Servier – Phlebolymphology

Several problems of considerable clinical importance are discussed in this issue of Phlebolymphology.

A paper from Hawaii, written by Alessandra Puggioni and Fedor Lurie, gives an update on surgical options for the treatment of obstruction and reflux in the deep venous system that cause postthrombotic syndrome. The discrepancy between the high incidence of the disease (3/1000 per year in the adult population) and the low number of surgical procedures reported in the literature raises the suspicion that there is still no ideal and standardized method that can be performed in a wide range of settings. However, superficial reflux may additionally contribute to the severity of signs and symptoms of postthrombotic syndrome. The authors underline that removal of a refluxing great saphenous vein is indicated in symptomatic patients if the deep system is not significantly obstructed. The potential damage caused by destroying important collaterals seems to be less relevant than the benefit derived from improving the reflux.

Abolishment of superficial reflux by “exo-stent repair” is the subject of the paper by Rodney J. Lane and Joseph A. Graiche from Australia. The Australian group speculates that neovascularization is a result of blocking the orthograde flow at the level of the junction, in a way similar to what occurs when the caval vein is blocked and collateral veins develop in the abdominal wall. External valvuloplasty would not impede flow and would therefore not cause neovascularization. During the last few years other theories have also emerged, one suggesting that the groin incision alone is the triggering factor. It would be interesting to compare the latest results of Rodney Lanes’ method with those after conventional flush ligature of the saphenofemoral junction, regarding both success and the occurrence of neovacularization.

The report of Charles E. Stonerock from the United States on his experiences as a visitor to several vein centers in France convincingly demonstrates the merits of the Servier Traveling Fellowship. It is refreshing to read that our young colleague learned a lot (not just French), and was able to make new friends as well.

Erysipelas, or cellulitis as it is also called in the English-speaking world, is not an infectious disease beyond the spectrum of vascular medicine, but is in fact associated with lymphatic disorders. This is one of the clear messages of the article by Loic Vaillant, Tours, France. Skin changes on the lower leg are frequently seen in phlebological practice and occasionally misdiagnosed as erysipelas.

Another frequent clinical condition is the symptom of heavy and swollen legs in premenstrual women. In his short presentation Jerry G. Nina reports an enlargement of the great saphenous vein at mid-thigh level in the premenstrual phase in comparison with the follicular phase in women suffering from these symptoms measured by Duplex ultrasonography. Unfortunately, no clinical classification (CEAP) of the 12 investigated legs is given. However, reflux of >0.5 seconds was found in 6/11 legs in the follicular phase, while all investigated legs showed a reflux duration of more than 2.5 seconds in the premenstrual luteal phase. One practical implication of these findings is that reflux duration depends not only on room temperature and the time of day of the investigation, but also on the menstrual cycle in females. As the author states, more work will be needed to establish the existence and the pathophysiology of a “premenstrual vasodilation syndrome.”

Interesting data are presented by C. E. Virgini-Magalhães and coworkers of Professor Bouskela’s group in Rio de Janeiro, Brazil. The orthogonal polarization spectral imaging technique was used to visualize skin capillaries in the ankle region in a cohort of different stages of chronic venous disorders C0-C6 according to the CEAP, and the results were compared with those of completely healthy individuals.

It is amazing to see that even individuals with a C1-pathology (small reticular veins and teleangiectasias) already showed abnormal changes in the microcirculation in the distal lower leg. Could this be related to local spider veins or even corona phlebectatica, perhaps not yet visible to the naked eye?

Happy reading.