Search

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7th-10th May 2012 in Mainz. The conference was organized by the German Society of Phlebology.This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, Polidocanol (POL) and Sodium tetradecyl sulphate (STS). Other sclerosants are not discussed in detail. In this paper the results from recent RCTs in sclerotherapy are reviewed.

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, Polidocanol (POL) and Sodium tetradecyl sulphate (STS). Other sclerosants are not discussed in detail. In this paper the recommendations concerning indications, contraindications, concentrations, volumes and technique of liquid and foam sclerotherapy of varicose veins and venous malformations are reviewed.

Aim:Endovenous thermal ablation (ETA) procedures are catheter-directed, ultrasound (US)-guided thermal methods for treatment in varicose veins disease. Radiofrequency, laser or steam energy thermally denatures vein wall collagen, leading first to vein wall inflammation, then fibrosis and finally to occlusion. The aim of this guideline is to give evidence-based recommendations for ETA procedures.Methods:These guidelines were drafted during a consensus meeting of a group of experts in the field of ETA in June 2012 (Hvar, Croatia) under the auspices of the International Union of Phlebology (IUP). These guidelines review the present state of knowledge as reflected in peer-reviewed published medical literature. The recommendations of these guidelines are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.Results:Recommendations on the use of ETA procedures were made based on the quality of evidence for efficacy, safety, tolerability, cosmetic outcome, patient satisfaction/preference and, where appropriate, on the experts' opinion. Health economics were not considered, since differences in national health systems and pricing make it difficult to form general conclusions that are relevant at an international level.

Leitlinien sind systematisch erarbeitete Empfehlungen, um Kliniker und Praktiker bei Entscheidungen uber die angemessene Patientenversorgung im Rahmen spezifi-scher klinischer Umstande zu unterstutzen. Leitlinien gelten fur so genannte Standard-situationen. Sie berucksichtigen aktuelle, zu den entsprechenden Fragestellungen verfug-bare wissenschaftliche Erkenntnisse. Leitlinien bedurfen einer standigen Uber-prufung und eventuell der Anderung auf Basis des wissenschaftlichen Erkenntnisstan-des und der Praktikabilitat in der taglichen Praxis. Durch die Leitlinien soll die arztliche Methodenfreiheit nicht eingeschrankt wer-den. Ihre Beachtung garantiert nicht in jedem Fall den diagnostischen und thera-peutischen Erfolg. Leitlinien erheben keinen Anspruch auf Vollstandigkeit. Die Entschei-dung uber die Angemessenheit der zu er-greifenden Masnahmen trifft der Arzt oder die Arztin unter Berucksichtigung der indivi-duellen Problematik.

Reference materials (RMs) play a vital role for the verification of the quality control of environmental analysis. The increasing requirements imposed to environmental control laboratories call for greater co-operation among RM producers and end-users to better define future production strategies. It is recognised that the present system is unlikely to be able to cope with the increasing demand for certified and non-certified RMs within the forthcoming years. These issues were discussed in the framework of a workshop funded by the M&T programme of the European Commission, which brought together RM producers, certification experts and end-users. This report summarises the round-table discussions and expert recommendations.

Leitlinien sind systematisch erarbeitete Empfehlungen, um den Kliniker und den Praktiker bei Entscheidungen über die angemessene Versorgung der Patienten im Rahmen spezifischer klinischer Umstände zu unterstützen.Leitlinien gelten für „Standardsituationen“ und berücksichtigen die aktuellen, zu den entsprechenden Fragestellungen zur Verfügung stehenden, wissenschaftlichen Erkenntnisse. Leitlinien bedürfen der ständigen Überprüfung und eventuell der Änderung auf dem Boden des wissenschaftlichen Erkenntnisstandes und der Praktikabilität in der täglichen Praxis. Durch die Leitlinien soll die Methodenfreiheit des Arztes nicht eingeschränkt werden. Ihre Beachtung garantiert nicht in jedem Fall den diagnostischen und therapeutischen Erfolg. Leitlinien erheben keinen Anspruch auf Vollständigkeit. Die Entscheidung über die Angemessenheit der zu ergreifenden Maßnahmen trifft der Arzt unter Berücksichtigung der individuellen Problematik.

