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FIFTY
per cent of women over 40 have problems with varicose or thread veins and
if you are a secretary or PA, your job might be making the problem worse,
according to Philip Bull, a consultant surgeon.
"The cause of varicose veins is not known," he explains, "but the hereditary factor is thought to be the main one. If your parents had them, you are 60 per cent likely to suffer. Immobility, lack of exercise and obesity exacerbates the condition which is much more common among women than men."
This is bad news if your job requires you to stand or sit behind a desk for long periods every day. Varicose veins are abnormal, dilated blood vessels caused by a weakening in the vessel wall that allows blood to flow the wrong way. The symptoms range from a feeling of heaviness and a dull ache to unsightly lumps, swelling, itchiness and skin discolouration. Thread veins, which appear like a spider's web of red lines, especially around the knees, can be covered up by foundation or thick tights. Varicose veins often require surgical intervention.
The conventional operative procedure, vein stripping, requires a general or spinal anaesthetic. An incision of 3-4cm is made in the groin or behind the knee to find the guilty vein. Through ultrasound, the route is tracked and incisions made along the leg. The vein is then tied at the points where its branches meet the main vein, so it effectively dies. Each section is then removed through the incisions. Patients typically need two weeks off work and a full recovery can take some months. Scarring can be a problem.
Now, however, there is a less invasive procedure, more suited to a busy lifestyle. EndoVenous Laser Treatment (EVLT) was developed in America and approved for use in the NHS by the National Institute for Clinical Excellence this year.
EVLT involves inserting a laser head into a small incision via a guide wire above or below the knee at the closest point to the vein. The guide wire is removed leaving the laser head in place. The head is then slowly withdrawn, flashing once a second to kill the vein through thermal injury. The procedure is carried out under local anaesthetic and takes about 20 minutes per leg.
Philip Bull believes that the new procedure is better for patients. "After EVLT the vein becomes hard to the touch and the patient may experience some redness and tenderness for some weeks, but it is not painful. The patient can walk around, travel and resume normal activities after only a two-hour stay in hospital to ensure the local anaesthetic has been absorbed." He advises patients to wear compression stockings for four to six weeks after surgery.
The procedure won't suit everybody. About 10 per cent will not benefit if they have had prior surgery for the same problem vein or suffer from thrombosis.
One person who successfully underwent the therapy, however, was Helen Cliffin, 34. She had the treatment when she became increasingly aware that her varicose veins were affecting her confidence and, because she was finding them painful, her day-to-day activity.
Helen's family has a history of varicose veins but she didn't worry about it until she became pregnant at 29 and her veins worsened significantly. She ignored them as she was so busy. When she was pregnant again at 32, her legs felt constantly tired and heavy. After the birth of her second child, she became embarrassed about her legs and stopped wearing skirts. She was advised to take regular walks and keep her legs elevated but found this did not help. She sought surgery and was relieved to find it unnecessary.
Her EVLT treatment involved two 40-minute sessions. "There was no pain, and it was easy and quick," she says. Helen had her treatment at the Private Patients Services clinic in London. A consultation costs £150 and the therapy from £1,200.
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What's New in ACS Surgery
The Evolution of Varicose Vein Treatment
from ACS
Surgery: Principles & Practice 
- William H. Pearce, MD, FACS (Posted 09/09/2003)
Today, the common clinical
problem of varicose veins can be addressed using a variety of techniques.
Treatments range from the standard surgical therapy of high ligation and stripping
of the greater saphenous and tributaries to sclerotherapy, laser vein ablation,
and vein closure devices. As the technique has evolved over time, microphlebectomy
has been used to remove varicosities below the knee, and the greater saphenous
is stripped from the groin to the knee.
Ablation
The two newest technologies--laser vein ablation and radiofrequency vein ablation--have
challenged traditional surgical thinking about varicose veins. Instead of
high ligation, both of these devices are placed intraluminally in close proximity
(< 2 cm) to the saphenofemoral junction. Either by heat generated from
the laser or by radiofrequency, the vein is ablated from the groin to just
above the knee. The saphenofemoral branches are left intact. Microphlebectomies
are used for the varicosities below the knee. Many studies have documented
excellent cosmetic outcomes; however, there are a few reports detailing recannalization,
arterialization, and deep vein thrombosis.
