Cyanoacrylate Embolization: A Novelty in the Field of Varicose Veins Surgery
Abstract
In the past 2 decades, varicose veins surgery went through a great turbulence and various innovations. A number of new techniques have been introduced with a goal to increase the success rate, reduce the periprocedural complications and, overall, to improve patients' quality of life. The latest of them, named cyanoacrylate embolization (CAE) technique, threatens to shake the glory of the currently well-established endovenous methods. We have analyzed all previous studies by searching MEDLINE base using PubMed. Although the idea of using n-butyl cyanoacrylate (NBCA) glue in medical purposes was not new, the very first in vivo and animal experiments using NBCA for vein closure were conducted just at the beginning of this millennium. The results of these studies gave warranty to begin with the first interventions in humans. Early studies reported very high success rates of more than 90%, with the longest follow-up period of 36 months. There were no major adverse events reported, while the minor ones-mostly phlebitic reactions-were defined as mild to moderate. The newest head-to-head studies showed that CAE is a noninferior technique to other endovenous methods, with higher occlusion rates and fewer adverse events. Short procedure time and no need for tumescent anesthesia or compressive stockings reduce patients' discomfort to the minimum and definitely seem to be a step forward answering the modern "walk in-walk out surgery" demands. As an easily handling technique, CAE undoubtedly pierces its path to the top of varicose veins surgery but more head-to-head clinical trials with longer follow-up periods are necessary to obtain a plain picture.
In the past 2 decades, varicose veins surgery went through a great turbulence and various innovations. A number of new techniques have been introduced with a goal to increase the success rate, reduce the periprocedural complications and, overall, to improve patients' quality of life. The latest of them, named cyanoacrylate embolization (CAE) technique, threatens to shake the glory of the currently well-established endovenous methods. We have analyzed all previous studies by searching MEDLINE base using PubMed. Although the idea of using n-butyl cyanoacrylate (NBCA) glue in medical purposes was not new, the very first in vivo and animal experiments using NBCA for vein closure were conducted just at the beginning of this millennium. The results of these studies gave warranty to begin with the first interventions in humans. Early studies reported very high success rates of more than 90%, with the longest follow-up period of 36 months. There were no major adverse events reported, while the minor ones-mostly phlebitic reactions-were defined as mild to moderate. The newest head-to-head studies showed that CAE is a noninferior technique to other endovenous methods, with higher occlusion rates and fewer adverse events. Short procedure time and no need for tumescent anesthesia or compressive stockings reduce patients' discomfort to the minimum and definitely seem to be a step forward answering the modern "walk in-walk out surgery" demands. As an easily handling technique, CAE undoubtedly pierces its path to the top of varicose veins surgery but more head-to-head clinical trials with longer follow-up periods are necessary to obtain a plain picture.
The Significance of Pain in Chronic Venous Disease and its Medical Treatment
Abstract
Chronic venous disease (CVeD) is a highly prevalent condition in the general population, and it has a significant impact on quality of life. While it is usually manifested by obvious signs, such as varicose veins and venous ulcers, other symptoms of the disease are less specific. Among the other symptoms, which include heaviness, swelling, muscle cramps and restless legs, pain is the symptom that most frequently compels CVeD patients to seek medical aid. However, there is a substantial discrepancy between pain severity and clinically detectable signs of CVeD, questioned by several opposing studies. Further evaluation is needed to clarify this subject, and to analyse whether pain development predicts objective CVeD progression. General management of CVeD starts with advising lifestyle changes, such as lowering body mass index and treating comorbidities. However, the mainstay of treatment is compression therapy, with the additional use of pharmacological substances. Venoactive drugs proved to be the drugs of choice for symptom alleviation and slowing the progression of CVeD, with micronized purified flavonoid fraction being the most effective one. Interventional therapy is reserved for advanced stages of the disease.
Keywords:
Chronic venous disease; hypertension; pain; spinal cord; treatment; venoactive drugs.
