Selection of publications dedicated to venous diseases

How does chronic venous disease progress from the first symptoms to the advanced stages?: A review.

Labropoulos N.

Risk factors for the development of progression chronic venous disease (CVD) and varicose veins are widespread and include advanced age, excess body weight, sedentary lifestyles and occupations, family history, and pregnancy. Varicose veins and CVD are associated with venous hypertension, venous reflux, dysfunctional venous valves, and vein wall inflammation, though the precise etiologies are unclear. Once venous pathology develops, it can progress through a vicious cycle of inflammation and leukocyte recruitment that leads to further deterioration of vein walls and valves, increased hypertension, and release of additional proinflammatory mediators. Early treatment of symptomatic varicose veins and CVD as well as lifestyle changes can help break the inflammatory cycle and alleviate symptoms. Physicians and patients should be aware of the risk factors for CVD, the treatments and measures available to slow disease progression, and the serious consequences of allowing the disease to progress unchecked.

For full text: Advances in Therapy; https://doi.org/10.1007/s12325-019-0885-3

Pathophysiology of internal hemorrhoids.

Margetis N.

Hemorrhoidal disease is a fairly common and debilitating clinical entity. Despite centuries’ of attempts to shed light on its pathophysiology, to cure those affected and to improve sufferers’ quality of life, many aspects of the disease remain elusive. Individual beliefs and historical legends, accompanied by undocumented theories, have established and perpetuated the confusion regarding the mechanisms leading to the development of the disease and the rules governing its treatment. Hemorrhoids are classified as internal or external and are viewed as a disease when they become symptomatic. Returning to basic medical sciences, this mini-review focuses on internal hemorrhoids and aims to define the histology and anatomy of the normal and abnormal internal hemorrhoidal plexus and to encourage clinicians to comprehend the pathophysiology of the disease. If doctors can understand the pathophysiology of hemorrhoidal disease, they will be able to clarify the nature of the associated symptoms and complications and to make the correct therapeutic decision.

For full text: Annals of Gastroenterology; https://doi.org/10.20524/aog.2019.0355

The seriousness of chronic venous disease: A review of real-world evidence.

Davies AH.

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.

For full text: Advances in Therapy; https://doi.org/10.1007/s12325-019-0881-7

Burden and suffering in chronic venous disease.

Nicolaides AN, Labropoulos N.

Chronic venous disease (CVD) is widespread, underdiagnosed, and can progress to chronic venous insufficiency and venous ulcers, which can require extensive treatment and hospitalization. These conditions negatively impact patient quality of life and place substantial burdens on healthcare resources. The two main risk factors for CVD are age and obesity. Thus, with the growing prevalence of obesity and the increasing longevity of the population, the burden of CVD is expected to increase dramatically in the coming decades. Appropriate lifestyle changes and care, which may include treatment with venoactive drugs, can slow disease progression, improve quality of life, and are likely to reduce healthcare costs. Physicians should be aware of this growing problem and of the effective treatments available for CVD. We recommend the accompanying short summaries from a symposium held at the recent European Venous Forum as a means for our colleagues to learn more about the burden and suffering associated with CVD.

For full text: Advances in Therapy; https://doi.org/10.1007/s12325-019-0882-6

Endovenous ablation, review article.

Vuylsteke M, Klitfod L, Mansilha A.

Varicose vein surgery is among the most commonly performed surgical interventions. The standard treatment “high ligation and stripping” has in many countries been replaced by endovenous techniques. However there are many different techniques available. All have a different way of action and sometimes need different skills. The purpose of this review article is to give an update in those different endovenous ablation techniques. We describe the indications, technique, mechanisms of action and results. We conclude that all different techniques can be used safely and are effective. Even on long term there seems to be no difference in outcome, even compared to high ligation and stripping.

For full text: International Angiology; https://doi.org/10.23736/s0392-9590.18.04047-6

Management of chronic venous disorders of the lower limbs: Guidelines according to scientific evidence part 1:

Developed under the auspices of The European Venous Forum, The International Union of Angiology, The Cardiovascular Disease Educational and Research Trust (UK), Union Internationale de Phlébologie

Nicolaides A, Kakkos S, Baekgaard N, Comerota A, De Maeseneer M, Eklof B, Giannoukas A, Lugli M, Maleti O, Myers K, Nelzen O, Partsch H, Perrin M.

This current document aims to describe current concepts for CVDs, update guidelines for management, and indicate the strength of evidence supporting the recommendations.

For full text: International Angiology; https://doi.org/10.23736/s0392-9590.18.03999-8

Pathophysiological mechanisms of chronic venous disease and implications for venoactive drug therapy.

Mansilha A, Sousa J.

