Servier – Phlebolymphology

New insights into calf muscle pump function

Chairmen: P Carpentier (Grenoble, France), and A Nicolaides (Nicosia, Cyprus)

Pathophysiology of the calf muscle pump
A Nicolaides (Nicosia, Cyprus)

The important role of muscle contraction in the lower extremities is to support the venous return at three consecutive levels: foot, calf, and thigh. The function is dependent on the competency of venous valves and may be impaired because of reflux in the superficial venous system at various locations (great saphenous vein, small saphenous vein, perforating veins). A proportion of the expelled blood returns down, resulting in an increased ambulatory venous pressure.

The efficacy of the muscle pump can be assessed by measuring blood volume changes during walking. One of the useful methods is air-plethysmography, which measures reflux in mL per second. To evaluate the reflux, venographic studies with a contrast agent were used in the past while today a precise measurement of its presence is possible noninvasively with duplex ultrasound.

The degree of reflux in mL per second correlates with the grade of venous insufficiency, with swelling and ulcer development, respectively. The other underlying cause of impaired muscle pump function and venous insufficiency is venous obstruction. The function may be improved by several measures, eg, elastic compression, intermittent pneumatic compression or electrical stimulation of calf muscles.
A Nicolaides (Nicosia, Cyprus)

Functional imaging of the calf muscle pump
JF Uhl and C Gillot (Paris, France)

3D imaging tools (anatomical dissection after latex injection of venous network, CT venography, MRI) have been used to demonstrate the complex anatomy of the muscular veins of the lower extremities. These veins work as a component of the muscle venous pump. Venous return from the lower extremities is performed by contraction of the muscles, propelling the blood in the veins from the foot to the thigh. The system includes: lateral plantar veins in the foot pump; soleus muscle (the lateral part being more important than medial) with its veins; popliteal pump consisting of gastrocnemial muscles (the medial being more important) and the respective veins; thigh pump represented by semimembranosus muscle with the venous arcades inside it. The most important component is the gastrocnemius pump. The four parts of this system unit produce a synchronous chain of events, thus working as a functional unit.

Electrical stimulation of the calf muscle pump
A Jawien (Bydgoszcz, Poland)

Failure of the muscle venous pump may have severe consequences, resulting even in skin damage. The possible causes of impaired function are valvular incompetence, perforator incompetence, deep vein thrombosis, and also paralysis and lack of mobility. Possibilities to improve the function of a muscle pump include compression, exercise, and electrical stimulation of the muscles. Ankle joint mobility is inversely related to the clinical stage of chronic venous insufficiency. Several publications have provided evidence of a role of structured exercise in improving ankle mobility, resulting in positive changes in the functional parameters of the muscle pump (increased ejection fraction and decreased residual volume fraction). An electrical stimulator of calf muscles is an option for activation of the physiological pump, leading to reduction of stasis and to significant improvement of venous return. The device can be used in twenty-minute sessions and may be of special interest in patients with reduced mobility or during long periods of sitting or standing (working, traveling, etc.). The search for efficacy and possible indications is ongoing.

Clinical microcirculation

Chairmen: M Vayssairat (Paris, France), P Carpentier (Grenoble, France)
Experts: C Allegra (Rome, Italy), AT Guillaumon (Brazil), J C Wautrecht (Brussels, Belgium)

This session was based on the interactivity between the audience and an international panel of experts, discussing decision making about 5 clinical cases with the help of script concordance tests and PowerVote.

Case report 1: A 30-year-old male from a small mountain village consulted his family doctor for itching, almost burning pain of the first left toe, which he discovered when waking up. He had a history of Raynaud’s phenomenon of mild intensity and both feet were involved with erythema, papula, and blistering of the left second toe. Chilblains were diagnosed. The diagnostic workup and the differential diagnoses were discussed. The need for Doppler investigation and positive antinuclear antibody determination was emphasized in order to differentiate from other vascular or systemic disorders (lupus). Chilblain lesions mainly involve the foot (87.6%) and blistering is present in 17.7% of the cases according to a former study.

Case report 2: A 27-year-old woman sought medical advice because of highly itching small papular lesions of both hands, which had bothered her a lot for the two last winters in spite of several local treatments she had tried. She had Raynaud’s attacks and a history of chronic urticaria accompanied by some arthralgia and swelling of the fingers. The diagnosis was chilblain lupus. In this clinical entity the elementary lesions are clinically quite similar to primary chilblains. It is classically associated with discoid lupus, but association with systemic lupus erythematosus can also be found. When associated with systemic lupus, chilblains are almost never inaugural; associated lupus manifestations are mostly cutaneous and rheumatic. Positive antinuclear antibody determination and skin biopsy (lupus band) help the diagnosis. The blue phase of Raynaud’s phenomenon is often secondary. There was intense discussion about when and how to treat this kind of patient. According to some experts, antimalarial drugs could be beneficial, but systemic treatment is not always needed, argued others.

Case report 3: A 48-year-old theater actress, nulliparous with no significant medical history, consulted her doctor because of toe pain that hampered her performances in winter. She described her pain as throbbing and worsened by a warm environment. She had scars on her right toe and permanent livedo reticularis not only on the legs but in the shape of irregular broken circles on the trunk also (called livedo racemosa). Her diagnosis was antiphospholipid syndrome. The 2006 Sydney criteria of diagnosis were discussed.

Case report 4: A 59-year-old butcher with a history of sarcoidosis was referred by his attending physician for a diffuse form of disabling chilblain-like lesions of the hands that worsened gradually for several years. This year the summer remission was restricted to July and August (patient’s vacation period) and in September he already had swollen and itching fingers, with a slight improvement every weekend, which made him think it was due to working in his cold room. His final diagnosis was occupational protein contact dermatitis. This was first described by Hjorth ad Roed-Petersen in 1976. It is a chronic and recurrent dermatitis caused by contact with proteinaceous material first observed in sandwich makers. Hand erythema, scaling and fissures with immediate urticaria after protein exposure can be observed. It is mainly induced by food proteins (meat, fish, milk, eggs), but also some flowers. The mechanism is unknown. The diagnosis is based on immediate reading skin tests.

Case report 5: The last case presented was that of a 21-year-old who had sold fish in a fish market for 18 months, and who was worrying about having to stop this job. Mornings at the market had become unbearable because of pain in the hands, the appearance of which, in addition, was off-putting for customers. He had tried wearing rubber gloves, but this did not avoid the occurrence of new deep cracks, which, on several occasions, became secondarily infected. His diagnosis was an analogue of “trench foot” called “immersion hand”. Trench foot or immersion foot was first described in the First World War, and appears as painful cyanotic edema with frequent complications (cellulitis, gangrene, nerve lesions) after prolonged exposure of a previously healthy foot to cold humidity >0 C (water, mud and so on) because of altered thermoregulation of the skin. It is not the same as frostbite. Its civilian forms are seen in homeless people. The above mentioned patient recovered completely after changing his job.

At the end of this very useful interactive session participants gained a broader understanding of the needs of patients seeking medical help for vascular acrosyndromes.

