Cosmetic Sclerotherapy

Mark Forrestal, MD, President-Elect, American College of Phlebology

As the specialty practice of phlebology has grown in the US over the years, more sophisticated anatomic and physiologic testing of the vascular system has taken place. At the same time, visual sclerotherapy has had a long history as an efficient and effective treatment modality for varicose veins and telangiectasia of the lower extremities and other body locations. As more complex venous anomalies are being appropriately addressed, patients continue to expect and demand more complete resolution of the tiniest of skin veins. Cosmetic sclerotherapy is the primary treatment that is able to consistently provide resolution of varicosities that are part of a complex, three dimensional abnormal venous network.

The study of the superficial venous system includes vessels from the deep system to skin telangiectasia. Cosmetic sclerotherapy studies from the US date back to Mitch Goldman’s rabbit ear work presented at the UIP in Strasburg, France, in 1989. Studies of the relationship of leg symptoms to cosmetic vein disease, as well as post-sclerotherapy compression, have been important and needed contributions to the sclerotherapy literature. The innovators in the field of cosmetic sclerotherapy have been assembled for the UIP 2013 in Boston. This first UIP meeting in the US follows a Chapter UIP meeting in San Diego in 2003.

Sclerotherapy is an integral tool in the practice of phlebology. Cosmetic sclerotherapy must be learned and mastered to provide our patients with the absolute best results. The physician experts participating in the symposium will give the latest insights into the art and science of sclerotherapy.

Electronic Abstract Presentation Competition (formerly called the Poster Competition) will be a unique occasion to share new scientific inputs form worldwide phlebologists under a new format. Posters will be presented electronically in a special area during the whole meeting period, and they will be orally explained by the presenters. Discussion and scoring will follow during the three poster sessions. Finally, the three best electronic posters will be shown as oral presentations by the main author from the podium to the widest audience in the main hall on the very last day and they will compete for the final three awards in a dedicated session.

Electronic posters not only represent an innovative and technologically advanced way of sharing selected abstract, but also this modality will permit an interactive discussion along the days, hence favoring exchange of ideas and questions and answers between attendees and authors.

Antonios Gasparis, MD

At the 2013 UIP, attendees will have the opportunity to sign up for hands-on simulation workshops. Eight different sessions will be offered, covering all aspects of venous interventions from compression to venous thrombolysis. The workshops are limited to small groups and are led by world experts in the venous world. Participants will have the opportunity to learn from the leaders in the field and have close interaction with them.

The hands-on workshops include:

• Ultrasound imaging
• IVC filter placement
• Endovenous ablation
• Intravascular ultrasound
• Pelvic embolization
• Ultrasound-guided and surface sclerotherapy
• Pharmacomechnical thrombolysis
• Compression therapy

The workshops will have simulation models which will allow each participant to become comfortable with the technical steps of the procedures. Discussion with the faculty on indications, technical tips and complication management will be an additional important aspect of these highly interactive sessions. Don’t waste time—sign up for this unique educational opportunity as space will be limited!

Peter Henke, MD, Leland Ira Doan Professor of Surgery President, American Venous Forum

We greatly appreciate the opportunity to be an integral part of the UIP 2013 meeting. The American Venous Forum has been at the forefront in many aspects of venous disease research leading to improvement in care and is pleased to be involved with this important meeting.

We look forward to our session of six speakers, focusing on areas that are somewhat unique to the American Venous Forum. These topics are also some of the main research areas that AVF members are involved with as well.

