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Objective: To assess the deep vein thrombosis risk of the treatment of the small saphenous veins depending on the anatomical pattern of the veins. Method: A multicenter, prospective and controlled study was carried out in which small saphenous vein trunks were treated with ultrasound-guided foam sclerotherapy. The anatomical pattern (saphenopopliteal junction, perforators) was assessed by Duplex ultrasound before the treatment. All patients were systematically checked by Duplex ultrasound 8 to 30 days after the procedure to identify a potential deep vein thrombosis. Results: Three hundred and thirty-one small saphenous veins were treated in 22 phlebology clinics. No proximal deep vein thrombosis occurred. Two (0.6%) medial gastrocnemius veins thrombosis occurred in symptomatic patients. Five medial gastrocnemius veins thrombosis and four cases of extension of the small saphenous vein sclerosis into the popliteal vein, which all occurred when the small saphenous vein connected directly into the popliteal vein, were identified by systematic Duplex ultrasound examination in asymptomatic patients. Medial gastrocnemius veins thrombosis were more frequent (p?0.02) in patients with medial gastrocnemius veins perforator. A common outlet or channel between the small saphenous vein and the medial gastrocnemius veins did not increase the risk of deep vein thrombosis. Conclusion: Deep vein thrombosis after foam sclerotherapy of the small saphenous vein are very rare. Only 0.6% medial gastrocnemius veins thrombosis occurred in symptomatic patients. However, the anatomical pattern of the small saphenous vein should be taken into account and patients with medial gastrocnemius veins perforators and the small saphenous vein connected directly into the popliteal vein should be checked by Duplex ultrasound one or two weeks after the procedure. Recommendations based on our everyday practice and the findings of this study are suggested to prevent and treat deep vein thrombosis. [ABSTRACT FROM AUTHOR]

The article presents guideline for liquid and foam sclerotherapy drafted on behalf of 23 European Phlebological Societies during a Guideline Conference in Mainz, Germany from May 7-10, 2012. The guideline focuses on sclerosing drugs, sodium tetradecyl sulphate and polidocanol, which are licensed in the majority countries of Europe. The guideline offers recommendations regarding efficacy, side-effects and indications of foam and liquid sclerotherapy of venous malformations and varicose veins.

The article presents guideline for sclerotherapy in chronic venous disorders and states that the guideline was drafted on behalf of the 23 European Phlebological Societies during a Guideline Conference, held from May 7-10, 2012 in Mainz, Germany, organized by the German Society of Phlebology. It further discusses recommendations on topics including large tissue necrosis, treatment complications and thrombosis.

Background: Superficial venous thrombosis (SVT) is perceived to have a benign prognosis. Objective: To assess the prevalence of venous thromboembolism in patients with SVT and to determine the 3-month incidence of thromboembolic complications. Design: National cross-sectional and prospective epidemiologic cohort study. (ClinicalTrials.gov registration number: NCT00818688) Setting: French office- and hospital-based vascular medicine specialists. Patients: 844 consecutive patients with symptomatic SVT of the lower limbs that was at least 5 cm on compression ultrasonography. Measurements: Incidence of venous thromboembolism and extension or recurrence of SVT in patients with isolated SVT at presentation. Results: Among 844 patients with SVT at inclusion (median age, 65 years; 547 women), 210 (24.9%) also had deep venous thrombosis (DVT) or symptomatic pulmonary embolism. Among 600 patients without DVT or pulmonary embolism at inclusion who were eligible for 3-month follow-up, 58 (10.2%) developed thromboembolic complications at 3 months (pulmonary embolism, 3 [0.5%]; DVT, 15 [2.8%]; extension of SVT, 18 [3.3%]; and recurrence of SVT, 10 [1.9%]), despite 540 patients (90.5%) having received anticoagulants. Risk factors for complications at 3 months were male sex, history of DVT or pulmonary embolism, previous cancer, and absence of varicose veins. Limitation: The findings are from a specialist referral setting, and the study was terminated before the target patient population was reached because of slow recruitment. Conclusion: A substantial number of patients with SVT exhibit venous thromboembolism at presentation, and some that do not can develop this complication in the subsequent 3 months. Primary Funding Source: GlaxoSmithKline, sanofi-aventis, and the Ministère Francais de la Santé et des Sports (Programme Hospitalier de Recherche Clinique). [ABSTRACT FROM AUTHOR]

Competing Interests: J.-L. Gillet déclare avoir été pris en charge, à l’occasion de déplacements pour congrès, par Kreussler Pharma.

