Today The College of Phlebology has launched its brand new online research library, presenting original research papers, case reports, and reviews from around the world that have not been published elsewhere.
All abstracts will be put up for the general public to see, with the full papers being available within our members area.
This is a fantastic platform for specialists to get their previously unknown research papers to be viewed by their peers, and all papers will be considered for publication.
We will be constantly adding new research papers to our library, so please check back regularly. If you have an unpublished research paper, case report or review that you would like to submit to us, please send your paper to firstname.lastname@example.org. If our research paper has already been published, please check that you have permission to reproduce it, and attach proof of this to your email.
Selected highlights of the 13th meeting of the European Venous Forum (28th-30th June 2012, Florence, Italy)
The 13th meeting of the European Venous Forum was held in the beautiful city of Florence at the very impressive Palazzo dei Congressi.
Despite beautiful weather and stunning architecture, a very interesting programme made sure of excellent attendance at the scientific sections.
The program had some fascinating insights and new advances into venous disease, a credit to the Congress president Dr Giovanni Mosti and the local organising committee, Massimo Capelli, Attilio Cavezzi, Vincenzo Gasbarro, Oscar Maleti, Allesandro Pieri and Paolo Zamboni.
Summary of some of the highlights:
Thursday 20th of June 2012:
The meeting started with debates.
Debate 1: Post thrombotic syndrome needs surgical correction
For the motion: Oscar Maleti
Against motion: Jean-Jerome Guex
Both discussants presented their views on post thrombotic syndrome and largely agreed as to which patients would benefit from surgical correction and in which patients, conservative compression would be optimal. This is clearly still a complex area with a great number of different clinical patterns causing post thrombotic syndrome. One of the confounding factors that still remains in such discussions is whether post thrombotic syndrome is an outflow problem caused by blocked or stenotic veins, or a reflux problem caused by valves not working in the deep system.
The debate ended without vote.
Debate 2: Perforator veins need to be always treated:
For the motion: Mark Whiteley
Against the motion: Massimo Capelli
Mark Whiteley presented his view that the current apparent complexity of the role of perforators could be simplified into those that are incompetent and allow venous blood to reflux during active pumping of the deep veins, when they should be competent, keeping the blood in the deep system so it can be pumped to the heart. Massimo Capelli presented his view that perforator veins were very complex with flow going both ways within them and so simple views of reflux were impossible to identify. A very active debate ensued with questions from the floor.
One of the questioners pointed out that, as Massimo Capelli had said, there are complex connections between perforators both above and below the fascia the facia making this a difficult subject to analyse. Mark Whiteley pointed out that firstly we have patients to treat and therefore we need to offer them something, and secondly, considerable research shows an association between recurrent varicose veins and the failure to treat incompetent perforators. Finally he explained that this apparent complexity could be likened to a city with a river running through the middle. If blood can be thought of as cars driving on the road, despite both sides of the city having complex roadways, the few bridges across the river allowed a separation of the two systems. Similarly, treating incompetent perforators at the fascia can effectively separate and impulse of pressure caused by muscle contraction in the deep veins from causing damage by outward flow through incompetent perforators.
The debate ended without vote.
Paulo Zamboni presented an elegant description of the use of venous duplex ultrasound scanning to be able to direct treatments only to the veins where reflux was found, allowing a functional correction of pathological venous reflux. This is the theory behind the CHIVA technique of treating varicose veins and more recently some other similar strategies such as ASVAL. These try to create a physiological correction of venous reflux as a basis of treatment. Research was presented showing an equivalence of CHIVA to open surgery.
Philip Coleridge-Smith countered, starting with a historical account of venous surgery showing how our understanding of veins had led us to stop treating just sections of veins. Years of study have shown that when reflux has been found to have started in the Great Saphenous Vein (GSV), ablation of the whole vein not only treated the reflux problem, but also reduced recurrence from progression of the venous reflux in the vein. He pointed out that although some doctors claim to have reasonable results from a CHIVA type strategy, these were hard to reproduce in many other units, whereas treatments that completely ablate or remove the Great Saphenous Vein (GSV) seem to have far better medium to long term results, particularly if the incompetent tributaries are adequately treated at the same time.
There was an active question session showing a polarised difference of opinion between the small number of physicians that believe in a selective CHIVA type approach and the larger number of doctors that except that ablation of the whole of Great Saphenous Vein (GSV) and tributaries is necessary for optimal results in Great Saphenous Vein (GSV)system incompetence.
The debate ended without vote.
There was a session of “Didactic” lectures from experts explaining why they perform certain venous procedures:
– Why I perform: surgery – Marianne de Maeseneer.
Marianne de Maeseneer explained that she thought that there was still a role for surgery in venous disease – although she then admitted that she had only performed three open procedures in the last year. Therefore her feeling is that surgery is only required in some cases, but when it is, it is a useful technique to have in the armamentarium.
– Why I perform: foam – Attilio Cavezzi
Attilio Cavezzi, who has a very long experience of foam sclerotherapy and is one of the original developers of the technique, presented a very powerful argument as to why he continues to use foam sclerotherapy. He pointed out although most people can now get good results with foam sclerotherapy in small diameter veins, many still have problems with larger diameter veins.
