News about Veins

CHANGE OF ADDRESS AS OF 14 SEPTEMBER 2006

We are thrilled to announce that as of Sept 14, 2006 we will be moving into our brand new refurbished office equipped with healthcare approved surgical theatre and state-of-the-art ultrasound scan. The Harley Street Medical Centre has been completely and magnificently renovated this past year and is professionally supervised by Dr Brian Leaker on the medical level and by Barbara Bird at the administrative level. To dowload a leaflet of the medical centre go here.

Consultation will be on Thursday afternoon and surgery is planned for Thursdays and Fridays.

Appointments can be arranged with Angela Brooks at the Medical Centre, Phone: 078 5239 5888

The Times, 20 October, 2004

There's no need to suffer in vein
by Claire Dight

FIFTY per cent of women over 40 have problems with varicose or thread veins and if you are a secretary or PA, your job might be making the problem worse, according to Philip Bull, a consultant surgeon.

"The cause of varicose veins is not known," he explains, "but the hereditary factor is thought to be the main one. If your parents had them, you are 60 per cent likely to suffer. Immobility, lack of exercise and obesity exacerbates the condition which is much more common among women than men."

This is bad news if your job requires you to stand or sit behind a desk for long periods every day. Varicose veins are abnormal, dilated blood vessels caused by a weakening in the vessel wall that allows blood to flow the wrong way. The symptoms range from a feeling of heaviness and a dull ache to unsightly lumps, swelling, itchiness and skin discolouration. Thread veins, which appear like a spider's web of red lines, especially around the knees, can be covered up by foundation or thick tights. Varicose veins often require surgical intervention.

The conventional operative procedure, vein stripping, requires a general or spinal anaesthetic. An incision of 3-4cm is made in the groin or behind the knee to find the guilty vein. Through ultrasound, the route is tracked and incisions made along the leg. The vein is then tied at the points where its branches meet the main vein, so it effectively dies. Each section is then removed through the incisions. Patients typically need two weeks off work and a full recovery can take some months. Scarring can be a problem.

Now, however, there is a less invasive procedure, more suited to a busy lifestyle. EndoVenous Laser Treatment (EVLT) was developed in America and approved for use in the NHS by the National Institute for Clinical Excellence this year.

EVLT involves inserting a laser head into a small incision via a guide wire above or below the knee at the closest point to the vein. The guide wire is removed leaving the laser head in place. The head is then slowly withdrawn, flashing once a second to kill the vein through thermal injury. The procedure is carried out under local anaesthetic and takes about 20 minutes per leg.

Philip Bull believes that the new procedure is better for patients. "After EVLT the vein becomes hard to the touch and the patient may experience some redness and tenderness for some weeks, but it is not painful. The patient can walk around, travel and resume normal activities after only a two-hour stay in hospital to ensure the local anaesthetic has been absorbed." He advises patients to wear compression stockings for four to six weeks after surgery.

The procedure won't suit everybody. About 10 per cent will not benefit if they have had prior surgery for the same problem vein or suffer from thrombosis.

One person who successfully underwent the therapy, however, was Helen Cliffin, 34. She had the treatment when she became increasingly aware that her varicose veins were affecting her confidence and, because she was finding them painful, her day-to-day activity.

Helen's family has a history of varicose veins but she didn't worry about it until she became pregnant at 29 and her veins worsened significantly. She ignored them as she was so busy. When she was pregnant again at 32, her legs felt constantly tired and heavy. After the birth of her second child, she became embarrassed about her legs and stopped wearing skirts. She was advised to take regular walks and keep her legs elevated but found this did not help. She sought surgery and was relieved to find it unnecessary.

Her EVLT treatment involved two 40-minute sessions. "There was no pain, and it was easy and quick," she says. Helen had her treatment at the Private Patients Services clinic in London. A consultation costs £150 and the therapy from £1,200.

Information, 0845 8504050; specific inquiries, 020-7323 2123.