We will start with Dr. Mike Vasquez, one of the experts on the assessment of quality of life and outcome measures in venous disease presenting “Chronic Venous Insufficiency and Quality of Life.” He has worked extensively on the VCSS and other scoring systems. Next, Dr. Harold Welch will discuss “State of Art for Wound Care and New Agents for Venous Stasis Ulceration,” which is one of the prime topic areas in the American Venous Forum. The AVF will be releasing new guidelines for evidence based treatment of venous stasis ulceration, followed by dissemination of these guidelines, and this topic will highlight an important aspect of that. Another major initiative is the VQI, or Vascular Quality Initiative, as we have transitioned our registry to the SVS-PSO for a more user-friendly, robust, and hopefully widely prescribed database. Dr. B. K. Lal, who has been instrumental in the registry for the AVF, will give an overview entitled, “Venous Quality Initiative: From Registry to PSO and Beyond.” We look next to our interventional radiology colleague, Dr. Suresh Vendantham, to discuss a challenging disease in “State of the Art Pulmonary Embolism Treatment.” Dr. Vendantham is the principal investigator of the ATTRACT trial, a national, multicenter, NIHsponsored trial evaluating interventional versus medical therapy for acute iliofemoral DVT. One of our past AVF presidents, Dr. Greg Moneta, will be discussing a topic of his expertise entitled “Effort Thrombosis, Evidence for and Against Aggressive Therapies.” This is a common and often debilitating disease of young people. Finally, Dr. John Blebea will round out the group of talks discussing his work and
others on the “Accreditation of Venous Centers,” for quality of care and good patient outcome.

Again, we look forward to full participation in the UIP this coming September.

Veno-active Drugs

Dr h.c. Albert-Adrien Ramelet, Inselspital, Bern, Switzerland

Veno-active drugs (VAD) are a major part of the conservative treatment of chronic venous disorders (CVD), but also a useful adjunct to compression and surgery. Main classes of VAD include alpha-benzopyrones (coumarin), gamma-benzopyrones (flavonoids, as diosmin and its derivatives, oxerutin and anthocyanosides), saponins (as horse chestnut seed and ruscus extracts), plant extracts (as gingko and red vine leaf) and synthetic products.

According to numerous randomized controlled clinical trials (RCTs), meta-analyses, and international consensus (Siena, Cyprus, Budapest, Larnaca), VAD should be used as an adjunct treatment for symptomatic C0s to C6s CVD. Besides their demonstrated anti-oedematous effect, VAD have a specific pain-killing effect that cannot be achieved with nonsteroidal anti-inflammatory agents. VAD may also be used instead of compression in specific situations such as hot climates, arteriopathies, neuropathies and intolerance to compression. As an adjunct to surgery, flavonoids may reduce postoperative pain after venous surgery. The action of flavonoids has been particularly well studied, both in experimental and clinical studies. Recent RCTs emphasize the interest, the effectiveness (on symptoms as pain and on signs as oedema) of flavonoids and saponins in patients suffering from both symptomatic CVD and from advanced stages of the CEAP classification (C3-C6, CVI).

VAD’s safety profile is good. However, coumarin and benzaron may induce hepatitis and some cases of agranulocytosis have been described after intake of calcium dobesilate.

Most VAD are not available in the United States or in the UK. New modalities of administration like phytotherapy, food supplement, alicaments and nutraceuticals are becoming increasingly popular. This session will be introduced by a detailed description of VAD by the chairman. Then, Andrew Nicolaides will review the literature about the evidence for VAD’s efficacy in general. Philip Coleridge-Smith will focus on the evidence for the efficacy of micronized purified flavonoid fraction. The impact of VAD on venous oedema is a fascinating subject, well studied by François-André Allaert. Arkadiusz Jawien has developed new biometric tools for evaluation of venous oedema and drug efficacy. What about pharmacologic treatment of venous ulcer patients? This will be the topic discussed by Manj Gohel. As a conclusion, Michel Perrin will present some guidelines for efficacy studies of VAD.

Complications of Venous Interventions

Stephen F. Daugherty, MD

One of the final concurrent sessions of the UIP meeting will focus on complications of superficial vein treatments. Though serious complications are rare, avoidance strategies, early recognition, and appropriate treatment are essential to minimize longterm adverse results, to reduce patient morbidity, and control costs of care.

