Servier – Phlebolymphology

Georges JANTET
Paris, France

The “CONTROVERSES ET ACTUALITES EN CHIRURGIE VASCULAIRE” (CACVS) meeting (“CONTROVERSIES AND UPDATES IN VASCULAR SURGERY”) is held every January in Paris and lasts two days (Friday and Saturday), with workshops and a parallel all-day meeting on venous diseases on Saturday.

The CACVS meetings started 17 years ago under the very efficient management of J-P. BECQUEMIN, Y. ALIMI, and J-L. GERARD. All the invited speakers are acknowledged experts in vascular or endovascular surgery or promising newcomers to the field. As its title indicates, the meeting focuses on current problems and controversies.

The pattern of the meetings remains unchanged: the speakers present their topic in 8 minutes, thus allowing ample time for questions and discussion. All the presentations, questions, and discussions are simultaneously translated into French or English, and all attendees are presented with a book containing a fuller version of each presentation written in English. The success of the pattern is reflected in the yearly increase in attendance, with 1212 participants in 2010. CACVS has become one of the leading European meetings in this field.

The opening session was entitled “Pelvic congestion syndrome” (PCS). In a very clear overview of this condition, P. LEMASLE emphasized the problems of diagnosis: the different presentations (from a few labial or vulval varices to severe pelvic pains; urinary symptoms such as hematuria or dysuria; pudendal, gluteal, or vulval varices; recurrent leg varices) may lead to a consultation with a gynecologist, urologist, or vascular specialist, each of whom should be aware of this syndrome. A PCS can be primary, when it is caused primarily by an incompetent refluxing utero-ovarian venous system or iliac venous system, or secondary, when it is associated with an obstructive pathology, such as May-Thurner syndrome (compression/obstruction of the left common iliac vein) or the nutcracker syndrome (entrapment of the termination of the left renal vein into which drains the left ovarian vein) or compression/obstruction of an element of the iliac venous system or even the vena cava.

The diagnosis is confirmed by ultrasound (US) examination and, in some cases, by selective pelvic phlebography. Primary pelvic/perineal varices may be associated with incompetent communicators between the pelvis and the lower limbs.

Treatment depends on the pathology and thus may range from simple sclerotherapy (for incompetent communicators) to embolization for primary ovarian venous insufficiency causing reflux or to stenting or even surgery for obstructive lesions.

J. LEAL MONEDERO et al stressed the importance of selective pelvic phlebography with pressure measurements and Valsalva maneuvers, as this is both diagnostic and a pathway for therapy such as embolization or stent placement. They are of the opinion that endovascular treatment is the best option in the presence of compression or reflux.

O. HARTUNG stressed that an obstructive cause of PCS should not be missed as it is eminently suitable for treatment. He presented his experience of 115 patients collected over 13 years, with iliac vein obstruction the cause of PCS in 38 of them. Treatment consisted of stenting of the obstruction and embolization of the varices with postoperative anticoagulation. At 5 years, 54% of patients were asymptomatic and a further 33% were improved with an overall patency rate of 100%.

S. RAJU (in his article, see footnote, p. 129) described in detail two patients with longstanding (10 and 31 years) severe pelvic pain found to be associated with stenoses/occlusions of left iliac veins with profuse venous collaterals. The obstructed veins were balloon dilated and stented, which afforded complete relief of symptoms and proven patency of the stented veins together with disappearance of the venous collaterals at short-term follow-up.

L. TESSARI pointed out that “at least 45% of varices of the great saphenous vein (GSV) do not originate at the saphenofemoral junction (SFJ)”. Recent studies have shown that valves are present in the iliac veins in only 10% of women and in the ovarian veins in 50%. Furthermore, free communications are present between the veins across both sides of the pelvis through venous plexuses around the pelvic structures (rectum, uterus, bladder, vagina). Pelvic venous insufficiency can be transmitted to the lower limbs via sites of leakage, one of which, according to C. FRANCESCHI, is situated at the termination of the pudendal canal (Alcock’s canal) in the perineum: this canal conveys the internal pudendal vein. TESSARI gave a report on the treatment of pudendal varices by echoguided sclerosing foam (SF) injection of this site of leakage localized by transabdominal and transvaginal ultrasond (US). He found that “in 95 women out of 647 with chronic venous disease of the lower limbs” there was venous reflux at this site which was controlled by the treatment with disappearance of the varices after a mean follow-up of 24 months.