Copyright 2004 Times Newspapers Ltd.
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What's New in ACS Surgery

The Evolution of Varicose Vein Treatment
from ACS Surgery: Principles & Practice   - William H. Pearce, MD, FACS (Posted 09/09/2003)

Today, the common clinical problem of varicose veins can be addressed using a variety of techniques. Treatments range from the standard surgical therapy of high ligation and stripping of the greater saphenous and tributaries to sclerotherapy, laser vein ablation, and vein closure devices. As the technique has evolved over time, microphlebectomy has been used to remove varicosities below the knee, and the greater saphenous is stripped from the groin to the knee.

Ablation
The two newest technologies--laser vein ablation and radiofrequency vein ablation--have challenged traditional surgical thinking about varicose veins. Instead of high ligation, both of these devices are placed intraluminally in close proximity (< 2 cm) to the saphenofemoral junction. Either by heat generated from the laser or by radiofrequency, the vein is ablated from the groin to just above the knee. The saphenofemoral branches are left intact. Microphlebectomies are used for the varicosities below the knee. Many studies have documented excellent cosmetic outcomes; however, there are a few reports detailing recannalization, arterialization, and deep vein thrombosis.

Recently, another device has become available for the treatment of varicose veins. This device is an illuminated power phlebectomy system that identifies the varicose veins and resects them. This technique is generally used in conjunction with the standard high ligation and surgical stripping to the knee. Early results are also promising.

Spider Varicosities
Sclerotherapy remains the mainstay of the treatment of spider varicosities. However, several reports have documented its efficacy for large vein varicosities. Similar to other vein ablation systems, the ability to eradicate all branches at the saphenofemoral junctions is somewhat limited by this technique. Like all of the procedures described above, sclerotherapy has advocates as well as critics.

Limitations of Evidence
Since many of these procedures are performed for cosmetic reasons, the impetus to conduct a randomized prospective study is limited. In addition, as a result of successful marketing, patients are directing their care and probably would not likely participate in such trials. When such gaps in evidence collection become apparent, practitioners must step forward and take the lead in providing valuable data to better assess both short-term and long-term results. Thus, it is important for practitioners to keep accurate records of patient outcomes, particularly when late outcome becomes important. Although the immediate result of these new techniques may be gratifying, late recurrence must be documented.

Bibliography
Cheshire N, Elias SM, Keagy B, et al: Powered phlebectomy (TriVex) in treatment of varicose veins. Ann Vasc Surg 16:488, 2002 [PMID 12085123]
Merchant RF, DePalma RG, Kabnick LS: Endovascular obliteration of saphenous reflux: a multicenter study. J Vasc Surg 35:1190, 2002 [PMID 12042730]
Min RJ, Zimmet SE, Isaacs MN, et al: Endovenous laser treatment of the incompetent greater saphenous vein. J Vasc Interv Radiol 12:1167, 2001 [PMID 11585882]
Tisi PV, Beverley CA: Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev (1):CD001732, 2002 [PMID 11869605]
Weiss RA, Dover JS: Leg vein management: sclerotherapy, ambulatory phlebectomy, and laser surgery. Semin Cutaneous Med Surg 21:76, 2002 [PMID 11911538]

For more information, visit
http://www.acssurgery.com
ACS Surgery: Principles and Practice

William H. Pearce, MD, FACS , Northwestern University Feinberg School of Medicine
ACS Surgery 2003. © 2003 WebMD Inc  All rights reserved.

Injection sclerotherapy for varicose veins
from Cochrane Review Abstracts  (Posted 04/01/2004)

A substantive amendment to this systematic review was last made on 13 September 2001. Cochrane reviews are regularly checked and updated if necessary.

Background: Injection sclerotherapy for varicose veins has been used widely since 1963, following popularisation of the technique by Fegan. The treatment aims to obliterate the lumen of varicose veins or thread veins. There is limited evidence regarding its efficacy.

Objectives: To determine whether sclerotherapy is effective in improving symptoms and cosmetic appearance, and has an acceptable complication rate; to define rates of symptomatic or cosmetic varicose vein recurrence following sclerotherapy.

Search strategy: Publications describing randomised controlled trials (RCTs) of injection sclerotherapy for treatment of varicose veins (excluding comparisons with surgery) were sought through EMBASE and MEDLINE (from inception to October 2002) and by hand-searching journals, using the search strategy described by the Cochrane Peripheral Vascular Diseases Review Group. Bibliographies of papers identified were examined for further RCTs. Manufacturers of sclerosants were contacted for additional trial information.