Venous thromboembolic diseases: evolving concepts and practices

Chairmen: I Quéré (Montpellier, France), A Comerota (Michigan, USA)

Medical significance of asymptomatic venous and pulmonary embolism
G Pernod (Grenoble, France)

Pulmonary embolism (PE) is a common disorder with an estimated annual incidence of approximately 300 000 cases in Europe and a mortality estimated to vary from 7% to 11%. The speaker reported that there have been an increasing number of diagnoses of incidental, asymptomatic PE detected in patients undergoing chest computer tomography for reasons other than studies on suspected PE. However, information on the prevalence and natural history of unsuspected silent PE is extremely limited. Furthermore, the optimal therapeutic strategies when asymptomatic PE is incidentally diagnosed are uncertain, but it is currently recommended to prescribe the same initial and long-term anticoagulation as for comparable patients with symptomatic PE.

New anticoagulants: their impact in the management of venous thromboembolic disease
E Kalodiki (London, UK)

The development of orally bioavailable anticoagulant drugs (anti-Xa and IIa agents), which are alternatives to oral anticoagulants, was reviewed. Both antifactor Xa (rivaroxiban and apixiban) and antithrombin (dabigatran) agents have been developed for oral use and have resulted in impressive clinical outcomes in randomized controlled trials for the postoperative prophylaxis of venous thrombosis. However, safety concerns related to liver enzyme elevations have been reported. The speaker considered that these newer parenteral and oral antithrombin and anti-Xa agents may be useful in the short- and long-term management of heparin-compromised patients, in particular those who develop thrombocytopenia. However, because of their lower molecular weight, they may pass through the placenta and also through the blood-brain barrier and cannot be used in pregnant women and patients with central nervous system disorders. The relative therapeutic value of the newer anticoagulants will remain unknown until additional clinical data become available. The generic versions of heparin and low-molecular-weight heparin along with other anticoagulants will become available, but their safety and efficacy have to be closely monitored and confirmed. The speaker concluded that heparins, warfarin, and aspirin will continue to play a major role in the management of thrombosis and related vascular disorders beyond 2010.

Superficial thrombophlebitis, a significant subset of venous thromboembolic disease
I Quéré (Montpellier, France)

Superficial venous thrombosis is very frequent according to the recent important advances in the epidemiological field. In the large prospective multicenter observational POST (Prospective Observational Superficial Thrombophlebitis) French study, one out of four patients with superficial venous thrombosis had concurrent deep venous thromboembolism (DVT, PE) and 10% of patients with isolated superficial venous thrombosis, ie, without concurrent deep venous thromboembolism at presentation, experienced a venous thromboembolism complication at three months.

The concept of early thrombus removal for iliofemoral deep venous thrombosis
A Comerota (Michigan, USA)

Patients with iliofemoral deep vein thrombosis have increased postthrombotic morbidity and suffer significantly higher recurrence rates than patients with infrainguinal deep vein thrombosis. Studies of the natural history of iliofemoral deep vein thrombosis treated with anticoagulation alone reveal that the overwhelming majority of patients have a poor quality of life, 15% will develop ulceration within 5 years, and at least 40% will have venous claudication. Randomized trials of venous thrombectomy versus anticoagulation alone have demonstrated that patients receiving thrombectomy have significantly better outcomes at 6 months, 5 years, and 10 years. It has recently been observed that the amount of thrombus removed is directly proportional to improved quality of life and reduced postthrombotic morbidity. The speaker concluded that based upon available data, a strategy of thrombus removal for patients with iliofemoral deep vein thrombosis appears superior to anticoagulation alone and should be recommended to all who are active and ambulatory.

Free communications on venous thromboembolic diseases

Comparison of the clinical history of symptomatic isolated muscular calf vein thrombosis versus deep calf vein thrombosis
J Galanaud, MA Sevestre, C Geny, J P Laroche, V Zyzka, I Quéré, J L Bosson (Montpellier, Amiens, Grenoble, Fort de France, France)

Distal deep vein thrombosis (DVT) represents about 50% of DVT in the legs and can occur in the calf axial deep veins or in muscular veins. Though the reported incidence of proximal extension is higher in the case of deep calf venous thrombosis (DCVT), the guidelines for the treatment of DCVT and muscular calf vein thrombosis (MCVT) do not differ.

OPTIMEV is a French national, multicenter, prospective, observational study of patients with venous thromboembolism. The data from this study were used to compare risk factors, clinical presentation, and outcome in 268 patients with symptomatic isolated DCVT and 457 with symptomatic isolated MCVT. DCVT manifested more often with swelling and MCVT with localized pain; otherwise there were no significant differences in clinical presentation, or in the risk factors. Of both groups, 222 patients with DCVT and 390 with MCVT were followed up for 3 months. Only 3% in both groups were not anticoagulated. The duration of treatment of DCVT was slightly longer. Venous thromboembolism recurrence was comparable in the two groups (1.4% in DCVT and 1.5% in MCVT). There were 29 cases of bilateral MCVT and this subgroup had a very high mortality (17.4%).

MCVT and DCVT differ in clinical presentation but have the same clinical profile and comparable outcome. However, the prognosis of bilateral MCVT seems to be poor.

Bleeding complications in patients with cancer receiving anticoagulant therapy for venous thromboembolism. Findings from the RIETE registry
A Visona, P Di Micco, JA Nieto, J Truijllo Santos, R Quintavalla, P Prandoni, M Monreal (Castelfranco Veneto, Naples, Parma, Padova, Italy – Cuenca, Cartagena, Badalona, Spain)

RIETE is an ongoing, multicenter, international registry of consecutive patients with acute venous thromboembolism.

Cancer is a known risk factor for venous thromboembolism and its recurrence, as well as for anticoagulation-related major bleeding. Moreover, cancer patients have a higher risk of fatal pulmonary embolism and of fatal bleeding. The reported risk factors of fatal bleeding are weight, recent bleeding, renal insufficiency, immobility, metastatic cancer.

Data from the RIETE registry were used to define the risk factors of major bleeding in deep venous thrombosis patients with active cancer during the first 3 months of anticoagulant therapy. Of 4709 patients, 200 (4.4%) developed major bleeding (fatal in 36% of them). The most common characteristics of the patients with major bleeding were anemia, immobility for more than 4 days, metastatic cancer, and the most common locations were gastrointestinal, genitourinary tract, or the brain. The risk of bleeding persisted throughout the 3 months of follow-up.

Fatal bleeding in patients receiving anticoagulant therapy for venous thromboembolism. Findings from the RIETE registry
A Visona, P Di Micco, A Niglio, M Amitrano, M Cimmaichella, P Prandoni, M Monreal, JA Nieto (Castelfranco Veneto, Naples, Avellino, Rome, Padova, Italy – Cuenca, Badalona, Spain)

Data from RIETE were used to assess the incidence of fatal bleeding in venous thromboembolism patients during the first three months of anticoagulant therapy and to identify the risk factors associated with fatal bleeding. Of 24 395 patients, 135 (0.55%) developed fatal bleeding. The independent risk factors for fatal bleeding were age above 75 years, recent major bleeding, metastatic cancer, immobility for more than 4 days, platelet count below 100×109/L, abnormal prothrombin time. In contrast, distal deep venous thrombosis location was a protective factor.

A clinical prediction model was derived from these parameters, stratifying the risk of fatal bleeding.

