Asian Chapter of the UIP, Kyoto, Japan, June 18-20, 2007

Summary

I - Report by the Members of the Medical

Reporters’ Academy of the Asian Chapter of the
Union Internationale de Phlébologie
The Westin Miyako Hotel Kyoto, Japan
Monday June 18-Wednesday June 20, 2007
1. Highlights
2. Epidemiology and risk factors
3. Basics
4. Investigations
5. Treatments
6. Miscellaneous

II - Report by Dr Jan T. Christenson, Geneva,

Switzerland of the Spring Meeting of the Swiss
Society of Phlebology University Hospital
of Geneva, Switzerland, Friday June 15, 2007

Phlebolymphology. Vol 14. No. 4. 2007 141

 Asian Chapter of the UIP, Kyoto, Japan, June 18-20, 2007

I
World Congress of the
Union Internationale de Phlébologie
Asian Chapter Meeting

Report
June 18-20, 2007
The Westin Miyako Hotel
Kyoto, Japan
Medical Reporters’ Academy (MRA)
The reports from the International Congress of Angiology were prepared by the following members of the MRA team:

Vassilios PAPAVASSILIOU Vadim BOGACHEV Armando MANSILHA

1st Sismanogliou street 1-st Moscow City Hospital Vascular Surgery Department
15126 Marousi Department of Surgery S. João University Hospital
GREECE 117049, Lenisky pr-t, 8-6 Alameda Prof. Hernani Monteiro
Moscow 4202-451 Porto
Grzgorz BIOLIK RUSSIA PORTUGAL
Department of General
& Vascular Surgery Chairman: Enrique MANUEL-RIMBAU
Medical Academy of Silesia Prof Andis NICOLAIDES MUNOZ
SPSK Nr 7 GCM Vascular Screening and Son Dureta Hospital.
Ziolowa Street 47 Diagnostic Centre C/Andrea Doria 55
40-635 Katowice 2 Kyriacou Matsi 07014 Palma de Mallorca
POLAND Ayios Dhometios SPAIN
2368 Nicosia
Giuseppe CALANDRA CYPRUS Grégoire LE GAL
Ospedale Israelitico Centre Hospitalier
Via Fulda 14 Universitaire de Brest
00148 Roma Hôpital de la Cavale Blanche
ITALY 29609 Brest
FRANCE

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 Asian Chapter of the UIP, Kyoto, Japan, June 18-20, 2007

Report Contents from the Asian Chapter of the UIP,

Kyoto, Japan, June 18-20, 2007

1. Highlights ................................................................................................................146

2. Epidemiology and risk factors .......................................................148

Chronic venous disease
Venous thrombosis

3. Basics ..........................................................................................................................153

4. Investigations .....................................................................................................155
Venous obstruction
Varicose veins
Venous valves
Lymphedema

5. Treatments ..............................................................................................................160
Venous thrombosis
Thromboprophylaxis
Thrombolysis
Air travel–related venous thromboembolism
Telangectasias
Varicose veins
Interventional treatments
Open surgery
Endovenous treatment

Noninterventional treatments
Compression
Sclerotherapy

Obstruction and stent placement

Iliac vein compression syndrome
Chronic venous insufficiency and venous ulcer

6. Miscellaneous ...................................................................................................183

Phlebolymphology. Vol 14. No. 4. 2007 145

1 - Highlights
The following highlights from the Asian Chapter of the Union Internationale de
Phlébologie, June 18-20, 2007, Kyoto, Japan were published in International Venous
Digest in July 2007. This document was produced by the members of the Medical
Reporters’ Academy (see picture on page 144 of the present issue).

Flow in the popliteal vein is markedly reduced (-40%) during sleep in the sitting
position. This is partially ameliorated by standard foot exercises recommended by
airlines. Blood flow is actually increased over and above baseline readings (+20%)
with foot exercises against severe resistance. According to Fletcher’s study, the effect
is short-lived and exercise needs to be repeated every 15 to 30 minutes.

Following an earthquake, Japanese people tend to sleep in their cars for several
days as a precaution against subsequent tremors. The incidence of duplex detected
calf deep vein thrombosis (DVT) in these individuals is 30% and decreases with
increasing distance from the epicenter of the earthquake.

An outstanding review by A. Skyropoulos (USA) of thromboprophylaxis with

LWMH emphasized the high prevalence of VTE in hospital patients, emphasizing
the fact that recent studies have shown that the prevalence in Asia is similar to
that found in Western countries. Evidence-based medicine has established the
efficacy of LMWH and its superiority over vitamin K antagonists. However, despite
the availability of guidelines , recent registries highlight the fact that many surgical
patients continue to receive suboptimal thromboprophylaxis (what is needed is
education not only of doctors but also the public - Editors’ comments).

The value of the D-dimer test in modern practice was highlighted by 2 presentations
(M. Dalsing, USA, and G. Palareti, Italy). A negative D-dimer result as a screening
tool in symptomatic low- to moderate-risk patients (Wells assessment method)
suspected of having DVT reduces the need for duplex scanning in 30% of patients.
In patients with established DVT, the finding of a high D-dimer value one month
after stopping vitamin K antagonists is associated with a high DVT recurrence
rate (OR 2.27; 95% CI 1.15 to 4.46). These patients should be considered for
more prolonged therapy.

Iliac vein stenting with or without recanalization performed for outflow obstruction
or restenosis in a series of 982 limbs by S. Raju, USA, has been shown to have a
primary and secondary patency rate of 79% and 100% at 6 years. Relief of pain
and swelling at 6 years (cumulative) was 62% and 32%, respectively. 58% of the
ulcers remained healed at 6 years despite the residual reflux.

Data from the Bonn epidemiological study (Presentation by E. Rabe) including

3072 participants, aged 18-79, have provided information on the prevalence of
chronic venous disease according to the CEAP classification: telangiectasias 87%,
varicose veins 23%, chronic venous insufficiency (C3- C6) 17%. The prevalence

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of venous leg ulcers (C5-C6) was 0.7%. The risk factors for varicose veins (age
over 60, female gender, number of pregnancies, and family history of varicose veins)
were different from the risk factors for chronic venous insufficiency (age over 50,
obesity, urban residence).

B. Eklof, Sweden, presented the 14 projects the members of the American Venous
Forum have volunteered to lead during the 5th Pacific Vascular Symposium (January
2004, Hawaii, USA). These projects are a vision for the future: what we know,
what we do not know, and what we dream could be done over the next 10 years.
A committee was created to support and encourage completion of the projects. The
next step for the committee is to produce a supplement for J Vasc Surg.

Phlebolymphology. Vol 14. No. 4. 2007 147

2 - Epidemiology and risk factors
Chronic venous disease
Epidemiology of severe stages of chronic venous insufficiency in the Bonn Vein Study
E. Rabe / Germany

The author presented the Bonn Vein Study, a population-based, cross-sectional,

one-year study with participants from a single random sample out of population
registers. The 3072 participants ranged in age from 18 to 79 years (43.9% male,
56.1% female). The response rate was 59%. The CEAP classification and duplex
scanning were used.

Chronic venous disorders are very common in the general population. The
prevalence was 87.5% for telangiectases, 23% for varicose veins, 17% for chronic
vein insufficiency (CVI) (C3-C6), and 0.7% for C5-6 (venous leg ulcers) in both
males and females. The most important risk factors for telangiectases and varicose
veins were age (over 60), female gender, pregnancies, and family history of
varicose veins. The most important risk factors for CVI besides age (over 50) were
obesity and urban residence.

Symptoms and signs of chronic venous disorders: what can we learn from epidemiologic studies?
E. Rabe, F. Pannier / Germany

The authors presented an epidemiological study from Germany to evaluate the

prevalence and risk factors associated with venous insufficiency in the general
population (screening of 3072 individuals aged 18 to 79) of the city of Bonn and
two rural cities. The prevalence was determined by means of the response to a
specific questionnaire and one duplex ultrasound study.

The majority of symptoms associated with venous insufficiency appeared in

patients at stages C3 to C6 of the CEAP. The presence of varicose veins relates to
genetic factors, obesity, female gender, and advanced age. Obesity, low social class,
living in a city, and sedentary lifestyle were associated with CVI.
The authors intend to continue the study to answer questions like: Why do symptoms
vary in patients with the same type of varicose veins and degree of reflux?

Chronic venous insufficiency: clinical presentations among Malaysian patients

N.C. Liew, K. Moissinac, L. Lee / Malaysia

The authors have produced a venous registry of 343 patients (520 limbs) with
symptoms of CVI. The incidence of CVI among the Asian population is not known.
In this series, patients tend to present late: 50% belong to CEAP classes C4-C6.
Postthrombotic syndrome is not infrequent, affecting 5% of the general population.
Better education of the general population so that medical advice is sought at

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earlier disease stages may perhaps alter the spectrum of patients presenting to a
venous clinic.

Venous thrombosis
Prevalence and indicators of deep vein thrombosis in medical patients
K. Sato, K. Hanzawa, T. Okamoto, F. Asami, M. Takekubo, O. Namura, J. Hayashi / Japan

In Japan, venous thromboembolism (VTE) is thought to be a rare disease, and

thromboprophylaxis is not routinely used in clinical practice. In this study, the
authors aimed to determine the risk of VTE in hospitalized medical patients and to
identify indicators of this risk.

Of 158 patients (mean age 60 years) bedridden for at least 48 h in an internal

medicine ward with an acute medical condition and who underwent compression
ultrasonography, 68 (43%) had thrombosis. Older age was associated with a
higher thrombotic risk. This incidence is particularly high, but it included 26
isolated soleal vein thromboses, 5 superficial vein thromboses, and 5 upper limb
thromboses after catheter insertion. These results suggest Japanese and Westerners
have a similarly high risk and underline the importance of preventing
thromboembolic risk in medical patients.

Prevalence of calf deep vein thrombosis in residents in rural Japan, and diameter of soleus vein indicates a risk of calf
DVT in Mid Niigata prefecture Earthquake 2004
K. Hanzawa, J. Hayashi, I. Fuse, F. Aizawa / Japan

During earthquakes, people often take refuge in their cars, sometimes for many
days because of the frequent aftershocks over the following days. After an
earthquake in 2004, 11 persons taking refuge in their cars suffered from pulmonary
embolism (PE), of which four died. This prompted a Japanese team to conduct
investigations on VTE risk in such a context. They performed systematic
ultrasonography of the calf in all residents taking refuge in their cars one week
after the quake and found 30% of them to have calf deep vein thrombosis (DVT).
One year after the quake, a similar study was performed in 1365 persons living
in the affected area. Prevalence of calf vein DVT was 7.8%. The authors found a
correlation between the Richter scale value at the place of residence and the risk
of thrombosis. The same study was performed in a control group in another city
100 km from the area of the quake. In this city, only 1.8% of tested subjects had
DVT. Also, the authors found the diameter of the soleal veins to be associated
with DVT risk. In particular, in the area hit by the quake, soleal vein diameters
were significantly higher in subjects who took refuge in their car than in those
who did not. It was higher in patients with calf DVT than in those without DVT,
with a 2.5 (95% CI 1.7 to 4.0) odds-ratio at the cut-off of 9 mm. The proportion
of subjects with an increased soleal vein diameter (above 9 mm) was higher in
the quake area than in the control study, and one year after the quake a significant
association between the soleal vein diameter and the risk of DVT was also found.

Phlebolymphology. Vol 14. No. 4. 2007 149

 The high proportion of calf DVT, even asymptomatic, observed after confinement
in cars for several days might represent a danger for the exposed population.
Although the criteria for selection of controls were not clearly stated, the risk of
thrombosis during the following year seems to be higher than in unexposed
patients.

Risk profile of patients with deep vein thrombosis diagnosed in ambulatory care - Data from the German TULIPA Registry
H. Gerlach, S.M. Schellong, V. Hach-Wunderle, E. Rabe, H.B. Riess, H. Carnarius, N. Banik, R. Bauersachs / Germany

Nowadays, patients with DVT are managed on an outpatient basis. The aim of the
German TULIPA registry (comprising 4976 patients referred by their GP for a
clinically suspected DVT to 341 ambulatory care vascular medicine physicians) was
to provide information on patient risk profiles in such a setting.

Prevalence of classic risk factors was higher in patients with DVT at ultrasonography
than in those without. Male gender, older age, a recent history of plaster cast,
surgery, confinement to bed, or acute disease were associated with DVT, as well
as a family history of VTE, active malignancy or the use of estrogens, corticosteroids
or anticancer therapy. However, odd-ratios for the association between these risk
factors and DVT were lower than usually reported, most of them being between
1.4 and 1.8. Varicose veins and long distance travel were not associated with DVT
in this study.

These results are not surprising, due to the study design. In fact, this was not a
case-control study. All patients were referred by their GP because DVT was
suspected, partly because of the patients’ risk factors. This reduced the contrast
between patients with and without DVT, those without DVT not being good
controls for an association study.

Importance of combination of persistent underlying factors in deep vein thrombosis

H. Yasuhara, N. Ohara, T. Hattori, O. Shigeta / Japan

In a cohort study of 122 patients with lower limb DVT, the authors aimed to
1) identify factors linked with an associated PE at the time of DVT diagnosis;
2) identify factors associated with a higher risk of VTE recurrence during a mean
21-month follow-up. 67 patients (55%) had an associated PE. Those patients with
recurrent DVT, prolonged bed rest, or who underwent venous catheter insertion
were more prone to associated PE. This was also true for patients with persistent
underlying risk factors (coagulopathy, active malignancy, collagen disease, or iliac
compression): hazard ratio 1.6. During follow-up, patients with a history of VTE
(hazard ratio 3.9) had a higher risk of DVT recurrence, as had those with one of
the predefined persistent underlying risk factors: hazard ratio 3.6.

These data confirm that a stratification of patients based on VTE history and the
presence or absence of transient or persistent risk factors for VTE is useful in
predicting severity and the risk of DVT recurrence, and have the potential to
improve management.

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 Asian Chapter of the UIP, Kyoto, Japan, June 18-20, 2007

Risk of recurrent deep venous thrombosis in patients with genetic thrombophilias

J.R. Gonzalez-Porras, I. Alberca, M.L. Lopez, F. Lozano / Spain

259 patients with DVT were included in the investigation. Genetic polymorphisms
of factor V Leiden, G20210A prothrombin and 677T methylene tetrahydrofolate
reductase and their influence on DVT recurrence were assessed. The authors
concluded that the double defect, and homozygosity or double heterozygosity for
factor V Leiden and G20210A were associated with an increased risk of recurrent
DVT. Patients who were heterozygous for factor V Leiden or G20210 had a risk
of recurrent DVT similar to that of patients who had neither mutation. The 677T
MTHFR mutation alone or combined with hyperhomocysteinemia was not
associated with an increased risk of recurrent DVT. In conclusion, the authors
recommended active (LMW-heparin or warfarin) thromboprophylaxis for all
patients at high risk of re-thrombosis.

A nonsense polymorphism in the protein Z-dependent protease inhibitor increases the risk of venous thrombosis
J. Corral, J.R. Gonzalez-Porras, R. Gonzales, I. Alberca, F. Lozano, V. Vicente / Spain

Z-dependent protease inhibitor (ZPI) is a new hemostatic serpin with anticoagulant

activity. There were 6 genetic mutations affecting the ZPI gene. All of them induced
ZPI deficiency and significantly increased the risk of DVT. The ZPI mutation is the
root cause of primary DVT in 0.9% cases.

Deep venous thrombosis incidence in patients immobilized by multiple sclerosis: a prospective study
G. Arpaia, P. Bavera, D. Caputo, L. Mendozzi, R. Cavarretta, G.B. Agus / Italy

Patients affected by multiple sclerosis experience a progressive reduction in walking

capacity and spend increasing time in a wheelchair or in the sitting position. Leg
swelling occurs in a short time often with pain and can lead to DVT. Up to now,
DVT in these patients has been underestimated and not much considered by
neurologists. The aim of this prospective study was to screen 200 patients with
multiple sclerosis: 100 with usual rehabilitation, 100 with the same but also
wearing below-knee stockings. The author presented preliminary data on 50
patients with a follow-up of 6 months and evaluation by duplex scan at several
levels (below-knee deep veins, popliteal, and femoral veins). DVT (either distal
or proximal) was found in 13 patients (19.6%) at the end of the 4 weeks of
rehabilitation.

Factors to predict the risk of venous thromboembolism recurrence

G. Palareti / Italy

The optimal duration of oral anticoagulant therapy (OAT) to prevent recurrences

after a first unprovoked venous thromboembolism (VTE) event is still uncertain.
The author reported data from a recently published, prospective, open label,
randomized controlled study to assess whether the D-dimer (DD) test may be
used to establish OAT duration. The DD test was performed 1 month after

Phlebolymphology. Vol 14. No. 4. 2007 151

 anticoagulation withdrawal in patients with a first unprovoked proximal deep
venous thrombosis or pulmonary embolism who had received OAT for 3 months.
Patients with a normal DD did not receive OAT. Patients with abnormal DD were
randomized to receive further such treatment or not. DD was abnormal in 223/608
(36.7%) patients. Recurrent VTE occurred in 24/385 patients with abnormal DD.
The adjusted hazard ratio of patients with abnormal DD who stopped
anticoagulation versus those with normal DD was 2.27 (1.15-4.46; P=0.02). In
conclusion, the DD test after OAT withdrawal can assess the risk of VTE recurrence.
Patients with abnormal DD have a higher risk of recurrence and should benefit
from prolonged anticoagulation.

