Conservative hemodynamic surgery for varicose veins

Conservative hemodynamic surgery for varicose veins is a minimally invasive, nonablative technique that preserves the saphenous vein and helps avoid excision of varicosities. It represents a physiologic approach to the surgical treatment of varicose veins based on knowledge of the underlying venous pathophysiology gained through detailed duplex scanning. A change in venous hemodynamics is attained through fragmentation of the blood column by interruption of the refluxing saphenous trunks, closure of the origin of the refluxing varicose branches, and preservation of the communicating veins that drain the incompetent varicose veins into the deep venous system. After surgery, varicose veins regress through a reduction in hydrostatic pressure and efficient emptying of the superficial system by the musculo-venous pump. Obvious advantages of this technique are that it is done in an ambulatory setting, minimizes the risk of surgical complications, and permits a rapid return to full activity. The long-term hemodynamic improvement and recurrence rate of this technique remain to be established.     

Primary great saphenous varicose veins revisited

Our knowledge of the prevalence, pathogenesis, and treatment of primary great saphenous varicose veins has been reviewed. There is now evidence that potentially correctable environmental factors contribute importantly to the development of primary varicose veins, but what these factors are is not known. It is suggested that the evidence that incompetence of the venous valves at and above the saphenofemoral junction initiates the development of primary great saphenous varicose veins is scientifically weak. There are a number of questions about the treatment of primary varicose veins that have scarcely been asked, far less answered. The case is argued for microepidemiological studies of the prevalence of primary varicose veins, for studies to test more rigorously the valve hypothesis of their causation, and for more prospective, long-term, clinical trials of treatment to be undertaken.

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Resumen Se revisa el estado del conocimiento actual sobre la prevalencia, patogénesis, y tratamiento sobre las várices primarias del sistema safeno mayor. Existe evidencia indicativa de que factores ambientales potecialmente corregibles contribuyen en forma importante al desarrollo de las várices primarias, pero se desconoce realmente cuales son tales factores. Se sugiere que el postulado sobre la incompetencia valvular venosa a nivel de, y por encima de la desembocadura safenofemoral, como factor que inicia el desarrollo de várices del sistema safeno mayor, es débil desde el punto de vista científico. Surge un numéro considerable de interrogantes sobre el tratemiento de las várices primarias, los cuales escasamente han sido planteados y, mucho me nos, respondidos en el pasado. Aparece evidente la conveniencia de emprender estudios microepidemiológicos sobre la incidencia de várices primarias, estudios orientados a comprobar en forma más rigurosa la hipótesis sobre la alteración valvular como factor causante, y ensayos terapéuticos prospectivos a largo plazo.

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Résumé Notre connaissance de la fréquence de la pathogénie et du traitement des varices primitives de la grande veine saphène a été réétudiée. Il est évident maintenant que des facteurs prédisposants susceptibles d'Être corrigés contribuent considérablement à l'apparition des varices primitives mais ils ne sont pas parfaitement connus. Il semble que l'incompétence des valves veineuses au niveau et au-dessus de la jonction saphéno-fémorale qui serait à l'origine du développement des varices primitives de la grande saphène à une base scientifique discutable. De nombreuses questions concernant le traitement de ces varices ont été soulevées mais n'ont pas reÇu de réponse précise. Il est nécessaire de procéder à des études micro-épidémiologiques concernant la fréquence des varices primitives, d'avoir recours à des méthodes plus rigoureuses pour confirmer l'hypothèse valvulaire de leur origine, et enfin d'entreprendre prospectivement des essais thérapeutiques en appréciant leurs résultats à long terme.

     

Stripping operation with preservation of the calf saphenous veins for primary varicose veins: hemodynamic evaluation

PURPOSE: To study early changes in venous hemodynamics in stripping operation with preservation of the calf saphenous veins. PATIENTS AND METHODS: From October 1999 to December 2000, 110 extremities of 73 patients were treated for primary varicose veins. Based on preoperative ascending venography, 40 extremities underwent the groin-to-knee stripping of the GSV, 20 underwent the proximal division of the LSV, and 50 received combinations of both surgeries. To evaluate venous hemodynamic changes, air plethysmography was performed before operation and 7-14 days after operation. RESULTS: The venous volume, venous filling index and residual volume fraction were improved after surgery, but the ejection fraction did not change. The overall incidence of nerve injury was 4.5% (five limbs). CONCLUSIONS: In stripping operations, the preservation of the calf saphenous veins, which is shown to be advantageous in reducing saphenous or sural nerve injuries, does not adversely affect early venous hemodynamic improvement.     

