VOLUME 32 . OCTOBER 2013 . Suppl. 1 to Issue No. 5

VOLUME 32 . OCTOBER 2013 . Suppl. 1 to issue No. 5

InternationalInternational AngiologyAngiology the premier association for vein care professionals.

The American College of Phlebology (ACP) is comprised of more than 2,000 physicians and allied health care professionals, who are setting the pace and direction for growth in the field of vein care. The ACP offers members advocacy, continuing education and training in the latest science and techniques with the goal of improving standards and the quality of patient care.

If you treat or have an interest in venous and lymphatic disease, the ACP is an unequivocal resource for your practice.

together we thrive continuing education latest news & information practice management resources improved patient outcomes advancing vein care join today Get more information on how to join by visiting www.phlebology.org or by calling 510.346.6800 advancing vein care www.phlebology.org 510.346.6800 INTERNATIONAL ANGIOLOGY Official Journal of International Union of Angiology, Union Internationale de Phlébologie, Central European Vascular Forum

FOUNDER AND EDITOR-IN-CHIEF EMERITUS EDITOR-IN-CHIEF P. BALAS, Athens, Greece A. NICOLAIDES, Nicosia, Cyprus CO-EDITORS A. SCUDERI, Sao Paolo, Brazil (UIP) G. GEROULAKOS, London, UK (Ang. Forum, RSM) J. FAREED, Chicago, USA (IUA) V. STVRTINOVA, Bratislava, Slovakia (CEVF)

SPECIALIST COMMITTEE S. A.N. ALAM, Dhaka, Bangladesh J. FLETCHER, Sydney, Australia L. MENDES PEDRO, Lisbon, Portugal F. A. ALLAERT, Dijon, France S. GEORGOPOULOS, Athens, Greece F. MIRANDA Jr, Sao Paolo, Brazil B. AMANN-VESTI, Zurich, Switzerland B. GORENEK, Eskisehir, Turkey J. L. NASCIMENTO Silva, Rio, Brazil P. L. ANTIGNANI, Rome, Italy A. GIANNOUKAS, Larissa, Greece L. NORGREN, Örebo, Sweden R. M. BAUERSACHS, Munich, Germany M. GRIFFIN, London, UK A. PANYIOTOU, Nicosia, Cyprus C. CAMPISI, Genoa, Italy J. D. GRUSS, Kassel, Germany H. PARTSCH, Vienna, Austria A. CARLIZZA, Rome, Italy H. HAYOZ, Lausanne, Switzerland Z. PECSVARADY, Budapest, Hungary P. CARPENTIER, Grenoble, France U. HOFFMANN, Munich, Germany M. PERRIN, Lyon, France J. CAPRINI, Chicago, USA M. HORROCKS, Bath, UK O. PICHOT, Grenoble, France M. CAZAUBON, Paris, France M. K. JEZOVNIK, Ljubljana, Slovenia A. PIERIDES, Nicosia, Cyprus S. CHENG, Hong Kong, China S. KAKKOS, Patras, Greece A. D. POLYDOROU, Athens, Greece D. CLEMENT, Ghent, Belgium P. KALMAN, Chicago, USA P. POREDOS, Ljubljana, Slovenia A. CORNU-THENARD, Paris, France E. KALODIKI, London, UK E. RABE, Bonn, Germany P. DIMAKAKOS, Athens, Greece A. KATSAMOURIS, Heraklion, Greece D. RADAK, Belgrade, Serbia E. CORRADO, Palermo, Italy R. KISTNER, Honolulu, USA G. H. R. RAO, Minneapolis, USA L. DAVIDOVIC, Belgrade, Serbia N. LABROPOULOS, New York, USA V. RIAMBAU, Barcelona, Spain C. DELIS, Athens, Greece B. B LEE, Washington DC, USA X. SCHMID-SCHOEBEIN, San Diego, USA C. DELTAS, Nicosia, Cyprus C. LIAPIS, Athens, Greece A. SCUDERI, Sorocaba, Brazil E. DIMAKAKOS, Athens, Greece F. H.A. MAFFEI, Sao Paolo, Brazil F. SPINELLI, Messina, Italy M. DOBLAS, Toledo, Spain A. MARKEL, Haifa, Israel M. SPRYNGER, Liège, Belgium R. DONNELLY, Nottingham, UK S. R. MARQUES, Recife, Brazil I. STAELENS, Brussels, Belgium D. DUPREZ, Minneapolis, USA R. MARTIN, Bristol, UK J. WALENGA, Chicago, USA B. EKLOF, Råå, Sweden P. J. MATLEY, Claremont, South Africa H. VANDAMME, Leuven, Belgium S. ESSAM, Cairo, Egypt R. MATTASSI, Milan, Italy Gu YONG-QUAN, Beijing, China

REGIONAL EDITORS N. S. ANGELIDES, Nicosia, Cyprus H. GIBBS, Brisbane, Australia E. PILGER, Graz, Austria L. BANFIÇ, Zagreb, Croatia P. GLOVICZKI, Rochester, USA E. PURAS, Madrid, Spain J. BELCH, Dundee, UK D. HOPPENSTEADT, Chicago, USA H. RIEGER, Engelskirchen, Germany H. BOCCALON, Toulouse, France S. HOSHINO, Tokyo, Japan K. ROZTOCIL, Praque, Czech Republic E. HUSSEIN, Cairo, Egypt T. SASAJIMA, Muroran, Japan T. BOWER, Rochester, USA H. SHIGEMATSU, Tokyo, Japan M. BRODMANN, Graz, Austria A. JAWIEN, Bydgoszcz, Poland R. SIMKIN, Buenos Aires, Argentina M. CAIROLS, Barcelona, Spain F. KHAN, Glasgow, UK V. TRIPONIS, Vilnius, Lithuania M. CASTRO SILVA, Belo, Horizonte, Brazil J. J. MICHIELS, Rotterdam, Netherlands J. ULLOA, Bogota, Colombia M. CATALANO, Milan, Italy M. MIRALLES, Barcelona, Spain O. N. ULUTIN, Istanbul, Turkey E. DIAMANTOPOULOS, Athens, Greece S. NOVO, Palermo, Italy A. van RIJ, Dunedin, New Zealand D. DZSINICH, Budapest, Hungary J. PANNETON, Rochester, USA M. VELLER, Parktown, South Africa J. FERNANDES E FERNANDES, Lisbon, Portugal J. PERREIRA ALBINO, Lisbon, Portugal Z. G. WANG, Beijing, China

EDITORIAL COMMITTEE E. ASCER, New York, USA A. FROIO, Milan, Italy S. RAJU, Jackson, USA M. AMOR, Nancy, France L. J. GREENFIELD, Ann Arbor, USA M. M. SAMAMA, Paris, France E. BASTOUNIS, Athens, Greece J. J. GUEX, Nice, France J. SCURR, London, UK P. BELL, Leicester, UK J. HALLET, Maine, USA S. J. SIMONIAN, Annandale, USA G. BIASI, Milan, Italy M. HENRY, Nancy, France C. SPARTERA, L’Aquila, Italy L. CASTELLANI, Tours, France L. HOLLIER, New Orleans, USA F. SPEZIALE, Rome, Italy K. CHERRY, Jr., Rochester, USA P. KALMAN, Chicago, USA A. TAKESHITA, Fukuoka, Japan M. CHOCHOLA, Praque, Czech Republic F. CRIADO, Baltimore, USA M. R. LASSEN, Aalbord, Denmark O. THULESIUS, Linkoping, Sweden E. B. DIETHRICH, Phoenix, Arizona M. MALOUF, Sydney, Australia P. VALE, Sydney, Australia J. A. DORMANDY, London, UK P. G. MATTHEWS, Melbourne, Australia J. L. VILLAVICCENCIO, Bethesda, USA E. ERACLEOUS, Nicosia, Cyprus M. A. McGRATH, Darlinghurst, Australia M. YOKOHAMA, Kobe, Japan I. ERIKSON, Uppsala, Sweden D. MIKHAILIDIS, London, UK J. ZHANG, Beijing, China J. R. ESCUDERO, Barcelona, Spain N. NAKAJIMA, Chiba, Japan C. K. ZARINS, Stanford, USA P. FIORANI, Rome, Italy W. PAASKE, Aarhus, Denmark R. E. ZIERLER, Seattle, USA

EDITORS EMERITUS C. ALLEGRA, Rome, Italy P. MAURER, Munich, Germany ADMINISTRATIVE EDITOR D. BOND, London, UK MANAGING EDITOR A. OLIARO, Turin, Italy Tratamiento de las Treatment of Varicose Venas Varicosas y and Spider Veins Telangiectasias PATIENT INFO INFORMACIÓ N PARA PACI ENTES

A publication of Una publicación de

www.phlebology.org

Healthy Veins… Healthy Legs

A Patient’s Guide to Phlebology the materials you want for the knowledge you need. patient & clinical education products

Venous 1 valve open 4 blood flows toward heart

9 Venous valve closed prevents blood from flowing backward 2

When venous valves don’t close, reverse 8 blood flow causes

The American College of Phlebology (ACP) is committed to advancing your knowledge the venous system pooling and vein wall weakening

Deep Venous System 1 Common Femoral Vein 6 2 Femoral Vein and skills in the field of vein care. That involves offering the latest in publications, videos 3 Popliteal Vein

Superficial Venous System 5 4 Saphenofemoral Junction 5 Saphenopopliteal Junction 3 6 Great Saphenous Vein 7 Small Saphenous Vein and other materials to improve your practice and help you educate your patients about 8 Perforator 7 9 Anterior Accessory Saphenous Vein of Thigh

advancing vein care

If you’re an ACP Member, take advantage of discounts on all products.

just some of the products available Treatment of Varicose & Spider Veins Brochure Healthy Veins…Healthy Legs Book Fundamentals of Phlebology: Venous Disease for Clinicians The Venous System Poster Core Curriculum for Phlebology Nurses Lower Extremity Superficial Venous Examination DVD to order Visit www.phlebology.org/resources or call 510-346-6800. advancing vein care www.phlebology.org 510.346.6800

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ö ÷ ø ù ù ø ú û ü ý ý ö þ ÿ ¡ ý ¢ £ ¤ ¥ ¦ ÿ § ¨ © þ ÿ ¡ ¨ ¦ ÿ ý ¢ XVII WORLD CONGRESS OF THE INTERNATIONAL UNION OF PHLEBOLOGY

Boston, September 8-13, 2013

EDIZIONI MINERVA MEDICA TORINO 2013 Organizing & Scientific Committee

Chairman NICK M ORRISON

Scientific Committee MARK M EISSNER (CHAIRMAN) ANTONIO G ASPARIS, NICK M ORRISON, THOMAS WAKEFIELD, JEAN-J ÉRÔME G UEX, MELVIN ROSENBLATT, STEVEN Z IMMET NICOS LABROPOULOS (AD HOC M EMBER)

UIP Executive Committee President ANGELO SCUDERI

Past President EBERHARD RABE

Vice-Presidents MEHMET KURTOGLU , NICK M ORRISON, FELIZITAS PANNIER, KUROSH PARSI, ARMANDO SCHAPIRA

General Secretary IVAN STEVENS

Assistant General Secretary PIER LUIGI ANTIGNANI

Treasurer JEAN-J ÉRÔME G UEX

President of Honour Founder RAYMOND TOURNAY

Presidents of Honour CLAUDIO ALLEGRA , HENDRICK ROELOF VAN DER M OLEN, JEAN VAN DER STRICHT, ANDRÉ DAVY, GEORGES J ANTET, HUGO PARTSCH

UIP Committee of Honour CLAUDIO ALLEGRA , PETER CONRAD, SHUNICHI HOSHINO, GEORGES J ANTET, JOHAN KUIPER, HUGO PARTSCH, MICHEL PERRIN, ALBERT RAMELET, PAULINE RAYMOND-M ARTIMBEAU, NEVER ROSLI, JEAN VAN DER STRICHT, SAUL UMANSKY, PIERRE WALLOIS CONTENTS