Incidence and clinical predictors of deep vein thrombosis in patients hospitalized with heart failure in Japan
S. Ota, N. Yamada, M. Nakamura, N. Isaka, M. Ito / Japan

The aim of this study was to estimate the incidence of venous thromboembolism
(VTE) in in-hospital patients with heart failure (HF). This study was performed
in 108 patients admitted to hospital with class 2 to 4 HF. They underwent systematic
compression ultrasonography during their stay. Despite the use of anticoagulant
therapy in 21 patients (mainly warfarin for their underlying cardiac condition),
the overall incidence of DVT was 13%. This correlated with the severity of HF:
5.4%, 7.1% and 23.2% in NYHA classes 2, 3 and 4, respectively. In a multivariate
analysis, class 4 HF and anticoagulation were independent predictors of risk, with
odds-ratios of 18 (95% CI, 3.0 to 117) and 0.22 (95% CI, 0.1 to 0.9), respectively.
Because LMWH use is restricted in Japan, where VTE is thought to be a rare
disease, this Japanese study provides valuable confirmation of the high incidence
of VTE in hospitalized HF patients and highlights the need for thromboprophylaxis
in such patients.

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3 - Basics
5th SERVIER FELLOWSHIP. Presentation of the new winner’s project:
Erythrocyte diapedesis during chronic venous insufficiency
C. Rosi / Italy

Chronic venous insufficiency (CVI) causes venular hypertension with erythrocyte

diapedesis and cutaneous deposition of hemosiderin leading to lipodermatosclerosis
and ulceration. In a preliminary study, the author evaluated skin samples from
legs with CVI to assess the mechanism of dermal damage by means of histology,
histochemistry, and immunohistochemistry data, and with drug administration
of micronized purified flavonoid fraction (MPFF). Skin samples were from patients
of CEAP classification C2, C3, C4a, C4b, C6. The erythrocyte diapedesis occurred
only during active inflammatory phases of skin dermopathy. In the presence of
MPFF, the action of MPFF mitigated the effects of the inflammatory action and
deposition of hemosiderin.

4th SERVIER FELLOWSHIP. Presentation of the 2005 winner’s research:

Physiological and histological characteristics of porcine model of superficial varicose veins
G.T. Jones, M. Grant, I.A. Thomson, A.M. Van Rij / New Zealand

This study determined the pathophysiological basis of superficial varicose veins

in a novel porcine model, as assessed by intravenous blood pressure, duplex
ultrasound, histology, and vein wall homogenate substrate zymography.

Right femoral arteriovenous fistulae were surgically fashioned in adult pigs. Gross
superficial varicosities developed after an initial lag period of 1-2 weeks. Varices
appeared to have a postural component to their filling and did not seem to be the
direct result of venous hypertension per se (non-pulsatile, with a mean pressure
of 23 mm Hg).

Venous blood flow velocities were elevated from approximately 5 cm/s in controls
to 15-25 cm/s in animals with patent fistulae.

Histopathological changes in porcine vein structure included the development of

enlarged tortuous veins, valve degeneration, failure of elastic tissue, and focal
medial atrophy with or without overlying intimal thickening. It was concluded
that the superficial varicose veins that developed within this porcine model have
a pathophysiology that is consistent with that observed in humans.

HMG-CoA reductase inhibitors reduce matrix metallo-proteinase-9 activity in human varicose veins
S. Nomura, K. Yoshimura, N. Morikage, A. Furutani, H. Aoki, M. Matsuzaki, K. Hamano / Japan

Varicose veins are an important public health problem because of their prevalence
and morbidity. Because the molecular pathogenesis of varicose veins is still unclear,

Phlebolymphology. Vol 14. No. 4. 2007 153

 few pharmacological options to treat varicose veins are available. The effects of
MGH-CoA reductase inhibitors (statins) on matrix metalloproteinase MMP-9
were therefore investigated in human varicose veins, because MMP-9 is implicated
in disruption of extracellular matrix in varicose veins.

Saphenous vein samples were obtained from 7 varicose vein patients and from 4
patients undergoing artery bypass grafting. Expression levels of MMP-9 protein
in the vein walls were analyzed by Western blotting and by immunostaining.
Human varicose vein tissue was cultured ex vivo to determine the effect of statins
on MMP-9 and urokinase-type plasminogen activator (u-PA), an activator of
MMP-9. Secretion levels of MMP-9 and u-PA in the culture media were determined
by gelatin zymography and enzyme-linked immunosorbent assay, respectively. The
selected activity and mRNA level of MMP-9 were determined by MMP-9 activity
assay and quantitative RT-PCR, respectively.

MMP-9 was significantly increased in varicose veins compared with controls

mainly in smooth muscle cells at the media, where marked degradation of
extracellular matrix was observed. Simvastatin and pravastatin caused striking
suppression of MMP-9 activity in ex-vivo culture of varicose vein tissue, while
they modestly reduced MMP-9 protein and tended to reduce its mRNA levels.
Interestingly, simvastatin significantly suppressed u-PA secretion. Furthermore,
while tumor necrosis factor TNF-a, a proinflammatory cytokine, caused a large
increase in MMP-9 activity secreted from varicose veins, simvastatin reduced
MMP-9 at both the mRNA and protein levels and also u-PA protein level, resulting
in the dramatic suppression of MMP-9 activity induced by TNF-a.

Statins suppressed multiple mechanisms of MMP-9 production and activation,

resulting in synergistic suppression of MMP-9 activity in varicose veins. Statins
may be useful in treating this common disease.

Vascular endothelial growth factor (VEGF) and VEGF-Receptor (VEGF-R) in the pathogenesis of primary and recurrent varicose
veins
S. Rewerk, K. Labretsas, M. Winkler, H. Nüllen, C. Duczek, A.J. Meyer, A. Gruber, R. Grobholz, N. Thomas / Germany

VEGF is known to be one of the strongest stimulators for angiogenesis in many

different tissues. To initiate this process, the VEGF-R must be present on the
endothelial cell surface. Patients were distributed into a control group (n=16), a
primary varicose vein group (n=110), and a group with recurrent varicose veins
after crossectomy (n=24). Thin-walled veins embedded in scar tissue
(neovascularization) were stained immunohistochemically with antibodies against
VEGF and its receptor VEGF-R. Higher staining intensity was seen in the recurrence
group than in the controls, indicating that VEGF and VEGF-R may play an
important role in angiogenesis associated with recurrent varicose veins.

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4 - Investigations
Venous obstruction
Assessment of venous obstruction with air plethysmography and duplex ultrasound
F. Lurie / USA

This study combines air plethysmography (APG) and duplex ultrasound (US) in
patients with deep venous obstruction. The study included 25 patients with deep
vein obstruction (10 iliac and 15 femoral) and a control group of 25 healthy
volunteers studied with both APS and US. The segmental distribution of the flow
was defined as a fraction of the total volume outflow contributed by each of the
three veins (superficial femoral vein SFV, profunda femoral vein [PFV], great
saphenous vein [GSV]) expressed in percent.

APG is a good test to determinate iliac vein occlusions, but is not effective in femoral
vein occlusions. In healthy volunteers, SFV contributes 40% to 60%, PFV 20% to
30%, and GSV 10% to 20% to the total outflow. In the presence of SFV occlusions,
the GSV flow increases to 80% of total flow, with no changes in PFV flow. It appears
that in the case of SFV occlusions, GSV flow makes an important contribution to
venous return. The contribution of PFV is these cases seems minor.

High peak reflux velocity in the proximal deep veins is a strong predictor of advanced postthrombotic sequelae
T. Yamaki, M. Nozaki, H. Sakurai, M. Takeuchi, K. Soejima, T. Kono / Japan

The presence of reflux in the deep venous system after an acute deep vein thrombosis
is considered to contribute to the development of advanced postthrombotic
syndrome. The aim of this study was to determine the ultrasound parameters
reflecting the progression of PTS. The study included 131 limbs (130 patients) for
which there was complete 6-year follow-up after an acute DVT. The patients were
studied by means of ultrasound at 2 and 6 years. The ultrasound parameters
analyzed at the popliteal vein (VP) and femoral vein (FV) were vein diameter,
peak reflux velocity (PRV), reflux time (RT), and the total refluxed volume. The
patients were divided into two groups depending on venous insufficiency severity
measured by CEAP score: group I (C0 to C3) and group II (C4 to C6).

There were 98 patients in group I and 33 in group II. The frequency of venous
reflux was significantly higher in group II, without differences in venous occlusion
between the two groups. The proportion of FV and PV incompetence was higher
in group II. There was no between-group difference in RT. Fifty-eight per cent of
group II patients developed advanced symptoms of PTS during follow-up. Statistical
analysis demonstrated that PRV>25.4 cm/s in PV and PRV>24.5 cm/s were strong
predictors of advanced CVI.

In conclusion, PRV in patients with deep vein thrombosis is an independent

predictor of the development of chronic venous insufficiency.

Phlebolymphology. Vol 14. No. 4. 2007 155

The utility of quantitative calf muscle near-infrared spectroscopy in the follow-up of acute deep vein thrombosis
T. Yamaki, M. Nozaki, H. Sakurai, M. Takeuchi, K. Soejima, T. Kono / Japan

The study was designed to examine venous segments in terms of occlusion, partial
recanalization, and total recanalization with the application of quantitative calf
muscle near-infrared spectroscopy (NIRS). The NIRS-derived calf venous blood
filling index (HHbFI), calf venous ejection index (HHbEI), and the venous retention
index (HHbRI) were assessed as markers of occlusion, partial recanalization, and
total recanalization.

A total of 78 limbs with an acute deep vein thrombosis ( DVT) involving 156
anatomic segments were evaluated with duplex scan and NIRS.

At 1 year, the HHbFI in POPV reflux patients was significantly higher than in
those with resolution (0.19±0.14, 0.11±0.05, P=0.009, respectively). Similarly,
there was a significant difference in the HHbRI between the two groups (3.08±1.91,
1.42±1.56, P=0.002, respectively). In patients with femoral vein occlusion, the value
of HHbRI was significantly higher than in those with complete resolution
(2.59±1.50, 1.42±1.56, P=0.011, respectively).

Calf veins showed more rapid recanalization than proximal veins. NIRS-derived
HHbFI and HHbRI could be promising markers of venous function during follow-
up in acute DVT. Thus physicians may detect patients who require much longer
follow-up studies.

Changes in the outpatient evaluation of deep venous thrombosis

M.C. Dalsing / USA

Currently, two main diagnostic approaches exist for patients with suspected DVT.
Serial proximal compression ultrasonography (CUS), which is mostly used in
North America, and which when negative has to be repeated one week later
when scanning is not performed below the knee. However, a negative single
complete (proximal and distal) ultrasonography has been shown to safely rule out
the diagnosis of DVT. Scanning proximal to the knee repeating the CUS one week
later is costly and time-consuming. This has led to the use of the D-dimer test as
part of the diagnostic algorithms. D-Dimer testing is useful in excluding DVT
(negative predictive value >95%), thereby reducing the need for duplex scanning
in 39% of patients as demonstrated by a randomized controlled study (Wells et
al, NEJM 2003). This strategy has proven effective and cost-effective.

Dalsing et al. propose the following approach. Patients with a high clinical
probability of DVT as assessed by the Wells’ score (Wells et al. Lancet 1997) undergo
a full duplex examination. Patients with a low or intermediate clinical probability
undergo a D-dimer test and, if positive, proceed to a full duplex scan. If negative,
they are left untreated. During off hours, patients in whom a CUS is required
receive a single injection of LMWH while awaiting the ultrasonic diagnostic test.
However, the safety and cost-effectiveness of this latter strategy remains to be
formally validated.1,2

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References
1. Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-Dimer in the Diagnosis
of Suspected Deep-Vein Thrombosis. N Engl J Med. 2003;349:1227-1235.
2. Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest
probability of deep-vein thrombosis in clinical management. Lancet.
1997;350:1795-1798.

Varicose veins
The evaluation of vein filling index of air plethysmography for type of varicose and lower-limb varicose vein treatment
M. Ojiro, S. Sane, S. Nakajima, K. Ehi, I. Omoto, T. Kuwahata / Japan

Aim: Although treatments of varicose veins include stripping sclerotherapy (foam)

with high ligation, sclerotherapy only, and compression stockings, in Japan the
main therapies are stripping (ST) and sclerotherapy with high ligation (LiG-SC).
However, evaluation of these two therapies has been controversial. So, we studied
the vein filling index (VFI) of air plethysmography (APG) and the clinical effects
of ST and LiG-SC.

Methods: VFI was measured in 40 limbs of the ST group and 117 limbs of the LiG-
SC group before and after treatment of varicose veins. VFI and improvement in
VFI were evaluated according to the method of treatment (ST vs LiG-SC), the
number of ligations (saphenofemoral junction, Dodd, Boyd’s perforation, and
other incompetent perforations), the type of varicose veins (saphenous major:
87 limbs, saphenous minor, and special type; 10 limbs), the severity of varicose
veins (CEAP classification), and recurrence (18 limbs).

Results: In the ST group, the level of VFI decreased from 6.95 A (4.3 to 2.1 A) 1.4
mL/s after treatment. In the LiG-SC group, VFI was high in severe cases, but
decreased to normal levels in almost all cases. The number of ligations increased
in severe cases. VFI improved in all cases in the ST group, but was still abnormally
high (above 2.2 mL/s) in 13 cases. In the LiG-SC group, VFI was abnormally high
in 30 cases (25.0%): 43.8% of cases with under 3 ligations, 24.4% of cases with
4-6 ligations, and 21.7% of cases with above 7 ligations. VFI was not abnormal
in saphenous vein minor and special types of varicose veins, and CEAP class 4-6
had a higher VFI than the other classes, but recurrence did not depend on VFI.

Conclusion: There was no significant difference in VFI improvement between the

ST and LiG-SC groups. However, in the LiG-SC group, the number of ligations
influenced the effect of VFI. Little improvement in VFI was noted for fewer than
3 ligations. The incidence of recurrence was higher in the LiG-SC group than in
the ST group. The severity of varicose veins depended on the VFI, but the relation
between recurrence and VFI is unknown.

Phlebolymphology. Vol 14. No. 4. 2007 157

Venous valve
Femoral vein valves: implantation of external support assessed by phleboscopy
G.M. Makhatilov, G.R. Askerkhanov, M.A. Kazakmurzaev, I.S. Ismailov / Russia Federation

The authors treated 28 limbs (24 patients) with primary venous valvular
insufficiency in the superficial femoral vein by means of external implantation of
Verdensky spirals. Phleboscopy identified 11 valves with elongated cusps and 16
with wide separation of cusps. Spirals restored valve competence in all 16 cases
of cusp separation. The authors conclude that the technical success of the
intervention depends on the type of valve insufficiency and the correct choice of
spiral diameter.

Lymphedema
New concept regarding lymphatic malformation
B.B. Lee, J. Laredo, D. Deaton, R. Neville / USA

The aim of this presentation was to enhance understanding of the two distinct
conditions of extratruncular and truncular lymphatic malformations (LMs),
clinically known as “cystic/cavernosus lymphangioma” and “primary
lymphedema”.

Retrospective analysis was done on N=445 patients with predominantly LM lesions

between 1995 and 2004. Lymphoscintigraphy was the most frequent diagnostic
test for the primary lymphedema due to the truncular LM. CDT (complex
decongestive therapy) or compression therapy or both were used to treat all cases
of truncular LM.

Surgical therapy was added to the CDT to improve its clinical management. MRI
and duplex ultrasonography were the basic tests for the lymphangioma due to
extratruncular LM. Sclerotherapy with OK-432 and/or ethanol was the primary
therapy, and surgical therapy was added mostly when the response to sclerotherapy
was poor.

Appropriate identification of truncular or extratruncular LM is essential for safe

management of either primary lymphedema or lymphangioma. A multidisciplinary
approach in which surgical treatments are added to conventional treatment can
improve the overall clinical management of both truncular and extratruncular LM.

Indocyanine green fluorescence imaging to detect lymphedema

I. Katoh, Y. Ogawa, H. Sogabe, H. Fujita, Y. Wakisaka, T. Kitagawa, M. Miwa, T. Shikayama / Japan

Pathological lymphatic dermal backflow is observed in patients who suffer from

local lymphatic obstruction or segmental lymphatic incompetence. It is possible
to investigate the superficial lymphatic system in swollen limbs with pathological

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skin backflow using indocyanine green (ICG) fluorescence. After ICG injection into
the normal leg or palm, the lymphatic channels and superficial nodes appeared
as a shining streams and spots with fluorescence from the side of injection to
proximal parts of the limb. Real-time observation of the skin lymph transport
visualizes superficial but not deep lymphatic channels and nodes.

For patients who suffer from lymphedema, an injection of ICG shows skin
lymphatic capillaries spreading out in all directions from the point of injection.
Reticulated patches of ICG are visible within one hour after injection and remain
for several days in this group of patients. This phenomenon is never observed in
the normal limb.

Patients with chronic venous insufficiency rarely present skin backflow. Further
investigation and adaptation of this method to the needs of medical practice can
provide a good and inexpensive tool which helps to differentiate lymphatic
pathology from chronic venous insufficiency or to recognize the coexistence of
both types of pathology.

