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Supplemental material, sj-pdf-1-phl-10.1177_0268355520936420 for Reducing the risk of venous thromboembolism following superficial endovenous treatment: A UK and Republic of Ireland consensus study by Nikesh Dattani, Joseph Shalhoub, Sandip Nandhra, Tristan Lane, Abdulsalam Abu-Own, Ahmed Elbasty, Aled Jones, Andrew Duncan, Andrew Garnham, Ankur Thapar, Anna Murray, Anzar Baig, Athanasios Saratzis, Atif Sharif, Bella Huasen, Claire Dawkins, Craig Nesbitt, Daniel Carradice, Darren Morrow, David Bosanquet, Eamon Kavanagh, Faisal Shaikh, Gergely Gosi, Graeme Ambler, Gregory Fulton, Gurdas Singh, Hannah Travers, Hayley Moore, James Olivier, Louise Hitchman, Martin O’Donohoe, Matthew Popplewell, Mekki Medani, Michael Jenkins, Mingzheng A Goh, Oliver Lyons, Olivia McBride, Paul Moxey, Philip Stather, Phillipa Burns, Rachel Forsythe, Rachel Sam, Ranjeet Brar, Robert Brightwell, Ruth Benson, Sarah Onida, Sharath Paravastu, Simon Lambracos, Srinivasa R Vallabhaneni, Stewart Walsh, Tasleem Aktar, Tony Moloney, Zola Mzimba and Isaac Nyamekye in Phlebology

Supplemental material, sj-pdf-1-phl-10.1177_0268355520968640 for A randomised controlled trial of neuromuscular stimulation in non-operative venous disease improves clinical and symptomatic status by Raveena Ravikumar, Tristan RA Lane, Adarsh Babber, Sarah Onida and Alun H Davies in Phlebology

Supplemental material, sj-pdf-1-phl-10.1177_0268355520968640 for A randomised controlled trial of neuromuscular stimulation in non-operative venous disease improves clinical and symptomatic status by Raveena Ravikumar, Tristan RA Lane, Adarsh Babber, Sarah Onida and Alun H Davies in Phlebology

Supplemental material, sj-pdf-1-phl-10.1177_0268355520936420 for Reducing the risk of venous thromboembolism following superficial endovenous treatment: A UK and Republic of Ireland consensus study by Nikesh Dattani, Joseph Shalhoub, Sandip Nandhra, Tristan Lane, Abdulsalam Abu-Own, Ahmed Elbasty, Aled Jones, Andrew Duncan, Andrew Garnham, Ankur Thapar, Anna Murray, Anzar Baig, Athanasios Saratzis, Atif Sharif, Bella Huasen, Claire Dawkins, Craig Nesbitt, Daniel Carradice, Darren Morrow, David Bosanquet, Eamon Kavanagh, Faisal Shaikh, Gergely Gosi, Graeme Ambler, Gregory Fulton, Gurdas Singh, Hannah Travers, Hayley Moore, James Olivier, Louise Hitchman, Martin O’Donohoe, Matthew Popplewell, Mekki Medani, Michael Jenkins, Mingzheng A Goh, Oliver Lyons, Olivia McBride, Paul Moxey, Philip Stather, Phillipa Burns, Rachel Forsythe, Rachel Sam, Ranjeet Brar, Robert Brightwell, Ruth Benson, Sarah Onida, Sharath Paravastu, Simon Lambracos, Srinivasa R Vallabhaneni, Stewart Walsh, Tasleem Aktar, Tony Moloney, Zola Mzimba and Isaac Nyamekye in Phlebology