Exploring causal correlations between inflammatory cytokines and varicose veins: A Mendelian randomization analysis

This study aimed to investigate the causal relationship between inflammatory cytokines and the risk of varicose veins. The data were sourced from genome-wide association studies (GWAS) of European individuals. Multiple Mendelian randomization (MR) methods were used to evaluate the association between inflammatory cytokines and varicose veins. The study found significant associations between elevated levels of certain inflammatory biomarkers (e.g., CASP-8, Vascular endothelial growth factor A levels (VEGF_A)) and an increased risk of varicose veins, while others (e.g., 4EBP1, MMP-10) showed a protective effect. The MR-Egger Intercept and heterogeneity tests indicated no significant pleiotropy or heterogeneity. This comprehensive MR analysis identifies several cytokines as potential contributors to the pathogenesis of varicose veins, offering insights into novel therapeutic targets. Our findings underscore the importance of inflammation in varicose veins and suggest that targeting specific cytokines could be a promising strategy for the treatment and prevention of varicose veins.     

Primary deep venous incompetence in limbs with varicose veins

Deep venous valvular incompetence (DVI) of primary, non-thrombotic origin has received little interest compared with secondary, postthrombotic DVI. In this study both limbs of 308 patients with untreated or surgically treated varicose veins in at least one limb were examined with Doppler ultrasound for signs of deep vein reflux. Ascending venography was used to exclude limbs with secondary DVI and descending venography to assess valve function. Doppler examination disclosed reflux in 3.5% of the "normal" limbs but in none of the limbs without recurrent varicose veins. A high incidence of primary DVI was found in limbs with untreated varicose veins (20.6%, p less than 0.001) and in those with recurrent or residual varicose veins (42.9%, p less than 0.001), compared with that in "normal" limbs. Popliteal vein reflux was observed in 14% and 37% in these two groups and a combination of femoral and popliteal reflux in 4% and 16%. Reflux of grade 2 or more at descending venography was noted in 43 of 78 limbs with Doppler evidence of reflux. Primary DVI is a common condition in patients with varicose veins. Further studies are needed to determine its clinical significance.     

Recurrent varicose veins

When Doppler ultrasound was introduced for the assessment of patients with varicose veins, a more accurate clinical appraisal of the pathophysiology of this condition became possible. In particular, it enabled identification of those patients with recurrent varicose veins who had had inappropriate or inadequate initial treatment. It facilitated planning of appropriate further treatment. The more widespread use of radiology, in particular varicography, as a means of preoperative assessment of recurrent varicose veins has enabled a more accurate definition of the abnormal anatomical features. The extension of this principle to the operating room has made surgery for recurrent varicose veins more precise. Patients with varicose veins secondary to deep venous disease remain a problem. When both superficial and deep venous disease are present, superficial venous disease should be treated as appropriate. Deep venous insufficiency will require continued supervision of support maintained by bandages or graduated elastic stockings.

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Resumen Con la introducción del Doppier de ultrasonido para la valoración de pacientes con venas varicosas se hizo posible determinar en forma más precisa la fisiopatología de esta entidad. Específicamente, se ha logrado la identificación de aquellos pacientes con venas varicosas recurrentes que habían tenido un tratamiento inicial inapropiado o inadecuado. También vino a facilitar la planeación de adecuado tratamiento ulterior.El más amplio uso de la radiología, y de la varicografía en particular, como método preoperatorio de valoración de las venas varicosas recurrentes, ha hecho factible una más precisa definición de la patología anatómica, y la aplicación de este método en el quirófano ha aportado mayor precisión a la cirugía de las várices recurrentes.Los pacientes con várices secundarias a patología venosa profunda continÚan siendo un problema. Cuando se conjugan la enfermedad venosa superficial y la enfermedad venosa profunda, la primera debe ser tratada con la operación indicada, en tanto que la insuficiencia venous profunda requiere continuada supervisión de soporte mediante vendas o medias elásticas de compresión graduada.