Phlebolymphology. Vol 14. No. 4. 2007 159

5 - Treatments
Venous thrombosis
Thromboprophylaxis
Thromboprophylaxis with LMWH: an evidence-based approach for clinical practice
A.C. Spyropoulos / USA

This was a key-note lecture. The author emphasized that venous thromboembolism
(VTE) is a major public healthcare problem worldwide. Recent epidemiologic data
indicate that there are nearly 300 000 VTE-related deaths in the USA and over
340 000 VTE-related deaths in the European Union, with approximately 60 000
fatal postoperative VTE events (1,2). In Asia, venographic studies reveal that the
range of incidence of asymptomatic DVT is similar to that found in Western studies
(3). The recently completed AIDA study conducted in Asia (including China,
South Korea, Taiwan, Thailand, Malaysia, and the Philippines) found a 25%,
42%, and 58% incidence of venographic DVT in patients undergoing total hip
replacement, hip fracture surgery, and total knee replacement surgery, respectively
(4). These rates are similar to venographic rates of DVT found in earlier Western
studies in patients undergoing major orthopedic surgery prior to the systematic
use of thromboprophylaxis.

Patients undergoing major orthopedic surgery and major general surgery over
the age of 40 years are at high risk of VTE, with fatal pulmonary embolism (PE)
occurring in up to 7.5% of patients after hip fracture surgery (5). Patients with
cancer undergoing surgery are another high-risk group, as this group has a three-
fold greater risk of fatal PE compared with patients without cancer undergoing
similar procedures (5).

The current global consensus guidelines from the American College of Chest
Physicians (ACCP) and the International Consensus Statement (ICS) guidelines
recommend the use of low-molecular-weight heparin (LMWH), unfractionated
heparin (UFH), vitamin K antagonists (VKA), and fondaparinux, depending on
the type of surgery (5,6). Aspirin as monotherapy is discouraged in VTE prevention
due to limited efficacy. In orthopedic surgery, LMWH is more effective than UFH
in reducing DVT and PE, whereas the ICS guidelines state that parenteral therapies
are preferred for in-hospital prophylaxis over oral anticoagulant therapy. In general
surgery, LMWHs are as effective and safe as UFH, with the advantages of once-
daily dosing and less risk of heparin-induced thrombocytopenia (7). The guidelines
also recommend extended out-of-hospital thromboprophylaxis with LMWH in
patients undergoing major surgery for cancer (5,6). Lastly, while mechanical
methods such as intermittent pneumatic compression and elastic stockings can
reduce the risk of DVT, they have not been shown to reduce the risk of PE (8).

The use of LMWH has become the standard of care of thromboprophylaxis in the
orthopedic and general surgical patient due to an excellent efficacy and safety

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profile. Despite effective means of thromboprophylaxis and the advent of evidence-

based guidelines, recent registries highlight the fact the many surgical patients
continue to receive suboptimal thromboprophylaxis (9).

References
1. Heit J et al. Blood. 2005;106.
2. Cohen AT 5th Annual Eur Fed Intern Med. 2005.
3. Leizorovicz A et al. J Thromb Haemost. 2004;3(1):28-34.
4. Piovella F et al. J Thromb Haemost. 2005;3(12):2664-2670.
5. Geertz WH et al. Chest. 2004;126suppl3:338S-400S.
6. Nicolaides AN et al. Int Angiol. 2006;25:101-161.
7. Martel N et al. Blood. 2005;106(8):2710-2715.
8. Urbankova J et al. J Thromb Haemost. 2005;94:1181-1185.
9. Friedman R et al. J Thromb Haemost. 2003;1suppl1:1436.

Deep vein thrombosis in thrombophilia. Clinical tendency to and necessity for anticoagulant therapy.
Y. Watanabe, H. Shigematsu, Y. Obitsu, N. Koizumi, S. Makimura, H. Sato /Japan

Among 208 patients with DVT, 19 (9.1%) had thrombophilia: 9 (4.3% of all DVT
patients) with protein S (PS) deficiency, 5 (2.4%) with protein C (PC) deficiency,
4 (1.9%) with antithrombin III (ATIII) deficiency, and 1 (0.5%) with
antiliphospholipid antibody syndrome. Five patients with thrombophilia had a
family history of DVT. The initial onset of DVT occurred significantly earlier in
patients with thrombophilia (average 41.4 years old) than in the other patients
(average 58.3 years old) (P<0.05). The authors concluded that confirmation of
thrombophilia is necessary in all cases of DVT. Patients with confirmed
thrombophilia need anticoagulant therapy, which should be lifelong.

Prevention of venous thromboembolism after varicose vein surgery

J.P. Fletcher / Australia

J. P. Fletcher reported 4 cases (1.4%) of venous thromboembolism (VTE) diagnosed

by Doppler ultrasound in 257 patients after varicose vein surgery. Although there
is a lack of data and further work is needed, he defined three categories of risk of
VTE after varicose vein surgery: low risk (operation <45 minutes, age <60 years
and no other risk factors like obesity, immobility, congestive cardiac failure or
infectious disease; operation >45 minutes, age <40 years and no other risk factors),
moderate risk (operation >45 minutes, age 40-60 years and no other risk factors;
operation <45 minutes, age >60 years and no other risk factors; operation
<45 minutes, age 40-60 years, history of VTE, estrogen therapy, other risk factors),
and high risk (operation >45 minutes, age >60 years and no other risk factors;
operation >45 minutes, age 40-60 years, cancer, history of VTE or other risk
factors; thrombophilia).

In his opinion, low-risk patients for varicose vein surgery must use graduated
compression stockings in addition to early walking and adequate hydration.
Prophylactic LDUH or LMWH is recommended in moderate-risk patients, and in

Phlebolymphology. Vol 14. No. 4. 2007 161

 high-risk patients, LDUH or LMWH should be continued for 7-10 days
postoperatively.
Finally, Fletcher concluded that most patients undergoing varicose vein surgery
are at low or moderate risk of developing VTE.

Thrombolysis
Subclavian and axillary vein thrombosis treated by catheter-directed thrombolysis therapy with urokinase:
report of three cases
N. Ushida /Japan

The author presented three consecutive cases of successful treatment DVT of the
upper extremity. Catheter-directed thrombolysis with urokinase (240 000 IU/day)
and unfractionated heparin (10 000 U/day) were administered for 3 to 5 days. Full
resolution of the thrombus was achieved in all cases. Warfarin was administered
to all patients.

Efficacy of catheter-directed thrombolysis for acute deep vein thrombosis

T. Hattori, H. Haeda, H. Umezawa, H. Goshima, T. Nakamura, H. Kobayashi, A. Takasaka, H. Kawachi, N. Negishi /Japan

Thirty patients with DVT (18 patients with iliac DVT, 4 patients with femoral vein
DVT, and 8 patients with inferior vena cava DVT) underwent catheter-directed
thrombolysis after implantation of a temporary IVC filter. Thrombolysis with urokinase
(500 000 IU/day) was carried out for 2 to 5 days. In 19 patients there was complete
thrombus resolution. Stenting for persistent stenosis was performed in 5 cases. There
was one patient with early re-thrombosis treated with repeat thrombolysis.

Both presentations confirmed the benefits and efficacy of early thrombolytic

therapy of DVT of the upper and lower extremities.

Others
Inferior vena cava filters in the management of pulmonary thromboembolism: overview and personal experience
S. Kalva / USA

The three unquestionable indications for inferior vena cava (IVC) filter insertion
are the coexistence of an acute venous thromboembolism (VTE) and 1) a formal
contraindication to anticoagulant therapy, 2) a complication of anticoagulant
therapy, or 3) recurrent VTE despite well-conducted anticoagulant therapy. The
author reported a series of 3438 patients who had an IVC filter since 1973 at the
Massachusetts General Hospital. Some patients had a filter for indications other
than those mentioned above: added protection in patients with compromised
cardiopulmonary reserve, patients who underwent catheter-directed thrombolysis
of proximal DVT, or patients noncompliant with anticoagulant therapy. Finally,
it was sometimes used as VTE prophylaxis in high-risk patients, mainly those
with major trauma or pelvic/long bone fractures.

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Although no conclusions can be drawn regarding filter indications on the basis

of the report, because almost all available filters were used over time in this
institution, it provides interesting data on safety. Before 1998, the overall prevalence
of post-filter PE was 5.6%, and that of IVC thrombosis 3.1% among 1753 patients.
More recent filters seem to be safer, with a 3.1% post-filter PE risk and no risk of
symptomatic IVC thrombosis among 751 patients. Finally, patients in whom a
retrievable filter was inserted experienced a 0.7% risk of post-filter PE, without
IVC thrombosis. Overall retrieval success rate was 78%. However, the post-filter
risk of PE in those patients should be interpreted with caution, because prophylaxis
was the indication for IVC filter in two- thirds of patients receiving retrievable filters,
as compared with 30% of those who received other types of filter.

Process of thrombus regression among different venous segments after deep vein thrombosis
Y. Hosoi, M. Nunokawa, N. Takahashi, N. Takahashi, H. Kubota, T. Fujiki, K. Tonari, H. Endo, H. Tsuchiya, S. Kenichi
/ Japan

The authors studied the differences among venous segments and degree of
resolution within 12 months after an episode of DVT. Eighty-eight limbs of 81
patients with acute DVT were evaluated and treated with i.v. unfractionated
heparin followed by oral warfarin. In calf veins, total recanalization was observed
in 71% of cases at 3 months and in 87% at 6 months. For popliteal veins, total
recanalization was seen in 45% of cases at 3 months and in 66% at 6 months. In
contrast, the regression process was relatively slow in the femoral and iliac veins.
It was concluded that calf veins show more rapid recanalization than proximal
veins.

Air travel–related venous thromboembolism

Effect of leg exercises on popliteal venous blood flow during prolonged immobility of seated subjects:
implications for prevention of travel-related deep vein thrombosis
J.P. Fletcher, K. Hitos, M. Cannon, S. Cannon, S. Garth / Australia

The aim of this study was to determine the most effective form of exercise in
preventing venous stasis in the lower limb veins of seated young healthy subjects.
Four interventions were compared: 1) control: sitting without exercise; 2) exercising
as recommended by airline companies; 3) foot exercises against moderate
resistances; or 4) foot exercises against strong resistances. The outcome was the
popliteal volume flow, as calculated from the popliteal vein velocity and cross-
sectional area. A single examiner performed all the tests, blinded to the exercise
group.

In the control group, a 40% decrease in blood flow was observed after 90 minutes.
The decrease was more marked in those who were sleeping and in those whose
feet were not flat on the floor. Airline recommended exercises were beneficial but
did not return venous flow back to baseline. The more vigorous the exercises, the
greater improvement was observed in venous flow during the 90-minute period.
In the group with foot exercises against strong resistances, there was a 20%

Phlebolymphology. Vol 14. No. 4. 2007 163

 increase of popliteal flow compared with baseline flow. During question time,
Prof Fletcher indicated that the response is variable and the effect of exercise lasts
approximately 15 to 30 min. These findings might form the basis for future exercise
recommendations for airline passengers.

Anything new in air travel–related venous thromboembolism?

B. Eklof / Sweden

In view of the growing evidence of an association between air travel and an

increased risk of VTE, the World Health Organization decided in March 2001 to
promote investigations whose objectives were 1) to confirm and evaluate the
magnitude of the thrombotic risk in travelers, 2) to examine whether or not
specific risk factors linked to air travel exist, and 3) to determine which preventive
measures should be taken.

Whereas the absolute risk of VTE in Dutch pilots was lower than in the overall
Dutch population, an epidemiological study conducted among airline employees
found a 3.5-fold increased risk of VTE during the 4-week post-flight period
(incidence 4.0 per 1000 person-years of exposure) as compared with other periods
(incidence 1.2 per 1000 person-years). Studies on specific air travel–related risk
factors yielded conflicting results. Whereas some coagulation markers (thrombin
generation, thrombin-antithrombin complex, but not factor VIIa, VIIIc or APCsr)
were found to be higher in healthy volunteers after an 8 hour-flight as compared
with control subjects exposed to a movie marathon, another study did not find
any effect on coagulation of 8-hour exposure to mild hypobaric hypoxia in a
hypobaric chamber. Unfortunately, no funding has yet been found for
interventional studies on prevention. Meanwhile, the author proposed a risk
stratification based on risk factors and history of VTE. General measures alone could
be recommended to low-risk patients (abundant fluid intake, no alcohol, no
sleeping pill abuse, leg exercises). Medium-risk patients (mainly those with VTE
risk factors) should wear compression stockings, whereas a single LMWH injection
should be considered in high-risk patients (that is, those with a personal history
of VTE, an active malignancy, or recent major surgery).

Telangectasias
With the participation of A.I. Shimanko / Russia, G. Serpieri / Italy, R.K. Miyake / Brazil, M. Kielar / Poland

This session consisted of a number a presentations from several countries, dealing

with the value of different techniques of sclerotherapy or laser therapy in the
treatment of telangiectasias.

R.K. Miyake (Brazil) presented data on 191 patients treated with an Nd:YAG 1064
nm laser followed by dextrose sclerotherapy, both used with a forced air-cooling
device. The VeinViewer TM was used to guide laser light. In 86% of patients, there
was partial or total improvement. No allergic, systemic reactions or skin burns were

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 Asian Chapter of the UIP, Kyoto, Japan, June 18-20, 2007

observed. In conclusion, the author suggested ambulatory phlebectomy to complete

treatment of those with unsatisfactory outcome.

H. Kielar (Poland) reported the use of electro-optical synergy technology (ELOS)

which consolidates diode 915 nm laser and radiofrequency (RF) simultaneously
during one exposure. ELOS was used to treat 150 women (mean age 41.4 years).
The medical evaluation was very good (total decline of spider nevi), good
(“shadows” of spider nevi), acceptable (better local appearance after 1-3 exposures),
poor (no visible changes after one exposure). After one exposure, 62% of patients
showed a good and very good effect, 11% acceptable, and 28% poor. After the
last exposure, effects were good and very good in 72% of cases, and poor in
28%. No photodermatoses, skin irritation, residual lesions were observed. In
conclusion, ELOS was safe, effective and had a very low complication rate.

Varicose veins
Interventional treatments
Open surgery

Morphological changes in deep veins of the lower limbs before and after stripping surgery—measurement of venous cross-
sectional areas by color Doppler ultrasonography
H. Tanaka, Y. Ishihara, A. Hakamata / Japan

Two groups of the patients were examined: a control group (40 normal limbs/20
healthy volunteers) and a varicose vein group (116 limbs with superficial
varicoses/82 patients). Cross-sectional areas of deep veins were measured using
a color duplex scan. Measurement was performed in 4 venous segments: common
femoral vein (CFV) above and below the saphenofemoral junction, superficial
femoral vein (SFV) above the knee, and the popliteal vein (PV). Investigation
was performed in the standing and supine positions before and after surgery. The
cross-sectional area of the PV was significantly increased in the standing position
before surgery, compared with post-surgery (P<0.0001). In the standing position,
the cross-sectional areas of the CFV and SFV in the varicose vein group were
larger than in the control group (P<0.001). After surgery, the difference in the cross-
sectional areas of the CFV and SFV between varicose vein patients and the control
group became smaller. The authors concluded that measurement of the cross-
sectional area of the deep veins could be useful for evaluation of the degree of
restoration of venous hemodynamics.

Should complete stripping to the ankle be used to treat primary varicose veins caused by long saphenous vein
insufficiency?
H. Uncu /Turkey

GSV stripping from groin to ankle was done in 96 patients (102 limbs). Common
postoperative complaints were pain (79.1%) and cosmetic problems (37.5%).

Phlebolymphology. Vol 14. No. 4. 2007 165

 There were small temporary complications: hematomas (19.6%), edema (10.8%),
local inflammation (13.7%), bruising (11.8%), calf deep vein thrombosis (2%).
Median follow-up time was 3.4 years after surgery. All complaints due to varicose
veins were resolved. Permanent paresthesia was found in two patients (2%). The
author concluded that total stripping of the GSV is an appropriate technique for
surgical treatment of the GSV insufficiency.

Prediction of long-term neurological symptoms after stripping operations by objective assessments of saphenous nerve
injury
D. Akagi, H. Arita, T. Komiyama, S. Ishii, K. Shigematsu, H. Nagawa, T. Miyata /Japan

In contrast to the above presentation, in this study 18 patients (27 limbs) were
investigated after inversion stripping of the GSV. Quantitative sensory function
was determined by current perception threshold (CPT) measurements using a
Neurometer® (Neuroton, Inc., USA). Neurological symptoms (pain, anesthesia,
paresthesia) were found in 13 limbs (48%), 10 (77%) of which showed a 20%
increase in CPT over the preoperative value. In contrast, only one of 14
asymptomatic limbs showed a CPT increase over 20%. So, CPT evaluation could
be a good objective method for estimation of neurological symptoms after venous
surgery. The discrepancy between these 2 presentations indicates that the
prevalence of neurological symptoms depends not only the method of stripping
but also on the methods used to investigate postsurgical complications.