Our faculty of six experts from France, Germany, Ireland, and the United States will discuss issues such as anticoagulation, avoidance and treatment of thrombotic complications, complications of foam sclerotherapy, techniques to avoid post-procedure pain, and complications associated with surgical treatment of superficial vein disorders. Come discuss these issues with some of the experts!

Boston Nurses’ Program

Barbara Deusterman, BSN, RN

The nurse and allied health members of the American College of Phlebology are honored to present 10 hours of continuing education presentations over Monday, Tuesday, and Thursday. Attendees may attend other presentations on Wednesday and Friday or take time to explore the amazing city of Boston.

Requests by members prompted us to include “Competency Training and Documentation,” which will be presented along with a Panel Discussion and Venous Problems in the Diabetic Patient. Other topics range from “Beginning Phlebology” all the way to “Advanced Nursing Practice,” with practice management presentations, RVT presentations and case studies, as well.

The Nursing Symposiums are divided into: Phlebology Nurse Basics on Monday morning which will focus on “Sclerotherapy—Pathophysiology of the Saphenous System,” “What Every Sclerotherapy Nurse Should Know,”
“Compression Therapy,” “Complications and Treatment following Sclerotherapy,” along with the presentation, “Empowering Your Patient,” by veteran speaker Kathy Melfy, BSN, RN. “Beyond Basics” on Monday afternoon includes material beyond sclerotherapy, including surgical aspects of phlebology nursing and practice management.

“Verbal Anesthesia and the Importance of Touch— Keeping Your Patient Comfortable During Phlebologic
Procedures” will be presented by veteran ACP presenter, Susie Baker, BSN, RN. “Unusual Case Presentations” will be presented by Janice Moreno Beans, BSN, RN. AJ Riviezzo and will speak on “Documentation and Coding for Maximum Reimbursement” and international speaker, Giovani Mosti, MD, will close out the symposium by speaking on “Bandaging in a Phlebology Practice.”

“Advanced Nursing” presented on late Monday afternoon, includes presentation by Diana Neuhardt, RVT, discussing “Microthrombi and Sclerotherapy.” Also presenting are Terri Morrison, RN, BS, on “Hand Sclerotherapy” and Terri Harper, MSN, RN, presenting on “Glycerin in the Treatment of Leg Telangiectasias.”

Tuesday will feature a General Nursing Symposium including talks on PTS, KTS, competency training, lymphedema, and dermatology with invited physician speakers Julie Stoughton, MD, Steve Zimmett, MD, Peter Mortimer, MD and Bob Kirtchner, MD. Return speakersGreg Funct, BSN, RN, and Jessica Farris, RVT, will be presenting on SVT and the “Importance of Ultrasound and Venous Insufficiency Pain.” Topics on pain are included, as some nursing boards require continuing education on painrelated topics annually to maintain RN licensure.

Thursday afternoon will include “Competency Training” by Michelle McEvoy, MSN, Nursing Section Chair, as well as a panel discussion on “Triaging Patients over the Phone” with veteran ACP nurse speakers led by Catherine Burdge, APRN. Helane Fronek, MD, will give a presentation on “Communication Matters,” and Barbara Deusterman, BSN, RN, will close out the session by presenting “Two Cases of DVT Following Cosmetic Sclerotherapy.”

Other speakers include Joyce Jackson, NP, Megan Kinney, RN, Jackie McGrath, RN, and Mary Sieggreen, MSN, RN.

We hope you enjoy the program!

