Importance of patient-reported outcomes in chronic venous disorders

The assessment of outcomes following treatment for chronic venous disease has been greatly improved over the last three decades. The personal opinion of the physician based on assessment of his own results has been replaced by more objective assessment based on well-defined criteria. The author describes and compares a number of different methods currently in use for this purpose.     

Chronic venous insufficiency

Opinion statement Patients with chronic venous insufficiency arguably have been relegated to a standard of care that is lower than that for those with the more appealing entity of peripheral arterial disease. Fortunately, the collaboration of an expanding group of clinicians (including cardiologists and vascular medicine specialists) with vascular surgeons is stimulating a renewed interest in the management of patients afflicted with venous disease. With the increased level of awareness of venous disease, technologic advances undoubtedly will augment the armamentarium available for the treatment of patients with chronic venous insufficiency. The focus on the prevention of venous thromboembolic complications has been advanced greatly, as witnessed by the growth of new pharmacologic agents, such as heparinoids, antiplatelet agents, direct thrombin inhibitors, thrombolytics, and pentasaccharides. In addition, the more aggressive strategy of intervening in acute deep venous obstruction by using thrombolytic agents and adjunctive mechanical thrombectomy devices potentially may obviate the future sequelae of chronic venous insufficiency. The tremendous growth of endovascular techniques in recent years has revolutionized the management of problems due to acute and chronic arterial obstructive disease. The application of these techniques in the future may have a similar impact in improving the clinical outcomes of patients with chronic venous disease and potentially, if proven safe and efficacious in clinical trials, may lower the threshold for intervention to an earlier disease stage. Similarly, with the advent of endovascular and endoscopic techniques, surgical procedures will also continue to evolve, with these procedures complementing one another, as opposed to serving as surrogates, which traditionally has been the case.     

Expert assessment of chronic venous insufficiency

In the expertise of a chronic venous insufficiency kind and stage of the venous disease must be proved as objectively as possible. The diagnostic demands in the individual step programmes serve for the exact assessment of the remaining part of efficiency. The criteria of valuation are summarized, in which case we also deal with several possibilities of combination with other vascular diseases. The expert opinion of an accident is discussed. References to the inability to work, rating of nursing money, increased material benefit in impairments of health and to the acknowledgement of an identity card for injured persons supplement the statements.     

Prevalence of lower extremity venous disease in inflammatory bowel disease.

AIM: Inflammatory bowel disease (IBD) has long been considered a risk factor for venous thromboembolism (VTE). Whereas most patients have persistent venous valvular dysfunction following lower extremity deep venous thrombosis (DVT), we hypothesized that patients with IBD would have an increased prevalence of valvular incompetence and changes of chronic DVT (reduced venous caliber with thickened walls) relative to patients with irritable bowel syndrome (IBS) or normal volunteers. METHODS: Subjects with confirmed IBD, clinical features of IBS or normal volunteers underwent complete, prospective duplex ultrasound assessment of their lower extremity venous vascular system. The sonographer performing the venous study was blinded to the clinical diagnosis of the patients. Valvular incompetence was graded as mild, moderate or severe based on accepted criteria. RESULTS: Eighty patients with IBD (ulcerative colitis, UC: 66; Crohn's disease: 14), 80 patients with IBS, and 80 healthy volunteers agreed to participate. One patient with UC was found to have non-occlusive chronic DVT within the left superficial femoral vein. Mild and moderate valvular incompetence was evenly distributed between the 3 groups. No patients met criteria for either acute DVT or severe venous incompetence. CONCLUSION: In patients with IBD, neither valvular incompetence nor chronic venous obstruction are over-represented compared to patients with IBS or normal volunteers. In this prospective assessment of venous physiology by duplex ultrasound, we were not able to confirm prior reports that IBD is a major risk factor for VTE.     