Maturation of the treatment of the refluxing great saphenous vein: the role of open surgery
M.C. Dalsing / USA

The author presented his personal experience in the evolution of treatment of

varicose veins. Initially, open surgery was the procedure usually used, but varicose
vein recurrence was too high (25% at 5 years) with a saphenous nerve injury
incidence of 4% to 8%. To reduce this incidence, the author changed his strategy.
He stripped the great saphenous vein (GSV) from groin to knee and then, with a
small stripper head, stripped the calf GSV. With this maneuver he decreased the
bulk of the vein pulled through the distal tunnel, but varicose vein recurrence at
five years continued to be high. For this reason, and with the introduction of new
therapies, principally endovenous treatment with radiofrequency and laser or
sclerotherapy, the author changed his philosophy and offered the patients the
new technologies. In the second part of his presentation, the author reviewed the
results of the new technologies as published. The most studied procedure is
radiofrequency ablation, for which the risk of varicose vein recurrence is 30% at
5 years, with less saphenous nerve injury. Laser ablation is less studied, the
incidence of nerve injury is very low, under 1%, but the varicose vein recurrence
is similar to that of other techniques (10% at two years). Foam sclerotherapy
needs to be repeated several times to obtain good results. In all of these therapies,
patient satisfaction, analyzed by quality of life questionnaires, has been very high.
Probably in the future, open surgery will be reserved for specific cases where less
invasive therapies cannot resolve the varicose vein problems.

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It was concluded that minimally invasive procedures are currently as effective as

open surgery, appear to cause less trauma to vulnerable nerves, and are preferred
by most patients. More long-term results are needed.

Mechanical inhibition of neovascularization to prevent recurrence of varicose veins

R.A. Van Rij, G. Hill, R. Christie, G.T. Jones, M. Amer, I. Thomson, R. Pettigrew, S. Packer / New Zealand

Recurrence of varicose veins following surgery can be attributed in large part to

neovascular reconnection at the saphenofemoral junction. The reasons for this
pathological process are not well understood and it seems that the surgical
technique has a small influence on the intensification of this process. The results
of the latest investigations show that neovascularization is dependent on the
individual patient’s predisposition and is related to the activity of specific markers
such as EphB4, NRP2 and COUP II. The process of new vein formation after
varicose surgery is totally different than angiogenesis in ischemic tissues. Ultrasound
and histological investigation focused on the top of ligated saphenofemoral junction
additionally covered by a patch (PTFE or silicon) revealed two ways of new vessel
formation. The main one is from the site of ligated SFJ (below the patch), and the
other is from the site of the scar proximal to the patch. The frequency of occurrence
using ultrasound was estimated as 15% to 20% of all operations, even when
there are no visible changes in the groin region. Thus the main problem is how
to stop the neoangiogenesis after varicose vein surgery: modify surgical technique,
use only the endovascular procedure, which eliminates the angiogenesis related
to scarring, or use angiogenesis inhibitors?

Saphenectomy without crossectomy, an alternative solution to endovenous techniques: short-term results

M. Lefebvre-Vilardebo / France

In this study, 285 great saphenous vein (GSV) trunks were removed without high
ligation. The indication was dilatation and incompetence of the thigh GSV.
Contraindication was incompetent saphenofemoral junction (SFJ). All operations
were performed under femoral nerve blockade and tumescent anesthesia. A
special flexible stripper was used in combination with microphlebectomy hooks.
Postoperative ultrasound investigation demonstrated that the residual SFJ was
completely patent, with good drainage through the tributaries in 199 cases (87.7%).
22 SFJs were partially patent. Total occlusive thrombosis was found in 6 SFJs.
Parietal thrombosis of the SFJ without penetration into the CFV was found in
20.6% of cases. These thrombi completely resolved without any treatment over
1 to 3 months. Thus surgical avulsion of the GSV without high ligation has all the
advantages of the endovenous techniques. Longer follow-up investigations are
needed for high ligation-free stripping of the GSV.

Phlebolymphology. Vol 14. No. 4. 2007 167

Does closing the cribriform fascia contain postoperative neovascularization at the saphenofemoral junction?
A prospective study
M.G. de Maeseneer / Belgium

After SFJ ligation in 193 patients (235 limbs) with primary SFJ incompetence, the
fossa ovale was closed with mobilized cribriform fascia. Postoperative duplex
scanning was performed after 2 and 12 months. The results were compared with
two historical control groups: silicone patch saphenoplasty (191 limbs) and no
barrier technique (189 limbs). After one year, neovascularization was found in
6.7% cases of the closed fossa ovale with fascia cribrosa. This was comparable
with the group with silicon patch saphenoplasty (5.2%). Neovascularization was
more frequent (14.8%) (P<0.01) in the open fossa ovale group. Thus, the
anatomical barrier formed by closing the fossa ovale after SFJ ligation reduces
neovascularization.

Varicose great saphenous vein: no need to treat 50% of junctions. A series of 613 legs
M. Lefebvre-Vilardebo, P. Lemasle / France

Nowadays, new treatments of varicose veins in patients with great saphenous

vein (GSV) incompetence tend to preserve the saphenofemoral junction
(ultrasound-guided foam sclerotherapy, endovenous techniques, crossectomy free
saphenectomy), even of the trunk (CHIVA). The question is: does saphenofemoral
junction preservation influence varicose vein recurrence?

To answer this question, the author used duplex ultrasound to study 613 legs
with primary varicose veins caused by an incompetent thigh GSV. Ultrasound
studies specifically investigated the cause of GSV reflux, which was seen in 79.3%
of junctions. Ostial valves were pathological in 53.8% of cases. Other causes of
reflux were preterminal reflux in 25.5% of cases and incompetent perineal veins
in 24.5%. In the rest of the cases, venous reflux was due to dystrophic changes
in lymph nodes in 2% of cases, thigh perforator insufficiency in 3.1%, and the
saphenopopliteal via the Giacomini vein in 2.6%. The results of this study were
similar to those published by Capelli in 2004.

In conclusion, ostial valve incompetence causes only 53.8% of cases of GSV reflux.
Crossectomy in the rest of cases may not be necessary. However, more data on
long-term outcome are needed.

Endovenous treatment

Bipolar coagulation: a new possibility of intravascular treatment of varicose veins

J. Strejcek, L. Pock, P. Fara, E. Skrivanova / Czech Republic

Bipolar radiofrequency-induced thermotherapy (RFITT), a new technique for the

treatment of varicose veins, can eliminate the possibility of vein wall perforation
by switching off the coagulation, when the thermal changes of the internal part
of the vein are sufficient, in contrast to endovenous radiofrequency and laser

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closure. The authors reported good results from a limited number of experiments
with RFITT in human saphenous veins obtained by stripping and rabbit saphenous
and ear veins, but concluded that a clinical multicenter study must be done.

Endovenous laser ablation: does fluence make a difference? Progression and recurrence of vein disease in patients treated
with endovenous laser ablation: one-year experience
T. King / USA

The author reported the use of a 980 nm laser in 240 cases and a 1320 nm laser
in 195 cases. There was no statistical difference in the overall failure rate between
the 980 nm (20/240) and 1320 nm (21/195) lasers. This was true for treatment
of the SFJ and the SPJ. Energy delivery (J/cm2) does not appear to be as reliable
a predictor of successful endovenous laser therapy (ELT) as fluence (J/cm2), and
this was true for both the 980 nm and 1320 nm lasers.

The author also presented a retrospective analysis of 96 patients (112 veins) treated
with ELT to evaluate progression and recurrence of vein disease at 12 months.
Complete duplex ultrasound scanning was done at 1, 3, 6 and 12 months and any
reflux (> 0.5 s) was noted. Incompetent perforators of the thigh (13.5%) and calf
(15.2%) and anterograde-flowing branch (feeder) veins (46.8%) were a greater
source of recurrence (16/112 at 1 year) in laser-treated veins than failure to close
or reopening of the SFJ (21.6%) or SPJ (2.9%). The author concluded that in the
first year after ELT recurrence of reflux in the treated veins is far more common
than progression of new disease, although the incidence of both decreases over time.

Comparison of endovenous treatment with 980 nm laser versus conventional classic varicose vein surgery in an ethni-
cally diverse society
M. Lakhwani, T.C. Lee / Malaysia

The results of a retrospective study of 292 cases (350 legs) comparing endovenous
treatment with 980 nm laser (152 legs) versus conventional varicose vein surgery
in nonhomogeneous groups (different CEAP classification) were presented. The
conclusion was that more than 95% were satisfied with each of the procedures,
but ELT was more widely acceptable due to its minimally invasive nature and
better cosmetic results.

T. Noppeney (Germany) gave one current evaluation of endoluminal

radiofrequency obliteration of the superficial venous system. He performed a
meta-analysis using two major data sources: the still ongoing clinical registry and
a prospective randomized trial (EVOLvES study) between RF obliteration and the
high ligation and stripping of the GSV. The overall occlusion rate after RF
obliteration was 87% up to 5 years postoperatively and during the follow-up
period more than 80% of the treated veins could not be seen by duplex ultrasound
any more. He concluded that midterm results up to 5 years are as good as those
of high ligation and stripping, with clear advantages for RF obliteration regarding
faster recovery and better quality of life perioperatively. Thus RF can be considered
a very established and standardized procedure for treating varicose veins.

Phlebolymphology. Vol 14. No. 4. 2007 169

Complications of endovenous laser treatment- avoidance and treatment
F. Pannier / Germany

The author presented the results of a prospective, open, nonrandomized study of

the efficacy and safety of endovenous laser treatment (ELT) in 89 limbs with GSV
or SSV incompetence. Traditional small complications were found over four weeks:
superficial ecchymoses (41%), moderate pain (50%), and paresthesia (10%).
There were only two serious complications: 1 case of the skin burn and 1 case of
arteriovenous fistula. There was no DVT or pulmonary embolism. Occlusion of
the treated veins was found in 95% cases during 2-year follow-up. The author
concluded that ELT is an effective, minimally invasive method for patients with
GSV and SSV incompetence.

Endovenous laser ablation compared with stripping—preliminary results of an ongoing, randomized, controlled multicenter
trial in Japan
T. Ogawa, S. Hoshino, S. Makimura, H. Shigematsu, N. Azuma, T. Sasajima, H. Sugawara, M. Ichiki, S. Shokoku / Japan

In this prospective, randomized, controlled, open multicenter study of 92 patients,

67 cases were analyzed. The ratio between endovenous laser treatment (ELT) and
stripping was 2:1. The patients were evaluated by duplex scan, air plethysmography,
CIVIQ2 quality of life score and clinical examination at 6-month follow-up. There
were no significant between-group differences in the frequency of adverse
postoperative events. There was significant improvement in the quality of life score
in both groups of patients without significant difference in the dynamics. The authors
underlined that the main significant difference between the ELT and stripping groups
was the shorter hospital stay after ELT (average 1.14 vs. 2.76 in stripping group).

Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in
patient with varicose veins: short-term results
L.H. Rasmussen, L.B. Rasmussen, M. Lawaetz, B. Lawaetz, A. Blemings, B. Eklof / Denmark

One hundred twenty-one patients (137 incompetent GSVs, CEAP C2-C4) were
randomized (envelope method) into two groups for EVL or high saphenous ligation
and Oesh stripping (HL/S). All procedures were performed under tumescent
anesthesia. The following criteria were recorded: occlusion or absence of the GSV,
complications, varicose vein severity score (VVSS), postoperative pain score,
Aberdeen score, SF-36 QoL, time off work and time of normal activity and costs.
There were no significant between-group differences in the frequency of the
complications and adverse events. Improvements in the quality of life (SF-36 and
Aberdeen scores) and in VVSS at three months were similar in the two groups.
Postoperative pain score was higher in the HL/S group than in the ELT group
(NS). Sick leave was 7.7 and 6.9 calendar days, while time to normal physical
activity was 7.6 and 7 days in the HL/S and ELT groups, respectively (NS). The
total cost of the procedures including work loss was 4053 USD per patient in the
HL/S group and 4492 USD per patient in the ELT group. There were no differences
between the two treatment modalities except for slightly increased postoperative
pain in the HL/S group. The ELT procedure was 10% more expensive.

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Endovenous ablation
With the participation of P.J.S. Montemayor / Philippines, C.K. Oh, H.K. Kim / Korea, K. Wasilewski / UAE,
M. Hirokawa / Japan, J.R. Kingsley, T. King, L. Cunningham / USA

Endovenous laser treatment (ELT) is a new alternative to surgical stripping of the

saphenous veins. It is performed by various specialists such as vascular surgeons
and dermatologists, preferably under tumescent local anesthesia.

The 1320 nm laser is the most effective. However, a large study analyzing the data
of 1000 cases showed that 98.5% and 98.1% of patients exhibited complete
ablation at six-month and one-year follow-up, respectively.

ELT is rarely followed by major complications such as deep venous thrombosis,

skin burns, arteriovenous fistula, or paresthesias. However, minor complications
such as redness, tenderness, hematoma, superficial thrombophlebitis, skin
hyperpigmentation, and prolonged pain are recorded more frequently. There are
also a few reports of satisfactory short- and intermediate-term results of ELT of
the small saphenous veins.

A new device, the closure FAST, has been introduced to reduce the duration of
the operation.

There are no available results assessing the long-term success of ELT and its effect
on quality of life. Therefore, prospective, randomized, comparative (to surgery)
studies should be designed and performed.

Results of treatment of superficial venous insufficiency: what do we really know?

B. Eklof / Sweden

The author reviewed the evidence concerning treatment of superficial venous

insufficiency (great saphenous vein, small saphenous vein, perforators and varicose
veins). In the past decade, the development of minimally invasive endovenous
techniques like endolaser treatment (ELT), radiofrequency (RF), and foam
sclerotherapy (FST) has changed the standard of care, which is considered to be
surgical treatment with high ligation and stripping (HL/S). The advantage of RF
over HL/S was demonstrated in four randomized, controlled trials (RCTs), the
most significant differences being quicker patient recovery, reduction in
postoperative morbidity, and improvement in quality of life.

Two RCTs comparing ELT with HL/S showed similar results apart from less bruising
and swelling for ELT in one of the studies. In one RCT comparing RF with ELT,
the occlusion rate was higher after RF, while the adverse event rates were the same.
There are two RCTs comparing surgery with FST. In the first surgery was superior
to Varisolve foam, and in the second FST combined with HL was less expensive,
required less treatment time, and resulted in more rapid recovery. The author
concluded that we need a large, randomized, multicenter study comparing the three
endovenous methods with surgery.

Phlebolymphology. Vol 14. No. 4. 2007 171

Long-term results of endovenous ablation: consensus statement and illustration by 5-7 years of results at the Straub Clinic
and Hospital
F. Lurie / USA

The consensus statement on Reporting Standards for Endovenous ablation (EVA)

recently published by the American Venous Forum and the Society of
Interventional Radiology was debated. This document emphasizes the need for
standardization of terminology (recanalization, neovascularization, primary
ablation, primary assisted ablation, secondary ablation) and methodology for
clinical research studies in this area and major points of consensus include general
information (patient population, age, gender, race, clinical indication, anatomic
location of treated veins, CEAP staging, clinical severity score, study design,
comorbid diseases, functional status and quality of life, pre-treatment imaging,
primary reason for treatment), treatment description (pre-treatment preparation,
method of vein access, intra-procedural imaging, device or chemical agent
description, energy source and duration, total energy deposited, or dose of
sclerosant, adjunctive techniques, anesthesia, length and diameter of vein), and
post-EVA evaluation (complications, follow-up imaging at regular intervals, follow-
up of clinical status, quality of life assessment, uniform duration of follow-up,
need for additional procedures, costs/cost effectiveness, primary outcomes) required
and recommended.

Endovenous laser treatment versus surgery for incompetent great saphenous veins: a prospective study
S. Jianu, E. Ursuleanu / Romania

A total of 546 patients were enrolled in a prospective study comparing endovenous

laser treatment (ELT) versus surgery (high ligation and stripping, HL/S) for
incompetent great saphenous veins. ELT (810 nm laser) was used in 264 patients
and HL/S in 282, under local anesthesia in all cases. In the ELT group the vein
occlusion rate was 91% at 18 months, morbidity rate was 4%, and 2 patients
required further crossectomy. In the surgical group, 2 patients required further
surgery and the morbidity rate was 10%. It was concluded that ELT is associated
with fewer complications than surgery and requires less recovery time, and that
the rate of further operations is the same for the two techniques.

Endovenous laser treatment of saphenous vein reflux: mid-term results

S. Shokoku / Japan

Mid-term follow-up results were presented for endovenous laser treatment (ELT)
of great saphenous vein (GSV) reflux (131 patients) caused by saphenofemoral
junction incompetence and small saphenous vein (SSV) reflux (27 patients) caused
by saphenopopliteal junction incompetence. Occlusion rate was 100% immediately
and 96.6% after 1 year, with most cases of recanalization concerning the SSV, due
to low energy delivery.

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Four-year results after ELVes for saphenous varicose veins

H.C. Wenzel / Germany

A single-center, retrospective, four-year study of ELVeS (980 nm diode laser) for

saphenous varicose veins (62 GSV and 12 SSV) found an occlusion index of about
96%, 91% satisfaction, and no significant side effects.

Venous stasis ulcers successfully treated with endovenous saphenous vein ablation: the first reported series
J.R. Kingsley, J.H. Isobe, S.A. Tadros / USA

This is the first reported series with results concerning venous stasis ulcers
successfully treated with endovenous saphenous vein ablation. There were 75
patients with venous stasis ulcers of the medial or lateral malleolus who underwent
82 saphenous vein ablation operations. Seventy-four procedures were performed
on the GSV and the remainder on the SSV. Twenty-two percent of patients also
underwent high ligation, 61% micro-phlebectomy, and 40% ultrasound-guided
FST. Seventy-three patients were treated with a 1320 nm laser, 7 with
radiofrequency, and 2 with a 940 nm diode laser. The ulcer healing rate was 93%
within one to six months and the author concluded than this may be a good
option for patients suffering from venous stasis ulcers and saphenous vein reflux.