MONDAY, SEPTEMBER 9, 2013 7:30 am – 8:45 am Ask the Experts - New Concepts in Compression Treatments No Abstracts Available Ask the Experts - The Management of Venous Malformations 03 Ask the Experts - Super!cial Veins No Abstracts Available Nursing Symposium – Phlebology Nurse Basics No Abstracts Available 9:00 am – 11:00 am UIP Session No Abstracts Available 11:30 am – 12:15 pm Invited Lecture: Comparative Effectiveness in the Treatment of Venous 03 Disease 12:45 pm – 2:00 pm4 Controversy of the Day: Foam Sclerotherapy is the Treatment of Choice No Abstracts Available for Most Patients with Super!cial Venous Re#ux 2:00 pm – 4:00 pm Electronic Abstracts See Below Free Paper Session 1 04 Practical Aspects of Lymphedema 06 Resolution of VTE: Natural, Anticoagulant and Pharmacomechanical 07 Cosmetic Sclerotherapy of Leg Veins 07 “Hands-On” Simulation Sessions - Ultrasound-Guided and Surface Scle- No Abstracts Available rotherapy “Hands-On” Simulation Sessions - Endovenous Ablation No Abstracts Available “Hands-On” Simulation Sessions - Ultrasound No Abstracts Available “Hands-On” Simulation Sessions - Pelvic Vein Embolization No Abstracts Available Nursing Symposium – Beyond Basics 08 4:30 pm – 6:00 pm Free Paper Session 2 08 Venous Education Around the World 10 Safety of Foam Sclerotherapy 12 Controversies in the Use of IVC Filters 13 Advanced Nursing No Abstracts Available

TUESDAY, SEPTEMBER 10, 2013 7:30 am – 8:45 am Ask the Experts - Ultrasound Evaluation of Abdominal and Pelvic Veins: No Abstracts Available How I Do It Ask the Experts - The Italian Neovalve: Techniques and Results 17 Ask the Experts - Foam Sclerotherapy: Keys to Success No Abstracts Available 7:45 am - 8:45 am Society Session: Joint Portuguese and Spanish Societies of Angiology and 17 Vascular Surgery 9:00 am – 11:00 am Free Paper Session 3 17 Society Session: Venous Association of India 21 Society Session: Associazione Flebogica Italiana 23 9:00 am – 10:30 am Society Session: Hungarian Venous Forum 20 Society Session: Sociedad Mexicana de Angiologia y Cirugia Vascular No Abstracts Available Society Session: European College of Phlebology and Benelux Society of No Abstracts Available Phlebology Society Session: Brazilian Society of Phlebology and Lymphology No Abstracts Available 11:30 am – 12:15 pm Invited Lecture: The Natural History of Deep Venous Thrombosis No Abstracts Available 12:45 pm – 2:00 pm Controversy of the Day: There is a Clear Relationship Between Multiple 24 Sclerosis and CCSVI Which has Important Implications for Treatment 2:00 pm – 4:00 pm Electronic Abstracts See Below Free Paper Session 4 25 The Basic Science of Thrombosis 28 Varicose Tributaries: When to Treat and How to Treat No Abstracts Available Saphenous Sparing Procedures 29 “Hands-On” Simulation Sessions - Pharmacomechanical Thrombolysis No Abstracts Available “Hands-On” Simulation Sessions - IVC Filter Placement and Retrieval No Abstracts Available “Hands-On” Simulation Sessions - IVUS No Abstracts Available “Hands-On” Simulation Sessions - Compression 30 General Nursing Symposium #1 No Abstracts Available 4:30 pm – 6:00 pm Free Paper Session 5 31 New Anticoagulants and Their Role in VTE No Abstracts Available Ablation Techniques for the Saphenous Veins 33 Chronic Iliofemoral Obstruction 34 Hemodynamic Considerations in Venous Disease 34

WEDNESDAY, SEPTEMBER 11, 2013

7:30 am – 8:45 am Ask the Experts - Ultrasound Evaluation of CCSVI: The Technical Details No Abstracts Available (LIVE PATIENT DEMO) Ask the Experts - How I Treat Iliofemoral Obstruction: Pearls from the No Abstracts Available Masters Ask the Experts - Emergencies in Phlebology: Anaphylaxis, Intra-Arterial No Abstracts Available Injection, Neurological Cardiac Ask the Experts - Management of Lymphedema No Abstracts Available 9:00 am – 11:00 am Free Paper Session 6 39 Society Session: Society of Phlebology and Lymphology Bonaerense 42 Society Session: Society for Vascular Ultrasound No Abstracts Available 9:00 am – 10:30 am Society Session: Association of Phlebology El Salvador 43 Society Session: European Venous Forum - What is New in the Interna- 44 tional Guidelines 2013 on the Prevention of Venous Thromboembolism Society Session: Polish Phlebological Society 45 Society Session: Italian Society of Phlebology 46 Society Session: Korean Society of Phlebology 47 11:30 am – 1:00 am4 UIP Consensus and Guidelines No Abstracts Available

THURSDAY, SEPTEMBER 12, 2013

7:30 am – 8:45 am Ask the Experts - Ultrasound Knobology: How to Optimize Your No Abstracts Available Ultrasound Ask the Experts - Pharmacomechanical Thrombolysis: Tips and No Abstracts Available Techniques Ask the Experts - Venous Anatomy 53 9:00 am – 11:00 am Free Paper Session 7 53 Society Session: Latin American Venous Forum 58 Society Session: Sociedad Argentina de Flebolgia y Linfologia 59 Society Session: Italian College of Phlebology 61 Society Session: Australian College of Phlebology - Frontiers in 62 Phlebology Research 9:00 am – 10:30 am Society Session: Austrian Society of Phlebology 57 Society Session: Canadian Society of Phlebology 58 Society Session: German Society of Phlebology 58 11:30 am – 12:15 pm Invited Lecture: The Diagnosis and Treatment of Pelvic Venous Disor- No Abstracts Available ders 12:45 pm – 2:00 pm4 Controversy of the Day: Both Theoretical Concerns and Clinical Evi- 63 dence Support a Hemodynamic Approach to Super!cial Venous Re#ux 2:00 pm – 4:00 pm Electronic Abstracts See Below Free Paper Session 8 63 The Role of Venoactive Drugs in Venous Disorders 67 Black Box Session No Abstracts Available “Hands-On” Simulation Sessions - Ultrasound-Guided and Surface No Abstracts Available Sclerotherapy “Hands-On” Simulation Sessions - Endovenous Ablation No Abstracts Available “Hands-On” Simulation Sessions - Ultrasound No Abstracts Available “Hands-On” Simulation Sessions - Pelvic Vein Embolization No Abstracts Available General Nursing Symposium #2 67 2:00 pm – 3:00 pm Chronic Venous Disease and Quality of Life – The Time Has Come to No Abstracts Available Choose a Tool 4:30 pm – 6:00 pm Free Paper Session 9 68 Length of Anticoagulation-How Should It Be Determined? No Abstracts Available Recurrent Varicose Veins 70 Deep Venous Interventions 71 An International Perspective on the Management of Venous Ulceration 71

FRIDAY, SEPTEMBER 13, 2013

7:30 am – 8:45 am Ask the Experts - Ultrasound in Super!cial Venous Disorders 75 Ask the Experts - Modern Saphenous Stripping No Abstracts Available Ask the Experts - Lymphatic Microsurgery: Is There a Role? 75 9:00 am – 11:00 am Free Paper Session 10 75 Society Session: Pan American Society of Phlebology and Lymphology No Abstracts Available Society Session: China Association of Phlebology 84 9:00 am – 10:00 am Society Session: Sociedad Venezolana de Flebologia 79 Society Session: Argentinian College of Venous and Lymphatic Surgery 79 Society Session: Paraguayan Society of Phlebology and Lynfology No Abstracts Available Society Session: Italian Society for Vascular Investigation 81 Society Session: Academia Mexicana de Flebologia y Linfologia - Mexi- 81 can Consensus of Sclerotherapy 9:00 am – 10:30 am Society Session: American Venous Forum Symposium 83 11:30 am – 12:15 pm Invited Lecture: The Basic Science of Primary Venous Insuf!ciency 85 12:45 pm – 2:00 pm4 Controversy of the Day: There is a Clear Role for Super!cial Venous No Abstracts Available Interventions in Healing Venous Ulcers 2:00 pm – 4:00 pm Electronic Abstract Competition No Abstracts Available Free Paper Session 11 86 Treatment of Super!cial Venous Thrombosis 89 The Burden of Venous Disease 89 “Hands-On” Simulation Sessions - Pharmacomechanical Thrombolysis No Abstracts Available “Hands-On” Simulation Sessions - IVC Filter Placement and Retrieval No Abstracts Available “Hands-On” Simulation Sessions - IVUS No Abstracts Available “Hands-On” Simulation Sessions - Compression No Abstracts Available 4:30 pm – 6:00 pm Free Paper Session 12 90 New Ablation Technologies 92 Management of Pelvic Veins 92 Controversies in Compression Therapy 92 Complications of Venous Interventions 93 ELECTRONIC ABSTRACTS 97 Sorted by Abstracts # INDUSTRY SPONSORED SYMPOSIA Sorted Alphabetically by Company Bauerfeind Tuesday, September 10, 2013 165 12:30pm – 2:00pm AND Friday, September 13, 2013 12:30pm – 1:30pm BSN medical Wednesday, September 11, 2013 166 4:00pm – 6:00pm BTG Monday, September 9, 2013 167 12:30pm – 2:00pm Covidien Tuesday, September 10, 2013 No Abstracts Available 12:30pm – 2:00pm Juzo Wednesday, September 11, 2013 No Abstracts Available 12:30pm – 1:30pm Medi Wednesday, September 11, 2013 No Abstracts Available 2:00pm – 4:00pm Servier Tuesday, September 10, 2013 167 9:30am – 11:00am STD Pharmaceuticals Thursday, September 12, 2013 No Abstracts Available 12:30pm – 2:00pm Vascular Insights Thursday, September 12, 2013 168 12:30pm – 2:00pm MONDAY, September 9, 2013