Chronic venous disease (CVeD) is a highly prevalent condition in the general population, and it has a significant impact on quality of life. While it is usually manifested by obvious signs, such as varicose veins and venous ulcers, other symptoms of the disease are less specific. Among the other symptoms, which include heaviness, swelling, muscle cramps and restless legs, pain is the symptom that most frequently compels CVeD patients to seek medical aid. However, there is a substantial discrepancy between pain severity and clinically detectable signs of CVeD, questioned by several opposing studies. Further evaluation is needed to clarify this subject, and to analyse whether pain development predicts objective CVeD progression. General management of CVeD starts with advising lifestyle changes, such as lowering body mass index and treating comorbidities. However, the mainstay of treatment is compression therapy, with the additional use of pharmacological substances. Venoactive drugs proved to be the drugs of choice for symptom alleviation and slowing the progression of CVeD, with micronized purified flavonoid fraction being the most effective one. Interventional therapy is reserved for advanced stages of the disease.
Keywords:
Chronic venous disease; hypertension; pain; spinal cord; treatment; venoactive drugs.
Negative-pressure wound therapy for deep groin vascular infections
Abstract
Introduction:
Infection of synthetic graft in the groin is a rare but devastating complication. When it occurs, several possibilities of treatment are available. Extra-anatomic reconstruction and in-situ implantation of new, infection resistant grafts are associated with high mortality and morbidity. Therefore, more conservative approach is needed in some cases. Negative-pressure wound therapy is one of the options in treating such patients.
Objective:
The aim of this study was to assess the outcome for deep groin vascular graft infection treated with negative-pressure wound therapy.
Methods:
Seventeen patients (19 wounds), treated for Szilagyi grade III groin infections between October 2011 and June 2014, were enrolled into this observational study.
Results:
Majority of the wounds (11/19) were healed by secondary intention, and the rest of the wounds (8/19) were healed by primary intention after initial negative-pressure wound therapy and graft substitution with silver-coated prostheses or autologous artery/vein implantation. No early mortality was observed. Minor bleeding was observed in one patient. Reinfection was noted in three wounds. Only one graft occlusion was noted. Late mortality was observed in three patients.
Conclusion:
Negative-pressure wound therapy seems to be safe for groin vascular graft infections and comfortable for both patient and surgeon. However, the rate of persistent infection is high. This technique, in our opinion, can be used as a “bridge” from initial wound debridement to definitive wound management, when good local conditions are achieved for graft substitution, either with new synthetic graft with antimicrobial properties or autologous artery/vein. In selected cases of deep groin infections it can be used as the only therapeutic approach in wound treatment.
Introduction:
Infection of synthetic graft in the groin is a rare but devastating complication. When it occurs, several possibilities of treatment are available. Extra-anatomic reconstruction and in-situ implantation of new, infection resistant grafts are associated with high mortality and morbidity. Therefore, more conservative approach is needed in some cases. Negative-pressure wound therapy is one of the options in treating such patients.
Objective:
The aim of this study was to assess the outcome for deep groin vascular graft infection treated with negative-pressure wound therapy.
Methods:
Seventeen patients (19 wounds), treated for Szilagyi grade III groin infections between October 2011 and June 2014, were enrolled into this observational study.
Results:
Majority of the wounds (11/19) were healed by secondary intention, and the rest of the wounds (8/19) were healed by primary intention after initial negative-pressure wound therapy and graft substitution with silver-coated prostheses or autologous artery/vein implantation. No early mortality was observed. Minor bleeding was observed in one patient. Reinfection was noted in three wounds. Only one graft occlusion was noted. Late mortality was observed in three patients.
Conclusion:
Negative-pressure wound therapy seems to be safe for groin vascular graft infections and comfortable for both patient and surgeon. However, the rate of persistent infection is high. This technique, in our opinion, can be used as a “bridge” from initial wound debridement to definitive wound management, when good local conditions are achieved for graft substitution, either with new synthetic graft with antimicrobial properties or autologous artery/vein. In selected cases of deep groin infections it can be used as the only therapeutic approach in wound treatment.
Massive necrotizing fasciitis following bellow-knee arterial surgery - A therapeutic challenge
Abstract
Introduction:
Necrotizing fasciitis is a rare, progressive bacterial infection of superficial fascia followed by secondary subcutaneous tissue necrosis. We pressented a patient with massive fulminant lifethreatening necrotising fasciitis after bellow-knee femoro-popliteal vein bypass grafting successfully treated by antibiotics, surgical debridement and final skin reconstruction using the Tierch method.