Noninterventional treatments
Compression

4th Bauerfeind Phlebology Award

How to utilize compression therapy after ultrasound-guided sclerotherapy with foam for the treatment of varicose saphe-
nous veins, a randomized controlled trial
R.P.M. Ceulen / The Netherlands

This award-winning, ongoing study is designed to determine the role of

compression after sclerotherapy with foam. The hypothesis is that compression
decreases the extent of thrombus formation, thus decreasing the risk of
recanalization and the incidence of postsclerotic pigmentation. This prospective,
randomized, controlled study included 72 patients with great or small saphenous
vein insufficiency divided into two groups according to venous diameter (<4 mm
and >4 mm). Both groups were divided into three subgroups depending on the
type of compression (no compression, compression for 1 week, compression for
4 weeks). Patients with very dark skin tone, GSV or SSV diameter greater than 1
cm, ankle/brachial index <0.7, age <18 years or >65 years, presence of obesity,
malignancy, acute superficial or deep vein thrombosis were excluded. The results
will be analyzed through blind assessment of photographs by 6 independent
reviewers. The presence of thrombophlebitis was analyzed by means of clinical
and ultrasound signs. Other variables analyzed are vein disappearance,
hyperpigmentation, and neovascularization. Clinical improvement was assessed
with one scale from 4 to 12 (4 poor result, 12 excellent result). Obliteration

Phlebolymphology. Vol 14. No. 4. 2007 173

 measured by duplex ultrasound, presence of venous complaints, and quality of
life are analyzed too. The study will start in September 2007, the final inclusion
will be in February 2008, follow-up will end in April 2008, and the results will
be presented in June 2008.

Postinterventional compression after active therapy of varicose veins

H. Partsch / Australia

The optimal compressive therapy after endovascular treatment of great saphenous

vein (GSV) insufficiency is not established. The pressure necessary to reduce the
vein lumen to avoid secondary effects after GSV endovascular treatment like
edema, local inflammation, and hematoma are not well defined. Professor
H. Partsch described the use of an inflatable cuff to determine under-cuff pressure
and vein diameter reduction measured by duplex ultrasound. The pressure
necessary to reduce GSV diameter was between 50 to 70 mm Hg in the upright
position. This high pressure is not easy to obtain with the bandages normally
used. The application of a specific pad over the treated vein, under the bandage,
allows the bandage pressure to be reduced to 30-40 mm Hg, maintaining vein
diameter reduction in the upright position.

Sclerotherapy

Efficacy and safety of Aethoxysklerol foam in a prospective randomized multicenter trial (ESAF-Study):
results of the first phase
E. Rabe, J. Otto, D. Schliephake, F. Pannier/ Germany

F. Pannier and E. Rabe described the study procedures and presented the results
of the ESAF-study, a prospective, multicenter, randomized clinical trial comparing
the efficacy and safety of polidocanol-foam with polidocanol-liquid for ultrasound-
guided sclerotherapy of great saphenous vein (GSV) incompetence. Patients with
incompetent GSV with a diameter <12 mm, a reflux >1 s (3 cm below junction)
and a PPG refilling phase <25 s were included (106 patients) and were treated with
up to 5 mL foam or up to 4 mL of 3% polidocanol liquid per treatment session,
and up to 3 sessions were allowed. To assess the efficacy of both treatments,
duplex ultrasound 3 cm below the saphenofemoral junction 3 months after the
last injection was done and patients with no reflux or a reflux <0.5 s were
considered as responders. The responder rate among patients treated with foam
was 70%, whereas the responder rate in the liquid group was just 31%, with no
differences in safety. The most successful centers injected a mean volume of 4.2
mL foam in comparison with 3.2 mL foam at the other centers. The authors
concluded that ultrasound-guided foam sclerotherapy is an effective and safe
technique, with better results than liquid. However, the optimum maximum
volume of foam to be injected must be standardized.

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The current role for sclerotherapy in the management of venous disease: the Australian perspective
G.M. Malouf / Australia

The sclerosants used included Aethoxysklerol, Fibrovein and hypertonic 20-24%

saline (restricted to microslerotherapy). After different phases, sclerotherapy is now
used as a follow-up to surgical or thermal truncal ablative procedures, or for
microslerotherapy. Ultrasound-guided therapy using liquid or foam is used just
for narrow (< 5 mm) refluxing GSV, SSV, Giacomini veins, and recurrent varicose
veins. The Australian experience showed fewer allergic reactions and less severe
complications for Aethoxysklerol, and stockings have been used to replace bandages
for compression after sclerotherapy, and the duration of compression has fallen
from 6 to 2 weeks or less.

The Japanese Polidocanol (Aethoxysklerol) clinical trial

H. Satokawa, S. Hoshino, S. Sakaguchi, C. Yamada / Japan

The first phase assessment of suitable concentration, safety and tolerability included
261 patients, none of whom developed any treatment-related systemic adverse
events, with a safety limit of 2 mg/kg polidocanol. In the second phase a double-
blind test to evaluate clinical usefulness included 86 patients, and the 69.2% to
100% efficacy noted with a single use of polidocanol was greater than that of
placebo.

Update on foam sclerotherapy: the 2nd European Consensus Meeting on Foam Sclerotherapy, April 28-30, 2006, Tegernsee,
Germany
F.X. Breu, S. Guggenbichler, J.C. Wollmann / Germany

The authors reported the guidelines from the last consensus on foam sclerotherapy
which took place in Germany in 2006. A total of 35 000 patients affected by small
and large varicose veins were managed. The main topics were access location, foam
volume, foam preparation, safety, and contraindications.

Access: when treating the great saphenous vein (GSV), access is by direct puncture
at the proximal thigh. Long catheters can be used to access the GSV below the
knee. When treating the small saphenous vein (SSV), access is at the proximal or
middle part of the calf.

Foam volume: the foam volume has to be limited to no more than 10 mL. If treating
large veins, a compact, viscous foam should be used: liquid/gas ratio 1/4

Foam preparation: the Tessari method is recommended in all situations.

Safety: to increase safety during treatment of the GSV, most operators use a volume
per puncture and per session. Also, for injection with needles and short catheters,
a minimal distance to the junctions of 8 to 10 cm should be used. Immediate
compression over the injected areas should be avoided. Ultrasound monitoring
of foam location should be used. Inject very viscous foam. There should be no

Phlebolymphology. Vol 14. No. 4. 2007 175

 movement of the patient or leg for 2 to 5 minutes, and no Valsalva maneuver or
muscle activation.

Contraindications: a known asymptomatic patent foramen ovale is a relative

contraindication. History of thromboembolism is a relative contraindication.
Heparin prophylaxis is appropriate in such cases, using low concentrations and
small volumes.

Ultrasound-guided foam sclerotherapy in the elderly patient: a minimally invasive treatment for chronic venous disease
C. Vandenbroeck, M. De Maeseneer, P. Van Schil / Belgium

The authors described the treatment of varicose veins with foam sclerotherapy
(USGFS) in an aging population. Fifty-eight patients (15 male, 43 female, age range
70-84) were treated and examined at 14 days and 6 months using duplex ultrasound.
The sclerosant used was 3% Polidocanol and the foam was created by the Tessari
method. After 14 days, full obliteration was obtained in 89% of cases; 8 legs needed
a second session because of only partial occlusion. No serious side effects occurred.
Minor symptoms as bruising, pigmentation, or induration occurred in 28% of
patients. Three patients required heparin for delayed superficial thrombophlebitis.

After 6 months, full obliteration was observed in 72% of cases. The authors
conclude that an adequate understanding of chronic venous disease can lead to
optimal foam sclerotherapy results in a group of patients who would otherwise
be left untreated.

Ascent of foam sclerotherapy in treating venous disorders

J. Bergan / USA

Dr Bergan gave a personal overview of the changes in practice due to the advent
of foam sclerotherapy, which has revolutionized the treatment of superficial
venous insufficiency and nowadays is an alternative to surgery and laser
obliteration.

Surgery for varicose veins requires anesthesia, is often associated with pain,
sometimes nerve injury, and above all unacceptable varicose vein recurrence rates
(30-60%). Endovenous laser therapy involves day surgery, local anesthesia, and
has a high equipment cost. It produces ecchymosis, patient discomfort, and often
multiple treatments are needed. Foam is made from a detergent solution. The
ratio is 1 part agent to 4 parts room air. Most practitioners use ultrasound-guided
saphenous vein access, some simply cannulate a varix, but both techniques involve
massaging the foam into the saphenous vein and into target varicosities. A varix
can be cannulated directly and the foam directed proximally, then leg elevation
directs the foam distally. Groin pressure is maintained and more foam is added if
necessary. Leg elevation is maintained to fix foam in the vein. Of 116 patients with
varicose veins treated with foam sclerotherapy, during a mean follow-up of 24
months, 72% showed complete fibrosis of saphenous vein, 21% 2-3 mm fibrotic
saphenous vein, 7% persistent reflux without varices.

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The tangle of dilated venules under the ulcer are the target of treatment by foam
sclerotherapy. In his personal experience of 869 patients, Dr Bergan has recorded
a low rate of adverse effects (cutaneous necrosis 2 cases, DVT 3 cases, chest pain
2 cases, ocular symptoms 4 cases, dry cough 3 cases, migraine-like attack 2 cases,
in total 3.2%).

In conclusion, surgery of varicose veins is nearly obsolete. Laser procedures are

acceptable surgical substitutes. Sclerosant foam is effective as an endovenous
procedure in obliterating dysfunctional veins. It is less expensive, painless,
nondisabling, efficient, and easy to use.

Obstruction and stent placement

Long-term outcome of iliac vein stenting
S. Raju / USA

Iliac venous stenting is a minimally invasive technique indicated for iliac obstructive
lesions. The procedure is percutaneous, carried out on an outpatient basis and does
not constitute a contraindication for future operation.

Iliac obstructive lesions occur commonly in postthrombotic disease (PTS), in

primary chronic venous disease (CVD) (for >90% of patients). They are called
obstructive non-thrombotic iliac vein lesions (NIVLs) and are diagnosed by means
of intravenous ultrasound (IVUS). MR imaging reveals asymptomatic NIVL in
about 60% of the general population.

Iliac obstructive lesions (permissive), although silent, may become symptomatic

when secondary pathologies such as reflux, infection, or trauma are superimposed.
Remission of symptoms may be achieved by correction of iliac obstructive lesions
alone, even when secondary pathologies are not addressed.

The author presented his experience on iliac vein stenting in 982 limbs stented
over an 8-year period: 518 for primary lesions and 464 in patients with PTS.
Follow-up was complete for 94% of them. Mortality (30 days) was zero. The
early (30 days) thrombotic event rate was 1.5% and the late rate was 3%.

Primary chronic venous disease: cumulative primary and primary assisted

patency were 79% and 100% at 6 years.

Postthrombotic disease: primary, primary assisted, and secondary patency were

57%, 80% and 86%, respectively.

In-stent restenosis was rare <5%.

Although 70% of stents were extended below the inguinal ligament, there were
no stent fractures or erosions.

Phlebolymphology. Vol 14. No. 4. 2007 177

 Complete relief of pain and swelling at 6 years was 62% and 32%, respectively,
and 58% of ulcers healed and remained healed at 6 years, although residual reflux
was not addressed in most of them.

In conclusion: long-term stent patency is excellent in PTS and 100% in primary

chronic venous disease, resulting in excellent clinical results. In primary chronic
venous disease, stenting of NIVLs results in clinical relief even when the associated
reflux is left uncorrected. Therefore, iliac venous stenting is the primary choice
in the management of iliac obstructions.

Follow-up results of 71 patients after stent placement for malignant obstruction of the superior vena cava
T. Nagata, S. Makutani, H. Uchida, K. Kichikawa / Japan

This was a retrospective review of a series of patients with superior vena cava
syndrome (SVCS) secondary to a compression for malignancy treated by
Spiral Z-Stent implantation, habitually used in the treatment of tracheobronchial
and biliary system stenosis. The right femoral vein approach was used. After
crossing the lesion, the hydrophilic guide was replaced by a stiffer guide. Normally
it was necessary to predilate to implant the Spiral Z-Stent. After treatment, the
patients were anticoagulated with heparin for two days followed by oral
anticoagulation and antiplatelet therapy. The Spiral Z-Stent was chosen because
of its radial tension, adaptability, and the possibility of implanting it through a
smaller introducer (12Fr).

Treatment was 100% technically successful in 71 patients. Improvement in edema

was obtained in 87% of cases, between the first and ninth day. The primary clinical
patency rate was 88% (57/65) and the secondary rate was 95% (62/65). All the
patients died, and the survival of 57 patients varied between 1 and 29 months.
There was no recurrence of SVCS. Unilateral stenting was useful in the 8 patients
with bilateral brachiocephalic vein thrombosis.

In conclusion, spiral Z-Stent placement seems to be effective in the treatment of

malignant obstruction of SVC, with an excellent clinical patency rate.

Iliac vein compression syndrome

The results of endovascular treatment for iliac vein compression syndrome
W.-H. Kwun, H.-J. Kim, B.-Y. Suh, W.-K. Park / Korea

This is a retrospective review of a series of 31 patients with iliofemoral vein thrombosis

and iliac vein compression (May-Thurner syndrome or Cockett syndrome) treated
by thrombolysis with local urokinase and aspiration thrombectomy. Complete lysis
was obtained in 28/31 patients, with subsequent stenting in all. All patients had
clinical improvement (100%). Iliac thrombosis recurred in four cases. It seems that
aggressive therapy can result in a high patency rate.

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Chronic venous insufficiency and venous leg ulcer

Effectiveness of ulcer stockings
M. Neumann / The Netherlands

For medical elastic compression stockings (MECS), the three characteristics of

major importance are elasticity, stiffness, and hysteresis. In this study, the Medi
Ulcer Kit was administered. Effectiveness was determined in terms of capillary
filtration rate (CFR) reduction, compression, and hysteresis. These parameters
were measured as follows.

In the supine position, the pressure exerted by the stocking exceeded the pressure
in the femoral vein, and caused significant reduction of edema by reducing CFR.
In the standing position, two stockings were used: low + class II stocking = class
III stocking. Two separate stockings result in increased hysteresis, which in turn
leads to a higher dynamic stiffness index. Therefore they are highly effective
during walking.

Limit of free skin grafting and application of free flaps for intractable venostatic crural ulcer
K. Tanaka, R. Murakami, A. Hirano / Japan

Venostatic ulcer complicates leg varices and often recurs after treatment. However,
there are a few cases of intractable ulcer, for which free skin grafting is less effective.
The authors presented an alternative method of ulcer reconstruction using a free
flap. A free flap from the groin was transplanted in 3 patients. No ulcer has recurred
as of 7-10 years after the procedure. Transplantation with good circulatory
conditions and anastomosis with a deep vein may have allowed inflow of venous
blood around the flap into the deep vein. Consequently, venous circulation may
have improved with tissue replacement.

Importance of surgical treatment in venous leg ulcers – Consensus document of the “Surgical Treatment in Venous Leg
Ulcers” study group of the German Society of Phlebology
H.J. Hermanns, C. Schwahn-Schreiber, F. Waldermann / Germany

Venous leg ulcers are still a major medical problem worldwide, especially in
industrialized societies. The poor results reported after have prompted further
search for more effective procedures.

Scientifically well founded and successful methods of surgical treatment of venous

leg ulcers are now available. The “Surgical Treatment in Venous Leg Ulcers” study
group of the German Society of Phlebology evaluated the current long-term results
from German vascular centers using different surgical methods. The conclusions
of the conferences in Vienna 2005 (Austria) and in Berlin 2006 (Germany) were
summarized as a consensus document.

Phlebolymphology. Vol 14. No. 4. 2007 179

 Three therapeutic concepts for the treatment of venous leg ulcers are available:
varicose vein surgery or endovascular techniques, methods including the fascia
cruris (fasciotomy and fasciectomy), and shave therapy or other local treatments.

Varicose vein surgery and endovenous techniques are used to eliminate primary
and secondary varicose veins. The indications for treatment of an incompetent
perforator have recently changed. In Germany only 0.8% are managed by SEPS.
Fasciotomy, indicated by a CEAP classification C4 to C6, has declined from 12.8%
(2001) to 7.1% (2004).

Shave therapy is the first choice of treatment of nonhealing leg ulcers, and has
given good long-term complete healing in 77.5% (Hermans) and 70.6%
(Schmeller) of cases. Fasciectomy is reserved for special indications (deep transfascial
necrosis and failure of shave therapy).

Fasciectomy in lateral venous leg ulcers: a nerve-sparing procedure

A. Obermayer, K. Göstl / Austria

The great medical problem after fasciectomy for nonhealing venous leg ulcer is
paresthesia related to peroneal nerve injury. The results of modified fasciectomy
for lateral located and nonhealing leg venous ulcer were presented. Fourteen legs
(12 patients) with chronic active venous ulcers (CEAP: C6) all lateral, were
surgically treated. The surgical procedure included surgical interruption of the
causative reflux and fasciectomy with mesh graft transplantation. As the superficial
peroneal nerve was adherent to the inflamed fascia, meticulous dissection was
performed in all cases. Afterwards the superficial peroneal nerve was transposed
between the musculus peroneus longus and musculus extensor digitorum longus.
The intensity of pre- and postsurgical pain was measured using a visual analogue
scale and the Nottingham Health profile. A median follow-up of 3 years after
surgery showed significantly reduced levels of pain. The excellent outcome of
healing (initial healing rate of 86% in a median 4.5 weeks) and recurrence
(recurrence ratio of 0) underlines the benefits of this surgical technique. Except
for two unhealed leg ulcers, there were no postsurgical complications.

