OBJECTIVE:The lack of objective hemodynamic criteria for diagnosing pelvic venous disorders (PeVD) limits interdisciplinary consensus in vascular surgery, radiology, phlebology and gynecology societies. We applied non-contrast 2D phase-contrast MRI (2D PC-MRI, QFlow) to quantify pelvic-lower-limb venous flow and assess diagnostic performance. METHODS:A retrospective cross-sectional study was conducted on 428 women who underwent 2D PC-MRI between 2017 and 2024. Participants included PeVD (n=138), healthy controls (HC; n=39), and symptomatic non-PeVD patients (Non-PeVD; n=251). An additional subset of symptomatic PeVD who underwent venous intervention (n=26) was analyzed. Hemodynamic parameters included stroke volume (SV), mean flux (MF) , stroke distance (SD), mean velocity (MV), and ankle interstitial pixel-shift signals. RESULTS:PeVD patients demonstrated a consistent hemodynamic signature marked by increased central flow, reduced superficial flow, and left gonadal vein (LGV) reflux. Compared with HC, PeVD showed higher right EIV SV and MF, lower left GSV SV and MF, and pronounced LGV abnormalities (SV 1.29 vs 0.54 mL; MF 1.50 vs 0.60 cm3/s; SD -0.50 vs 2.14; MV -0.49 vs 2.39; all p=0.0001). Popliteal vein flow was altered, and ankle signals were elevated. ROC analysis identified left GSV hypoflow (AUC 0.69-0.71) and LGV SD/MV (AUC ∼0.70-0.71) as the most informative markers. CONCLUSIONS:Non-contrast 2D PC-MRI yields objective morphology and segment-specific hemodynamics in lower body venous system. LGV reflux and GSV hypoflow are the most informative markers of PeVD.
BACKGROUND:Symptomatic marginal veins and progressive limb overgrowth are hallmark features of Klippel-Trenaunay syndrome (KTS) and other PIK3CA-related overgrowth spectrum (PROS) disorders. Data on endovenous laser ablation (EVLA) using modern wavelengths in pediatric populations with long-term follow-up remain limited. METHODS:A retrospective, single-arm cohort study was conducted at a tertiary university hospital. Forty-four pediatric KTS patients (mean age 12.5 years) with symptomatic marginal vein incompetence underwent EVLA using a 1940-nm wavelength (4-6 W, 50-70 J/cm). Technical success, adverse events, limb circumference, Vein-QOL scores, and reintervention rates were assessed over 4 years. RESULTS:Technical success was 100% (44/44). Post-procedural pain (90.9%) and mild skin complications (95.5%) resolved almost entirely within one month (p < 0.001). Mean Vein-QOL scores increased from 828.4 (SD 93.95) to 1562.1 (SD 162.40) at 4 years (p < 0.001). Leg and thigh circumferences decreased by 8.1 cm and 8.9 cm, respectively (p < 0.001). Late recanalization occurred in 4.5% of patients. No deep vein thrombosis or pulmonary embolism was recorded. CONCLUSIONS:In this retrospective analysis, early 1940-nm EVLA for symptomatic marginal veins in pediatric KTS appears safe and highly effective, with durable improvements in limb hypertrophy and quality of life sustained at 4 years.
BACKGROUND:Post-thrombotic syndrome (PTS) develops in 20-50% of patients following deep vein thrombosis (DVT) due to persistent vein wall injury, inflammation, and fibrotic remodeling. Current anticoagulant therapies do not directly address PTS pathogenesis and carry bleeding risks. We characterized the extracellular matrix (ECM) components and evaluated whether pharmacological inhibition of α6β1 integrin with pranlukast (PLK) could modulate post-thrombotic vein wall injury in a preclinical DVT model. METHODS:ECM protein composition was characterized in C57BL/6 mice by western blotting of IVC harvested after IVC ligation from 4 to 21 days, identifying the laminin-α6β1 integrin axis as a therapeutic target. Presence of α6β1 was confirmed via immunofluorescence in post-thrombotic mice up to 21 days. Pranlukast (PLK), a candidate α6β1 integrin antagonist, was tested in vitro and in vivo. Venous endothelial cells were treated with PLK to assess transcription of integrins (Itga6, Itgb1) and inflammation markers (sele). In vivo, C57BL/6 mice received PLK or vehicle before and after IVC ligation. Thrombus characteristics, vein wall remodeling, integrin protein expression, and cellular composition were evaluated. RESULTS:Laminin, fibrin, thrombomodulin, and fibronectin were present in the post-thrombotic IVC in mice. The ECM protein laminin and its primary receptor, α6β1 integrin (CD49f/CD29), were highly expressed up to 21 days post-thrombosis in the vein wall. In vitro, PLK treatment significantly decreased transcription of Itga6, Itgb1, and sele after 24 hours. PLK did not affect thrombus formation, with comparable thrombus weights and lengths across groups, demonstrating a safety profile. The administration of PLK was associated with decreased levels of α6 and β1 integrins in the vein wall and thrombus, but also with a significant reduction in vein wall thickness (VWT) (PLK: 44.95 μm ±5.09, DMSO: 56.84 μm ±6.54, p=0.0081) at 8 days and in proinflammatory monocytes (CCR2+) compared to control (PLK: 14.73 ±1.69, DMSO: 23.15 ±2.38, p<0.0001). CONCLUSIONS:This study demonstrates that targeting α6β1 integrin with PLK reduces vein wall fibrotic injury following experimental DVT without altering thrombus formation. These findings identify a novel, non-anticoagulant therapeutic strategy for PTS prevention that warrants further investigation in chronic models and translational studies.