Best practices for the prevention and treatment of venous leg ulcers

Chronic venous insufficiency is the most common cause of leg ulcers. Its incidence increases as the population ages. Managing venous leg ulcers involves treating the cause, optimizing local wound care, and addressing patient-centered concerns. The cornerstone of the diagnosis of chronic venous insufficiency includes demonstrating venous disease. The clinician must rule out significant coexisting arterial disease by performing a thorough clinical assessment and obtaining an ankle brachial pressure index. The most important aspect of treatment is resolving edema through high compression therapy for those individuals with an ankle brachial pressure index greater than or equal to 0.8. Other components of successful chronic venous insufficiency management include increasing mobility and medical management. Selected patients may respond to surgery, biologicals, adjunctive therapies, and lifestyle enhancements. Twelve recommendations are made incorporating current best clinical practices and expert opinion with available research. The approach to venous disease is best accomplished through a multidisciplinary team that revolves around the active participation of patients and their families. The authors' intent is to provide a practical, easy-to-follow guide to allow healthcare professionals to provide best clinical practices.     

Quality of life in chronic venous insufficiency. An Italian pilot study of the Triveneto Region.

AIM: Chronic venous insufficiency (CVI) is a chronic disease, whose disability has not been appreciated clearly, and several treatment costs are not covered by Public Health Service, probably because its any social impact is not well known. The aim of the study was to assess the impact of CVI on quality of life (QoL), and to compare the sensitivity of more diffused instruments for QoL assessment. METHODS: One hundred and four patients with CVI received the Italian version of four QoL assessment instruments (MOS SF-36; CIVIQ-2; Euro-QoL 5D and a visual analogical scale). The poorest QoL was adjusted as 0, the best as 100. After filling the questionnaires, patients underwent a clinical and instrumental examination to assess the diagnosis according to the CEAP classification. RESULTS: The QoL is progressively impaired from CEAP class C1 to class C5-6. The SF-36 showed a normal QoL in patients of CEAP class C1 and C2. Class C3 showed a significant (P<0.0018) reduction of QoL (physical role and bodily pain), and the decline was more significant (P<0.0001) in class C4, involving all physical items and several mental ones. Class C5-6 showed very low scores of physical and social functioning, general health and vitality. Physical and emotional scores were better than C4 patients. CONCLUSIONS: QoL is progressively impaired in CVI, involving primarily the physical items and the emotional role, with worsening of mental items only in advanced stages. This early involvement of physical items underlines how CVI is not an esthetic problem, but, a disease. Its impact on the lifestyle and QoL is similar to that of other chronic diseases (diabetes, cancer, chronic pulmonary disease), reaching in the class C5-6 the poorest level, similar to heart failure.     

脑静脉窦血栓形成的动物模型

脑静脉窦血栓形成(cerebral venous and sinus thrombosis,CVST)是一种少见的缺血性脑血管病,60%的患者病变累及多个静脉窦,其中以上矢状窦血栓形成最为常见.CVST的发病机制及病理生理学迄今尚未完全阐明,建立稳定和理想的动物模型能为研究其发展、预后和疗效评估提供基础.文章对现有几种CVST模型的特点和优势进行了总结,但各种方法均有自身局限性.因此,建立更理想的动物模型有助于全面了解CVST的发病机制和病理过程.     

Pathophysiology of pain in venous disease

Pain is the leading complaint of patients with venous disease. It has a significant effect on the patient's quality-of-life. For the clinician and the researcher however it is difficult to apprehend how pain is related to the venous disease, both because of the multiple factors involved and because of the lack of any strong relationship between pain symptoms and the severity of the venous disease. Currently, several hypotheses concerning the pathogenesis of pain in venous disease have focused on the causal impact of local inflammation. Over the last five years, a large body of evidence has been accumulation showing an inflammatory reaction around varicose veins, but the precise mechanism of how inflammatory mediators interact with venous nociceptors, which might explain part of the variability in pain observed in venous disease, remains elusive, both clinically and experimentally.     