Amjad Belramman,1 Roshan Bootun,1,2 Sarah Onida,1,3 Alun H Davies,1,3 Tristan RA Lane1,31Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK; 2East of England Deanery Vascular Surgery Training Programme, Cambridge, UK; 3Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UKCorrespondence: Tristan RA LaneSection of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, 4N12A, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UKEmail tristan.lane@imperial.ac.ukAbstract: The American Venous Forum and the National Institute for Health and Care Excellence recommend endothermal ablation (ETA) techniques as the first line treatment for superficial venous incompetence. However, these techniques require the use of tumescent anaesthesia prior to energy delivery, which may be a source of discomfort for the patient and can prolong procedure time. Recently, nonthermal, nontumescent (NTNTs) techniques such as mechanochemical ablation (MOCA) have been developed to address some of the negative aspects associated with ETA. This article reviews this technique from a patient selection and perspective point view.Keywords: endovenous ablation, varicose veins, venous disease, mechanochemical ablation

Trial Spirit 2013 Checklist. (DOC 125 kb)

Retrospective comparative study of TASC D lesions treated with either endovascular methods or open surgical bypass at the West London Vascular Unit.

Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Checklist: recommended items to address in a clinical trial protocol and related documents. (DOC 123 kb)

Presented in the Sol Cohen Founder's Prize Session at the Vascular Society Annual Scientific Meeting, Manchester, UK 2013

Comparison of the two main quality of life scoring systems for varicose veins - Aberdeen Varicose Vein Questionnaire and CIVIQ. Presented at the AVF 2013 congress.

Introduction Varicose veins are a common problem with 25-50% of the population symptomatically affected, and chronic venous disease leads to significant impairments in quality of life with substantial health system cost implications. Significant variability exists in the symptoms suffered by patients, the treatment offered and the outcomes achieved. Identification of the optimal treatment pathways for patients remains difficult. Aims i. To ascertain primary care disease knowledge. ii. To assess what affects treatment and identify which patients benefit most. iii. To generate a predictive model of varicose vein outcomes. iv. To assess the impact of altering treatment of varicosities in the context of endovenous truncal vein ablation v. To investigate the early impact of new technologies Methods i. Two survey studies were completed: ⁃ 21 questions assessing venous disease management pathways was disseminated to General Practitioners. ⁃ 19 questions assessing the management of superficial venous thrombosis and was distributed to General Practitioners and Vascular Surgeons. ii. A cohort of consecutive patients with symptomatic chronic venous disease were assessed and completed quality of life questionnaires pre and postintervention. iii. Uni-variable and multi-variable analysis of patient cohort data to facilitate the creation of generalised model of venous treatment outcomes iv. A randomised clinical trial assessing the timing of varicosity avulsion in the context of local anaesthetic endovenous truncal ablation. ⁃ Ambulatory Varicosity avUlsion Later or Synchronised (AVULS) trial. v. Assessment of new technologies ⁃ The European Sapheon Closure system Observed ProspectivE (eSCOPE) study a multi-site cohort observational study of cyanoacrylate glue occlusion of truncal vein incompetence ⁃ The VNUS Versus Clarivein for Varicose Veins (VVCVV) multi-centre randomised clinical trial comparing the procedural pain profile of radiofrequency and mechanochemical ablation. Results i. Education outcomes ⁃ 138 responses were received. The management of chronic venous disease in the primary care setting is disparate and knowledge of current techniques is poor, despite extensive guidance. ⁃ 369 responses were received, from 197 vascular specialists and 172 primary care physicians. Superficial thrombophlebitis management is shown to be diverse and does not adhere to recent evidence. ii. 461 patients were recruited. Patients suffering from chronic venous disease suffer from substantial quality of life impairment, including previously under-recognised depressive symptoms. Treatment of the underlying venous condition provides relief from venous symptoms and improves quality of life. ⁃ Patient symptoms and quality of life do not correlate with anatomical vein diameter, however clinical severity scores do. iii. Predictive modelling produces models that account for 30-41% of the variability in post-operative scores for disease specific quality of life tools, generic quality of life tools, and clinical severity scores. iv. The AVULS trial recruited 101 patients. Simultaneous treatment leads to improved clinical outcomes at up to 1 year and early quality of life improvement. Delayed treatment has a significantly increased risk of requiring further treatment (Odds Ratio 27.78, Relative Risk 18.36, p

Poster Presentation from the American Venous Forum 2014 detailling Modelling on a Venous Data Cohort and the effects on outcome.