Foam Sclerotherapy

Dr. G. Mark Malouf, Surgeon, Sydney, Australia

Foam sclerotherapy (chemical ablation of veins using foamed detergent sclerosants) is an effective, inexpensive and invaluable method of treating varicose veins and venous malformations, either as the sole form of treatment or in conjunction with thermal ablation or surgical ligation and removal of refluxing saphenous trunks and accessory veins (Rabe E, Creton D, Uhl JF, King T, Patel M). Sometimes repeat sclerotherapy is required to achieve adequate vein closure. Foam sclerotherapy is often performed with duplex ultrasound guidance to enter the target vein (Cabrera J). It is effective treatmentfor reflux in the GSV and SSV trunks, more successful in trunks of smaller calibre (Myers KA). Refluxing tributary veins and clusters of varicosities can be similarly treated. Foam sclerotherapy is an extremely useful and effective method of management for residual and recurrent varicose veins following surgery or thermal ablation. Such recurrence may be clinically obvious or diagnosed by observing duplex ultrasound reflux at follow-up consultations. Neovascularization following surgery at major junctions (SFJ SPJ) or along the tract of previous stripping is especially amenable to foam sclerotherapy under ultrasound guidance.

With the rise worldwide of thermal ablation of saphenous trunks, the majority of patients require additional foam sclerotherapy, either concurrent or delayed, to treat diseased tributaries and clusters of varicosities. Ambulatory phlebectomy can be added to this treatment mix as required “a la carte vein treatment” (Cavezzi A, de Maeseneer M, Scuderi A). Foam sclerotherapy adjacent to venous leg ulcers improves healing rates by reducing local venous hypertension (Hertzman P).

The two detergent liquid sclerosants, widely registered and available, used to produce the microfoam are polidocanol and sodium tetradecyl sulphate in various concentrations. The foam-producing gas may be air, CO2 or O2/CO2 producing foam of variable stability. In many
countries the use of the registered liquid sclerosant as a foam constitutes “off label” use and must be brought to the attention of the patient when the treating doctor obtains informed consent. Efforts are being made to register the foam itself (Wright D). The benefits of using foam include a much more successful result than using the liquid form of sclerosant (Coleridge Smith P, Hamel-Desnos C, Bradbury A). Foam is usually produced at the time of treatment by passing the mixture of liquid and gas many times from one syringe to another through a three-way tap. (Tessari L).

The rare potential adverse outcomes of sclerotherapy are well known (Guex JJ). Specific concerns have been raised about the use of sclerosant foam, specifically the fate of the microbubbles on e they escape the target vein, particularly in the 30% of the population with a right to left
shunt (Morrison N, Gillet JL). Detailed research into the incidents and possible causes of CNS complications following foam sclerotherapy (Parsi K, Frullini A) have reassured most phlebologists that the incredibly low overall numbers of these complications can be minimized by limiting the volume of foam to 10-15ml and perhaps using CO2 in foam production.

The effectiveness and low complication rate of foam sclerotherapy, its low cost and ability to be easily repeated if and when necessary, and combining it with Doppler ultrasound for accurate placement, means that no matter where you are in the phlebology landscape, this treatment option will be part of your vein world. I urge all who are planning to attend the UIP World Congress in September 2013 in Boston and phlebologists worldwide to listen to and read the published data on foam sclerotherapy so that you can better use this method of treatment for the benefit of your patients.

New Superficial Ablation Techniques from Canada

Doug Hill, MD

Canadian phlebologists have traditionally been both innovators and early adopters of new ablation techniques to treat superficial venous disease. Paradoxically, unlike their American colleagues, the majority of Canadian surgeons continue to employ high ligation and proximal stripping to treat great saphenous vein incompetence. This phenomenon is probably patient driven. Government-funded health care insurance pays for ligation and stripping but provides little or no coverage for sclerotherapy and none for newer techniques such as endovenous thermal ablation. In some provinces, physician
regulatory bodies have restricted thermal ablation techniques to vascular surgeons and interventional radiologists.

The majority of endovenous laser procedures in Canada are performed by vascular surgeons with the remainder done by an assortment of physicians specialized in phlebology, general surgery, interventional radiology, plastic surgery or anaesthesiology. Many physicians are switching from the shorter wave length lasers like the 810 nm and 980 nm to longer wavelengths targeting water such 1320 nm and 1470 nm. Jacket-tipped and radial-tipped fibers are often employed. The radio frequency closure method has been slow to develop in Canada but has been gaining ground recently. Mechanical-chemical vein ablation is offered in several centers and is being considered by others. There is also interest in steam ablation and cyanoacrylate glue closure; however, these procedures are not currently approved in Canada.