Venous thromboembolism in the elderly: epidemiological data overview based on the prospective OPTIMEV cohort
G Pernod, MA Sevestre, C Genty, J Labarere, P Couturier, JL Bosson (Grenoble, Amiens, France)

It is well known that age is one of the strongest risk factors of venous thromboembolism (VTE). OPTIMEV is a French national, multicenter, prospective, observational study of VTE patients. The data from OPTIMEV were used to evaluate clinical characteristics of VTE patients older than 75 years. The diagnosis was confirmed in 655 of 2149 subjects with suspected VTE.

Proximal deep venous thrombosis with or without pulmonary embolism was found in 69%; distal in 31%. Compared with a control group, without VTE and aged less than 75 years, the following risk factors were found: bed rest, acute cancer, history of previous VTE, cardiac or respiratory failure and travel.

Logistic regression was used to test the possible interaction between age and risk factors. The results revealed that male gender, recent surgery, and lower limb immobilization were significantly more associated with VTE in younger patients (less than 75 years old).

It seems that there are few VTE risk factors specific to older patients.

Thrombosis of atypical location, Mayo series: profile of local causes in organ vein thrombosis
W Wysokinski, R McBane (Rochester, USA)

Atypical locations of venous thrombosis include retinal veins, cerebral venous sinuses, renal, ovarian and splanchnic veins (portal, superior mesenteric, inferior mesenteric, hepatic). These cases are usually considered as a result of a general prothrombotic state. However, local causes may also be important risk factors.

In the Rochester Epidemiologic Project, the following numbers of patients with atypical venous thromboses were included – 154 patients with thrombosis in cerebral, 218 in renal, 35 in ovarian, 329 in portal, 76 in mesenteric, 62 in splenic, and 45 in hepatic veins.

In cerebral vein thrombosis, the identified risk factors were female gender, pregnancy, estrogen therapy, brain cancer, and neurosurgery. Renal vein thrombosis occurred more often on the left side, in men, in patients with cancer (especially renal cancer) and with nephrotic syndrome. Ovarian vein thromboses were distributed equally bilaterally, the patients were young or middle-aged and the risk factors were cancer (predominantly pelvic cancer), infection (mainly ovarian), estrogen therapy and surgery (mainly pelvic). In splanchnic veins, the associated factors were hepatobiliary or gastrointestinal cancer, cirrhosis, inflammatory bowel disease, pancreatitis, myeloproliferative disease, surgery (especially abdominal), and infection (mainly abdominal).

Taken together, with the exception of cerebral sinus thromboses, most of the atypical venous thromboses were associated with local causes.

Evaluation of a pneumatic device to prevent venous disorders in air travel

F Fernandez, I Chirosa, M Martinez, JJ Sanchez-Cruz, E Ros (Granada, Spain)

Limited mobility and resulting venous stasis in the legs is one of the risk factors of travel-related venous thromboembolism. A special pneumatic device was developed to improve venous stasis by device-mediated exercise. In a randomized controlled trial, the efficacy of this device was evaluated in 60 healthy volunteers, in conditions simulating air travel (hypoxia-hypobaric altitude at 2400 meters, space and condition similar to those of a commercial flight). The anthropometric parameters were obtained, ultrasound of the leg and venous occlusion plethysmography were performed, and a quality of life questionnaire was administered before and after exposure and with and without induced exercise. Significant differences were found in the following parameters: decreased edema (decrease in dermis-fascial distance, measured by ultrasound) and improved venous return (outflow and capacitance, measured by plethysmography). Exercise simulation by pneumatic compression may be useful in prevention of venous stasis during long-haul flights.

Venous thromboembolic diseases –Thrombophilia

Chairmen: G Pernod (Grenoble, France), P Nguyen (Reims, France)

Experts: A Visona (Padova, Italy), ME Reno de Castro Santos (Brazil), M Sprynger (Belgium)

An interactive session with case report presentations and discussions with the expert

Case report 1: A 17-year-old girl was hospitalized with deep vein thrombosis on the left side (ileofemoral with vena cava inclusion) and bilateral pulmonary embolism. The only identified risk factor was the use of contraceptive pills. Therapy with lowmolecular- weight heparin was started but, later on, a neural deficit developed. Catheter-directed thrombolysis was performed. The next day, a recurrence of the thrombosis occurred. After inferior vena cava filter implantation, catheter-directed thrombolysis was continued, with thrombus aspiration and subsequent balloon angioplasty and stenting of iliac vein (because of stenosis of the iliac vein, evaluated as May-Thurner syndrome).

Later on, the girl developed fever and shock. CT scan revealed a changed position of the inferior vena cava filter – the head of the filter was in the renal vein, one branch in the vertebra and one branch in the duodenum, thus causing septicemia with digestive bacteria.

The filter was removed; the anticoagulation therapy (low-molecular-weight heparin with transition to warfarin) was restarted. One year later, the patient was in a good condition, without any sequelae. Despite complete thrombophilia screening, no hypercoagulable state was found. The cause of the venous thromboembolic event was probably the combination of contraception pills and local conditions (May-Thurner syndrome).

Case report 2: A 35-year-old man presented in 2001 with distal deep venous thrombosis. He reported a history of bone marrow transplantation at the age of 19 (because of acute leukemia; his brother was a donor). He was treated with anticoagulants for 3 months. Shortly after treatment discontinuation he developed superficial thrombophlebitis in the great saphenous vein (the vein was not varicose).

Because of these two episodes (not very serious but unprovoked) and because of a family history of venous thromboembolism, thrombophilia screening was performed. Resistance to activated protein C was confirmed. However, factor V Leiden was negative.

An unusual explanation was found. In fact, the patient was a carrier of factor V Leiden but the cells tested in genetic assays were his blood cells. Blood cells are produced by the bone marrow. He underwent bone marrow transplantation many years ago and the donor – his brother- was factor V Leiden negative. Thus, the patient was an example of a genetic chimera.

Case report 3: A young patient (25 years old) suffering from abdominal pain for 2 weeks was diagnosed with splanchnic vein thrombosis (upper mesenteric, portal, pancreaticoduadenal vein). Treatment with unfractionated heparin was started, and later switched to low-molecular-weight heparin and warfarin.

Though the guidelines are not consistent regarding the recommendation for thrombophilia screening in cases of abdominal vein thrombosis, in this patient testing was done because of the absence of any local factor. However, no thrombophilia was revealed, only a slight decrease of antithrombin. The basal level was normal, indicating aacquired antithrombin deficiency.

More detailed testing was performed, taking into consideration the other possible underlying causes – paroxysmal nocturnal hematuria and myeloproliferative disease (in spite of a normal blood count and differential count). The patient tested positive for JAK-2 kinase mutation (V617F mutation, respectively). This mutation is associated with myeloproliferation and therefore the patient should be followed up by a hematologist because of the possibility of developing myeloproliferative disease.

Abdominal aortic aneurysm: an update

Chairmen: P Gloviczki (Rochester, USA), A Jawien (Bydgoszcz, Poland)

Pathogenesis of the abdominal aortic aneurysm
E Allaire (Créteil, France)

Abdominal aortic aneurysms form and rupture because of the destruction of aortic extracellular matrix digested by an excess of proteinases and some of these proteinases are activated by the plasmin pathway. Inflammatory cells infiltrating the aortic wall are important sources of proteinases, and other cells like endothelial or vascular smooth muscle cells can be other putative sources. The speaker explained that an important observation is the disappearance of vascular smooth muscle cells in the media layer of abdominal aortic aneurysms, which may impair adequate wall repair. He also emphasized that vascular smooth muscle cells produce TGF-beta1 and inhibitors of proteinases, thereby protecting the aortic wall against inflammation and proteolysis. Consequently, lack of vascular smooth muscle cells may turn the aortic wall into a structure vulnerable to inflammationdriven proteolysis. Another striking feature is that patients with abdominal aortic aneurysms associated with atherosclerosis have generalized “atrophy” of vessels distant to the main lesion, and that other tissues of these patients heal poorly. Recent data from his own laboratory suggest that mechanisms of healing of tissues under strain are altered in these patients and this observation may help identify new molecular and genetic factors linked to this deadly aortic disease.

