Servier – Phlebolymphology

Management of saphenous reflux in 2014

Comparative efficacy of different methods of treatment.
M. de Maeseneer

This was an excellent summary on the current situation with comparative efficacy of different methods of saphenous reflux treatment. While endovenous thermal ablation is recommended by several international guidelines as a first-choice treatment, no strong data exist supporting that those methods can get better results than surgery. Modern phlebectomy is as effective in terms of recurrence and quality of life as thermoablation.

In our daily practice: which technique for which patient?
C. Hamel-Desnos

Ultrasound-guided foam sclerotherapy might be the most used technique in France. It is preferably used by vascular practitioners, especially in cases of recurrent varicose veins, if the saphenous trunk is less than 5 mm in diameter, and if important obstructive sequalae of superficial vein thrombosis exists. Patients prefer sclerotherapy to other methods because it is faster, less aggressive, cheaper, and can be reimbursed.

Recent improvements in foam sclerotherapy techniques.
A. Cavezzi

The rationale for the use of tumescent anesthesia in foam sclerotherapy was discussed. If we treat large saphenous veins, we need higher doses of sclerosants; therefore, it results in higher risks of deep venous thrombosis or cerebral complications. Cavezzi and colleagues performed a small, nonrandomized, comparative study on three patient groups treated with tumescence, echo-guided tumescence, or no tumescence. The occlusion rate was significantly better with echo-guided tumescence at a median 14-month follow-up with no clinical recurrence in this group.

Randomized trial comparing thermoablation, foam sclerotherapy, and stripping in GSV varicose veins.
Outcome after 5 years.
L. Rasmussen, M. Lawaetz, The Danish Vein Centers.

One of the most known randomized controlled studies comparing different ways of saphenous ablation is by L. Rasmussen. He published one-year results in 2011. Now his team has 5-year results that confirmed previous data. No differences in recurrence rate, great saphenous vein reflux, needs in the new procedure, quality of life, and venous clinical severity scoring were found between laser, radiofrequency ablation, stripping, and ultrasound-guided foam sclerotherapy.

Sclerotherapy

Feasibility of a new system of standardized foam fabrication and comparison with Tessari’s method.
E. Roche, R. Pons, A. Puig, J. Puig

One problem of sclerosing treatment with foam is a great variability in the devices used, the exact ratio between the sclerosant and gas, temperature, etc. A new system of standardized foam fabrication was invented by E. Roche (Spain) and his team. The foam from this system is less heterogeneous than the classic Tessari’s foam, but it is >5 times more stable when using air and 2 times more stable when using a mixture of oxygen and carbon dioxide.

Vein wall penetration of detergent sclerosants: an in vitro study using immunohistochemistry.
C. T. D. Lee, M. S. Whiteley, J-M. Li

The authors investigated vein wall penetration by detergent sclerosants using immunohistochemistry in vitro. They found that endothelial cell damage is incomplete and to get an effective damage of the wall, penetration into the media may be needed. The greater damage was obtained with 10 min exposure of sodium tetradecyl sulfate. Using a shorter time or polidocanol led to lower reduction in damage.

Consequences of population aging in the management of varicose veins by sclerotherapy.
J. Gillet, C. Hamel Desnos, M. Lausecker, C. Daniel, J-J. Guex, F. Allaert

The presentation pointed out the problems coming from the aging populations because 176 out of 418 patients who were included were older than 75 years. Compared with younger patients, this subgroup was more often treated for “curative” rather than “symptomatic” or “cosmetic” indications. However, large veins were treated as often in the elderly as in the control group. Lower amounts of foam were injected in older patients. No complications or needs for special precautions were observed.

Thermal ablation

The European study of radiofrequency segmental thermal ablation (RSTA) of the great saphenous vein: five year follow-up.
T. M. Proebstle, O. Pichot

The authors presented the five-year results of the European study of radiofrequency segmental thermal ablation (RSTA) of the great saphenous vein on 295 limbs. An immediate success rate (occlusion of the GSV) was 99.7% at 3 days. A total of 91.9% of veins remained occluded after 5 years, but about one-third of the legs were with a Clinical, Etiologic, Anatomic, and Pathophysiologic classification (CEAP) of C2. This means a high frequency of recurrent varicose veins.

Compression therapy

Sport stockings using stiff material increases the ejection fraction of the calf pump.
H. Partsch, G. Mosti

The question of whether sport stockings using stiff material increases the ejection fraction of the calf pump was addressed. The authors used magnetic resonance imaging (MRI) for this purpose and found that conventional sport stockings do not increase calf pump function, but when wrapped with stiff bands, it expels more blood volume with exercise.