ZusammenfassungDie Ursachenfindung eines therapieresistenten Ulcus cruris ist und bleibt eine Herausforderung. Wir berichten über Kryoglobulinämie als Ursache von schmerzhaften Ulcera crurum einer 73-jährigen Patientin mit bekannter Hepatitis- C-Virus-Infektion. Kryoglobuline sind eine häufige Begleiterscheinung einer Hepatitis-C-Virus-Infektion und können über vaskulitische Prozesse mit Blasenbildung bis hin zu Ulzerationen eine wichtige Rolle in der Pathogenese des Ulcus cruris spielen.

Objectives: A variety of studies have suggested that flavonoids are effective for the treatment of CVD. However, many questions remain about their mechanism of action and when, how, and for what signs and symptoms they should be used. Method: A panel of experts in CVD met in Budapest, Hungary in December 2011 to discuss the current state of knowledge of CVD and the role of flavonoids in its treatment. The discussion was based on a literature search in the current databases. The goals of this paper are recommendations for further studies on the use of flavonoids in the treatment of CVD. Results: There is good evidence to recommend the use of flavonoids in the treatment of CVD. However, because of the poor quality of some older clinical trials, inadequate reporting, and insufficient information, much work is still needed to firmly establish their clinical efficacy and to determine when and how they should be employed. In particular, long-term randomized, placebo-controlled, double-blind studies are needed to establish the efficacy and safety of flavonoids. Additional studies are also needed to establish their mechanism of action, pharmacokinetics, toxicity, and cost-effectiveness. Conclusions: Aside from good evidence for the use of flavonoids in CVD further studies are indicated to establish long term treatment in this indication.

Endoluminal catheter-based procedures enable venous reflex in varicose saphenous veins to be eliminated. The catheter tip is positioned in the sapheno femoral or popliteal junction under ultrasound guidance. The energy necessary to ablate the vein is generated as heat by high-frequency current (radiofrequency) by laser light or by steam. Advantages of this procedure include low invasiveness, subcutaneous infusion anesthesia (SIA), low perioperative morbidity and rapid restoration of mobility of patients.

The first CEAP (clinical, aetiological, anatomical and pathological elements) consensus document was published after a consensus conference of the American Venous Forum, held at the sixth annual meeting of the AVF in February 1994 in Maui, Hawaii. In the following years the CEAP classification was published in many international journals and books which has led to widespread international use of the CEAP classification since 1995. The aim of this paper is to review the benefits and limits of CEAP from the available literature. In an actual Medline analysis with the keywords ‘CEAP’ and ‘venous insufficiency’, 266 publications using the CEAP classification in venous diseases are available. The CEAP classification was accepted in the venous community and used in scientific publications, but in most of the cases only the clinical classification was used. Limitations of the first version including a lack of clear definition of clinical signs led to a revised version. The CEAP classification is the gold standard of classification of chronic venous disorders today. Nevertheless for proper use some facts have to be taken into account: the CEAP classification is not a severity classification, C2 summarizes all kinds of varicose veins, in C3 it may be difficult to separate venous and other reasons for oedema, and corona phlebectatica is not included in the classification. Further revisions of the CEAP classification may help to overcome the still-existing deficits.

La forte toxicite du TBT et sa remanence dans l'environnement ont entraine la mise au point d'une methode permettant le dosage et la speciation des butyletains en traces. Les differentes etapes de cette technique par generation d'hydrures, chromatographie gazeuse et spectrometrie d'absorption atomique four en quartz (H.G./G.C./ Q.F.A.A.S.), sont presentees de l'extraction a la detection. Cette methode est appliquee a des echantillons naturels (eaux, sediments et materiaux biologiques). Les limites de detection obtenues sont de l'ordre du ng·l-1 ou ng·g1

Although an increase in volume of the legs during prolonged standing is a well-known phenomenon, there is little information on the initial phase in orthostasis. The aim of this study is to measure the increase in volume and its distribution in the lower extremities during orthostatic stress in healthy and varicose patients.In this prospective study volume changes of the legs in 16 healthy individuals and 24 patients with varicose veins were investigated using an optoelectric volume measurement system (Perometer®) during 10 minutes in a standing position.We could show that during a 10 minute standing experiment, a significant increase in volume of the entire leg, in both the healthy vein group (2.48%) and the varicose group (2.1%) occurred. Significant volume increase appeared in the upper and lower leg respectively. No significant differences could be demonstrated between right and left leg or between healthy and varicose legs.These results in accordance with other published data indicate that changing position from lying or sitting to standing initially leads to a rapid increase in volume of the leg. These changes take place very quickly and with respect to their volume changes, are significant. The volume increase is following a bi-exponential function fitting to a fast filling compartment (venous pooling) and a slow filling compartment reflecting extravasation. Over the course of the day additional edema formation may occur.