XVII WORLD CONGRESS OF THE INTERNATIONAL UNION OF PHLEBOLOGY

anesthesia. Diluted contrast (30-50%) and the double-needle SEPTEMBER 9, 2013 technique are commonly used. Extravasation of sclerosant is likely the cause of the majority of complications. Signs of MONDAY extravasation (geometric smooth or lenticular contrast collection around needle tip and expansion artifacts on venography) should be noted. Hydration (double maintenance), pain control and observation for hemoglobinuria and oliguria are essential compo- ASK THE EXPERTS nents of a safe procedure. The Management of Venous Malformations A.I. Alomari Division of Vascular and Interventional Radiology and The Vascular INVITED LECTURE Anomalies Center, Boston Children’s Hospital and Harvard Medical School, Boston, USA Comparative Effectiveness in the Treatment of Ve- Despite the considerable progress in our understanding nous Disease of the clinical and genetic aspects of vascular anomalies, ad- A.H. Davies, K.J. Williams, T.R.A. Lane vancements in treatment of these challenging lesions are still Academic Section of Vascular Surgery, Imperial College London, UK largely limited to traditional methods. Minimally-invasive interventions largely replaced the traditional surgical approach Venous disease is common worldwide, affecting 35% of the as the !rst line treatment for venous malformations. Myths general population, with incidence increasing with age. It rep- and misconceptions in the clinical practice and published lit- resents a signi!cant health and socio-economic burden. In the erature about the diagnosis and management of these anoma- UK healthcare costs have doubled over the last decade to £126 lies continue are pervasive with frequent adverse consequenc- billion annually, and a similar picture is seen in the USA with es. Managing venous malformations (VM) usually requires the spending now at $1.2 trillion/year, equivalent to over 8% GDP. collaboration of several experienced specialties (interdiscipli- Austerity measures in the UK must be balanced against caring nary approach). for an ever more elderly and frail population, and are a major Venous malformations typically manifesting as solitary drive of research into cost-effectiveness of medical therapies. blood-!lled spongiform lesions and can be dis!guring. Pain is Symptoms of venous disease are often vague and non- chie#y caused by clots, engorgement and articular involvement. speci!c but include aching, discomfort, pruritus and muscle Speci!c morbidities includes joints (e.g. hemarthrosis and de- cramps; however, there are more obvious and objective symp- generation of knee), airways (obstruction), extensive osseous toms which include varicose eczema, pigmentation, bleeding (deformity and fracture) and GI/GU involvement (bleeding). and ulceration. Extensive previous work has shown that ve- Some genetic mutations cause highly characteristic types of nous disease signi!cantly impairs quality of life. VMs such TIE2 in cutaneomucosal venous malformation and The treatment of patients with super!cial venous re#ux Glomulin in glomuvenous malformation. Blue rubber bleb ne- has changed in recent years following the widespread accept- vus syndrome (Bean syndrome) is sporadic with soft tissue and ance of minimally invasive, endovenous modalities including gastrointestinal multiple venous malformations. Fibroadipose ultrasound-guided foam sclerotherapy (UGFS), endovenous vascular anomaly (FAVA), Klippel-Trenaunay and CLOVES laser ablation (EVLA), and radiofrequency ablation (RFA). syndromes are associated with phlebectasia within the affected The treatment of symptomatic varicose veins has been demon- extremity with increased risk of venous thromboembolism. strated to improve quality of life, alleviate symptoms of depres- The management approach for the spongiform VMs is dif- sion and treat the complications of venous disease. Current ferent than phlebectasia. Ultrasonography (US) and MRI are evidence suggests that the treatment of varicose veins at all the most helpful imaging modalities. The most important MR stages of symptomatic disease is cost-effective. In randomised sequences T2-WI with fat-saturation. MR venography is not controlled trials equivalence of endovenous procedures under routinely needed. Treatment should be initiated early in life, local anaesthetic has been shown. RFA was shown to be as- as smaller lesions require less procedures and smaller volumes sociated with less postoperative pain leading to a faster return of sclerosants. to work and therefore a better cost-effectiveness analysis com- Minimally-invasive approaches to VMs include sclerother- pared with open surgery or laser ablation. UGFS remained the apy, laser and photodynamic therapy, embolization of anoma- cheapest option, but was associated with a signi!cantly higher lous phlebectasia and combinations. Of note, none of these recurrence rate at one year. modalities cure VMs. Sclerosing and embolic agents include Varicose veins have a multitude of treatment options, all of dehydrated ethanol, sodium tetradecyl sulfate, bleomycin, N- which provide excellent improvements in quality of life at a butyl cyanoacrylate glue, and coils. cost-effective level. Overall costs have fallen dramatically de- US guidance and an angiographic unit are typically used spite material requirements, and no patient should be without for sclerotherapy for VMs, which is usually performed under a treatment option.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 3 FREE PAPER SESSION 1 diofrequency ablation in 56 limbs, surgery/sclerotherapy/endovenous laser in 436 limbs, sclerotherapy/radiofrequency in Prevention of Endothelin Related Side Effects of 48 limbs, and sclerotherapy/endovenous laser in 377 limbs. Sclerotherapy with Aminaftone Pre-Treatment Injections were ultrasound guided in 92.4%. Sodium tetradecyl sulphate foam was most common, (1:3 or 1:4 dilution, us- 1 2 3 4 4 A. Frullini , E. Da Pozzo , S. Burchielli , F. Felice , R. Di Stefano ing CO2 or O2). Legs were elevated in 64.9%. Less than 5ml 1Studio medico "ebologico, Figline Valdarno-Florence, Italy was injected in 35%, and >16ml in 7%. The GSV was injected 2Department of Pharmacy, University of Pisa, Pisa, Italy 3CNR, National Research Council, Pisa, Italy in 13%, SSV 0.6%, AASV 4%, perforators (thigh 21.5%, knee 4Vascular and Cardiothoracic department University of Pisa, Pisa, Italy 10%, calf 13.5%, ankle 3%) and other veins 32%. Conclusions. Sclerotherapy has established a signi!cant Aim. A possible cause of sclerotherapy complications could role in the management of varicose veins. In a cohort of over be the release of Endothelin 1 (ET 1). We have studied in vivo 6,000 patients across the US, it was utilized in 21% of varicose and in vitro the anti-ET1 action of Aminaftone (AMNA). vein procedures either as a stand-alone technique, or in con- Methods. We studied 3 groups of rats treated with po- junction with other modalities. lidocanol (POL) sclerotherapy: the group C, control, and the groups G1 and G2, that received respectively a 30mg/kg/die or a 150mg/kg/die of AMNA for 15 days before sclerotherapy. In vitro studies were performed on HUVEC cells: cells surviv- Neovascularisation and Dilated Pre-Formed Veins al was analyzed in presence of AMNA and POL at different at Saphenofemoral Junction - Therapy with Duplex concentrations, and ET 1 level measurement was performed Guided Foam Sclerotherapy through an immunoenzymatic assay. S. Kaspar Results. Rats in group C showed an early mortality of 40%. Flebocentrum, Hradec Kralove, Czech Republic This value was only 13,3 % and 20 % in group G1 and G2. The treatment with AMNA 6µg/ml did not affect HUVEC viability. Aim. Patients who undergo traditional surgery for varicose After POL 0,05% and 0,5% treatments, HUVEC were viable veins involving the groin quite often develop recurrent varices. in 44,36 % and 2,25% respectively. After AMNA pre-treatment The neovascularisation is considered to be one of the leading and POL treatment, ET 1 cellular release was signi!cantly low- causes of recurrence. The aim of this study is summarisation er after 6 (p<0.01) and 12 hours (p<0.05) in respect to control of our results of duplex guided foam scleroterapy (DGFS) of without AMNA. the groin neovascularization Conclusions. This study con!rms ET 1 release after scle- Methods. DGFS was used to treat 68 limbs with groin recur- rotherapy and lower in vivo mortality in G1 and G2 groups rence of neovascularisation origin. Foam was prepared with gives us a clue of ET-1 possible role in generating side effects. 1-2% polidocanol mixed with 4 time its volume of room air. Aminaftone has been proven to be effective in inhibition of ET Foam was injected under ultrasound guidance directly to re- 1 release from endothelial cells after sclerotherapy. No other current varices through butter#y needle or through long cath- conclusion can be made at this moment on a possible role of eter just before endothermal ablation in case of residual re- anti-endothelin drugs in the prevention of sclerotherapy side #uxing saphenous trunk. Ambulatory phlebectomy of varicose effects. tributaries was performed in all cases. All procedures were performed under tumescent local anaesthesia in an ambulatory setting. Patients were assessed clinically and by colour duplex ultrasound after 5 and 30 days and then after 6 months. Sclerotherapy for Chronic Venous Insuf#ciency: A Results. 52 limbs showed complete obliteration of neovas- Report from the American Venous Registry cularisation, in 9 limbs re#ux in the groin was reduced signi!- J. Almeida1, L. Kabnick 2, T. Wake!eld 3, J. Raffetto 4, R. McLafferty 5, P. cantly and in 7 cases no change was observed at the groin on Pappas6, J. Blebea7, D. Gillespie8, B. Lal9 ultrasound. No visual disturbances, nor deep venous thrombo- 1Miami Vein Center, Miami, FL, USA sis and pulmonary embolism were detected during the follow- 2NYU Langone Medical Center, New York, NY, USA up. 3University of Michigan Hospitals & Health Centers, Ann Arbor, MI, USA Conclusions. We suggest that ultrasound guided foam scle- 4Vascular Surgery Division VA Boston Healthcare System Surgery 112, rotherapy should be the !rst-line treatment for groin neovas- West Roxbury, MA, USA 5Southern Illinois University Healthcare, Spring#eld, IL, USA cularisation except when duplex scanning reveals an intact in- 6Brooklyn, NY, USA competent saphenous stump at the saphenofemoral junction 7University of Oklahoma at Tulsa, Tulsa, OK, USA with a massive re#ux !lling the peripheral varicose network 8Division of Vascular Surgery University of Rochester, Rochester, NY, USA which means the technical error of the previous surgical pro- 9University of Maryland Medical Center, Baltimore, MD, USA cedure. Aim. Minimally invasive procedures for the treatment of venous disease have been rapidly adopted across the USA during the past decade. We analyzed data from the Varicose Vein Treatment of Bilateral Saphenous Vein Re"ux and module of the American Venous Registry (AVR) to identify the relative frequency and technique of sclerotherapy used for the Associated Varicose Veins in One Session Under treatment of varicose veins. Local Anaesthetic Without Sedation: 5 Year Experi- Methods. The AVR is a cooperative registry of venous pro- ence with 12 Month Follow Up cedures contributed by multiple specialties including vascular H. Gajraj surgeons, general surgeons, interventional radiologists and The Veincare Centre, Dorset, United Kingdom others. De-identi!ed data was obtained from this web-based registry at 37 sites with 6,253 vein ablation procedures be- Aim. It is unclear whether saphenous vein re#ux and its tween 2007-2012 in 6,149 patients. This report represents an associated varicose veins should be treated simultaneously analysis of 1,307 procedures where a sclerosant was utilized or as staged procedures. It is also unclear, whether bilateral alone or in conjunction with additional procedures. venous disease should be treated one leg at a time on sepa- Results. Isolated sclerotherapy was used in 352 limbs, rate occasions. This study investigates the outcome of a policy surgery/sclerotherapy in 38 limbs, surgery/sclerotherapy/ra- of treating bilateral saphenous vein re#ux and varicose veins

4 INTERNATIONAL ANGIOLOGY October 2013 in one session under local anaesthetic without sedation by a at 7 days and 12 months. VCSS and AVVQ scores were meas- combination of endovenous thermal ablation, phlebectomy ured preoperatively and after 12 months. Follow up is sched- and foam sclerotherapy. The outcome was measured by pa- uled for 5 years tient satisfaction surveys, recurrence of re#ux as judged by du- Results. Three hundred and !fty GSVs in 312 patients were plex ultrasound and by the need for secondary procedures as randomized for Radial Fiber Biolitec AG (n= 174)and Covidi- requested by the patients. en ClosureFast ( n=177). There was no difference in VAS pain Methods. Patients presenting with bilateral saphenous scores during the !rst 14 days (VAS mean 0.54-2.19). Partial vein re#ux and varicose veins (C2-C5) to an ambulatory ve- recanalization was observed after 1 ClosureFast procedure nous clinic between 1st February 2007 and 31st January 2012 and 1 total recanalization occurred after radial EVLA. Total were prospectively studied. Patients with C1 and C2 disease primary occlusion rate after 12 months was 99,0 % after both were excluded. Treatment was by a combination of endov- treatments. No SAEs were observed. Average VCSS and AVVQ enous thermal ablation, phlebectomy and foam sclerotherapy had similar improvements after 12 months. VCSS ClosureFast under tumescent local anaesthesia. Operating time, local an- preop :3,7 ( SD 2,0), 12 months:2,0 ( SD 1,9). Radial EVLA pr- aesthetic volume, number of phlebectomies and foam sclero- eop :4,0 (SD 2,3), 12 months: 2,1 ( SD 1,9). AVVQ ClosureFast sant volume were recorded. Patients were reviewed at 6 weeks, preop: 11,4( SD 8,3) ,12 months: 5,4 (SD 5,5 ). Radial EVLA 6 months and 12 months by clinical photography, duplex ul- preop 13,0 (SD 9,7), 12 Months 4,8 ( SD 5,6) trasonography, patient satisfaction surveys and the need for Conclusions. RFA ClosureFast and Radial Fiber EVLA were further treatment. Phlebectomy sites were reviewed at 48-72 both equally effective and associated with minimal postpro- hours for redressing. cedural pain. Clinical and quality-of-life improvements were Results. 207 patients were studied: 148 patients had bi- similar after 2 weeks and 12 months for the two treatments. lateral great saphenous vein (GSV) re#ux; 42 had bilateral small saphenous vein (SSV) re#ux: 13 had bilateral GSV and unilateral SSV re#ux; 4 had bilateral GSV and SSV re#ux. Follow-up was complete in 201 patients (97%). The median Incidence of Accessory Vein Re"ux in the Long operating time was 90 minutes (range 65 – 145), median local Term Follow-Up after Endovenous Laser Ablation of anaesthetic volume was 950 ml (range 550- 1000ml ), median Great Saphenous Vein foam sclerosant volume was 16ml ( range 8-20ml), the median P. De Zolt 1, D. Kontothanassis2, N. Labropoulos3 number of phlebectomies was 32 (range 9-42). In 6 patients 1 it was not possible to perform endovenous thermal ablation Istituto Flebologico Italiano, Ferrara, Ferrara, Italy 2Istituto Flebologico Italiano - MediClinic Hospital, FERRARA, Italy for technical reasons and the saphenous re#ux was treated by 3Stony Brook University Medical Center, Stony Brook, NY, USA foam sclerotherapy. At 12 months, 5 patients had developed recurrent re#ux in the treated saphenous vein and this was Aim. Determine the true incidence and clinical outcome of subsequently treated by foam sclerotherapy. Eleven patients accessory vein re#ux in the long term follow-up after endov- required additional treatment of varicose veins within the 12 enous Laser ablation (EVLA) of great saphenous vein (GSV). month period. At 12 months follow up, 185 patients (92%) had Methods. Patients with chronic venous disease CEAP class successful treatment of bilateral saphenous vein re#ux and as- 2 or higher that had EVLA and minimum 5 years follow-up sociated varicose veins in a single session. At 12 months, 190 were included. Clinical examination and duplex scanning of patients (95%) were either very or completely satis!ed with the lower extremity veins were performed prior to treatment the Results. and at the last follow-up. A detailed venous re#ux map was Conclusions. Treating bilateral saphenous re#ux and asso- constructed. Ablations were performed with a 980 nm Laser. ciated varicose veins simultaneously under local anaesthetic Patients’ clinical characteristics, presence and re#ux of acces- without sedation by endovenous thermal ablation, phlebecto- sory vein were recorded in detail. my and foam sclerotherapy is effective with high patient satis- Results. There were 58 patients, 45 females, mean age 50 faction and a low re-intervention rate. Reference - Schanzer H. years (range 29-69), mean BMI 26.4 kg/m2 (range 19.1-43.9), Endovenous ablation plus microphlebectomy/sclerotherapy having a mean follow up of 88 months (range 66-110). Before for the treatment of varicose veins: single or two-stage proce- EVLA a continent accessory vein was found in 10 (17.2%) pa- dure. Vasc Endovasc Surg 2010; 44(7): 545-9 tients. Patients treated for re#ux of accessory were excluded. At the !rst follow-up, duplex scanning con!rmed the presence of 10 competent accessory vein and the absence of re#ux. In the last follow-up 3 (5.1%) accessory vein had become incom- 12 Months Follow-Up of a Randomized Study Com- petent. Only 1 (1.7%) patient with accessory vein re#ux was paring Endovenous Occlusion of the Incompetent symptomatic and was treated with sclerotherapy. Great Saphenous Vein with Radial EVLA (1470nm) Conclusions. After a detailed duplex scanning we found a Versus RFA ClosureFast high prevalence of accessory vein in patients treated of GSV J. Lawson1, C. Vlijmen1, S. Gauw1, M. Mooij2 EVLA. In a long term follow-up only few patients developed a new disease of accessory vein (5.1%), were symptomatic and 1Skin and Vein Center Oosterwal, Alkmaar, Netherlands 2Centrum Oosterwal, Alkmaar, Netherlands only 1.7% required a new treatment. There is no need to treat simultaneously a competent accessory vein during EVLA of Aim. Thermal saphenous ablation with RFA ClosureFast has GSV in order to prevent recurrences in the follow-up. a smooth recovery and minimal postoperative pain scores in comparison with bare tip laser !ber. The use of radial laser !ber should have a better recovery pro!le than bare tip !ber. A comparison between RFA ClosureFast and Radial EVLA is needed Long Term Physical and Qol Follow-Up for Different Methods. A prospective randomized study was conducted C2 Treatments at a single center between October 2010 and August 2012. F. Catarinella 1, C. Wittens2 Thermal ablation with RFA ClosureFast and Radial Fiber were 1Maastricht University Medical Centre, Maastricht, Belgium done under tumescent anesthesia without sedation. Post-in- 2Eben Emael, Belguim terventional compression stockings were used for 1 week. Var- icose tributaries were treated by sclerotherapy after 1 week. Aim. Investigate the long term (+10 years) Quality of Life Duplex ultrasound and clinical examination were performed effects of super!cial (C2) varicose vein treatments. Since: Ef-