OBJECTIVE:To develop and internally validate a prototype multimodal artificial intelligence system for automated CEAP (Clinical, Etiological, Anatomical and Pathophysiological) classification of venous duplex ultrasound (VDUS) reports, integrating natural language processing of free-text components with computer vision analysis of hand-drawn anatomical diagrams. METHODS:Single centre retrospective observational study using routinely collected clinical data. One thousand consecutive venous duplex ultrasound reports from Cambridge University Hospitals NHS Foundation Trust, UK (July 2024 - May 2025) were labelled according to the CEAP classification, excluding the Etiological component, which could not be reliably determined from duplex reports alone. Transfer learning was applied using ClinicalBERT for text and MobileNetV3 for diagrammatic data. Clinical classes were predicted from request line text. Text- and image-based pathophysiological models were developed for four anatomical territories (Great Saphenous Vein, Small Saphenous Vein, Deep system, Perforators), combined using late fusion with probability averaging. RESULTS:The clinical CEAP model achieved accuracy of 0.91, macro-F1 of 0.82, and macro-AUC of 0.98. Pathophysiological prediction varied, with text models broadly outperforming image models. Fusion yielded heterogeneous benefits, improving SSV performance but reducing Deep system accuracy. The performance of the final pathophysiological CEAP fusion models varied across anatomical territories: accuracy ranged from 0.70-0.92 and macro-AUC from 0.80-0.92. CONCLUSION:This study demonstrates the feasibility of automated CEAP classification from VDUS reports. Despite class imbalance affecting minority class predictions, the strong discriminatory performance validates this multimodal ML model for extracting clinically meaningful information from real-world data. This approach offers potential, pending external validation, to streamline vascular services through automated triage and guideline-compliant decision making.
Objective This study aimed to develop and validate a deep learning framework to classify chronic venous insufficiency - related skin lesions and differentiate them from other lower-extremity dermatological conditions using dermoscopic images. Methods We retrospectively analyzed 677 high-resolution dermoscopic images from 248 patients, all histopathologically confirmed by skin biopsy. The dataset was categorized into three clinically distinct groups: (1) skin conditions related to chronic venous insufficiency (e.g., stasis dermatitis), (2) common inflammatory dermatological diseases, and (3) vasculitis. A Swin Transformer-based architecture — a deep learning model that processes images at multiple spatial scales to capture both fine local detail and broader contextual patterns — was implemented to analyze dermoscopic images. A strict patient-level split was employed to ensure model robustness, so that images from the same patient were never shared between training and test sets, which could otherwise artificially inflate performance estimates. Results The proposed Swin Transformer model demonstrated superior diagnostic performance, achieving an overall area under the curve of 0.935 and classification accuracy of 0.848, significantly outperforming conventional convolutional neural networks and Vision Transformer baseline models. Group-specific area under the curve values were 0.942 for chronic venous insufficiency-related conditions, 0.929 for inflammatory dermatoses, and 0.934 for vasculitis. Misclassifications were predominantly associated with overlapping dermoscopic features, such as purpuric patterns shared between stasis dermatitis and early-stage vasculitis. Notably, misclassification errors were directed more often toward the lower-risk pathway, with three chronic venous insufficiency-related lesions misread as vasculitis, compared with only one vasculitis case misread as a chronic venous insufficiency-related lesion. Conclusion This study demonstrates that a Swin Transformer-based deep learning model can effectively differentiate chronic venous insufficiency-related skin lesions from inflammatory and vascular conditions, providing objective, non-invasive diagnostic support with the potential to streamline clinical workflows, facilitate early referrals to specialized care, and reduce reliance on invasive diagnostic procedures in the management of lower-extremity skin diseases.
