Until recently, medical literature and the practice of vascular medicine focused on the cosmetic aspects of venous disease and the advanced stages of venous insufficiency such as painful varicose veins and venous ulcers. The systemic effects of venous insufficiency resulting from a reduction of venous return and increased transit time of blood from the lower extremities that can mimic heart failure are only recently being recognized. This article reviews the diagnosis and treatment options for the patients with venous insufficiency, and increases awareness about the systemic effects of venous disease and its role in the practice of cardiovascular medicine.

BACKGROUND:

Health surveys (HS) are a well-established methodology for measuring the health status of a population. The relative merit of using information based on HS versus electronic health records (EHR) to measure multimorbidity has not been established. Our study had two objectives: 1) to measure and compare the prevalence and distribution of multimorbidity in HS and HER data, and 2) to test specific hypotheses about potential differences between HS and EHR reporting of diseases with a symptoms-based diagnosis and those requiring diagnostic testing.

METHODS:

Cross-sectional study using data from a periodic HS conducted by the Catalan government and from EHR covering 80% of the Catalan population aged 15 years and older. We determined the prevalence of 27 selected health conditions in both data sources, calculated the prevalence and distribution of multimorbidity (defined as the presence of >=2 of the selected conditions), and determined multimorbidity patterns. We tested two hypotheses: a) health conditions requiring diagnostic tests for their diagnosis and management would be more prevalent in the EHR; and b) symptoms-based health problems would be more prevalent in the HS data.

RESULTS:

We analysed 15,926 HS interviews and 1,597,258 EHRs. The profile of the EHR sample was 52% women, average age 47 years (standard deviation: 18.8), and 68% having at least one of the selected health conditions, the 3 most prevalent being hypertension (20%), depression or anxiety (16%) and mental disorders (15%). Multimorbidity was higher in HS than in EHR data (60% vs. 43%, respectively, for ages 15-75+, P <0.001, and 91% vs. 83% in participants aged >=65 years, P <0.001). The most prevalent multimorbidity cluster was cardiovascular. Circulation disorders (other than varicose veins), chronic allergies, neck pain, haemorrhoids, migraine or frequent headaches and chronic constipation were more prevalent in the HS. Most symptomatic conditions (71%) had a higher prevalence in the HS, while less than a third of conditions requiring diagnostic tests were more prevalent in EHR.

CONCLUSIONS:

Prevalence of multimorbidity varies depending on age and the source of information. The prevalence of self-reported multimorbidity was significantly higher in HS data among younger patients; prevalence was similar in both data sources for elderly patients. Self-report appears to be more sensitive to identifying symptoms-based conditions. A comprehensive approach to the study of multimorbidity should take into account the patient perspective.

During endovenous laser ablation, which is performed as an alternative to surgery for the treatment of superficial venous insufficiency of lower extremity and associated varicose veins, it was realised that the distal end of the catheter protecting the fibre sheared off; the retained catheter fragment in the saphenous vein was removed by a mini incision. Herein, we aim to present a rare complication of endovenous laser ablation.

Different systems for delivering tumescent solution exist in endovenous laser ablation (EVLA). This study evaluated three different tumescent delivery systems in patients with primary varicose veins due to great saphenous vein reflux who were treated with EVLA. In this prospective non-randomized study, 60 patients with isolated GSV varicose veins were divided into three groups. All patients received EVLA treatment. Three different tumescent solution delivery systems were used. Systems consisted of a needle and a syringe in Group 1, a needle connected to an infusion bag system in Group 2 and a peristaltic infiltration pump in Group 3. Tumescent delivery durations were in Group 1: 6.56 SD 1.18 minutes, Group 2: 6.05 SD 2.19 minutes and Group 3: 5.19 SD 1.15 minutes (P = 0.014). In the outcomes of the study there were no significant difference between groups. Although peristaltic pump systems might provide shorter tumescent delivery durations without hand fatigue, shorter duration does not have any practical importance (about 1 minute and also it is not cost-effective. For delivering tumescent solutions in EVLA procedures, there was no major superiority between systems.