Screening for abdominal aortic aneurysm
J S Lindholt (Viborg, Denmark)

Abdominal aortic aneurysm includes an asymptomatic phase with a relatively low-risk treatment, compared with the symptomatic phase, which is a good argument to consider screening. Ultrasonographic screening is a valid, suitable, and acceptable method of screening as sensitivity and specificity are estimated to be 98% and 99%, respectively, fulfilling the criteria formulated by the Council of Europe. The speaker emphasized that the benefits of screening must outweigh the costs and all four existing randomized trials reported benefit of screening of men aged 65 and above. The pooled mid-term and long-term relative risk reduction is both around 50% with 2% reduction in overall mortality. Cost effectiveness has proven attractive in the large MASS trial, and recently the Viborg Study reported after 14 years that the number needed to screen to save one life was just 135 and the frequency of emergency operations due to rupture was significantly reduced by 56%. The speaker concluded that the cost per life year gained has been calculated as 157€ and the cost per QALY as 178€ based upon all-cause mortality. This is less than 1/10 of the cost in well-known implemented cancer programs.

The long-term results of the EVAR-1 trial
JT Powell (London, UK)

The 3 published randomized trials (EVAR-1, DREAM and OVER) comparing elective endovascular versus open repair for abdominal aortic aneurysms have been remarkably consistent in showing a 3-fold 30-day operative survival benefit of endovascular aneurysm repair (EVAR). The EVAR 1 trial randomized patients with large aneurysms (at least 5.5 cm in diameter, anatomically suitable for EVAR) to either endovascular repair or open repair and after 8 years of follow-up EVAR was not associated with a long-term survival benefit. In fact, 54% remained alive, but exactly the same proportion in those randomized to EVAR as in those randomized to open repair. According to the speaker, the reporting of new endograft-related complications was highest within the first 6 months of aneurysm repair (22.9 new complications per 100 patient years of follow-up), reducing to 3.4 new complications per 100 patient years of follow-up between 6 months and 4 years, with weak evidence that rates might start to increase again after 4 years. There is evidence that EVAR might not be as durable as open repair because there were 25 secondary ruptures after EVAR, the majority (72%) of which proved to be fatal. In contrast, there were no secondary ruptures reported after open repair. The speaker concluded that these endograft ruptures appear to explain the erosion of the statistically significant 3% aneurysm-related survival benefit for EVAR versus open repair, observed during the first 4 years of follow-up, and these longterm results question the durability of EVAR.

Medical approach to the patient with an abdominal aortic aneurysm
F Becker (Geneva, Switzerland)

Rupture of an abdominal aortic aneurysm (AAA) is not the main cause of patient death and may even be the least important. Operative mortality in scheduled surgery for AAA is largely due to pre-existing co-morbidities. Even if we have no evidence-based drug to slow the progression of AAA, actions against some reducible factors (like smoking and sedentary lifestyle) are likely to slow the AAA progression rate. Faced with a patient who has just been found to have an AAA <50 mm, we must monitor not only the progression of AAA by scheduled ultrasound examinations, but also cardiovascular risk factors and comorbidities able to increase surgical risk. The speaker concluded that smoking cessation, improvement of respiratory function, regular exercise, and pharmacological treatment of cardiovascular risk factors are probably as important as repeated ultrasound scans.

Carotid stenosis: evolving concepts and practices

Chairmen: E Bastounis (Athens, Greece), F Becker (Geneva, Switzerland)

Surgical treatment of carotid stenosis: new information from recent trials and what is required for future studies
J Fernandes e Fernandes (Lisbon, Portugal)

Carotid endarterectomy (CEA) has been shown to reduce stroke risk in stenosis >70% for symptomatic and asymptomatic patients (ECST; NASCET, ACAS and ACST) and became the established procedure for the treatment of severe carotid bifurcation disease, because there was less combined mortality and neurological morbidity than with the best medical treatment. The speaker showed that recently published randomized clinical trials (EVA-3S, SPACE, ICSS and CREST) comparing CEA and carotid angioplasty and stenting (CAS) in symptomatic >70% stenosis have provided evidence that CAS is associated with higher incidence of ipsilateral stroke, and increased incidence of silent brain infarcts as assessed by DW NMR (ICSS), and concluded that CEA should continue as the procedure of choice for symptomatic patients. The speaker considered that asymptomatic carotid stenosis is a relatively benign disease with a stroke risk of 3%/year as suggested in natural history studies and is a marker of cardiovascular disease. He emphasized that increased stroke risk in asymptomatic stenosis must be associated with plaque vulnerability as assessed by its echogenicity, plaque structure analysis, and evidence of progressing stenosis on repeated duplex examinations. He also reported that noninvasive evaluation of plaque activity provided by the Activity Index identifies asymptomatic stenosis with higher risk of developing neurological events, thus improving selection of patients who will benefit from carotid interventions to prevent stroke. He concluded that a study in asymptomatic patients at high risk of stroke is required to compare interventional procedures (CEA and CAS) with a subgroup of patients receiving the best well-established contemporary medical treatment.

Carotid stenosis: place of carotid stenting
J L Mas (Paris, France)

Randomized clinical trials in patients with symptomatic carotid disease show inferior results of carotid angioplasty and stenting (CAS) compared with carotid endarterectomy (CEA) with regard to the risk of stroke or death within 30 days of treatment. These two methods of treatment seem to have similar efficacy at preventing medium-/long-term ipsilateral stroke after the perioperative period, but with wide confidence intervals, despite a higher incidence of restenosis in patients treated with stenting. The speaker considered that to improve the riskbenefit profile of stenting, it is crucial to establish which factors among patient characteristics (age, gender, anatomical features) and the procedure itself (material, cerebral protection, operator experience) are associated with a high risk of stroke after CAS. A recent meta-analysis showed a striking age-related difference, with equivalent risks of stroke or death after stenting and surgery below the age of 70 and a two-fold increase in risk of stenting over endarterectomy above this age.

The speaker pointed out that randomized clinical trials in patients with asymptomatic stenosis have shown that the absolute benefit of endarterectomy versus medical treatment alone is small, especially in women. In addition, there is growing evidence that the risk of ipsilateral stroke without surgery has been decreased to <1% per year, thanks to more effective medical therapy. If CAS is associated with an excess procedural risk of stroke (as it probably is), this excess risk will probably erode or nullify the small benefit of revascularization versus medical treatment alone. The speaker concluded that in asymptomatic patients the right question may be whether CEA/CAS further reduces stroke risk in patients who receive best medical therapy and, if revascularization is deemed necessary, whether CEA is a safer option and CAS can be an alternative only if there is a contraindication to CEA.