Recently, another device has become available for the treatment of varicose
veins. This device is an illuminated power phlebectomy system that identifies
the varicose veins and resects them. This technique is generally used in conjunction
with the standard high ligation and surgical stripping to the knee. Early
results are also promising.
Spider Varicosities
Sclerotherapy remains the mainstay of the treatment of spider varicosities.
However, several reports have documented its efficacy for large vein varicosities.
Similar to other vein ablation systems, the ability to eradicate all branches
at the saphenofemoral junctions is somewhat limited by this technique. Like
all of the procedures described above, sclerotherapy has advocates as well
as critics.
Limitations of Evidence
Since many of these procedures are performed for cosmetic reasons, the impetus
to conduct a randomized prospective study is limited. In addition, as a result
of successful marketing, patients are directing their care and probably would
not likely participate in such trials. When such gaps in evidence collection
become apparent, practitioners must step forward and take the lead in providing
valuable data to better assess both short-term and long-term results. Thus,
it is important for practitioners to keep accurate records of patient outcomes,
particularly when late outcome becomes important. Although the immediate result
of these new techniques may be gratifying, late recurrence must be documented.
Bibliography
Cheshire N, Elias SM, Keagy B,
et al: Powered phlebectomy (TriVex) in treatment of varicose veins. Ann Vasc
Surg 16:488, 2002 [PMID 12085123]
Merchant RF, DePalma RG, Kabnick LS: Endovascular obliteration of saphenous
reflux: a multicenter study. J Vasc Surg 35:1190, 2002 [PMID 12042730]
Min RJ, Zimmet SE, Isaacs MN, et al: Endovenous laser treatment of the incompetent
greater saphenous vein. J Vasc Interv Radiol 12:1167, 2001 [PMID 11585882]
Tisi PV, Beverley CA: Injection sclerotherapy for varicose veins. Cochrane
Database Syst Rev (1):CD001732, 2002 [PMID 11869605]
Weiss RA, Dover JS: Leg vein management: sclerotherapy, ambulatory phlebectomy,
and laser surgery. Semin Cutaneous Med Surg 21:76, 2002 [PMID 11911538]
For more information, visit
http://www.acssurgery.com
ACS
Surgery: Principles and Practice
William H. Pearce, MD, FACS , Northwestern University Feinberg School of Medicine
ACS Surgery 2003. © 2003 WebMD Inc All rights reserved.
Injection sclerotherapy for varicose veins
from Cochrane
Review Abstracts
(Posted 04/01/2004)
A substantive amendment to this systematic review was last made on 13 September
2001. Cochrane reviews are regularly checked and updated if necessary.
Background: Injection sclerotherapy for varicose veins has been used
widely since 1963, following popularisation of the technique by Fegan. The
treatment aims to obliterate the lumen of varicose veins or thread veins.
There is limited evidence regarding its efficacy.
Objectives: To determine whether sclerotherapy is effective in improving
symptoms and cosmetic appearance, and has an acceptable complication rate;
to define rates of symptomatic or cosmetic varicose vein recurrence following
sclerotherapy.
Search strategy: Publications describing randomised controlled trials
(RCTs) of injection sclerotherapy for treatment of varicose veins (excluding
comparisons with surgery) were sought through EMBASE and MEDLINE (from inception
to October 2002) and by hand-searching journals, using the search strategy
described by the Cochrane Peripheral Vascular Diseases Review Group. Bibliographies
of papers identified were examined for further RCTs. Manufacturers of sclerosants
were contacted for additional trial information.
Selection criteria: RCTs of injection sclerotherapy versus graduated
compression stockings or 'observation', or comparing different sclerosants,
doses and post-compression bandaging techniques on patients with symptomatic
and/or cosmetic varicose veins or thread veins were considered for inclusion
in the review.
Data collection and analysis: Twelve studies were included. These compared:
sodium tetradecyl sulphate (STD) versus another sclerosant; sclerosant versus
sclerosant plus local anaesthetic; Molefoam versus Sorbo pads at injection
sites; elastic compression versus conventional bandaging; short-term versus
standard bandaging; sclerotherapy versus graduated compression stockings.