Superficial vein thrombosis (SVT), a manifestation of venous thromboembolism (VTE), is a common condition, yet of all the types of VTE, it has been the least well studied. Recent studies have challenged the conception that SVT is a benign disease, showing that its risk factors overlap with those of deep-vein thrombosis (DVT) and that it is frequently associated with DVT or pulmonary embolism (PE). In 2010, the CALISTO trial demonstrated the benefit of treatment with fondaparinux at the dose of 2.5mg (one injection per day) for 45days for lower limb SVT. Prior to CALISTO, the treatment of SVT was based on venous compression therapy, nonsteroidal anti-inflammatory drugs (NSAID) and anticoagulation using various therapeutic regimens. Surgery could also be envisaged in certain cases. In CALISTO, the inclusion criteria designed to obtain a homogeneous population meant that numerous questions remained unanswered with respect to SVT occurring in other locations and under other circumstances, notably in pregnant women, patients with renal insufficiency, and patients with recurrent SVT or superficial vein thrombosis less than 5cm long. The aim of this section is to review the current state of knowledge of SVT and to propose or recommend therapeutic strategies for the management of SVT according to the clinical context, the location of the thrombosis, and the presence of particular risk factors., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Background: Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events., Objectives: To categorise contraindications to sclerotherapy based on the available scientific evidence., Methods: An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited., Results: Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes., Conclusions: Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of ' no intervention as a treatment option ' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.

Objective: The aim was to evaluate the distribution of the diameter of the great saphenous vein (GSV) at mid-thigh level and to investigate its association with clinical class, symptoms, and proximal extent of reflux., Methods: Vascular physicians, members of the French Society of Phlebology, were invited to participate in a consecutive observational study in patients presenting with symptoms and/or signs of uni- or bilateral chronic venous disorders (CVDs) in previously untreated limbs (clinical class of the CEAP classification C0s - C6). Patients were included between January and March 2015. They completed a specially designed venous symptoms questionnaire. Duplex ultrasound of the included limbs was performed with the patient standing to detect reflux in the GSV and to measure the GSV inner diameter at mid-thigh., Results: Between January and March 2015, 35 physicians examined 1245 patients (2450 limbs after excluding 40 limbs): 77% were female, mean age 52 ± 14; 69% of the patients had venous symptoms in one or both legs. The most frequent symptoms were feeling of heaviness, feeling of swelling and aching. Predominant CEAP clinical classes were C2 (38% of limbs) and C1 (35%). In case of GSV reflux (40% of limbs), the average diameter was 5.6 ± 2 mm and the distribution was 62% < 6 mm, 30% between 6 and 8 mm, and 8% > 8 mm. The study showed a clear association between clinical class and GSV diameter (the higher the clinical class, the larger the diameter; p < .0001), between venous symptoms and diameter (the larger the diameter, the higher the intensity of symptoms, p < .0001 for overall discomfort) and between proximal extent of reflux and diameter (the more proximal the extent of reflux, the larger the diameter, p < .0001)., Conclusion: The DIAGRAVES study demonstrated that in France for patients consulting with CVDs, more than half of the incompetent GSVs had a diameter < 6 mm, while large diameters were relatively infrequent. This should be kept in mind when considering management strategies in patients with CVDs., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Essentials Long-term risk of recurrence of isolated superficial vein thrombosis (SVT) is under-studied. We analyzed data from a cohort of first SVT and proximal deep vein thrombosis (DVT) without cancer. The risk of recurrence as DVT or pulmonary embolism is twice lower in SVT patients. However, overall risk of recurrence is similar between SVT and proximal DVT patients. Click to hear Dr Decousus' perspective on superficial vein thrombosis SUMMARY: Background Isolated superficial vein thrombosis (iSVT) (without concomitant deep vein thrombosis [DVT] or pulmonary embolism [PE]) is a frequent event, but available data on long-term outcomes are scarce and retrospective. Therefore, we aimed to determine prospectively the risk and type of venous thromboembolism (VTE) recurrence after iSVT and compare them with those of proximal DVT. Methods Using data from the prospective, multicenter, observational, OPTIMEV study, we assessed, at 3 years and after anticoagulants were stopped, the incidence and the type of VTE recurrence (iSVT/DVT/PE) of patients with a first objectively confirmed iSVT without cancer (n = 285), and compared these with those of patients with a first proximal DVT without cancer (n = 262). Results As compared with proximal DVT patients, iSVT patients had a similar overall incidence of VTE recurrence (5.4% per patient-year [PY] versus 6.5% per PY, adjusted hazard ratio [aHR] 0.9, 95% confidence interval [CI] 0.5-1.6), but iSVT recurred six times more often as iSVT (2.7% versus 0.6%, aHR 5.9, 95% CI 1.3-27.1) and 2.5 times less often as deep-VTE events (2.5% versus 5.9%, aHR 0.4, 95% CI 0.2-0.9). Varicose vein status did not influence the risk or the type of VTE recurrence. Saphenian junction involvement by iSVT was not associated with a higher risk of recurrence (5.2% per PY versus 5.4% per PY), but was associated with recurrence exclusively as deep-VTE events. Conclusion In patients with a first iSVT without cancer, after stopping anticoagulants, the incidence of deep-VTE recurrence is half that of DVT patients, but the overall risk of recurrence is similar. Ssaphenian junction involvement seems to influence the risk of deep-VTE recurrence, whereas varicose vein status has no impact or a low impact on VTE recurrence., (© 2017 International Society on Thrombosis and Haemostasis.)