Varikosis ist ein deskriptiver Krankheitsbegriff und bezeichnet eine degenerative Erkrankung der Venen mit der Ausbildung von Varizen (Varix = lat. Knoten). Varizen bezeichnen das morphologische Korrelat der Varikosis, die erkrankten Venen. Der deutsche Begriff Krampfadern gibt wegen seiner sprachlichen Nahe zum (Muskel)-Krampf auch heute immer noch bei Arzten ebenso wie bei Patienten Anlass zu Verwechselungen bzw. Fehlinterpretationen. Etymologisch verweist Krampfader hingegen auf Krampfader (althochdeutsch) = Krummader, womit auf die haufige Schlangelung der erkrankten Venen verwiesen ist.

In den letzten Jahrzehnten wurden weltweit zahlreiche epidemiologische Studien zu chronischen Venenkrankheiten durchgefuhrt. Die meisten konzentrierten sich auf das Krampfaderleiden (Beebe-Dimmer et. al 2005, Evans et. al 1994, Evans et al 1999, Fischer 1981, Fowkes et al. 2001a, Heit et al. 2001, Ruckley et al. 2002, Widmer et al. 1981). Bei der Bewertung dieser Studien wurden einige grundsatzliche Probleme deutlich. Zum einen verwandte man in den verschiedenen Studien unterschiedliche Definitionen von Varizen und chronischer venoser Insuffizienz, zum anderen wurden unterschiedlich Alterseinteilungen verwendet. Nur in sehr wenigen Studien basierte die untersuchte Studienpopulation auf einer randomisierten Stichprobe der Allgemeinbevolkerung (Rabe et al. 2003). In vielen Studien wurden nur die Ergebnisse eines Fragebogens genutzt. Klinische und duplexsonographische Untersuchungen fanden selten Berucksichtigung, ebenso wie die Einarbeitung der CEAPKlassifikation in das Studiendesign (Rabe et. al 2003, Carpentier et al. 2004, Chiesa et al. 2005a, Chiesa et al. 2005b, Criqui et al. 2003, Jawien et al. 2003).

Objectives Foam sclerotherapy of varicose veins has recently proven to be an effective, economic and safe treatment modality. The present study attempts to evaluate the haemodynamic changes after sclerotherapy in addition to the clinical results. Methods In a prospective observation trial, 67 sites (2/3 of which were recurrent varicose [RV] veins after previous treatment) in 53 patients were treated with polidocanol foam, and the results were assessed clinically, by duplex, photoplethysmography and strain gauge plethysmography. Results With the exception of two sites (3.0%), all treatments resulted at least in an improvement, and about 80% of the treated veins were completely occluded as demonstrated by duplex ultrasound examination. The haemodynamical results accordingly reflected a significant improvement of the venous function. Patients with post-thrombotic syndrome showed poorer results. Conclusion Foam sclerotherapy is a highly effective and safe method for the treatment of primary and RV veins.

Major side effects after endovenous laser ablation (EVLA) are pain and bruising. The aim of this study was to compare outcome and side effects after EVLA of incompetent great saphenous veins (GSV) with a 1 470 nm diode laser (Ceralas E, biolitec) using a power of 15 or 25 W.Between 28 November 2007 and 15 January 2008, 40 consecutive patients (40 legs) with an incompetent GSV were treated by EVLA. The patients were randomized in two groups. In Group A (20 patients) was used a 15-W-power laser and in Group B (20 patients) a 25-W-power laser was used. All patients were re-examined after 1, 10 and 30 days clinically and by Duplex for complications and occlusion in the treated vein segment in a standardized way.There was no significant difference concerning gender, age, C of CEAP, body mass index or diameter of the treated vein. In Group A a mean of 465 mL tumescence fluid (TF) was used and in Group B TF was of 433 mL. In Group A the mean linear endovenous energy density (LEED) was 109.7 J/cm and in Group B 132.6 J/cm. The subgroup Bsub included 16 patients of Group B with a comparable mean LEED of 115.8 J/cm. In all groups occlusion of the treated veins was achieved for all patients. The diameter of the GSV reduced at 3 cm below the sapheno-femoral junction from 1.1 to 0.6 cm, 1.0 to 0.6 cm and 0.9 to 0.6 cm respectively in the three groups. The modified CEAP clinical score improved significantly in all groups. In Group A patients have been administered analgesic tablets for a shorter period. There was also a trend to less postinterventional pain and analgesic use in Group A, but it was not significant. Ecchymosis was rare in both groups (8 in Group A, 7 in Group B).In this prospective randomized comparative study the power of the laser did not influence the occlusion rate when a high LEED with comparable values was used. In both groups pain and ecchymoses were less frequent in this study with a 1 470 nm diode laser than reported in studies with 810-980 nm systems. A lower power level significantly reduced use of analgesic tablets.

