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Venous Hemodynamic Changes in Lower Limb Venous Disease: the UIP Consensus According to Scientific Evidence Anno: 2016 Lavoro: Mese: June titolo breve: Hemodynamic Changes in Lower Limb Venous Disease: the UIP Consensus Volume: 35 primo autore: Lee No: 3 pagine: 236-352 Rivista: International Angiology citazione: Int Angiol 2016;35:236-352 Cod Rivista: Int Angiol , The online version of this article is located at http://www.minervamedica.it International Angiology 2016 June;35 (3):236-352 GUIDELINES Venous hemodynamic changes in lower limb venous disease: the UIP consensus according to scientific evidence Byung-Boong LEE, Andrew N. NICOLAIDES, Kenneth MYERS, Mark MEISSNER, Evi KALODIKI, Claudio ALLEGRA, Pier Luigi ANTIGNANI, Niels BÆKGAARD, Kirk BEACH, Giovanni BELCARO, Stephen BLACK, Lena BLOMGREN, Eliete BOUSKELA, Massimo CAPPELLI, Joseph CAPRINI, Patrick CARPENTIER, Attilio CAVEZZI, Sylvain CHASTANET, Jan T. CHRISTENSON, Demetris CHRISTOPOULOS, Heather CLARKE, Alun DAVIES, Marianne DE MAESENEER, Bo EKLOF, Stefano ERMINI, Fidel FERNÁNDEZ, Claude FRANCESCHI, Antonios GASPARIS, George GEROULAKOS, Sergio GIANESINI, Athanasios GIANNOUKAS, Peter GLOVICZKI, Ying HUANG, Veronica IBEGBUNA, Stavros K. KAKKOS, Robert KISTNER, Tilo KÖLBEL, Ralph L.M. KURSTJENS, Nicos LABROPOULOS, James LAREDO, Christopher R. LATTIMER, Marzia LUGLI, Fedor LURIE, Oscar MALETI, Jovan MARKOVIC, Erika MENDOZA, Javier L. MONEDERO, Gregory MONETA, Hayley MOORE, Nick MORRISON, Giovanni MOSTI, Olle NELZÉN, Alfred OBERMAYER, Tomohiro OGAWA, Kurosh PARSI, Hugo PARTSCH, Fausto PASSARIELLO, Michel R. PERRIN, Paul PITTALUGA, Seshadri RAJU, Stefano RICCI, Antonio ROSALES, Angelo SCUDERI, Carl-Erik SLAGSVOLD, Anders THURIN, Tomasz URBANEK, Andre VAN RIJ, Michael VASQUEZ, Cees WIH. A. TTENS, Paolo ZAMBONI, Steven ZIMMET, Santiago Zubicoa EZPELETA (For affiliations and contributions of authors see Appendix) Document developed under the auspices of American College of Phlebology, Australasian Society of Phlebology, Cardiovascular Disease Educational and Research Trust (UK), European Venous Forum and Union International du Phlebologie Corresponding author: Byung- Boong Lee, Division of Vascular Surgery, Department of Surgery, George Washington University Medical Center, 22nd and I Street, NW, 6th Floor, Washington, DC 20037, USA. E-mail: [email protected] ABSTRACT There are excellent guidelines for clinicians to manage venous diseases but few reviews to assess their hemodynamic background. Hemody- namic concepts that evolved in the past have largely remained unchallenged in recent decades, perhaps due to their often complicated nature and in part due to emergence of new diagnostic techniques. Duplex ultrasound scanning and other imaging techniques which evolved in the latter part of the 20th century have dominated investigation. They have greatly improved our understanding of the anatomical patterns of venous reflux and obstruction. However, they do not provide the physiological basis for understanding the hemodynamics of flow, pressure, compliance and resistance. HemodynamicMINERVA investigations appear toCOPYRIGHT® provide a better correlation withMEDICA post-treatment clinical outcome and quality of life than ul- trasound findings. There is a far better prospect for understanding the complete picture of the patient’s disability and response to management by combining ultrasound with hemodynamic studies. Accordingly, at the instigation of Dr Angelo Scuderi, the Union Internationale de Phlebologie (UIP) executive board commissioned a large number of experts to assess all aspects of management for venous disease by evidence-based prin- ciples. These included experts from various member societies including the European Venous Forum (EVF), American Venous Forum (AVF), American College of Phlebology (ACP) and Cardiovascular Disease Educational and Research Trust (CDERT). Their aim was to confirm or dispel long-held hemodynamic principles and to provide a comprehensive review of venous hemodynamic concepts underlying the pathophysi- ology of lower limb venous disorders, their usefulness for investigating patients and the relevant hemodynamic changes associated with various forms of treatment. Chapter 1 is devoted to basic hemodynamic concepts and normal venous physiology. Chapter 2 presents the mechanism and magnitude of hemodynamic changes in acute deep vein thrombosis indicating their pathophysiological and clinical significance. Chapter 3 describes the hemodynamic changes that occur in different classes of chronic venous disease and their relation to the anatomic extent of disease in the macrocirculation and microcirculation. The next four chapters (Chapters 4-7) describe the hemodynamic changes resulting from treatment 236 INTERNATIONAL ANGIOLOGY June 2016 This document is protected by international laws.This