Selection criteria: RCTs of injection sclerotherapy versus graduated compression stockings or 'observation', or comparing different sclerosants, doses and post-compression bandaging techniques on patients with symptomatic and/or cosmetic varicose veins or thread veins were considered for inclusion in the review.

Data collection and analysis: Twelve studies were included. These compared: sodium tetradecyl sulphate (STD) versus another sclerosant; sclerosant versus sclerosant plus local anaesthetic; Molefoam versus Sorbo pads at injection sites; elastic compression versus conventional bandaging; short-term versus standard bandaging; sclerotherapy versus graduated compression stockings. Data were extracted by both authors.

Main results: One RCT comparing sclerotherapy to graduated compression stockings in pregnancy found that sclerotherapy improved symptoms and cosmetic appearance. Two studies comparing STD to alternative sclerosants found no significant differences in outcome or complication rates. Adding local anaesthetic to sclerosant reduced the pain from injection (one study) but had no other effects. One study comparing Molefoam and Sorbo pad pressure dressings found no difference in erythema (redness) or successful sclerosis. The degree and duration of elastic compression had no significant effect on varicose vein recurrence rates, cosmetic appearance or symptomatic improvement. Increased compression prevented slipping of dressings, but also increased discomfort, as did increased duration of compression.

Reviewers' conclusions: Evidence from RCTs suggests that the type of sclerosant, local pressure dressing, degree and length of compression have no significant effect on the efficacy of sclerotherapy for varicose veins. The evidence supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery, and thread veins. A comparison of surgery versus sclerotherapy is needed.

Citation: Tisi PV, Beverley CA. Injection sclerotherapy for varicose veins (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.

Cochrane Rev Abstract 2004. © 2004 The Cochrane Collaboration

Chronic Venous Insufficiency: The Effects of Health-Care Reforms on the Cost of Treatment and Hospitalisation - an Italian Perspective
From Current Medical Research and Opinion  (Posted 01/15/2004)

In 1993/94, reforms were made to the Italian health system in order to reduce costs for the treatment of CVI. One of these reforms was the de-reimbursement of phlebotropic drugs (the mainstay of treatment of CVI in Italy). By analysing the Italian experience before, and after, 1994, we can evaluate the effect these reforms had in terms of health-care costs. In so doing it is seen that, although the goal of the Italian health reforms was to reduce costs, the reality was such that the de-reimbursement of phlebotropic drugs resulted in the opposite, namely increased costs for the treatment of CVI. Further studies are required to confirm these preliminary results on a larger scale.

Acknowledgements
The author wishes to acknowledge the assistance of Gerald Rickard in the preparation of this manuscript.

Reprint Address
Address for correspondence: Prof Claudio Allegra, Chief of Angiology Department, San Giovanni Hospital, Via Sant Erasmo 14, 35184 Rome, Italy. Tel: +39 06 770 55 565; Fax: +39 06 704 93 570; email: allegraclaudio@libero.it

Varicose Vein Surgery from ACS Surgery: Principles & Practice  (Posted 08/04/2003)
John J. Bergan, MD, FACS , Vein Institute of La Jolla, Luigi Pascarella, MD , University of California, San Diego, School of Medicine

Duplex Scanning, Physical Exam Key to Evaluation

Discusses indications, preoperative evaluation, operative planning and technique, surgical options, complications, alternatives to saphenous vein stripping, and outcome evaluation.

Over the years, surgical treatises have devoted a great deal of space to clinical examination of the patient with varicose veins. Numerous clinical tests have been described, many of which carry the names of famous persons interested in venous pathophysiology. This august history notwithstanding, the Trendelenburg test, the Schwartz test, the Perthes test, and the Mahorner and Ochsner modifications of the Trendelenburg test are, for the most part, useless in preoperative evaluation of patients today.