A recent survey of participants at a meeting of the Canadian Society of Phlebology revealed that the majority utilized ultrasound-guided foam sclerotherapy to treat saphenous vein incompetence. Many Canadian physicians using ultrasound guided sclerotherapy come from aprimary care background although some general surgeons and interventional radiologists also employ the technique. Sodium tetradecyl sulphate is the most common sclerosant choice. About 25% of the survey respondents reported selection of polidocanol as an alternative. Polidocanol is not an approved drug in Canada so its use has been limited. Most ultrasound-guided foam sclerotherapy practitionersin the survey also reported use of liquid sclerosants as an alternative to treat saphenous incompetence. Approximately one third of the phlebologists employed CO2, O2 or a CO2/ O2 mix to make their foam, the rest used room air. A ratio of 4:1 gas to liquid was by far the most common choice. Roughly one half of the respondents described junctional compression and/or leg elevation after injection. One quarter of the practitioners prescribed a period of patient immobility immediately post-treatment.

The practice of ultrasound-guided foam sclerotherapy began early in Canada following a presentation to the Canadian Society of Phlebology by Dr. Juan Cabrera in 1997. As experience grew with the procedure, rare complications such as chest tightness, DVT and air emboli were reported, prompting Canadian phlebologists to search for technical refinements to reduce the possibility of adverse events. The most effective innovations appear to have been the use of CO2 instead of air in conjunction with syringe filters and short catheters to permit unhurried injection of high quality microfoam.

In 2013, phlebology in Canada continues its traditional focus on innovative treatment, paired with the study of techniques to maximize safe delivery.

International Perspective on the Management of Venous Ulceration

Robert L. Kistner, MD

Progress in understanding the causes and clinical progression of the chronic venous state that culminates in venous ulceration comes from all corners of the globe. This meeting of the UIP is an opportunity to reflect on the widespread interest in furthering progress in this field from far-flung sources in the world.

There continues to be strong input from Europe about the effects of compression on the healing of venous ulcers with the emergence of the Compression Club, yet we are still in the early stages of trying to understand just what amount of compression is needed to achieve optimal results for a given condition and the relative roles of elastic stockings versus inelastic, short stretch garments. The addition of the concept of stiffness to considerations of interface pressure and the use of both static and dynamic pressure effects may be leading to actual dosing of a prescribed amount of pressure at a given location on the extremity for different clinical states.

Forces within the USA are in the early stages of stimulating a nationwide effort to decrease the incidence of venous ulceration by 50% with the goal of causing a major impact in 10 years. For this to be successful, a powerful effort is needed to stimulate the multiple disciplines of primary care to recognize and refer or manage the early stages of CVD. Effective early treatment is needed before the soft tissues of the gaiter area are destroyed by the scarring of neglected chronic insufficiency states. The challenge is to convince the practitioner that the progressive nature of CVD requires a fundamental change of management in early venous disease states from one of neglect into early action.

At the other end of the spectrum of venous ulcer disease there is an active group of surgeons around the world who are pursuing the surgical repair of advanced deep vein disease. The creation of functional autogenous neo-valves in the post-thrombotic limb appears to be an important breakthrough in Italy. Sweden has shown the way with control of the venous ulcer problem in a defined
population of Skaraborg. Russia and China have produced large numbers of valve repairs with encouraging results not widely publicized in the English language. Australia has continued to analyze nonsurgical approaches to chronic venous disease and Canada has been a leader in developing protocols for post-thrombotic and embolic venous disease.

South America and Latin America maintain high interest in both early and advanced venous disease and report encouraging results with aggressive surgical approaches for advanced CVD and venous ulceration. The Middle East is actively developing training and educational programs in advanced venous disease.