Painful venous leg ulcers located on the lateral side of the lower leg benefit from
surgical interruption of the pathogenetic reflux, fasciectomy combined with the
sparing of the superficial peroneal nerve, and mesh graft transplantation.

Combined treatment of arterial and venous insufficiency by using the incompetent saphenous vein as graft in patients with
ulcer
O. Nelzén / Sweden

Elderly patients with combined arteriovenous insufficiency are often difficult to

treat and the risk of later amputation is high. The main aim of this study was to
look at ulcer healing and the durability of vein grafts.

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All 13 patients (14 legs) with combined arteriovenous insufficiency and ulcer
underwent high ligation of the great saphenous vein (GSV) and short saphenous
vein (SSV), and a bypass procedure using the incompetent saphenous vein as a
graft was performed. Patients were followed up for 12 months or until the ulcer
healed. Long-term follow-up was conducted through repeated telephone contact.

In-situ bypass was used in 7 legs, and the remaining 7 had reversed short bypasses.
One graft occluded within 30 days and the patient had to undergo amputation.
Within the first 12 months, 9/14 ulcerated limbs healed. Two patients died with
patent grafts but unhealed ulcers after 5 and 6 months, respectively. One patient
had successful re-do surgery with a vein patch procedure and precutaneous
transluminal angioplasty (PTA) of the distal anastomosis. One had PTA + stenting
of the iliac artery. The median long-term follow-up was 3.5 years (range 1.5-10).
Two patients had later PTA, both combined with successful thrombolysis, and
they had no remaining ulcers. At the last follow-up, 8/11 (73%) legs followed up
beyond the first 12 months were healed. By intention-to-treat, 57% were
successfully healed.

It appears that this combined arteriovenous treatment gave satisfactory palliation

and ulcer healing for the majority of these elderly patients with a relatively short
life expectancy.

Recalcitrant and recurrent leg venous ulcer after surgical treatment: long-term follow-up
K. Ziaja, G. Biolik, D. Ziaja, T. Urbanek, P. Nowakowski, M. Kasibucki, M. Glanowski / Poland

Recurrent or nonhealing leg venous ulcer is the most serious complication of

chronic venous insufficiency (CVI). Conservative treatment and surgical treatment
have proven unsatisfactory. Sufascial endoscopic perforator vein surgery (SEPS)
is recognized as an effective method of treatment of incompetent perforator veins,
but in many cases this is not a sufficient procedure. The aim of the study was to
determine the efficacy of SEPS + saphenectomy and SEPS + crossectomy in patients
with nonhealing or recurrent venous leg ulcers. The study was performed in
63 patients (11 men and 52 women) aged 54 years (22 to 76 +/- 4.23) who were
divided into two groups:
- group I – SEPS + crossectomy – 37 patients
- group II – SEPS + saphenectomy – 26 patients

The 10-year observation period was from 1996 to the end of 2005.

Recalcitrant leg venous ulcer was observed in 10.8% of patients in the crossectomy
group and in 3.8% in the saphenectomy group. Venous ulcer recurred at the
same site in 21.6% of patients in the crossectomy group and in 19.2% in the
saphenectomy group. Venous ulcer at a new site of the same leg was noted in 8.1%
of patients in the crossectomy group and in 3.8% in the saphenectomy group.
Investigation of valvular competence of the deep venous system revealed that
valvular insufficiency was 3 times more frequent in the superficial femoral vein
(10.8% patients) and nearly 2 times more frequent in the popliteal vein (24.3%
patients) in the crossectomy group.

Phlebolymphology. Vol 14. No. 4. 2007 181

 New calf vein thrombosis was observed in 10.8% of patients in the crossectomy
group and in 3.8% of patients in the saphenectomy group. Insufficiency of the
Cockett I perforator vein was 50% in both groups.

On the basis of these findings, the author drew the following conclusions:
- In most patients treated by SEPS + crossectomy, there was GSV insufficiency,
which was the main cause of ulcer recurrence or nonhealing.
- Valvular insufficiency of the popliteal vein is probably the second most important
factor in ulcer recurrence or nonhealing.
- There is no single ideal method of treatment which eliminates all signs and
symptoms of CVI and leads to permanent ulcer healing.

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Miscellaneous
The future management of acute and chronic venous disease:
report from the American Venous Forum’s Hawaiian Summit in 2006
B. Eklof / Sweden

At the American Venous Forum (AVF) in Washington DC in September 2004,

three major goals were formulated:
• to create a curriculum in venous disease for the new fellowship program in
vascular surgery in collaboration with the program directors,
• to introduce a national screening program for venous disease in collaboration
with the American Vascular Association (AVA),
• to organize a meeting of experts to draw up the guidelines for venous disease
research and development over the next 5-10 years.

Thanks to help from many AVF members, Joann Lohr submitted the venous
curriculum to the program directors in early 2006. The screening program for
venous disease started in the fall of 2005 through the efforts of Robert McLafferty
and his committee, in collaboration with the AVA.

The 5th Pacific Vascular Symposium on January 20-24, 2006 in Hawaii covered
the following topic: “Mapping the future of venous disease, an international
summit”.

In the invitation to the experts, we wrote: “Would you be willing to explore where
the field stands at present, to identify where sticking points; and perhaps… propel
the field into a new orbit, by defining the next 5-10 years, including postulation
of research and development priorities?”. Sixty experts were invited representing
all the continents and several specialties—angiology, clinical physiology,
dermatology, interventional radiology, thrombosis / hemostasis, and vascular
surgery. Twelve experts represented industrial research and development for
artificial valves and stents, compression therapy, obliteration of veins using laser
or radiofrequency, pharmacologic and mechanical endovenous thrombus removal,
venotonic drugs, and wound care. Before the meeting, 32 AVF members had each
produced an updated report on the state of the art in acute and chronic venous
disease, reports that were sent to all participants before the meeting.

The first day was a conventional meeting with presentation of the 32 reports.
The following four days were completely different, as the meeting was taken over
by four professional facilitators, who each took care of one of the four groups
into which we were divided: diagnostics/hemodynamics, acute venous
thromboembolism, primary chronic venous disease, and secondary chronic venous
disease. Irv Rubin, the chief facilitator, said that “This will be a dramatic departure
from the previous symposium format. Using an intense fast-pace novel process
my colleagues and I will ask you to join in with open-minded and open-hearted
full participation, and we are confident that you will be able to shape the future
to hasten beneficial change in the way you treat your patients”. The process was

Phlebolymphology. Vol 14. No. 4. 2007 183

 built on the theory of “Appreciative inquiry—a positive approach to building
cooperative capacity where the four D’s can describe the phases of activity:
discovery, dream, design, and destiny”. Alternating between break-out sessions
for the groups and plenary sessions where the group outcomes were discussed,
the second day was devoted to the issue “Where have we come to in our field—
the discovery phase” followed by “Sharpening a vision for the future—the dreaming
phase”. The third day we were “defining and prioritizing critical issues—the design
phase”, which was further discussed during the fourth day when we were defining
a plan of action for the next ten years. During the fifth and last day the plan of
action was discussed with commitment from the experts to participate in special
projects, and ways to monitor progress of the projects—the destiny phase.

IMUA mission statement: to promote venous health through innovative research,

education and technology.

The AVF created a committee to follow up the meeting, the IMUA committee
(IMUA is Hawaiian for moving forward!) with the following members: Bo Eklof
(chair), Peter Gloviczki, Robert Kistner, Joann Lohr, Fedor Lurie (secr), Mark
Meissner, Gregory Moneta and Thomas Wakefield, and we have added Michael
Dalsing (AVF President), Brajesh Lal (Chair of AVF research committee) and Sardra
Shaw (Chair of AVF’s industrial advisory committee). Each of the four groups
came up with >20 projects. These >80 projects were reduced to 21 after voting
within the groups and at the plenary sessions, and the IMUA committee has
merged and reduced the number to 14 projects: 12 investigational and
2 administrative projects. AVF members have volunteered to initially lead these
14 projects:

1 - MR outflow obstruction of venous disease. PI Mark Meissner

a. Explore the use of MRV for assessing venous obstruction
b. Use CINE-gated MRV to evaluate and quantify outflow obstruction
c. Perform pre- and post-therapy testing

2 - Duplex ultrasound in diagnosis and prognosis of DVT. PI Mark Meissner

a. To evaluate if a single US is sufficient for the evaluation of acute DVT
b. Produce better guidelines for diagnosing acute DVT and define adequate
scan techniques
c. Evaluate the natural history of DVT in relation to the characteristics of the
thrombus

3 - Early clot removal. PI Tony Comerota

a. Create a multicenter international RCT comparing
b. Catheter-directed thrombolysis
c. Endovenous mechanical/pharmacological thrombectomy
d. Vs anticoagulated controls
e. Assessing iliofemoral patency, femoropopliteal competence and quality of life

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 Asian Chapter of the UIP, Kyoto, Japan, June 18-20, 2007

4 - Biomarkers in diagnosis and prognosis of DVT. PI Thomas Wakefield and Tony

Comerota
a. To study the utility of biomarkers such as D-dimers, TAT, F1-2 and PAI-1
antigen in diagnosing DVT and for providing prognostic information to guide
type and duration of therapy
b. End points will include thrombus extension, recurrence and incidence of PE

5 - Core-lab consortium and genetic database. PI Peter Pappas

a. To identify measuring parameters at the tissue level: vein skin/blood samples
b. Specimens bank, analysis, database
c. Correlation between genes, the inflammatory reaction and clinical status of
CVD
d. A repository of information for researchers, drug industry

6 - Evaluation and standardization of venous testing. PI Fedor Lurie

a. Standardize testing for acute and chronic venous disease for both clinical
practice and research
b. Identify a standard for quality of life outcomes and hemodynamic outcomes
c. Develop uniform protocols
d. Develop a wireless functional venous test to enable real-time study during
exercise

7 - Assessment of reflux and its relation to progress of CVD. PI Joann Lohr

a. Correlate patterns of reflux parameters that most accurately identify CEAP
categories
b. Identify patterns of reflux that will identify those patients who will go on
to develop class 3-6 clinical signs
c. Develop a severity score for valvular incompetence

8 - IVC filters in trauma patients. PI David Gillespie

a. To develop a prospective study comparing
b. Permanent IVC filters vs
c. Removable IVC filters vs
d. A strategy of DVT surveillance
e. In trauma patients and patients with intracerebral hemorrhage

9 - Improvement of existing endovenous valves and venoscopic valve repair.

PI Seshadri Raju
a. Develop a valve which is nonthrombogenic, nonimmunogenic, flexible and
size-adaptable to all venous segments
b. Develop the least invasive techniques to restore valve function

10 - Pathophysiology in chronic venous disease. PI Joseph Raffetto

a. Hypothesis: capillary endothelium contains the sensor mechanism which
detects the blood flow changes produced by venous hypertension
b. Plan human and animal experiments to assess role of endothelium and
identify mechanisms of ambulatory venous hypertension, inflammatory
skin changes and ulceration.

Phlebolymphology. Vol 14. No. 4. 2007 185

 11 - External compression device. PI Joseph Caprini
a. To develop a compression device to treat severe stages of CVI that
b. Is as portable as compression stockings
c. Is easy to use
d. Responds to patient movements and position
e. Positively assists venous return
f. Gives feedback to the physician

12 - Development of dedicated venous stent. PI Peter Neglen

a. To create a modular stent system for caval confluence
b. Identification of vessel reaction to stent material
c. Rate of in-stent restenosis and nature of mechanism
d. Assess modification by preoperative pharmacotherapy

13 - Joint Venous Council. PI Robert Kistner

a. To form a new organization
b. To raise awareness about venous disorders among physicians, government,
industry, and the general public
c. To foster relationships with industry, government, academics and pertinent
national and international societies
d. To consolidate resources to minimize duplication of effort and to maximize
progress in the field
e. To identify and develop sources of funding and other support for the activities
needed to advance the venous field

14 - AVF a broad-based inclusive organization. PI Michael Dalsing

a. Achieve influence through critical mass and excellence
b. Act as project/grant clearing house
c. Create evidence-based practice guidelines

The IMUA committee’s tasks are to:

- Produce a supplement for Journal of Vascular Surgery containing the 32 guidelines
and the proceedings from the Venous Summit. A 370-page manuscript is
submitted: publication planned in the summer of 2007.
- Support and encourage completion of the projects.

Contemporary approach to Budd-Chiari syndrome among Asians with endovascular management

B.B. Lee, J. Laredo, D. Deaton, R. Neville / USA

Budd-Chiari syndrome (BCS) is hepatic venous outflow obstruction at the

suprahepatic inferior vena cava and/or hepatic veins. There are various primary
and secondary causes of BSC: congenital, inflammatory, infectious, etc.

Primary, idiopathic BCS is a relatively rare condition with great geographic variance
and etiologic or predisposing factors that differ between Caucasian and Asian
patients. The “thrombosis theory” is more compatible with the situation in
Caucasian patients than the “developmental anomaly theory”, which is more
frequently relevant in Asian and African patients. Management strategy remains

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 Asian Chapter of the UIP, Kyoto, Japan, June 18-20, 2007

a critical issue: decompression procedure versus curative radical procedure. Today

the gold standard of interventional treatment for different types of BCS has not
been established. Thus the indication for combination of various surgical and
endovascular procedures needs further investigation.

The last study of an Asian population revealed that the initial process leading to
BCS starts during embryogenesis and is related to pathological formation of the
vitelline vein and umbilical veins. All these produce an outflow obstruction on
the proximal hepatic veins or supraphrenic part of the inferior vena cava. The
majority cases of BCS in Asian populations are related to the segmental stricture
of the supraphrenic segment of the IVC and/or malformations of the hepatic
veins. Pathological segmental venous hypertension results in hepatic vein
thrombosis. So, decompression of hepatic outflow seems to be very important. In
many cases it can be achieved by endovascular procedures—endovascular balloon
decompression of the supraphrenic part of the IVC with or without stent placement
even after IVC thrombosis. When it is not possible to obtain IVC decompression,
or if BCS is related to hepatic vein malformation, cirrhosis and hepatocellular
carcinoma are subsequently common in these patients.

Transjugular intrahepatic portosystemic shunt (TIPS), a typical endovascular

procedure, is very useful for treatment of patients without obstruction of the
supraphrenic segment of the IVC. This procedure is widely performed in Europe
and Japan. However, the benefits of this procedure are very limited for patients
who present with IVC stricture or malformation of hepatic veins. Liver
transplantation is possible, but not a good solution because the long-term results
are poor. So prophylaxis against BCS seems to be very important for Asian and
African patients, optimal medical treatment being conditional upon early diagnosis
of the IVC stricture or segmental hepatic vein hypertension.

Phlebolymphology. Vol 14. No. 4. 2007 187

 Asian Chapter of the UIP, Kyoto, Japan, June 18-20, 2007

II
Spring Meeting of the
Swiss Society of Phlebology

Report
June 15, 2007
University Hospital of Geneva
Geneva, Switzerland
This report from the spring meeting of the Swiss
Society of Phlebology, was written by

Jan T. CHRISTENSON, MD

Address for corrsepondence:

Division of Cardiovascular Surgery
University Hospital of Geneva
24 rue Micheli-du-Crest
CH-1211 Geneva, Switzerland

E-mail: jan.christenson@hcuge.ch

190 Phlebolymphology. Vol 14. No. 4. 2007

 Asian Chapter of the UIP, Kyoto, Japan, June 18-20, 2007

Program of the Spring Meeting of the Swiss Society

of Phlebology,
University Hospital of Geneva, Geneva, Switzerland, Friday June 15, 2007

Chronic venous insufficiency – Postthrombotic syndrome

Incidence, symptoms and signs and conservative treatment
Dr Salah Gueddi, Geneva, Switzerland

Combined thrombolysis and thrombectomy to prevent

sequels of deep venous thrombosis
Prof Jon Largiadèr, Zurich, Switzerland

Evaluation and selection of patients for deep vein reconstruction

Prof Robert L Kistner, Honolulu, Hawaii, USA

The role and possibilities for deep venous reconstructive surgery

in patients with severe chronic venous insufficiency
Dr Michel Perrin, Chassieu, France

Endophlebectomy in the postthrombotic vein

Prof Robert L Kistner, Honolulu, Hawaii, USA

Neo-valve construction
Dr Marzia Lugli, Oscar Maletti Modena, Italy

Recurrent venous ulcers – the role of surgery –

a local experience
Dr Jan T. Christenson, Geneva, Switzerland

Round table discussion

Reconstructive venous surgery of the deep venous system,
for and against
Moderator: Dr Stefan Küpfer, Bad Ragaz, Switzerland,
Dr Jan T. Christenson, Geneva, Switzerland

Panelists:
Prof Robert Kistner, Honolulu, Hawaii, USA, Dr Marzia Lugli, Modena, Italy,
Dr Michel Perrin, Chassieu, France, Dr Christina Jeanneret, Basel, Switzerland,
Prof Henri Bounameaux, Geneva, Switzerland and Prof Jon Largiadèr, Zurich,
Switzerland

Phlebolymphology. Vol 14. No. 4. 2007 191

Deep Venous Reconstructive Surgery
In Patients with Severe Chronic Insufficiency:
Role and Possibilities

INTRODUCTION

Phlebologists, angiologists, dermatologists, and vascular surgeons are frequently

faced with the difficult clinical question of how best to care for patients with
severe venous insufficiency caused by deep venous reflux or partial obstruction
or both, superficial venous reflux alone, or a combination of both.