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 5 fect on QoL is established CVI has signi!cant negative impact The Impact of Depression and Anxiety on the Per- on QoL Treatment improves QoL in short term Progression ception of Success and Satisfaction Following Vari- is proven But: Most C2 studies focus on clinical signs / CEAP cose Vein Interventions No(t) (many) long term studies Long term effect of treatment H. Moore1, J. Shalhoub2, T. Lane3, A. Davies2 on QoL not clear 1Academic Section of Vascular Surgery, Imperial College London, Lon- Methods. 2 multicenter RCT’s (started in 2002) compar- don, London ing endovenous to classic stripping: Cryo: 191 patients VNUS: 2Academic Section of Vascular Surgery, Imperial College London, Lon- 93 patients Classic strip: 272 patients Total: 556 patients QoL don, United Kingdom evaluation with AVVQ and SF-36, pre intervention, after 6 3London, United Kingdom months and after 10 years Duplex ultrasound examination after 10 years. 213 patients completed the whole follow-up so Aim. Patient reported outcome measures (PROMs) have far. Follow-up is still ongoing. been collected on all patients undergoing varicose vein treat- Results. AVVQ avg pre op: 14.83, after 6 months: 8.27, af- ments in the UK National Health Service (NHS) since 2009. ter 10 years: 10.22 P =. 000 AVVQ per treatment type: Cryo: The aim of this study was to examine PROMs for varicose vein pre op: 15.12, after 6 months: 9.00, after 10 years: 11.37 Clas- interventions, and the impact of depression and anxiety on pa- sic strip: pre op: 14.58, after 6 months: 6.82, after 10 years: tient reported perception of success and satisfaction. 9.12 VNUS: pre op: 14.90, after 6 months: 10.51, after 10 Methods. Centrally-compiled PROMs data for varicose years: 11.30 P = ?, to be determined after all patients have vein procedures carried out within the NHS from 2009-2011 been analyzed. Additional super!cial treatment during the 10 was obtained from the Hospital Episode Statistics data ware- years of follow-up leads to a HIGHER AVVQ end score. No house for England. Statistical analysis was performed using additional super!cial treatment during the 10 years of follow- Prism (version 5.0c). up leads to a lower AVVQ end score. Duplex pre op: CRYO: Results. Data for 35,093 patient episodes (63% female) was 21.4% insuf!cient SFJ Classic strip: 19% insuf!cient SFJ P available for analysis. As data was not normally distributed, =. 314 Duplex after 10 years: CRYO: 27.9% insuf!cient SFJ non-parametric statistical tests were employed. 7.8 per 10,000 Classic strip: 9.8% insuf!cient SFJ P =. 008 Other treatment reported a diagnosis of depression. Quality of life, by all meas- types yet to be analyzed. ures employed, improved post-intervention as compared with Conclusions. Progression is unavoidable: - Clinically (Bonn pre-intervention (Wilcoxon matched-pairs signed rank test, Vein I/II) - QoL (this serie) Even with treatment in between. p<0.0001). In individuals reporting pre-procedural moderate QoL decreases dramatically in 10 years. to extreme anxiety or depression, this signi!cantly improved with intervention. Levels of patient reported perception of success and satisfaction were signi!cantly increased with increasing pre- and post-intervention self-reported depression and anxiety (Kruskall-Wallis test, p<0.0001). Patient Follow-Up after Varicose Vein Interventions Conclusions. This analysis reinforces the evidence that in the UK – The View of Surgeons, General Practi- varicose vein interventions improve quality of life, anxiety and depression. Individuals with depression and anxiety appear to tioners and Patients derive particular bene!t; this should be considered when as- H. Moore1, K. Adesina-Georgiadis2, T. Lane3, A. Davies4 sessing patients for intervention. 1Academic Section of Vascular Surgery, Imperial College London, Lon- don, London 2Imperial College London, London, United Kingdom 3London, United Kingdom 4Academic Section of Vascular Surgery, Imperial College London, Lon- PRACTICAL ASPECTS OF LYMPHEDEMA don, United Kingdom Lymphatic Involvement in Venous Disease Aim. Following varicose vein interventions in the UK, pa- H. Partsch tient follow-up practices are changing, and increasingly, GPs Emeritus Professor of Dermatology, Medical University Vienna, Austria are seeing these patients. This study aims to establish who should carry out follow up. Aim. To demonstrate morphological and functional abnor- Methods. In 2012-3, a survey of GPs, surgeons and patients malities of lymphatics in patients with chronic venous disease. before varicose vein interventions was carried out, to assess Methods. Data are available from patients with venous how, where and by whom they feel they should be followed up. edema (CEAP C3), lipodermatosclerosis (C4) and with venous An online survey program was employed. ulceration (C6) mainly due to postthrombotic syndrome. Iso- Results. 112 Surgeons, 110 GPs and 40 patients replied topic lymphography after injection of radio-colloids into dif- to date. 64% of surgeons, 49% of GPs and 18% of patients ferent injection sites has been used to assess lymph drainage did not expect routine follow-up by the surgical team, but in a semi- quantitative way. In addition we performed indirect 40% of surgeons, 50% of GPs and 75% of patients felt the lymphography using water soluble contrast media to assess surgical team should. If complications occurred, 94% and morphologic aberrations of initial lymphatics and of lymph- 96% of surgeons and GPs felt that the surgical team should collectors in areas of compromised skin. follow-up the patient. 66% of surgeons felt that there was no Results. Venous edema is typically characterized by an in- need to follow-up all patients, but half felt that follow-up by crease of pre-fascial lymph drainage showing enlarged lymph the GP or no-one was inadequate. 42% of GPs felt they were collectors and increased peristaltic propulsion of the dye. con!dent to follow up patients but would need additional Indirect lymphography performed in the areas of lipoder- funding, 21% felt they would need training, 26% felt they matosclerosis shows irregular initial lymphatics with extrava- would not be happy to follow up these patients. 80% of pa- sations, but at the same time normal or even enlarged lymph tients felt that all should be seen by their surgical team after collectors proximal to the skin changes, compatible with a lo- any procedure. calized lymphedema. Conclusions. This survey highlights that if practice is fol- In venous leg ulcers lymphatics are ruptured, sometimes low-up practice is changing towards either GP or no follow-up lymph can be shown oozing from the skin defects. following varicose vein procedures, additional measures must Postthrombotic syndrome, but also acute deep vein throm- be in place for education to ensure safety, and patient informa- bosis is characterized by a disturbed sub-fascial lymph-trans- tion should be improved. port which can be improved by compression therapy.