The fact is that the whole world is engaged to a variable extent in the study of better ways to diagnose and treat venous ulcer disease. In this setting, the UIP is positioned to play an important role by stimulating progress and disseminating up-to-date thinking in this initiative.

Practical Aspect of Lymphedema

Dr. Giovanni Mosti

Edema can be defined as clinically evident accumulation fluid into the interstitial tissue. The amount of accumulated fluid depends on the permeability of the capillary walls (coefficient of filtration) and the hydrostatic and oncotic pressure gradient between blood and tissue. The difference in hydrostatic pressure causes an extravasation of fluid towards the compartment where the hydrostatic pressure is lower. The difference in oncotic pressure causes a reabsorption of fluid towards the compartment where the oncotic pressure is higher. The connection between these factors is represented by the Starling equation.

In the session dealing with practical aspect of lymphedema, updated information will be provided to understand what chronic edema means. It will be clarified that swelling results when fluid filtration from blood capillaries and venules exceeds the lymphatic system’s ability to remove the extravasated fluid. In fact, in some peripheral tissues (e.g., skin, subcutaneous tissue and muscle) reabsorption of fluid through the venous system is only transient as soon as an excess of interstitial fluid occurs. Otherwise in the steady state, tissue fluid is reabsorbed by the lymphatic system so any chronic edema means lymphatic failure.

When edema tends to stabilize, fluid and protein increase significantly in the interstitial space. Interstitial protein concentration is finely regulated—protein excess tends to retain a correspondent amount of water. So in chronic edema it is more the bulk, rather than the concentration of tissue proteins, which increases with the chronicity of edema. Interstitial proteins and fluid excess favor tissues inflammation and fibrosis which, in turn, lead to lymphatic vessels malfunction impeding more and more protein and water reabsorption into the initial lymphatics and contributing to further fluid congestion.

The strong connections between venous disease and specifically venous edema and lymphatic involvement caused by venous reflux or obstruction will be underlined as the most common clinical conditions favoring an excess of fluid extravasation from capillaries. In the lower leg, edema formation is easier to occur because, in addition or alternatively to venous diseases, the force of gravity tends to impede the venous return, thus increasing venous stasis and venous filtration.

Nevertheless, as long as the lymphatic system is able to reabsorb the excess of filtrated fluid, no edema will appear. But as soon as the lymphatic vessels are not able to compensate for this interstitial fluid excess, edema will result.

During this session it will be also clarified that leg edema may be the clinical manifestation of many medical conditions such as heart, lungs, kidneys or liver disease. It can occur also in case of immobility, sedentary occupation, obesity, and calf muscle pump failure. An increase of fluid filtration may be due also to an increased capillary permeability (hormones, heat-dependent vasodilatation, or inflammation), or to the reduction of osmotic pressure which tends to retain fluid within vessels (renal failure, blood protein deficiency as in malnutrition). Finally edema can be due to a reduction of reabsorption of interstitial fluid into the lymphatic vessels because of a functional decompensation which occurs when the lymphatic system is no longer able to reabsorb the excess extravasated fluid, or to a primary lymphatic deficiency. Edema is a clearly visible condition but the degree must be assessed in order to measure its reduction when treatment starts to work. For this reason, all the possible methods to assess edema and its reduction will be discussed—from the very simple tape measurement and water displacement to the more sophisticated optoelectronic methods.

Primarily, the focus will be on treatment of chronic edema. Compression therapy is a mainstay and can be substantially divided into two phases: treatment phase to reduce edema and maintenance phase to maintain the result and prevent recurrences. In the treatment phase, inelastic material has been proved more effective than elastic material in reducing lymphedema. In the maintenance phase, elastic stockings are enough to maintain the result and prevent recurrences.