Objective The primary objective is to assess current practice for evaluating and managing vulvar (V3a) and pelvic origin lower extremity (V3b) varicose veins to inform future research priorities and guideline development. Methods An electronic survey was internationally distributed to vascular specialists to assess the current state of pelvic venous disorder (PeVD) care. The 51-question survey utilized the Qualtrics platform and was distributed through medical society forums, international vascular meeting mailing lists, and direct distributions. The survey was open from June 2024 to July 2024, requiring approximately 10-15 minutes to complete. Background information included respondent age, gender, training experience, primary medical specialty, practice type, and practice location, with responses remaining anonymous. The survey included 5 sections, with evaluation and management of women with V3 disease being the focus of this paper. This study was reviewed by the institutional review board and qualified for exemption. Results The majority of survey respondents were vascular surgeons (47%) and interventional radiologists (38%) from the US (43%), Asia (17%), and Europe (16%). 194 respondents reported treating women with extra-pelvic varices of pelvic origin and completed this portion of the survey. For V3a and V3b women, 46% utilized the SVP classification tool as a part of the clinical assessment prior to treatment. The preferred imaging modality prior to intervention is duplex ultrasound of the lower extremity (81%) and ultrasound of the vulvar region (62%). In women without pelvic pain, a “top down” pelvic embolization first approach is utilized by 47% treating V3a and 42% treating V3b, and a “bottom up” direct injection sclerosis was used by the remainder. The technical approach to pelvic embolization when choosing a “top down” approach is variable, with the majority using foam sclerosant for pelvic venous embolization (69%) as well as for vulvar or lower extremity varicose veins (84%). The majority prefer both imaging and clinical follow up, with 75% utilizing a clinical outcome tool post-procedurally. Management of persistent or recurrent symptoms after treatment is variable, ranging from conservative care (8%), re-treating with the same approach (10-29%), or utilizing a different approach (if “top down” initially, then “bottom up” or if “bottom up” initially, then “top down”) (22-27%). Conclusion This survey demonstrates the significant diagnostic and therapeutic heterogeneity of V3a and V3b in the absence of pelvic pain, including equipoise for top down and bottom up management. This heterogeneity demonstrates that significant evidence gaps exist, and highlights the need for comparative outcomes research to clarify them.
Artificial intelligence (AI) has the potential to support personalized, multidisciplinary, data-driven care for venous thromboembolism (VTE) prevention, detection, imaging, management, and follow-up. We reviewed 23 studies: 20 prediction or detection studies were assessed with PROBAST+AI, while 3 evaluated clinical-impact interventions. Of these, 18 of 20 studies (90.0%) were at high risk of bias. Only 7 studies (35%) showed meaningful external or prospective validation, though 5/7 remained high risk of bias. Calibration was not reported in 14 studies (70.0%). Discrimination scores ranged from modest to high, but performance varied across cohorts and was often limited by retrospective design, internal validation, class imbalance, low event counts, and overfitting. Currently, agentic AI remains conceptual and needs human oversight. Future research should emphasize prospective multicenter evaluation, calibration, transparent reporting, regulatory adherence, and standardized bias auditing before AI is used routinely in clinical practice.
INTRODUCTION:Endovenous thermal ablation (EVTA) has become increasingly used for treatment of saphenous vein incompetence. However, severe adverse events leading to rehospitalization remain insufficiently characterized in large real-world populations. This study aimed to evaluate 30-day rehospitalization after great saphenous vein (GSV) and small saphenous vein (SSV) interventions in France and to compare outcomes between EVTA and surgery. METHODS:We conducted a nationwide observational study using the French National Health Data System (SNDS). Adult patients undergoing GSV or SSV intervention between January 2020 and November 2024 were identified using International Classification of Diseases (ICD-10) and Common Classification of Medical Acts (CCAM). The primary outcome was all-cause 30-day rehospitalization after discharge. Secondary outcomes included rehospitalization for thromboembolic events, major bleeding, infection, and other procedure-related complications. Multivariable logistic regression analyses were performed to identify factors associated with rehospitalization. RESULTS:A total of 450,202 patients underwent saphenous vein intervention, including 65,485 SSV and 384,717 GSV procedures. EVTA represented 77.3% of SSV interventions and 83.4% of GSV interventions. Thirty-day rehospitalization occurred in 1.2% of patients after SSV treatment and 4.3% after GSV treatment. Rehospitalizations due to thromboembolic complications were exceptionally rare (0.01% after SSV treatment and 0.03% after GSV treatment), while major bleeding and infectious complications were nearly absent. For SSV interventions, treatment modality was not independently associated with rehospitalization after adjustment. For GSV interventions, surgery was associated with a lower risk of 30-day rehospitalization compared with EVTA (adjusted OR 0.54, 95% CI 0.41-0.71). Among patients treated with EVTA for GSV incompetence, no difference was observed between endovenous laser ablation and radiofrequency ablation (adjusted OR 0.97, 95% CI 0.81-1.16). CONCLUSIONS:In this nationwide French cohort, 30-day rehospitalization after saphenous vein intervention was uncommon and severe complications requiring rehospitalization were exceptionally rare. EVTA was the predominant treatment modality and demonstrated an excellent safety profile. Rehospitalization appeared to be influenced primarily by patient characteristics rather than major procedure-related complications, supporting the safety of contemporary treatment strategies for both GSV and SSV incompetence.