Chronic venous disease (CVD) is a common pathology, with significant physical and psychological impacts for patients and high economic costs for national healthcare systems. Throughout the last decades, several risk factors for this condition have been identified, but only recently, have the roles of inflammation and endothelial dysfunction been properly assessed. Although still incompletely understood, current knowledge of the pathophysiological mechanisms of CVD reveals several potential targets and strategies for therapeutic intervention, some of which are addressable by currently available venoactive drugs. The roles of these drugs in the clinical improvement of venous tone and contractility, reduction of edema and inflammation, as well as in improved microcirculation and venous ulcer healing have been studied extensively, with favorable results reported in the literature. Here, we aim to review these pathophysiological mechanisms and their implications regarding currently available venoactive drug therapies.

For full text: International Journal of Molecular Sciences; https://doi.org/10.3390/ijms19061669

The significance of pain in chronic venous disease and its medical treatment.

Radak D, Atanasijevi I, Neskovic M, Isenovic E.

Chronic venous disease (CVeD) is a highly prevalent condition in the general population, and it has a significant impact on quality of life. While it is usually manifested by obvious signs, such as varicose veins and venous ulcers, other symptoms of the disease are less specific. Among the other symptoms, which include heaviness, swelling, muscle cramps and restless legs, pain is the symptom that most frequently compels CVeD patients to seek medical aid. However, there is a substantial discrepancy between pain severity and clinically detectable signs of CVeD, questioned by several opposing studies.
Further evaluation is needed to clarify this subject, and to analyse whether pain development predicts objective CVeD progression. General management of CVeD starts with advising lifestyle changes, such as lowering body mass index
and treating comorbidities. However, the mainstay of treatment is compression therapy, with the additional use of pharmacological substances. Venoactive drugs proved to be the drugs of choice for symptom alleviation and slowing the progression of CVeD, with micronized purified flavonoid fraction being the most effective one. Interventional therapy is reserved for advanced stages of the disease.

For full text: Current Vascular Pharmacology; https://doi.org/10.2174/1570161116666180209111826

Is catheter-directed foam sclerotherapy more effective than the usual foam sclerotherapy for treatment of the great saphenous vein?

Camillo O

This retrospective study presents the long-term results of catheter-directed foam sclerotherapy of the great saphenous vein. Method From January 2003 to June 2017, 277 patients with varices and great saphenous vein incompetence were treated with echo-guided foam sclerotherapy. Forty-six patients were treated with long-catheters guided by foam sclerotherapy. Foaming was carried out with sodium-tetra-decyl-sulphate. Results Results were examined in the two groups: A (long-catheters) and B (other procedures). The median overall follow-up was 52.1 months. In the A-group, the complete occlusion rate was 34/46 pts (73.9%) and partial occlusion was 10/46 (21.7%). In the B-group, respectively, 130/231 (56.2%) and 90/231 (38.9%). Comparisons between groups were statistically significant (p = 0.023; p = 0.021). Failures involved, respectively, 2/46 (4.3%) and 11/231 (4.7%) with no statistical significance. The complication rates were similar in the two groups. Conclusions In this long-term experience (median follow-up exceeding four years), foam-guided sclerotherapy of the great saphenous vein with a long-catheter turned out to be more effective than the usual foam-guided sclerotherapy.

For full text: Phlebology; https://doi.org/10.1177/0268355518756503

Hemorrhoids: What are the options in 2018?

Jacobs DO

Efforts continue to improve the treatment of patients with symptomatic hemorrhoidal disease by interventions designed to improve efficiency and effectiveness, including by reducing intraoperative and postoperative pain, decreasing operating times, minimizing blood loss and controlling symptoms and recurrence rates. Simultaneously, there are also renewed efforts to minimize the number of patients who will require procedural intervention by focusing on conservative measures that encourage better bowel regulation and habits. The purpose of this brief report is to review the current status of the diagnosis and treatment of patients with hemorrhoidal disease. Overall, new procedures or procedural refinements to existing techniques continue to be introduced with promising short-term outcomes – at least in some instances. In most instances, long-term follow-up or equivalency data are still being accumulated such that a definitive, unequivocal answer to what is truly the best alternative to traditional hemorrhoidectomy remains controversial. One of the challenges is heterogeneity as regards diagnosis, intervention and, especially, outcomes measures such that comparing therapies is too difficult. A recent initiative to standardize metrics has promise. Recent studies largely appear to suggest that conservative treatment approaches and managing patient expectations are critically important in which a primary objective should be to minimize the progression to symptomatic disease and complications in patients who are diagnosed with hemorrhoids. The pace of change as regards the development of new or improved surgical techniques appears may be accelerating. Progress is being made and the knowledge base is being expanded as regards the treatment options for patients with hemorrhoids and expected outcomes. A key initiative to standardize the approaches to diagnosis and treatment about staging, procedural interventions and outcomes will facilitate comparative analytics, if successful.

For full text: Curr Opin Gastroenterology; https://doi.org/10.1097/MOG.0000000000000408

Clinical Practice Guidelines: The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids

Davis B, Lee-Kong S, Migaly J, Feingold D, Steele S.