Objectives Anomalous intraosseous venous drainage is a rare and almost unknown entity; only 14 cases have been reported in the literature and 4 mentioned in textbooks. We report the characteristics of 35 further cases observed in 32 patients. Method After the presentation of two cases at the congress of the French Society of Phlebology in Paris (2013), 12 colleagues joined to present a large series of so-called bone perforators observed in their practice, all identified with at least a duplex investigation. Results Thirty-two patients suffering from varicose veins and/or skin changes (C 2 -C 6 ) associated with a bone perforator of the tibia (with bilateral anomalies in three) are reported: 19 females and 13 males, average age 56.9. The majority of the affected legs were symptomatic (30/35). Bone perforator was an isolated finding in 27/35 legs. In three cases, the investigations revealed that the venous reflux in the bone originated from an incompetent posterior tibial vein. Conclusions We suggest the name of "bone perforators" for an anomalous tibial intraosseous venous drainage, feeding varicose veins, and in more advanced stages lipodermatosclerosis and leg ulcers. Most of them were successfully treated with surgery or sclerotherapy.

Objectives An aging population requires evaluation of methods of treatment for older patients. Our objective was to evaluate the indications, practical modalities, safety and tolerability of sclerotherapy in patients 75 years of age and older (group 1) and compare with a control group of patients 18 to74 years of age (group 2). Method This observational, multicentre, prospective and comparative study was conducted by the French Society of Phlebology. Each centre collected in 10 to 20 patients ≥75 years of age and an equal number of patients <75 years of age treated by sclerotherapy, the treatment indication, the patient's personal history, the CEAP clinical class, the type of the veins being treated, the characteristics of sclerotherapy and the complications (immediately after treatment and at one-month follow-up). Results Population: In total, 418 patients were enrolled in 15 centres: 176 patients in group 1 (mean: 79.4 years) and 242 patients in group 2 (mean: 52.7 years).CEAP clinical classes C4, C5 and C6, history of deep vein thrombosis (12.5%) and superficial vein thrombosis (11.9%), long-term anticoagulant therapy (9.1%) and antiplatelet therapy (16.5%) were more frequent in older patients.All types of veins were treated from saphenous veins to telangiectasias. Sclerotherapy features: There was no difference in concentration of the sclerosing agents. When foam sclerotherapy was used (84% of patients), the injected volume was lower in group 1., Complications: One vasovagal syncope occurred in group 1. One asymptomatic distal deep vein thrombosis, confined to the Medial Gastrocnemius Veins, was reported in both groups at one-month follow-up. Conclusions This study shows the feasibility and safety of sclerotherapy in older patients, with no specific complications nor need for special precautions.

Superficial venous thrombosis (SVT) prognosis is debated and its management is highly variable. It was the objective of this study to assess predictive risk factors for concurrent deep-vein thrombosis (DVT) at presentation and for three-month adverse outcome. Using data from the prospective multicentre OPTIMEV study, we analysed SVT predictive factors associated with concurrent DVT and three-month adverse outcome. Out of 788 SVT included, 227 (28.8%) exhibited a concurrent DVT at presentation. Age >75years (odds ratio [OR]=2.9 [1.5-5.9]), active cancer (OR=2.6 [1.3-5.2]), inpatient status (OR=2.3 [1.2-4.4]) and SVT on non-varicose veins (OR=1.8 [1.1-2.7]) were significantly and independently associated with an increased risk of concurrent DVT. 39.4% of SVT on non-varicose veins presented a concurrent DVT. However, varicose vein status did not influence the three-month prognosis as rates of death, symptomatic venous thromboembolic (VTE) recurrence and major bleeding were equivalent in both non-varicose and varicose SVTs (1.4% vs. 1.1%; 3.4% vs. 2.8%; 0.7% vs. 0.3%). Only male gender (OR=3.5 [1.1-11.3]) and inpatient status (OR=4.5 [1.3-15.3]) were independent predictive factors for symptomatic VTE recurrence but the number of events was low (n=15, 3.0%). Three-month numbers of deaths (n=6, 1.2%) and of major bleedings (n=2, 0.4%) were even lower, precluding any relevant interpretation. In conclusion, SVT on non-varicose veins and some classical risk factors for DVT were predictive factors for concurrent DVT at presentation. As SVT remains mostly a clinical diagnosis, these data may help selecting patients deserving an ultrasound examination or needing anticoagulation while waiting for diagnostic tests. Larger studies are needed to evaluate predictive factors for adverse outcome.

