymphatic systems, although the exact mechanisms remain unclear.2,4,5 One study that used near-infrared spectroscopy to monitor changes in tissue oxy hemo - globin and deoxyhemoglobin re ported that limb oxygenation increased with the use of graduated compression stockings, especially with highcompression stockings.4 Another study showed that levels of proinflammatory cytokines (e.g., interleukin-1α, interleukin-6 and interferon-γ) in ulcer tissue in patients with active ulcers were significantly reduced following compression therapy.5 Although we found no RCT that compared compression with no compression in patients with venous skin changes (CEAP class C4), it is generally accepted that the management of such patients should include graduated compression stockings if tolerated.1,20 There is high-quality evidence that venous ulcers heal more rapidly with than without compression therapy.1,21,22 Patients with venous ulcers are often treated with compression bandages. However, there is some evidence that graduated compression stockings are equally effective.22,23 A meta-analysis of eight RCTs (n = 692) reported that the proportion of ulcers that healed was significantly higher with graduated compression stockings than with bandages (62.7% v. 46.6%).23 The average time to ulcer healing was also significantly shorter with the stockings, by three weeks. Graduated compression stockings may also be associated with less pain than bandages are.21,23 A systematic review of graduated compression stockings for the prevention of deep vein thrombosis in patients admitted to hospital because of conditions other than stroke identified 18 RCTs.29 Graduated compression stockings were used alone or in combination with another form of prophylaxis (e.g., heparin, acetylsalicylic acid and sequential compression). All but one of the RCTs assessed surgical patients. Deep vein thrombosis was diagnosed mostly through screening with ultrasonography, venography or isotope studies. Deep vein thrombosis developed in 13% of patients given graduated compression stockings, as compared with 26% of those with no stockings. In the trials in which stockings were given in combination with another prophylactic method, deep vein thrombosis developed in 4% of patients given the stockings plus another method, as compared with 16% of those given the other method alone. It was concluded that graduated compression stockings were effective in reducing the risk of deep vein thrombosis among patients in hospital, especially when used with another method of prophylaxis.29
Deep venous stenting is increasingly used in the treatment of deep venous obstruction; however, there is currently no consensus regarding post-procedural antithrombotic therapy. The aim of the ...present study was to determine the most commonly used antithrombotic regimens and facilitate global consensus.
An electronic survey containing three clinical scenarios on venous stenting for non-thrombotic iliac vein lesions, acute deep vein thrombosis (DVT), and post-thrombotic syndrome was distributed to five societies whose members included vascular surgeons, interventional radiologists, and haematologists. The results of the initial survey (phase 1) were used to produce seven consensus statements, which were distributed to the respondents for evaluation in the second round (phase 2), along with the results of phase 1. Consensus was defined a priori as endorsement or rejection of a statement by ≥ 67% of respondents.
Phase 1 was completed by 106 experts, who practiced in 78 venous stenting centres in 28 countries. Sixty-one respondents (58% response rate) completed phase 2. Five of seven statements met the consensus criteria. Anticoagulation was the preferred treatment during the first 6–12 months following venous stenting for a compressive iliac vein lesion. Low molecular weight heparin was the antithrombotic agent of choice during the first 2–6 weeks. Lifelong anticoagulation was recommended after multiple DVTs. Discontinuation of anticoagulation after 6–12 months was advised following venous stenting for a single acute DVT. No agreement was reached regarding the role of long-term antiplatelet therapy.
Consensus existed amongst respondents regarding anticoagulant therapy following venous stenting. At present, there is no consensus regarding the role of antiplatelet agents in this context.
Sport-related vascular trauma is an important consequence of increased physical activity. Repetitive, high-intensity movements predispose athletes to vascular disease, including arterial pathology, ...by exerting increased pressure on neurovascular structures. This is an important source of morbidity in an otherwise young and healthy population. Arterial pathology associated with repetitive trauma is often misdiagnosed as musculoskeletal injury. This article increases awareness of sport-related arterial disease by reviewing the symptomatology, investigation, and treatment modalities of this pathology. In addition, prognostic outcomes specific to the athlete are discussed.
Arterial thoracic outlet syndrome and vascular quadrilateral space syndrome are associated with athletes involved in overhead throwing exercises. Sport-related arterial pathology of the lower limb include external iliac artery endofibrosis (EIAE), popliteal artery entrapment syndrome (PAES), and adductor canal syndrome. Vascular stress and kinking secondary to vessel tethering are important contributors to pathology in EIAE. Chronic exertional compartment syndrome must also be considered, presenting with clinical features similar to PAES. In addition, athletes are predisposed to blunt mechanical trauma. Hypothenar hammer syndrome is one such example, contributing to a high burden of morbidity in this population.