Presentation of a meta-analysis on the timing of varicosity treatment in the context of endovenous ablation of truncal varicose veins. Presented at the 2013 AVF congress.

Poster Detailing UK Burden of Disease and Treatment profile. Presented at SARS 2013.

Poster Presentation of the AVULS Varicose Vein Intervention Trial comparing simultaneous and delayed phlebectomies. Presented to the American Venous Forum 2014.

Poster of Distinction at Society of Academic and Research Surgery Conference 2013 detailing survey of primary and secondary care management of superficial venous thrombosis

Peer reviewed: True, Acknowledgements: The authors wish to thank the clinical, nursing and physiotherapy teams in Colorectal, Urology and Vascular surgery at Imperial College Healthcare NHS Trust., OBJECTIVES: To investigate the acceptability and safety of neuromuscular stimulation (NMES) as an adjunct for rehabilitation after vascular and general surgery. METHODS AND ANALYSIS: Prospective, single-centre, single-blind, parallel group, randomised controlled study. This study will be conducted in a single-centre, secondary care setting (National Healthcare Service Hospital) in the UK. All patients aged over 18 years undergoing vascular or general surgery with Rockwood Frailty Score of 3 or above on admission. Exclusion is inability or unwillingness to participate in trial, implanted electrical device, pregnancy and acute deep vein thrombosis. Target number of recruitment is 100. Participants will be randomly assigned to active NMES group (group A) or placebo NMES group (group B) prior to surgery. Participants will be blinded and asked to use the NMES device, 1-6 sessions daily (30 min per session) after surgery in addition to standard National Health Service rehabilitation care until discharge. The primary study outcomes are acceptability and safety of NMES assessed by the device satisfaction questionnaire on discharge and adverse events recorded during hospital stay. The secondary outcomes are the postoperative recovery and cost-effectiveness compared between two groups, assessed by various activity tests, mobility and independence measures and questionnaires. ETHICS AND DISSEMINATION: Ethical approvals were provided by London-Harrow Research Ethics Committee (REC) and the Health Research Authority (HRA), Ref: 21/PR/0250. Findings will be published in a peer-reviewed journal and presented at national and international conferences. TRIAL REGISTRATION NUMBER: NCT04784962.

Diabetic neuropathy (DN) is a common complication of diabetes that is becoming an increasing concern as the prevalence of diabetes rapidly rises. There are several types of DN, but the most prevalent and studied type is distal symmetrical polyneuropathy, which is the focus of this review and is simply referred to as DN. It can lead to a wide range of sensorimotor and psychosocial symptoms and is a major risk factor for diabetic foot ulceration and Charcot neuropathic osteoarthropathy, which are associated with high rates of lower limb amputation and mortality. The prevention and management of DN are thus critical, and clinical guidelines recommend several strategies for these based on the best available evidence. This article aims to provide a narrative review of DN prevention and management strategies by discussing these guidelines and the evidence that supports them. First, the epidemiology and diverse clinical manifestations of DN are summarized. Then, prevention strategies such as glycemic control, lifestyle modifications and footcare are discussed, as well as the importance of early diagnosis. Finally, neuropathic pain management strategies and promising novel therapies under investigation such as neuromodulation devices and nutraceuticals are reviewed.

Distal symmetrical polyneuropathy (DSPN) is a serious complication of diabetes associated with significant disability and mortality. Although more than 50% of people with diabetes develop DSPN, its pathogenesis is still relatively unknown. This lack of understanding has limited the development of novel disease-modifying therapies and left the reasons for failed therapies uncertain, which is critical given that current management strategies often fail to achieve long-term efficacy. In this article, the pathogenesis of DSPN is reviewed, covering pathogenic changes in the peripheral nervous system, microvasculature and central nervous system (CNS). Furthermore, the successes and limitations of current therapies are discussed, and potential therapeutic targets are proposed. Recent findings on its pathogenesis have called the definition of DSPN into question and transformed the disease model, paving the way for new research prospects.