Radiofrequency ablation (RFA) and endovenous laser treatment (EVLT) are minimal invasive methods to treat saphenous varicose veins. The short- and mid-term results are excellent with an occlusion rate for RFA of almost 90% after 5 years and about 95% for EVLT after 2 years. Severe side effects are rare in both cases. Prospective randomised comparative studies are available for RFA and surgery showing comparable short-term results and superiority of RFA concerning short-term quality of life outcome. For laser treatment no prospective randomised comparative studies are available. Endovenous treatment is only a part of the complex treatment concept of varicose veins. Insufficient tributaries have to be treated in addition. The fact that the insufficient saphenous vein is treated without high ligation seems not to influence the short-term and mid-term recurrence rates. More prospective randomised comparative studies comparing endovenous treatment and surgery or foam sclerotherapy are necessary to decide which method is the best for which patient.

Sclerotherapy is a standard treatment for intradermal varicose veins and branch varicosities. In the treatment of insufficient saphenous veins, crossectomy and stripping used to be the methods of choice. In the last few years good results have also been reported for endovenous methods such as endovenous laser and radio frequency treatment. Sclerotherapy is more effective and even appropriate for larger saphenous veins when the sclerosing liquid is replaced by a foam agent. This cost-effective approach can be done on an outpatient basis without additional anesthesia. Prospective randomized studies are need to confirm the effectiveness.

Venous diseases which require emergency care include deep venous thrombosis, superficial thrombophlebitis and variceal bleeding. The clinical diagnosis of deep venous thrombosis is often inaccurate, but can be confirmed in most cases with noninvasive tools such as sonography and d-dimer testing. Standard therapy includes compression of the leg and low molecular weight heparin in a therapeutic dosage. Superficial thrombophlebitis includes a variety of disease processes involving superficial veins, some thrombotic and others inflammatory. The most important is varicophlebitis or varicothrombosis, which involves the deep venous system in up to 20% of cases. Along with immediate surgical procedures when the thrombus reaches the deep venous system in the groin, short term therapy with low molecular weight heparin can be used. Variceal bleeding is a typical complication of severe varicose veins. It can be treated by elevating the leg and compression therapy. In addition sclerotherapy or ligation of the bleeding vein can be performed.

Diseases of the venous system are among the most frequently occurring diseases in the German population. However, the last comprehensive population-based German data were obtained in 1979. Since then, diagnostic methods have improved substantially. Here, we examine the prevalence of venous diseases in women and their association with pregnancies and intake of hormones.We conducted a population-based cross-sectional study in Bonn and rural environments (Recruitment period: 11/2000 - 11/2001; response: 59 %; 3072 study participants (1350 men, 1722 women), 18 to 79 years of age; investigation: standardised medical history, physical examination, duplex sonography, photography and CEAP-classification of veins of the legs). The following definitions were used: 1) Varicosis: clinical classification C2-C6 (primary varicosis only, excluding those showing spider-bursts exclusively); 2) Chronic venous insufficiency (CVI): C3-C6. For women, the risk factors examined were the number of pregnancies (P) and intake of hormones. Odds ratios (OR) and 95 % confidence intervals (95 %-CI) were calculated by multiple logistic regression (adjusted for age, region of residence and socioeconomic status). In addition, never pregnant women and men were compared regarding the two outcome variables.713 participants (23 %) had varicosis and 522 (17 %) CVI. The OR for women (reference group: men) was OR = 1.4, 95 %-CI: 1.25 - 1.79 (varicosis) and OR = 1.2, 95 %-CI: 0.93 - 1.42 (CVI). There was a positive dose-response relationship between the number of pregnancies and varicosis: 1 P: OR = 1.3 (95 %-CI: 0.89 - 1.96), 2 P: OR = 1.4 (95 %-CI: 1.00 - 2.07), 3 P: OR = 1.6 (95 %-CI: 1.05 - 2.41), 4 P: OR = 1.9 (95 %-CI: 1.18 - 3.20),or = 5 P: OR = 2.2 (95 %-CI: 1.28 - 3.74) and this trend was similar for CVI. Never-pregnant women (n = 518) and men had a similar prevalence. We did not see a consistent effect of intake of hormones in varicosis (OR = 0.9 [95 %-CI: 0.68 - 1.22]), but a negative association with CVI (OR = 0.6 [95 %-CI: 0.47 - 0.89]).Our results confirm the known association between diseases of the venous system and pregnancies, which seem to explain a big share of the sex-specific differences in the prevalence of these diseases.

