16th EVF Annual Meeting
A summary by Evgeny Shaydakov and Olga Porembskaya
Angelo Scuderi, Brazil
At the beginning of July 2015, St. Petersburg was the center of events in the European phlebology community. More than 800 participants of the European Venous Forum came to St. Petersburg from 60 countries around the world and 67 regions of Russia. It was the first time in the 16 years of the European Venous Forum that Russia had the honor of organizing the largest European phlebology conference.
Evgeny Shaydakov, who has been the chair of the phlebology association of St. Petersburg and the northwest region of Russia for many years, was elected as the 2015 President of the European Venous Forum.
An intensive scientific program, which dealt with practically all aspects of modern phlebology, occurred hand in hand with various cultural events that introduced delegates from different countries to the rich historical heritage of Russia. A fabulous dinner in Peterhof, the imperial palace near St Petersburg, was highlighted with a ceremony of the big cascade fountains, which made the setting of the 16th European Venous Forum unforgettable.
A committee of experts, under the guidance of the European Venous Forum chairperson, selects the most important and interesting abstracts from a scientific and practical point of view for oral and poster presentations. A total of 250 abstracts were submitted, and in the end, the best 35 were selected. Several pre-sessions were held before the main program of the conference. One session was devoted to the problems and the place of compression therapy in the treatment of various forms of chronic venous insufficiency. The latest investigations from a group of European specialists, including Susan Kahn and others, cast doubt on the effectiveness of using elastic compression stockings after acute deep vein thrombosis to prevent the development of a postthrombotic syndrome. Interesting reports by Giovanni Mosti, Hugo Partsch, Joseph Caprini, which were based on the results of international research and their own experience, resulted in a lively discussion that provided answers to many questions. The INNOVATE program, which was successfully started in December 2014 in St. Petersburg at the 7th St. Petersburg’s Venous Forum, aroused great interest. The main objective of this international program is to implement the standards of venous thromboembolic prophylactics, treatment, and practical implementation. During the discussion, a group of leading Russian experts, in the sphere of diagnostics and treatment of acute venous thrombosis, outlined a concrete program of practical implementation of these tasks in Russia.
One session was devoted to the problem of diagnostics and treatment of patients with clinical, etiological, anatomical, and physiological classification C0s (symptoms of the disease are present without signs) was organized under the unanimous resolution of the Forum program committee. To emphasize the importance of the problem, Andrew Nicolaides (Cyprus) and Eberhard Rabe (Germany) presented the results of the Bonn Vein Study, which was carried out on 1800 volunteers. According to the data, 50% of all people examined showed symptoms typical of chronic venous insufficiency. Venous reflux in the saphenous vein by the end of the day in patients showing signs of chronic venous insufficiency occurred in 63% of the patients with C0s, whereas 30% revealed venous blood flow acceleration with the increase invenous filtration at the ankle. During the discussion, Yuriy Tsoukanov (Russia) shared his point of view based on his recent work devoted to treating C0s patients.
The discussion of chronic venous disease pathogenesis started with Armando Mansilha (Portugal) stating: “We are just at the beginning of our understanding of the principles of venous deficiency development.” There is still an obvious dissonance between the data on the morphological changes in the venous wall and the data about the hemodynamic aspects of the veins. Further research, including estimation of the microvascular changes, is necessary to form a complete picture of the changes in the venous system.
With all the unique possibilities of the modern instrumental examination, we still do not have the opportunity to quantitatively measure hemodynamic shifts in the venous system and assess their role in the hierarchy of the changes leading to venous insufficiency (Marzia Lugli, Italy). Many speakers mentioned the necessity of acquiring this kind of knowledge. Andrew Nicolaides (Cyprus) noted that laser dopplerography of microvessels with an estimation of the co2 and Pco2 content in the skin of lower extremities, capillaroscopy, and orthogonal polar spectral methods can help answer a number of questions. Eliete Bouskela (Brazil) widely uses capillaroscopic methods in her work, and she showed that a reduction in the density of functioning microvessels, an increase in skin papillae diameter, and an increase in capillary diameter accompanies disease progression. The different morphological changes are shown as an increase in pathologic capillary percent correlation. The same type of instrumental examination is indispensable when estimating the effectiveness of venoactive drugs at various stages of chronic venous disease, including the C0s stage (Carlos Virgini-Magalhaes, Brazil). Capillaroscopic information shows the effective use of venoactive remedies in chronic venous disease therapy. Measuring cytokine levels, ie, interleukin 1, tumor necrosis factor, and vascular endothelial growth factor, reveals the authentic fluctuation in their concentrations during treatments containing micronized purified flavonoid fraction (Vadim Bogachev, Russia).