Data were extracted by both authors.
Main results: One RCT comparing sclerotherapy to graduated compression
stockings in pregnancy found that sclerotherapy improved symptoms and cosmetic
appearance. Two studies comparing STD to alternative sclerosants found no
significant differences in outcome or complication rates. Adding local anaesthetic
to sclerosant reduced the pain from injection (one study) but had no other
effects. One study comparing Molefoam and Sorbo pad pressure dressings found
no difference in erythema (redness) or successful sclerosis. The degree and
duration of elastic compression had no significant effect on varicose vein
recurrence rates, cosmetic appearance or symptomatic improvement. Increased
compression prevented slipping of dressings, but also increased discomfort,
as did increased duration of compression.
Reviewers' conclusions: Evidence from RCTs suggests that the type of
sclerosant, local pressure dressing, degree and length of compression have
no significant effect on the efficacy of sclerotherapy for varicose veins.
The evidence supports the current place of sclerotherapy in modern clinical
practice, which is usually limited to treatment of recurrent varicose veins
following surgery, and thread veins. A comparison of surgery versus sclerotherapy
is needed.
Citation: Tisi PV, Beverley CA. Injection sclerotherapy for varicose
veins (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester,
UK: John Wiley & Sons, Ltd.
Cochrane Rev Abstract 2004. © 2004 The Cochrane Collaboration
Chronic Venous Insufficiency: The Effects of Health-Care Reforms on the
Cost of Treatment and Hospitalisation - an Italian Perspective
From Current
Medical Research and Opinion
(Posted 01/15/2004)
In 1993/94, reforms were made to the Italian health system in order to reduce
costs for the treatment of CVI. One of these reforms was the de-reimbursement
of phlebotropic drugs (the mainstay of treatment of CVI in Italy). By analysing
the Italian experience before, and after, 1994, we can evaluate the effect
these reforms had in terms of health-care costs. In so doing it is seen that,
although the goal of the Italian health reforms was to reduce costs, the reality
was such that the de-reimbursement of phlebotropic drugs resulted in the opposite,
namely increased costs for the treatment of CVI. Further studies are required
to confirm these preliminary results on a larger scale.
Acknowledgements
The author wishes to acknowledge the assistance of Gerald Rickard in the
preparation of this manuscript.
Reprint Address
Address for correspondence: Prof Claudio Allegra, Chief of Angiology Department,
San Giovanni Hospital, Via Sant Erasmo 14, 35184 Rome, Italy. Tel: +39 06
770 55 565; Fax: +39 06 704 93 570; email: allegraclaudio@libero.it
Varicose Vein Surgery from ACS
Surgery: Principles & Practice
(Posted 08/04/2003)
John J. Bergan, MD, FACS , Vein Institute of La Jolla, Luigi Pascarella, MD
, University of California, San Diego, School of Medicine
Duplex Scanning, Physical Exam Key to Evaluation
Discusses indications, preoperative evaluation, operative planning and technique,
surgical options, complications, alternatives to saphenous vein stripping,
and outcome evaluation.
Over the years, surgical treatises have devoted a great deal of space to clinical
examination of the patient with varicose veins. Numerous clinical tests have
been described, many of which carry the names of famous persons interested
in venous pathophysiology. This august history notwithstanding, the Trendelenburg
test, the Schwartz test, the Perthes test, and the Mahorner and Ochsner modifications
of the Trendelenburg test are, for the most part, useless in preoperative
evaluation of patients today.
There is no doubt that clinical evaluation can be improved by using handheld
Doppler devices. In our view, however, preoperative evaluation is best performed
by means of duplex scanning and physical examination. Although many cite cost
considerations as a reason for omitting duplex evaluation, we believe that
duplex scanning for venous insufficiency is in fact both simple and cost-effective.
Duplex mapping defines individual patient anatomy with considerable precision
and provides valuable information that supplements the physician's clinical
impression.
