V. Miscellaneous venous topics

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V. Miscellaneous venous topics

Latest advances in managing C1 disease
Paul Pittaluga (Monaco, Monaco)
Sclerotherapy of telangiectasia and reticular veins is the oldest, but still the most common method of treatment. On one hand, it is simple, cheap, office-based, and requires no anesthesia. On the other hand, it needs several sessions, is not easy to perform, has variable results, and leads to pigmentation. The other option is skin laser because it requires no injections, it is office-based, it allows for the treatment of matting, and it is perceived as a modern technique; however, it is expensive, provides unequal results, and its efficacy is controversial. The modern approach includes radiofrequency ablation of the veins, but there is no clear data on efficacy. The surgical methods under local anesthesia are limited with the inability to remove the telangiectasia. The novel percutaneous surgical approach involves local anesthesia, driving the blood out from the vessel, and performing multiple focal destructions along the vessel with a specifically designed microinvasive tool. The tumescent anesthesia is injected just into the reticular layer of the skin (not papillary to avoid compression of the telangiectasia) to reduce the blood supply from the deeper vessels and keep the target vessels visible. The telangiectasias are interrupted by multiple microcuts and removed by slicing and emptying them. The procedure is fast and larger zones can be treated during the same session. The short-term results provide full disappearance of treated veins at 35 days.

New horizons for venous specialists
Sriram Narayanan (Singapore, Singapore)
Nonthrombotic iliac vein lesions may be responsible for most cases of chronic venous disease. The true prevalence of nonthrombotic iliac vein lesions is unknown. Nonthrombotic iliac vein lesions were observed in 23% to 32% of all cadavers, in 18% to 40% of patients with left lower limb deep vein thrombosis (DVT), but, by intravenous ultrasound, it may be found in 70% to 90% of all investigations. Pelvic congestion syndrome may be related to outflow obstruction (nonthrombotic iliac vein lesions, nutcracker syndrome, retroaortic left renal vein) in 90% of cases or may be primarily due to an increase in ovarian, uterine, and pelvic vein volume during pregnancy and estrogen intake in 10% of cases.

Pelvic congestion syndrome affects 10% to 15% of women during their lifetime and may be associated with symptomatic pelvic venous hypertension that can manifest as pain, dysmenorrhea, bleeding, dyspareunia, or leg swelling and recurrent varicose veins in a specific localization (perineal, gluteal). Pelvic venous hypertension may be identified using a specifically designed questionnaire. If identified, it should be treated with ovarian vein embolization under intravascular ultrasound guidance, which can provide adequate sizing of the embolic device and confirm the nutcracker effect. The embolization may be completed by balloon-controlled foam sclerotherapy.

The same problem may be represented in men as corporal veno-occlusive erectile dysfunction. It usually occurs in 30 to 40 year old men with a varicocele that is idiopathic and lifestyle-related, sometimes after pelvic fracture and radical pelvic surgery. The incidence typically increases with age. To assess erectile function in such patients, the Sexual Health Inventory for Men (SHIM) may be used. Scores of 22 and lower suggest erectile dysfunction, with lower scores suggesting more severe forms. To verify the venous etiology of erectile dysfunction, a complex hemodynamic assessment may be performed, including measuring blood pressure in the arm and penis, calculating the penile-brachial index, measuring pulse volume by photoplethysmography on the thumb and penis, measuring peak systolic velocity and end-diastolic velocity on the 4 penile arteries by Doppler, as well as recording the erectile hardness score at 10 and 20 minutes after the corporal injection of prostaglandin. An end-diastolic velocity >5 cm/s with normal peak systolic velocity and penile-brachial index suggests a venous reason for the erectile dysfunction. This pathology may be treated with glue ablation of the deep dorsal venous bifurcation (GAVI technique) using a venesection and specific microcatheter under local anesthesia with sedation. The 6-month results from 19 patients demonstrate a significant improvement in the sexual status according to the SHIM score, an increase in the erectile hardness score, and a normalization of the end-diastolic velocity. Therefore, diagnosis and treatment of pelvic venous hypertension in women and men is a new horizon for venous specialists.

