Phebolymphology N°78 – Editorial

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Dear Readers,

This issue contains some very good review articles about venous anatomy, the thrombotic risks of patients undergoing varicose vein surgery, conservative treatment of chronic venous disease, and the value of venous endoscopy.

The first article, written by Dr Alberto Caggiati from Rome, gives a very interesting description of the distribution of the valves in the deep, superficial, and perforating veins of the lower limb. This review article explains the embryology of venous valve development as well as the age-related changes in valves which can explain why aging is an important risk factor for vein thrombosis. These data also afford some insights into varicose disease development. There is a relationship between the mean number of valves and the risk of developing varicose disease. There is support for the hypothesis that, for skin changes to occur, valve incompetence in both the larger vessel network and the microvenous network is necessary.

Dr Andreas Oesch from Bern has written an excellent survey of thrombosis and pulmonary embolism risk in patients undergoing varicose vein surgery. Thromboembolism cases seem to be underreported for several reasons. The incidence can reach 5.3% after stripping of the great saphenous vein. Most thromboses are localized in the calf, are very often asymptomatic, and the potential damage is limited. Pulmonary embolism is exceptional. Therefore, the use of antithrombotic prophylaxis could be restricted to high-risk patients. A postoperative thrombotic event can occur up to 2 months after the procedure. Ten days of prophylaxis had no advantage over the use of an oral non-steroidal anti-inflammatory agent. Therefore, if the prophylaxis is started, it should be continued for longer. Patients should also be motivated to undergo early and extensive mobilization post-treatment.

The third article, by Dr Giovanni Agus from Milan, emphasizes the importance of the conservative treatment option for chronic venous disease. The prevalence of chronic venous disease seems to be higher than expected and reaches 64% of the population when considering patients classified between the C1 class and the C6 class. The aim of treating patients is to relieve symptoms and to prevent or treat complications. The troublesome problem of varicose vein recurrence after surgery and the increasing costs of this treatment reopen the discussion about the indications for surgery. Conservative therapy includes three tenets: lifestyle changes, pharmacological treatment, and compression therapy. Venoactive drugs can be administered at all stages of chronic venous disease to decrease symptoms, to reduce edema, and to promote ulcer healing. Compression therapy is a basic treatment for chronic venous disease of the lower limbs for its effects on venous hemodynamics, hydrostatic pressure, and edema reduction.

Finally, Dr Firmilian Calota from Craiova explains the benefits of using venous endoscopy. It allows the visualization of normal and pathological structures. A classification of normal venous valves and valvular lesions is presented. Phleboendoscopic observations have revealed that the deep venous system is more valvular than the superficial venous system and has a higher number of tributaries. The use of venous endoscopy can have some unexpected therapeutic potential. Adapted instruments inserted through a working channel can be used for endoscopic valvuloplasty, embolectomy, stent placement, etc, thereby promoting better and faster recovery for patients with chronic venous disease. In the future, early treatment of deep venous thrombosis will benefit from this new option.

Have an enjoyable read!
Marc Vuylsteke
Tielt, Belgium