Background: Visual disturbances (VDs) are reported with an average rate of 1.4% after foam sclerotherapy (FS). Some clinical clues indicate that they could correspond to migraine with aura (MA)., Aims: To validate the hypothesis that VDs occurring after FS correspond to MA and are not transient ischaemic cerebro-vascular events., Method: A prospective multicentre study was carried out by the French Society of Phlebology in collaboration with the Neurology Department of the Marseille University Hospital (France). We included prospectively and consecutively all patients who experienced VDs after FS using air to make the foam. The patients were assessed (1) clinically with a specific form describing procedures of FS and recording neurological symptoms, later analysed by a neurologist specialized in migraine; and (2) by a brain diffusion-weighted magnetic resonance imaging (MRI) (T1, T2, T2*, diffusion) carried out within two weeks and analysed by a neuroradiologist., Results: Twenty patients, 16 women and four men, were included in 11 phlebology clinics. All kinds of veins were treated. VDs occurred in average seven minutes after FS. Clinical assessment showed that VDs presented characteristics of MA in all patients, with headache in 10 and without in 10. Paresthesia was observed in five patients and dysphasic speech disturbance in one. Fifteen patients (75%) had a personal history of migraine. Fifteen MRIs were performed within two weeks (mean: 8 days) and three were late (26 days). All of them were normal. MRI was not performed in two patients., Conclusion: These results show that VDs occurring after FS correspond to MA and are not transient ischaemic cerebro-vascular events. We suggest a pathophysiological hypothesis resting on the release of endothelin that would reach the cerebral cortex through a paten foramen ovale.

Objectives: The aim of this study was to assess thrombotic complications following sclerotherapy in thrombophilic patients in combination with thromboprophylaxis, in two randomized arms using low molecular weight heparin (LMWH) or warfarin. Patients and methods This study received approval from the Ethics Committee. A total of 105 patients (81 females, 24 males) ranging in age from 20 to 82 years (mean 50) were selected: 75 with Factor V Leiden mutation, 18 with prothrombin 20210A mutation, 7 with high level of Factor VIII, 5 combinations of these. After randomization, 51 and 54 patients received warfarin and LMWH, respectively. A total of 199 sclerotherapy sessions were performed. Foam was used in 160 treatments., Results: No episodes of symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) occurred; no instances of DVT were revealed by ultrasound-monitoring., Conclusions: This study suggests that in the three most common forms of thrombophilia, sclerotherapy, in combination with thromboprophylaxis, can be performed safely. Prophylaxis with LMWH is easier to use than warfarin.

Objectives: Increasing interest in foam sclerotherapy (FS) for saphenous insufficiency has highlighted the need to study the side-effects and complications of this treatment. The aim of this study is to better assess their nature and incidence., Methods: A multicentre, prospective and controlled study was carried out in which patients treated with FS for great (GSV) and small saphenous veins (SSV) trunk incompetence were included. Immediate untoward events were reported. Duplex ultrasound (DUS) examination was carried out to assess all patients between the eighth and 30th day. In addition, 20% of patients were called by an external auditor., Results: In total, 818 GSV and 207 SSV were treated in 1025 patients in 20 phlebology clinics. Ninety-nine percent of patients were controlled with DUS and non-duplex-checked patients were all called. The saphenous trunk was occluded in 90.3% of patients. Twenty-seven (2.6%) side-effects were reported: migraine (n = 8, 4 with visual disturbance); visual disturbance alone (n = 7); chest pressure alone (n = 7); and chest pressure associated with visual disturbance (n = 5). Eleven thrombo-embolic events occurred: 10 deep vein thrombosis (DVT) but only five in symptomatic patients, and one pulmonary embolism that occurred 19 days following the FS without DVT identified by DUS. One transient ischaemic stroke, with complete clinical recovery in 30 minutes, and one septicaemia with satisfactory outcome were reported as well., Conclusion: This study demonstrates in a large sample of patients a low rate of adverse reactions after FS of great and small saphenous trunks. However, but the eventuality of exceptional but more serious complications has to be taken into account in the management of patients. A multicentre study like this one takes into account different practices and reports all possible complications, thus demonstrating the need for a common validated protocol.