OBJECTIVE:We sought to determine the impact of great saphenous vein (GSV) ablation on below-the-knee pre- and postsaphenous vein pressures using the novel VeinPress device (Compremium). Venous pressures were correlated to clinical outcomes using the Venous Clinical Severity Score (VCSS). METHODS:Patients with symptomatic GSV insufficiency undergoing planned GSV ablation were prospectively enrolled into the study at a single tertiary center. GSV pressure, although standing, was measured at the ankle level utilizing the VeinPress device (Compremium) pre- and post- GSV ablation. Patient demographics, comorbidities, periprocedural complications, body mass index (BMI), and VCSS were obtained. GSV pressure was compared pre- and postablation. Based on median BMI, a subgroup analysis was performed on patients separated into BMI >31 vs ≤31 kg/m2. RESULTS:A total of 31 patients (average age, 68 years old; 45% female) underwent GSV ablation with 100% technical success. The mean VCSS preablation was 7.64 ± 3.5 (n = 31), which significantly decreased after ablation to 5.0 ± 2.9 (n = 27; P < .001). The mean baseline GSV pressure at the ankle (83.8 ± 28 mmHg; n = 31) significantly decreased postablation to (76.5 ± 18; n = 27; P = .05). There was poor correlation between change in GSV pressure and delta VCSS (r = 0.24; P = .239). There was a significant mean difference in postprocedure GSV pressure for patients with BMI > 31 kg/m2 (Hodges-Lehman estimate, -13.9 mmHg; 95% CI,-39.4 to -3.8; P = .006). A significant difference was not identified for BMI ≤ 31 kg/m2 (Hodges-Lehman estimate, -1.9 mmHg; 95% CI, -16.5 to 15; P = .724). Preablation GSV pressures did not differ significantly when comparing BMI ≤31 vs >31 kg/m2 groups (74.6 ± 29 vs 93.7 ± 24; P = .1). There was no difference in preablation VCSS scores in BMI ≤ 31 kg/m2 (8.3 ± 4.2) and BMI > 31 kg/m2 (6.9 ± 2.3; P = .472). There was no significant correlation between baseline GSV pressure and C classification (r = 0.022; P = .9). CONCLUSIONS:Among patients with symptomatic GSV reflux, ablation resulted in a decrease in ankle region GSV pressure. This effect was most observed in patients with a BMI > 31 kg/m2. GSV pressure did not demonstrate a correlation with venous clinical severity score.
OBJECTIVE:Patients with chronic venous disease (CVD) often experience pain and heaviness; however, many report additional neuropathic symptoms, such as burning, tingling, and decreased sensations. Despite these occurrences, the nature and pathophysiology of neuropathy in patients with CVD are unclear. The objective of this systematic review was to estimate the prevalence and features of neuropathy in patients with CVD, identify methods for assessing neuropathy in this population, and explore potential pathophysiological mechanisms underlying its development. METHODS:This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with the protocol registered on International Prospective Register of Systematic Reviews (PROSPERO; CRD420251124308). The MEDLINE, EMBASE, and Cochrane CENTRAL databases were searched from 1947 to August 2025. The eligibility criteria included studies examining patients with CVD who underwent objective neuropathy assessments. Studies involving patients with comorbidities predisposing them to peripheral neuropathy were excluded. Studies without objective neuropathy assessments were also excluded. RESULTS:Of 2313 articles retrieved from the search, eight articles were included in this review. The majority of studies investigated sensory neuropathy. The most common objective neuropathy assessment methods were testing vibration detection thresholds, which was performed in five studies, and temperature discrimination, which was performed in four studies. Other assessment methods included the Neuropathy Disability Score, nerve conduction studies, monofilament testing, tendon reflex testing, and skin biopsies. Various nerve fibers responsible for different functions were affected, including A-alpha, A-beta, A-delta, and C-fibers. Furthermore, patients with more severe CVD (C5-C6) had significantly worse neuropathy. CONCLUSIONS:The included studies reported neuropathy prevalence ranging from 33% to 100%; however, direct comparability was greatly limited by heterogeneous assessment methods and the lack of pooled confidence intervals. There was evidence of both sensory and motor neuropathy in patients with CVD. Potential pathophysiological mechanisms underlying neuropathy in patients with CVD include venous hypertension translating to increased endoneurial pressure and ischemia, venous microangiopathy, and axonal hypoxia. Sensory impairment due to nerve injury associated with CVD may increase the risk of skin trauma potentially leading to venous leg ulceration. This systematic review underscores the potential association between neuropathy and patients with CVD and suggest that neuropathy may be associated with more severe CVD.
