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Katherine J Williams, Hayley M Moore, Mary Ellis, Alun H Davies Academic Section of Vascular Surgery, Imperial College London, London, UKCorrespondence: Alun H DaviesAcademic Department of Vascular Surgery, 4th Floor, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UKTel +44 20 3311 7320Email a.h.davies@ic.ac.ukIntroduction: Neuromuscular stimulation (NMES) has been shown to improve peripheral blood flow in healthy people. We investigated the effect of bilateral leg NMES on the symptoms of chronic venous disease.Methods: Forty subjects were recruited from four groups: healthy, superficial insufficiency, deep insufficiency, and deep obstruction. Haemodynamic venous measurements were taken from the right femoral vein with ultrasound, laser Doppler fluximetry from the left hand and foot. Devices were then worn for 4– 6 hours per day, for 6 weeks. Haemodynamic measurements were repeated at week 6. Quality of life questionnaires were taken at week 0, 6 and 8.Results: The mean age was 48.7, BMI 28.6kg/m2, and maximum calf circumference 39.0 cm. Twenty-four subjects were men. NMES increased femoral vein peak velocity, TAMV and volume flow by 55%, 20%, 36% at 20 minutes (all p< 0.05), which was enhanced at week 6 (PV and TAMV p< 0.05). Mean increases in arm and leg fluximetry were 71% and 194% (both p< 0.01). Leg swelling was reduced by mean 252.7 mL (13%, p< 0.05) overall; 338.9 mL (16%, p< 0.05) in venous disease. For those with venous pathology, scores for disease specific and generic quality of life questionnaires improved. Those with C4-6 disease benefitted the most, with improvements in VDS score of 1, AVVQ of 6, and SF-12 of 10.Conclusion: NMES improves venous haemodynamic parameters in chronic venous disease, which is enhanced by regular use. NMES reduces leg oedema, improves blood supply to the skin of the foot, and may positively affect quality of life.Clinical Trials: This trial was registered with www.clinicaltrials.org.uk (NCT02137499).Keywords: neuromuscular, electrical, stimulation, venous disease, venous insufficiency

Objectives: Peripheral artery disease is estimated to affect 237 million individuals worldwide. Critical limb ischaemia, also known as chronic limb threatening ischaemia is a consequence of the progression of peripheral artery disease which occurs in ∼21% of patients over a five-year period. The aim of this systematic review is to assess the use of additional below-the-ankle angioplasty in comparison to the use of above-the-ankle angioplasty alone, and the subsequent rates of amputation, wound healing, restenosis, rest pain, reintervention and complications. Methods: This systematic review was undertaken in accordance with PRISMA guidelines following a registered protocol (CRD42019154893). Online databases were searched using a search strategy of 20 keywords. Included articles reported the outcome for inframalleolar (pedal artery, pedal arch, plantar arteries) angioplasty with additional proximal angioplasty in comparison to proximal angioplasty alone. GRADE assessment was applied to assess the quality of the evidence. Results: After screening 1089 articles, 10 articles met the inclusion criteria. Comparative performance assessment of below-the-ankle with above-the-ankle versus above-the-ankle angioplasty alone was undertaken in 3 articles, with the remaining 7 articles reporting outcomes of below-the-ankle with above-the-ankle angioplasty with no distinct comparator group. Significant decrease in major lower limb amputation at the last follow-up in the below-the-ankle group when compared with the above-the-ankle angioplasty alone group was observed in a single study (3.45% vs. 14.9%, p < 0.05). Improved wound healing rate at follow-up in the below-the-ankle group versus above-the-ankle angioplasty alone group was also reported in a single study (59.3% vs. 38.1%, p < 0.05). Subsequent rate of amputation after below-the-ankle angioplasty has been estimated as 23.5%. Conclusion: To date, there is a lack of studies assessing inframalleolar interventions and their use in improving limb salvage, wound healing and symptomatology. Prospective RCTs should be undertaken with adequate participant numbers to be sufficiently powered and report clinically important end-points. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this systematic review is to assess the performance of graduated compression stockings (GCS) in comparison to no venous thromboembolism (VTE) prophylaxis in the prevention of hospital-acquired thrombosis in low-risk surgical patients undergoing short-stay procedures. Methods: Aligning with PRISMA guidelines, online databases MEDLINE and EMBASE, Cochrane Library® and trial registries were searched. Eligible articles reported the VTE rate in low-risk surgical patients either receiving GCS or no VTE prophylaxis. Results: Narrative synthesis was performed on a single eligible article. The included study arm consisted of participants undergoing knee arthroscopy with the use of GCS alone reporting a total of 29 VTE events (4.4%), 16 of which were asymptomatic DVTs (2.4%). Conclusion: There is a complete lack of evidence to support the use of GCS in the prevention of HAT for low-risk surgical patients. An adequately powered trial is required to provide level-IA evidence to support this practice. [ABSTRACT FROM AUTHOR]