Venous insufficiency can be defined as a fixed venous outflow disturbance of the limbs. It is caused by the malfunction of the venous system, that may or may not be associated with venous valvular insufficiency and may involve the superficial or deep venous system of the lower limbs, or both. The CEAP scale includes clinical, etiologic, anatomic and pathophysiologic aspects and has been used in the assessment of venous insufficiency Clinical classification comprises of 7 groups. It takes into account the appearance of the skin of the lower limbs, presence of edema, teleangiectasis and varicose ulcers. CLINICAL GRADING: Group C0 - no visible changes in the clinical examination; Group C1 - telangiectasis, reticular veins, redness of the skin around the ankles; Group C2 - varicose veins, Group C3 - the presence of edema without skin changes; Group C4 - lesions dependent of venous diseases (discoloration, blemishes, lipodermatosclerosis); C5 Group - skin changes described above with signs of healed venous ulcers; Group C6 - skin lesions such as in groups C1 to C4 plus active venous ulcers. ETIOLOGICAL CLASSIFICATION INCLUDES: Ec - congenital defects of the venous system, Ep - primary pathological changes of the venous system, without identification of their causes; Es - secondary causes of venous insufficiency of known etiology (post-thrombotic, post-traumatic, etc.). There are many methods of assessing the venous system. One of the most accurate methods is an ascending phlebography which is especially useful in determining detailed anatomy of the venous system, venous patency and identification of perforans veins. The second method may be a descending phlebography useful in determining the venous reflux and morphology of venous valves. Another radiological method is varicography in which the injection of the contrast medium directly into the veins is performed. It is especially useful in the ,,mapping" of venous connections. Trans-uterine phlebography when contrast medium is injected into the bottom of the uterus and its flow is observed, is a very rare test. A similar method is used in a selective phlebography of the ovarian vein and internal iliac vein. This examination is performed when there is a suspicion of connections between varicose veins of the inferior extremities and the pelvis, in case of the occluded iliac and femoral veins. However these tests are highly invasive, causing a lot of discomfort and are connected with numerous complications, particularly the development of venous thromboembolism. An invasive study but not exposing to the emission of ionizing radiation, is a measurement of the marching pressure (known also as ambulatory venous pressure - AVP). Ultrasound Doppler is the "gold standard" in the diagnosis of venous system. Color Doppler technique is irreplaceable due to its non-invasiveness, availability constantly improving of the ultrasound machines and is the method of choice in pregnancy Unfortunately clinical correlation of Doppler ultrasound and thrombosis is bad. Invasive methods, which include various types of phlebographies, have been reserved only for cases of very high diagnostic doubt.

In many western countries endovenous thermal ablation techniques have largely replaced classical surgery for the treatment of saphenous varicose veins as they are more effective and patient friendly. Because these treatments can be performed under local tumescent anaesthesia, patients can mobilize immediately after the procedure. A new method of thermal ablation is endovenous steam ablation, which is a fast and easy procedure. Steam ablation may cause less pain than laser ablation and it is also cheaper and more flexible than segmental radiofrequency ablation.

Recurrent varicose veins (RVV) occur in 13% to 65% of patients following treatment, and remain a debilitating and costly problem. RVV were initially thought largely to be due to inadequate intervention, however, more recently neovascularization and other factors have been implicated. This review aims to provide an overview of the current understanding of the etiology and pathogenesis of RVV.A systematic search of the PubMed database was performed using the search terms including "recurrent," "varicose veins," and "neovascularization."Three types of RVV have been reported, namely residual veins, true RVV, and new varicose veins, although the definitions varied between studies. RVV are attributable to causes including inadequate treatment, disease progression, and neovascularization. Using duplex ultrasonography, neovascularization has been observed in 25% to 94% of RVV. These new vessels appear in various size, number, and tortuosity, and they reconnect previously treated diseased veins to the lower limb venous circulation. Histologically, these vessels appear primitive with incomplete vein wall formation, decreased elastic component, and lack of valves and accompanying nerves. Although the rate of RVV following open surgery and endovenous treatment appears similar, neovascularization seems less common following endothermal ablation. Other causes of RVV following endovenous treatment include recanalization and opening of collaterals.Recurrence remains poorly understood following treatment of varicose veins. Neovascularization is an established and common cause of RVV, although other factors may contribute.

