Servier – Phlebolymphology

Saint Peregrine is the patron saint of the venous ulcer. The biography of this medieval monk reports that he developed large varicose veins because he refrained from lying down as a kind of penance. The veins became so large that the leg became ulcerated. This is the classical description of varicose vein ulceration. Only since we have been using Duplex to investigate our ulcer patients on a regular basis have we are becoming aware of the fact that at least 50% of patients have superficial reflux, many of them without extensive visible varicose veins. At least those without concomitant deep venous insufficiency are therefore potential candidates for venous surgery (and not for amputation, as was proposed to St Peregrine by his doctor).

However, as demonstrated in the review by Michel Perrin in this issue of Phlebolymphology there have been no convincing data available until now to show that the removal of incompetent superficial veins promotes ulcer healing in comparison with compression treatment alone. In recent years, the interest has mainly focussed on the eradication of incompetent perforators, and the importance of the “blow down” was probably underestimated. This may change with future studies, which will show that superficial reflux can also be corrected by catheter procedures or by foam sclerotherapy.
On the other hand, evidence-based data medicine demonstrate that ulcer recurrence may be reduced by surgery of the superficial veins.

The article by Leal Monedero and coworkers from Madrid, based on an extraordinary experience, directs our interest to the widely ignored fact that many recurrent varicose veins in the lower extremity are associated with reflux originating in the pelvic region. Embolization of refluxing intrapelvic veins, such as the ovarian veins, using coils and foam sclerotherapy, provide very good results, especially concerning the subjective symptoms of pelvic congestion syndrome. This procedure is usually combined with phlebectomy of the varicose veins on the leg.

At the present time the ablation of varicose veins by radiofrequency and by laser is a very fashionable treatment mode. In fact these methods are not so new, as shown to us by Nicholas Fassiadis and Anthony Theodorides in their historical review.

The last presentation comes from Professor Claudio Allegra’s team, describing the broad variety of entities attributable to “functional venous disease.” Following the CEAP classification, C may range between 0 and 4 (C0=no varicose veins, C1=teleangiectasias, reticular veins, C2=large varicose veins, C3=edema, C4=skin changes on the lower leg), the etiology E is primary, anatomy A is classified as zero, and Pathophysiology P as unclassified. About 30% of outpatients fall into this category. Compression therapy and surgery are not successful. Changes in lifestyle, physiotherapy, and venotonic drugs may be helpful.

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