BACKGROUND:Pelvic congestion syndrome (PCS) is characterized by chronic pelvic pain persisting for over 6 months that is exacerbated by sexual activity, menstruation, and prolonged standing. PCS is associated with ovarian and iliac varicose veins (VV) and primarily affects female patients of childbearing age, often resolving at menopause. The purpose of this study is to detect national trends of PCS, in comparison with other common venous pathologies, chronic venous insufficiency (CVI), and VV. METHODS:Patient data were collected from the Healthcare Cost and Utilization Project's National Inpatient Sample 2004 to 2021, bridging International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes for PCS (ICD-9, 625.5; ICD-10, N94.89), CVI (ICD9, 459.8; ICD-10, I87.2), VV (ICD-9, 454.x; ICD-10, I83.x), and pelvic varices (ICD-9, 456.5-6; ICD-10, I86.2-3), were isolated for analysis. Data extraction and statistical programming were conducted via Stata version 17.0 (StataCorp LLC). RESULTS:During the years using the ICD-9 coding system, the prevalence of PCS decreased. However, with the transition to ICD-10, PCS prevalence began to rise, continuing to increase through 2021, from 8605 cases in 2016 to 9250 cases in 2021. Similarly, the prevalence of VV and CVI showed an increasing trend across the ICD-9 to ICD-10 transition period. VV cases rose from 44,185 in 2004 to 71,180 in 2021, and CVI cases increased from 173,430 to 232,850 over the same period. In contrast, the prevalence of pelvic varices decreased, from 2185 cases in 2004 to 990 cases in 2021. In addition, no major trends were observed in the prevalence of inpatient abdominal venous procedures or leg venous procedures, indicating a stable incidence rate for these conditions. CONCLUSIONS:This study highlights the rising prevalence of PCS, particularly the growth in national inpatient diagnoses following the transition to the ICD-10 coding system. This upward trend likely reflects improved recognition and coding rather than a true surge in incidence. The increasing trends in these venous conditions underscore the need for heightened clinical awareness and targeted interventions to manage these conditions effectively. As the National Inpatient Sample captures only hospitalized patients, these findings should be interpreted as inpatient diagnostic trends and do not fully represent the overall prevalence or outpatient management of PCS.
OBJECTIVE:Embolization of insufficient pelvic veins has been established as the standard first-line therapy in women with chronic pain due to pelvic venous disorder; however, the clinically available embolic devices vary widely, with coils, vascular plugs, glue, and sclerosants or combinations of these devices being the most common. This study aims to evaluate the ability of different devices to reduce pain and their individual rates of success and complications. METHODS:A systematic search was conducted using PubMed, ScienceDirect, Cochrane, and ClinicalTrials.gov for studies published on the embolization of insufficient pelvic veins up until November 2025. The primary outcome measure was the effect of embolization on pelvic pain as measured using visual analog scale (VAS). The secondary end points were the technical and clinical success rates as well as the recurrence, complication, and reintervention rates. RESULTS:A total of 28 studies met the inclusion criteria, totaling 2688 patients across 34 individual cohorts who were grouped into five treatment categories. The technical success rate was high across all the embolization methods, ranging from 98.6% to 100%, and the clinical success rate ranged from 68.3% to 100%. All the endovascular treatment options led to a reduction in pain as measured using VAS, which ranged from 4.67 (95% confidence interval [CI], 3.87-5.47) points reduction in the sclerosant-only group to 6.12 (95% CI, 5.46-6.78) in the vascular plugs group. The clinical success rate was the highest in the sclerosant-only and plugs groups at 97.5% (95% CI, 93.7-99.3) and 94.7% (95% CI, 86.9-98.5), respectively. Complications, especially in the form of device migration, most frequently appeared in the coils group at 2.63% (95% CI, 1.76-3.78) and least frequently in the sclerosant-only group at 0.45% (95% CI, 0.01-2.48). Sclerosants led to the lowest recurrence at 1.69% (95% CI, 0.49-4.87) but the highest number of reinterventions at 13.3% (95% CI, 5.1-26.8). Vascular plugs resulted in few complications (0.6% [95% CI, 0.07-2.15]), as well as low recurrence (3.47% [95% CI, 1.6-6.49]) and reintervention (2.59% [95% CI, 1.12-5.04]). CONCLUSIONS:All the embolization methods showed excellent technical success rates and marked reduction in pain as measured using VAS. Using coils seems to be associated with the highest occurrence of device migration. The vascular plugs and sclerosant-only groups had high clinical success with low complication rates. Due to the small sample sizes and lack of inter-group comparisons, the conclusions should be viewed cautiously.