In the lively discussion which followed these presentations it was stressed that the existence of PCS could no longer be denied and that it was very probably underdiagnosed. It should be considered in all patients with chronic pelvic pain or with atypical varices (perineal, pudendal, gluteal) or in patients with varices on the medial aspect of the thigh in the presence of a competent SFJ and in recurrent varices of the thigh. It probably also plays an important role in the development of varices during pregnancy. Accurate diagnosis of the cause of PCS and application of the appropriate treatment would probably improve the management of varicose veins of the legs and certainly improve, and even relieve, the disabling symptoms of this syndrome.

In a very instructive session on “Hemodynamics”, O. PICHOT discussed the use of duplex ultrasound, which is now mandatory in the assessment of a patient with a venous disorder. It allows a better and more detailed analysis of venous hemodynamics than can be obtained by purely clinical means and thus a better planning of the management: accurate and recordable findings are obtained and thus less radical, more selective treatment, adapted to each particular patient, is rendered possible.

In an excellent presentation A. COLIGNON discussed the essential role of the 3 valves involved in SFJ incompetence that have been elucidated by ultrasond (US) examination. The SFJ is the meeting point of the abdominal (pelvic) venous system and the lower limb venous system and is “controlled” by the 3 valves of the ostial valvular system at the SFJ—the lowest iliac valve (when present), the ostial (terminal) valve of the GSV, and the pre-terminal valve of the GSV. This system separates the abdominal from the lower limb venous systems and explains the importance of the SFJ in venous hemodynamics. Careful hemodynamic study of these valves has clarified the role of each one and has led to the more conservative management of this important part of the venous system: this was not possible before the advent of US imaging.

The traditional view of the etiology of superficial venous insufficiency (SVI) —the “valvular hypothesis”—was based on the concept of the development of points of reflux, mostly at the SFJ, from the deep to the superficial venous systems, leading to venous hypertension in the superficial system and progressive valvular decompensation retrogradely down the leg, with gradual dilatation of the tributaries of the saphenous veins leading to the development of varices and CVI, with its accompanying trophic changes. Treatment was based on this concept and explains why the radical “destruction” of the SFJ was almost systematically recommended.

The present trend favors the “parietal hypothesis”, which is based on careful study of the results of the traditional treatment and hemodynamic studies. This suggests that the disease starts in the wall of the peripheral veins, which dilate in an antegrade direction towards the groin. This explains, for example, why varices can develop in the absence of any SFJ or SPJ (saphenopopliteal junction) incompetence and why this incompetence, when present, can disappear when the only treatment has been the removal of peripheral varices by phlebectomy.

P. PITTALUGA et al favor the “parietal hypothesis”. They consider that the enlarging incompetent network of superficial varices creates a “varicose reservoir” the drainage of which causes an overload on the draining saphenous veins, which become functionally incompetent. Thus treatment aims at removing the “reservoir” exclusively. The ASVAL (“Ablation Sélective des Varices sous Anesthésie Locale”) method is based on this concept. Treatment is thus much simplified, is carried out under local anesthesia, and is more conservative as only the varices are removed and the saphenous veins are preserved.

A fruitful discussion took place after these presentations. Ideally, all physicians involved in the vascular field should be trained in the use of ultrasond (US). As regards the ASVAL method, long-term follow-up (5 years minimum and preferably 10 years) will show whether it is valid and, in particular, whether it applies to all varices whatever their severity. There was a short discussion involving the (rare) supporters of the CHIVA (“Cure Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire”) method who contend that the ASVAL method is essentially the same as the CHIVA method. This is denied by the ASVAL supporters who point out that the two methods are different in concept, clarity, and execution. At this stage, neither has any satisfactory long-term evidence!