document is protected by copyright No additional reproduction is authorized. of this Article. only one file and print only one copy and save use to download personal It is permitted for It is not permitted additional copies to make either printed purpose. or electronic) of the Article any for or systematically, (either sporadically of the article It is not permitted the electronic copy to distribute through online internetother file sharingelectronic mailing or any and/or intranet systems, access to the Article. allow means which may part The use of all or any Commercial Use is not permitted. of the Article any for works from the Article The creation of derivative is not permitted. personal or commercial use is The production of reprints for post on the Article. notices or terms may copyright the Publisher of use which or change any block, obscure, not permitted. trademark, overlay, logo It is not permitted techniques to enclose any or use framing to frame cover, It is not permitted to remove, or other proprietary of the Publisher. information Lavoro: titolo breve: Hemodynamic Changes in Lower Limb Venous Disease: the UIP Consensus primo autore: Lee pagine: 236-352 citazione: Int Angiol 2016;35:236-352 , HEMODYNAMIC CHANGES IN LOWER LIMB VENOUS DISEASE: THE UIP CONSENSUS LEE by compression using different materials, intermittent compression devices, pharmacological agents and finally surgical or endovenous ablation. Chapter 8 discusses the unique hemodynamic features associated with alternative treatment techniques used by the CHIVA and ASVAL. Chapter 9 describes the hemodynamic effects following treatment to relieve pelvic reflux and obstruction. Finally, Chapter 10 demonstrates that contrary to general belief there is a moderate to good correlation between certain hemodynamic measurements and clinical severity of chronic venous disease. The authors believe that this document will be a timely asset to both clinicians and researchers alike. It is directed towards surgeons and physicians who are anxious to incorporate the conclusions of research into their daily practice. It is also directed to postgraduate trainees, vascular technolo- gists and bioengineers, particularly to help them understand the hemodynamic background to pathophysiology, investigations and treatment of patients with venous disorders. Hopefully it will be a platform for those who would like to embark on new research in the field of venous disease. (Cite this article as: Lee BB, Nicolaides AN, Myers K, Meissner M, Kalodiki E, Allegra C et al. Venous Hemodynamic Changes in Lower Limb Venous Disease: the UIP Consensus According to Scientific Evidence. Int Angiol 2016; 35:236-352) Key words: Venous hemodynamics - Venous disease - Venous hemodynamic changes after treatment - Association between venous clinical sever- ity and hemodynamic abnormalities - Venous macrocirculation - Venous microcirculation. CONTENTS — Foreword 237 — Chapter 1. Basic Concepts for Venous Hemodynamics and Physiology of Venous Flow 238 — Chapter 2. Hemodynamic Changes in Acute DVT 249 — Chapter 3. Hemodynamic Changes in Chronic Venous Disease 252 — Chapter 4. Effects of Different Types of Compression on Venous Hemodynamics and the Microcirculation 282 — Chapter 5. Effects of Intermittent Pneumatic Compression and Electrical Calf Muscle Stimulation Devices on 290 — Venous Hemodynamics and the Microcirculation — Chapter 6. Effects of Pharmacotherapy on Venous Tone, Flow and the Microcirculation 299 — Chapter 7. Hemodynamic Effects of Abolition of Reflux in Superficial, Perforating or Deep Veins 310 — Chapter 8. Hemodynamic Changes after CHIVA, ASVAL and Hook Phlebectomy 317 — Chapter 9. Hemodynamic Effects of Relieving Pelvic Venous Reflux and Obstruction 330 — Chapter 10. Venous Clinical Severity and Associated Hemodynamic Changes 341 — List of Authors 350 FOREWORD The UIP consensus document on venous hemodynamics repre- UIP Consensus documents and was very well connected with the sents the great effort of Prof. BB Lee and his collaborators over the main European experts on hemodynamics. Prof. BB Lee accepted past four years. the challenge and confronted the huge task ahead requesting col- At the time I took over the UIP presidency, I was challenged laboration with three distinguished Professors: Prof. Andrew Nico- by a group of colleagues to establish official documents on new laides, Prof. Mark Meissner and Prof. Ken Myers. aspects of modern Phlebology particularly in some rapidly devel- This document is now concluded and published. As it will be oping areas with sparse publications that were polemic, short on confirmed in the following pages, there are various and important evidence or controversial. The idea to produce a consensus docu- topics that did not reach unanimous opinions. Likewise, several ment on “Venous Hemodynamics”
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