The annual spring meeting of the Swiss Society of Phlebology, held in Geneva,
Switzerland on June 15, 2007, brought together an international group of experts
to discuss the role and possibilities of deep venous reconstructive surgery, how to
evaluate and select suitable patients, who should perform this type of surgery, and
what are the results of these surgical procedures. Also discussed was how to avoid
sequelae of deep venous thrombosis and the role of subcutaneous fasciotomy as
an additional surgical procedure in treating venous ulcer disease. This review
summarizes the presentations and discussions during the meeting.

The speakers were: Professor Robert L. Kistner, Honolulu, Hawaii, USA, Dr Michel
Perrin, Chassieu, France, Dr Marzia Lugli and Oscar Maleti, Modena, Italy, Professor
Jon Largiadèr, Zurich, Switzerland, Dr Salah Gueddi and Dr Jan T. Christenson,
Geneva, Switzerland (see program, page 191).

CHRONIC VENOUS INSUFFICIENCY AND POSTTHROMBOTIC SYNDROME

Chronic venous insufficiency is a common disease estimated to affect 10% to

35% of the entire US population, and 4% of people older than 65 years have
active venous ulcers. Recent epidemiologic studies have shown that severe chronic
venous disease, according to the CEAP-classification (C4–C6), affects 3.6-6.1% of
European populations.1-3 The prevalence of chronic venous insufficiency has been
calculated to cost more than 1 billion US dollars yearly in the US. 4 Venous
hypertension is thought to be the most important factor in the development of
severe chronic venous insufficiency. Venous hypertension may occur as a result
of venous reflux in the superficial or in the deep venous system, or a combination

Keywords: Chronic venous insufficiency, deep venous thrombosis, postthrombotic syndrome, surgery in chronic
venous disease, venous ulcer disease, venous valve, fasciotomy

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of the two, or as result of complete or partial venous outflow obstruction.5,6 The

underlying cause of venous hypertension has been described as primary venous
valve reflux (70-80% of cases), congenital (1-3%), traumatic or deep vein
thrombosis (DVT) (18-25%).7

The development of venous hypertension triggers a cascade of pathologic events

resulting in symptoms such as leg edema, heaviness, pain, and itchiness, and signs
such as varicose veins, eczema, hyperpigmentation, edema, lipo-dermatosclerosis,
and venous ulcers.8 In the US, more than 20 000 new patients with venous ulcers
are treated each year and 12% of them require hospitalization, leading to a large
burden on the health service.9 The estimated incidence of severe venous
insufficiency in the US is 76/100 000 persons per year and of venous ulcers 18/
100 000 persons per year.10

Postthrombotic syndrome is defined as a late complication of DVT characterized

by deep and/or superficial (secondary varicose veins) venous axial reflux with or
without partial or complete persistent venous obstruction.11 It is estimated that 20%
to 40% of patients with symptomatic DVT will develop postthrombotic syndrome
within 2 years despite adequate treatment of DVT (anticoagulation therapy and
external compression).12 Postthrombotic syndrome severely impairs the daily life
of the affected individual, and 90% of patients cannot sustain their normal work
or manage their daily activities 10 years following iliofemoral thrombosis.13

PREVENTION OF POSTTHROMBOTIC SYNDROME

Even though the risks of acute DVT are effectively reduced with anticoagulation
therapy, 50% of patients with a first ileofemoral vein thrombosis develop symptoms
and signs of postthrombotic syndrome very early. 10 The more extensive the
thrombosis and the more active the patient, the more severe are the postthrombotic
manifestations. The patients that are active with an expected survival of more than
2 years should be offered a strategy of thrombus removal.14

Thrombus removal can be achieved by systemic thrombolysis, surgical

thrombectomy, and catheter-directed thrombolysis, or a combination thereof.
Venous patency can be achieved with good long-term results as demonstrated in
a randomized trial of venous thrombectomy and temporary arteriovenous
fistula.15,16 Catheter-directed thrombolysis for iliofemoral deep vein thrombosis
has also been found to be effective for thrombus removal, with documented
improvement in health-related quality of life.17 Combined regional thrombolysis
and surgical thrombectomy as treatment strategy have been shown to preserve
vein patency and restore valve function and thus prevent postthrombotic
syndrome,18,19 and in combination with stenting of the common iliac vein in
patients with venous spur.20,21

Catheter-directed thrombolysis is performed with a catheter inserted into a foot

vein, with the leg excluded from the circulation using a pneumatic cuff placed on
the thigh with the patient under general anesthesia. Urokinase and heparin are
then infused and allowed to act for 30 minutes, while the pelvic axis is cleared

Phlebolymphology. Vol 14. No. 4. 2007 193

 surgically with a Fogarty catheter through an inguinal incision. The external iliac
vein is then clamped and the cuff removed. Detached thrombi are flushed out by
reactive hyperemia and squeezed manually by external leg compression.18

CONVENTIONAL MANAGEMENT OF CHRONIC VENOUS INSUFFICIENCY

Conventional management of chronic venous insufficiency falls into three

categories; conservative treatment, surgical treatment, and skin and ulcer care.
Conservative treatment aims to control edema and lower venous hypertension,
often by adequate compression therapy22 and systemic drug therapy, such as
micronized purified flavonoid fraction (Daflon 500 mg*, Servier, Paris, France).23,24

Surgical treatment includes eradication of superficial venous reflux and closure of

incompetent perforating veins. These veins can be ligated, removed, or obliterated
by surgery, ultrasound-guided foam sclerotherapy and/or endovenous obliteration
using either radiofrequency or laser as energy source, with often good results. 25-27

Local skin and ulcer care includes local skin treatment and skin grafting.

EVALUATION AND SELECTION OF PATIENTS FOR DEEP VEIN RECONSTRUCTION

The decision to consider reconstructive surgery in the deep venous system should
be based on the effect of the venous problem on the daily activities of the patient,
since chronic venous disease can always be controlled by matching the lifestyle
of the patient to the limbs’ ability to tolerate the erect position. Any degree of
chronic venous insufficiency can be controlled by sufficient bedrest and elevation
of the extremity. When the venous symptoms (venous ulceration, skin changes,
swelling, or pain) become so severe that they alter the lifestyle or the type of
work the individual can do, and when conventional
management fails to control these symptoms, a choice
must be made between accepting these limitations or
trying to do something about it. Using this approach,
approximately 10% to 15% of patients with chronic
venous insufficiency will be potential candidates for
deep vein reconstructive surgery.

The selection of candidates for deep venous

reconstruction should be limited to those who have
lifestyle-limiting sequelae of chronic venous disease
after failure of conventional treatment of superficial and
perforator veins.

The diagnostic workup for venous reconstruction is

demanding since it is important to determine the sites
Fig. 1: Algorithm for evaluation of patients with chronic venous of reflux and obstruction, partial or complete, segment
insufficiency. by segment, throughout the venous distribution from

*Also registered as Ardium, Alvenor, Arvenum 500, Capiven, Detralex, Elatec, Flebotropin, Variton and Venitol.

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the diaphragm to the lower legs. The three phases of the workup include the clinical
assessment of history, physical examination, and hand-held Doppler, the noninvasive
laboratory assessment of duplex ultrasound scanning and volume studies, and the
invasive phase of ascending and descending venography (Fig. 1). Candidates should
in addition be evaluated for hypercoagulable states.

The choice of the procedure for a given case requires consideration of the pathology
present, its location amongst the venous segments, and the requirements that will
be placed upon the repaired extremity as a result of the patient’s occupation, age,
and other clinical factors. Since total repair is usually not possible in deep venous
disease, the aim of treatment is to provide sufficient functional capacity for the
individual’s lifestyle for as long as it may be needed.

The duplex examination should be done on all of the deep and superficial veins,
and each vein segment is screened for both obstruction and reflux. This test
separates patients with saphenous vein reflux or obstruction from those with
deep involvement, or those with involvement of both superficial and deep veins.

Plethysmography and physiologic testing with pressure are sometimes helpful in

estimating the severity of involvement.

With completion of noninvasive testing, the sites of reflux

and obstruction in the superficial, deep and perforator veins
will have been identified.28 The etiology of the venous disease
may be apparent from the noninvasive testing, but often
requires venography for exact diagnosis. Primary venous
disease causes pure reflux, while secondary venous disease
is often characterized by mixed reflux and obstruction.

Patients with or without incompetent perforator veins who

need only treatment of superficial reflux do not require further
investigations, which is also true for patients with deep
involvement who are not candidates for deep reconstructive
surgery.

Venography evaluation includes ascending venography, which

provides information regarding the status of the veins of the
entire limb, and also outlines the location of incompetent
perforator veins. It may also indicate the presence of
deformities due to partial thrombosis (Fig. 2). However, to
evaluate reflux in the deep venous system, a descending
Fig. 2: Venography in a postthrombotic limb, showing the pattern venogram is required.29
of partial vein obstruction.
Primary venous disease is most suited to surgical repair,
because it is a degenerative condition which causes only reflux. The key to success
is to restore a competent valve to each axial anatomic division of the venous
drainage from the lower extremity. This includes the saphenous axis, the femoral-
popliteal-tibial axis, the deep femoral-popliteal-tibial axis, and variations that
might occur through collateral channels.

Phlebolymphology. Vol 14. No. 4. 2007 195

 Secondary, postthrombotic disease is often more difficult to diagnose and to treat
than primary disease, because it comprises elements of postrecanalization,
obstruction (partial or complete) as well as reflux. In the postthrombotic limb
there is an inflammatory change in the venous wall and lining, during which
both valves and endothelial linings are permanently deformed.

The role of a more aggressive approach to serious vein disease has been
controversial since its first introduction, but the alternatives for management of
the venous handicap are relatively grim. All age groups contain populations of
venous-impaired individuals whose lives are seriously restricted by pain, swelling,
and advanced skin changes, including venous ulcers, in the lower extremities. These
individuals, who are faced with a life of frustrating efforts at dressing changes,
elevation routines, and activities restricted by conventional management, long for
any alternative that will release them from the bondage of venous disability.

While venous reconstruction is not for the casual surgeon because it is complicated
in both its diagnostic and treatment techniques, there is an important place for
centers of venous reconstruction where the broad spectrum of deep venous
management is performed with sufficient frequency to provide a standard of
successful results comparable with those published in the literature.

THE ROLE, POSSIBILITIES AND RESULTS OF DEEP VEIN RECONSTRUCTIVE SURGERY

The era of deep vein reconstruction began in 1954 when Warren and Thayer30
described transplantation of the saphenous vein for postphlebitic stasis, and
Eiseman and Malette31 described an operative technique for the construction of
venous valves. In the 1960’s, deep venous reconstructive surgery was reported
both for treatment of obstruction and reflux.32,33 Developments have continued
up to the present day. In the past several years new techniques for endovenous
valve repair in both primary and in postthrombotic veins have been described,34,35
and the ability to operate successfully in the chronically diseased postthrombotic
vein36,37 has been confirmed.

The choice of the procedure for a given case requires consideration of the pathology
present. In all cases the evaluation should fulfill the requirements of the CEAP
classification,38 including the Clinical, Etiologic, Anatomic, and Pathophysiologic
factors.

Documented surgical techniques for reflux in the deep venous system can be
classified in 3 groups: 1) those that involve phlebotomy, such as internal
valvuloplasty, venous segment transfer, vein valve transposition, cryo-preserved
allograft, and neovalve construction, 2) those that do not involve phlebotomy, such
as external valvuloplasty (transmural or trans-commissural), cuffing, and external
stenting, and 3) percutaneously placed devices.

Surgical techniques in cases of deep vein obstruction include various bypass

procedures, recanalization, or stenosis balloon dilatation, often completed with
an endovenous stent.

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In primary venous disease, where reflux is the main

feature, the most frequent procedure is valvuloplasty
(Fig. 3). This procedure is reported to achieve 70%
excellent results in terms of clinical outcome, including
absence of venous ulcer recurrence, valve competency,
and hemodynamic improvement over the long term (5-
year follow-up).39,40

For surgery performed for reflux in secondary venous

disease, long-term results have been published
concerning transposition and vein valve transfer
(Fig. 4).41 A meta-analysis has demonstrated good
clinical results and valve competence in 50% of cases
Fig. 3: Deep venous reconstruction. A-internal valve repair, B-external valve with more than 5 years of follow-up. However, results
repair. (RL Kistner) following cryo-preserved allograft valves have been
poor.42 Neovalve construction, on the other hand, has
shown promising results.35

Results following surgery for nonthrombotic obstruction are sparse in the literature,
but one center has reported a series of 319 patients (332 limbs) treated by balloon
dilatation and stenting. The cumulative results at 2.5 years showed clinical
improvement in 75% to 80% of the patients and ulcer healing in approximately
70%.43

Regarding thrombotic obstruction, good results have been reported after venous
thrombectomy alone and in combination with regional thrombolysis.15,17,18

It is generally recognized that the venous refilling time should be less than 12
seconds to be regarded as abnormal. Only reflux of grade 3-4 should be considered
for deep venous reconstructive surgery. Concerning venous obstruction, there is
no consensus regarding the degree of stenosis that should be considered significant.
The decision to operate is therefore solely based on the clinical status of the patient.

In situations of combined venous reflux and venous obstruction, it is emphasized

that the obstruction should always be treated first.
Fig. 4: Deep venous reconstruction.
Transfer of venous valve. The reports of these venous reconstructive procedures in the deep venous system
(RL Kistner) are among the most careful case series in the venous literature. The rigorous
preoperative evaluation allows for targeted postoperative evaluation, and the
controversial nature of the subject demands objective postoperative testing. Each
of the procedures is successful in certain sites. Many have been found to have
prolonged competence or patency in the range of 50% to 70% for 2-4 years and
beyond.44 These are good outcomes in a highly selected population of failure
cases that would have a dim outlook without this intervention. Morbidity rates
for these surgical repairs are in an acceptable range of 10% to 15%, and mortality
is a rare occurrence in all of these procedures.

As large, randomized, controlled trials comparing conservative treatment and

deep venous reconstructive surgery would be difficult to conduct, we must rely

Phlebolymphology. Vol 14. No. 4. 2007 197

 on the outcome data presented in the literature. Available literature provides
grade 2 b or c recommendations. Even if deep venous reconstructive surgery is
not often indicated, its potential must be more frequently recognized, keeping in
mind that this type of surgery must be performed in specialized units.

ENDOPHLEBECTOMY IN THE POSTTHROMBOTIC VEIN

Venous reconstruction in the postthrombotic vein remains the greatest challenge

in management of advanced venous insufficiency. The very concept of performing
elective endosurgery in the postthrombotic vein was long regarded as impossibly
flawed, but more recent clinical evidence has shown that this might be a useful
technique that would change the way we regard the postthrombotic vein. The
literature describes everything from the “no-touch” techniques of handling
phlebitic vessels to reports citing high postoperative rethrombosis rates. However,
in contrast to the fear of surgical manipulation of the postphlebitic veins,
numerous reports of patency rates of 50% to 75% followed45,46 the Palma report
of 1960, 32 which described saphenous bypass of postphlebitic obstruction
of the iliac vein.

Thrombectomy of iliofemoral veins was already reported in the 1950’s, and

involved surgery at the acutely inflamed thrombotic stage.47 Good results, successful
clearing of the thrombosed segment, and freedom from rethrombosis were reported,
but several reports of failure gave the surgery a bad name. However, with an
added temporary arteriovenous fistula venous, thrombectomy regained its place
as a treatment of choice for iliofemoral venous thrombosis.48 Excellent results of
venous thrombectomy combined with catheter-directed thrombolysis have recently
been reported in the literature.18

Many reports on successful reconstructive surgery in the postthrombotic veins have

been published. Raju49 has reported success with surgery on postthrombotic
valves, and Puggioni et al37 reported success with removal of endovenous scars
and striae during venous reconstruction and bypass procedure on deep
postthrombotic veins. In addition, many authors have mentioned clearing of focal
sites of postthrombotic partitions, scars, and endovenous masses during venous
reconstructive surgery. It is important to stress that in endarterectomy the
endothelium is removed, while in endophlebectomy the endothelium is preserved,
and it is the endoluminal scar that is removed. A recent report has described
construction of an endovenous valve in postthrombotic tissue with good long-term
patency and function.50

Kistner: “The accumulation of these clinical experiences demonstrates that the

postthrombotic vessel can be operated upon successfully, not only by bypass of
diseased segments but even by direct surgery inside and outside of the diseased
segments. Correction of both occlusive and reflux states has been achieved. This
surgery is done under selective circumstances and requires the protection of
perioperative anticoagulation. Reduction of thrombosis by heparin incurs the
price of a higher frequency of postoperative hematoma formation, so the indications
for intervention need to be carefully applied.

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Elements that may be important in selecting patients for postthrombotic

endoluminal surgery include the following: 1) identification, and possible
elimination, of patients who are hypercoagulable, 2) length of time since the last
thrombotic episode. This is based upon the assumption that the endothelial surface
becomes less thrombogenic in the late postthrombotic period, 3) choice of segment
to be repaired. Long-term patency following endosurgery requires a segment with
sufficient inflow from below and outflow from above the surgically treated segment
to avoid severe postoperative stasis. Technical criteria for successful endovenous
surgery include: a) peri- and postoperative heparinization, and b) preservation of
as much of the lining endothelium inside the vein as possible.”