Stroke and thrombolytic therapy: an update
V Larrue (Toulouse, France)

Fifteen years after demonstration of its efficacy, intravenous thrombolytic therapy with alteplase remains the only validated treatment of acute ischemic stroke. According to the author, the efficacy of treatment is strongly time-dependent: better results have been demonstrated up to 4.5 h after stroke onset and efficacy rapidly decreases after this. He showed that the safety of intravenous thrombolysis for stroke in clinical practice has been confirmed by large phase IV studies, but that implementation of this treatment is still a challenge in many hospitals because it requires expertise in both clinical neurology and brain imaging interpretation. In addition, the efficacy of intravenous thrombolysis remains uncertain in important subgroups such as patients over 80 years and intravenous thrombolysis with alteplase is poorly effective in patients with large vessel occlusion. He concluded by saying that additional or alternative therapies are currently being evaluated in these patients, including thrombolysis acceleration with transcranial ultrasound, intra-arterial administration of fibrinolytics, and embolectomy with mechanical devices.

Asymptomatic carotid stenosis and risk stratification
A Nicolaides (Nicosia, Cyprus)

Best evidence indicates that the annual risk of ipsilateral cerebral stroke in patients with moderate-severe asymptomatic internal carotid stenosis (ACS) receiving optimal medical intervention alone has fallen to approximately 1% per year, making routine carotid endarterectomy unjustified. However, while patient subgroups with sufficiently higher average risk, despite current optimal medical intervention, can be reliably identified, then carotid surgery may still be justified. The ACSRS study performed under the auspices of the IUA was a prospective, multicenter, cohort study of patients undergoing medical intervention for vascular disease, and has answered this question. Severity of stenosis, history of contralateral TIAs or stroke, GSM, plaque area and presence of discrete white areas without acoustic shadowing (DWA) were independent predictors of ipsilateral stroke. The speaker concluded that modern medical intervention is highly effective and that cerebrovascular risk stratification is possible using a combination of clinical and ultrasonic plaque features, but we need further studies to validate these results in patients receiving current optimal medical therapy.

Early detection of the high vascular risk subjects

Chairmen: J Belch (Dundee, UK), S Novo (Palermo, Italy)

Screening for peripheral arterial diseases in the general population
V Aboyans (Limoges, France)

The usefulness of screening for a disease in the general population depends on three conditions: a poor prognosis and consistent prevalence of the disease; availability of an efficient screening test; and the chance to improve the prognosis with management. Peripheral artery disease has a pooor prognosis and its prevalence increases consistently with age; it can be easily detected by anklebrachial index (ABI) measurements. This technique was first published 40 years ago, is easily accessible, relatively easy and cheap, but still underused in practice. The abnormal ABI values (ie, outside the range 1.1-1.4) correlate well with cardiovascular mortality and add value to the traditional cardiovascular risk factors. However, some unresolved issues remain, such as insufficient standardization of ABI measurement and lack of evidence concerning the benefit of the management of asymptomatic subjects with abnormal ABI.

Role of asymptomatic carotid lesions and inflammation in predicting future cardiovascular events
S Novo (Palermo, Italy)

Screening asymptomatic subjects for subclinical atherosclerosis provides an opportunity to improve the prevention of cardiovascular diseases. Abnormal ultrasound findings in the carotid arteries (increased intima-media thickness, ie, above 0.9 mm, with or without an atherosclerotic plaque) are some of the indicators of asymptomatic atherosclerosis. Some laboratory tests can be used in cardiovascular risk assessment. Inflammatory markers especially are correlated with increased cardiovascular risk (circulating TGF-beta, soluble sCD40L, IL-6, fibrinogen, highsensitivity CRP). Markers of subclinical organ damage can further improve the risk evaluation. There is a possible interaction between various risk factors. Using a combination of factors improves risk prediction. Some subjects considered to be at low risk may subsequently be reclassified to a higher risk category.

Early markers of hypertension: many are of vascular origin
DL Clément (Ghent, Belgium)

According to the recent guidelines, patients with arterial hypertension should be evaluated for total cardiovascular risk. Various tests and techniques may be used (ECG, echocardiography, intima-media thickness, carotid-femoral pulse wave velocity, creatinine or glomerular filtration rate, ankle-brachial index, microalbuminuria, and fundoscopy). The usefulness of these tests in daily practice differs because of variable accessibility, financial cost, and predictive value for cardiovascular events. Microalbuminuria is easily performed, cheap, and correlates very well with cardiovascular risk, but is still underused by clinicians. Abnormal ankle-brachial index also has a high prognostic value (below as well as above normal range) and is very easy to determine. Intima-media thickness of carotid arteries, measured by ultrasound, correlates very well with total cardiovascular risk. Fundoscopy has a moderate prognostic value, but nowadays it can be digitized and provide quantifiable information.

These relatively easy and not too expensive tests may detect the signs of subclinical organ damage and thus enable earlier prevention.

Atherosclerosis and venous thrombosis: the same disease entity with two different faces
P Poredos (Ljubljana, Slovenia)

Arterial and venous thromboses have long been considered as different entities, but they have common features revealed by some recent findings (etiology, autopsy findings, risk factors, clinical manifestations). A new study was presented, focusing on the preclinical markers of atherosclerosis in 49 patients with idiopathic deep venous thrombosis. The patients, as well as 48 age- and sex-matched controls, underwent ultrasound of carotid and femoral arteries and endothelial dysfunction testing (flow-mediated dilation, nitroglycerin-mediated dilation in the brachial artery and laboratory assays – von Willebrand factor, P-selectin, VCAM-1, TNFalpha). In the patient group, there was significantly increased intima-media thickness, number of atheroslerotic plaques, total plaque thickness, impaired endothelium-dependent and independent dilating capacity and increased levels of laboratory markers of endothelial dysfunction.

Arterial and venous thromboses are probably closely interrelated, having an important common pathogenetic mechanism – chronic inflammation.

Physical exercise and vascular medicine

Chairmen: PL Antignani (Rome, Italy), GM Andreozzi (Padova, Italy), P Abraham (Angers, France)

Effects of physical exercise on the cardiovascular system
P Abraham (Angers, France)

A normal vascular function is essential for exercise. The energy substrate ATP required for the biochemical processes leading to movement, as well as the oxygen used to oxidize this substrate, are both provided to the exercising muscle by blood. Muscle blood flow must increase with exercise to fit the oxygen and metabolic requirements of the active muscle. As a result, the increase in workload is linearly associated with an increase in blood flow to the exercising muscles. As is well known, cardiac output increases to fit the increase in muscle blood flow and a redistribution of the total flow to the different vascular beds (splanchnic, renal, cutaneous, etc.) also occurs during exercise. The fraction of the cardiac output distributed to each vascular bed is variable and depends on the intensity and duration of exercise, environmental conditions and training status. Among the physiological mechanisms involved in blood flow regulation in peripheral vessels during exercise there are local (mechanical, neurogenic, NO, adenosine, myogenic, etc.) regional (flow-mediated vasodilatation, retrograde vasodilatation) and systemic (posture/baroreflex, renin-angiotensin-aldosterone system, chemoreceptors, epinephrine, thermoregulation, splanchnic sympathetic activity, etc.) factors also. The underlying mechanism of short-term and long-term vascular changes induced by exercise are still subject to debate.