Case report:
A 61-year-old patient was admitted to the Vascular Surgery Clinic for below-knee femoro-popliteal bypass grafting. He complained of intermittent claudication in the left leg after 50 m, ankle brachial indexes were 0.45 on the left and 1.0 on the right side. Femoropopliteal below-knee bypass grafting was done using the autologous great saphenous vein. In the very next day, initial signs of skin infection appeared including local inflammation, erythema, swelling and cellulitis restricted to saphenectomy site. These changes had rapidly spread in the following days on the deep tissue of the whole upper and lower leg, including the groin and with clinical signs of life-threatening systemic infection. Immediate surgical debridement was done followed by extensive wound packing and wide spectrum antibiotics administration for the next 33 days when final skin reconstruction by the Tierch method was performed. Interesting point is that this entire time wound swab was sterile.
Conclusion:
In the presented case immediate surgical debridement, wide spectrum antibiotics administration and consistent wound packing gave satisfactory results in this life-threatening systemic infection. Wound swab is not always a reliable indicator of the infection while clinical findings and surgeons' experience are of great significance in rapid reaction to this rare surgical complication.
Introduction:
Necrotizing fasciitis is a rare, progressive bacterial infection of superficial fascia followed by secondary subcutaneous tissue necrosis. We pressented a patient with massive fulminant lifethreatening necrotising fasciitis after bellow-knee femoro-popliteal vein bypass grafting successfully treated by antibiotics, surgical debridement and final skin reconstruction using the Tierch method.
Case report:
A 61-year-old patient was admitted to the Vascular Surgery Clinic for below-knee femoro-popliteal bypass grafting. He complained of intermittent claudication in the left leg after 50 m, ankle brachial indexes were 0.45 on the left and 1.0 on the right side. Femoropopliteal below-knee bypass grafting was done using the autologous great saphenous vein. In the very next day, initial signs of skin infection appeared including local inflammation, erythema, swelling and cellulitis restricted to saphenectomy site. These changes had rapidly spread in the following days on the deep tissue of the whole upper and lower leg, including the groin and with clinical signs of life-threatening systemic infection. Immediate surgical debridement was done followed by extensive wound packing and wide spectrum antibiotics administration for the next 33 days when final skin reconstruction by the Tierch method was performed. Interesting point is that this entire time wound swab was sterile.
Conclusion:
In the presented case immediate surgical debridement, wide spectrum antibiotics administration and consistent wound packing gave satisfactory results in this life-threatening systemic infection. Wound swab is not always a reliable indicator of the infection while clinical findings and surgeons' experience are of great significance in rapid reaction to this rare surgical complication.
Factors related to venous ulceration: a cross-sectional study
Abstract
The aim of the study was to determine the factors related to venous ulceration. Patients with venous ulceration (278 patients) were compared with 1401 patients in other categories of clinical classification of venous disease (clinical, etiologic, anatomic, and pathophysiological [CEAP]). Demographic, anthropometric, and clinical data were collected. Univariate and multivariate logistic regression analyses were used. According to multivariate analyses, risk factors for venous ulceration were age, male sex, personal history of superficial and deep venous thrombosis, diabetes, high blood pressure, skeletal or joint disease in the legs and emphysema or chronic obstructive pulmonary disease, higher body mass index and physical inactivity, parental history of ankle ulcer as well as reflux in deep and perforator veins, deep obstruction, and combination of reflux and obstruction. It seems reasonable to pay special attention to patients in whom the postulated risk factors for venous ulceration are present.
Keywords:
chronic venous disease; cross-sectional study; risk factors.
The aim of the study was to determine the factors related to venous ulceration. Patients with venous ulceration (278 patients) were compared with 1401 patients in other categories of clinical classification of venous disease (clinical, etiologic, anatomic, and pathophysiological [CEAP]). Demographic, anthropometric, and clinical data were collected. Univariate and multivariate logistic regression analyses were used. According to multivariate analyses, risk factors for venous ulceration were age, male sex, personal history of superficial and deep venous thrombosis, diabetes, high blood pressure, skeletal or joint disease in the legs and emphysema or chronic obstructive pulmonary disease, higher body mass index and physical inactivity, parental history of ankle ulcer as well as reflux in deep and perforator veins, deep obstruction, and combination of reflux and obstruction. It seems reasonable to pay special attention to patients in whom the postulated risk factors for venous ulceration are present.
Keywords:
chronic venous disease; cross-sectional study; risk factors.
Incidence and distribution of extravascular compression of extracranial venous pathway in patients with chronic cerebrospinal venous insufficiency and multiple sclerosis
Abstract
Objective:
To examine the incidence and distribution of extravascular compression of the extracranial venous pathway (the jugular and/or azygous veins) in multiple sclerosis patients with chronic cerebrospinal venous insufficiency evaluated by mulitislice computer tomographic angiography.
