Reply to: Saphenous sparing laser modern options (comment to Gianesini et al., Veins and Lymphatics 2013;2:e21 and Veins and Lymphatics 2015;4:5246)

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2 Pathophysiology of Reflux

Abstract Physiological Venous Hemodynamics Physics Laws Governing Flow A review of the physical laws governing fluid motion is required to understand reflux pathophysiology. Venous blood flows not just because of a pressure gradient, as is commonly believed, but because of an energy gradient, in which pressure is only a single determinant. In accordance with the thermodynamics zero principle, there will be no energy exchange between systems presenting with the same energy values: no venous flow will occur. In accordance with the thermodynamics second principle, energy exchange will occur from a system presenting higher energy values to one at a lower energy state: venous flow will occur. Considering that reflux, like every physiological flow, needs an energy gradient to be generated, a simple but highly selective and reasoned therapeutic action against the escape, and in favor of the reentry, points will lead to a conservative but effective venous drainage restoration

Spontaneous thrombosis of primary external jugular veins aneurysms

External jugular vein (EJV) aneurysms represent a rare condition whose origin, evolution and consequent best therapeutic options still need further investigations. We present herein two peculiar clinical cases. In the first one, an EJV aneurysm developed around a malformed valve which embedded a spontaneous thrombosis. Transverse cutaneous nerve compression by the aneurysmatic mass was identified. In the second case, a recurring thrombosed EJV aneu - rysm was found pinched among the platysma muscle and the superficial layer of the cervical fascia. A pertinent literature review is also presented in order to interpret the findings herein never previously described

Short endovenous laser ablation of the great saphenous vein in a modified CHIVA strategy

Mini-invasiveness, ease of use and execution speed represent the reasons for endovenous laser ablation success. Nevertheless, the strategic choice remains the ablation of the saphenous trunk. Hemodynamic correction (CHIVA) represents an option, based on a saphenous-sparing therapeutic strategy. We tested the feasibility of a modified CHIVA strategy by means of endovenous lasers (EL) shrinkage of segmental great saphenous vein (GSV) tracts, in networks characterized by sapheno-femoral incompetence and re-entry perforators focused on the GSV. We report the follow up of the first 2 chronic venous disease [C1,2,3sEpAsPr1,2,3, venous clinical severity score (VCSS) 8 and 9 respectively] treated cases. At 1-year follow up both patients were C1,2,3sEpAsPr1,2,3 and the VCSS were 1 and 2 respectively. The non-treated GSV tracts maintained their patency. ELs were herein used within a saphenous-sparing therapeutic plan, thanks to an accurate pre-operative hemodynamic assessment, which allowed the shrinkage of only the first saphenous trunk tract only. Proper technical and hemodynamic considerations are discussed

Elastic stockings effect on leg volume variability in healthy workers under prolonged gravitational gradient exposure

The aim of this study was to determine the elastic stockings effect on healthy workers (HW) who are exposed to a prolonged hydrostatic pressure overload for professional reasons. The cohort was composed by 20 HW who voluntarily underwent a water plethysmography test before and after eight hour of standing up in an operating room, wearing elastic stockings. After 8 h of gravity exposure, we demonstrated the absence of leg volume increase in case of elastic stockings use. In the morning measurement we found that the lower limb volume was 1967.5 mL±224, while in the evening it was 1962.5 mL±227 (P<0.0828). The decreased volume is significantly correlated with the time that was spent under gravity forces for working purpose wearing elastic stockings (R2=0.99, P<0.0001). Our experiment demonstrates that elastic stockings may effectively counteract the increased leg volume over time in workers who are exposed to prolonged gravitational gradient. Further longitudinal studies are needed to determine if the above effect could correct one of the major risk factors for the development of chronic venous insufficiency

Histologic and sonographic features of holmium laser in the treatment of chronic venous disease

A new holmium laser (HOL) has been introduced to the market. The device is able to reduce the great saphenous vein (GSV) caliber in a tumescence-free procedure, favoring an effective sclerotherapy of large vessels. Aim of the present investigation is to provide the first in vivo data about the effect of HOL on GSV histology