6 INTERNATIONAL ANGIOLOGY October 2013 “Venous lymphedema” was described in recent literature in poorest chance for recanalization on anticoagulation alone. patients with morbid obesity and in proximal venous obstruc- The reason is the underlying most often left sided iliac com- tion which may be reversible after iliac vein stenting. pression syndrome. The catheter system allows precise ma- Conclusions: 1. Chronic venous insuf!ciency (CEAP C3- nipulation most often through the popliteal vein and permits C6) is invariably connected with lymphatic disturbances cor- placement of stents to abolish the obstructive lesions in the responding to a “chronic veno-lymphatic insuf!ciency”. 2. iliac vein during the procedure. The method has mostly been Phlebo-lymphedema due to venous insuf!ciency can be con- used for acute episodes of iliofemoral DVT according to the sidered as a precursor of skin changes and chronic in#amma- de!nition meaning thrombus not older than 14 days. The as- tory tissue changes which may ultimately lead to open legs. 3. sumption of reversible endothelium damage within that peri- Lymphatics are always involved in any kind of edema. Long od of time underlines this strategy. Recombinant t-PA has been standing edema of any pathology (“chronic edema”) is a sign the most used lytic agens because of its short life-time, making of a functional decompensation of the lymph drainage. 4. Ad- the procedure safe avoiding systemic in#uence if a decrease ditionally there is also an organic damage of lymphatics in the in the plasma !brinogen occurs. There has in the last 10 years ulcer region. 5. Reduction of edema by compression is a major not been published any death connecting to the procedure if target in patients with phlebo-lymphedema. the safety prescriptions have been followed. The hope with CDT is to obtain competent veins meaning patent veins with functional valves and in the long run positive in#uence of occurrence of post thrombotic syndrome (PTS). Common Reasons for Leg Swelling What about the results? There are several publications dur- M.L. Flour ing the years with most often positive results and only few with long-term follow-up. Among these our own results from Dermatology Department, K.U.Leuven University Hospital, Leuven, Bel- gium Copenhagen showing competent veins of 87 % after 5 years in 109 lower extremities. PTS is reduced to a level less than Common reasons for systemic oedema with prominent leg 20% with QOL worse than the patients with competent veins. swelling are cardiac, hepatic, or renal insuf!ciency, protein A meta-analysis from 2011 based on 4 RCT´s favors the risk of de!cit or drug induced swelling. Endocrinopathies that may annulment of venous obstruction, 2 RCT´s favors reduction of induce or exaggerate leg swelling are often overlooked; they in- PTS and 2 RCT´s with a trend of reduction in the risk for ve- clude obesity, metabolic syndrome, diabetes or thyroid disor- nous re#ux, all about CDT compared to anticoagulation alone. ders. In these situations, as well as in lipoedema, tissue chang- A recent publication has found that only 15 % of patients es are part of the problem. Unilateral or bilateral leg swelling with iliofemoral DVT suitable for CDT were referred to treat- are most often due to lymphatic failure in situations of high ment. This is a disappointing experience since the CDT proce- or low output needs, and/or due to disturbances of the venous dure is bene!cial compared to anticoagulation. return as is the case in chronic venous insuf!ciency, deep venous thrombosis and it’s sequellae, or in the case of a failing venous pump like in stasis, inappropriate compression, com- COSMETIC SCLEROTHERAPY OF LEG VEINS partment syndrome, or immobility due to several causes. In vascular malformations with or without overgrowth of tissues, Compression After Cosmetic Sclerotherapy: Critical leg swelling may be one of the presenting symptoms. Complex Evaluation of the Evidence neuro-vascular functional disturbance is a well-known mecha- P. Kern 1, A.A. Ramelet2 nism of swelling in re#ex sympathetic dystrophy and probably 1Private of#ce of vascular medicine Vevey and Service of Angiology Uni- also partially in erythromelalgia. Chronic in#ammatory disor- versity Hospital, Lausanne, Switzerland ders, and chronic or recurrent infections or parasitic infesta- 2Dept of Dermatology, Bern, Switzerland tions are frequent causes especially in endemic territories. A systematic clinical examination and a comprehensive per- Whether medical compression stockings (MCS) improve sonal and familial history taking will support the alert clini- the results of sclerotherapy for telangiectasias has been long cian in the distinction of several types of leg swelling. Referral debated. Nowadays, several studies demonstrate a bene!t for for multidisciplinary assessment and differential diagnostic MCS in this indication. investigations may be crucial for con!rmation of a suspected Effectiveness was shown for telangiectasias greater than 0.5 clinical diagnosis. mm in diameter (Goldman 1990) and the best effects were observed in patients wearing MCS 20-30 mmHg for three weeks (Weiss 1999). Post-sclerotherapy pigmentations were signi!- cantly reduced. In a prospective study (Kern 2007), patients RESOLUTION OF VTE: were randomized after one session of sclerotherapy with chro- NATURAL, ANTICOAGULANT mated glycerin for telangiectasias on the lateral aspect of the AND PHARMACOMECHANICAL thigh (C 1A or SEPAS1 PN) either to wear daily for three weeks MCS 23 – 32 mmHg or no compression. Two blinded experts could analyse digital photographs of 96/100 patients. The objective Thrombus Resolution with Lytic Therapy rating of vessel disappearance was signi!cantly better with N. Bækgaard compression (p=. 026). Poor results were more frequent in the Vascular Clinic, Gentofte University Hospital, Copenhagen, Denmark no compression group (43% versus 24% with a score <6/10, 10 marks an excellent result). Micro-thrombi were less prevalent in Lytic therapy has been known for several decades, but only the compression group (10% versus 15.2%). A subsequent study in the last two decades the principle of catheter-direceted (Nootheti 2009) comparing 1 to 4 week MCS con!rmed that thrombolysis (CDT) has become an alternative treatment mo- longer is better, it showed a signi!cant reduction of post-scle- dality for some types of DVT in the lower extremities. With rotherapy pigmentations when MCS was worn 3 weeks more. application limited to the thrombus alone thereby minimizing In conclusion, instead of foam sclerotherapy of saphenous the universal in#uence known from the systemic treatment is veins where the evidence of ef!cacy of wearing compression is minimized. CDT has especially been introduced for treatment still lacking, there is now strong evidence that wearing MCS of DVT with involvement of the iliofemoral segment while this after sclerotherapy for telangiectasias enhances signi!cantly segment having most importance as the out#ow tract and the the results of the treatment. This results from improved clini-

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 7 cal vessel disappearance and/or reduced rate of pigmenta- Methods. We propose a standardized report of venous tions. Last but not least MCS not only ensure a better success ultrasound which includes the following: 1). Reason for the of sclerotherapy for telangiectasias but limit also failures. study 2). Details of the equipment with which the study was conducted 3). Patient’s condition and whether it was standing or lying (elderly, obese, etc.) 4). Picture or drawing of varicose veins, ulcers or tentative !ndings 5). Systematic description NURSING SYMPOSIUM – BEYOND BASICS of the venous system emphasizing: a). permeability, b). Re- #ux after Valsalva´s maneuver, c). Further details like: diam- Leg Ulcers: Warning Signs, Prevention, and Treat- eter, thickness of wall, intensity of re#ux, etc. To complete the ment study a big draw of the !ndings with a color system or symbols M.Y. Sieggreen showing Obstruction, re#ux, varicose veins, etc. Harper University Hospital, Detroit Medical Center, Detroit, MI, USA Results. Initial tests show uniformity in the application of the method Venous ulcers have been recognized for centuries. Scien- Conclusions. The UIP has published two venous Ultra- tists in this century are still searching for effective methods to sound consensus and guidelines to perform USG Venous prevent and treat these ulcers. With proper intervention this study, however the report is hardly a third of a page of the !rst manifestation of venous disease can be managed. This pres- consensus. The main importance of consensus in the USG VE- entation reviews the most current evidence based practice for NOUS REPORT is that when the study is reviewed by another venous ulcer prevention, risk factors, and treatment. doctor, or the patient become in a case study and the attending physician is not the same person or when is legally required to prove the provenance, and pre-existence or venous system FREE PAPER SESSION 2 status prior to a procedure is needed. It is undisputed the need for a consensus on venous ultrasound Heritability of Chronic Venous Disease D. Fiebig Kompetenznetz Chronische Venenkrankheiten, Kiel, Germany Sourcing Based Diagnosis of Severe Venous Leg Ul- cers Aim. Genetic risk factors are thought to play an important A. Obermayer role in the etiology of chronic venous disease (CVD). We evalu- Karl Landsteiner Society, Institute of Functional Phlebologic Surgery, ated the genetic impact upon CVD by estimating the heritabil- Melk, Austria ity. Methods. All index patients were classi!ed using the CEAP Aim. Finding the cause of atypical and severe venous leg ul- classi!cation. Preoperative diagnostic tests included Doppler cers is often dif!cult and tedious. We demonstrate a very help- evaluation of the great and small saphenous veins as well as ful and simple method of duplex investigation called “sourc- venous duplex sonography. The genetic contribution was as- ing” to !nd the responsible re#ux routes causing local venous sessed by estimating the heritability of the disease using a hypertension: the direct cause for leg ulceration. pedigree-based likelihood approach as implemented in the Methods. By manual compression of the ulcerated area SOLAR software package. The statistical signi!cance was as- the underlying capillaries and veins are emptied. When com- sessed by means of a likelihood-ratio-test. pression is released the blood column swings back to re!ll the Results. Family information was provided by all 2,701 in- empty veins and the pressure in the ulcerated tissue increases dex patients which generated 4,033 nuclear families, compris- immediately. We call this up and down movement which can be ing 16,434 individuals from all over Germany. The narrow- repeated at discretion “swinging blood column”. During inter- sense heritability of CVD equals 17.3% (standard error 2.5%. mittent manual compression of the venous ulcer this “swing- likelihood ratio test P = 1.4 x 10-13. The proportion of disease ing blood column” can be followed by scanning upwards to its risk attributable to age and sex, the two main risk factors for connection with the deep venous system: the saphenofemoral, CVD, was estimated as 10.7% (Kullback-Leibler deviance R2). saphenopopliteal junction or to an incompetent perforator. 169 The mean ascertainment age of our patients was 56.2 years ulcers presenting with venous re#ux were investigated. (SD) 11.1 years, range 18 – years. No signi!cant age difference Results. Every !fth venous ulcer was caused by a crossover was observed between the two sexes. re#ux pattern corresponding to “extraterritorial ulcers”: 46% Conclusions. The heritability of CVD is high. Suggesting of lateral ulcers were caused by an incompetent great saphen- a notable genetic component in the etiology of the disease. ous vein and 11% of medial ulcers by an incompetent small Heritability was found to vary only little with disease severity saphenous vein. 20% showed no clinically visible varicose (from 18.5% (C2) to 16.7% (C4)). We revealed a statistically veins. There was no correlation between the severity of ulcer signi!cant association between a higher CEAP grade and an disease and the diameter of incompetent veins. older current age of patients. An inverse relationship was ob- Conclusions. “Duplex-Sourcing” for detecting the origin served between a higher CEAP grade and an older current age. of the local venous hypertension is essential for proving the venous nature of leg ulcers and for planning rational steps of management. The Need of a Consensus On Venous USG Report, Its Reasons F. Vega Rasgado 1, C. Lemoine Piñones 2, M. Salinas P. 3, M. Vega Díaz 4, The Different Sources of Re"ux of the Incompetent L. Vega Rasgado5 Great Saphenous Vein. Duplex Scan Examination. 1 Academia Mexicana de Flebología y Linfología, Tlalnepantla, Mexico F. Vin 1, S. Muller2 2Academia mexicana de Flebología y Linfología, México, Mexico 3Clinica de Várices y Ulceras de México, México, Mexico 1American hospital of Paris, Neuilly Sur Seine, France 4E.N.C.B., I.P.N., México, Mexico 2Neuilly Sur Seine, France 5E.N.C.B., México, Mexico Aim. Duplex scan examination of the groin in patient with Aim. Highlight the urgent need for consensus on the report incompetence of the great saphenous veins at the middle of of venous ultrasound the thigh to locate the source of re#ux.