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Résumé Lorsque le Doppler a été introduit pour étudier les varices, une méthode d'investigation plus précise d'appréciation de la physiopathologie de cette affection est devenue possible. En particulier, elle a permis l'étude des varices qui ont récidivé après un traitement inapproprié ou inadéquat. Elle permet de planifier la nouvelle intervention.L'emploi large de la radiologie, en particulier de la varicographie, a permis une définition plus précise de l'anatomie pathologique des varices. La pratique de cette exploration en salle d'opérations a rendu la chirurgie des récidives variqueuses plus efficace.Les varices secondaires à la thrombose veineuse profonde posent un problème thérapeutique tourjours difficile. Quand cette condition pathologique est présente un traitement adéquat des varices superficielles doit Être mis en oeuvre. L'insuffisance veineuse profonde impose une surveillance attentive du traitement exercé par bandage ou compression progressive par bas élastiques.

     

Duodenal varicose veins

Summary Duodenal varices (DV) are rare. We present a review of published cases with emphasis on the management and outcome, as illustrated by our own case, which reflects the experience reported in the literature. The diagnosis of DV must be considered in patients with gastrointestinal bleeding. Two-thirds of all reported cases have portal venous hypertension caused by hepatic cirrhosis. In the remaining one-third prehepatic portal hypertension as a consequence of either a compromised portal venous circulation (caused by perivenous tumor or inflammation) or a primary haematological disease is the underlying cause. Previously, duodenoscopy has often failed to detect and correctly interpret DV, and was similarily unsuccessful in our case. This case report demonstrates the problems and shortcomings in the management of DV and documents a hither to unreported cause. Treatment depends on the severity of bleeding. When conservative measures cannot control the haemorrhage, emergency laparotomy may be indicated. The type of surgery should be chosen according to the aetiology, site and extent of the bleeding DV. Among 112 reported cases of DV, information on outcome exists for only 35 patients who presented with haemorrhage. The aetiology was liver cirrhosis in 26 of these patients, 10 of whom had a fatal outcome, and prehepatic portal hypertension in the remaining 9, 1 of whom had a fatal outcome.     

Glycosaminoglycans of normal veins and their alterations in varicose veins and varicose veins complicated by thrombophlebitis

The aim of the study was to examine the content and molecular differentiation of glycosaminoglycans (GAGs) in the wall of varicose veins. The studied material consisted of normal, varicose veins and varicose veins complicated by thrombophlebitis collected during operations on 26 patients. In the wall of varicose veins the mean GAGs' content as well as the content of sulphated GAGs, except heparan sulphate was increased, whereas the amount of hyaluronic acid was decreased. Furthermore, the increased quantitative ratio between sulphated and nonsulphated GAGs was demonstrated. The results indicate an evident extracellular matrix remodelling in the wall of varicose veins particularly those complicated by thrombophlebitis, that is characterised by alterations in the content and molecular differentiation of GAGs.     

Haemorrhage from varicose veins and varicose ulceration: A systematic review

Varicose veins (VVs) and varicose ulceration (VU) are usually considered non‐life‐threatening conditions, but in some cases they can lead to major complications such as fatal bleeding. The aim of this systematic review is to evidence the most updated information on bleeding from VV and VU. As evidence acquisition, we planned to include all the studies dealing with “Haemorrhage/Bleeding” and “VVs/VU”. We excluded all the studies, which did not properly fit our research question, and with insufficient data. As evidence synthesis, of the 172 records found, after removing of duplicates, and after records excluded in title and abstract, 85 matched our inclusion criteria. After reading the full‐text articles, we decided to exclude 68 articles because of the following reasons: (1) not responding properly to our research questions; (2) insufficient data; the final set included 17 articles. From literature searching, we identify the following main issues to be discussed in the review: epidemiology and predisposing factors, pathophysiology and forensic aspects, first aid. It has been estimated that deaths for bleeding due to peripheral venous problems account up to 0.01% of autopsy cases. From a pathological point of view, venous bleeding may arise from either acute or chronic perforation of an enlarged vein segment through the weakened skin. From a forensic point of view, in cases of fatal haemorrhage the death scene can even simulate non‐natural events, due to crime or suicide. In most cases, incorrect first aid led to fatal complications. Further investigation on epidemiology and prevention measures are needed.     