Objectives: To analyze prevalence, incidence mechanisms, physiopathology, investigations, treatment techniques and results of recurrent varices at the popliteal fossa after surgery., Methods: Published literature was analyzed as personal experience., Results: Recurrent varices after surgery at the popliteal fossa are much less frequent than at the sapheno-femoral junction because the short saphenous vein is less often the site of incompetence and treated by surgery. Precise prevalence and incidence is unknown. An analysis of recurrences at the popliteal fossa revealed three causes: (1) Incomplete division of the sapheno-popliteal junction (SPJ) at the terminal valve, which was incompetent at the initial surgery. The persisting reflux fills tributaries still connected to the saphenous stump; (2) Neovascularization reconnects the popliteal vein to the superficial network with new vessels, which are valveless; (3) Because the initial diagnoses is wrong and the incompetence involves the other veins of the popliteal fossa or arises from pelvic veins, which had not been recognized. Duplex scanning (DS) should identify the various sites of reflux and give precise anatomical and haemodynamic data. Treatment methods after recurrence at the popliteal fossa are repeat surgery, sclerotherapy or pelvic vein embolization when identified as the cause. Results provided by these different methods were analysed., Conclusions: At present, no randomized control has given grade 1A, 1B or 2A, 2B recommendations. We recommend that ultrasound-guided foam sclerotherapy should be the treatment of choice unless DS shows an incompetent stump at the SPJ with a gross reflux filling the venous network.

Background: Although muscular calf vein thrombosis (MCVT) is commonly seen in everyday practice, no treatment guidelines are available. This study evaluated short-term and mid-term outcome of isolated symptomatic MCVT., Method: We included prospectively and consecutively all patients referred to an outpatient clinic with isolated MCVT. Clinical signs were pain or edema, or both, of the calf. Diagnosis was established with duplex ultrasound (DUS) examination. Not completely occlusive and asymptomatic MCVTs were excluded. Patients were followed up clinically and with DUS at 1, 3, and 9 months, and up to 36 months. Anticoagulant therapy at curative dosage associated with compression was prescribed for 1 month and was extended for 2 additional months in case of incomplete recanalization at 1 month or if risk factors for venous thromboembolism (VTE) were present., Results: Included were 128 patients (78 women, 50 men) presenting with 131 MCVTs. Their mean age was 57.02 +/- 15.36 years (range, 20 to 87 years). Thrombus was present in the soleal veins (SoV) in 73 patients (55.7%) and in the medial gastrocnemius veins (MGV) in 58 (44.3%). Initial symptoms were isolated pain in the calf in 90 patients, isolated edema of the calf in six, and pain plus edema in 32. Anticoagulant therapy was prescribed in 53 patients (41.4%) for 1 month, in 59 (46.1%) for 3 months, and in 13 (10.2%) for >or=6 months. At baseline, nine pulmonary embolisms (7%), complicated with MCVT, were observed in six MGV patients (10.3%) and three SoV patients (4.1%; P = .18). Two nonfatal hemorrhagic events occurred. Three patients died during the follow-up after anticoagulant therapy had been discontinued. Recanalization of MCVT was considered complete at 1, 3, and 9 months in 54.8%, 84.7%, and 96% of cases, respectively, with no significant difference between the MGV and the SoV groups. Twenty-nine VTE symptomatic recurrences (PE, n = 6; DVT including MCVT, n = 23) were observed in 24 patients (18.8%), with similar figures in both thrombosis groups: none at 3 months, 11 between 3 and 9 months and 18 between 9 and 36 months. No extension of the MCVT or a recurrence of VTE was observed in patients treated with anticoagulant therapy. Twelve cases of superficial thrombophlebitis occurred during the follow-up period., Conclusion: This study confirms the place of MCVT in VTE disorders. Pulmonary embolism at the MCVT initial diagnosis was not rare, and mid-term follow-up (mean, 26.7 months) revealed that 18.8% of patients had at least one VTE recurrence. The treatment of acute MCVT needs to be standardized because no guidelines currently exist.