Chronic venous diseases such as varicosis, post-thrombotic syndrome, and chronic venous insufficiency are among the most frequent clinical pictures in the Western world. The resultant consequences are persistent complaints such as a feeling of heaviness, tendency for swelling, and leg pain as well as vast skin changes culminating in an open leg ulcer. Although a series of past epidemiological studies are available, they are quite inconsistent with regard to implementation and definition of the clinical picture so that they cannot always be compared. Some are based solely on registration of disease history by questionnaires, which are inadequate to reliably assess actual prevalence. In only a very few studies are the results based on the actual examination of the subjects. Moreover, entirely difference age intervals and random samples are evaluated. The present study summarizes the most important epidemiological results with particular regard to the current Bonn Vein Study.

Leitlinien sind systematisch erarbeitete Empfehlungen, um Kliniker und Praktiker bei Entscheidungen zur Versorgung ihrer Patienten im Rahmen spezifischer Umstände zu unterstützen. Leitlinien gelten für „Standardsituationen“ und berücksichtigen die aktuellen, zu den entsprechenden Fragestellungen zur Verfügung stehenden wissenschaftlichen Erkenntnisse. Leitlinien bedürfen der ständi-gen Überprüfung und eventuell der Ände-rung auf dem Boden des wissenschaftlichen Erkenntnisstandes und der Praktikabilität in der täglichen Praxis. Leitlinien entbinden den Arzt nicht von seiner Sorgfaltspflicht und der Beachtung der individuell angepassten diagnostischen und therapeutischen Maß-nahmen. Leitlinien erheben keinen Anspruch auf Vollständigkeit.

Leitlinien sind systematisch erarbeitete Empfehlungen, um Kliniker und Praktiker bei Entscheidungen zur Versorgung ihrer Patienten im Rahmen spezifischer Umstände zu unterstützen. Leitlinien gelten für „Standardsituationen“ und berücksichtigen die aktuellen, zu den entsprechenden Fragestellungen zur Verfügung stehenden wissenschaftlichen Erkenntnisse. Leitlinien bedürfen der ständi-gen Überprüfung und eventuell der Ände-rung auf dem Boden des wissenschaftlichen Erkenntnisstandes und der Praktikabilität in der täglichen Praxis. Leitlinien entbinden den Arzt nicht von seiner Sorgfaltspflicht und der Beachtung der individuell angepassten diagnostischen und therapeutischen Maß-nahmen. Leitlinien erheben keinen Anspruch auf Vollständigkeit.

After optimisation of sample pretreatment and determination procedures, butyltin compounds were determined in selected marine sediments and biota using the hydride generation/gas chromatography/quartz furnace atomic absorption spectrometry method. Butyltins were detected in all surface sediment samples of Arcachon Bay, though at widely different concentrations (from a few ng g-1 in remote areas to 158 ng g-1 in marinas). The relative abundances of mono-, di- and tri-butyltin vary with the distance to point pollution sources and the depth of burial (i.e. the storage time). Half-life times of the three butyltin compounds were estimated in a marina sediment as close to 1.1, 1.9 and 2.1 years, respectively. Quite significant concentrations of butyltin compounds were measured in some commercial sea-shell samples.

96p., nombr. photos coul.

38 p.