评价腔内激光闭合术治疗原发性下肢静脉曲张的效果

目的评价腔内激光闭合术治疗原发性下肢静脉曲张的效果。方法随机将2017-06—2018-01间郑州大学第二附属医院血管外科收治的50例原发性下肢静脉曲张患者分为2组。对照组(24例)行大隐静脉高位结扎+主干与曲张静脉分段剥脱术;观察组(26例)实施腔内激光闭合术。比较2组的疗效。结果观察组的治疗总有效率、踝围改善效果及皮下渗血灶面积、小腿隐神经受损导致的局部皮肤异常感觉发生率,均优于对照组,差异均有统计学意义(P0.05)。结论腔内激光闭合术治疗原发性下肢静脉曲张,可明显改善患者踝围、减少术后并发症发生率,临床疗效显著。     

Epidemiology of varicose veins

The prevalence rate of varicose veins in adults varies from less than 1% in lowland New Guinea women to over 50% in women in south Wales. Within populations the prevalence increases with age, is generally greater in women, is directly related to body mass, has an inconsistent relationship with occupation, and usually increases with increasing parity. None of these factors explain the striking geographic variation in the occurrence of varicose veins. The 2 most plausible hypotheses implicate low-fiber diets and prolonged chair-sitting as the primary causal factor. Epidemiological studies are required within populations to establish the merits of these 2 competing hypotheses. Since varicose veins are potentially preventable, further research is well justified.

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Resumen La tasa de incidencia de venas varicosas en adultos varía entre menos de 1% en mujeres de las tierras bajas de Nueva Guinea hasta más de 50% en las mujeres del país del Sur de Gales. Dentro de las poblaciones la prevalencia aumenta con la edad, generalmente es mayor en las mujeres, está directamente relacionada con la masa corporal, exhibe una relación inconsistente con la ocupación, y usualmente se aumenta con el incremento de la multiparidad. Ninguno de estos factores explica la notable variación geográfica en la tasa de incidencia de las venas varicosas. En cuanto a la etiología, las 2 hipótesis más plausibles implican las dietas de bajo contenido de fibra y el hábito de permanecer sentado en una silla por tiempos prolongados como los factores causales primarios. En los estudios de población aparece necesario realizar investigaciones epidemiológicas a fin de establecer los méritos de estas 2 hipótesis competidoras. Puesto que las venas varicosas son potencialmente prevenibles, se justifica adelantar investigaciones adicionales.

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Résumé La fréquence des varices chez l'adulte varie de moins de 1% chez les femmes des basses plaines de la Nouvelle Guinée à 50% chez les femmes des Galles du Sud. Dans les différentes populations la fréquence augmente avec l'âge, est plus importante chez la femme, est liée directement au poids corporel ainsi qu'au nombre des grossesses alors qu'elle paraÎt indépendante de la profession ou de l'occupation. Aucun de ces facteurs n'explique la frappante variation géographique de la fréquence des varices. Les 2 causes favorisantes possibles sont le régime alimentaire pauvre en fibres végétales et la position assise prolongée. Des études épidémiologiques paraissent indispensables pour déterminer la valeur exacte de chacune de ces 2 hypothèses. L'apparition des varices étant susceptible d'Être prévenue des recherches sérieuses concernant leur prévention méritent d'Être entreprises.

     

Possible impact of hemodynamic factors on the development of recurrent reflux in primary varicose veins

Definition of reflux as a centrifugal flow within an incompetent vein connecting both poles of the ambulatory pressure gradient and causing ambulatory venous hypertension is presented. Recurrent reflux occurs also after correctly performed crossectomy and stripping. Growth of new vessels (neo-angiogenesis) or dilatation of pre-existing venous channels (vascular remodelling) has been claimed to be the main cause of recurrences in these instances. Attempts to blockade the development of recurrent reflux in the groin by inserting mechanical barriers over the ligated saphenofemoral junction failed to prevent recurrences. The synergistic effect of two hemodynamic factors - pressure difference between the femoral vein and the saphenous remnant in the thigh on one side, and the propensity to restore centrifugal flow on the other side - may play a crucial role in the development of recurrent reflux. Pressure gradient apparently triggers the event. Restoration of centrifugal flow might be the pre-programmed phenomenon that improves compromised blood supply in arterial occlusions, but evokes recurrent reflux in incompetent superficial veins. In this way, it can be explained why recurrent reflux can occur after any therapeutic procedure.