8 INTERNATIONAL ANGIOLOGY October 2013 Methods. 1049 patients with varicose veins in the greater were calculated for the complete sample and for each group. saphenous veins aera were checked by duplex scan examina- To make the samples comparable with the series of Gibson tion. All the patients had an incompetence of the great saphen- et al a subanalysis of Group 2 with C max between 2 and 5 ous trunk in the saphenous compartment. Patients with deep was performed. Data analysis was performed with Statistical venous thrombosis were not included in the study. Package for the Social Sciences (SPSS) 13.0. To compare sub- Results. Among 1049 incompetence of the great saphen- groups, chi- squared tests for nominal and t-tests for paramet- ous vein, the population was 79% female and 21% male. 655 ric data were applied. Pearson correlations were calculated to patients (62.4%) had a re#ux of the sapheno-femoral junction compare vein diameters with other parameters. A p < 0.05 was (46.3% terminal and 16.1% preterminal). In 10.5 % of the cas- considered signi!cant. A stepwise regression analysis was con- es the re#ux come from pudendal veins, 3.1% from inguino- ducted to calculate the in#uence of GSV diameter on VCSS abdominal wall, 1.9% perforating veins ,1.9% Giacomini vein, independently from other affecting variables. 1.2% lympho-nod network and in 14.7% of the cases associa- Results. 120 legs were included, 39 without re#ux (Group tion of different sources of re#ux 1) and 81 with re#ux (Group 2). 25 male legs (Goup. 1: 7 / Conclusions. In this study, the source of re#ux of the great- Group. 2: 18) and 95 female legs (Group 1: 32 / Group 2: 63), er saphenous vein is the sapheno-femoral junction in only 57 right legs and 63 left legs. Mean age was 54.9 years over all 62.4% of the cases. The other sources of re#ux are the puden- (21 – 89 years, SD ±14.0), Group 1: 54.6 years mean and Group dal veins and the association of different sources of re#ux. The 2: 55.1 years mean. Mean BMI was 26.97 ranging from 18.8 re#ux into the lympho-nod network is found in only 1.2% of to 45.4, SD 5.79. BMI Group 1: 26.07 Group 2: 27.40. No dif- the cases. ference was found between the groups for these parameters. Mean re!lling time after muscle pump activation was 26.97 ranging from 4 to 48 seconds with SD ± 12.65. Group 1: 34.3 Correlation Between Great Saphenous Vein Diam- seconds mean, Group 2: 23.45 seconds mean, difference being eters and Venous Clinics Severity Score signi!cant with p<0.0001. Within Group 2 (re#uxive) 31 legs E. Mendoza had an above knee re#ux only and 50 an above and below knee re#ux in GSV. In 32 legs we found an incompetent terminal Venenpraxis Wunstorf, Wunstorf, Germany valve with re#ux emerging from the deep vein (Type A). 43 legs presented with competent terminal valve and re#ux emerging Aim. Varicose veins are very variable, clinics do not cor- from tributaries (Type B). In 6 cases we found the re#ux was relate to the extent of visible veins and may be in#uenced by emerging from both sources – deep veins and tributaries, both other factors. So “hard facts” are deserved to help decision valves incompetent in these patients (Type C). Venous clinics making in order to recommend a treatment to the patient. severity score was 3.56 over all ranging from 0 to 23, SD: ± There is still a controversy concerning the value of GSV diameter to determinate the degree of the illness with two contra- 4.04. Group 1: mean value 0.90 (0 – 6), Group 2: mean value dictory recent publications (Gibson JVS 2012; 56(6):1634-41, 4.84 (0 – 23) (difference signi!cant p<0.0001) Mean value for EJVES 2013; 45: 76-83). As the diameter is a parameter easy to maximum C score (C max) was 2.35 (0 – 6), SD 1.32. C max assess it is used widely for preoperative evaluation in venous in group 1 was 1.74, in Group 2 2.65. Difference signi!cant treatment studies. The aim of this work is • To analyze the at p<0.0001. Correlation between results (Pearson) – applied correlations between diameter of GSV at SFJ and at proximal to all participants, to Group 1 only, to Group 2 and to a sub- thigh with Clinics (C) and VCSS • To analyze the contradiction group of Group 2 with C max between C2 and C5 (see table of both publications • To propose standardized measurement 1): All legs (Group 1 and Group 2, N=120) Weak correlation points for the future between Cmax and age and between weight and BMI and di- Methods. After getting the approval of the local ethics com- ameters. Median correlation between weight and Cmax and mittee consecutive patients of our of!ce between July and Sep- VCSS, nearly same result for BMI. Re!lling time correlates tember 2012 having a consultation for a possible venous dis- moderately with diameters, C and VCSS. Re#ux source cor- ease or a treament on varicose veins ,willing to participate and relates moderately with diameters and Cmax as well as VCSS. meeting the following exclusion and inclusion criteria were Diameter at the groin correlates strongly with the diameter at enrolled. Inclusion criteria: • Age over 18 years Exclusion cri- proximal thigh (r=0.738) and moderately with C and VCSS. Di- teria: • pregnancy • severe disease making it impossible to be ameter at proximal thigh correlates slightly better with VCSS upright for 5 minutes • prior treatment of leg veins • prior or and Cmax than diameter at the groin. Cmax and VCSS show acute deep or super!cial vein thrombosis • re#ux only in the a strong correlation with r=0.727. (Fig 1 and 2) Correlations short saphenous vein Patients were investigated in standing in Group 1 (N=39) are very weak, only remarkable correla- position with a Fuji Fazone Ultrasound device and a 7.5 MHz tion is between the diameters themselves, as well as between linear probe by one single experienced investigator. Clinical BMI and C max (r=0.429). Interestingly, the re!lling time cor- exploration and patient interview were performed, CEAP and relates with the VCSS (r=0.455) even though this group has VCSS were classi!ed by the investigator. Duplex Ultrasound healthy GSV. Correlation between Cmax and VCSS shows an was conducted to !nd exclusion criteria. Included legs were r=0.544. Correlations in Group 2 (N=81): Nearly all above de- classi!ed into non re#uxive GSV (Group 1) or re#uxive GSV scribed correlations are slightly weaker if not compared with (Group 2), cutoff time for re#ux was 0.5 seconds. In all cases healthy legs. Nevertheless the strongest correlation found is the diameter of GSV was measured at two places: Maximum between diameter at proximal thigh and Cmax (r=0.532) and GSV diameter within the !rst 5 cm of the SFJ (groin) and VCSS (r=0.557). Correlation between Cmax and VCSS is very diameter 15 cm footwards to the SFJ at the proximal thigh strong with r=0.794. Correlations in the subgroup of Group 2 (PT) as well as re!lling time after muscle-pump activation was corresponding to Gibson’s work (Cmax 2 – 5) (N=72) In this determined in all investigated legs (Elcat Vasoquant). In case group the mean diameter at the groin was 10.32 mm and a the of re#ux the following data was collected: • Origin of Re#ux: proximal thigh 6.28mm. Correlation between diameter at the A - deep vein through incompetent terminal and preterminal groin and the proximal thigh with Cmax is still moderate with valve B - from tributaries of the groin with competent terminal r=0.258 and r=0.388 respectively, correlation between diame- and incompetent preterminal valve C – both sources (deep vein ters and VCSS is slightly stronger with r=0.362 and r=0.490 re- and tributaries) • Extension of the re#ux in the GSV (above spectively. Stepwise multiple regression analysis showed that knee, below knee) Pearson’s correlations between general data the VCSS was in#uenced by the PT diameter independently of (weight, BMI, age, sex) as well as phlebological data (re!ll- the in#uence of CEAP, re#ux and BMI adding 4% to the total ing time, origin of re#ux, Cmax, VCSS and both diameters) variance, which is highly signi!cant.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 9 Conclusions. These data show that a correlation between were studied by multispiral computed tomography (MSCT) diameters of GSV taken at the groin and at proximal thigh venography with purpose to assess condition of saphenous (PT) and clinical criteria is obvious. These data con!rm prior stem. published data and seem to contradict the work from Gibson Methods. 83 patients (85 limbs with C2,C3 classes of CEAP) 2012. Considering re#uxive and non re#uxive legs the correla- with re#ux at the saphenofemoral junction and grossly nor- tion between diameters and other illness criteria is obvious. mal GSV were treated with high ligation from January 2007 to Considering only legs with re#uxive GSV the correlations are November 2012. Varicose tributaries of GSV and accessorial moderate. Limited to those legs with Cmax 2-5, the correlation veins were excised through multiple incisions. 16 patients (16 between diameters and clinics gets weak. If a parameter should limbs) with RVV were studied by MSCT venography (trans- be used to discriminate between persons with little disease and versely and longitudinally) during 16-26 (mean 21,4) months manifest disease evaluating the effectiveness of the parameter after operation. all legs should be included. Including only legs with Cmax 2–5 Results. Accessory saphenous veins were developed into the discriminatory effect of diameter becomes weak. But if we varicose veins in all 16 limbs. GSV segments below the knee include all legs, those with little disease and those with manifest did not become varicose in all 16 limbs with varicosities. 12 disease, the worth of the diameter, especially at PT, as one extra (75%) of limbs had slightly dilated GSV segments above knee. aspect to de!ne the degree of disease becomes evident. GSV dilatation and tortuosity above knee was revealed in two limbs (12,5%). Conclusions. MSCT venography examination conducted to patients with RVV after GSV preservation surgery showed that Where Does the Perforators Flow Go During Muscu- GSV length and lumen dimensions were suitable for vascular lar Diastole? conduit in majority of limbs. S. Gianesini1, E. Menegatti 2, M. Tessari 2, M. Zuolo 3, S. Occhionorelli 4, S. Ascanelli4, P. Zamboni5 1Vascular Disease Center University of Ferrara-Italy, Ferrara, Italy 2Vascular Disease Center University of Ferrara-Italy, Ferrara, Italy Real Time Visualization of Lymphatic Dysfunction 3Center of Vascular Diseases, University of Ferrara (Italy), Ferrara, Italy 4Vascular Disease Center, University of Ferrara (Italy), Ferrara, Italy in Venous Ulcer Patients: The Effect of Pneumatic 5University of Ferrara, Ferrara, Italy Compression, Results of a Pilot Study with IC Green C. Fife1, M. Aldrich2, R. Guilliod1, J. Rasmussen1, E. Sevick3, I. Tan 4 Aim. In chronic venous disease (CVD) the perforating veins 1UTHSC Houston, Houston, TX, USA (PV) are considered incompetent whenever exhibiting an out- 2The University of Texas Health Science Center, Houston, TX, USA ward lasting more than 0.35 s and/or bidirectional #ow. Nev- 3University of Texas Health Science Center, Houston, TX, USA ertheless, detailed assessments of the bidirectional PV #ow 4UTHSC Houston, Houston, USA during muscular contraction/relaxation are still lacking. This work is designed 1) to evaluate the exact rates of in-ward and Aim. 1. Visualize lymphatic function in real time 2. Relate outward #ow in the PV. visualization of lymphatic function to venous ulcer 3. Observe Methods. Six-hundred-thirty-one limbs of 454 CVD (C1- the effect of pneumatic pumping on the lymphatics of patients 6EpAs,p,dPr) patients underwent an echo-color-Doppler (ECD) with venous stasis ulcers in standing position. The evaluation focused on the bi-directional Methods. An investigational imaging technique using NIR PV (bPV) identi!cation, considering them re#uxing whenever the #uorescence indocyanine green (ICG) which employs “night outward #ow lasted >0.35s. The re#ux was elicited both by man- vision” technology to ef!ciently collect #uorescent light at 830 ual compression/relaxation and foot dorsi#exion manoeuvres. nm was conducted on 7 patients with VSU and CVI. After 8 The bPV diameter, re#ux time, transient average velocity, peak intradermal injections of 25 micrograms to each leg baseline velocities, in-ward and outward #ow were recorded. QDP multi- imaging was performed for up to 0.5 hr. PCD was then admin- gated echo-Doppler technology was performed into the tortuous istered to one leg for one hour, and imaging resumed for 0.5 hr. PV for a qualitative multiple directional #ow assessment. Results. NIRF imaging was used to assess lymphatic Results. The ECD investigation identi!ed 4653 PV, with 2681 structure and function evaluated before and after pneumatic (57.6%) re#uxing ones. Among these, only 198 PV (7.4%) showed compression. Some CVI patients were noted to have baseline a diastolic out-ward #ow, mainly located at the mid thigh. To lymphatic abnormalities similar to those in postmastectomy the contrary the vast majority, 2483 (92.6 %), bPV belonged to lymphedema such as dermal back#ow, aberrant vessels, and the region from the mid calf down (2357, 94.9%) and paratibial lack of lymphatic “pumping.” In response to PCD treatment, (126, 5.1%) group. Ninety-two (3.7%) bPV presented a net out- !ve out of seven patients exhibited new lymphatic vessel re- ward directed #ow (p<0,001). QDP assessment was performed cruitment to regions proximal to the wound. In some cases, in 1991 (74.3%) tortuous PV, reliably detecting the net #ow di- lymphatic vessel pumping was remarkably enhanced follow- rection, in accordance with the muscular pump activity. ing PCD. Conclusions. In course of primary CVD, the majority of Conclusions. This study is the !rst to demonstrate in real- the generally considered incompetent PV presents an in-ward time the lymphatic abnormalities present in CVI. Findings diastolic #ow, so representing a re-entry point during calf mus- also demonstrate that PCD treatment can enhance lymphatic cular pump relaxation. function among patients with CVI and VSUs. Further research is warranted to understand the effect of PCD on CVI.

Multispiral Computed Tomography Venography in Examination of Recurrent Varicose Veins After VENOUS EDUCATION AROUND THE WORLD Saphenous Preservation Surgery M. Kazakmurzaev, G. Askerkhanov, M. Makhatilov, A. Akavov US Situation Medical centre named after R.P. Askerkhanov, Makhachkala, Russian S. E. Zimmet Federation American Board of Venous & Lymphatic Medicine, Austin, TX, USA

Aim. Limbs with recurrent varicose veins (RVV) which de- Many of the important innovations in the !eld of venous veloped after great saphenous vein (GSV) preservation surgery disease have come into common use without any opportunity

