This article is one of four stories that highlights the venous components covered at the November 2014 VEITHsymposium. Here is a list of the the remaining three articles that highlight what was covered at the symposium:
New Developments in Venous Disease Treatments
by Jose Almeida, MD; Lowell Kabnick, MD; and Thomas Wakefield, MD
The 2014 VEITHsymposium devoted much attention to venous disease. As a matter of fact, the three-day course was titled Venous, Venous, Venous. The reason for added coverage in venous disease relates to the endovenous revolution that commenced in 1999 when the FDA approved radiofrequency ablation of the saphenous vein. This paradigm shift to minimally invasive surgery led to better outcomes and better patient acceptance, and the frequency of superficial venous procedures began to increase. More technology developed as lasers entered the space. Once these minimally invasive procedures became standardized, office-based and insurance reimbursed, specialists—besides surgeons —began performing superficial venous intervention.
In the past five to 10 years, we have also witnessed the same phenomenon with deep venous disease. Venous stenting has replaced previously complex deep vein reconstructions. Currently, interventionalists are tackling more complex venous disease, the most challenging being post-thrombotic venous occlusive disease. What follows is only a sampling of what was presented at the VEITHsymposium.
Advances and new information in venous disease and its treatment
In the section titled “Advances and New Information in Venous Disease and its Treatment,” Jose Almeida kicked off the session with talks on more discriminant patient selection. The first talk emphasized CEAP & VCSS establishing the treatment plan based on clinical findings. The second talk, by Lowell Kabnick, discussed what duplex ultrasound mapping adds to the exam. Then, Seshadri Raju taught us how to quantify saphenous reflux. The session ended with Andrew Nicolaides taking a new look at venous hemodynamics and the importance of measuring both reflux and venous outflow obstruction.
Vein treatment strategies and techniques
We then followed with superficial vein treatment strategies and techniques, which were initiated by Bo Eklof, who discussed randomized controlled trials on endovenous thermal ablation. Peter Henke disseminated information on what’s on the horizon in venous thrombosis research, while Alan Dietzek reviewed why standardization is needed with endovenous therapy. We learned of interventional strategies for thromboembolic disease, with an overview of current role of lysis, mechanical thrombectomy and stents for acute and subacute iliofemoral and caval deep vein thrombosis by Mark Meissner. Mark Garcia shed light on pharmacomechanical thrombolysis of large volume (extensive) deep vein thrombosis, using the rapid lysis method. Thomas Wakefield discussed medical strategies involving P-selectin inhibition—specifically how it promotes thrombus resolution and prevents vein wall fibrosis.
Imaging has become quite important, and the current practice for MRV and CTV in imaging of pelvic and abdominal venous compressive pathologies and syndromes was presented by Barry Stein.
Strategies to reduce venous hypertension
The most exciting information probably came in the session entitled “Femoro-Iliocaval Interventional Strategies to Reduce Venous Hypertension, Hot Ideas for Recanalizing Chronic Total Occlusions.” What has become a very controversial subject (“Femoral Vein Recanalization via Popliteal Access Establishes Better Inflow than Common Femoral Vein Endovenectomy”) was tackled by Mark Garcia. Crossing femoro-iliocaval chronic total occlusions using graduated support and tinkering was demonstrated in a talk by Jose Almeida; then more aggressive techniques such as re-opening occluded femoro-iliocaval stents using aggressive sharp devices was presented by Brooke Spencer. The session concluded with Constantino Pena examining off-label use of arterial CTO devices for crossing venous CTO’s.
Dealing with saphenous incompetence and varicose veins
To deal with saphenous incompetence and varicose veins, Lars Rasmussen presented his RCT comparing open surgery, radiofrequency, and laser and foam sclerotherapy for varicose veins. The incidence, causes and treatment of recurrent varicose veins following endovenous thermal ablation was presented by Edward Mackay.
RIVAL & PVCS
Ramesh Tripathi flew all the way from India to talk about reduction internal valvuloplasty (RIVAL), a new technique for deep vein valve reconstruction early results. Also coming to the forefront is pelvic incompetentence and its consequences, which were presented by a very experienced interventionalist in this area, Mel Rosenblatt. He discussed the diagnosis and treatment paradigm for patients with pelvic venous congestion syndrome. Constantino Pena followed with a session called “Ovarian Vein, Hypogastric Vein Incompetence or Compression Syndrome? Coil. Stent. Both. Neither?”
The open-case challenge & IVC Filter Retrieval
For those who enjoy a large open case challenge, patient selection for in-line caval reconstruction was beautifully shown with operative imagery by William Quinones-Baldrich. Last but not least, Paul Foley III brought the audience some new tips and tricks about a growing problem that vexes venous doctors: IVC filter retrieval.
Step-by-step tutorials & more
Later in the meeting, there was another day totally dedicated to venous topics. The day was initiated by talks regarding venous valvular physiology (Fedor Lurie), embryology (Jean Francois Uhl), and the pathophysiology of venous hypertension (Sylvain Chastanet). Venous insufficiency was then discussed by Joe Raffetto, and skin changes by Peter Pappas. We then deliberated about CEAP and VCSS (by William Marston), what to do when clinical findings and the duplex do not correlate (by Edward Mackay), and step-by-step tutorials on using sclerotherapy (Mark Whiteley), laser ablation (Mark Adelman), MCA (Julianne Stoughton), foam scherotherapy (Lowell Kabnick), and recurrent varicose veins (Tom O’Donnell).
Varicose veins: techniques, treatments & reducing complications
We then spoke of techniques for large varicose veins via sclerotherapy (Neil Khilnani), ambulatory phlebectomy (Alan Dietzek), powered phlebectomy (Thomas Wakefield), and then a number of talks on how to reduce complications. Subsequently, a series of presentations were given involving societal issues on varicose vein treatment (Mark Meissner), vein center accreditation (Lowell Kabnick), and the new SVS/VQI venous registry (Thomas Wakefield). Completing the session, Raghu Kolluri discussed the management of lymphedema.
Other interesting topics
We then followed with a session on evidence and research needs for endovenous treatments. Peter Lawrence spoke on venous ulcers and specific superficial vein treatments, and there was a lively debate between Mark Whiteley and Lowell Kabnick on whether early ultrasound is mandatory after saphenous ablation. Then, the important topic of performing thermal ablation while on anticoagulation was presented (Glen Jacobowitz). We discussed different laser wavelengths (Ian Chetter and Lowell Kabnick), homemade foam vs. FDA foam (Lowell Kabnick), and then pearls of using different techniques (Thomas O’Donnell, Alan Dietzek, Lowell Kabnick, Julianne Stoughton, Ian Franklin and Steve Elias). Pelvic congestion syndrome was discussed in detail (Neil Khilnani), as was a new look at venous hemodynamics (Andrew Nicolaides), when and how to use phlebectomy (Paul Pittaluga), and a primer on how to apply bandages (Joe Caprini).
During the meeting, other interesting topics discussed included the diagnosis of venous obstruction with thoracic outlet syndrome and the treatment of venous abnormalities with this diagnosis (Enrique Criado), whether we are following the proper indications for the placement of IVC filters (John Rectenwald), and how to reopen totally occluded IVCs in the presence of thrombosed IVC filters (David Williams).
Thus, you can see the wide variety and complete coverage of venous topics in the 2014 VEITHsymposium.