There is no doubt that clinical evaluation can be improved by using handheld Doppler devices. In our view, however, preoperative evaluation is best performed by means of duplex scanning and physical examination. Although many cite cost considerations as a reason for omitting duplex evaluation, we believe that duplex scanning for venous insufficiency is in fact both simple and cost-effective. Duplex mapping defines individual patient anatomy with considerable precision and provides valuable information that supplements the physician's clinical impression.

Saphenous Vein Stripping vs. Ligation

Ligation of the saphenous vein at the saphenofemoral junction has been widely practiced in the belief that it would control gravitational reflux while preserving the vein for subsequent arterial bypass. It is true that the saphenous vein is largely preserved after proximal ligation; however, reflux continues and hydrostatic forces are not controlled. Recurrent varicose veins are more frequent after saphenous ligation than after stripping and are more common after saphenous ligation and sclerotherapy than after saphenous stripping and sclerotherapy.

Consulting the Evidence
A prospective randomized trial comparing proximal saphenous vein ligation and stab avulsion of varices with stripping of the thigh portion of the saphenous vein and stab avulsion of varices showed the latter approach to be superior. Routine saphenous vein stripping reduces the rate of varicosity recurrence and the need for reoperation for recurrent saphenofemoral incompetence

Optimizing Management of Chronic Venous Insufficiency

Disclosures  Kenneth Murphy, MD, FSIR

Chronic venous disease of the lower extremity is a very common condition in the United States. It is estimated that 3% to 8% of the US population has symptomatic lower-extremity venous insufficiency and 1% of adults over the age of 60 years have chronic ulceration. [1] The estimated total healthcare cost of treating this disease to the US economy was approximately $1 billion in 2002. [1] The clinical manifestations of lower extremity venous insufficiency vary from minor cosmetically displeasing lesions to severely disabling disease. The most common clinical manifestation of venous insufficiency in the lower extremities is varicose veins, which are estimated to occur in 30% to 60% of adults. The predominant risk factors associated with the development of varicose veins include female gender, pregnancy, and increased age.

Traditionally, surgical vein stripping or ligation has been used to manage patients with lower-extremity varicose veins. These treatments are associated with significant pain, a prolonged recovery period, and a high rate of recurrence. Recently, new percutaneous endovenous techniques have been introduced that permit a minimally invasive option for the management of patients with lower-extremity venous insufficiency. The 28th Annual Scientific Meeting of the Society of Interventional Radiology (SIR), which convened in Salt Lake City, Utah, March 27-April 1, devoted significant emphasis to this topic, including featured symposia, plenary session, workshop session, and a scientific session. The featured symposia, plenary session, and workshop profiled the epidemiology, pathophysiology, clinical patterns, and duplex ultrasound evaluation of venous insufficiency, percutaneous techniques for the treatment of saphenous vein reflux (radiofrequency ablation and endovenous laser ablation), prosthetic venous valves, and practice development issues. Robert J. Min, MD, Cornell Vascular, New York, New York, and John A. Kaufman, MD, Dotter Interventional Institute, Portland, Oregon, moderated the symposia and plenary sessions, respectively.

Pathophysiology and Anatomic Considerations of Lower - Extremity Venous Insufficiency
Managing patients who have lower-extremity venous insufficiency necessitates a thorough understanding of the venous anatomy and pathophysiology of venous insufficiency. The lower-extremity venous anatomy is composed of a deep and superficial system that is regulated by a calf muscle pump system. The superficial venous system is composed of the greater and lesser saphenous veins in the lateral (subdermic) venous system. The deep venous system includes the deep veins of the thigh and calf. The deep venous system and superficial system communicate via the major perforating veins, which predominate in the calf. There are four named groups of perforator veins associated with greater saphenous vein (GSV) reflux that are clinically relevant to the physician diagnosing and treating venous insufficiency. They include the Hunterian (mid-upper medial thigh), Dodd's (above medial knee), Boyd's (medial below knee), and Cockett's veins (above ankle). The pathophysiology of venous insufficiency is most often caused by valvular failure with resultant varicose veins. Valvular failure results in reflux, elevated venous pressure, and dilatation in that segment. The most common site of reflux is at the saphenofemoral junction (SFJ) with resultant superficial varicosities. A second, less common, cause of varicosities is valvular incompetence involving the perforator veins, which is typically a result of high-pressure leak gradient toward the superficial venous system with subsequent dilatation and varicose vein formation.