Compression treatment for superficial vein thrombosis. An RCT.
K. Boehler, H. Kittler, S. Stolkovich, S. Tzaneva

The objective of the study was to evaluate the treatment effect of compression stockings on the acute stage of superficial vein thrombosis (SVT) compared with no compression. A total of 73 patients with symptomatic SVT, with a thrombus extent of at least 5 cm, and with the upper level no closer than 2 cm to the saphenofemoral or saphenopopliteal junction were randomized. The primary outcome was pain. No differences were found at 3 weeks between wearing compression stockings or not. This finding contradicts the traditional view on compression as a key point of SVT treatment, but there are many limitations of the study (sample size, use of painkillers, and absence of compliance assessment with stockings) that are keeping the question open.

Compression therapy by stocking and epifascial veins.
D. Rastel

The pressure performed by elastic compression (with medical compression stockings [MCS]) in the lower limb follows a Laplace-type MCS (different due to curves) more than a fluid-type MCS. There are two different methodological approaches: (i) measuring the changes in epifascial and great saphenous veins, and its effect in curvature radius and area in 5 patients with a Clinical, Etiologic, Anatomic, and Pathophysiologic classification (CEAP) of C2 in 12 varicose leg areas with and without compression type 2 MCS; and (ii) using a numerical model of qualification of physical properties of leg components to make a simulation of biomechanical responses to varicose veins with elastic compression.

The conclusions were that, in the standing position, MCS does not reduce epifascial vein calibers significantly; MCS, even at a medium range pressure ≈20 mm Hg, decrease transmural pressure; external pressure is modulated by the fat tissue behavior; and skin inflammations following foam sclerotherapy are more frequently seen for epifascial veins than for saphenous veins. Therefore, they hypothesized that MCS, which increases perivenous pressure, could create a protective environment against local side effects of foam sclerotherapy.

Impact of compression stockings on the cutaneous microcirculation as assessed by skin thermal conductivity.
J. P. Gobin

The instantaneous local physiological effect of compression stockings on skin microcirculatory activity by an original device (Hematron) based on the thermal conductivity of tissues was studied. The thermal conductivity of tissues is a physiological variable, an indicator of metabolic and microcirculatory activity, and increases linearly with skin blood flow in the capillary network. The device is an ambulatory miniaturized system that measures the effective skin thermal conductivity in real time monitoring (wireless) and with local data storage in the memory card. In this study, they measured the calf in the supine position in 30 male patients with a medium age of 42 (age range, 25 to 55), 11 patients with Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) class of C0, and 19 patients with CEAP class of C1. Subjects were explored in the supine position with and without elastic compression stockings with a pressure of 13 mm Hg at the ankle. The data analysis was the calculation of the relative difference (%) between the value of skin thermal conductivity measured with and without stockings. They found significant improvements in skin microcirculatory activity with elastic compression (7.6% improvement, P<0.0001 and an 83% rate of earning of the investigated population).

In conclusion, the Hematron device is suitable to measure the evolution of microcirculatory activity under compression stockings and the use of compression stockings provides a benefit on the skin’s physiological properties with a significant improvement in skin perfusion. Further studies can explore the effects of medical compression stockings in other positions of daily life (sitting, standing, and walking) and the outcomes of other levels of compression (8, 10, 20, 30, and 40 mm Hg).

Enhancement of body balance. Another benefit of compression.
R. Lepers

Another benefit of medical compression stockings (MCS) to the usually accepted enhancement of venous return in subjects with chronic venous insufficiency–preventing occupational leg swelling at the end of the day–is the potential benefits for physical performance and recovery in athletes. The study was aimed to answer two questions: (i) do compression garments influence the balance during dynamic exercise such as jumping?; and (ii) do compression garments reduce muscle vibrations while running?

They studied 15 physically active male subjects using the Sigvaris Run sleeves Pulse Road. Balance ability was measured with a counter movement jump platform and they found that stability after landing improves with compression. They found no differences in reaction time, movement duration or duration for stabilization after landing, and it may be beneficial for injury management and injury prevention of lesions caused by jumping.

To measure calf vibrations, the calf movements were studied in three different points with accelerometers–one in the anterior tibial cell beside the anterior tibial crest and two in the posterior part of the calf. They studied the calf vibrations at slow and medium running speed, with and without compression (20 mm Hg). They found no improvement in the anterior tibial cell, but compression garments reduced tricep sural vibrations while running. It may reduce muscle damage during prolonged running exercises and provide faster recovery of neuromuscular function with lower limb compression.