Duplex ultrasound (DUS) is an imaging technique that is widely used in order to assess venous system conditions in healthy subjects and in patients with chronic venous disease, deep venous thrombosis and superficial thrombophlebitis. A thoroughly performed DUS is crucially important for precise diagnostics and treatment. DUS is widely accepted as mandatory in phlebology practice. Other specialists are often in need for duplex ultrasound also in order to exclude deep venous thrombosis as a complication of different pathologic conditions. This is an updated version of guidelines developed by an expert group. The document systematizes data on the ultrasound anatomy of the veins of the lower extremities. It describes the main algorithms DUS as well as requirements for the configuration and settings of the ultrasound machine. The position of the patient during the study, ultrasound transducer placing, depending on the situation are presented. Criteria of pathologic venous reflux are discussed. DUS methodology for different venous segments are presented. A newly developed algorithms of examination of patients having different clinical scenarios are presented. The document suggests examples for formal conclusions based on the results of the ultrasound examination. A lawyer’s report based on the results of the analysis of the regulatory documentation regarding justification of the use of DUS by phlebologists in their clinical practice is presented. Guidelines are addressed to ultrasound diagnostics specialists, phlebologists, vascular specialists, general surgeons and others.
Outpatient management and early discharge for patients with pulmonary embolism (PE) who are at low and intermediate-low risk for early mortality are emerging approaches that are gaining increased attention. Objective. This study aims to evaluate the efficacy and safety of different management strategies for patients with PE: early hospital discharge, outpatient care, and standard inpatient treatment. Material and methods. The study cohort comprised 127 patients recently diagnosed with PE, categorized into those with hospital stays of 3–4 days (early discharge) or 5 days or more (standard inpatient treatment), as well as patients receiving outpatient care. The primary efficacy outcome measured was the incidence of symptomatic recurrent venous thromboembolism (VTE) and/or VTE-related death following the initiation of anticoagulant therapy. The primary safety outcome assessed was the bleeding rate, along with evaluations of VTE-related and all-cause mortality rates. Results. The outpatient group included 50 patients, the early discharge group 37, and the standard inpatient group 40. The mean ages were 65±10, 63.6±12.1, and 61.5±12.4 years, respectively. No fatal VTE recurrences were reported in any group. Bleeding rates were 2% (1 patient) in the outpatient group, 5.4% (2 patients) in the early discharge group, and 0% in the standard inpatient group (p=1). Re-admission rates were similar across the groups: 2 patients (4%) in the outpatient group, 1 patient (2.7%) in the early discharge group, and 1 patient (2.5%) in the standard inpatient group (p=1). The rates of VTE recurrence were comparable among the groups. Chronic heart failure emerged as the only potential predictor for VTE recurrence (odds ratio [OR] 5.02; 95% confidence interval [CI] 1.03–24.51). Outpatient management did not lead to an increased rate of VTE recurrence (OR 0.63; 95% CI 0.12–3.35). Conclusion. Both outpatient management and early discharge for hemodynamically stable patients with PE at low and intermediate-low risk of 30-day mortality are safe and effective alternatives to standard inpatient treatment.
The lecture presents findings from studies on endothelial function and the glycocalyx, contemporary data on the significance of markers of endothelial dysfunction, and initial results from electron microscopy of the glycocalyx in the venous wall endothelium of patients with varicose veins in the lower extremities. Research conducted over the past two decades has consistently indicated that protecting the endothelium is essential for preventing thrombus formation and inhibiting the progression of venous-specific inflammation. The endothelial glycocalyx is a crucial structural component of the venous wall, mediating endothelial adaptation to various hemodynamic conditions while protecting the endothelium. In cases of varicose veins and chronic venous insufficiency, there is observable systemic damage and shedding of the endothelial glycocalyx. The loss of this protective layer exposes adhesive molecules on the endothelial surface, initiating a cascade of pathological events: leukocyte and platelet adhesion occur, leading to localized inflammation, disrupted barrier function, increased vascular permeability, and a significant reduction in antithrombotic potential. Therefore, damage to the endothelial glycocalyx is a key factor in the emergence of endothelial dysfunction in veins. The restoration of the glycocalyx is recognized as a promising therapeutic approach, not only for enhancing venous tone but also for providing pathogenetic treatment of chronic venous diseases. The lecture outlines methodologies for studying glycocalyx integrity and markers of endothelial dysfunction, as well as results on the effectiveness of comprehensive correction strategies using sulodexide in patients with varicose veins.
The case presented highlights the challenges of clinically and instrumentally differentiating between clitoral hypertrophy and vulvar varicose veins (VVV) in a 47-year-old female patient. The patient reported perineal and clitoral pain, significant clitoral enlargement when in an upright position, and discomfort during intercourse. Following an initial clinical assessment by both a gynecologist and a vascular surgeon, VVV was suspected. Further examinations were conducted, including duplex ultrasound (DUS) of the pelvic and perineal veins, as well as computed tomography venography (CTV) of the pelvis. These investigations revealed no abnormalities in the pelvic and perineal veins; however, a hypodense, non-contrast-enhanced lesion was identified in the clitoral area, leading to a diagnosis of clitoral hypertrophy. A surgical procedure was subsequently performed, which revealed not only clitoral enlargement but also localized vein dilation measuring up to 1 cm in the clitoral region. A clitoral resection was carried out, along with the resection of the dilated vein. Postoperative recovery was smooth, with no complications reported. During follow-up examinations, the patient exhibited no symptoms, and clitoral size returned to normal. This clinical case illustrates the discordance between clinical findings, imaging results, and intraoperative observations, suggesting a likely interplay of organ-related and venous factors contributing to clitoral enlargement and perineal pain. The phlebological awareness of the gynecologist during the procedure facilitated the identification of the localized vein dilation in the clitoral area, allowing for a simultaneous clitoral vein resection alongside the clitoral resection.
Objective. To develop and assess an algorithm for open surgery in patients with traumatic gunshot arteriovenous fistulas (AVFs). Material and methods. The early results of open surgery were retrospectively assessed in 60 wounded subjects with traumatic gunshot AVFs admitted to a level 5 rear military medical facility. All the wounded were men with an average age of 34.5±8.9 years. The individual management approach depended on the presence of acute complications of AVF, the location and width of the AVF, the presence of a false aneurysm of the main vessel, intraoperative findings, and the decision on which intervention to perform based on the morphology of the artery and vein samples. The intervention was performed in four consecutive steps: precise isolation of the AVF and the false aneurysm, AVF separation, repair of the artery, and repair of the vein. Results. Fifty-nine patients underwent surgery;. 6 (10%) interventions were emergent, 4 (6.8%) were urgent, 4 (6.8%) were delayed, and 45 (76.3%) were elective. The main artery was grafted with reversed autologous vein in the majority of cases (38 patients, 63.3%). Main veins were mostly ligated (51 patients, 88.5%). No deaths were registered. There was no need for secondary amputations. An additional revascularization procedure was required in 2 (3.4%) cases due to arrosive bleeding and thrombosis of the PTFE popliteal artery graft. Non-massive pulmonary embolism developed in 1 (1.7%) patient. Conclusion. Individualized management of traumatic gunshot AVFs of the lower extremities with a four-step open intervention is effective and safe.