Could the balance or imbalance of atherosclerosis risk factors compromise the results of physical training in claudicants?
G M Andreozzi (Padova, Italy)

The goals of conservative treatment in intermittent claudication are prevention of fatal and nonfatal cardiovascular events, prevention of disease progression, and improvement of walking ability. These goals can be achieved by interventional/surgical procedures, physical training, and drugs. The correction of atherosclerotic risk factors is essential to maximize the effectiveness and duration of the results of any pharmacological and surgical intervention. There is clear evidence that supervised physical training can improve walking ability and quality of life in claudicants.

The speaker presented a study whose aim was to verify if the presence/absence of risk factors and the degree of their correction could compromise the responsiveness of claudicant patients to supervised physical training. Initial (ICD), absolute (ACD) claudication distance, and recovery time (RT) were measured by maximal treadmill exercise (speed 3.2 km/h, slope 12-15%) in 74 claudicants, according to a published protocol (Int Angiol 2008). These measurements were repeated after 18 days of supervised physical training (3 days/week for 6 weeks) consisting of a daily walking with a distance target of 1-2 km or a time target of at least 30 min (exercise-rest-exercise pattern). The working load of each single training session was tailored to 60-70% of the ACD measured by a sub-maximal treadmill exercise (speed 1.5 km/h, slope 6±2%) according to the same protocol. At day 10 a new assessment of walking ability was performed. Before entering the study the patients had undergone clinical and duplex arterial examination and cardiac evaluation. The risks/benefits of alternative therapeutic options (pharmacologic, percutaneous and surgical intervention) were also discussed. The patient cohort was stratified in seven groups and eighteen subgroups according to their atherosclerotic risk factors and concomitant cardiovascular diseases (age, BMI, smoking, diabetes, hypercholesterolemia, arterial hypertension, endothelial dysfunction, previous myocardial infarction and TIA or stroke). Half of the population of this study showed inadequate control of the risk factors, which is not an occasional feature and is attributable to the low adherence to guideline recommendations in clinical practice. At the same time the results confirmed the effectiveness of supervised physical training in increasing the walking capacity of claudicants. Moreover, there weren’t any significant differences between the groups, indicating that risk factors did not influence the result of physical training. This is a very important statement, because it highlights that physical training is the only therapeutic tool which is independent of the results of risk factor treatment. Therefore, GPs and vascular specialists should propose physical training in claudicants even if the correction of risk factors is inadequate.

Interval training in patients with intermittent arterial claudication
B Villemur (Grenoble, France)

The 2008 Cochrane Database Review of 22 trials with 1200 patients shows improvements in maximum walking time, pain-free distance (or initial claudication distance), and maximum walking distance (or absolute claudication distance). The exercise did not affect ankle-brachial pressure index. The improvements were seen for up to 2 years, but the results were inconclusive on mortality, amputation rate, and peak exercise calf blood flow. There are limited studies on exercises compared with surgical intervention, angioplasty, pneumatic foot and calf compression, or drug therapy. Therefore, vascular rehabilitation is a first intention treatment if not contraindicated. It is more efficient and superior to simple walking. In the case of failure after 3 months of vascular rehabilitation and medication, revascularization should be considered. Vascular rehabilitation has positive effects on muscle metabolism, muscle microcirculation, and cardiovascular risk factor control. Vascular rehabilitation for arterial claudication consists of upper (arm ergometer) and lower extremity exercises, intermittent pressotherapy, gymnastics, education, and risk factor control. There are two types of treadmill training. The first uses constant intensity and moderate velocity during a given period of time (McDermott MM et al, JAMA 2009) or higher intensity with walking periods until exercise has to be stopped because of claudication (Bronas et al, Vasc Med 2009, Gardner et al J Vasc Surg 2002, Milani et al, Vas Med 2007). The second is interval training with submaximal training periods and an active recovery period which was never used before for peripheral artery disease and was mainly used in the training of athletes. This interval training was recently used in rehabilitation of heart failure, metabolic syndrome, and after coronary artery by-pass and has been recommended for cardiac rehabilitation since 2001.

The objective of the study presented was to determine the effects and the adverse events of treadmill interval training with active recovery in a prospective design. Eleven patients at the second stage of peripheral arterial disease took part in a rehabilitation program 5 days a week for 2 weeks. Each day they had to practice global physical activity, upper and lower extremity exercises, intermittent pressotherapy and a program of treadmill walking. Maximum walking distance was measured on days 0, 15 and 30. The interval training program consisted of treadmill exercise for 30 minutes each morning and evening with increased intensity: for the first week speed was increased, for the second the slope. Each session of interval training consisted of 5 successive 6-minute cycles. Each cycle consisted of 3 minutes of work followed by 3 minutes of active recovery. At the end of the 2 weeks, every patient had significantly increased their walking distance (from an average of 610 m to 1252 m). No adverse event was noted. Patients’ motivation was excellent. This study shows that interval training with active recovery is efficient and safe for arterial claudicant patients. More studies are needed to confirm these results, concluded the author.

Physical exercise in elderly arterial disease patients
M Prior (Verona, Italy)

The beneficial effects of exercise response in peripheral arterial disease patients include improvements in leg blood flow and oxygen delivery due to increased muscle capillary density and nitric oxide release, improved skeletal muscle metabolism, and blood viscosity. Moreover, exercise reduces local and systemic inflammation, and in addition improved biomechanics of walking may contribute to increased walking ability. An elevation of pain perception threshold, possibly induced by an increase in endorphine release, could also be considered. The best results are obtained when a supervised treadmill walking program is used. More than 100% increases in treadmill exercise performance, together with significant improvements in peak oxygen consumption and quality of life are described. These effects of exercise do not seem to be age-related. Older PAD patients benefit from exercise training too, provided that comorbidity does not limit their involvement in the training session. Once the main exercise response determinants are considered, age is not per se significantly correlated with a reduced increase in claudication distance upon completion of the treadmill walking program. Moreover, the lower the initial fitness, the greater the fitness increase at the same training load. It is particularly important that elderly arterial disease patients take part in specific supervised exercise training programs, given they are usually more compromised than younger ones in functional capabilities and quality of life.

The author’s rehabilitation program includes treadmill training sessions with gymnastics based on physical exercises specifically aimed to enhance proprioceptive ability, joint flexibility, muscle mass and strength, and walking mechanics. Such a program led to improvement not only in walking distance, but also in quality of life scores measured with questionnaires. A short supervised training program may be as effective as longer ones in increasing walking ability, while reducing training costs. A simple and clear definition of the work load may help produce better results and avoid the risk of activating inflammation. Although treadmill training is probably the best to increase claudication distance, other types of exercise can be taken into account to further improve quality of life, concluded the speaker.