IVUS in venous interventions – reduction in radiation exposure
Narayan Karunanithy (London, UK)
Radiation exposure in complex venous interventions is significant. The radiation burden during a unilateral iliofemoral vein stent implantation may be as high as 32.4 Gycm2, and it may be increased up to 60.8 Gycm2 during an inferior vena cava reconstruction. Considering that most of the patients undergoing such procedures are young (35 to 45 years old) and require additional preinterventional and postinterventional CT scans, the added lifetime cancer risk may be as high as 1:270 for iliofemoral stenting and 1:100 for inferior vena cava reconstruction. Therefore, decreasing radiation exposure is an important issue. IVUS can be used at all procedural steps, which not only reduces the radiation exposure, but also achieves more clinical efficacy. Intravascular ultrasound is better than phlebography for the assessment of lesion severity, as was demonstrated in the VIDIO study (Venogram vs Intravascular ultrasound for Diagnosing Iliac vein Obstruction). Moreover, at the base of the measurement of the stenosis area, it can predict clinical improvement after stenting. In addition, it can be used to assess lesion extension, to choose the proper size of the stent, and to control poststent deployment. Therefore, the routine use of the intravascular ultrasound will reduce radiation exposure and improve technical outcomes.

Where do we stand with IVC filters in 2019?
Richard McWilliams (Liverpool, UK)
In the last years, implantation of an inferior vena cava filter is associated with increased litigations resulting in multibillion dollar penalties for the manufacturers. At the same time, manufacturers are issuing safety notices calling physicians to inform the patients better about possible outcomes and complications of filter implantation, improve routine follow-up, and increase the retrieval rate. However, there is a lack of clinical data on the current inferior vena cava filters. There are some ongoing studies, such as PRESERVE (PREdicting the Safety and Effectiveness of infeRior VEna cava filters), which is analyzing six different manufacturers, and CIVC (Cook Inferior Vena Cava filter study), which is analyzing only the Tulip and Celect filters. The recently finished DENALI trial (a prospective, multi-center study of the Bard® DENALI™ retrievable inferior vena cava filter) on the DenaliTM filter recruited 200 patients and demonstrated a good retrieval rate (121 removals of 124 attempts) during 5 to 736 days (mean, 201 days) after implantation without adjunctive use of loop snares or endobronchial forceps. However, the filter retrieval rate is relatively low due to organizational reasons. The main factors associated with low retrieval attempts are repeated surgery, long stays in the intensive care units, inter-hospital transfers, and an unstable address. At the same time, developing a proper inferior vena cava filter pathway increases the retrieval rate from 63% to 100% due to the absence of loss for follow-up patients. The other way for improvement is educating specialists on retrieval techniques with the emphasis on retrieval, properly following guidelines, and teamwork, as well as developing bio-convertible inferior vena cava filters. Data from the SENTRY trial (Study of the Novate SENTRY Bio-convertible Vena Cava Filter), a prospective, multicenter study with a 12-month follow-up, was published recently, demonstrating encouraging results.

The current and future role of medical apps in venous care
Oscar Johnson (London, UK)
There is an increasing number of smartphone users, meaning that the applications have a big potential for data storage and analysis, patient education and consultation, procedures and investigations, machine learning and virtual clinics, and a multidisciplinary team input. The potential concerns are access to technology, connectivity, technological literacy, financial ability, wellness to engage, accessibility, training and education, technical support, fueling the addiction, compatibility, access, data collection and storage, and security. Some applications already on the market are only related to clinical reference and scoring services. Therefore, the real potential of smartphone applications has still not been revealed. One application that is trying to overcome these limitations is the Leg Ulcer Pathway Audit (LUPA) from Guy’s and St. Thomas Hospital (London, UK). It uses the Memopad Health monitoring application to improve remote patient healing monitor. It contains patient data and investigation timelines, and it is available on different platforms for the multidisciplinary team.