On the initiative of the President, a joint session of the European Venous Forum with the Deep Venous Reconstructive Surgery club (DVRS club), a community of specialists dealing with reconstructive venous surgery, recently organized by Robert Kistner (USA), was held for the first time this year. In April and May 2015, two master classes of the DVRS club were successfully held in Modena, Italy (chaired by Oscar Maleti and Marzia Lugli). Their reports and the presentations by Michel Perrin, Anthony Comerota, and Evgeny Shaydakov summed up the possibilities of deep vein surgery. They showed that specialists from different countries are interested in acquiring skills on manipulating the deep veins. As Oscar Maleti mentioned in his presentation, a decrease in the interest to conduct deep vein reconstructive surgery in the 1970’s and 1980’s has been changed by the current increase in interest. This is definitely connected with the new possibilities of diagnostics to determine the state of deep veins, the appearance on intravascular ultrasound, and new treatment methods.
Anthony Comerota (USA), Director of Jobst Vascular Institute in Toledo, Ohio, spoke about the methods currently available to surgeons for preventing postthrombotic syndromes. Long-term results of open thrombectomy and thrombolysis in numerous randomized investigations exceed the possibilities of anticoagulant therapy alone in preserving venous patency. The CaVenT study (Catheter-directed Venous thrombolysisin acute iliofemoral vein Thrombosis) confirms patency preservation of the iliofemoral venous segment 6 months after catheter-directed thrombolysis with a significant 66% preservation rate, whereas anticoagulation alone is only 47%. At 1-year posttreatment, the difference between the long-term results of catheter-directed thrombolysis and anticoagulation were still significant: 56% and 41%, respectively. The data presented by Niels Baekgaard (Denmark) on prospective research comparing long-term results of anticoagulation therapy and catheter-directed thrombolysis are also in favor of thrombolytic therapy.
The retention of venous obstruction inevitably leads to the development of postthrombotic syndrome. Deep vein obstruction is responsible for one-third of the cases of postthrombotic syndrome, whereas the combination of deep vein obstruction and venous reflux is responsible for two-thirds of the cases (Marzia Lugli). Stenting of the deep veins is the only way to eliminate venous obstruction in such situations, and the guidelines have assigned a Grade 1B level of recommendation for stenting in patients with severe symptoms of postthrombotic syndrome and a Grade 2B recommendation for moderate cases. Stenting preserves the patency of the deep veins in 90% to 100% of cases with nonthrombotic obstruction and in 74% to 89% in cases of postthrombotic syndrome, saving patients from pain in 86% to 94% of cases, from edema in 66% to 89% of cases, and healing of venous ulcers in 58% to 89% of cases. There are many problems discussed concerning the time of deep vein stenting and the choice of a proper stent. Currently, technologies are being developed to create an ideal venous stent by obtaining all the necessary characteristics, including flexibility, resistance against compression and high hoop strength, low adhesiveness for thrombocytes, tolerable radius curvature without protrusion of metallic components into the cell structure (Athanasios Giannoukas, Greece). Any remaining deep vein reflux that causes symptoms should be corrected after stenting to increase the patient’s quality of life. Possible approaches include transposition, valve transplantation, or neovalve creation.
During the last day of the conference, a didactic session introduced a variety of experimental studies on venous disease pathogenesis. It is obvious that further development of modern phlebology is impossible without such research. The session opened with a presentation by Thomas Wakefield (USA), one of the directors of the Samuel and Jean Frankel Cardiovascular Centre at the University of Michigan, where he summed up recent research on the increasing possibility of accurate diagnostics for deep vein thrombosis and its recurrence using the combination of D-dimer levels, soluble P-selectin levels, and the Wells score.