Saphenous Vein Stripping vs. Ligation
Ligation of the saphenous vein at the saphenofemoral junction has been widely
practiced in the belief that it would control gravitational reflux while preserving
the vein for subsequent arterial bypass. It is true that the saphenous vein
is largely preserved after proximal ligation; however, reflux continues and
hydrostatic forces are not controlled. Recurrent varicose veins are more frequent
after saphenous ligation than after stripping and are more common after saphenous
ligation and sclerotherapy than after saphenous stripping and sclerotherapy.
Consulting the Evidence
A prospective randomized trial comparing proximal saphenous vein ligation
and stab avulsion of varices with stripping of the thigh portion of the saphenous
vein and stab avulsion of varices showed the latter approach to be superior.
Routine saphenous vein stripping reduces the rate of varicosity recurrence
and the need for reoperation for recurrent saphenofemoral incompetence
Optimizing Management of Chronic Venous Insufficiency
Disclosures
Kenneth Murphy, MD, FSIR
Chronic venous disease of the lower extremity is a very common condition in
the United States. It is estimated that 3% to 8% of the US population has
symptomatic lower-extremity venous insufficiency and 1% of adults over the
age of 60 years have chronic ulceration. [1] The estimated total healthcare
cost of treating this disease to the US economy was approximately $1 billion
in 2002. [1] The clinical manifestations of lower extremity venous insufficiency
vary from minor cosmetically displeasing lesions to severely disabling disease.
The most common clinical manifestation of venous insufficiency in the lower
extremities is varicose veins, which are estimated to occur in 30% to 60%
of adults. The predominant risk factors associated with the development of
varicose veins include female gender, pregnancy, and increased age.
Traditionally, surgical vein stripping or ligation has been used to manage
patients with lower-extremity varicose veins. These treatments are associated
with significant pain, a prolonged recovery period, and a high rate of recurrence.
Recently, new percutaneous endovenous techniques have been introduced that
permit a minimally invasive option for the management of patients with lower-extremity
venous insufficiency. The 28th Annual Scientific Meeting of the Society of
Interventional Radiology (SIR), which convened in Salt Lake City, Utah, March
27-April 1, devoted significant emphasis to this topic, including featured
symposia, plenary session, workshop session, and a scientific session. The
featured symposia, plenary session, and workshop profiled the epidemiology,
pathophysiology, clinical patterns, and duplex ultrasound evaluation of venous
insufficiency, percutaneous techniques for the treatment of saphenous vein
reflux (radiofrequency ablation and endovenous laser ablation), prosthetic
venous valves, and practice development issues. Robert J. Min, MD, Cornell
Vascular, New York, New York, and John A. Kaufman, MD, Dotter Interventional
Institute, Portland, Oregon, moderated the symposia and plenary sessions,
respectively.
Pathophysiology and Anatomic Considerations of Lower - Extremity Venous
Insufficiency
Managing patients who have lower-extremity venous insufficiency necessitates
a thorough understanding of the venous anatomy and pathophysiology of venous
insufficiency. The lower-extremity venous anatomy is composed of a deep and
superficial system that is regulated by a calf muscle pump system. The superficial
venous system is composed of the greater and lesser saphenous veins in the
lateral (subdermic) venous system. The deep venous system includes the deep
veins of the thigh and calf. The deep venous system and superficial system
communicate via the major perforating veins, which predominate in the calf.
There are four named groups of perforator veins associated with greater saphenous
vein (GSV) reflux that are clinically relevant to the physician diagnosing
and treating venous insufficiency. They include the Hunterian (mid-upper medial
thigh), Dodd's (above medial knee), Boyd's (medial below knee), and Cockett's
veins (above ankle). The pathophysiology of venous insufficiency is most often
caused by valvular failure with resultant varicose veins. Valvular failure
results in reflux, elevated venous pressure, and dilatation in that segment.
The most common site of reflux is at the saphenofemoral junction (SFJ) with
resultant superficial varicosities. A second, less common, cause of varicosities
is valvular incompetence involving the perforator veins, which is typically
a result of high-pressure leak gradient toward the superficial venous system
with subsequent dilatation and varicose vein formation.
