Society For Clinical Vascular Surgery

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Is bathing associated with hemorrhage from lower extremity varices?
Amrit Hingorani, Anil Hingorani, Natalie Marks, Enrico Ascher.
Total Vascular Care, Brooklyn, NY, USA.

Objectives. While the commonly described manifestations of venous insufficiency include telangtasia, varicose veins, swelling, hyperpigmentation, lipodermatosclerosis and ulcers, we have noted some patients who present with external hemorrhage from their lower extremity varices. Since there have little recent data examining this entity, we herein describe our experience. Specifically, we examined the presentation of the patients, pattern of distribution of associated venous insufficiency and our treatment algorithm. Methods.From 4/10/15 to 9/7/17, we had 32 patients present with history of hemorrhage from lower extremity varices. There were 15 males and 17 females with ages ranging from 38 to 89 (average=60.2years). Interestingly, 16 of these patients presented after a warm bath. For the remainder, the bleeding was spontaneous. In terms of the overall pattern of disease, 28 patients presented reflux >500msec in the GSV, 19 in the SSVs and 1 in the accessory vein. 8 patients had reflux >1second in their femoral veins while 6 had severe reflux in their popliteal veins. Results.All of these patients were treated with weekly Unna boots until the ulcer healed followed by an average of 2.16 thermal ablations of GSV, SSV, and ASV veins–20 of the patients underwent thermal ablation of these superficial veins. It took an average of 2.12 weeks to heal wounds after beginning treatment with an Unna boot. Comparing patients that bled after a warm bath and those that bled spontaneously showed a significant difference (p=0.0426) between the number of Unna boots and thus, the length of treatment, needed to heal the wounds (average of 1.75 Unna boot treatments for patients who bled after bathing compared to 3.5 Unna boot treatments for patients with spontaneous bleeds). There was no significant difference between laterality, age, or gender between patients who bled after bathing when compared to those that bled spontaneously. The ulcers recurred in 3 of the patients and Unna boot treatment was reapplied until wounds healed once more. Patients had an average follow up of 7.2 months and we noted no recurrent bleeding episodes. Conclusions.The fact that the majority of our patients with bleeding varices presented with hemorrhage after bathing warrants further investigation in terms of pathogenesis of this entity. This treatment algorithm does not incorporate immediate sclerotherapy as prior literature suggested yet seems highly safe and efficacious.

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