Phlebolymphology N° 65 – Editorial
Advances in the Management and Prevention of Chronic Venous Disease
Major advances in the management and prevention of chronic venous disease have been made in the last few years. The stimulus has been the realization of the magnitude of the problem and better understanding of the pathophysiology of the condition at the macrocirculatory, microcirculatory, and molecular levels. Although deep vein thrombosis is responsible for some of the most severe forms of chronic venous disease, especially if its treatment is suboptimal, it should be remembered that in most cases, including those with venous ulceration, chronic venous disease is not the result of previous thrombosis, but of chronic changes in the venous wall that damage valves and produce reflux and venous hypertension.
The most important advance in understanding chronic venous disease pathophysiology has been the realization that changes in blood shear stress with activation of leukocytes and endothelial adhesion followed by subendothelial migration, stimulation of proteolytic enzymes such as MMPs, and accumulation of extracellular material have a key role in the development of chronic venous disease. These changes are associated with the production of IGF-_1 and FGF-_1, which stimulate collagen synthesis and smooth muscle cell migration. In addition, the increased plasma level of VEGF promotes capillary growth, increased capillary permeability resulting in the characteristic skin changes and lipodermatosclerosis. With this as background knowledge, drugs have been developed which can counter the above changes.
The development and availability of appropriate tools to assess the severity of symptoms, and the objective determination of the effects of treatment on signs such as edema, venous ulceration, and quality of life, have enabled us to embark on appropriate randomized clinical trials. The results have provided level I evidence and grade A recommendations for therapies: compression, medication, and surgery. Medications such as Daflon 500 mg have now a proven place with grade A recommendations for the whole spectrum of chronic venous disease, ie, early disease, as an adjunct to surgery in moderate and advanced disease and in the treatment of leg ulcers. Recommendations are now available in guidelines for the management and prevention of chronic venous disease drawn up in North America and Europe.
The four articles that follow provide a clear and comprehensive review of the latest advances in this field.