AVF SYMPOSIUM – Part 6
THE MANAGEMENT OF VENOUS DISORDERS:
GUIDELINES OF THE AMERICAN VENOUS FORUM
Chairpersons: P. GLOVICZKI (USA) A. J. COMEROTA (USA)
Current management of acute iliofemoral venous thrombosis:
the AVF guidelines
A. J. COMEROTA (USA)
What is the goal of therapy of deep vein thrombosis? We want to prevent the worst immediate consequences, such as pulmonary embolism, but in the long term we must also prevent the postthrombotic syndrome, a highly debilitating situation that frequently results from iliofemoral venous thrombosis, especially if both venous incompetence and venous obstruction are present.
There are studies showing that an aggressive approach to eliminate clots via a surgical approach or local thrombolysis can lead to good patency results and improve quality of life.
One large, randomized, national multicenter trial, called TOLEDO, has just been approved by the Food and Drug Administration.
Considering the current options available, the author suggests that for acute iliofemoral deep vein thrombosis, catheter-directed thrombolysis is the option of choice, using thrombectomy in patients where thrombolysis is contraindicated, correcting any eventual stenosis of the venous system, and subsequently putting the treated patients on anticoagulant therapy.
The CEAP Classification: update based on recent Pacific and
Caribbean consensus meetings
B. EKLOF (Sweden)
The CEAP classification is 10 years old, having arisen from discussions during the fifth annual meeting of the American Venous forum, in 1993, where the idea of using a system similar to that of the TNM classification for cancer was launched.
The next national meeting saw the creation of an international ad hoc committee, chaired by Professor Nicolaides, that produced a consensus document.
CEAP stands for a classification of chronic venous disease that is based on Clinical manifestations, Etiologic factors, Anatomy, and Pathophysiologic findings.
The document enjoyed a very wide distribution, and was published worldwide in dozen of journals, in at least eight languages.
Important contributions were made at a Paris meeting in 1998, and during an international consensus meeting organized in Rome in 2001.
In 2002 the President of the American Venous Forum appointed an ad hoc committee to review the classification and present the results of their work in 2004.
The actual prospective is to maintain the overall structure of the CEAP classification, adding precise definitions of its four components.
The results are eagerly awaited, as the CEAP classification has shown its worth in getting researchers to speak the same language worldwide, and allowing the daily practice to achieve a scientific analysis of treatment alternatives.
Current guidelines for evaluation of chronic venous disease
F. T. PADBERG, Jr (USA)
The clinical score of the CEAP classification has been complemented by severity scoring systems, elaborated by an American Venous Forum committee on venous outcomes.
On the Venous Clinical Severity Score (VCSS) 10 clinical characteristics of chronic venous disease are scored from 0 for their absence, up to 3 for a severe manifestation.
The Venous Disability Score (VDS) divides the patients into four grades, from a symptomatic (score 0) to unable to perform their daily activities, even wearing compression (score 3).
The Venous Segmental Disease Score (VSDS) grades major venous segments according to the presence of reflux and obstruction.
These scores appear to be clinically useful, and have been tested for reliability.
Other useful data for characterizing chronic venous disease can arise from the patients themselves, and are the various Quality Of Life questionnaires, which complement the information obtained by doctors, from the patient’s point of view.
Other aspects that must be assessed are the results of ultrasound and physiological studies.
Much remains to be done in specific areas such as “why doesn’t this ulcer heal?,” the influence of morbid obesity, calf pump dysfunction, and more subtle aspects of chronic venous disease.
Current guidelines for management of symptomatic venous
reflux and varicose veins
E. J. HARRIS, Jr (USA)
Superficial venous insufficiency usually requires correction of great saphenous vein reflux.
The gold standard intervention for the management of great saphenous vein reflux remains high ligation and stripping of the vein to the knee.
It has been shown that ligation and stripping give better results than ligation alone.
Up to now, no benefits have been proven for sclerotherapy when compared with stripping of larger vessels.
Today preoperative Duplex ultrasound is an important adjunct to our clinical studies.
Ultrasound-guided foam sclerotherapy is a new technique that is widely used, and could prove to be more effective than the traditional methods.
Endovascular saphenous ablation is a new and successful technique that uses radiofrequency resistive heating along the vein wall to obtain closure of the vein itself.
Thermal skin injury appears to be the main adverse effect in 2% to 3% of the patients.
A similar technique is laser obliteration, which, from preliminary reports, appears to have good results, similar to radiofrequency ablation, with lower costs and decreased treatment times.
Further studies will demonstrate whether the initial results of these techniques can be maintained in the long term; up to now we can say that the recurrence rate favours stripping.
The main advantage of these new techniques consists in the patient losing fewer working days compared with venous stripping, and it is one of the main reasons why such procedures can show an advantage in costs over conventional interventions. Moreover the patient’s satisfaction after surgery is higher after these innovative methods, even if there is no difference after 4 months of therapy.
We still need long-term objective follow-up studies to properly address the role that each single procedure will have in the future.
Guidelines for nonoperative treatment of advanced chronic
venous insufficiency and local treatment of venous ulcers
P. COLERIDGE SMITH (UK)
Compression treatment is effective in the management of varicose veins, preventing edema and helping to obtain up to 70% ulcer healing, even if the bad news is that with venous leg ulcers we have a 25% annual recurrence.
Using drugs to treat ulcers make sense, as the underlying cause for ulceration does not appear to be reflux alone, there being little difference in the reflux patterns of subjects with chronic venous insufficiency with or without ulceration.
Many drugs have been applied topically, but none of them have been shown to have great effect, and some can harm the patient, sensitizing the skin around the ulceration.
Only two drugs have been successfully tested in patients with venous leg ulcers.
Pentoxiphilline is one of them, and eight randomized controlled trials have confirmed a benefit in ulcer healing using this drug, with six patients needing to be treated to achieve one healed ulcer.
Flavonoids, namely micronized purified flavonoid fraction, have quite recently been the subject of a meta-analysis that has collected original data from five prospective, randomized, controlled, multicenter studies.
This meta – analysis has demonstrated that adding micronized purified flavonoid fraction to conventional compression therapy gives a significant advantage in ulcer healing time, and that there is also a significant reduction in ulcer area compared with conventional therapy.
Moreover, there is also a significant improvement in patient symptoms.
They should be used as an adjunct to the conventional therapy based on compression and surgical correction when possible, but it has been shown that drug therapy is an effective and cost-saving adjunct to conventional treatment.
Current guidelines for surgical, endoscopic, and endovenous
treatment of advanced chronic venous insufficiency
P. GLOVICZKI (USA)
Chronic venous insufficiency is a widespread disease, and when advanced to the point of causing leg ulceration, it has a huge social and economic cost.
When the main cause appears to be superficial vein incompetence, surgical intervention appears to be the most rational approach.
However, even in fully compliant patients, the recurrence rate is not negligible.
A treatment of incompetent perforators can be suggested in these cases, and this can be accomplished in several ways, namely by conventional surgery, but there is still room for subfascial endoscopic perforator surgery (SEPS), a technique that uses an endoscopic approach.
Its benefit has not been clearly demonstrated, but in an institution such as the Mayo clinic, about 12% of perforator surgery is approached through the SEPS technique.
In treating large-vein obstruction, with high pressure gradients, the placing of stents has proved useful.
Treatment of incompetent perforators can be useful, and we need more studies to compare the SEPS technique with more conventional interventions and determine its place in venous surgery.