Aneurysmic transformation of the venous system in venous angiodysplasias of the limbs

Based on a retrospective evaluation of 107 patients with congenital venous angiodysplasia of the Type Klippel-Trenaunay (n = 76) and Type Servelle-Martorell (n = 31) the frequency and pathogenesis of aneurysm formation in the venous system has been analysed. The vascular patterns include both cylindric ectasias and fusiform aneurysms with an incidence of approximately 40%. Preferred locations are subcutaneous drainage veins, the popliteal, external iliac vein and atypic communicating veins between the superficial and the deep venous system. Complications of the aneurysm such as local thrombosis, recurrent pulmonary embolism or bleeding from rupture were not observed. From a pathogenetic point of view the aneurysm formation in venous angiodysplasias results probably from two causative factors, i.e., a congenital weakness of the venous wall (inborn error?) and an abnormal hemodynamical stress situation. The latter is caused by concomitant malformations of the deep venous system (avalvulia, hypo- and/or aplasia). The persistent intermittent venous hypertension associated with a more or less pronounced increase of the venous volume in the affected venous system of the limb results in a deep venous insufficiency respectively venous reflux disease. Surgery is indicated under two conditions: a) in the presence of aneurysm complications or b) for the elimination of a pathological short circuit flow in some drainage veins. Antireflux surgery, e.g., venous valve transfer form the brachial vein, is up to recently still in a stage of experimental-clinical investigation. The therapy of choice is predominantly conservative, i.e., external compression bandages or stockings to reduce the deleterious effects of a chronic deep venous insufficiency respectively venous reflux disease.     

Risk factors for venous thromboembolism

Venous thromboembolism is a common and potentially lethal disease. Patients who have pulmonary embolism are at especially high risk for death. Death owing to pulmonary embolism is independent of other comorbid conditions (e.g., cancer, chronic heart disease, or lung disease). Sudden death is often the first clinical manifestation. Only a reduction in the incidence of venous thromboembolism can reduce sudden death owing to pulmonary embolism and venous stasis syndrome owing to deep vein thrombosis. The incidence of venous thromboembolism has been relatively constant since about 1980. Improvement in the incidence of venous thromboembolism will require better recognition of persons at risk, improved estimates of the magnitude of risk, the avoidance of risk exposure when possible, more widespread use of safe and effective prophylaxis when risk is unavoidable, and targeting of prophylaxis to those persons who will benefit most. Recognition of venous thromboembolism as a multifactorial disease with genetic and genetic-environmental interaction has provided significant insights into its epidemiology and offers the possibility of improved identification of persons at risk for incident and recurrent venous thromboembolism.     

A latex D-dimer reliably excludes venous thromboembolism

BACKGROUND: D-Dimer, a cross-linked fibrin degradation product, has a high sensitivity in patients with suspected venous thrombosis. Traditional latex D-dimer assays, however, have not been sufficiently sensitive to exclude venous thromboembolism. METHODS: To determine the clinical utility of a latex D-dimer assay (MDA D-Dimer; Organon Teknika Corporation, Durham, NC) in patients with suspected venous thromboembolism, we conducted a retrospective cohort study involving 595 unselected patients at 4 tertiary care hospitals. Patients had blood drawn for performance of the D-dimer assay and underwent objective testing for venous thromboembolism. Pretest probability was determined using validated models in 571 patients. Patients were classified as venous thromboembolism positive or negative according to results of objective tests and 3-month follow-up. The sensitivities, specificities, predictive values, and negative likelihood ratios of the assay were calculated for all patients and for subgroups of patients with known cancer or a low, moderate, or high pretest probability of venous thromboembolism. RESULTS: The prevalence of venous thromboembolism was 19.0% (113/595). Of those who had a pretest probability assessment, 35.9% had a low pretest probability, 49.7% a moderate pretest probability, and 14.4% a high pretest probability. Using a discriminant value of 0.50 microg fibrinogen equivalent units per milliliter, the assay showed an overall sensitivity of 96%, a negative predictive value of 98%, a specificity of 45%, and a negative likelihood ratio of 0.09. In patients with a low or moderate pretest probability, the sensitivity, negative predictive value, and negative likelihood ratio were 97%, 99%, and 0.07, respectively. CONCLUSIONS: The MDA D-Dimer assay is the first latex agglutination assay with sufficient sensitivity to be clinically useful in the exclusion of venous thromboembolism. A negative result has the potential to be used as the sole test to exclude venous thromboembolism in patients with a low or moderate pretest probability of disease.     

