Servier – Phlebolymphology

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II. Consensus reports

UIP consensus report – contraindications to sclerotherapy
Kurosh Parsi (Australia)

This presentation was a summary of the available literature. Absolute contraindications include previous anaphylaxis to sclerosants and acute deep vein thrombosis. Relative contraindications include deep venous obstruction, peripheral vascular disease, a thrombophilic disorder increasing the risk of deep vein thrombosis, immobility, acute superficial vein thrombosis, pregnancy and breastfeeding, estrogen therapy, hormone replacement therapy, asthma, migraine, systemic disease associated with skin changes, obesity, advanced age, anticoagulation, pelvic tumors causing varicose veins, foramen ovale, and proposed long-distance travel.

UIP consensus report – pelvic venous insufficiency
Zaza Lazarashvili (Georgia) and Pier Luigi Antignani (Italy)

The main clinical symptom of pelvic congestion syndrome is noncyclical pelvic vein, which can be exacerbated by postural changes, walking, and sexual intercourse; also during menstruation. Other clinical manifestations that may be present include dysmenorrhea, vaginal discharge, dysuria, urinary frequency, nausea, bloating, abdominal cramps, and rectal discomfort. The main clinical sign is the presence of varicose veins on perineal, vulval, gluteal, or posterior thigh areas. Transabdominal ultrasound is the first noninvasive investigation that can exclude intrinsic pelvic conditions, demonstrate pelvic varicosities, and suggest ovarian vein insufficiency. However, transvaginal ultrasound is considered to be the examination of choice since it offers better visualization of pelvic venous plexus. In addition, duplex ultrasonography of the lower extremity veins is a necessary part of the protocol especially in the presence of atypical varicose veins. Catheter-directed retrograde selective venography of ovarian and internal iliac veins is the method of choice for the diagnosis of pelvic venous pathology. Diagnostic criteria for pelvic congestion syndrome include (i) an ovarian vein diameter more than 6 mm with proven reflux, (ii) contrast retention for more than 20 seconds, (iii) congestion of the pelvic venous plexus and/ or opacification of the ipsilateral (or contralateral) internal iliac vein, or (iv) filling of vulvovaginal and thigh varicosities. Treatment consists of transcatheter embolization (with mechanical and/or chemical agents) in order to occlude insufficient venous axes as close as possible to the origin of the reflux. Medical therapy for pain relief and micronized purified flavonoid fraction are useful adjuvants. Current challenges consist of (i) adoption of modern terminology and definitions instead of historical nomenclature, (ii) creation of a new classification, (iii) development of a disease-specific patient-reported outcome tool, (iv) introduction of new International statistical classification of diseases and related health problem codes to improve relations with insurance companies, reimbursements, and money for the initiation of large, multicenter clinical trials.

UIP consensus report – venous mapping
Kurosh Parsi (Australia) and Pier Luigi Antignani (Italy)

Currently, inconsistent and variable venous maps are produced by various radiology practices and vascular laboratories. Maps should include the whole system of superficial and deep veins above and below the knee. All veins should be assessed for patency or occlusion. Signs of previous thrombosis (septa, synechia, and wall thickening) should be recorded. Competence and reflux should also be recorded. Additional findings should be recorded, such as duplication, absence or agenesis, popliteal vein or artery compression, Baker’s cyst, and vascular anomalies, eg, arteriovenous malformation. Symbols should be used to denote key findings. Proposed symbols in the International Union of Phlebology Consensus on venous mapping should be universally adopted.

UIP consensus report – venous rehabilitation
Alberto Caggiati (Italy)

Currently, prevention and rehabilitation in patients with venous diseases is limited to compression stockings and medications. In contrast to cardiac, arterial, and lymphatic disorders, most guidelines do not mention rehabilitation protocols for venous patients, despite the fact that several studies have demonstrated the efficacy of nonsurgical and nonpharmacological protocols in preventing disease progression and/or recurrence. The aim of venous rehabilitation is to prevent disease progression, prevent complications, reduce symptoms, and improve quality of life. A number of comorbidities influencing venous return should be addressed, such as loss of weight in obese patients, correction of plantar abnormalities, ankle joint flexibility, and muscle strength. Gait analysis has demonstrated that, in venous disease patients, joint flexibility and muscle efficiency are impaired compared with normal age-matched subjects. The goal of gait reeducation is to regain the correct sequence of weight bearing, gait cadence, step length and speed, and to discourage the shuffling gait. Appropriate sports activities should be undertaken. It should be pointed out that the rehabilitative approach is expensive for patients and for the National Health Services; it also time consuming and not remunerative for phlebologists.

Pan-American consensus on ultrasound-guided foam sclerotherapy
Victor Canata (Paraguay) and Sergio Garbarz (Australia)

This presentation was held in the form of questions and answers.
1. Why do you consider ultrasound-guided foam sclerotherapy useful? Ultrasound guided foam sclerotherapy is useful because it allows a complete view of the superficial intravenous space observing the foam and providing great safety by avoiding the deep venous system.
2. Should the vein be empty prior to the injection? The vein has to be as empty as possible during the injection.
3. Is ultrasound-guided foam sclerotherapy on its own an efficient method of sclerosing venous axes or does it require additional physical procedures? Ultrasound-guided foam sclerotherapy is an efficient method of treatment on its own, but it is not 100% positive.
4. What is the goal of the treatment? The goal of the treatment is the elimination of reflux with eventual occlusion of the vein without residual thrombus.
5. What are the treatment advantages? Ultrasound-guided foam sclerotherapy has the lowest cost with a quick return of the patient to a normal life.
6. How important is the quality of the foam? It is crucial, in terms of density as well as durability. It is important to obtain a strong, dense, and homogenous foam with no visible bubbles.
7. What are the most important ultrasound observations? Vasospasm, parietal edema, needle visualization, direction of the circulation, and foam distribution.
8. What is the liquid:gas ratio? The liquid:gas ratio used in preparation of the foam is 1: 4.
9. What is the needle caliber? The needle caliber used is the same for veins of all sizes.
10. Where should the treatment start? In a patient with great saphenous reflux from groin to ankle, the treatment should start proximally.
11. What is the amount of foam injected? The usual amount of foam is between 1 and 10 mL.
12. What is the maximum amount of foam? The maximum amount of foam is 10 mL for each treatment.
13. Is elastic compression necessary? Elastic compression is used for 7 to 10 days by 55% and 30 days by 40% of phlebologists.