Volume-rendering computed tomography (CT) without contrast medium has clearly demonstrated the 3-D mapping of the saphenous vein (SV). Contrastless volume-rendering CT was used to preoperatively evaluate the SV anatomy before coronary artery bypass grafting (CABG). This technique was useful for atypical anatomical variations, such as partial duplication of SV (Case 1) or varicose veins (Case 2). Volume-rendering CT may also help with redo CABG (to determine remaining SV) or during endoscopic SV harvesting with restricted view. Volume-rendering CT is an objective, less time-consuming modality to evaluate the SV preoperatively and may be less invasive in terms of avoiding unnecessary skin incision.

The study was aimed at determining the dynamics of saphenous veins in patients with varicophlebitis of the great saphenous vein (GSV) in a subacute period (during compression therapy) and at assessing efficacy of 4-month medicamentous protection thereof. We examined a total of 32 patients presenting with the first episode of non-embolic varicophlebitis of the great saphenous vein. The comparison group comprised 16 patients undergoing 4-month compression (degree 2) therapy alone, and the study group patients (n = 16) were subjected to compression therapy combined with a 4-month course of micronized diosmin (1 tablet twice a day). The patients were included into the groups alternately as they attended our medical facility. Duplex scanning before and after the treatment course was used to measure the following parameters: 1) the evening diameter of veins and 2) an increase in the vein's diameter measured overnight as compared to the morning measures - the orthostatic gradient. The obtained results showed that the subacute period of varicophlebitis of the GSV is accompanied and followed by an increase in the diameter of the GSV and SSV and that of their orthostatic gradient, caused by imparted tonicity and viscoelastic properties. Compression therapy alone in the subacute period of varicophlebitis does not provide complete safety of saphenous veins from secondary lesions. Compression therapy combined with a 4-month-long course of taking micronized diosmin increases the efficacy of treatment.

Varicose veins (VVs) are a common venous disease of the lower extremity characterized by incompetent valves, venous reflux, and dilated and tortuous veins. If untreated, VVs could lead to venous thrombosis, thrombophlebitis and chronic venous leg ulcers. Various genetic, hormonal and environmental factors may lead to structural changes in the vein valves and make them incompetent, leading to venous reflux, increased venous pressure and vein wall dilation. Prolonged increases in venous pressure and vein wall tension are thought to increase the expression/activity of matrix metalloproteinases (MMPs). Members of the MMPs family include collagenases, gelatinases, stromelysins, matrilysins, membrane- type MMPs and others. MMPs are known to degrade various components of the extracellular matrix (ECM). MMPs may also affect the endothelium and vascular smooth muscle, causing changes in the vein relaxation and contraction mechanisms. Endothelial cell injury also triggers leukocyte infiltration, activation and inflammation, which lead to further vein wall damage. The vein wall dilation and valve dysfunction, and the MMP activation and superimposed inflammation and fibrosis would lead to progressive venous dilation and VVs formation. Surgical ablation is an effective treatment for VVs, but may be associated with high recurrence rate, and other less invasive approaches that target the cause of the disease are needed. MMP inhibitors including endogenous tissue inhibitors (TIMPs) and pharmacological inhibitors such as zinc chelators, doxycycline, batimastat and marimastat, have been used as diagnostic and therapeutic tools in cancer, autoimmune and cardiovascular disease. However, MMP inhibitors may have side effects especially on the musculoskeletal system. With the advent of new genetic and pharmacological tools, specific MMP inhibitors with fewer undesirable effects could be useful to retard the progression and prevent the recurrence of VVs.