The session on “Thermal ablation and sclerotherapy” opened with a cautionary presentation by N. LABROPOULOS who reviewed the literature and concluded that, as regards ablation of the saphenous veins, thermal ablation by either laser or radiofrequency produced good cosmetic results in the short and medium term. Foam sclerotherapy is more effective than liquid sclerotherapy, but requires repeated treatments to obtain saphenous vein closure rates comparable to those of thermal ablation, and the closure rates of the tributaries were better than those of the saphenous trunks when the tributaries were less than 6 mm in diameter. He also expressed a possible concern regarding the effect of repeated treatment with foam on the “cognitive function of the patients”. He stressed the need for well-designed and powered randomized controlled trials with longterm follow-up to assess these newer methods.

C. WITTENS pointed out in his presentation that it was totally unreasonable to compare the results of new minimally invasive techniques with those of “oldfashioned surgery” — this being the case in all published articles except one! The comparison should be with modern venous surgery techniques, which he described and which incorporate the use of US investigation preoperatively, careful SFJ ligature, limited and invaginating stripping, early ambulation, etc.

T. PROEBSTLE reported on the interesting results of a prospective European multicenter trial to elucidate whether accessory saphenous veins should be treated concomitantly with the GSV during thermal ablation. In a series of 93 limbs treated by thermal ablation of the GSV, an accessory anterior saphenous vein was present in 43 (48%), but only 2 showed reflux. However, at 2- year follow-up this had increased to 16 (30%).

Unfortunately, no predictive parameter was found to determine which of these accessory veins would become incompetent. Posterior accessory saphenous veins were initially present in 6 limbs (7%), but none developed reflux over the 2-year follow-up. The debate therefore remains open.

In a series of 91 consecutive patients (106 limbs), M. GOUGH et al reported the use of endovenous laser ablation (EVLA) in the management of recurrent varices after surgery when the recurrence was associated with the presence of a refluxing residual GSV, accessory saphenous vein or SSV (if neovascularization connected the residual truncal vein to the deep vein, this was additionally injected with sclerosing foam). He discussed the technical difficulties and reported that this method, adopted as the method of choice in his unit, is safe and effective, but has not been compared with other methods of treatment.

L. KABNICK et al studied the thrombosis produced in the GSV after radiofrequency ablation (RFA) or EVLA and, particularly, the outcome when the thrombosis involved the SFJ (with the danger of spread). Apparently, this type of thrombus behaves differently from a “spontaneous” thrombus and definite recommendations as to management require further studies.

G. SPREAFICO et al studied the relationship between the size of the GSV (measured at various levels in the standing position) and the outcome of EVLA of the GSV in a series of 145 selected patients. They concluded that a saphenous trunk with a mean diameter of 10 mm “can always be permanently occluded if a sufficient amount of energy and adequate tumescent anesthesia are administered”.

T. BAYENS et al, concerned by the transient neurological and cardiac embolic complications of foam sclerotherapy, advocate performing a “crossectomy” of the GSV or SSV “through a 1-cm incision, under US control” before injecting the foam through a catheter introduced at the ankle. In a series of 111 patients (188 limbs), a complete (100%) occlusion rate was obtained with complete disappearance of the saphenous vein on US at 1-year follow-up. No neurological or cardiac abnormalities were reported. As a comment on this presentation, it should be pointed out that the “operation” described is not a “crossectomy” — it is, at best, a ligature of the saphenous trunk below the junction with the deep veins, leaving a stump draining several tributaries…the commonest cause of recurrent varices after surgery!

As M. LUGLI et al discussed in their presentation during the session on “Anesthesia for varicose veins”, SFJ ligature and stripping can be performed satisfactorily under local or tumescent anesthesia. So, why is it, ask J. VANHANDENHOVE et al, that “general anesthesia for varicose veins remains so popular in Europe”? They are unable to suggest an answer! In a similar “vein”(!), M. PERRIN analyzes “why traditional surgery remains so popular in France”: he suggests it is due to a lack of teaching and training in the use of US and other methods of treatment together with Health Service regulations concerning fees. While this may well be partly the case as regards surgery, a fair comment could well be added. Surgeons have shown repeatedly that they are perfectly prepared to change their treatment methods when it is shown that it is in the long-term interest of the patient (even if it is not in their financial interest). They are also less likely to be impressed by “newer, fashionable” methods, often with a strong commercial background, as such “discoveries” have been acclaimed in the past, only to disappear as they have not stood the test of time. C. Wittens (see above) points out that most comparisons with surgery are flawed. A further possible flaw is in the severity of the varices treated by surgery compared with those treated by conservative methods: are the varices treated surgically more severe or advanced than those treated nonsurgically? There is circumstantial evidence that this may be the case. At present, all varices are classed C2 in the CEAP classification irrespective of their size or extent; should this be refined to take into consideration their total physical size/volume? Should the volume of the “varicose reservoir” be quantified?