Risk factors for venous thromboembolism in children.

The incidence of venous thromboembolism (VTE) is increasing in children as a result of therapeutic advances and improved clinical outcome in primary illnesses that previously caused mortality. VTE is mostly diagnosed in hospitalized children, especially sick newborns with central venous catheters and older children with a combination of risk factors. Infants older than 3 months and teenagers are the largest groups developing VTE. The most important triggering risk factors are the presence of central venous lines, cancer and chemotherapy. Pathological conditions such as severe infection, sickle cell disease, trauma and antiphospholipid syndrome are associated with the presence of a hypercoagulable state in children. The thrombotic risk in otherwise healthy children with a single identified thrombophilic defect appears to be extremely low. Venous thromboembolism in pediatric patients is mainly caused by combinations of at least 2 prothrombotic risk factors for venous thromboembolic events in children are usually associated with underlying clinical conditions and a triggering risk factor. In addition, recurrence of VTE after withdrawal of anticoagulant treatment occurs in about 20% of patients after re-exposure to a triggering risk factor. A non negligible mortality and morbidity is related to VTE in childhood. This supports the need for international multicenter randomized clinical trials to determine optimal prophylactic and therapeutic treatment for children with VTE. Risk factor assessment for VTE in children has to be improved in order to optimize the prophylactic and therapeutic strategies. The specific evolutionary characteristics of the hemostasis in children has to be taken into consideration when a prophylactic or therapeutic strategy is applied.The incidence of venous thromboembolism (VTE) is increasing in children as a result of therapeutic advances and improved clinical outcome in primary illnesses that previously caused mortality. VTE is mostly diagnosed in hospitalized children, especially sick newborns with central venous catheters and older children with a combination of risk factors. Infants older than 3 months and teenagers are the largest groups developing VTE. The most important triggering risk factors are the presence of central venous lines, cancer and chemotherapy. Pathological conditions such as severe infection, sickle cell disease, trauma and antiphospholipid syndrome are associated with the presence of a hypercoagulable state in children. The thrombotic risk in otherwise healthy children with a single identified thrombophilic defect appears to be extremely low. Venous thromboembolism in pediatric patients is mainly caused by combinations of at least 2 prothrombotic risk factors for venous thromboembolic events in children are usually associated with underlying clinical conditions and a triggering risk factor. In addition, recurrence of VTE after withdrawal of anticoagulant treatment occurs in about 20% of patients after re-exposure to a triggering risk factor. A non negligible mortality and morbidity is related to VTE in childhood. This supports the need for international multicenter randomized clinical trials to determine optimal prophylactic and therapeutic treatment for children with VTE. Risk factor assessment for VTE in children has to be improved in order to optimize the prophylactic and therapeutic strategies. The specific evolutionary characteristics of the hemostasis in children has to be taken into consideration when a prophylactic or therapeutic strategy is applied.     

Epidemiology of chronic venous disease

Chronic venous disease of the legs occurs commonly in the general population in the Western world. Estimates of the prevalence of varicose veins vary widely from 2-56% in men and from 1-60% in women. These variations reflect differences in variability of study populations including age, race and gender, methods of measurement and disease definition. Definitions of chronic venous disease may rely on reports of varicose veins by study participants, based on self-diagnosis or recall of a diagnosis, or on a standardized physical examination. Venous ulceration is less common, affecting approximately 0.3% of the adult population. Age and pregnancy have been established as risk factors for developing varicose veins. Evidence on other risk factors for venous disease is inconclusive. Prolonged standing has been proposed, but results of studies should be interpreted with caution given the difficulty in measuring levels of posture. Obesity has been suggested as a risk factor in women, but appears to be an aggravating factor rather than a primary cause. Other postulated risk factors include dietary intake and smoking, but evidence is lacking. Longitudinal studies using standardized methods of evaluation are required before the true incidence of chronic venous disease and associated risk factors can be determined.     

