Servier – Phlebolymphology

Many roads lead to Rome and many routes may be chosen to treat varicose veins…

In this issue of Phlebolymphology, guidelines on the treatment of varicose veins elaborated by a group of prominent American vascular surgeons are reported and commented on by prominent European vascular surgeons (Marzia Lugli and Oscar Maleti from Modena, and Michel Perrin from Lyon). Those who are looking for clear recommendations on which method is the most successful to treat varicose veins in a specific clinical setting will be disappointed. However, the comments of our European colleagues on the American suggestions are quite stimulating. It is interesting to note that the American surgeons have also included statements regarding the role of drug treatment and have recommended the use of micronized purified flavonoid fraction in both symptomatic venous patients and venous ulcer patients to accelerate healing. Together with the recently published reviews of randomized controlled trials in the treatment of varicose veins written by Michel Perrin and Bo Eklöf (Phlebolymphology. 2011,18:(4)196-207 [Part I] and Phlebolymphology. 2012,13:(2)91-99 [Part II]), the reader now has a substantial amount of information that critically reviews the current concepts in the treatment of varicose veins.

The prevalence of chronic cerebrospinal venous insufficiency (CCSVI) and the relationship between CCSVI and multiple sclerosis (MS) remain controversial topics. Marian Simka, Katowice, Poland, gives a well-balanced overview of the present knowledge, elegantly putting the diagnostic weight on phlebography rather than ultrasound, and clearly stating that only a few small open-label studies investigating the clinical efficacy of endovascular treatment for CCSVI in MS patients have been published. He estimates that so far, about 12 000 MS patients have had endovascular therapy worldwide.

The present issue of Phlebolymphology also contains interesting results from an interim report on some outcomes of the large international VEIN CONSULT program, a joint initiative between the International Union of Phlebology and Servier. This is the first survey to make the distinction between C0a (healthy people) and C0s participants (patients complaining of symptoms in the absence of chronic venous disease signs). To ascertain whether C0s patients, who do not present with a detectable venous pathophysiology (Pn) have a venous disorder, medical questioning should delve deeper into the symptoms since we know that many subjective leg symptoms (eg, night cramps) can have other causes as well.

Amanda D. Shepherd, Tristan R. Lane and Alun H. Davies, from London, have written an excellent review documenting the natural history of venous disorders. The authors have not only provided a comprehensive overview of the longitudinal studies dealing with clinical disease progression and the effects of intervention on disease progression, but also included longitudinal studies evaluating the venous hemodynamics and risk factors for the development of venous ulceration. A real gem, this article summarizes all the data published to date in this field of high socioeconomic importance.

This issue of Phlebolymphology concludes with a basic-science article from Geert W. Schmid-Schönbein, University of San Diego, USA, demonstrating the complex relationships between metabolic syndrome, insulin resistance, hypertension, chronic inflammation in chronic venous disease, and the multifaceted cell dysfunctions described in the genetic model of the spontaneously hypertensive rat. Pharmacological approaches against some of these complex mechanisms need to be carefully selected since some players (eg, certain metalloproteinases) are an integral part of tissue repair in the inflammatory process.