Funder: Actergy Health, BACKGROUND: This randomised controlled trial investigates the dosing effect of neuromuscular electrical stimulation (NMES) in patients with chronic venous disease (CVD). METHODS: Seventy-six patients with CEAP C3-C5 were randomised to Group A (no NMES), B (30 minutes of NMES daily) or C (60 minutes of NMES daily). Primary outcome was percentage change in Femoral Vein Time Averaged Mean Velocity (TAMV) at 6 weeks. Clinical severity scores, disease-specific and generic quality of life (QoL) were assessed. RESULTS: Seventy-six patients were recruited - mean age 60.8 (SD14.4) and 47:29 male. Six patients lost to follow-up. Percentage change in TAMV (p

Graphical Abstract This online structured survey has demonstrated the global impact of the COVID-19 pandemic on vascular services. The majority of centres have documented marked reductions in operating and services provided to vascular patients. In the months during recovery from the resource restrictions imposed during the pandemic peaks, there will be a significant vascular disease burden awaiting surgeons. Graphical Abstract One of the most affected specialties

Introduction Varicose vein disease is a common ailment affecting the population. It is associated with causing an adverse effect on the quality of life of patients, with treatment of the condition known to improve it. The introduction of endovenous ablation has enabled the cost-effective treatment of the condition with procedures being carried out as day cases with an earlier return to normal activities. However, with healthcare expenditure increasingly under scrutiny, newer pathways are needed to continue the evolution of varicose vein management. Aim 1. To explore and compare the current and newer endovenous methods of treatment 2. To assess patients’ views of the current management of the condition 3. To evaluate a new referral and treatment pathway of varicose vein disease 4. To assess possible improvement in the post-procedural management of varicose veins Methods 1. A randomised controlled trial was conducted to compare radiofrequency ablation to mechanochemical ablation as well as a pilot study evaluating the use of a new cyanoacrylate adhesive sealing system. In addition, a systematic review and cost-effectiveness analysis was undertaken to evaluate the newer endovenous ablation methods. 2. A patient survey was carried out to understand the reasons for their referral as well as exploring a new management pathway. 3. A pilot study was undertaken to evaluate the feasibility of a One Stop Vein Clinic, offering same day diagnosis and treatment. 4. A randomised controlled trial comparing the use of compression stockings following endovenous ablation. Results 1. (a) With 170 patients recruited, the randomised controlled trial comparing radiofrequency and mechanochemical ablation shows that pain score during the procedure was less with the latter method, and that there were no other major differences between the two techniques. (b) This pilot study of 20 patients in the use of the new cyanoacrylate demonstrates that it is a safe and effective method, though a larger study would be able to provide further evidence of efficacy. (c) The systematic review shows that surgery and the endothermal methods seem to have lower re-intervention rates compared to foam sclerotherapy. However, a lack of comparative studies involving the non-thermal techniques meant that this analysis was unable to provide sufficient evidence as to their re-intervention rates and cost-effectiveness. 2. The patient survey of 106 patients revealed that they favoured less waiting time between appointments and their treatment. A high proportion of patients were also keen on attending a One Stop Clinic. 3. The early results of this pilot study of One Stop Vein Clinic shows that patients waited on average 4 weeks from being referred by their GP, but this study was hampered by unavailability of the treatment room for long periods and reduced possibility to add patients to the veins lists. 4. One hundred and nine patients have been recruited to the randomised controlled trial of the use of compression stockings. This shows that patients in the compression group had significantly less discomfort in the first few days following treatment, but there were no major differences by 2 weeks. Conclusions This work illustrates that varicose vein treatment is fast evolving. The newer technologies show promise, but currently, there is insufficient evidence to demonstrate their superiority over conventional endothermal methods. The One Stop Vein Clinic also shows potential, but may be difficult to incorporate into current practice without clear protocols between the different departments. The use of compression stockings following endothermal ablation indicates that it might be advantageous in the first few days, but may not necessarily have a long-term benefit. Open Access