The purpose of this guideline is to provide information for all practitioners, healthcare workers and patients who desire information on which decisions can be made about the management of hemorrhoids.

For full text: Disease Colon Rectum; https://doi.org/10.1097/DCR.0000000000001030

Executive Summary – The Association of Colon & Rectal Surgeons of India (ACRSI) Practice Guidelines for the Management of Haemorrhoids

Agarwal N, Singh K, Sheikh P, Mittal K, Mathai V, Kumar A.

This paper outlines the recommendations from the Association of Colon & Rectal Surgeons of India (ACRSI) practice guidelines for the management of haemorrhoids²2016. It includes diagnosis and management of haemorrhoids including dietary, non-surgical, and surgical techniques. These guidelines are intended for the use of general practitioners, general surgeons, colorectal surgeons, and gastrointestinal surgeons in India.

For full text: Indian J Surgery; https://doi.org/10.1007/s12262-016-1578-7

Post thrombotic Syndrome

Busuttil A, Lim CS, Davies AH.

Venous insufficiency following deep venous thrombosis is known as the post thrombotic syndrome. Whilst its presentation and symptoms can vary slightly between individuals, it can have a profound effect on quality of life. Symptoms range from mild limb swelling to severe intractable ulceration. A number of scoring systems have been developed to help monitor the disease progression, response to treatment as well as to classify patients for research purposes.Treatment involves a combination of therapies, including compression stockings, venous stenting for out flow obstruction and in some instances deep venous bypass. A considerable effort is made in preventing post thrombotic syndrome with a number of trials looking into the effect of prompt and stable anticoagulation, the effect of compression stockings, the effect of exercise and the outcomes following early thrombus removal strategies such as catheter directed and pharmacomechanical thrombolysis.

For full text: Adv Exp Med Biol; https://doi.org/10.1007/5584_2016_126

Guidelines for the treatment of hemorrhoids (short report).

Higuero T, Abramowitz L, Castinel A, Fathallah N, Hemery P, Laclotte Duhoux C, Pigot F, Pillant-Le Moult H, Senéjoux A, Siproudhis L, Staumont G, Suduca JM, Vinson-Bonnet B

Hemorrhoids are a common medical problem that is often considered as benign. The French Society of Colo-Proctology (Société nationale française de colo-proctologie [SNFCP]) recently revised its recommendations for the management of hemorrhoids, based on the literature and consensual expert opinion. We present a short report of these recommendations. Briefly, medical treatment, including dietary fiber, should always be proposed in first intention and instrumental treatment only if medical treatment fails, except in grade ≥III prolapse. Surgery should be the last resort, and the patient well informed of the surgical alternatives, including the possibility of elective ambulatory surgery, if appropriate. Postoperative pain should be prevented by the systematic implementation of a pudendal block and multimodal use of analgesics.

For full text: J Visc Surgery; https://doi.org/10.1016/j.jviscsurg.2016.03.004

Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS): Management of Chronic Venous Disease

C. Wittens, A.H. Davies, N. Bækgaard, R. Broholm, A. Cavezzi, S. Chastanet, M. de Wolf, C. Eggen, A. Giannoukas, M. Gohel, S. Kakkos, J. Lawson,T. Noppeney, S. Onida, P. Pittaluga, S. Thomis, I. Toonder, M. Vuylsteke, ESVS Guidelines Committee

The aim of this document is to assist physicians in selecting the best management strategy for patients with CVD. By summarizing and evaluating all available evidence in the field, recommendations for the evaluation and treatment of patients with CVD have been formulated.

For full text: Eur J Vascular Endovascular Surgery; https://doi.org/10.1016/j.ejvs.2015.02.007

An Epidemiological Survey of Venous Disease Among General Practitioner Attendees in Different Geographical Regions on the Globe: The Final Results of the Vein Consult Program.

Vuylsteke ME, Colman R, Thomis S, Guillaume G, Van Quickenborne D, Staelens I.

This study measured the prevalence of chronic venous disease (CVD, C1-C6), chronic venous insufficiency (C3-C6) in 23 countries. The possible influence of risk factors was assessed. Patient recruitment was carried out by general practitioners. Patient characteristics, prevalence of risk factors, and C-classification were recorded. We assessed differences in prevalence and risk factors between Asia (A), Eastern Europe (EE), Latin America (LA), and Western Europe (WE). A total of 99 359 patients were included. The prevalence of CVD (51.9% A, 70.18% EE, 68.11% LA, and 61.65% WE) was significantly ( P < .001) lower in A. Risk factors such as age, obesity, smoking, having regular exercise, use of birth control pills, prolonged standing and sitting, and having a positive family history differ significantly between regions. After model-based probabilities corrected for risk factors, significant differences in the probability of having CVD were only found in the older age-group (>65 years). The lowest prevalence was noted in A. Chronic venous disease is very common and the prevalence varies between different geographical areas. After correcting for risk factors, these differences diminished.

For full text: Angiology; https://doi.org/10.1177/0003319718759834