Clinical and Duplex Evaluation
Neil Khilnani, MD, Cornell Medical Center, New York, New York, stressed that
clinical assessment and duplex evaluation are critical to the success of any
endovenous procedure. Clinical evaluation involves compiling a detailed patient
history with targeted questions that include questions about history of pregnancy,
trauma, hypercoagulable syndromes, and prior deep venous thrombosis. Physical
examinations of the patient should be performed in the erect position with
attention to the lower-extremity, lower abdomen, and pubic region. Dr. Khilnani
stressed that the clinical exam should be supplemented by a comprehensive
duplex ultrasound evaluation. The principle objectives of the duplex evaluation
include determining the patency of the deep and superficial venous systems,
identifying and localizing reflux, and pinpointing the blood flow source to
the varicose segments. The GSV is mapped with duplex ultrasound from the level
of the SFJ to the level of the ankle. The exam is performed with the patient
standing, and with the patient's weight supported on the contralateral limb.
The leg to be evaluated is flexed, and the exam commences from the top of
the thigh to the level of the lowest varicosities and/or ankle. The saphenofemoral
junction (SFJ) is assessed for competency. Reflux is evaluated using color
and pulse wave Doppler with simultaneous augmentation of the venous segments
below the level that is being examined. In similar fashion, the lesser saphenous
vein and perforators are examined. The deep venous system is also interrogated
for any underlying deep venous thrombosis (DVT).
Percutaneous Techniques for Treatment of Saphenous Vein Reflux
There are two techniques for the percutaneous endovenous treatment of GSV
reflux. These techniques are radiofrequency ablation and laser occlusion.
Radiofrequency involves using the Closure Device (VNUS, Medical Technologies,
Sunnyvale, California), which is a US Food and Drug Administration-approved
technology that promotes venous occlusion by applying radiofrequency (RF)
thermal energy to the wall of the vein. The device consists of a 6-F or 8-F
catheter containing retractable electrodes that deliver the RF energy. A generator
delivers electrical current to the probe, which results in frictional heating
at the probe tip. The heating produces local thermal energy, which, when maintained
at 85º C, results in vessel wall damage that is characterized by protein
denaturation and collagen deposition. The device is placed in the GSV at/or
below the knee, using ultrasound guidance. Dr. Rosenblatt, Connecticut Image-Guided
Surgery, Milford, Connecticut, stressed that the device must be positioned
close (1-2 cm) to the SFJ for clinical success. The device is retracted along
the course of the GSV. The procedure can be performed in an outpatient setting
using local tumescent anesthesia, which involves infiltrating the perivenous
space with a large volume of 0.25% lidocaine. According to Dr. Rosenblatt
and other investigators at SIR 2003, conscious sedation is not generally required
for this procedure. Dr. Rosenblatt indicated that other refluxing veins identified
during the preprocedure duplex mapping can be treated with RF ablation, provided
the course is straight enough to facilitate device passage under fluoroscopic-guidance,
which is typically done through a guidewire. A recent study compared postprocedure
pain, the convalescent period, and the cost of the RF endovenous approach
with conventional surgical stripping. The study documented that the incidence
of postoperative pain, recovery time, and cost of the RF obliteration is significantly
less than conventional surgery. [2]
In the scientific session at SIR devoted to this topic, Dr. Rosenblatt [3]
described the radiographic and clinical outcomes of RF treatment of GSV reflux
in 124 patients who had symptomatic venous insufficiency. Symptomatic improvement
occurred in 97.1% of patients, and ultrasound occlusion of GSV was documented
in 95.7% of patients on a mean follow-up at 3.4 months. Complications included
mild transient paresthesias (11%) and skin burns (1.4%). Treatment failures
were retreated with success in every case. Treatment failures were associated
with a large incompetent GSV perforator, which the investigators hypothesized
may have acted as a heat-sink preventing adequate thermal ablation of the
vein wall at that level. In a second scientific presentation, Dr. Rosenblatt
[4] described RF ablation of non-greater saphenous lower extremity veins for
managing venous insufficiency. In this study, 42 patients who had non-GSV
reflux were treated with radiofrequency occlusion. Technical success was achieved
in all cases, duplex ultrasound occlusion was documented in 92.6% of cases
on follow-up, and symptomatic improvement was seen in 96% of cases. Non-greater
saphenous lower extremity veins treated included the anterior-lateral tributaries,
GSV perforators, and lesser saphenous veins.