NEOVALVE CONSTRUCTION

A surgical technique has been developed to construct a neovalve in the femoral

vein to obtain axial antireflux mechanisms in patients with postthrombotic
syndrome with nonhealing or recurrent venous ulcers.37

The technique consists in creating a neovalve in the femoral

vein by wall dissection. The most frequently used site to
perform a valve reconstruction is the femoral vein at mid-
thigh level. After femoral vein exposure, a lengthwise
venotomy is performed. Using microsurgery instruments, a
wall dissection is undertaken. The length of the dissection
depends on the vein diameter so as to avoid reflux (Fig. 5). The
wall dissection can be performed on two half circles so as to
create an effect similar to a bicuspid valve or a wider dissection
on a single circle to create a mechanism similar to that of a
monocusp valve. Usually no further technical procedures are
Fig. 5: Construction of a neovalve in the femoral vein. required and the operation is concluded with a closing suture.
The Maleti-Lugli technique. Frequently, the presence of postthrombotic wall trabeculae
makes it necessary to perform a preliminary endophlebectomy. The choice between
a mono- and bicuspid valve is dictated by anatomical elements related to the
venous wall.

During the postoperative period, a 35 mm Hg, foot-thigh elastic stocking is applied.

Intravenous heparin is continued and subsequently replaced by oral anticoagulant
therapy such as to obtain a ratio of 2.5 – 3 for six months.

Between 2000 and 2006, 27 neovalve constructions in 24 patients were performed

with this technique without any mortality and with excellent long-term results
(mean of 42 months of follow-up). Venous ulcers healed in 91.6% of patients.
Early thrombosis, below the neovalve site, occurred in two patients (7.4%) and
a late occlusion was diagnosed in one patient (3.7%). Recurrent ulcer occurred
in one patient (3.7%). No pulmonary embolism was observed. 35

Phlebolymphology. Vol 14. No. 4. 2007 199

RECURRENT VENOUS ULCERS
THE ROLE OF SURGERY IN CONVENTIONAL MANAGEMENT

The benefit of surgery as part of conventional management of chronic venous leg

ulcers has frequently been reported in the literature.51

Severe chronic venous insufficiency often leads to dermatoliposclerosis and venous

leg ulcers frequently occur. Many of these ulcers are difficult to heal by conservative
therapy, such as compression therapy and skin grafting, and the recurrence rate
is high. The pathophysiological role of the lower limb fascias and two defined
compartments of the lower limb, the superficial compartment (limited by the
skin, fascia and bone) and the muscular compartment (limited by fascias and
bone) has not been explored.

The principal therapy of venous leg ulcers is compression therapy and, if possible,
elimination of pathological reflux by surgery, endovenous vein ablation, or
ultrasound-directed sclerotherapy.

Earlier studies have demonstrated that in patients with lymphedema, subcutaneous

and intramuscular tissue pressures are increased and, in patients with chronic
venous insufficiency, intramuscular tissue pressures are often increased.52-54 The
role of fasciotomy as an additional surgical intervention to promote ulcer healing
therefore seems reasonable.

In 22 patients (25 limbs) with recurrent, therapy-resistant venous leg ulcers due
to severe chronic venous insufficiency, CEAP class C6 subcutaneous fasciotomy
was performed in addition to removal of superficial reflux. Eighteen patients (24
limbs) had no fasciotomy and served as controls. Intramuscular and subcutaneous
tissue pressures and TcPO2 were measured pre- and postoperatively.

Patients with severe chronic venous insufficiency and therapy-resistant or recurrent

venous ulcers have significantly increased subcutaneous and intramuscular tissue
pressures and lowered transcutaneous oxygen tension at the edge of the ulcer.
Eradication of the superficial reflux including incompetent perforator veins lowered
subcutaneous tissue pressures significantly, while intramuscular tissue pressures
remained high. However, additional fasciotomy also lowered the intramuscular
tissue pressure almost to normal values. Superficial reflux eradication resulted in
an ulcer healing rate of 46% compared with 96% when additional subcutaneous
paratibial fasciotomy was performed.

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CONCLUSIONS
Chronic venous insufficiency is a very common disease, and economic burden on
health services around the world, which causes considerable human suffering,
while not being life-threatening. Its pathophysiology is not yet fully understood
and more funding is required for research.

Even though conventional therapy for chronic venous insufficiency is successful

in a vast majority of patients, a thorough and adequate diagnostic evaluation is
required in order to select the most appropriate therapy in each individual patient.
An evaluation of the severity of the patient’s symptoms together with a careful
clinical examination should always be undertaken, followed by noninvasive
duplex scanning.

Conventional therapy includes compression stockings, drug therapy, and surgical

eradication of superficial reflux and incompetent perforator veins. In cases of
recurrent or therapy-resistant venous ulcers, subcutaneous paratibial fasciotomy
might be added to conventional surgical intervention. Recognition of the
importance of correct diagnosis and adequately performed surgery has put venous
surgery on an equal footing with arterial surgery, as stated by Dr Gloviczki in his
presidential address to the American Venous Forum some years ago,55 and venous
centers have been established in many countries.

Indications for interventional treatment for iliofemoral and iliocaval venous

obstruction are still debated, due to lack of comparative studies. However, venous
bypass surgery, venous thrombectomy, balloon dilatation and stenting, combined
with catheter-directed thrombolysis and, in chronic situations, endophlebectomy
are the first line of interventional treatment and the mid-term results are promising.

The selection of candidates for deep venous reconstructive surgery should be

limited to those patients who have lifestyle-limiting sequelae of chronic venous
disease, and only after failure of conventional treatment, including surgical
treatment of superficial and perforator veins.

Deep venous surgery for reflux is effective in selected cases (a Grade 1 c

recommendation). The results of deep venous reconstructive surgery reported so
far have been better in primary disease, where reflux is the main feature, than in
secondary disease, which often comprises both reflux and obstruction. However,
new surgical techniques such as neovalve construction and endophlebectomy are
now proving promising in secondary disease too.

As rather few patients are candidates for deep venous reconstructive surgery, and
because more in-depth investigations are required, such as ascending and
descending venography, the final decision on suitability for surgery should be
made in specialized centers, where the surgical treatment itself should be performed
by well-trained teams familiar with this quite demanding procedure.

Phlebolymphology. Vol 14. No. 4. 2007 201

REFERENCES

1. Carpentier PH, Maricq HR, Biro C, Poncot-Makinen CO, Franco A. Prevalence, risk factors and clinical patterns of
chronic venous disorders of lower limbs. A population-based study in France. J Vasc Surg. 2004;40:650-659.

2. Jawien A, Grzela T, Ochwat A. Prevalence of chronic venous insufficiency in men and women in Poland: multicenter
cross-sectional study in 40 095 patients. Phlebology. 2003;18:110-121.

3. Rabe E, Pannier-Fischer F, Bromen K, et al. Bonner Venenstudie der Deutchen Gesellschaft für Phlebologie –
epidemiologische Untersuchung zur Frage der Hautigkeit und Ausprägung von chronischen Venenkrankheiten in
der städtischen und ländlichen Wohnbevölkerung. Phlebologie. 2003;32:1-14.

4. Patel NP, Labropoulos N, Pappas P. Current management of venous ulceration. Plast Reconstr Surg.
2006;117(Suppl):254S-260S.

5. Tassiopoulos AK, Gotts E, Oh S, Labropoulos N. Current concepts in chronic venous ulceration. Eur J Endovasc Surg.
2000;20:227-232.

6. Padberg F. The physiology and hemodynamics of the normal venous circulation. In: Glovicki P, Yao JS, eds. Handbook
of Venous Disorders, 2nd ed., Guidelines of the American Venous Forum. New York, NY: Arnold; 2001:25-35.

7. Labropoulos N, Tiongson J, Pryror L, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg.
2003;38:793-798.

8. Pappas PJ, Duran WN, Hobson RW. Pathology and celluar physiology of chronic venous insufficiency. Gloviczki P,
Yao JS, eds. Handbook of Venous Disorders, 2nd ed., Guidelines of the American Venous Forum. New York, NY: Arnold;
2001:58-67.

9. Korn P, Patel ST, Heller JA, et al. Why insurers should reimburse for compression stockings in patients with chronic
venous stasis. J Vasc Surg. 2002:35:950-957.

10. Heit JA, Rouke TW, Silverstein MD, et al. Trends in the incidence of venous stasis syndrome and venous ulcer:
a 25-year population based study. J Vasc Surg. 2001;33:1022-1027.

11. Danielsson G, Eklof B, Grandinetti A, Lurie F, Kistner RL. Deep axial reflux, an important contributor to skin changes
and ulcer in chronic venous disease. J Vasc Surg. 2003;38:1336-1341.

12. O’Donnell TF Jr, Browse NL, Burnand KG, Thomas ML. The socioeconomic effects of an ilio-femoral venous
thrombosis. J Surg Res. 1977;22:483-488.

13. Prandoni P, Fralla M, Mosena L, et al. Below-knee elastic stockings to prevent the post-thrombotic syndrome: a
randomized controlled trial. Ann Intern Med. 2004;141:249-256.

14. Comerota AJ, Paolini D. Treatment of acute ilio-femoral thrombosis: A strategy of thrombus removal. Eur J Vasc
Endovasc Surg. 2007;33:351-360.

15. Plate G, Eklof B, Norgren L, Ohlin P, Dahlstrom JA. Venous thrombectomy for ilio-femoral vein thrombosis-10
year results of a prospective randomized study. Eur J Vasc Endovasc Surg. 1997;14:367-374.

16. Neglen P, Al-Hassan HK, Endrys J, Nazzal MM, Christenson JT, Eklof B. Iliofemoral venous thrombectomy
followed by percutaneous closure of the temporary arteriovenous fistula. Surgery. 1991;110:493-499.

202 Phlebolymphology. Vol 14. No. 4. 2007

 Spring Meeting of the Swiss Society of Phlebology, Geneva, Switzerland, June 15, 2007

17. Comerota AJ, Throm RC, Mathias SD, Haughton S, Mewessen M. Catheter-directed thrombolysis for iliofemoral
deep venous thrombosis improves health-related quality of life. J Vasc Surg. 2000;32:130-137.

18. Blattler W, Heller G, Largiadèr J, Savolainen H, Gloor B, Schmidli J. Combined regional thrombolysis and surgical
thrombectomy for treatment of iliofemoral vein thrombosis. J Vasc Surg. 2004;40:620-625.

19. Baldwin ZK, Comerota AJ, Schwartz LB. Catheter-directed thrombolysis for deep vein thrombosis. Vasc Endovasc
Surg. 2004;38:1-9.

20. Husmann MJ, Heller G, Kalka C, et al. Stenting of common iliac vein obstruction combined with regional
thrombolysis and thrombectomy in acute vein thrombosis. Eur J Vasc Endovasc Surg. 2007;34:87-91.

21. Mickley V, Schwagierek R, Rilinger N, Gorich J Sunder-Plassmann L. Left iliac venous thrombosis caused by
venous spur: treatment with thrombectomy and stent implantation. J Vasc Surg. 1998;28:492-497.

22. Barwell JR, Davies CE, Deacon J, et al. Comparison of surgery and compression alone in chronic venous ulceration
(ESCHAR study): randomized controlled trial. Lancet. 2004;363:1854-1859.

23. Coleridge-Smith P, Lok C, Ramelet AA. Venous leg ulcer: a meta-analysis of adjunctive therapy with micronized
purified flavonoid fraction. Eur J Endovasc Surg. 2005;30:198-208.

24. Simka M, Majewski E. The social and economic burden of venous leg ulcers: focus on the role of micronized purified
flavonoid fraction adjuvant therapy. Am J Clin Dermatol. 2003;4:873-881.

25. Tawes RL, Barron ML, Coello AA, Joyce DH, Kolvenbach R. Optimal therapy for advanced chronic venous
insufficiency. J Vasc Surg. 2003; 37:545-551.

26. Lurie, F, Creton D, Eklof B, et al. Prospective randomized study of endovenous radiofrequency obliteration
(closure) versus ligation and stripping (EVOLVeS): two-year follow-up. Eur J Vasc Endovasc Surg. 2005;29:67-73.

27. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux: long-term results. J Vasc
Interv Radiol. 2003;14: 991-996.

28. Kistner RL, Eklof B, Masuda EM. Deep venous valve reconstruction. Cardiovas Surg. 1995;3:129-140.

29. Kistner RL, Ferris EB, Randhawa G, Kamida CB. A method of performing descending venography. J Vasc Surg.
1986;4:464-468.

30. Warren R, Thayer TR. Transplantation of the saphenous vein for postphlebitic stasis. Surgery. 1954;35:867-876.

31. Eiseman B, Malette W. An operative technique for the construction of venous valves. Surg Gynecol Obstet.
1953;97:731-734.

32. Palma EC, Esperon R. Vein transplants and grafts in the surgical treatment of the post-phlebitic syndrome. J
Cardiovasc Surg. 1960;1:94-107.

33. Kistner RL. Surgical repair of a venous valve. Straub Clin Proc. 1968;34:41-43.

34. Tripathi R, Ktenidis KD. Trapdoor internal endophlebectomy—a new technique for primary deep vein valvular
incompetence. Eur J Vasc Endovasc Surg; 2001;22:86-89.

35. Maleti O, Lugli M. Neovalve construction in postthrombotic syndrome. J Vasc Surg. 2006;43:794-799.

36. Hurst DR, Forauer AR, Bloom JR, et al. Diagnosis and endovascular treatment of iliocaval compression syndrome.
J Vasc Surg. 2001;34:106-114.

Phlebolymphology. Vol 14. No. 4. 2007 203

37. Puggioni A, Kistner R, Eklof B, Lurie F. Surgical disobliteration of postthrombotic deep veins—endophlebectomy—
is feasible. J Vasc Surg. 2004; 39:1048-1052.

38. Porter JM, Moneta GL. International Consensus Committee on Chronic Venous Disease. Reporting standards in
venous disease: an update. J Vasc Surg. 1995;21:635-645.

39. Wang SM, Hu ZJ, Li SQ, Huang XL, Ye CS. Effect of external valvuloplasty of deep vein in the treatment of
chronic venous insufficiency of the lower extremity. J Vasc Surg. 2006;44:1296-1300.

40. Kistner RL, Eklof B, Masuda EM. Deep venous valve reconstruction. Cardiovasc Surg. 1995;3:129-140.

41. Masuda EM, Kistner RL. Long-term results of venous valve reconstruction: a 4- to 21-year follow-up. J Vasc Surg.
1994;19:391-403.

42. Dalsing MC, Raju S, Wakefield TW, Taheri S. A Multicenter, phase I evaluation of cryo-preserved venous valve
allografts for the treatment of chronic deep venous insufficiency. J Vasc Surg. 1999;30:854-864.

43. Raju S, Neglen P. High prevalence of non-thrombotic iliac vein lesions in chronic venous disease: a permissive
role in pathogenicity. J Vasc Surg. 2006;44:136-143.

44. Kistner RL, Eklof B, Yang D, Masuda EM. Venous Reconstruction: Evidence-based Analysis of Results. In: Ballard
JL and Bergan JJ, eds. Severe Chronic Venous Insufficiency: Diagnosis and Treatment. London, UK: Springer-Verlag;
2000:139-150.

45. Husni EA. Clinical experience with femoro-popliteal venous reconstruction. In: Bergan JJ, Yao JST, eds. Venous
Problems. Chicago, Ill: Medical Book Publishers; 1978:485.

46. Halliday P, Harris J, May J. Femoro-femoral crossover grafts (Palma operation). A long term follow-up study. In:
Bergan JJ, Yao JST, eds. Surgery of the Veins. New York, NY: Grune&Sratton; 1985:241.

47. Mahorner H. A new method of management for thrombosis of deep veins of the extremities. Am Surg. 1954;20:487.

48. Plate G, Einarsson E, Ohlin P, Jensen R, Quarfordt P, Eklof B. Thrombectomy with temporary arteriovenous
fistula. The treatment of choice in acute ilio-femoral venous thrombosis. J Vasc Surg. 1984;1:867-876.

49. Raju S, Fredericks RK, Hudson CA, Fountain T, Neglen PN, Devidas M. Venous valve station changes in “primary”
and postthrombotic reflux: an analysis of 149 cases. Ann Vasc Surg. 2000;14:193-199.

50. Maleti O, Lugli M. Neovalve construction in postthrombotic syndrome. J Vasc Surg. 2006;43:794-799.

51. Obermayer A, Gostl K, Walli G, Benesch T. Chronic venous leg ulcers benefit from surgery: Long-term results
from 173 legs. J Vasc Surg. 2006;44:572-579.

52. Qvarfordt P, Eklof B, Ohlin P. Reference values for intramuscular pressure in the lower leg in man. Clinical
Physiology. 1982;2:427-434.

53. Christenson JT, Shawa NJ, Hamad MM, Al-Hassan HK. The relationship between subcutaneous tissue pressures
and intramuscular pressures in normal and edematous legs. Microcirc Endothelium Lymphatics. 1985;2:367-384.

54. Christenson JT, Al-Hassan HK, Shawa NJ. Subcutaneous and intramuscular pressures in the post-phlebitic limb.
Scand J Clin Lab Invest. 1986;46:137-141.

55. Gloviczki P. Presidential address: venous surgery—from stepchild to equal partner. J Vasc Surg. 2003;38:871-877.

204 Phlebolymphology. Vol 14. No. 4. 2007