Search

Introduction: Treatment of reflux has been shown to improve time to healing of Venous Leg Ulcers (VLU). Terminal Interruption of the Reflux Source (TIRS) treats reflux within the plexus of veins around an active VLU using foam sclerotherapy. The efficacy of TIRS in managing VLU has never been tested. Methods: We performed a pragmatic, single centre, assessor-blinded, randomised controlled trial comparing endovenous ablation of the axial superficial veins (Axial Ablation-AA) vs TIRS. Patients of any age with VLU of any duration were eligible. Results: 98 Participants were randomised to AA or TIRS. 39/55, 70.9% (95%CI; 57.1-82.37) healed their VLU in the AA group, while 29/39, 74.36% (95%CI; 57.87-86.96) healed their VLU in the TIRS group, P = 0.45.4 were lost to follow-up. Median time to ulcer healing was 84 days (95%CI; 74.67-93.33) in the axial ablation group and 84 days (95%CI; 73.02-94.98) in the TIRS group. Hazard Ratio for ulcer healing with AA vs TIRS was 0.96 (95%CI 0.59-1.56). There were no significant quality of life differences. Conclusion: The AAVTIRS trial did not show that axial ablation was superior to TIRS in the primary outcome of number of VLU healed in 6 months, or time to VLU healing. This trial is not powered to show non-inferiority. TIRS is a viable option for treatment of VLU. Further investigation is necessary before it can be recommended as an alternative to axial ablation. Trial registered at clinicaltrials.gov NCT04484168. [ABSTRACT FROM AUTHOR]

Objective: A prospective cohort study aimed to determine factors which influence the progression of chronic venous disease (CVD) in an attempt to aid in the early identification of those at patients who are likely to benefit from early intervention. Methods: A prospective cohort study of patients referred to tertiary vascular services with varicose veins over 7 years was conducted. The primary outcome measure was the rate of disease progression from time of referral to time of consultation. The secondary outcome measure was to the rate of venous complications during the same time period. Results: 1000 patients from routine varicose vein waiting lists were included in the study. The mean waiting time was 2.96 ± 1.25 years. The majority of patients were female (73% versus 27%), and the average age was 57.8 ± 14.7 years. One fifth of the cohort developed a complication or showed evidence of disease progression. Logistic regression showed that advancing age and previous episodes of cellulitis are significant risk factors for the development of CVD progression. Conclusions: Varicose veins are more than a cosmetic issue and can be associated with substantial health and economic costs. Continuous identification of risk factors will enable clinicians to implement treatment strategies earlier for at risk patients., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Mixed Arterial and Venous Leg Ulcers (MAVLU) are challenging. Clinical evidence specific to MAVLU management is scarce. We evaluated our recent experience with MAVLU patients and reviewed current data regarding MAVLU epidemiology, aetiology, diagnostic assessment and management options., Methods: A prospective leg ulcer database was retrospectively interrogated to determine the prevalence and clinical outcome of MAVLU over 2-year period (2021-2022). The literature was reviewed to determine if optimal treatment strategies., Results: 307 patients attended the ulcer clinic over a 2-year period. Most were venous leg ulcers (71%), 24% were arterial and 5% were MAVLU. The highest healing rate was in MAVLU (93%), followed by (74%) and (41%), in arterial and venous leg ulcer groups, respectively., Conclusion: Evidence-based guidelines for MAVLU remain lacking. Well-developed randomised controlled trials are warranted to guide current clinical practice., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: As the population ages, vascular surgeons are treating progressively older, multimorbid patients at risk of peri-operative complications. An embedded physician has been shown to improve outcomes in general and orthopaedic surgery. This systematic review and meta-analysis aimed to investigate the impact of surgeon-physician co-management models on morbidity and mortality rates in vascular inpatients., Data Sources: PubMed, Scopus, Embase, conference abstract listings, and clinical trial registries., Review Methods: Studies comparing adult vascular surgery inpatients under co-management with standard of care were eligible. The relative risks (RRs) of death, medical complications, and 30 day re-admission between co-management and standard care were calculated. The effect of co-management on the mean length of stay was calculated using weighted means. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies, and certainty assessment with the GRADE analysis tools., Results: No randomised controlled trials were identified. Eight single institution studies between 2011 and 2020 with 7 410 patients were included. All studies were observational using before-after methodology. Studies were of high to moderate risk of bias, and outcomes were of very low GRADE certainty of evidence. Co-management was associated with a statistically significant lower relative risk of death (RR 0.64, 95% confidence interval [CI] 0.44 - 0.92; p = .02), cardiac complications (RR 0.47, 95% CI 0.25 - 0.87; p = .02), and infective complications (RR 0.49, 95% CI 0.35 - 0.67; p < .001) in vascular inpatients. No statistically significant differences in length of stay (standard mean difference -0.6 days, 95% CI -1.44 - 0.24 days; p = .16) and 30 day re-admission (RR 0.96, 95% CI 0.84 - 1.08; p = .49) were noted., Conclusion: Early results of physician and surgeon co-management for vascular surgery inpatients showed promising results from very low certainty data. Further well designed, prospective studies are needed to determine how to maximise the impact of physicians within a vascular service to improve patient outcomes while using hospital resources effectively., (Copyright © 2024 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Few studies have evaluated the association between asymptomatic cholesterol emboli on fundoscopy (known as Hollenhorst plaque) and the subsequent risk of stroke or death. 1 ., Aim: To evaluate the association between the presence of asymptomatic cholesterol retinal emboli and the risk of cerebrovascular events, with assessment of the need for carotid intervention., Methods: PubMed, Embase, and Cochrane Library databases were searched using appropriate terms. The systematic review was conducted according to PRISMA guidelines., Results: Initial search revealed 43 in Medline and 46 in Embase databases. Twenty-four potentially eligible studies were included after duplicate and non-related studies were excluded based on title and abstract. Three more studies were identified from reference lists. Seventeen studies were included in the final analysis. Asymptomatic cholesterol emboli were present in 1343 patients. Approximately 17.8% ( n = 181) had history of either cerebro-vascular Accident (CVA) or transient ischaemic attacks (TIAs) at presentation (more than 6 months). Nine studies mentioned the incidence of cerebrovascular events during follow-up. Of 780 patients, 93 evolved to stroke, TIAs, or death from a major carotid event during the follow-up period (6-86 m), an incidence of about 12%. Death due to stroke was documented in 3 studies ( n = 12)., Conclusion: The presence of asymptomatic retinal emboli indicates a risk of a cerebrovascular event when compared to patients with no plaques seen on fundoscopy. The evidence suggests that these patients warrant referral for medical optimization of cardiovascular risk factors. Currently, there is no recommendation to support carotid endarterectomy in patients with Hollenhorst plaques, or retinal emboli, and further studies are needed to assess this., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Endovenous ablation has revolutionized treatment of varicose vein surgery but is associated with a risk of venous thromboembolism. There is no consensus regarding anticoagulation protocols for these patients. This network meta-analysis (NMA) aims to identify which anticoagulant is optimal in this cohort for clot prevention with minimal risk of adverse bleeding events., Methods: Library databases were searched for studies where patients were treated with one or more anticoagulants following endovenous ablation for varicose veins. The methodological quality of included studies was quantified using the Risk of Bias (ROB) assessment tools. Findings were reported using the meta-analysis of observational studies in epidemiology (MOOSE) checklist. Statistical analysis was carried out using metainsight (rpackage)., Results: Observational data on just under 1500 patients prescribed post ablation anticoagulation (Rivaroxaban, Enoxaparin, Fondaparinux) were analyzed. Patient characteristics were comparable across the cohorts. 81 thrombotic and 40 minor bleeding events occurred in total. Overall rivaroxaban is found to be superior to the other agents., Conclusions: This NMA indicates that prophylactic rivaroxaban is the highest ranked anticoagulant for thromboprophylaxis in patients post endovenous ablation for varicose veins, with a low risk of adverse bleeding. The choice whether to anticoagulate these patients is likely to remain at the discretion of the treating clinician., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.