Clinical and Duplex Evaluation
Neil Khilnani, MD, Cornell Medical Center, New York, New York, stressed that clinical assessment and duplex evaluation are critical to the success of any endovenous procedure. Clinical evaluation involves compiling a detailed patient history with targeted questions that include questions about history of pregnancy, trauma, hypercoagulable syndromes, and prior deep venous thrombosis. Physical examinations of the patient should be performed in the erect position with attention to the lower-extremity, lower abdomen, and pubic region. Dr. Khilnani stressed that the clinical exam should be supplemented by a comprehensive duplex ultrasound evaluation. The principle objectives of the duplex evaluation include determining the patency of the deep and superficial venous systems, identifying and localizing reflux, and pinpointing the blood flow source to the varicose segments. The GSV is mapped with duplex ultrasound from the level of the SFJ to the level of the ankle. The exam is performed with the patient standing, and with the patient's weight supported on the contralateral limb. The leg to be evaluated is flexed, and the exam commences from the top of the thigh to the level of the lowest varicosities and/or ankle. The saphenofemoral junction (SFJ) is assessed for competency. Reflux is evaluated using color and pulse wave Doppler with simultaneous augmentation of the venous segments below the level that is being examined. In similar fashion, the lesser saphenous vein and perforators are examined. The deep venous system is also interrogated for any underlying deep venous thrombosis (DVT).

Percutaneous Techniques for Treatment of Saphenous Vein Reflux
There are two techniques for the percutaneous endovenous treatment of GSV reflux. These techniques are radiofrequency ablation and laser occlusion. Radiofrequency involves using the Closure Device (VNUS, Medical Technologies, Sunnyvale, California), which is a US Food and Drug Administration-approved technology that promotes venous occlusion by applying radiofrequency (RF) thermal energy to the wall of the vein. The device consists of a 6-F or 8-F catheter containing retractable electrodes that deliver the RF energy. A generator delivers electrical current to the probe, which results in frictional heating at the probe tip. The heating produces local thermal energy, which, when maintained at 85º C, results in vessel wall damage that is characterized by protein denaturation and collagen deposition. The device is placed in the GSV at/or below the knee, using ultrasound guidance. Dr. Rosenblatt, Connecticut Image-Guided Surgery, Milford, Connecticut, stressed that the device must be positioned close (1-2 cm) to the SFJ for clinical success. The device is retracted along the course of the GSV. The procedure can be performed in an outpatient setting using local tumescent anesthesia, which involves infiltrating the perivenous space with a large volume of 0.25% lidocaine. According to Dr. Rosenblatt and other investigators at SIR 2003, conscious sedation is not generally required for this procedure. Dr. Rosenblatt indicated that other refluxing veins identified during the preprocedure duplex mapping can be treated with RF ablation, provided the course is straight enough to facilitate device passage under fluoroscopic-guidance, which is typically done through a guidewire. A recent study compared postprocedure pain, the convalescent period, and the cost of the RF endovenous approach with conventional surgical stripping. The study documented that the incidence of postoperative pain, recovery time, and cost of the RF obliteration is significantly less than conventional surgery. [2]

In the scientific session at SIR devoted to this topic, Dr. Rosenblatt [3] described the radiographic and clinical outcomes of RF treatment of GSV reflux in 124 patients who had symptomatic venous insufficiency. Symptomatic improvement occurred in 97.1% of patients, and ultrasound occlusion of GSV was documented in 95.7% of patients on a mean follow-up at 3.4 months. Complications included mild transient paresthesias (11%) and skin burns (1.4%). Treatment failures were retreated with success in every case. Treatment failures were associated with a large incompetent GSV perforator, which the investigators hypothesized may have acted as a heat-sink preventing adequate thermal ablation of the vein wall at that level. In a second scientific presentation, Dr. Rosenblatt [4] described RF ablation of non-greater saphenous lower extremity veins for managing venous insufficiency. In this study, 42 patients who had non-GSV reflux were treated with radiofrequency occlusion. Technical success was achieved in all cases, duplex ultrasound occlusion was documented in 92.6% of cases on follow-up, and symptomatic improvement was seen in 96% of cases. Non-greater saphenous lower extremity veins treated included the anterior-lateral tributaries, GSV perforators, and lesser saphenous veins.