Currently, research is being conducted on the use of galectine-3 as a biological marker for venous thromboembolism and the first promising results were published in 2013 in Blood. Al Shevela (Russia) discussed genetic markers for varicose veins. The high-frequency matrix metalloproteinase (MMPs) gene combinations (MMP-3 1171 dupA 5A/6A; MMP-12 82 A/G) and vascular endothelial growth factor determine the phenotype that is typical for people suffering from varicose veins. Andreas Fiebig (Germany) and F. Matthys (Belgium) spoke about the influence of heredity and age on the development of chronic venous diseases. Jawed Fareed (UK) reviewed the biomarkers for chronic venous insufficiency and acute thromboses. The laboratory of Anthony Comerota (USA) also delivered a very interesting presentation on the subject. Evgeny Shaydakov and Fedor Lurie (USA) showed that deep venous valve insufficiency is one of the predictors of acute deep vein thrombosis. These authors were awarded the first prize of the American Venous Forum for the best poster report showing the preliminary results of this research.
The Russian section of the European Venous Forum presented works by leading Russian specialists. Sergey Sapelkin (Russia) presented the work of the group headed by Anatoly Pokrovsky, concerning the results of endovascular radiofrequency treatment of inborn vascular malformations and the demonstrated effectiveness in treating vascular tumors of the limbs and soft tissue of the head that comprises the combination of afferent vessel embolization, radiofrequency obliteration following resection of the tumors. I. Serebriysky (Russia) presented the current research on thrombodynamics. The insufficiency of anticoagulant therapy, which results in recurrent deep vein thrombosis, can develop due to low doses of medicine and peculiarities in the coagulation system. Therefore, thrombodynamic tests can aid in the implementation of individual doses of anticoagulants. T. Vavilova (Russia) discussed the necessity of regularly monitoring anticoagulant in blood plasma while taking anticoagulants for safer therapy and for reducing the risk of thrombosis. The rivaroxaban and dabigatran concentrations found in the plasma in many patients often do not correspond to the expected concentrations, which can result in reduced efficacy. Olga Porembskaya (Russia) summed up the results of the enormous work by Evgeny Shaydakov (Russia) and O. Alukhanyan (Russia) on the technical aspects of venous valve reconstruction in patients with a combined reflux of deep and superficial veins. Robert Kistner’s suggested method of valvuloplastics involves using a different access than the generally accepted one to avoid cutting valve commissures and to help remove deep venous reflux in the majority of cases in the immediate and long term postsurgical periods. The problems of incompetent perforating vein treatment and the possibilities of implementing various surgical methods were discussed by Sergey Belentsov and Aleksej Fokin (Russia). For transverse reflux elimination, perforating vein subfacial dissection (SEPS) with radiofrequency ablation had comparable results to laser ablation with foam sclerotherapy. Therefore, the aggressive method of treatment (SEPS), which is accompanied with a greater number of complications, can be rejected in favor of less invasive endovenous procedures.
The European Venous Forum traditionally discusses the problems associated with compression therapy. Existing data show equal possibilities for class 1 and 2 compression devices in treating venous symptoms; however, only 2 classes of elastic devices diminish venous reflux in the lower limbs (Werner Blatter, Switzerland). Joseph Caprini (USA) discussed the importance of compression stockings in preventing deep vein thrombosis. The increase in the compression of knitted wear with effective use is possible by adequately controlling the pressure they create (Hans Thomae, Germany). The results of research show that compression stockings have no advantages compared with knee-high compression stockings. If prophylactic measures using compression are combined with other methods, including intermixing pneumocompression and neuromuscular stimulation, better results can be obtained in deep vein thrombosis and preventing venous thrombolysis (Ramaswamy Ravikumar, UK). According to Kirill Lobastov and V. Barinov (Russia), anticoagulant therapy is an absolute leader in preventing deep vein thrombosis, and in combination with intermixing pneumocompression, it is the safest way to prevent the disease, even in patients at a high risk of deep vein thrombosis.
Evi Kalodiki (UK) reported the results of experiments designed to find a treatment for the hemorrhagic bleeding that occurs while taking the anticoagulant therapy with rivaroxaban, dabigatran, and apixaban. The combination of a concentrated complex of prothrombin, a Feiba preparation (an anti-inhibitor coagulation complex containing several coagulation factors), and σ-aminocaproic acid shows promise for treating hemorrhagic bleeding after anticoagulant therapy. Joseph Caprini (USA) stated that while there are no antidotes for the mentioned preparations, the data seem to be extremely important, considering the widespread use of anticoagulation therapy and the accompanying 3.4% risk of bleeding.