Chronic deep venous obstruction: definition, prevalence, diagnosis, management

Ilio-caval venous obstruction has an important role in the expression of symptomatic chronic venous disease regardless of aetiology. The presence of obstruction has been more or less previously ignored and emphasis placed on reflux alone. Stenting of the ilio-femoral veins guided by intravascular ultrasound (IVUS) can now be performed with low morbidity and mortality using appropriate technique. Current diagnostic modalities do not allow a definitive assessment of haemodynamically critical venous obstruction, which hampers selection of limbs for treatment. The diagnosis must be based on morphological studies (preferably IVUS) in patient selected with specific history, signs and symptoms. A high index of suspicion and generous use of morphological investigations are critical in the initial recognition of venous outflow obstruction. Stenting of the ilio-femoral vein appears to be durable with a substantial improvement in limb pain and swelling, high rate of ulcer healing, enhanced quality of life and decreased disability. The beneficial clinical outcome occurs regardless of the presence of remaining reflux, adjunct saphenous procedures or aetiology of obstruction.     

Risk assessment for recurrent venous thrombosis

Venous thrombosis is a common disease that frequently recurs. Recurrence can be prevented by anticoagulants, albeit at the cost of bleeding. Thus, assessment of the risk of recurrence is important to balance the risks and benefits of anticoagulation treatment. Many clinical and laboratory risk factors for recurrent venous thrombosis have been established. Nevertheless, prediction of recurrence in an individual patient remains a challenge. Detection of some laboratory markers is associated with only a moderate risk of recurrence, and the relevance of others is not known. Many patients have several risk factors and the effect of combined defects is obscure. Routine screening for these laboratory markers should therefore be abandoned. Risk assessment can be improved by measurement of global markers that encompass the effects of clotting and fibrinolytic disorders. Analysis of preliminary data suggests that risk assessment can also be refined through integration of prothrombotic coagulation changes and clinical risk factors.     

Hepatic portal venous gas: an unusual presentation of Crohn's disease

Hepatic portal venous gas is associated with numerous conditions and traditionally has been regarded as an ominous prognostic sign. There are several reports of hepatic portal venous gas occurring in patients with inflammatory bowel disease after or during the performance of colonic diagnostic studies. We report an unusual case of Crohn's disease whose initial presentation included hepatic portal venous gas. The literature of hepatic portal venous gas associated with inflammatory bowel disease is reviewed.     

Aneurysma transformation in congenital venous angiodysplasias in lower extremities

Based on a retrospective evaluation of 107 patients with congenital venous angiodysplasia of the Type Klippel-Trenaunay (n = 76) and Type Servelle-Martorell (n = 31) the frequency and pathogenesis of aneurysma formation in the venous system has been analysed. The vascular patterns include both cylindric ectasia and fusiform aneurysms with an incidence of approximately 40%. Preferred locations are subcutaneous drainage veins, the popliteal, external iliac vein and atypic communicating veins between the superficial and the deep venous system. Complications of the aneurysm such as local thrombosis, recurrent pulmonary embolism or bleeding from ruptur were not observed. The aneurysma formation in venous angiodysplasias results probably from the causative factors: congenital weakness of the venous wall and an abnormal hemodynamical stress situation. The latter is caused by concomitant malformations of the deep venous system. The persistent intermittent venous hypertension associated with a more or less pronounced increase of the venous volume in the affected venous system of the limb results in a deep venous insufficiency respectively venous reflux disease. The therapy of choice is predominantly conservative, i.e., external compression bandages or stockings to reduce the deleterious effects of a chronic deep venous insufficiency respectively venous reflux disease. Surgery is indicated under two conditions: a) in the presence of aneurysm complications or b) for the elimination of a pathological short circuit flow in some drainage veins. Antireflux surgery, i.e., venous valve transfer from the brachial vein, is up to recently still in a stage of experimental-clinical investigation.     