In arterial thoracic outlet syndrome and vascular quadrilateral space syndrome, surgery is advocated in symptomatic individuals, with postoperative outcomes favorable for the athlete. Acute limb ischemia may occur as a result of secondary thrombosis or embolization, often without preceding claudication. PAES and adductor canal syndrome are associated with functional entrapment in the athlete, secondary to muscular hypertrophy. Surgical exploration may be indicated. Poorer outcomes are noted when this process is associated with vascular reconstruction. Surgical treatment of EIAE follows failure of conservative management, with limited data available on postoperative prognosis. Investigations for all these conditions should be targeted based on clinical suspicion. A delay in diagnosis can have severe consequences on return to competition in these high-functioning individuals.
Background Hypoxia may contribute to the pathogenesis of various diseases of the vascular wall. Hypoxia-inducible factors (HIFs) are nuclear transcriptional factors that regulate the transcription of ...genes that mediate cellular and tissue homeostatic responses to altered oxygenation. This article reviews the published literature on and discusses the role of the HIF pathway in diseases involving the vascular wall, including atherosclerosis, arterial aneurysms, pulmonary hypertension, vascular graft failure, chronic venous diseases, and vascular malformation. Methods PubMed was searched with the terms “hypoxia-inducible factor” or “HIF” and “atherosclerosis,” “carotid stenosis,” “aneurysm,” “pulmonary artery hypertension,” “varicose veins,” “venous thrombosis,” “graft thrombosis,” and “vascular malformation.” Results In atherosclerotic plaque, HIF-1α was localized in macrophages and smooth muscle cells bordering the necrotic core. Increased HIF-1α may contribute to atherosclerosis through alteration of smooth muscle cell proliferation and migration, angiogenesis, and lipid metabolism. The expression of HIF-1α is significantly elevated in aortic aneurysms compared with nonaneurysmal arteries. In pulmonary hypertension, HIF-1α contributes to the increase of intracellular K+ and Ca2+ leading to vasoconstriction of pulmonary smooth muscle cells. Alteration of the HIF pathway may contribute to vascular graft failure through the formation of intimal hyperplasia. In chronic venous disease, HIF pathway dysregulation contributes to formation of varicose veins and venous thromboembolism. However, whether the activation of the HIF pathway is protective or destructive to the venous wall is unclear. Increased activation of the HIF pathway causes aberrant expression of angiogenic factors contributing to the formation and maintenance of vascular malformations. Conclusions Pathologic vascular wall remodelling of many common diseases of the blood vessels has been found to be associated with altered activity of the HIF pathway. Therefore, understanding the role of the HIF pathway in diseases of the vascular wall is important to identify novel therapeutic strategies in the management of these pathologies.
The structure of microvasculature cannot be resolved using conventional ultrasound (US) imaging due to the fundamental diffraction limit at clinical US frequencies. It is possible to overcome this ...resolution limitation by localizing individual microbubbles through multiple frames and forming a superresolved image, which usually requires seconds to minutes of acquisition. Over this time interval, motion is inevitable and tissue movement is typically a combination of large- and small-scale tissue translation and deformation. Therefore, super-resolution (SR) imaging is prone to motion artifacts as other imaging modalities based on multiple acquisitions are. This paper investigates the feasibility of a two-stage motion estimation method, which is a combination of affine and nonrigid estimation, for SR US imaging. First, the motion correction accuracy of the proposed method is evaluated using simulations with increasing complexity of motion. A mean absolute error of 12.2 \mu \text{m} was achieved in simulations for the worst-case scenario. The motion correction algorithm was then applied to a clinical data set to demonstrate its potential to enable in vivo SR US imaging in the presence of patient motion. The size of the identified microvessels from the clinical SR images was measured to assess the feasibility of the two-stage motion correction method, which reduced the width of the motion-blurred microvessels to approximately 1.5-fold.
Background Open repair is the gold standard management for juxtarenal aneurysms. Fenestrated endovascular aneurysm repair (FEVAR) is indicated for high-risk patients. The long-term outcomes of FEVAR ...are largely unknown, and there is no Level I comparative evidence. This systematic review and meta-analysis of case series compares elective juxtarenal aneurysm surgery by open repair and FEVAR. Methods A systematic literature search was conducted for all published studies on elective repair of juxtarenal aneurysms by FEVAR and open repair. The MEDLINE, EMBASE, and Cochrane databases were searched from 1947 to April 2013. The exclusion criteria were case series of <10 patients or ruptured aneurysms. The primary outcomes were perioperative mortality and postoperative renal insufficiency. The secondary outcomes were secondary reinterventions and long-term survival. Results We identified 35 case series with data on 2326 patients. Perioperative mortality was 4.1% in open repair and FEVAR case series (odds ratio for open repair with FEVAR, 1.059; 95% confidence interval, 0.642-1.747; P = .822). Postoperative renal insufficiency was not significantly different (odds ratio for open repair with FEVAR, 1.136; 95% confidence interval, 0.754-1.713; P = .542). FEVAR patients had higher rates of secondary reintervention, renal impairment during follow-up, and a lower long-term survival compared with open repair patients. Conclusions FEVAR and open repair have similar short-term outcomes but have diverging long-term outcomes that may be secondary to the selection bias of FEVAR being offered to high-risk patients. FEVAR is a favorable option in high-risk patients, and open repair remains viable as the gold standard.
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