Laser-assisted strategy for reflux abolition in a modified CHIVA approach

The aim of this study was to assess feasibility and efficacy of an endovenous laser (EL) assisted saphenous-sparing strategy in chronic venous disease (CVD). Fourteen CVD patients (C2,3,4s Ep As Pr1,2,3) underwent a saphenofemoral junction (SFJ) treatment by EL just from below the superficial epigastric vein downward for a limited tract, together with a flush ligation of the incompetent tributaries of the great saphenous vein (GSV) along the leg. The following GSV parameters were assessed 15 cm below the SFJ: reflux time, caliber, peak systolic velocity (PSV), end diastolic velocity (EDV), resistance index (RI). Venous clinical severity score and the Clinical, Etiological, Anatomical, and Pathophysio logical (CEAP) classification clinical classes were assessed. At 1 year follow up 3 cases were considered failures because of a GSV thrombosis, even if they presented a GSV recanalization with a laminar flow within at the 2 years follow-up. Eleven procedures succeeded because neither minor nor major peri-procedural complications were reported, apart 2 cases of self-healing bruising. In these last 11 cases the procedure led to a GSV reflux suppression (from 3.1±0.4 s to a retrograde laminar draining flow), to a GSV caliber reduction (from 9.4±0.5 to 3.1±0.2 cm, P<0.001), to a PSV reduction (from 50.2±4.6 to 18.4±3.5 cm/s, P<0.001), to a RI reduction (from 0.9±0.2 to 0.51±0.2, P<0.005) and to an oscillatory flow suppression (EDV from -8.9±1.6 to 6.2±2.3 cm/s, P<0.001). Both CEAP and venous clinical severity score improved from 3 to 1 (P<0.001) and from 7±2 to 2±1 (P<0.05), respectively. The GSV flow reappeared below the shrunk tract draining into the re-entry perforator. Sapheno-femoral reflux suppression can be obtained by just a GSV segmental closure. An almost 80% of success rate of the present investigation paves the way for an even wider diffusion of endovenous techniques, moreover erasing the surgical requirements for those who would like to perform a saphenoussparing strategy. In this way new devices could be used inside equally innovative strategies

Assessment of lower limbs edema in healthy workers who are exposed to long-term gravity

The aim of this study is to establish changes in leg volumes in healthy subjects (HS) after prolonged standing and prolonged lying. The study was carried out on two HS groups: the group A (20 subjects) included physicians and nurses who underwent a water plethysmography test, before and after eight hours of standing still in the operating room. The group B (20 subjects) included volunteers who were assessed before and after 10 h of supine resting. Group A: baseline leg volume was 1857.5 mL±196.9 on the right and 1850 mL±194.7 on the left limb. After eight hours of hydrostatic pressure action the two lower limbs volume was significantly increased to 1945 mL±209.6, and to 1940 mL±216.2, respectively (P<0.0001). The increased volume is significantly correlated with time (R2=0.95, P<0.0001). Group B: baseline leg volume was 1875 mL±175.1 on the right, and 1862.5 mL±166.9 on the left limb. After ten hours of resting supine the volume was 1770 mL±195.6, and to 1757.5 mL±194.2, respectively (P<0.0001). The decreased volume is significantly but inverted correlated with time (R2=−0.98, P<0.0001). This study demonstrates how the hydrostatic pressure is a main determinant for fluid accumulation in the lower extremity. To counteract the gravitational gradient becomes the mandatory prophylactic approach for healthy individuals who are exposed to an increased chronic venous disease risk

Randomized controlled trial on occupational graduated compression clinical and cost-effectiveness

Background: Subjects exposed to occupational standing are at risk of developing chronic venous disease. Graduated compression stockings (GCS) counteract venous hypertension. Aim of the present investigation was to assess GCS clinical and cost effectiveness in prolonged standing up workers. Methods: Randomized controlled trial involving 75 healthy healthcare professionals working in 6 hours standing up shifts without or with GCS (group A and B, respectively). Outcome measures were performed before and after the shift, at baseline (T0), at 1 (T1), 6 (T6) and 12 (T12) months and included lower limb volume, air plethysmography (APG), quality of life, and dedicated cost-effectiveness questionnaires. Results: Seventy-two subjects completed the data collection. Leg volume increased in group A and decreased in B at all assessment points (T0, 1, 6, 12) (P&lt;0.0001). Venous filling index did not change within the 12 months, but, after every shift, its value was lower in B compared to A (P&lt;0.0001). At 12 months, VVSymQ worsened in A and improved in B (P&lt;0.0001) and CIVIQ significantly worsened in A (P&lt;0.0001), while in B it significantly improved (P&lt;0.0001). Perceived disability was higher in A at 12 months (P&lt;0.001) and the cost calculation revealed a saving of 1510 euro per year in B. Conclusions: GCS counteracted occupational oedema and positively influenced venous filling index, while improving vein specific quality of life measurements in addition to cost savings

A specifically designed aquatic exercise protocol to reduce chronic lower limb edema

Objective Despite the fact that muscle pump activation is known to positively impact chronic lower limb edema, objective measurements of standardized exercises for venous-lymphatic rehab are lacking. The aim of this investigation is to determine the effectiveness of an addressed physical activity exploiting the advantages of an aquatic environment.Material and methods Thirty-two lower limbs of 16 patients affected by bilateral chronic leg swelling were included (12 females, 4 males). All the patients underwent a protocol of five sessions of physical exercises specifically conceived inside a pool. Volumetry, subcutaneous thickness, ankle range of motion and symptomatology were assessed as outcome measures.Results One week after the end of the protocol, the average reduction in lower limb volume was 303.1369.72ml (p=0.00002) and 334.38 +/- 62.50ml (p=0.000003) in the right and left legs, respectively. Ankle range of motion and feeling of heaviness significantly improved.Conclusion A specifically designed aquatic protocol is able to positively impact chronic leg swelling offering a first line rehab for this medical condition