Christopher Lattimer (UK) and Andrew Nicolaides (Cyprus) conducted research confirming the importance of the changes in venous wall elasticity during postthrombotic processes, which results in a number of hemodynamic changes. These changes were confirmed using air plethysmography and show a reduction in the venous drainage index, which is caused by a reduction in the emptying of deep veins due to a reduction in their wall resistance. Air plethysmography estimates the influence of all three PTC components of venous hemodynamics of the lower limbs: venous wall obstruction, reflux, and elasticity. George Geroulakos (UK) reported on treatment algorithms for subclavian vein thrombosis. Thrombolysis was suggested as the main approach. According to this algorithm, in partial subclavian vein stenosis after thrombolysis with moderate-to-severe symptoms, the second stage of treatment should be a first rib resection. In nonsuccessful thrombolysis with further development of severe symptoms, a subclavian-jugular bypass may be performed.
Many delegates from different countries presented the results of their research on the modern methods of treatment. Endovascular methods have become the main approach for treating postthrombotic syndrome (Mehmet Kurtoglu, Turkey) and managing the pelvic venous congestion syndrome (V. Ryzhkov, Russia). Ultrasound thrombolysis, a recently available technology, eliminates the venous thrombus present as thromboembolic complications with high effectiveness compared with catheter directed thrombolysis (Nathan Liang, USA); this work was conducted by the American Venous Forum prizewinners Nathan Liang and Rabih Chaer, who were delegates of the European Venous Forum.
In pediatric practice, the formation of lymphatic venous anastomosis for generalized lymphatic dysplasia is successfully being conducted by Makoto Mihara (Japan), who was one of the prizewinners from the Japan Phlebological Society. Hitoshi Inafuku (Japan), another prizewinner from the Japan Phlebological Society, demonstrated the wide possibilities of surgical treatment for the Budd-Chiari syndrome, where the dilation of the retrohepatic inferior vena cava with a pericardium patch and opening of the hepatic veins increases the life expectancy for these patients. Nick Morrison (USA) reported on the successful results obtained using recently introduced methods for endovascular varicose vein ablation, including cyanoacrylate-based medical glue. The work of the group headed by Yury Shevchenko and Y. Stoiko (Russia) showed a higher effectiveness after increasing the number of radiofrequency cycles in saphenous vein ablation.
In addition to the delegates of American Venous Forum and Japanese Phlebological Society, Marlin Schul, the prizewinner of the American College of Phlebology, also became a delegate to the European Venous Forum. His work is devoted to the clinical severity of the refluxing anterior accessory saphenous vein compared with the refluxing great saphenous vein.
The first-place European Venous Forum prize was awarded to the Joseph El-Sheikha (UK) and coauthors who presented the results of a 5-year observational clinical, technical, randomized study comparing endovenous laser ablation (810 nm) with open surgical methods for the treatment of varicose veins. The results showed an equal effectiveness of both approaches, but revealed two different reasons for recurrent varicose veins–saphenofemoral junction reflux and neovasculogenesis, respectively. Caitlin Latimer was awarded the second-place prize for his work devoted to the correlation of thigh compression pressure with the venous drainage index. The third place prize was awarded to Prakash Saha (UK) who presented the results of the 1-year observational study on postthrombotic obstruction stenting. Russian delegate R. Bredikhin was awarded the prize for the best poster presentation.
The festive dinner became one of the most unexpected moments of the 2015 European Venous Forum. The main reason was the intrigue, as the location was kept secret throughout the European Venous Forum. This year, the 2015 President of the European Venous Forum Evgeny Shaydakov started a new tradition by the awarding gold medals for outstanding contributions in phlebology. All participants supported the idea of awarding annual gold medals to the most eminent surgeons and scientists, whose work has led to further developments in the field of phlebology all over the world. The first gold medals of St. Petersburg’s Phlebology Association were awarded to people whose contribution to “the art of phlebology” is beyond estimating: Bo Eklöf (Sweden) and Michel Perrin (France). The 22nd honorable member of the European Venous Forum, Y. Soiko (Russia) was elected during the Gala Diner. The crowning point of the 2015 European Venous Forum was the ceremony that launched the Peterhof fountains, which appeared as a magical mix of music, fountains, and fireworks.