Concurrent with the development of RF venous ablation, laser techniques have been used with success. In 1998, the fiberoptic laser fiber was introduced as an alternative method for using laser energy for treatment of GSV reflux. The procedure is analogous to the radiofrequency technique and is typically performed under ultrasound guidance after local anesthesia is administered with tumescent anesthesia. Treatment is limited to GSVs that have diameters of 2 mm-12 mm. The endovenous laser catheters are inserted into the GSV through a 5 F introducer sheath, at or below the knee level. The laser tip is positioned at approximately 1-2 cm below the SFJ, and the position of the tip is confirmed on ultrasound. The typical diode laser energy is 810 nm (Diomed, Inc., Hanover, Massachusetts) and/or 980 nm wavelength (Angiodynamics, Inc., Queensbury, New York). The laser induces focal injury to the endothelium and vein wall without significant extension into fat and tissue. Results of the endovenous laser technique for GSVs demonstrated 99% vessel occlusion at 1-9 months follow-up. [5] In a scientific session, Robert Min, MD, [6] described 2-year follow-up results for management of saphenous vein reflux using this technique. In his study, a total of 389 GSVs in 344 patients were treated with the 810 nm diode laser. At follow-up, ultrasonography was obtained in 88 limbs, and 93% of these were occluded at a minimum of 2 years. There were no skin burns, paresthesias or DVTs. Dr. Min concluded that endovenous laser treatment of saphenous vein reflux is a successful technique with a low (7%) recurrence rate and a minimum complication rate.

After occlusion by either laser technique or radiofrequency ablation, the patient is discharged and instructed to wear compression stockings for approximately 7 days. The patient is also instructed to continue normal daily activities, without significant exercise during this initial recovery period. Postablation sclerotherapy or ambulatory phlebectomy can be performed approximately 4 weeks after the initial procedure.

Sclerotherapy of Spider Veins and Varicose Veins
Dr. Min and other presenters on this topic at SIR 2003 stressed the importance of adjunct sclerotherapy for the treatment of spider veins and varicose veins after GSV occlusion. These additional treatment strategies are necessary to ensure a "successful outcome and amelioration of symptoms and cosmetic defects," according to Dr. Min. The mainstay of such therapy is sclerotherapy. The indications for adjunct techniques include telangiectasias, reticular veins, and residual varicose veins. Injection sclerotherapy involves targeted delivery of a sclerosant agent into a superficial vein, which initiates intimal irritation and is followed by an intense inflammatory reaction and the subsequent ingrowth of granulation tissue and fibrosis. This results in a fibrous cord-like vein that is permanently obliterated. The sclerosant agents available include sodium tetradecyl sulfate, polidocanol, dextrose/sodium chloride, and chromated glycerin. Sodium tetradecyl sulfate and polidocanol are preferred agents; however, polidocanol is currently not approved for use in the United States. The volume injected depends on the target; typically, 0.2 to 0.5 mL is used for reticular veins and 0.1 to 0.4 mL is used for telangiectasias. The injection is typically performed with the patient in the horizontal position, which reduces the venous pressure and allows for complete injection into an "empty" vein. The sclerosant injection is usually painless; typically, a compression bandage or stocking is applied postinjection for a period of 3 days to several weeks. Dr. Min and other researchers stressed the importance of diligent follow-up at approximately 2 weeks to evaluate patients for optimal results, as well as for areas of "trapped" blood. Areas of trapped blood can be associated with focal tenderness and may result in pigmented areas that are cosmetically displeasing. A simple puncture with a 25 G or slightly larger gauge needle facilitates aspiration of trapped blood.

An additional adjunct technique is ambulatory phlebectomy, which is a minor surgical procedure that involves careful dissection, isolation, and ligation of superficial and reticular veins.