Concurrent with the development of RF venous ablation, laser techniques have
been used with success. In 1998, the fiberoptic laser fiber was introduced
as an alternative method for using laser energy for treatment of GSV reflux.
The procedure is analogous to the radiofrequency technique and is typically
performed under ultrasound guidance after local anesthesia is administered
with tumescent anesthesia. Treatment is limited to GSVs that have diameters
of 2 mm-12 mm. The endovenous laser catheters are inserted into the GSV through
a 5 F introducer sheath, at or below the knee level. The laser tip is positioned
at approximately 1-2 cm below the SFJ, and the position of the tip is confirmed
on ultrasound. The typical diode laser energy is 810 nm (Diomed, Inc., Hanover,
Massachusetts) and/or 980 nm wavelength (Angiodynamics, Inc., Queensbury,
New York). The laser induces focal injury to the endothelium and vein wall
without significant extension into fat and tissue. Results of the endovenous
laser technique for GSVs demonstrated 99% vessel occlusion at 1-9 months follow-up.
[5] In a scientific session, Robert Min, MD, [6] described 2-year follow-up
results for management of saphenous vein reflux using this technique. In his
study, a total of 389 GSVs in 344 patients were treated with the 810 nm diode
laser. At follow-up, ultrasonography was obtained in 88 limbs, and 93% of
these were occluded at a minimum of 2 years. There were no skin burns, paresthesias
or DVTs. Dr. Min concluded that endovenous laser treatment of saphenous vein
reflux is a successful technique with a low (7%) recurrence rate and a minimum
complication rate.
After occlusion by either laser technique or radiofrequency ablation, the
patient is discharged and instructed to wear compression stockings for approximately
7 days. The patient is also instructed to continue normal daily activities,
without significant exercise during this initial recovery period. Postablation
sclerotherapy or ambulatory phlebectomy can be performed approximately 4 weeks
after the initial procedure.
Sclerotherapy of Spider Veins and Varicose Veins
Dr. Min and other presenters on this topic at SIR 2003 stressed the importance
of adjunct sclerotherapy for the treatment of spider veins and varicose veins
after GSV occlusion. These additional treatment strategies are necessary to
ensure a "successful outcome and amelioration of symptoms and cosmetic
defects," according to Dr. Min. The mainstay of such therapy is sclerotherapy.
The indications for adjunct techniques include telangiectasias, reticular
veins, and residual varicose veins. Injection sclerotherapy involves targeted
delivery of a sclerosant agent into a superficial vein, which initiates intimal
irritation and is followed by an intense inflammatory reaction and the subsequent
ingrowth of granulation tissue and fibrosis. This results in a fibrous cord-like
vein that is permanently obliterated. The sclerosant agents available include
sodium tetradecyl sulfate, polidocanol, dextrose/sodium chloride, and chromated
glycerin. Sodium tetradecyl sulfate and polidocanol are preferred agents;
however, polidocanol is currently not approved for use in the United States.
The volume injected depends on the target; typically, 0.2 to 0.5 mL is used
for reticular veins and 0.1 to 0.4 mL is used for telangiectasias. The injection
is typically performed with the patient in the horizontal position, which
reduces the venous pressure and allows for complete injection into an "empty"
vein. The sclerosant injection is usually painless; typically, a compression
bandage or stocking is applied postinjection for a period of 3 days to several
weeks. Dr. Min and other researchers stressed the importance of diligent follow-up
at approximately 2 weeks to evaluate patients for optimal results, as well
as for areas of "trapped" blood. Areas of trapped blood can be associated
with focal tenderness and may result in pigmented areas that are cosmetically
displeasing. A simple puncture with a 25 G or slightly larger gauge needle
facilitates aspiration of trapped blood.
An additional adjunct technique is ambulatory phlebectomy, which is a minor
surgical procedure that involves careful dissection, isolation, and ligation
of superficial and reticular veins.