Introduction: Post-thrombotic syndrome (PTS) is a common lifelong condition affecting up to 50% of those suffering from deep vein thrombosis (DVT). PTS compromises function and quality of life with subsequent venous ulceration in up to 29% of those affected.Areas covered: A literature review of surgical and non-surgical approaches in the prevention and treatment of PTS was undertaken. Notable areas include the use of percutaneous endovenous interventions and the use of graduated compression stockings (GCS) after acute proximal DVT.Expert opinion: In patients with acute iliofemoral DVT, we think it is important to have a frank conversation with the patient about catheter-directed thrombolysis, aiming to reduce the severity of PTS experienced. We advocate ultrasound-accelerated thrombolysis with adjunctive procedures, such as deep venous stenting for proximal iliofemoral DVT. For patients with isolated femoral DVT, we believe that anticoagulation and GCS should be recommended. In patients with established PTS, we recommend GCS for symptomatic relief. We recommend that patients engage in regular exercise where possible with the prospect of gaining symptomatic relief. For those with severe PTS that has a significant effect on quality of life, we discuss the patient's case at a multi-disciplinary team meeting to plan for endovenous intervention. [ABSTRACT FROM AUTHOR]

Introduction: Enhancement of peripheral circulation has been shown to be of benefit in many vascular disorders, and the clinical effectiveness of intermittent pneumatic compression is well established in peripheral vascular disease. This study compares the haemodynamic efficacy of a novel neuromuscular electrical stimulation device with intermittent pneumatic compression in healthy subjects. Methods: Ten healthy volunteers (mean age 27.1 � 3.8 years, body mass index 24.8 � 3.6 kg/m2) were randomised into two groups, in an interventional crossover trial. Devices used were the SCD Express Compression System, (Covidien, Ireland) and the geko, (Firstkind Ltd, UK). Devices were applied bilaterally, and haemodynamic measurements taken from the left leg. Changes to haemodynamic parameters (superficial femory artery and femoral vein) and laser Doppler measurements from the hand and foot were compared. Results: Intermittent pneumatic compression caused 51% (p=0.002), 5% (ns) and 3% (ns) median increases in venous peak velocity, time-averaged maximum velocity and volume flow, respectively; neuromuscular electrical stimulator stimulation caused a 103%, 101% and 101% median increases in the same parameters (all p=0.002). The benefit was lost upon deactivation. Intermittent pneumatic compression did not improve arterial haemodynamics. Neuromuscular electrical stimulator caused 11%, 84% and 75% increase in arterial parameters (p<0.01). Laser Doppler readings taken from the leg were increased by neuromuscular electrical stimulator (p<0.001), dropping after deactivation. For intermittent pneumatic compression, the readings decreased during use but increased after cessation. Hand flux signal dropped during activation of both devices, rising after cessation. Discussion: The neuromuscular electrical stimulator device used in this study enhances venous flow and peak velocity in the legs of healthy subjects and is equal or superior to intermittent pneumatic compression. This warrants further clinical and economic evaluation for deep venous thrombosis prophylaxis and exploration of the haemodynamic effect in venous pathology. It also enhances arterial time-averaged maximum velocity and flow rate, which may prove to be of clinical use in the management of peripheral arterial disease. The effect on the microcirculation as evidenced by laser Doppler fluximetry may reflect a clinically beneficial target in microvascular disease, such as in the diabetic foot. [ABSTRACT FROM AUTHOR]

Objectives: Percutaneous pharmacomechanical thrombectomy is an emerging therapy for acute deep vein thrombosis and may reduce long-term incidence of post-thrombotic syndrome. This study investigates the proportion of patients presenting with lower limb deep vein thrombosis who are potentially suitable for percutaneous pharmacomechanical thrombectomy. Methods: A retrospective review of all duplex ultrasound scans for lower limb deep vein thrombosis over two-year period at a regional vascular unit was conducted. All acute occlusive iliofemoral deep vein thrombosis were screened for percutaneous pharmacomechanical thrombectomy suitability according to predefined criteria. Results: There were 2513 duplex ultrasound scans for suspected lower limb deep vein thrombosis in the two-year period. There were 120 cases of acute occlusive iliofemoral deep vein thrombosis. After application of inclusion and exclusion criteria 48 out of 120 (40%) patients were identified as potential candidates for percutaneous pharmacomechanical thrombectomy. Conclusions: This indicates that a large randomised trial of percutaneous pharmacomechanical thrombectomy is feasible given expected recruitment rates in a multicentre study [ABSTRACT FROM AUTHOR]