Future Venous Therapeutic Alternatives
Dusan Pavcnik, MD, Dotter Institute, Portland, Oregon, outlined some of the exciting developments in the technology of prosthetic venous valves. One such valve is the bioprosthetic, bicuspid valve, which is composed of a square stent and small intestinal submucosal covering. This prosthetic valve has been placed successfully in a sheep model. A manufactured, percutaneous, nonimmunogenic venous valve is currently under development. This prototype employs a square stent as the foundation supporting a prosthetic valve biomaterial. These valves are potentially available in various diameters and may not require anticoagulation. Further development and clinical trials to explore the efficacy of these technologies are underway.

Ramping Up Your Venous Insufficiency Practice
Gerald Niedzwiecki, MD, Meese Countryside Hospital, Safety Harbor, Florida, spotlighted the elements of establishing a successful venous management practice. A dedicated physician and staff with appropriate training are mandatory. In addition, most chronic venous insufficiency work is best managed in an outpatient setting. Success is dependent on the state-of-the-art equipment, nursing, ancillary staff, and diligent patient follow-up. Dr. Niedzwiecki stressed that the management of venous insufficiency is an evolving field that interventionalists should embrace as part of their mission of offering customers a comprehensive program of quality patient care.

References
1. Callam MJ. Epidemiology of varicose veins. Br J Surg. 1994;81:167-173. Abstract
2. Rautio T, Ohinmaa A, Perala J, et al. Endovenous obliteration versus conventional stripping operation in the treatment of primary varicose veins: a randomized controlled trial with comparison of the costs. J Vasc Surg. 2002;35:958-965. Abstract
3. Rosenblatt M, Burdge C, Gandhi RT. Treatment of venous insufficiency due to greater saphenous vein reflux with endovenous radiofrequency ablation. J Vasc Interv Radiol. 2003;14:S35.
4. Rosenblatt M, Burdge C, Gandhi RT. Endovenous radiofrequency ablation of non-greater saphenous lower extremity veins to treat venous insufficiency. J Vasc Interv Radiol. 2003;14:S36.
5. Min R, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser treatment of the incompetent greater saphenous vein. J Vasc Interv Radiol. 2001;12:1167-1171. Abstract
6. Min RM, Khilmani N. Endovascular laser treatment of saphenous vein reflux. Two year follow-up results. J Vasc Interv Radiol. 2003;14:S35.

May 11, 2004 — Risk factors for venous thromboembolism (VTE) in patients hospitalized for acute medical illness include infection, age older than 75 years, cancer, and history of VTE, according to the results of a randomized trial published in the May 10 issue of the Archives of Internal Medicine

"There is limited information about risk factors for venous thromboembolism (VTE) in acutely ill hospitalized general medical patients," write Raza Alikham, BSc, MBBS, and colleagues from Guy's, King's and St. Thomas' School of Medicine in London, England. "The rationale for providing thromboprophylaxis is that prevention is clinically and financially beneficial compared with treatment of a thromboembolic event once it has occurred."

In the Prophylaxis in Medical Patients with Enoxaparin (MEDENOX) trial, an international, double-masked, placebo-controlled study that enrolled 1,102 acutely ill, immobilized general medical patients, the low-molecular-weight heparin enoxaparin sodium was effective in preventing thrombosis. To evaluate independent risk factors for VTE, the investigators performed a new logistic regression analysis of the MEDENOX data, looking at risks associated with acute illness such as heart failure, respiratory failure, infection, rheumatic disorder, and inflammatory bowel disease, and predefined factors such as chronic heart and respiratory failure, age, previous VTE, and cancer.

Acute infectious disease, age older than 75 years, cancer, and a history of VTE were statistically significantly associated with an increased risk of VTE, based on primary univariate analysis. Multiple logistic regression analysis revealed that each of these factors was independently associated with risk of VTE.

"Our analysis extends the findings of the MEDENOX study, revealing that certain disease and patient factors are independently related to the genesis of VTE in acutely ill medical patients," the authors write. "These findings allow recognition of individuals at increased risk of VTE and will contribute to the formulation of an evidence-based risk assessment model for thromboprophylaxis in hospitalized general medical patients."

Aventis Pharmaceuticals supported this analysis. The authors report no relevant financial interest in this article. Arch Intern Med. 2004;164:963-968