Future Venous Therapeutic Alternatives
Dusan Pavcnik, MD, Dotter Institute, Portland, Oregon, outlined some of the
exciting developments in the technology of prosthetic venous valves. One such
valve is the bioprosthetic, bicuspid valve, which is composed of a square
stent and small intestinal submucosal covering. This prosthetic valve has
been placed successfully in a sheep model. A manufactured, percutaneous, nonimmunogenic
venous valve is currently under development. This prototype employs a square
stent as the foundation supporting a prosthetic valve biomaterial. These valves
are potentially available in various diameters and may not require anticoagulation.
Further development and clinical trials to explore the efficacy of these technologies
are underway.
Ramping Up Your Venous Insufficiency Practice
Gerald Niedzwiecki, MD, Meese Countryside Hospital, Safety Harbor, Florida,
spotlighted the elements of establishing a successful venous management practice.
A dedicated physician and staff with appropriate training are mandatory. In
addition, most chronic venous insufficiency work is best managed in an outpatient
setting. Success is dependent on the state-of-the-art equipment, nursing,
ancillary staff, and diligent patient follow-up. Dr. Niedzwiecki stressed
that the management of venous insufficiency is an evolving field that interventionalists
should embrace as part of their mission of offering customers a comprehensive
program of quality patient care.
References
1. Callam MJ. Epidemiology of varicose veins. Br J Surg. 1994;81:167-173.
Abstract
2. Rautio T, Ohinmaa A, Perala J, et al. Endovenous obliteration versus conventional
stripping operation in the treatment of primary varicose veins: a randomized
controlled trial with comparison of the costs. J Vasc Surg. 2002;35:958-965.
Abstract
3. Rosenblatt M, Burdge C, Gandhi RT. Treatment of venous insufficiency due
to greater saphenous vein reflux with endovenous radiofrequency ablation.
J Vasc Interv Radiol. 2003;14:S35.
4. Rosenblatt M, Burdge C, Gandhi RT. Endovenous radiofrequency ablation of
non-greater saphenous lower extremity veins to treat venous insufficiency.
J Vasc Interv Radiol. 2003;14:S36.
5. Min R, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser treatment of
the incompetent greater saphenous vein. J Vasc Interv Radiol. 2001;12:1167-1171.
Abstract
6. Min RM, Khilmani N. Endovascular laser treatment of saphenous vein reflux.
Two year follow-up results. J Vasc Interv Radiol. 2003;14:S35.
May 11, 2004 — Risk factors for venous thromboembolism (VTE) in patients
hospitalized for acute medical illness include infection, age older than 75
years, cancer, and history of VTE, according to the results of a randomized
trial published in the May 10 issue of the Archives of Internal Medicine
"There is limited information about risk factors for venous thromboembolism
(VTE) in acutely ill hospitalized general medical patients," write Raza
Alikham, BSc, MBBS, and colleagues from Guy's, King's and St. Thomas' School
of Medicine in London, England. "The rationale for providing thromboprophylaxis
is that prevention is clinically and financially beneficial compared with
treatment of a thromboembolic event once it has occurred."
In the Prophylaxis in Medical Patients with Enoxaparin (MEDENOX) trial, an
international, double-masked, placebo-controlled study that enrolled 1,102
acutely ill, immobilized general medical patients, the low-molecular-weight
heparin enoxaparin sodium was effective in preventing thrombosis. To evaluate
independent risk factors for VTE, the investigators performed a new logistic
regression analysis of the MEDENOX data, looking at risks associated with
acute illness such as heart failure, respiratory failure, infection, rheumatic
disorder, and inflammatory bowel disease, and predefined factors such as chronic
heart and respiratory failure, age, previous VTE, and cancer.
Acute infectious disease, age older than 75 years, cancer, and a history of
VTE were statistically significantly associated with an increased risk of
VTE, based on primary univariate analysis. Multiple logistic regression analysis
revealed that each of these factors was independently associated with risk
of VTE.
"Our analysis extends the findings of the MEDENOX study, revealing that
certain disease and patient factors are independently related to the genesis
of VTE in acutely ill medical patients," the authors write. "These
findings allow recognition of individuals at increased risk of VTE and will
contribute to the formulation of an evidence-based risk assessment model for
thromboprophylaxis in hospitalized general medical patients."
Aventis Pharmaceuticals supported this analysis. The authors report no relevant
financial interest in this article. Arch Intern Med. 2004;164:963-968