OBJECTIVE:There is limited data demonstrating the benefit of artificial intelligence (AI) technology for the diagnosis and triage of pulmonary embolism (PE). This study aimed to demonstrate improved time to diagnosis of PE and subsequent anticoagulation and intervention, with the goal of reducing in-hospital mortality. We hypothesized that implementation of AI-assisted computed tomography pulmonary angiogram (CTPA) detection would reduce time to diagnosis, anticoagulation, and intervention compared with the standard radiology-based workflow. METHODS:A single institution retrospective review from July 2018 to March 2025 was performed to identify patients diagnosed with PE who underwent pulmonary angiogram with mechanical thrombectomy and/or thrombolytics. Patients were divided into a pre-AI cohort (July 2018-2022) and a post-AI cohort (2022-March 2025) corresponding to the institutional implementation of Viz.ai PE (Viz.ai), a Food and Drug Administration-cleared, Health Insurance Portability and Accountability Act-compliant AI platform for automated PE detection on CTPA. Time to diagnosis was defined as the interval from CTPA scan completion to AI-generated alert (post-AI cohort) or to the final radiology report issuance (pre-AI cohort). Time to anticoagulation and intervention was measured from the time of confirmed PE diagnosis. In-hospital mortality was also evaluated. RESULTS:From July 2018 to March 2025, a total of 148 patients were diagnosed with PE and underwent endovascular intervention. Twenty-four patients were excluded. Forty-two patients were diagnosed in the pre-AI era and 82 in the post-AI era. The median age was 65 [interquartile range (IQR), 53-73] and 65.5 (IQR, 52-73.5) years, respectively. Time to diagnosis improved significantly from 72.5 (IQR, 44.5-93.3) to 40 (IQR, 28-68.2) minutes (P = .00005). Time to anticoagulation was 76 (IQR, 48.3-99.8) vs 61.5 (IQR, 46.8-110) minutes (P = .824, not significant). Time to intervention improved from 1360 (IQR, 1075.5-1790.2) to 1224 (IQR, 601.6-1563) minutes (P = .036). Two in-hospital deaths occurred, both in the pre-AI cohort. CONCLUSIONS:Implementation of AI-assisted CTPA detection using Viz.ai PE significantly improved time to diagnosis and intervention in patients with acute PE requiring catheter-directed therapy. Time to anticoagulation was not significantly different between groups; this was study was insufficiently powered to detect differences in clinical outcomes including mortality.
BACKGROUND:Residual venous obstruction and in-stent restenosis are common and challenging complications that may occur after interventional procedures performed for acute deep vein thrombosis or chronic iliofemoral venous obstruction. A novel fully integrated thrombectomy system [Recana Thrombectomy Device (RTD)] was designed to treat (in-stent restenosis) and native vessel obstructions. The system includes a debulking catheter, collection baskets, and a family of sheaths. This report describes its use in animal models of native and stented veins to assess safety compared with currently available thrombectomy devices. METHODS:The RTD was studied in comparison to two currently marketed thrombectomy devices, the Argon CLEANER 15 (CLEANER; Argon Medical Devices Inc.) and the Inari ClotTriever (ClotTriever Catheter; Inari Medical, Inc.). Devices were studied in a porcine iliac vein model used in a manner consistent with good laboratory practice for Nonclinical Laboratory Studies. A total of 26 iliac veins in 13 animals were studied to evaluate performance in normal veins (9 animals, 18 iliac veins) and in four animals with eight iliac veins pretreated with iliac stents implanted 21 days before device treatment. Twelve normal iliac veins were treated with the RTD, four normal veins were treated with CLEANER, and two with the ClotTriever. Five prestented iliac veins were treated with the RTD, and three prestented veins were treated with the CLEANER. Procedures were completed under fluoroscopic and intravascular ultrasound guidance. For each model, both iliac veins were treated with 10 passes of the test or control thrombectomy device through the length of the common and external iliac veins. Survival and sacrifice periods were completed at varied time points to evaluate peak histological injury potential, vein wall healing, and vein patency. Necropsy was performed at 5 ± 2 or 30 ± 2 days after catheter intervention for gross evaluation of the iliac veins and other related tissues. Histology was performed on representative sections of treated iliac veins to evaluate wall damage, thrombosis, or other effects of intervention. RESULTS:All animals survived to their designated end points with no unexpected mortality. One common femoral vein access complication led to unilateral perivenous hematoma and thrombosis. Another animal showed postintervention venous constriction with eventual vessel occlusion. All other iliac veins (n = 24) remained patent without significant stenosis at necropsy. No clinically relevant lacerations, perforations, or hemorrhagic events were observed with either the Test or Control devices. Histology revealed intimal disruption and inflammation with all devices, more pronounced with the RTD compared with CLEANER but similar to those seen after use of the ClotTriever. Mild perivenous bruising occurred in some Test device cases, without evidence of transmural bleeding. CONCLUSIONS:In an in vivo model of stented and native iliac veins, a novel venous tissue debulking system was able to engage intraluminal material without serious injury. Vein wall trauma was comparable to a commonly used mechanical thrombectomy device, with no transmural lacerations or device-related hemorrhage. These findings support continued development toward initial clinical trials in patients with venous obstruction. CLINICAL RELEVANCE:This experimental study utilizes a porcine model for examination of a novel venous thrombectomy device in normal and stented iliac veins. The study examines the degree of injury occurring within the vein wall in normal and stented iliac veins after treatment with the test device compared with currently marketed thrombectomy devices. The feasibility of removal of the material causing in-stent restenosis is established using the Test device. The study also provides key information on the response of the iliac vein wall in this model to intraluminal devices that impact the wall during treatment.