A separate session was allocated to the difficult and specialized subject of “Vascular malformations”, which are not to be confused with vascular tumors.

C. LAURIAN et al and P. BURROWS et al discussed highflow arteriovenous malformations (AVMs) which are congenital vascular anomalies made up of 3 components: feeding arteries, fistulae or “nidus” (the body) of small vessels, and draining veins. Congenital arteriovenous fistulas (AVFs) are a rare form of malformation, but the acquired form is typically the result of penetrating injuries. AVMs can involve deep as well as superficial tissues including bone; they evolve over time and may lead to irreversible damage to the surrounding tissues, leading to major functional impairment of limbs. AVFs, which can lead to high output cardiac failure, are easier to control than AVMs, treatment of which is usually not undertaken until significant symptoms or marked progression occurs. US and CT-scanning have led to a better understanding of these lesions and allowed a more aggressive therapeutic approach. Active treatment includes percutaneous sclerotherapy, and embolization often combined with some reconstructive surgery; occasionally amputation is necessary. Sclerotherapy is delivered percutaneously into the nidus of the malformation: ethanol is very effective, but can cause severe complications. Embolization involves the intraarterial injection of particulate agents into the feeding arteries producing an occluding thrombosis, but recanalization can occur. Liquid embolic agents, such as adhesive acrylic polymers, are also used as they reach the nidus itself where they polymerize instantly producing a strong exothermic reaction, which results in local necrosis. Adjuvant pharmacological agents have also been used. When the AVM is drained by a single vein, as in direct AVFs, this can be occluded by coils and a sclerosant. Over the past decade the need for amputation has been reduced.

B. CRIQUI presented another type of vascular malformation – a Maffuci syndrome which is a very rare “congenital non-hereditary mesodermal dysplasia associating soft tissue venous malformations and multiple enchondromas most commonly in the phalanges of the hands and feet”. The vascular lesions are slow-flow capillary and cavernous venous malformations presenting as bluish nodules on the limb extremities and, very rarely, in other sites. The enchondromas carry a 30% risk of malignant transformation to chondrosarcomas; there is also a higher risk of developing other malignant tumors. Treatment is recommended only if the patient is symptomatic or malignant change has occurred, but regular surveillance is mandatory.

Another, more common, form of vascular malformation is Klippel-Trenaunay syndrome (KTS), which was discussed by A. ALOMARI and by P. GLOVICSKI. KTS is clinically characterized by the combination of slow-flow vascular malformations (lymphatic, capillary, and venous) in a hypertrophied limb. Clinically, the capillary malformation presents as a nevus (port wine stain) situated on the lateral aspect of the limb; the venous malformation presents characteristically as a large varicose dilatation of a persistent embryonic “lateral marginal vein” (the vein of Servelle), which is tortuous and incompetent (involvement of the deep venous system is controversial, but many patients also have a persistent embryonic sciatic vein); the lymphatic malformation is manifest by the frequent presence of skin vesicles, lymphatic cysts in the deep tissues, and by lymphedema of the limb. These malformations can extend to the pelvis and the external genitalia. The limb hypertrophy is due to extrafascial fatty overgrowth and hypertrophy of the bone (occasionally, however, the affected limb is atrophic). KTS is a sporadic mesodermal abnormality due to genetic mutation characterized by an arrest in the development of veins, capillaries, and lymphatics, producing a low-flow vascular malformation. It should be distinguished from Parkes- Weber syndrome, which is a high-flow, high-shunt AVM of different management and prognosis. Treatment of KTS is essentially conservative: at the Mayo Clinic, during the period 1987-2007, 684 patients with KTS were seen, but only 49 (7%) were operated on. The incompetent superficial veins are treated on their merits either surgically or by conservative endovenous methods; some centers perform debulking operations. A multidisciplinary approach is often necessary and orthopedic procedures may be necessary to control limb overgrowth.