Compression reduces the venous hydrostatic pressure and increases the interstitial pressure; these two effects lead to a) a reduction of venous reflux b) an increase of blood and lymph velocity and of the anterograde flow (toward the heart). The final result is a reduction of the filtration of capillary fluid and an increased reabsorption of fluid into the lymphatic vessels resulting in the reduction and subsequent disappearance of edema.

Finally, it will be explained that swelling may be relieved by elevation, which reduces fluid filtration by reducing venous pressure. The reduction of fluid filtration reduces lymph overload and favors fluid absorption. Drugs that claim efficacy in reducing fluid filtration will be discussed. One example is coumarin, a benzopyrone, which seems to be effective in hydrolysing tissue proteins, facilitating their absorption and stimulating lymphatic collectors. But the exact role for benzopyrones as an adjunct therapy in lymphedema is not yet exactly determined including the appropriate formulations and dose regimens since, for example, in higher doses coumarin could be hepato-toxic.

New Anticoagulants

Dr. Malay Patel

Five experts will make their presentations in the symposium on “New Anticoagulants and Their Role in VTE” which starts at 4.30 pm on Tuesday, September 10, 2013. New anticoagulants (NAs) belong to two main classes—direct thrombin inhibitors and factor Xa inhibitors. Both NAs are active orally with predictable pharmacodynamics. The first two talks will tell us more about both of these orally active compounds. The third talk will be of more interest to the practicing physician, as it will discuss “New Anticoagulants and the Management of Bleeding Complications.” NAs have a bleeding incidence that is lower than oral vitamin K antagonists (OVKAs), but because they have no known antidote at present, treating the bleeding complication is complex. This talk will help us understand this issue better and stimulate us toward searching for better antidotes to NAs.

As with any new pharmacotherapeutic agent, there are always questions about the best indication/s to use them and when to use them. The speaker of the fourth talk, “When Should Use of the New Anticoagulants Be Considered in VTE?,” will discuss these issues. The fifth talk of this symposium, “Anticoagulant Strategies for Reducing Post- Thrombotic Syndrome,” will tell us more about reducing the morbidity from the post-thrombotic syndrome. Any reduction in patient morbidity and health care costs from the current status will mean progress.

A 10-minute discussion followed by a panel discussion for half an hour will the best time to generate new ideas and clear doubts. So let’s see you fill up every seat in the hall for this exciting time.

Varicose Disease Treatment: Revolutions…Not Achieved?

Paul Pittaluga, MD

For many decades, the so-called radical therapeutic approach to varicose disease has been univocal in attempting to eliminate saphenous reflux using surgical treatment with a combination of high ligation
and stripping of the saphenous vein (SV). This treatment fits in with the traditional descending pathophysiologic description of varicose disease, which is considered to develop from the junctions
between the deep venous system and the SV. According to this theory,the appearance of reflux at the terminal valve of the SV was the key point in the progression of saphenous insufficiency, leading to the appearance of varicose veins in the tributaries.

The first revolution was in the late 20th century when experience with less invasive approaches to treatment using thermal laser energy or radiofrequency energy led to new methods and techniques using an endovascular route, just as in arterial surgery. At the same time, sclerotherapy was revolutionized
by the use of foam sclerosants, which were considerably more effective in larger veins and which, therefore, also provided serious competition to traditional surgery.

However, these technical developments took place without calling into question the principle behind surgical treatment, namely, the systematic ablation of the refluxing SV, which is supposed to be responsible for the appearance of varices in its tributaries. But to make the procedures less invasive, high ligation no longer accompanied thermal ablation or sclerotherapy of the SV. This “detail” caused the utility of high ligation, which was inseparable from traditional surgical treatment, to be called into question.

The absence of routine elimination of ostial reflux with good results led to the importance of the descending hemodynamic theory of varicose disease, with progression from the SV being doubted. This was supported by work based on increased hemodynamic understanding, thanks to the development of ultrasound technology. Some observations supported the idea that varicose disease developed from distally to proximally. A minimally invasive surgical approach appeared, based on treatment of the varicose reservoir (VR) by means of phlebectomy and preservation of the SV, even if the SV presented preoperative reflux. Supporters of this conservative approach cited the physiological role played by the SV, as well as the hemodynamic and clinical efficacy in the medium term of a rigorous, isolated
resection of the VR.