Chronic venous disease and varicose veins (VVs) are highly prevalent yet remain inconsistently managed despite existing guidelines, with variability in treatment selection, patient stratification, and use of conservative therapies. This multinational initiative sought to establish expert consensus on key clinical questions in venous disease management. A Delphi-like process involved 38 phlebologists from 15 countries across Europe, North Africa, and Central Asia. Four thematic workshops addressed interventional and conservative approaches for both chronic venous disease and VV. Twenty predefined questions were discussed, and resulting statements were rated on a 5-point Likert scale, with consensus defined as ≥75% agreement. Of 34 proposed statements, 30 (88%) achieved consensus. The panel emphasized that treatment decisions should be driven primarily by symptoms and quality of life rather than anatomy alone. Endovenous procedures were supported for symptomatic disease, with endovenous laser ablation and radiofrequency ablation considered equivalent for VV. Diosmin-based venoactive drugs, often combined with compression, were endorsed across Clinical, Etiologic, Anatomic, and Pathophysiologic classes for symptom relief, although adherence to conservative therapy remains limited. This consensus provides practical guidance for individualized care and highlights unmet needs in risk stratification, adherence, and long-term comparative outcomes.
OBJECTIVE:Endovenous therapies are the current standard of care for managing pelvic venous disorders (PeVD) secondary to pelvic venous insufficiency. We previously reported superior short-term results after iliac vein stenting (ST) compared with ovarian vein embolization (OVE). The purpose of this investigation is to determine the long-term durability and clinical effectiveness of endovenous therapies for PeVDs and to identify the time point at which maximal pain reduction is observed. METHODS:A retrospective review of prospectively collected data at the Center for Vascular Medicine from October 2016 to October 2022 was performed. Women with a PeVD secondary to an iliac vein stenosis and/or ovarian vein reflux were included. Assessments and interventions consisted of an evaluation for other causes of PeVD by a gynecologist, Clinical-Etiology-Anatomy-Pathophysiology, pre-, 1, 3, 6, 12, 24, and 36 months postoperative visual analog pain scores, transabdominal duplex ultrasound stent surveillance, stent type, diameter, and length. Patients were separated into three treatment groups: pelvic pain alone, leg pain alone or pelvic, and leg pain and analyzed according to treatment type. Patients treated with venoplasty or venoplasty and OVE were excluded. Differences between groups were analyzed using analysis of variance. RESULTS:A total of 521 women with a PeVD were evaluated and treated with either OVE alone, OVE and ST or ST alone: pelvic pain (n = 33), leg pain (n = 208), and pelvic plus leg (Mixed; n = 280). The average age of the cohort was 52 ± 13.4. Patients with pelvic and mixed pain were younger compared with patients with leg (P ≤ .001). No racial differences by symptom presentation were observed. Patients with pelvic and leg symptoms had a higher prevalence of endometriosis and ovarian cysts (P ≤ .001). The average preintervention ST, OVE and OVE plus ST visual analog scale scores by presentation were the following: pelvic (ST plus OVE, 3.07 ± 3.71; OVE, 5.27 ± 3.2), leg (ST, 6.18 ± 3.07), Mixed (ST, 7.47 ± 2.28; OVE plus ST, 6.67 ± 2.56). Significant improvements in pain scores were observed in all treatment groups. Regardless of the symptom presentation, patients who received OVE plus ST demonstrated significant pain reduction at 1 month with no further decrement in pain that was sustained up to 36 months (P ≤ .001). Patients with ST and OVE alone demonstrated pain reduction up to 3 months with no further pain decrement that was sustained up to 36 months (P ≤ .001). CONCLUSIONS:Women with PeVD often present with concomitant pelvic and lower-extremity venous symptoms. Regardless of the symptomatology or treatment modality, patients report improved and sustained symptom relief up to 36 months. Patients receiving OVE plus ST demonstrated maximal pain reduction at 1 month with sustained relief up to 36 months, whereas patients with OVE or ST alone required 3 months for maximal and sustained pain reduction. These data suggest that combined therapies provide faster pain relief in patients with ovarian vein reflux and iliac vein stenoses. If a staged approach with OVE followed by ST is used, ST should be considered at 3 months as no further improvement at 6 months was observed.