Varicose vein treatment in the future

Chairmen: M de Castro-Silva (Brazil), P Nicolini (Lyon, France)

Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum on the care of patients with varicose veins
P Gloviczki (Rochester, USA)

The guidelines provided by the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) for treatment of patients with varicose veins (CEAP Class 2) were presented together with recommendations for treatment of superficial and perforator vein incompetence in patients with more advanced (CEAP Class 3-6) venous disease. The recommendations were divided into grade 1 (for strong recommendation) and grade 2 (for weak recommendation), and the level of available evidence was marked as A (for high level of evidence), B (for medium level of evidence), or C (for low level of evidence). The following recommendations were proposed:
– in patients with varicose veins a complete history and detailed physical examination must be complemented by duplex scanning of the deep and superficial veins (Grade 1A);
– the CEAP classification must be used for patients with varicose veins and the revised Venous Clinical Severity Score to assess treatment outcome (both Grade 1B);
– compression therapy for patients with symptomatic varicose veins (Grade 2C);
– compression therapy as the primary treatment to aid healing of venous ulceration and as an adjuvant treatment to prevent ulcer recurrence (Grade 1B);
– ablation of the incompetent superficial veins in addition to compression therapy to decrease recurrence of venous ulcers (Grade 1A);
– for treatment of the incompetent great saphenous vein (GSV) the committee recommended endovenous thermal ablation (radiofrequency or laser) over high ligation with inversion stripping of the saphenous vein to the level of the knee (Grade 1 B);
– the committee also recommended phlebectomy or sclerotherapy to treat varicose tributaries (Grade 1B) and suggested foam sclerotherapy as an option for treatment of the incompetent saphenous vein (Grade 2C);
– the committee advised against selective treatment of perforator vein incompetence in patients with simple varicose veins (CEAP Class 2, Grade 1B), and suggested treatment of pathologic perforators (outward flow of > 500 ms duration, vein diameter of >3.5 mm) located underneath healed or active ulcers (CEAP Class 5-6, Grade 2B);
– the committee also recommended treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs or transcatheter sclerotherapy, used alone or in combination (Grade 2B).

Future techniques for varicose vein ablation
P Nicolini (Lyon, France)

During the last 10 years, crossectomy and stripping of the saphenous veins associated with stab avulsions have been gradually replaced by endovenous thermal ablation (radiofrequency or laser). According to the speaker a new technique of thermal destruction with steam is in the course of evaluation. The technique consists of warm sterile water that is sent under pressure (600 bars) in the form of vapor (temperature from 100 to 150 °C) into the trunk of the saphenous vein by a percutaneous approach. The results of a prospective multicenter study in 80 patients begun in November 2008 showed no differences compared with radiofrequency and laser. The speaker concluded that this technique is promising, cheaper than other endovenous thermal techniques, and also allows treatment of collateral varicose veins without phlebectomy. These results must be confirmed by other prospective studies.

We need to know more about the natural history of venous hemodynamics in patients with varicose veins
P Carpentier (Grenoble, France)

The natural history of venous hemodynamics in patients with varicose veins is far from understood. The speaker stated that the classic model favoring the reflux hypothesis and describing chronic vein disease progressing downwards under the effect of venous hypertension lacks objective scientific evidence and is currently challenged by the theory of a primary parietal disease of the venous wall. According to the speaker several observational studies using duplex ultrasound have produced evidence in favor of the ascending hypothesis of varicose disease progression. It has been demonstrated that primary venous reflux can occur in any superficial or deep veins of the lower limbs, suggesting that reflux appears to be a local or multifocal process and that the type of reflux correlates with the age of patients as well as with the CEAP clinical class. On the other hand, some data suggest that reflux progression does not affect all patients and thus competent valves will not necessarily deteriorate over time. The speaker concluded that prospective studies of the natural history of superficial vein disease are needed with standardized evaluation of postoperative outcomes after different varicose vein treatment modalities. These studies should help to optimize therapeutic strategy.

Molecular mechanisms for microvascular endothelial apoptosis under pressure elevation and therapeutic targets
G Schmid-Schonbein (San Diego, USA)

Chronic venous hypertension is associated with elevated markers of microvascular inflammation, tissue remodeling, and apoptosis, but the cellular and molecular mechanisms underlying these processes remain uncertain. The speaker presented a study which tested the hypothesis that acutely elevated venous pressure together with reduction of shear stress can induce elevated enzymatic activity in venules. Using a rodent model for venous hypertension by repeated venular occlusions of 15-min duration, microzymographic techniques for enzyme activity detection in vivo, and immunohistochemistry for receptor labeling, they found increased activity of matrix metalloproteases (MMP-1, -8 and -9). In this short time they also observed that elevated pressure causes in some venules causes reduced labeling density with an antibody against the extracellular domain of the vascular endothelial growth factor receptor 2 (VEGFR2), while in other venules they observed increased VEGFR2 expression compared with the levels before venous pressure elevation. He concluded that short-term pressure elevation increases enzymatic activity in venules, which may contribute to the endothelial dysfunction associated with this disease.

Efficient compression therapy to treat venous disease: scientific, medical and practical key factors

Chairmen: P Carpentier (Grenoble, France), P Kern (Vevey, Switzerland)

Compression therapy in chronic venous disorders: a bright future requiring much effort
P Carpentier (Grenoble, France)

The speaker emphasized that although compression therapy is increasingly acknowledged as the cornerstone of treatment in chronic venous disorders, its use in everyday practice is far from satisfactory. Despite the well-known beneficial effects of compression therapy, compliance with treatment is very low. Therefore considerable effort is required from vascular scientists, manufacturers, attending physicians, and patients to maximize the benefits of this major therapeutic tool. Manufacturers are nowadays able to make highly sophisticated elastic textiles with better physical properties and acceptability (esthetics, comfort, ease of handling). However, a lot remains to be done. Testing pressure, working pressure, hysteresis and, the massage effect of medical compression stockings are all important physical properties which have to be taken into consideration in order to improve the effectiveness and quality of medical compression stockings. From the medical point of view vascular scientists need a single worldwide classification of compression categories to be able to speak a common language in phlebology. There is a need to better characterize the compression device (not just ankle pressure) and to conduct phase II and phase III trials. Attending physicians have to play their part in therapeutic education programs (like “Veinothermes” presented by the author) and are key to building motivation, to insuring the device is appropriate to the patient’s vascular status, and to customizing it to the patient’s personal needs. Of course, education of physicians is also necessary. Patients wish to have more personalized products, have to use and look after medical compression stockings, and need to adapt their lifestyle to the treatment. All these objectives require knowledge, skills, and motivation, which points to the need for specific therapeutic education programs. All these efforts and their coordination are necessary to make compression therapy more effective in real life.

New strategies to improve compliance to compression therapy
D Rastele (Grenoble, France)

Compression therapy is part of or key to treatment of severe venous disorders. Postthrombotic syndrome is the main example of this: at least 30 mm Hg at the ankle is required over a 2-year period of wearing. Nevertheless, compliance to compression therapy is poor. A survey in France conducted by JJ Guex shows that 24% of patients are not compliant for French class 3 (20-36 mm Hg) medical compression stockings. The greatest difficulty reported was the putting on of compression stockings (70% of patients). New research strategies have been followed to improve compliance by identifying patient morphology, resistance, skin parameters, difficulties, by innovations in the manufacture of stocking textiles, by educating patients and family, improving posture, and so on. One of the key points for compliance is the putting on compression hosiery, where the main parameter is fabric friction at the instep and ankle. The objective of the strategy was to reduce friction, by studying the skin-stocking interface, coefficient of friction, secondary skin parameters, hydration, microstructure, water loss, and elasticity. A biomechanical approach has been used to optimize the ergonomic description of the patient’s body movement when putting stockings on and taking them off. Muscle activities were investigated using surface electromyography measurements. The speaker concluded that muscle activity of the thumb is mainly involved in putting on medical compression stockings, and muscle groups of the shoulder in removing them. To facilitate the putting on process (slipperiness), improvements (yarn selection) and innovations (dynamic elasticity) were implemented in the design of medical compression stockings. The putting on process was improved in 79% of patients, 93% of whom felt more comfortable with these new stockings.