However Dr Cavezzi briefly described a new technique he was to present later in the conference to allow successful treatment of larger truncal veins. He also pointed out that in recurrent and complex veins, foam sclerotherapy is virtually the only option for effective treatment. He did explain that he does not use foam sclerotherapy in large bulging surface veins as these cause brown staining. In these veins he prefers phlebectomy.
– Why I perform: EV laser – Nick Morrison
Nick Morrison gave a wide-ranging talk pointing out there are different wavelength lasers and different devices, with variation of fibres and particularly with different fibre tips. He pointed out that there seems to be a decrease in pain with the longer wavelengths when treating the truncal veins although power levels and different tips might play a role. He also showed that the EV laser is clearly a successful method of ablation when used correctly. Surprisingly he discounted a research finding showing damage of the laser fibre by needle penetration, claiming to have repeated the procedure and not being able to reproduce the damage – although different fibres have different coatings and construction, and previous evidence has clearly shown this mechanism in one of the coated types of fibres.
– Why I perform: radiofrequency – Ian Franklin
Ian Franklin gave a talk on his experience with VNUS ClosureFAST and announced the new 3 cm catheter which will allow more versatility and enable shorter veins to be treated if needed. He showed the simplicity of using the VNUS Closure FAST catheter and explained the learning curve to get good results with this catheter is very short. However other forms of radiofrequency ablation such as RFiTT were not discussed.
– Why I perform: steam – Rene Milleret
Rene Milleret presented his technique of performing his own invention of Steam Vein Sclerosis (SVS). He explained that in his hands it is the one thermoablation technique that allows treatment to all veins. He explained that multiple access points may be necessary to introduce the steam tips precisely where they are needed and that different tips are needed for different veins.
An active discussion then followed from the floor with a great many questions. The general consensus amongst phlebologists seemed to be that there are great many different techniques available, many of which work better or worse in different veins. In order to get optimal treatments for patients with different patterns of venous disease, it is necessary to use an “à la carte” approach selecting the optimal technique or combination of techniques for the individual patients.
An afternoon session of deep venous incompetence and deep venous surgery explored different areas of investigation and treatment of the deep veins. Peter Neglen presented some interesting work showing how the volume of deep venous reflux could be calculated for assessment and classification of the patient.Friday 29th of June:There were a series of very interesting papers relating to CCSVI in the treatment of multiple sclerosis followed by several papers on compression therapy, both in terms of how it should be measured and the clinical effects.The afternoon had some miscellaneous research on the subjects of compression and venous surgery – open and endovenous.
An interesting paper given by L Corcos of the Italian Society of Phlebolymphology suggested that from observations made at re-operation for recurrent varicose veins, most of the recurrences were due to “residual tributaries” – in other words, veins that were left at the first operation and therefore “bad” initial surgery, rather than re-growth by neovascularisation or neogenesis (veins re-growing again).
However, it was pointed out in the following questions that this conclusion could not be drawn from this paper unless a full investigation with duplex had been made immediately after the original surgery and each patient followed through their clinical course (a longitudinal study). In this way it would be seen if there were veins missed at the original surgery that caused the recurrence, or – as has been suggested by other studies – that these veins re-connect and cause recurrent varicose veins by re-growth of the ends that have been operated on. This would then prove neovascularisation or neogenesis is actually the cause of these recurrences.
Ted King presented a very well-constructed audit showing the very low incidence of DVTand EHIT (clot at the top of an endovenous ablation procedure) in a very large number of patients (over 21,000) in 41 clinics all undergoing EVLA (EndoVenous Laser Ablation). Despite many different lasers being used in the different clinics, the DVT and EHIT rates were very low – and very interestingly he showed that no EHITs were found at all in the Small Saphenous Vein (SSV) treatments. This shows that the risk of any sort of DVT is very low in endovenous laser treatments.
In the afternoon there were a series of fascinating lectures regarding compression therapy. Jean Francois Uhl and Fedor Lurie presented imaging of the deep and superficial veins during compression. Jean François Uhl showed that in MRI studies, it appears that the effects of compression are not due to a direct action on the veins but instead compression exerts its effects by enhancing the action of the calf pump. He showed that when standing, compression had to be over 70 mmHg to flatten the superficial veins whereas fairly normal compression has a profound effect on compression of the deep veins. Fedor Lurie however, showed that with compression the adipose tissue compartment became compressed, whereas the volume of the subfascial compartment (muscle compartment) changed very little if at all. This suggested that with compression, blood was displaced from the superficial compartment into the femoral vein.
Hugo Partsch then presented a thought-provoking paper entitled “Report from ICC: challenging dogmas in compression”. He showed the differences in waveform between elastic and inelastic compression and pointed out that veins could not be completely closed in the leg whilst there was still arterial inflow. He also put forward arguments for the counterintuitive idea that low pressure may be better than high-pressure compression for effective treatment of lymphoedema.
The session was completed by three other talks – Giovanni Mosti looking at new indications for elastic stockings, Franz Schingale discussing the new compression regime as they are using for lymphoedema and showing very impressive results and finally a talk on compression after vein procedures by Marzia Lugli.