OBJECTIVE:The purpose of this systematic review was to evaluate imaging and diagnostic modalities for their roles in (1) diagnosing upper and lower extremity lymphedema, (2) detecting subclinical disease through prospective surveillance, (3) providing anatomical assessment of the lymphatic system, and (4) guiding surgical treatment planning. METHODS:A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The search included PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus from January 2010 to April 2026. Four reviewers screened 2847 articles using Covidence software. The inclusion criteria were studies that reported original data on one or more imaging modalities and presented diagnostic accuracy, reliability, staging parameters, or impact on surgical planning. RESULTS:A total of 28 studies were included, comprising four randomized controlled trials, 12 prospective diagnostic studies, six cohort studies, one observational study, and five systematic reviews or meta-analyses. In upper extremity studies, predominantly composed of breast cancer-related lymphedema (BCRL), bioimpedance spectroscopy (BIS) demonstrated a sensitivity of up to 100% and a specificity of 98% for early detection, with the PREVENT trial showing a 59% relative risk reduction in chronic BCRL through BIS-triggered surveillance. Indocyanine green (ICG) lymphography achieved 100% diagnostic accuracy vs 62% for lymphoscintigraphy in early disease, and ultra-high-frequency ultrasound imaging at 70 MHz achieved 94.9% sensitivity for vessel detection. In the lower extremity, magnetic resonance lymphangiography (MRL) at 3.0 T achieved 100% sensitivity for lymph vessel abnormalities vs 79% for lymphoscintigraphy (κ = 0.93 for delayed drainage). Ultrasound imaging achieved 95.5% sensitivity and 92.9% specificity for vessel detection. Two validated ICG-based classifications, saphenous calf thigh and Shinaoka, enabled lower extremity-specific severity staging. CONCLUSIONS:This systematic review identified important differences in the evidence supporting imaging and diagnostic modalities across the four clinical domains evaluated. For diagnosis and subclinical detection, BIS-triggered prospective surveillance for upper extremity lymphedema is supported by randomized controlled trial evidence demonstrating significant reduction in chronic BCRL progression. However, comparable trial data for the lower extremity remains absent. For anatomical assessment, region-specific ICG classification systems (saphenous calf thigh and Shinaoka) address the unique drainage patterns of the lower extremity, while MRL provides comprehensive deep and superficial system visualization across both regions. For surgical planning, the combined use of near-infrared fluorescence lymphangiography and MRL offers complementary information to guide microsurgical interventions.
OBJECTIVE:The study aims to evaluate the incidence of 30-day thrombosis after iliac vein stent placement, stratified by age, and to analyze long-term follow-up outcomes. METHODS:A retrospective analysis was conducted of 4312 procedures performed in 2642 patients with symptomatic chronic venous insufficiency (Clinical, Etiologic, Anatomic, and Pathophysiologic [CEAP] clinical classes C3-C6) from 2012 to 2024. Patients underwent iliac vein assessment using intravascular ultrasound (IVUS) examination and received stent placement. Follow-up included iliac vein duplex ultrasound assessments at 3 to 7 days postoperatively, with additional evaluations at 3 to 6 months during the first year. For subsequent years, follow-up occurred at 6- to 12-month intervals. Intraoperative heparin was not administered, and postoperative management included daily clopidogrel (Plavix). Stents were assessed for partial and complete thrombosis. RESULTS:The mean age of the study population was 73 years (range, 30-108 years), with 39.30% male and 60.70% female patients. Age distribution by decade, based on the number of nonthrombotic iliac vein lesions treated, was as follows: patients in their 30s (43), 40s (151), 50s (498), 60s (926), 70s (1116), 80s (1035), and >90s (543). Thirty-day thrombosis rates by age group were as follows: 30s (0%), 40s (0.01324%), 50s (0.0200%), 60s (0.0118%), 70s (0.0179%), 80s (0.0116%), and >90s (0.0074%). Thirty-day thrombosis rates by CEAP clinical class were as follows: C3 (0.01395%), C4 (0.0121%), C5 (0.0172%), and C6 (0.0166%). Among patients with thrombosis within 30 days of stent placement, 76.3% experienced partial stent thrombosis and 27.7% experienced complete stent thrombosis. The mean age of patients with complete thrombosis was 71.4 ± 17 years, compared with 71.8 ± 12 years for those with partial thrombosis. Of patients with complete thrombosis, 71.43% were female. Of the 14 patients with complete thrombosis within 30 days, 10 cases occurred between 2012 and 2021, three in 2022, and one in 2023. Binary logistic regression revealed no significant association between 30-day thrombosis and age (P = .719), CEAP clinical class (P = .938), or laterality (P = .326). CONCLUSIONS:Iliac vein stenting for symptomatic nonthrombotic iliac vein lesions is a safe and effective procedure with a low incidence of early thrombosis. Age, laterality, and CEAP clinical class were not significantly associated with 30-day thrombosis outcomes. This study supports the use of iliac vein stenting in patients across a broad spectrum of chronic venous insufficiency severity, demonstrating its effectiveness in an office-based laboratory setting.