Objective: The negative predictive value of D-dimer (DD) assay in patients with venous thromboembolic disease is well established for deep vein thrombosis and pulmonary embolism. Little is known about the value of DD assay in patients with superficial thrombophlebitis (ST). The purpose of this study was to assess the value of DD assay in patients with ST of the lower limb., Method: The study group was composed of 100 consecutive patients, irrespective of age. Patients with clinical manifestations suggestive of ST of the lower limbs with positive duplex color Doppler evidence confirming the diagnosis and DD assay results (Vidas D-Dimer Exclusion) within 24 hours were included in the study. Patients with thrombosis in another site in addition to the superficial vein of the lower limb, those taking anticoagulants for more than 48 hours, and those with a condition known to potentially elevate DD levels were excluded. The volume of the thrombus was determined echographically and reported as mean diameter and length., Results: Sixty-two women and 38 men were included. Mean age (+/- 5) was 58 years +/- 13.48 (range 18-90; median: 57). The ST involved the Great saphenous (n=74), the small saphenous (n=11) or another vein (n=15). Mean thrombus volume was 4453 mm(3) +/- 7101 (range 94-38484; median: 1751). Mean DD level was 829 ng/ml +/- 516.72 (range 100-2567; median: 715.5). DD assay was negative (<500 ng/ml) in 32 patients (32%) and positive in 68 (68%). For these three items, there was no significant difference between ST with and without varicose veins. DD assay was always positive (>or=500 ng/ml) in all patients aged over 70 years (n=22). In patients aged less than 70 years (n=78), DD assay was positive in 46 (59%) and negative in 32 (41%). DD level was positively correlated with thrombus volume in patients aged less than 70 years (P<0.0001). ROC analysis, sensitivity as a function of specificity by thrombus volume for the entire population, determined the usefulness of a negative DD assay. Considering the critical threshold at 5914 mm(3), sensitivity was 1.0 (95CI 0.89-1.0), with 0.29 specificity (95CI 0.19-0.42), 1.00 negative predictive value and 0.75 positive predictive value. However, the thrombus volume was less than this threshold value in three of the nine cases of ST with extension to the terminal portion of the saphenous., Conclusion: A positive DD assay was observed in 68% of patients with ST, with no significant difference with or without varicose veins. The test was positive in all patients aged over 70 years and in 59% of those aged under 70 years. There was a correlation between DD level and thrombus volume, yielding a threshold volume (5914 m(3)) above which all DD tests were positive. Nevertheless, this threshold volume was too great to include all ST extending to the terminal portion of the saphenous. Measurement of DD level is thus not contributive to the diagnosis of ST.

Patients who undergo surgery involving the groin and the popliteal fossa often develop recurrent varices which require careful management. Several surveys using various classification systems have estimated the prevalence of recurrent varices after groin and popliteal surgery. Patients may seek medical care for various reasons: unsightly recurrent varicose veins, vein-related symptoms, appearance of cutaneous or subcutaneous changes, concerns about the health risk related to their veins or limitation of activity. Recurrent varices may also be found at routine follow-up examinations. An analysis of recurrence at this location reveals three main mechanisms: incomplete resection of the saphenofemoral or saphenopopliteal junctions in patients with an initially incompetent terminal valve. The persisting reflux feeds the tributaries connected at the saphenous stump; the second mechanism is related to neovascularisation that reconnects the deep venous system with the superficial network; the neo-veins are valveless. This phenomenon appears to be more frequent when the resection of the saphenous vein ending has been complete; the third mechanism is due to a tactical error; the refluxive pelvic veins that had not been diagnosed feed the varices. Duplex scanning identifies the different possible mechanisms and provides anatomical and hemodynamic data. Interventional treatment methods after varices recurrence are redosurgery, sclerotherapy and pelvic vein embolization when they are at issue. All these methods are described in details. Results provided by these treatments are analysed. Unfortunately no randomized control study enables grade A or B recommendations. Personally we suggest that ultrasound guided foam sclerotherapy should be the first-line treatment except when duplex scanning reveals an intact incompetent saphenous stump at the saphenofemoral junction or/and saphenopopliteal junction with a massive reflux filling the varicose network.