This was followed by one of the highlights of the conference when Fedor Lurie presented his EVF invited lecture “New insight in venous pathology based on duplex and biophysics data”. In a fascinating talk, Dr Lurie showed some counterintuitive research showing that valves do not completely open when blood flows through them and instead, they seem to exert some of their influence by acting as minor stenoses and therefore causing resistance to flow in the vein.
In addition, he showed how the flow of blood around the valves stops them opening fully and in some circumstances, can lead to the formation of thrombus. He also presented evidence as to how valves work more like “switches” than simple valves in some cases and evidence that the angles of the valves in the veins vary, allowing blood to flow in a helical (spiral) pattern when flowing in the veins.
This work will hopefully end up in a more comprehensive understanding of the role of valves in the venous system. It certainly shows that there is much more to venous disease than is usually thought – even by experts!
Saturday 30th of June 2012:
A miscellaneous group of research papers explored several areas of venous treatments.
A study of the “tulip fibre” was presented, investigating the “tulip” tip that has been developed by the presenting group to attach to the end of a bare fibre. This “tulip” end effectively holds the vein wall away from the bare tip, preventing direct contact with the laser tip and the vein wall. Not surprisingly this shows a reduction in the vein wall perforation and therefore reduction in pain and bruising (ecchymosis). This clearly shows advantages over the bare tip fibres, particularly using lower wavelengths, but it would have been interesting to know a bit more about the proposed mechanism of action.
For instance, if the vein wall is being held away from the tip, what is the chromophore that is being interacted with? If it is haemoglobin, then some of the power will be lost in heating the blood before transmission of power to the wall. If the mechanism of action is that the laser energy hits the vein wall at a “glancing blow” rather than being hit directly by the full laser beam, then the question is whether this “tulip tip” has any advantage over the radial firing laser tips.
Two fascinating studies were presented by Attilio Cavezzi – the first on behalf of Prof Tessari, looking at the binding of STS (sodiumtetradecysulfate) foam with blood proteins. In a very well-planned experiment, STS foam sclerotherapy was injected into veins in the legs and samples were taken from the femoral vein on the same side (to measure the STS that gets into the main circulation and heads towards the heart and lungs) and the brachial vein (to measure the STS that has got through the lungs).
The result showed an increasing amount of STS at 1 min, 5 min and 10 min in both situations, but all of the STS was protein bound and inactive. The conclusion was that there was no active STS getting to the lungs in foam sclerotherapy. However questions from the floor suggested that we might know more if a sample were also taken at 5 to 10 seconds, to see if there if there is a “hit” of active STS foam going immediately to the lungs after injection. A second question asked whether there was any possibility of the STS and blood binding in the test tube after sampling.
The second paper presented by Attilio Cavezzi, and the paper that might change the world of superficial venous surgery more than anything else that has been presented at this meeting, was his own research into using a long catheter to put foam sclerotherapy into a truncal vein whilst keeping it closed with external tumescence.
Not only did Attilio show excellent closure of the vein in terms of lack of flow, but most interestingly he showed the vein started to disappear after six months, suggesting destruction of the vein wall and permanent fibrosis. This technique, if perfected and shown to be reproducible, would challenge the thermoablation techniques for treatment of truncal venous reflux.
Written by Mark Whiteley MS FRCS (Gen) FCPhleb on 3rd July 2012
AngioDynamics, a leading company in the endovenous world, is setting up four training centres for EVLT (EndoVenous Laser Treatment) in Europe. These centres are to be in the UK, Netherlands, Germany and France.
In June 2012, AngioDynamics announced in Barcelona that the UK centre is to be at The Clinical Exchange (www.theclinicalexchange.com) in Guildford. Furthermore, the UK centre is going to be the main training centre of the four and hence is going to be the International EVLT Training Centre. The Clinical Exchange is well equipped for such training being the training arm of The Whiteley Clinic, one of the leading vein clinics in the world.
The main device that training will centre around is the Venacure EVLT system.
This system allows the use of two different wavelengths of laser – the Venacure 1470 nm laser which has a direct action on water in the blood or cells of the vein wall and the DELTA 810 nm laser which interacts directly with the haemoglobin in the blood.
The endovenous laser fibre used with this system is the “never touch” fibre which has also been dubbed the “gold tip” laser due to the gold sheath that is wrapped around the end of the device. This sheath stops the tip of the laser from touching the wall of the vein directly, significantly reducing the risk of perforation of the wall and bruising.
The training courses are currently being developed and will teach delegates the latest updates in the theory of venous reflux, the principles of venous reflux surgery and endovenous surgery as well has how to get the optimal results from the endovenous devices.The Clinical Exchange has a strong history of running courses both under its own brand and individual courses for companies. However this commitment from AngioDynamics to run regular courses to teach EVLT (endovenous laser treatment) will enable The Clinical Exchange to use all of its resources to the advantage of the delegates whether they are beginners or those wanting advanced training.Finally, as The College of Phlebology has strong links with The Clinical Exchange, all endovenous training from the International Training Centre at The Clinical Exchange will be accessible through the College’s website for members.