10 INTERNATIONAL ANGIOLOGY October 2013 for formal training for those already in practice, regardless of — Paris in January specialty background. Much of modern practice depends on — Maastrich in March skills and techniques that must be learned through conferenc- — London in April es, peer-to-peer interactions and other individual postgraduate — European Society for vascular surgery in September. educational experiences. The national phlebological societies in most European Similar challenges exist even for those currently enrolled in countries are very active with annual scienti!c and education- a formal training program, regardless of specialty. For exam- al meetings. European Venous Forum (EVF) was founded in ple, in dermatology one must have instruction in sclerothera- 2000 with its !rst annual meeting in Lyon. EVF started its an- py, but there is nothing in the curriculum about ultrasound, nual Hands-on Workshop (EVF HOW) in 2010. Several coun- thermal ablation, phlebectomy or VTE. Such knowledge has tries have formed alliances: to be obtained outside the standard dermatology training pro- — Benelux Society of phlebology founded in 1957 gram. — Scandinavian Venous Forum is celebrating its 50th an- In regards to vascular surgery, a review of the most recently niversary this year available ACGME case logs (2011) reveals the following train- — UK Venous Forum founded in 1983 ing experiences: — Balkan Venous Forum founded in 2009, now with 11 member countries — Baltic Venous Forum founded in 2009 with 3 member • Sclerotherapy Average 1 case Median 0 cases countries • Endoluminal Ablation Average 11.2 Median 7 — Russian Venous Forum is under development. • Operation for Varicose Veins Average 6.4 Median 4 Educational programs leading to certi!cation in phlebology has been established in Germany. A European program is un- Although case logs are not reported by vascular interven- der development through the European College of phlebology. tional radiology training programs, we know that no program currently offers a comprehensive venous curriculum. It is clear is that no single specialty routinely provides a comprehensive curriculum to cover the full spectrum of ve- Other Countries nous disease. Most thoughtful and objective physicians would 1 2 agree that the venous curriculum, even in vascular specialties, M Kurtoglu , M. Aksoy would bene!t from being standardized and strengthened. 1Department of General Surgery, Medical Faculty of Istanbul, Istanbul University, Istanbul, Turkey The practice of venous medicine has many of the attributes 2Department of General Surgery, Liv Hospital, Medical School of Bah- often associated with a specialty or sub-specialty. Venous med- cesehir University, Istanbul, Turkey ical societies exist in many countries. There are many medical and surgical conferences and multiple journals dedicated Despite being trained in different disciplines, phlebolo- to venous disease. Many physicians’ practices focus mostly or gists share a common ground for practice, which are venous primarily on venous disease. Given this reality, the fact that disorders. Although the number of physicians involved in most practitioners have no opportunity to receive comprehen- phlebology is high, there are no training standards in many sive formal training in the !eld represents both a challenge countries. In many European countries, the specialty of Phle- and an opportunity. It’s time to strengthen and standardize bology is still missing. In Turkey, phlebology is performed by venous curricula and training in all relevant specialties, using general surgeons, cardiovascular surgeons, plastic surgeons a consensus multidisciplinary approach in order to develop and dermatologists. However, the lack of a proper training quali!ed comprehensive specialists. poses a problem during licensure. The training during resi- The American Board of Venous & Lymphatic Medicine is dency does not include ultrasonographic evaluation of the ve- using a collaborative, multi-specialty consensus process to es- nous system and interventions under ultrasonography such tablish educational standards for training programs in venous as sclerotherapy, and ablation techniques. Moreover, there disease. We have outlined the knowledge & skills considered are no minimum requirements settled for diagnostic and essential in a Core Content document, and are developing pro- therapeutic techniques. The surgical procedures for venous gram requirements consistent with the Core Content. This will diseases are usually well covered in general and cardiovas- enable training programs interested in improving their venous cular surgery training, whilst sclerotherapy techniques and education to adapt their curriculum consistent with the pro- external laser treatment of thread veins are better covered gram requirements and Core Content. during the dermatology or plastic surgery training. There- fore, there does not seem to be a single training program, which covers all the details of venous disorders. Hence, many “technicians” have the certi!cate to practice as health-care European Situation providers without a proper knowledge of phlebology. This B. Eklöf is an obstacle in front of a phlebology practice in a sense Lund University, Lund, Sweden of state-of-the-art. There are several ways of standardizing the training in disciplines. Recognition of Phlebology as a Signi!cant advances have been made in the understanding specialty or subspecialty of different disciplines is an option. of acute and chronic venous disease regarding pathophysiol- However, this cannot be accomplished in many countries be- ogy, diagnosis and treatment during the last decades. I have cause of various bureaucratical, political and ethical reasons. had the privilege to join the faculty at the Veith symposium A proper training can be possible if the standards of train- in New York the last ten years – the largest vascular meeting ing are described and include the minimum requirements in the US. As an indicator for the increased interest in venous before the candidate is approved for practice. The minimum disease we can look at the number of presentations: 10 years requirements should be agreed for diagnostic tests such as ago there were 7 papers presented at a late session on Friday duplex ultrasound evaluation of the venous system, venogra- when the vast majority of delegates left for the entertainment phy, intravascular ultrasound and other diagnostic tests. Fur- in the Big Apple. In November 2012 there were 152 papers on thermore, they should be set for treatment modalities such as venous disease presented at 10 sessions over three days. It is surgical and endovenous interventions. In countries, where dif!cult to satisfy the need for education and update on the current situation does not enable such regulations, certi!ca- progress in venous disease. At the major vascular meetings in tion stands as an alternative solution. The certi!cation can be Europe the venous part is expanding: carried out by the societies for phlebology, which should not

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 11 be dominated by a single discipline but rather a collaboration — in many countries foam sclerotherapy is still an off label of different disciplines. treatment with peculiar legal implications — sclerotherapy is usually performed in private of!ce as an ambulatory treatment were complications may not be managed as in a large hospital SAFETY OF FOAM SCLEROTHERAPY Recent studies has demonstrated the release of active sub- stances (e.g. Endothelin 1) from the sclerosed vein and their Small Volume Injection to Reduce Foam Migration role in generating visual or neurological disturbances. T. Yamaki From the beginning of 2012 we are using a pre-treatment Department of Plastic and Reconstructive Surgery, Tokyo Women’s Medi- protocol with low molecular weight heparin (LMWH) as anti- cal University, Tokyo, Japan thrombotic prophilaxis (six days starting the day before sclerotherapy), Aminaphtone as anti-endothelin (75 mg bid starting Aim. One possible hazardous complication that may be as- three days before) and Cetirizine as anti-allergic prophilaxis sociated with foam sclerotherapy is air embolism. This com- (10 mg one hour before sclerotherapy). plication may be minimized if a large amount of foam scle- The incidence of thrombotic complications related to sclerosant does not enter the deep venous system. Therefore, the rotherapy is very low. Moreover visual or neurological distur- purpose of this study was to compare the proportion of foam bances or allergic reactions are rare as well and it is not clear sclerosant that enters deep veins between multiple injections evidence in literature whether LMWH or Aminaphtone are ca- of <0.5 ml foam per injection and a few injections of >0.5 ml pable of signi!cant risk reduction. foam per injection, in order to establish a safer injection pro- Despite this we have adopted a pre-treatment behaviour for cedure. several reasons: Methods. One hundred and seven patients with super!- — from a legal point of view in our country the adoption of cial venous insuf!ciency were randomized to receive either special prophilaxis is very important in order to exclude mal- multiple injections of <0.5 ml 1% polidocanol (POL)-foam practice (multiple injections) or a few injections of >0.5 ml 1% POL- — the drugs used for a short prophilaxis have a very good foam per injection (few injections) for the treatment of vari- safety pro!le cose tributaries. All patients then received ultrasound-guid- — the occurence of a severe complication in an of!ce set- ed foam sclerotherapy for re#uxing great saphenous vein ting needs to be heavely prevented using 3% POL-foam. Only a single session was allowed per In conclusion a pre-treatment of complications with patient in order to standardize treatment. Qualitative ultra- LMWH, Aminaphtone and Cetirizine may be an effective tool sonographic inspection of the foam was carried out during for defensive medecine. It is still debated whether such prophi- a 5-min period before compression was applied. Post-sclero- laxis can signi!catively reduce the risk of complications. therapy surveillance was done at day 3, 2 weeks, 1 month, 3, and 6 months. Results. Fifty-six limbs in 53 patients were treated with multiple injections and the remaining 56 limbs in 54 patients were treated with a few injections. There were no signi!cant What is the Evidence that Total Foam Volume is Re- differences in age or male:female ratio between the groups. lated to Safety? The mean volume of 1% POL-foam was 2.2 ± 0.6 ml (range: 0.7-4.0 ml) in the multiple injections group and 2.5 ± 0.6 ml S. Guggenbichler (range: 1.0-4.0 ml) in the few injections group (p=0.003). The Private Practice Ambulantes BeinCentrum, Munich, Germany mean volume of 3% POL was 1.5 ml (range: 0.7-3.0 ml) and 1.4 ml (range: 0.7-3.0 ml), respectively (p=0.137). Ultrasonograph- Since the !rst Consensus meeting, which was held at Te- ic inspection immediately after sclerotherapy demonstrated gernsee in Germany in 2003, the foam volume has been lim- that foam was distributed signi!cantly more commonly in the ited to 10 ml per treatment session for safety reasons. The deep veins of patients treated with a few injections (p=0.0003). fear of triggering a deep vein thrombosis was augmented by Two (3.7%) of the patients treated with a few injections de- experiences of sclerotherapists using high volumes of foamed veloped migraine during the procedure, but recovered quickly sclerosant. At the !rst European Consensus meeting in 2006 with no further complications. There was no signi!cant dif- there was little evidence for limiting the foam volume to 10 ference in the success rate between the groups at 6 months ml but this recommendation was given again. In the recently (p=0.257). published European Guidelines for Sclerotherapy the follow- Conclusions. These !ndings suggest that multiple small- ing advice is given for foam volumes: dose injections can reduce the amount of foam sclerosant and “There is no evidence-based limit for the maximum volume the risk of foam sclerosant entering the deep veins in patients of foam per session. The incidence of thromboembolic com- with super!cial venous insuf!ciency. plications and transient side-effects (e.g. visual disturbances) rises with higher volumes of foam. The recommendation is a maximum of 10 ml of foam per session in routine cases (Grade 2B) and that higher foam volumes are applicable according to the individual risk-bene!t Is Pre-Treatment for Foam Sclerotherapy Warrant- assessment (Grade 2C).” ed? K. Meyers has clearly shown in 2008 that with higher vol- A. Frullini umes of foam the rate of thromboembolic events increases Studio medico "ebologico, Figline Valdarno-Florence, Italy from 0.6% to 3%. Wright had to change his study design due to an inacceptable rate of deep vein thrombosis using high foam Foam sclerotherapy has become one of the most popular volumes in the sclerotherapy group. treatment of saphenous trunk with the number of patients On the other hand, T. Sarvananthan suggested that the vol- treated with sclerotherapy largely exceeding stripping and li- ume of foam seems not to be correlated to higher rates of tran- gation. sient neurological symptoms. Despite the low incidence of side effects, the topic of a pre- Considering the main studies published in the last years, ventive treatment for such complications is gaining impor- the mean volume injected at each session was usually around tance for three reasons: 10 ml of foam which was generally suf!cient for good Results.

12 INTERNATIONAL ANGIOLOGY October 2013 A Survey among the members of the sclerotherapy working embolism (PE) when anticoagulant therapy is not an option group, a subgroup of the German Society of Phlebology, car- due to a high risk of bleeding complications. The SIR pub- ried out in 2012 clearly showed that 90% of the highly skilled lished strati!ed guidelines with absolute and relative thera- phlebologists do not use more than 10 ml of foam for scleros- peutic indications in addition to prophylactic indications for ing veins in one session. !lter placement. Additional guidelines speci!c to trauma have In conclusion, these studies underline the !rst experiences also been published. stated in the Consensus 2003 where the recommendation was Absolute therapeutic indications for IVC !lter insertion in- given that it is better to limit the foam volume than the conclude PE despite therapeutic anticoagulation and the presence centration of the sclerosant. It makes sense for safety reasons of a recent proximal DVT with a contraindication to therapeu- to limit the foam volume and rather increase the number of tic anticoagulation. Recognized contraindications to antico- sclerotherapy sessions instead of the volume of foam at a sin- agulation include intracranial hemorrhage, incomplete spinal gle session. cord injury with adjacent hematoma, ongoing uncontrolled hemorrhage, uncorrected coagulopathy, intraventricular monitor or epidural catheter, heparin induced thrombocytopenia, and platelet count of less than 50,000. CONTROVERSIES IN THE USE OF IVC FILTERS Relative therapeutic indications for IVC !lter insertion include proximal free #oating thrombus in the IVC or iliofemoral Indications for IVC Filter Implantation vein and patients with known DVT in need of major surgery. C.M. Black Optional IVC !lters are often placed for venothromboembolic Interventional Radiology, The Intermountain Vein Center, Provo, USA (VTE) prophylaxis in high-risk trauma patients such as those suffering from traumatic brain injury, spinal cord injury, pel- Due to limited prospective data, the indications for inferior vic fracture and long bone fracture, or multiple long bone frac- vena cava (IVC) !lter implantation, speci!c !lter selection, tures. Prophylactic !lter placement is also frequently consid- and post-placement IVC !lter management are the subject to ered in high-risk surgical patients and in patients with limited ongoing debate and controversy. The use of IVC !!lters lters has in- cardiopulmonary reserve. creased substantially. The reasons for increased !lter place- IVC !lters are associated with well-described complica- ments are multifactorial, but include the advent of optional tions including malposition, migration, caval stenosis, caval !lters and a shift from reliance on absolute placement indica- occlusion, iliocaval thrombosis, and caval penetration. In or- tions toward relative indications that are based primarily on der to minimize the morbidity of IVC !ltration, compliance consensus-based criteria. with established guidelines for placement and management Guidelines published by American College of Chest Phy- is critical. Interventionists should work in consultation with sicians (ACCP) and the Society of Interventional Radiology referring physicians to assist in guideline interpretation and (SIR) are based primarily on expert consensus with minimal patient selection in order to de!ne which patients are the most level I evidence. The ACCP advocates the use of IVC !lters in likely to bene!t from !lter placement and to optimize post- patients with deep venous thrombosis (DVT) or pulmonary implantation care.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 13