Background: The objective of this study was to evaluate the prevalence and profile of patients presenting with chronic venous insufficiency (class C3-C6) and cascading deep venous reflux involving femoral, popliteal, and crural veins to the ankle., Methods: From September 2001 to April 2004, 2,894 patients were referred to our center for possible venous disorders. The superficial, deep, and perforator veins of both legs were investigated with color duplex scanning. The criterion for inclusion in this study was the existence of cascading deep venous reflux involving the femoral, popliteal, and crural veins to the ankle whose duration had to be longer than 1 second for the femoropopliteal vein and longer than 0.5 seconds for the crural vein. The advanced CEAP classification, the Venous Clinical Severity Score (VCSS), the Venous Segmental Disease Score (reflux; VSDS), and the Venous Disability Score (VDS) were used., Results: Seventy-one limbs in 60 patients were identified. Eleven limbs (15.5%) were classified as C3, 36 (50.7%) as C4, 21 (29.6%) as C5, and 3 (4.2%) as C6. A primary etiology was identified in 11 (15.5%) limbs, and a postthrombotic etiology was identified in 60 limbs (84.5%). In the latter group, all but four patients were aware that they had had a previous deep venous thrombosis. In addition to femoropopliteal and calf veins, reflux was present in the common femoral vein in 60 (84.5%), the deep femoral vein in 27 (38%), and the muscular calf veins in 62 (87.3%). Incompetent perforator veins were identified in 53 (74.6%) limbs. Fifty-one (71.8%) limbs had a combination of superficial venous insufficiency (AS(2), AS(2,3), AS(4), or their combination) previously treated or present. Of these, 11 had primary etiology alone, and 40 had a secondary etiology with or without primary disease. Means and 95% confidence intervals of the VCSS, VSDS, and VDS were 9.72 (8.91-10.53), 7.2 (6.97-7.42), and 1.08 (0.83-1.32), respectively. A significant increase in the VCSS and in the VSDS (P < .0001) paralleled the CEAP clinical class. The VDS was higher in the C3 and C6 classes but did not reach significance. There was a significant link between the pain magnitude in the VCSS and the VDS (P < .0001). Severity of pain and high VDS did not depend on the wearing of elastic compression stockings. VCSS increased significantly according to the presence of an incompetent perforator vein (P < .05) and/or reflux in the deep femoral vein (P < .05)., Conclusions: This study confirmed the value of the Venous Severity Score as an instrument for evaluation of chronic venous insufficiency. A significant increase in the VCSS and VSDS paralleled CEAP clinical class; VDS was higher in classes C3 and C6 without reaching significance, probably because of the small size of the samples. Some clinical and anatomic features need to be clarified to facilitate scoring.

Background: Growing interest in sclerotherapy has emphasized the need for complete knowledge of all aspects of this method., Objective: To precisely delineate the actual incidence of immediate and delayed untoward events of daily sclerotherapy., Methods: A multicenter prospective registry was established in 22 phlebology clinics to report their activity and complications., Results: During the study period, 12,173 sessions of sclerotherapy were carried out, 5,434 with liquid, 6,395 with foam, and 344 using both. Four thousand eighty-eight (33.9%) sessions were carried out with ultrasound guidance. Forty-nine incidents or accidents (0.4%) occurred, of which 12 were with liquid and 37 with foam. These were reported during the time of the study and an additional 1-month follow-up. Most numerous were 20 cases of visual disturbances (in 19 cases, foam or air block was used); all resolved shortly, without any after-effects. A femoral vein thrombosis was the only severe adverse event in this study., Conclusions: This study demonstrates that sclerotherapy is a safe technique.

Unlabelled: Recent publications allow better understanding of superficial thrombophlebitis (ST) of the lower limb veins. However ST occurring in non varicose veins (NVV) and those occurring in varicose veins (VV) are seldom distinguished in literature., Aims of the Study: 1) To estimate the potential gravity of ST occurring in NVV by putting a figure on the frequency of associated deep venous thrombosis (DVT) and symptomatic pulmonary embolism (PE); 2) to identify some risk factors (thrombophilia, systemic disease, thromboembolic events); 3) to assess the different types of thromboembolic recurrent events after superficial thrombophlebitis (TRST) and identify the risk factors for recurrence., Material and Method: Forty-two cases of ST occurring in NVV were included consecutively and prospectively in this series; TRST possible risk factors were evaluated. Patients were assessed at 1 month and followed up to 3 years. Isolated ST was treated with low-molecular-weight heparin at prophylactic dosage from 15 to 21 days and with elastic compression., Results: 1) A DVT was combined in 12 cases (28.6%) located in the calf (n=9) or in the femoro-politeal axis (n=3). One symptomatic PE occurred confirmed by ventilation-perfusion lung scan; 2) The risk factor investigations identified a neoplasm in 2 patients (4.8%), a non neoplasic systemic disease in 4 (9.5%) and a thrombophilia in 20 patients. The most frequent thrombophilia was the heterozygous mutation of coagulation factor V (Leiden); 3) All patients were assessed at 1 month with a clinical examination and Duplex Scanning. We did not identify either new DTV, PE or extension of the previous DVT; 4) 17 TRST were identified in 13 patients. Three patients had 2 recurrences; one patient presented a TRST located at 2 different sites. In total 8 new ST and 9 DVT were identified., Discussion: The analysis of the literature shows that early complications or combinations (DVT and PE) occur with the same prevalence in NVV and VV groups. A risk factor was identified in 62% of patients in this series (thrombophilia was the most common) and TRST were statistically more frequent in this series than in groups of ST occurring in VV we had previously analyzed. A post-thrombotic syndrome and a DVT associated with the ST were identified as statistically significant risk factors for recurrence., Conclusion: ST occurring in NVV, although representing 5 to 10% of all ST, is seldom reported in the literature. Like ST occurring in VV, they have a potential gravity (associated DVT and PE). However these two diseases should be distinguished. A risk factor is more often identified and TRST are more frequent in the group of ST occurring in NVV. We advise active management of these thromboses including screening for a risk factor, the implementation of measures for preventing venous thrombosis recurrence and patient follow-up.