Chronic venous disease is a common condition, bearing significant morbidity to patients. It is predicted that the population suffering from this disease will significantly increase in the coming years, with a growing demand for specialists in the field of phlebology.Training and delivery of services are highly heterogeneous in the European Union. The establishment of the European College of Phlebology marks the opportunity to address these differences from a European perspective, with the aim of providing all patients with standardised, high-quality, accessible medical care.In this paper, we review the current status of phlebology from a European and an international perspective, as well as highlighting the current and future roles of the European College of Phlebology. [ABSTRACT FROM PUBLISHER]

Deep vein thrombosis is common with an incidence of 1 in 1000. Acute thrombus removal for extensive proximal deep vein thrombosis using catheter-directed techniques highlights the need for accurate assessment of thrombus age. This systematic review summarises experimental and clinical evidence of imaging techniques for aging deep vein thrombosis. Ultrasound elastography and magnetic resonance imaging were highlighted as the most studied imaging modalities. Elastography was shown to distinguish between acute and chronic clots, despite demonstrating difficulty in accurate aging of clots older than 10 days in rat models. Elastography is noted as a feasible adjunct to current first-line imaging for deep vein thrombosis using duplex ultrasonography. Combinations of magnetic resonance imaging techniques can identify acute, sub-acute and chronic thrombi using endogenous contrast agents and provide objective standardisation of the diagnostic process, with reduced onus upon operator dependency. Further validation is required of these novel imaging techniques prior to clinical implementation for deep vein thrombosis aging. [ABSTRACT FROM PUBLISHER]

ATP binding cassette transporter A1 (ABCA1) mediates the cellular efflux of phospholipids and cholesterol to lipid-poor apolipoprotein A1 (apoA1) and plays a significant role in high density lipoprotein (HDL) metabolism. ABCA1's role in the causation of Tangier disease, characterized by absent HDL and premature atherosclerosis, has implicated this transporter and its regulators liver-X-receptorα (LXRα) and peroxisome proliferator activated receptorγ (PPARγ) as new candidates potentially influencing the progression of atherosclerosis. In addition to lipid regulation, these genes are involved in apoptosis and inflammation, processes thought to be central to atherosclerotic plaque progression. A Medline-based review of the literature was carried out. Tangier disease and human heterozygotes with ABCA1 mutations provide good evidence that ABCA1 is a major candidate influencing atherosclerosis. Animal and in vitro experiments suggest that ABCA1 not only mediates cholesterol and phospholipid efflux, but is also involved in the regulation of apoptosis and inflammation. The complex and beneficial interactions between apoA1 and ABCA1 seem to be pivotal for cholesterol efflux. The expression of the ABCA1 is tightly regulated. Furthermore the plaque microenvironment could potentially promote ABCA1 protein degradation thus compromising cholesterol efflux. PPAR-LXR-ABCA1 interactions are integral to cholesterol homeostasis and these nuclear receptors have proven anti-inflammatory and anti-matrix metalloproteinase activity. Therapeutic manipulation of the ABCA1 transporter is feasible using PPAR and LXR agonists. PPAR agonists like glitazones and ABCA1 protein stabilization could potentially modify the clinical progression of atherosclerotic lesions. [ABSTRACT FROM AUTHOR]

Objectives: We sought to investigate whether positron emission tomography/computed tomography (CT) angiography using [11C]-PK11195, a selective ligand for peripheral benzodiazepine receptors expressed in activated macrophages, can be used to image vascular inflammation. Background: Activated macrophages and T lymphocytes are fundamental elements in the pathogenesis of large-vessel vasculitides. Methods: Fifteen patients (age 52+/-16 years) with systemic inflammatory disorders (6 consecutive symptomatic patients with clinical suspicion of active vasculitis and 9 asymptomatic control patients) underwent positron emission tomography with [11C]-PK11195 and CT angiography. [11C]-PK11195 uptake was measured by calculating target-to-background ratios of activity normalized to venous blood. Results: Coregistration of positron emission tomography with contrast-enhanced CT angiography facilitated localization of [11C]-PK11195 arterial wall uptake. Visual analysis revealed focal [11C]-PK11195 uptake in the arterial wall of all 6 symptomatic patients, but in none of the asymptomatic controls. Although serum inflammatory biomarkers (C-reactive protein, erythrocyte sedimentation rate, white cell count) did not differ significantly between the 2 groups, symptomatic patients had increased [11C]-PK11195 vascular uptake (target-to-background ratio 2.41+/-1.59 vs. 0.98+/-0.10; p=0.001). Conclusions: By binding to activated macrophages in the vessel wall, [11C]-PK11195 enables noninvasive imaging of vascular inflammation. Alternative longer-lived radioligands for probing peripheral benzodiazepine receptors are being tested for wider clinical applications. [ABSTRACT FROM AUTHOR]