Methods and results:
Study group consisted of 51 consecutive patients with multiple sclerosis in whom chronic cerebrospinal venous insufficiency was diagnosed by color Doppler sonography (CDS). Mulitislice computer tomographic angiography was performed in all patients, and it revealed significant extravascular compression (>70%) of extracranial venous pathway in 26 patients (51%), while in 25 patients (49%) no significant extravascular compression was seen. Extracranial compression due to transverse processus of cervical vertebrae was seen in 23 patients, carotid bulb compression was seen in two patients, and in one case, compression presented as a thoracic outlet syndrome.
Conclusion:
Our data indicate that extravascular compression of the extracranial venous pathway is frequent in multiple sclerosis patients with chronic cerebrospinal venous insufficiency, and that it is mainly due to compression caused by transverse processus of cervical vertebrae. Further studies are needed to evaluate potential clinical implications of this phenomenon.
Keywords:
Extravascular compression; MSCT angiography; multiple sclerosis.
Objective:
To examine the incidence and distribution of extravascular compression of the extracranial venous pathway (the jugular and/or azygous veins) in multiple sclerosis patients with chronic cerebrospinal venous insufficiency evaluated by mulitislice computer tomographic angiography.
Methods and results:
Study group consisted of 51 consecutive patients with multiple sclerosis in whom chronic cerebrospinal venous insufficiency was diagnosed by color Doppler sonography (CDS). Mulitislice computer tomographic angiography was performed in all patients, and it revealed significant extravascular compression (>70%) of extracranial venous pathway in 26 patients (51%), while in 25 patients (49%) no significant extravascular compression was seen. Extracranial compression due to transverse processus of cervical vertebrae was seen in 23 patients, carotid bulb compression was seen in two patients, and in one case, compression presented as a thoracic outlet syndrome.
Conclusion:
Our data indicate that extravascular compression of the extracranial venous pathway is frequent in multiple sclerosis patients with chronic cerebrospinal venous insufficiency, and that it is mainly due to compression caused by transverse processus of cervical vertebrae. Further studies are needed to evaluate potential clinical implications of this phenomenon.
Keywords:
Extravascular compression; MSCT angiography; multiple sclerosis.
Percutaneous angioplasty of internal jugular and azygous veins in patients with chronic cerebrospinal venous insufficiency and multiple sclerosis: early and mid-term results
Abstract
Purpose:
To assess the safety of endovascular treatment of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS).
Materials and methods:
A total of 72 patients with CCSVI and MS (44 with relapsing remitting--RR, 4 with primary progressive, 20 with secondary progressive and 4 with benign MS) underwent percutaneous angioplasty. Outcome measures were colour Doppler ultrasonography parameters, gradient pressure at the vein abnormality level, postoperative complications, re-stenosis, disease severity scored by means of Expanded Disability Status Scale (EDSS) and patients' assumption of disease status. Controls were done after one month on 72 patients, six months on 69 patients and one year on 61 patients, respectively (the average follow-up was 11 months).
Results:
There were no postoperative complications. Colour Doppler ultrasonography showed significant improvement in cross-sectional area parameters (P < 0.05) and significant decrease in confluence velocity values (P < 0.05). Postoperative gradient pressure decreased, in internal jugular vein (IJV) significantly (P < 0.05). Re-stenosis appeared in 5.3% of patients. EDSS score was significantly improved (P < 0.01) and about half of patients reported significant or mild improvement in disease status and none of them worsening of symptoms.
Conclusion:
Endovascular treatment of the IJV and azygous veins in patients with CCSVI and MS is a safe procedure with no post-procedural complications followed by significant improvement of IJV flow haemodynamic parameters and decrease in the EDSS score. Whether CCSVI percutaneous treatment might affect clinical improvement in patients suffering from MS is yet to be seen after completion of major multicentric clinical trials, still it seems like that this procedure is not negligible.
Keywords:
chronic cerebrospinal venous insufficiency; internal jugular vein; multiple sclerosis; percutaneous angioplasty.
Purpose:
To assess the safety of endovascular treatment of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS).