These attempts to improve compliance in a poorly documented field constitute progress, but we still need more data on skin parameters (the heel, for example), morphology, and improvements in posture and textile5.

Compression after sclerotherapy
P Kern

The aim of applying compression after sclerotherapy is to reduce the size of the endoluminal thrombus, to decrease inflammation, enhance endofibrosis, reduce the risk of recanalization, lower the rate of pigmentation, and decrease the risk of thrombophlebitis. There are many differences regarding the use of compression therapy after sclerotherapy in different countries. As recommended in the guidelines of the German Society of Phlebology, most specialists apply compression after sclerotherapy of saphenous varicose veins and tributaries. Applying extrinsic selective compression combined with compression bandaging after sclerotherapy of the great saphenous vein significantly enhances results at 2 years. In contrast, short-term results (less than 6 weeks) and the incidence of side effects are not influenced by compression. Trials are too scarce to permit any definite conclusion. But as Ferrara showed, compression could have an effect on long-term results and recanalization rate, particularly using selective eccentric compression under medical elastic stockings to compress the saphenous veins. However, formal proof of this is required. Interestingly, in the setting of telangiectasias, several earlier studies demonstrated a beneficial effect of wearing medical compression stockings after sclerotherapy. Recently, this benefit was confirmed by a prospective study conducted by the author of this presentation. Therefore, after the sclerotherapy of telangiectasias we now have strong evidence that wearing medical compression stockings significantly enhances the esthetic results of treatment (better clinical vessel disappearance, avoiding treatment failures, reducing pigmentation). The mechanisms underpinning this beneficial effect are unclear. Compression of the reticular feeder veins could play a role. The utility of wearing medical compression stockings after sclerotherapy of saphenous veins seems obvious, but its efficacy is less well documented in this indication than after sclerotherapy of telangiectasias.

The effects of medical compression stockings on venous anatomy
J F Uhl

Thanks to imaging techniques it is now possible to evaluate in vivo the biophysical impact of compression of veins. The speaker presented 3 different tools for studying the effects of medical compression stockings on both the superficial and deep veins of the lower limbs. Duplex ultrasonography through a stocking with a transparent window is a simple way to assess the anatomical and hemodynamic effects of medical compression stockings on the venous system. Spiral computed tomography with 3D reconstruction of the lower limbs with or without injection is an accurate method to assess the 3D shape of the leg and the diameter of the superficial/deep veins. It is possible to obtain a realistic 3D model of the leg and its anatomical structures for use in evaluating interface pressure and effects due to compression stockings. T2-weighted magnetic resonance imaging in the standing position is a more informative protocol. It is also possible to do 3D modeling of calf anatomy in the standing position and to quantify venous volume before and during compression.

These studies show that the Laplace law and interface pressure measurement work well regarding the superficial veins. A compression of about 25 mm Hg is necessary to obtain a significant flattening in the lying position, and 50 mm Hg to occlude the vein. In reality, however, the problem is much more complex regarding the effect of medical compression stockings on the deep veins: during muscle contraction they act like an “extra aponeurosis” and seem to play an important role even for a lower pressure interface, concluded the speaker.

Therapeutic education of the vascular patient

Therapeutic education of the patient with peripheral arterial disease
PH Carpentier

Patients with peripheral arterial disease can be treated mainly by concentrating on underlying arterial modifications (called the “lesion-centered approach” by the author). This could be effective in the short term, but fails in the long term because of inadequate risk factor reduction and lifestyle modification. In a diseasecentered approach, patients are expected to control their risk factors, to be compliant with nonsymptomatic long-term treatment, and to be able to detect any warning signs of complications. This cannot be achieved only by the usual information delivered by the physician during a classic medical consultation. The patientcentered approach, beyond pharmacological intervention, includes a lifestyle modification program plus help with stopping cigarette smoking, supervised exercise training 3 times a week, weight reduction dietetic guidance, and a multidisciplinary therapeutic education program including psychological help and involvement of patients’ spouses. The aim of this approach is to modify behavior and help the patient cope with the disabilities related to the disease or its treatment and to make him or her an active partner in the management of the disease. Of course, these three approaches should be combined in daily practice and are not mutually exclusive.

A program called “Let’s walk” was developed by the vascular medicine teams of Grenoble and Montpellier with the collaboration of a group of patients with arterial claudication. This educational course consists of three educational consultations and five workshops where small groups of patients were interactively informed about the risk factors, natural history, and treatment modalities of peripheral arterial disease and atherothrombosis, and are motivated to exercise more, implement dietary changes, and implement other needed lifestyle changes. Only two-thirds of the patients completed the whole educational course, but this group experienced a significant increase in knowledge, motivation, self-perceived health status, and physical activity. This program is currently available in 12 other French centers.

In conclusion, the speaker emphasized that therapeutic education of the patient is an important cultural change in medical practice. It increases the effectiveness of the usual medical care, greatly changes the patient-physician relationship, and makes our highly technical medical practice more humane.

Therapeutic education of the patient with venous thromboembolic disease
P Léger (Toulouse, France)

Therapeutic education of patients with thromboembolic disease is mainly focused on anticoagulation treatment. The objectives are to avoid hemorrhagic and thrombotic events, to train the patient on how to manage treatment with vitamin K antagonists through a comprehensive patient-centered approach by sharing knowledge and expertise with caregivers. The aim is to integrate the treatment and disease in the patient’s daily life and allow him or her to achieve an acceptable quality of life. For this purpose a multidisciplinary team is needed. Education is based on the achievement of educational diagnosis for each patient and the setting up of a therapeutic agreement with patient followed by an action plan and evaluation. The speaker referred to the minimum knowledge required for the patient as a “safety agreement”. The education program should be done in the doctor’s office, pharmacy, hospital, specialized center, and also at home.

Recent studies confirm the importance and efficiency of therapeutic patient education, especially in self-monitoring of oral anticoagulation. Education reduces bleeding and thrombosis complications and therefore saves lives.

Therapeutic education of the patient with chronic venous disorders
B Satger (La Léchère, France)

The speaker pointed out that chronic venous disease has no effective curative therapy and needs long-term care management. Patients have to manage their disease for a long time, so high motivation and good compliance to compression therapy are required, along with important lifestyle changes and venous hygiene. In order to address these needs, several educational programs for voluntary patients were developed in French spa resorts, some improvement being made over the years. The first one called “The Vein School” started 15 years ago in the spa resort of La Léchère, with topics approached during interactive work groups, as follows: anatomy and physiology of the circulatory system, venous diseases, and practical aspects of life with compression stockings. A series of patients showed improved knowledge and compliance to compression therapy. The “Veinothermes” program developed by a multidisciplinary group with the help of referred patients combines three educational workshops and an individual education consultation aimed at defining goals that the patients must achieve within three months. A systematic evaluation of the first 94 patients showed significant behavioral changes, including improved compliance to compression therapy and quality of life. A third program was used for people with a recent history of proximal deep vein thrombosis, with a six-day training course combining four educational workshops and a specific rehabilitation program using spa therapy and 3 months of telephone follow-up.

In conclusion, the speaker stressed the great interest of patients in such programs. The programs provide short-term improvement of knowledge, long-term beneficial effects on compliance to compression therapy, and significant behavioral changes among patients with venous disorders.