Quantification of venous reflux by means of some duplex scanner and light reflection rheography parameters and its correlation with chronic venous insufficiency symptoms

BACKGROUND: The quantification of venous reflux is rarely made but it is valuable for studying the natural history of CVI, its prognostic implications and the therapy effectiveness. We have evaluated some parameters of chronic venous insufficiency, caused by valvular incompetence, by means of duplex scanner and light reflection rheography searching for a better correlation with the clinical stages of vein disease. METHODS: We have examined 107 patients (35 males, 72 females; aged 22-78, mean 61.5 +/- 14.3) with long saphenous insufficiency in different clinical stages and measured the venous reflux, the reflux duration, the reflux grade, the vein diameter near the saphenofemoral junction with the duplex scanner and the refilling time with the light reflection rheography. The reproducibility of the studied techniques has been determined by examining 20 legs four times each in the same day or on different days. Statistical analysis of the data was performed by means of the variance analysis followed by the Waller-Duncan test. RESULTS: The venous reflux, the venous diameter and the refilling time can easily range between mild and severe insufficiency: reflux is 6.3 +/- 2.5 ml/sec at stage I; 27.5 +/- 10.1 at stage III; venous diameter is 6.04 +/- 1.4 at stage I; 10.6 +/- 2.2 at stage III; refilling time is 23.6 +/- 9.6 at stage I; 5.4 +/- 2.4 at stage III. The reflux time and reflux grade are unable to separate the various CVI stages. CONCLUSIONS: The measurement of venous reflux, venous diameter and refilling time is simple, quick, reproducible; these indices are able to differentiate mild from severe CVI but unable to separate patients at the second stage of the venous disease from those at the third stage and then ineffective in the ulcer risk assessment but the reflux is highly predictable. The ulcer risk is practically absent for reflux < 12 ml/sec; highly probable for reflux > 15 ml/sec (20/46 cases; 43.4%).     

Obesity as a risk factor in venous thromboembolism

PURPOSE: Whether obesity is an independent risk factor for pulmonary embolism or deep venous thrombosis has not been fully determined. METHODS: We used the database of the National Hospital Discharge Survey to further investigate the potential risk of obesity in venous thromboembolic disease. RESULTS: The relative risk of deep venous thrombosis, comparing obese patients with non-obese patients, was 2.50 (95% confidence interval [CI] = 2.49-2.51). The relative risk of pulmonary embolism was 2.21 (95% CI = 2.20-2.23). Obese females had a greater relative risk for deep venous thrombosis than obese males, 2.75 (95% CI = 2.74-2.76) versus 2.02 (95% CI = 2.01-2.04). Obesity had the greatest impact on both men and women aged less than 40 years. CONCLUSION: The data indicate that obesity is a risk factor for venous thromboembolic disease in men as well as women.     

Posttreatment ultrasound-detected residual venous thrombosis: a risk factor for recurrent venous thromboembolism and mortality

PURPOSE OF REVIEW: The cumulative risk of recurrent venous thrombosis may rise to 30% over 8 years. Extended oral anticoagulation is effective but major bleeding is increased. To balance these risks attention has focused on identifying patients with the highest likelihood of recurrence for whom continued therapy is most beneficial. Another issue of interest has been the increased probability of death after venous thrombosis, due primarily to malignancy but also to vascular disease. RECENT FINDINGS: Unprovoked events and cancer are known to be associated with recurrent thrombosis. Residual posttreatment thrombosis confirmed by compression ultrasound is regarded as another risk for recurrence. Confounders in the published studies are the patient mix and the ultrasound technique employed. Other variables such as gender and D-dimer may also predict risk. Although arterial disease is increased in patients with venous thromboses, the association between idiopathic venous thromboembolism and atherosclerosis remains circumstantial. SUMMARY: There are no validated approaches for predicting recurrent venous events. Ultrasound interrogation for residual thrombosis after primary therapy may improve treatment stratification by defining patients suitable for extended anticoagulation.