Materials and methods:
A total of 72 patients with CCSVI and MS (44 with relapsing remitting--RR, 4 with primary progressive, 20 with secondary progressive and 4 with benign MS) underwent percutaneous angioplasty. Outcome measures were colour Doppler ultrasonography parameters, gradient pressure at the vein abnormality level, postoperative complications, re-stenosis, disease severity scored by means of Expanded Disability Status Scale (EDSS) and patients' assumption of disease status. Controls were done after one month on 72 patients, six months on 69 patients and one year on 61 patients, respectively (the average follow-up was 11 months).
Results:
There were no postoperative complications. Colour Doppler ultrasonography showed significant improvement in cross-sectional area parameters (P < 0.05) and significant decrease in confluence velocity values (P < 0.05). Postoperative gradient pressure decreased, in internal jugular vein (IJV) significantly (P < 0.05). Re-stenosis appeared in 5.3% of patients. EDSS score was significantly improved (P < 0.01) and about half of patients reported significant or mild improvement in disease status and none of them worsening of symptoms.
Conclusion:
Endovascular treatment of the IJV and azygous veins in patients with CCSVI and MS is a safe procedure with no post-procedural complications followed by significant improvement of IJV flow haemodynamic parameters and decrease in the EDSS score. Whether CCSVI percutaneous treatment might affect clinical improvement in patients suffering from MS is yet to be seen after completion of major multicentric clinical trials, still it seems like that this procedure is not negligible.
Keywords:
chronic cerebrospinal venous insufficiency; internal jugular vein; multiple sclerosis; percutaneous angioplasty.
Management of chronic venous disease by general practitioners in Serbia: a cross-sectional study
Abstract
Background:
Chronic venous disease (CVD) is one of the most prevalent medical conditions in the general population worldwide.
Objective:
To evaluate the management of CVD provided by general practitioners (GPs).
Methods and materials:
The 2-center cross-sectional study comprised 2284 patients with CVD diagnosed and treated by GPs. Demographic and clinical data were obtained by physical examinations and standardized interviews.
Results:
Patients were counseled about different types of therapy; lifestyle advice was recommended to 88.8%, venoactive drugs to 90.8%, compression therapy to 44.0% of patients, anticoagulants to 16.7%, surgical treatment to 8.3%, and other types of therapy were recommended to 7.8% of patients. The most common types of treatment were dual and triple therapies recommended to 39.5% and 33.1%, respectively. The number of therapies recommended to patients increased with CVD progression. Treatment was not recommended to < 1% of patients. Only 8.4% of patients were referred to a vein specialist.
Conclusions:
Although GPs had undergone special medical training about CVD before they were included in the study, some patients did not receive complete management of their condition. Continuous training of GPs and clinical guidelines for the management of CVD may help GPs to make adequate decisions.
Background:
Chronic venous disease (CVD) is one of the most prevalent medical conditions in the general population worldwide.
Objective:
To evaluate the management of CVD provided by general practitioners (GPs).
Methods and materials:
The 2-center cross-sectional study comprised 2284 patients with CVD diagnosed and treated by GPs. Demographic and clinical data were obtained by physical examinations and standardized interviews.
Results:
Patients were counseled about different types of therapy; lifestyle advice was recommended to 88.8%, venoactive drugs to 90.8%, compression therapy to 44.0% of patients, anticoagulants to 16.7%, surgical treatment to 8.3%, and other types of therapy were recommended to 7.8% of patients. The most common types of treatment were dual and triple therapies recommended to 39.5% and 33.1%, respectively. The number of therapies recommended to patients increased with CVD progression. Treatment was not recommended to < 1% of patients. Only 8.4% of patients were referred to a vein specialist.
Conclusions:
Although GPs had undergone special medical training about CVD before they were included in the study, some patients did not receive complete management of their condition. Continuous training of GPs and clinical guidelines for the management of CVD may help GPs to make adequate decisions.
A case of extrinsic chronic cerebrospinal venous insufficiency in a patient with multiple sclerosis
Abstract
We aim to present a very rare case of chronic cerebrospinal venous insufficiency due to both brachiocephalic vein obstruction by aberrant right subclavian artery and internal jugular vein distal compression by first cervical vertebra transverse process, demonstrated by multislice computerized tomography in a patient with multiple sclerosis.
We aim to present a very rare case of chronic cerebrospinal venous insufficiency due to both brachiocephalic vein obstruction by aberrant right subclavian artery and internal jugular vein distal compression by first cervical vertebra transverse process, demonstrated by multislice computerized tomography in a patient with multiple sclerosis.