If this theory turns out to be well founded, the challenge for endovonous procedures and foam echosclerotherapy will be to show themselves capable of treating the VR, while still preserving the SV as precisely and reliably as ambulatory phlebectomy.

Thus, the second revolution for the treatment of varicose veins might be on the way.

Hemodynamic Effects in the Microcirculation

Joseph D. Raffetto, MD

The microcirculation is composed by terminal arterioles, capillaries and venules which drain capillary blood. This network of the circulation is important in regulating blood flow and perfusion to tissues, blood pressure, fluid homeostasis, oxygen transport/release and uptake of carbon dioxide, and regulation of body temperature. Importantly in the pathology of chronic venous disease the microcirculation begins with inflammation involving the activation of the endothelium and leukocytes. Alteration in shear stress in concert with transmitted venous hypertension leads to the expression of integrins on the endothelium and leukocytes and damage to the endothelial glycocalyx. This sets up a chronic inflammatory state with the production of chemokines, cytokines, matrix metalloproteinase, and a prothombotic environment. Many of the alterations taking place in the microcirculation in chronic venous disease occur in the post-capillary venules. Further research and understanding in the microcirculation is necessary to develop therapeutic strategies in treating the array of conditions presented in chronic venous disease.

Invited Lecture: The Basic Science of Primary Venous Insufficiency

Joseph D. Raffetto, MD

The pathophysiology of primary venous disease is a complex entity leading to the dilated tortuous, valve insufficient varicose veins, venous hypertension and the associated clinical manifestations seen with chronic venous disease. Genetic and environmental influences are certainly key factors in the initiation and progression of primary venous insufficiency. Changes in the endothelium with overexpression of ICAM-1 and VCAM-1, the expression of slectins on the leukocytes and endothelium, initiates the interaction between the endothelial vein wall and valve and leukocyte attachment and migration. Inflammation results and the release of cytokines and matrix metalloproteinases in the venous wall components progresses with alteration in venous contractile function and structural protein changes. Understanding the inciting events involving the interaction between endothelium and leukocytes, the responsible molecules involved in inflammation and venous function, and the regulatory mechanism responsible in venous dysfunction, will provide important information to afford effective therapy at different levels in the complex process of chronic venous disease development.

Venous Education Around the World

Steven E. Zimmet, MD

Those with an interest in venous disorders are actively discussing a very important question: how best to assure that clinicians now and in the future will be able to obtain comprehensive training so that patients can receive care from those who are well trained in the field.

Many of the important innovations and developments in the field of venous disease have come into common use without any opportunity for formal training for those already in practice, regardless of specialty background. Much of modern practice depends on skills and techniques that must be learned through conferences, peer-to-peer interactions and other individual postgraduate educational experiences.

However, similar challenges exist even for those currently enrolled in a formal training program, regardless of specialty. There is no single specialty that routinely provides a comprehensive curriculum to cover the full spectrum of venous disease. Most would agree that venous curricula, even in vascular specialties, would benefit from being standardized and strengthened.

Thus, it is very timely that the UIP Boston meeting will include a session, “Venous Education Around the World.” Luminaries will review the training in venous disease available in their respective countries and continents. Understanding the current reality in venous education can help us plan a course for improvement.

The practice of venous medicine has many of the attributes often associated with a specialty or subspecialty. Venous medical societies exist in many countries. There are many medical and surgical conferences and multiple journals dedicated to venous disease. Many physicians’ practices focus mostly or primarily on venous disease. Only by strengthening and standardizing venous curricula and training in all relevant specialties can we reliably develop qualified comprehensive specialists and achieve true subspecialty status.