Objectives: Our objectives were first to estimate the potential gravity of superficial venous thrombosis (SVT) of the lower limbs by determining the frequency of associated deep venous thrombosis (DVT), pulmonary embolism (PE) and extensions of the junction or a perforating vein and second to identify factors of risk (neoplasia, thrombophilia, connective tissue disease, thromboembolic events)., Method: We conducted a prospective study in 100 cases of SVT in 88 patients with varicose veins (VV) and 12 patients without varicose veins (NVV)., Results: Superficial venous thrombosis was identified in 32 cases (32%): muscle vein in 23 (gastrocnemius, solesu), popliteo-femoro-iliac system in 5, and posterior tibial or fibular vein in 4. In 17 cases (17) the SVT extended to deep veins at distant localizations in 15 (15%). Pulmonary embolism was suspected clinically in 10 cases (10%) and confirmed in 3 (3%). An extension to the saphenous junction was observed in 17 cases (17%) and the thrombus migrated into a deep vein in 7. There were 6 cases of a unique extension to a perforating vein. Search for etiology was conducted in 86 cases: 64 were negative (74.4%), there was a neoplasia context in 5 (6%) and a hemostasis disorder in 17 (19.8%) including 6/12 (50%) in the NVV group and 11/74 (15%) in the VV group., Conclusion: Superficial venous thrombosis is often considered to be benign although severe situations can occur in patients with a hemostatis disorder. Consideration of these different factors (risk factors, presence of a deep venous thrombus or pulmonary embolism) should be helpful in determining the etiology and for a better choice of a therapeutic option (medical/surgical) depending on the different subpopulations identified.

Aims of the Study: Does preoperative Duplex Scan (DS) allow to determine anatomy of the ending of the short saphenous vein (SSV), gastrocnemius vein (GV) and reflux in popliteal vein (PV), SSV and GV. Postoperative DS was performed to detect deep vein thrombosis (DVT) and GV thrombosis., Material and Methods: From June 94 to November 95 one hundred and eighty lower limbs operated for SSV were included consecutively and prospectively. Mean age in these 154 patients was 52 yr (24-80) with a sex ratio 4F/1M. An anatomical classification was previously defined. Type A: separate termination of SSV and GV; Type B: common ostium of SSV and GV in the popliteal vein; Type C: common trunk of the SSV and GV; Type D: Others. Forty-eight limbs (26.10%) had ligation of GV: 21 (11.10%) for reflux and 27 (16%) for anatomical or surgical reasons. Ten type A with GV reflux (10/31 = 32%) were not treated. Eighty two patients (45%) received preventive low molecular weight heparin (LMWH) treatment including the 48 limbs whose GV were ligated., Results: Anatomical correlation between DS and surgery findings were calculated. Positive predictive values of DS in the different types were: A, 77%; B, 68%; C, 90%; D, 79%. That gave a global predictive value of 80%. Two limited DVT were identified in group D by postoperative DS (2/10 = 1.1%). These two patients had complete recanalization of PV without reflux. In the group of limbs which had ligation of GV we identified 37.5% of GV thrombosis. In the group without ligation of GV we found 3% of GV thrombosis., Conclusion: Duplex scanning appears to be the investigation of choice before surgery for superficial vein incompetence in the popliteal fossa. It is a reliable investigation to determine termination patterns of SSV and GV (80%). It brings to the surgeon essential information which helps in the management of surgical procedure and particularly to ligation of gastrocnemius veins. But at this time there is no consensus on this point. The occurrence of DVT after SSV surgery including GV ligation was very low. Two questions remain: is anticoagulation necessary in all patients or selective after surgery of the SSV? is Duplex Scan mandatory during postoperative monitoring? On the basis of this study, one recommendation can be made: A routine postoperative DS is necessary after ligation of the GV or when the dissection of the popliteal fossa has been extensive (Type D).