TUESDAY, September 10, 2013

From the global perspective of IRCA, indicate the LEV in CEAP SEPTEMBER 10, 2013 stages C2 to C6, if advisable, the conversion of C6 to C5.En principle no limitation in diameter. Phlebectomies association TUESDAY is a surgical gesture that complements the surgical outcome. Do not forget the double con#uent or double shafts. In saphenous caliber no limitation. But regardless of their portion of the ASK THE EXPERTS possible complications. La subfascial above as the saphenous saphenous back are other indications. In tibial branches of the The Italian Neovalve: Techniques And Results saphenous be careful with the power to use for the risk of skin burns. In perforating veins is feasible, with short !bers and ad- O. Maleti, M. Lugli equate power. Before a complete thrombosed deep vein system Vascular Surgery, Hesperia Hospital, Modena, Italy can raise LEV treatment. With regard to SEPS, the LEV is a less aggressive and complications, treating venous segments re- The neovalve is a technique usually employed in post sponsible. Is suggestive the possibility of internal valvuloplasty, thrombotic syndrome and less frequently in valve agenesia. causing an annular vein controlled retraction. Depending on The purpose is to create an antire#ux mechanism in patient the technical improvements of the endo!bras, you may con- affected by deep venous re#ux when conservative treatments sider closing the points of re#ux causing pelvic varices and vari- or super!cial treatments are not able to prevent dystrophic le- cocele. Another possibility for action by LEV in speci!c cases of sions C4b-C6. The neovalve is usually performed by parietal relatively low #ow, well located and accessible that you can try dissection. In post thrombotic syndrome the venous wall is closing the !stula. Whenever we !nd ourselves before a com- !brotic and allow us to create a pocket by parietal dissection. plete recanalization of the deep venous system can raise LEV When the vein’s !brosis is circumferential and symmetrical a treatment, looking for thermal ablation of perforator vein seg- bicuspid valve can be performed but given that the !brosis is ments dependent as it means less surgical aggression and there- frequently asymmetrical a monocuspid neovalve is more fre- fore is associated with a lower risk of thrombotic suffer another quently feasible. The basic technique was submitted to techni- episode. In this case be associated longer adequate prophylaxis cal improvement to obtain a thinner and more mobile #ap, and low molecular weight heparin (10 days) and a right elastic and performing the neovalve at the source of a principal tribu- containment. Technical dif!culties common ones are: Complex tary vein in order to determine a competing #ow. malformations or multiple vanishing points in the saphenofem- This technical solution presents two advantages: 1) an ex- oral con#uence. Angulated tortuous paths of more than 75-90 tremely mobile #ap; 2) a washing out action. °.-Collateral vein impaction.-Natural stenosis or stricture by Over the period from January 2000 to May 2013 we performed previous sclerosis. Incorrect positioning of the optical !ber tip 602 procedures addressing the deep venous system in the infe- relative to the catheter.-Fornix caliber perforator.-Below we rior cava system, both open (352) and endovascular (250). The see a piercing that prevents the passage of the catheter by im- neovalve outcomes are excellent in the short term, good in the paction in the same, or the next picture, a signi!cant stenosis medium term and overlapping those of the vein transposition saphenous femoral shaft post-sclerosis that prevents the pas- in the long term. The neovalve offers patients a safe opera- sage of the catheter. To conclude formal contraindications are:- tion, with allow them to bene!t from a protracted ulcer free lack of experience in doctor’s dóppler and ecomarcaje.-The one period over 65 at ten years. Contraindications to treatment no learning curve.--A inadequate infrastructure potential and are represented by severe trombhophilia, severe COPD, severe which could cause dangerous consequences for the patient and arteriopathy, impaired deambulation and contraindications to informed consent, which should be mandatory. anticoagulant therapy. Neovalve is indicated in patient classi- !ed C3-C6 after failure of conservative treatments and after previous treatment of super!cial system. The previous treatment of perforators is controversial. Neovalve construction is FREE PAPER SESSION 3 a technical option from among other leading techniques, like vein transposition and vein transplant. Before correcting the Modulation of Matrix Metalloproteinases and Cy- deep venous re#ux we should verify the absence of proximal tokines by Glycosaminoglycan Sulodexide in Mac- obstructions, given that both in primary and secondary chron- rophage-Like Cells: Possible Role and Treatment in ic venous insuf!ciency lesions at iliocaval level are frequent. Chronic Venous Diseases The preliminary treatment of proximal obstructive lesions can F. Mannello 1, D. Ligi2, M. Canale3, J. Raffetto4 improve the patient’s conditions without correcting the re#ux, 1University, URBINO, Italy hence deep venous surgery is indicated in patients with iso- 2Dept Biomolecular Sciences, Section Clinical Biochemistry & Cell Biol- lated deep venous re#ux or absence of improvement after pre- ogy, University Urbino, Italy, Urbino, Italy liminary proximal treatment. 3Dept Biomolecular Sciences, Section Clinical Biochemistry & Cell Biol- ogy, University Urbino Italy, Urbino, Italy 4Vascular Surgery Division VA Boston Healthcare System Surgery 112, West Roxbury, MA, USA

SOCIETY SESSION: Aim. 1. Evaluate matrix metalloproteinases (MMP) and cytokines in U-937 macrophage-like cells after in#ammatory JOINT PORTUGUESE AND SPANISH SOCIETIES stimuli 2. Study anti-proteolytic/anti-in#ammatory effects of OF ANGIOLOGY AND VASCULAR SURGERY glycosaminoglycan sulodexide (SDX) 3. Improve our knowledge of SDX activity against in#ammatory cells that are in- Removing Varicose Vein by Endolaser volved in chronic venous diseases (CVD) V.J. Ibañez Methods. An in vitro study. Concentration- and time-de- Angiologist and Vascular Surgeon, Vascular Unit, Health Hospital. Gra- pendent treatment of human U-937 macrophage-like cell line nada, Spain with lipopolysaccharide (LPS) and SDX (Alfa-Wassermann, Bologna Italy). Histochemical localization of MMP in en- Treatments that have been used in the treatment of varicose dothelial cells from varicose veins before and after in vitro su- veins are: Saphenectomy, phlebectomies multiple sclerosis or lodexide treatment. Analyses of MMP-2 and MMP-9 isoforms ecoesclerosis guided, radiofrequency and endovenous laser. by SDS-PAGE gelatin zymography. Measurements of complete

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 17 cytokinome by multiplex ELISA assay (Bio-Plex 27-ILs, Bio- ease (CVD) and leg ulcers in order to identify the respective Rad, Milan, Italy). advantages and lacunae of existing tools Results. The enzyme activity and zymographic pro!le of Methods. In February 2013, a research protocol was built pro- and complexed forms of MMP-9 in naïve (unstimulated following the PRISMA statement and the PICOS criteria. Three basal levels) U-937 cells were signi!cantly reduced by SDX databases: EMBASE, CINHAL and Cochrane were screened treatment (P<0.001). LPS-treatment of U-937 macrophage- without time-window. The identi!ed references were chrono- like cells induced in#ammation-related increase of MMP-9 logically ranked. Relevant systematic reviews, randomized activity with a speci!c cytokine pro!le. Dose-dependent treat- trials, comparative studies and psychometric/linguistic valida- ments of LPS-in#amed U-937 cells with SDX signi!cantly de- tion studies were included creased MMP-9 activity and secretion (P<0.0001), without any Results. Inclusion criteria were met in 88 of the 530 displacement of MMP prodomains. SDX-dependent MMP-9 references, in which 10 scales were identi!ed: 3 for leg ul- down-regulation was also con!rmed by immuno-histochemis- cers, 4 for CVD, and 3 for both. Among them, CIVIQ and try in endothelial cells from varicose veins. SDX treatment of VEINES-QOL/Sym were the most validated scales and had LPS-stimulated U-937 macrophage-like cells down-regulated the longest iterative validation process. Three types of stud- the release of speci!c in#ammatory cytokines (e.g., IL-1β, -2, ies were identi!ed: 25 validation studies 54 empirical stud- -6, MIP-1β) (P<0.001). ies and 9 rapid-overviews. The validation studies were based Conclusions. SDX suppresses the activity and secretion of on face, construct, and group validity, as well as reliability, MMP-9 and the expression of in#ammatory cytokines in U-937 and responsiveness. The empirical studies comprised 24 ran- macrophage-like cells. In addition, SDX reduces MMP expres- domized trials, 2 observational studies with controls, and 28 sion in endothelial cells derived from varicose veins. These without controls. data suggest that SDX, a glycosaminoglycan mixture with an- Conclusions. This systematic review was carried out ac- tithrombotic/ pro!brinolytic properties, may have a signi!cant cording to the Cochrane criteria and confirmed that CVD role in modulating cytokines production and MMP activity in has an important effect on the QOL. The majority of the in#ammatory cells and LPS-in#amed macrophage like cells, studies addressed the application rather than the validation and offer a potential treatment in patients with CVD including of the 9 identified scales. Two scales, CIVIQ and VEINES- venous ulcers. QOL/Sym, emerged as being thoroughly validated instruments, though factorial stability was not demonstrated for the latter. Our findings confirm a paucity of validation Revisiting Heredity of Chronic Venous Disorders: studies. An Epidemiological Study in 21319 Patients V. Crébassa 1, F. Allaert2 1Clinique du Millénaire, Montpellier, France 2Dijon, France Distribution and Extent of Re"ux and Obstruction Aim. To evaluate the contribution of heredity to chronic in Patients with Active Venous Ulceration venous disease (CVD) after adjustment for sex, age, clinical A. Kanth1, S. Khan2, A. Gasparis3, N. Labropoulos4 stage, and hormone status, and to calculate the odds ratio 1Stony Brook School of Medicine, Port Jefferson, NY, USA linked a parental history of venous disease. 2Stony Brook School of Medicine, Stony Brook, NY, USA Methods. Epidemiological study conducted in daily medi- 3Stony Brook vein center, Stony Brook, NY, USA cal practice of medical practitioners. Each general practition- 4Stony Brook University Medical Center, Stony Brook, NY, USA er described over two consecutive days the venous status of all patients consulting them, whatever the reason for the consul- Aim. This study was performed to precisely de!ne the tation, and recorded their family history of venous disorders. underlying pathophysiology in patients with active venous Odds ratios and their 95% con!dence intervals were calculat- ulcers. ed after adjustments in a logistic regression model. Methods. A PubMed search was conducted from 1991 to Results. The prevalence of CVD was 58.8% among 21 319 2013 to select papers reporting the anatomic and physiologic patients, 60.4% of whom had a family history of CVD. After etiology of ulceration in CEAP Class 6 patients. Studies which adjustment for age and sex, there was a signi!cant (P<0.0001) did not decipher between active and healed ulcers, did not use odds ratio of 3.2 for a history of CVD in one parent and of 5.6 clear de!nitions, or did not give detailed accounts on the dis- [5.0;6.2] for a history in both parents. In the context of a his- tribution/extent of venous pathology were excluded. Using the tory in both parents, the odds ratio increased to 5.6 for women PRISMA guidelines 12 studies were selected for further analy- and 8.4 for men. If there was a hereditary risk, the frequency sis. and severity of the illness were greater, regardless of the age Results. Primary insuf!ciency was reportedly the most group studied (P<0.0001). Pregnancy was a risk factor, but not common etiology of ulcers. Re#ux most frequently occurred hormone status. in the super!cial system, either isolated or in conjunction Conclusions. At all ages, male or female patients with a he- with perforating and/or deep systems. Combined super!- reditary risk are affected by CVD at a younger age, more often cial and deep disease was observed in a median of 11.6% and more severely than those without any heredity. This calls of limbs [range of 0-48%]. Triple system disease was seen into question the notion of a predominantly maternal charac- in a median of 31.6% of limbs [range of 22-52%]. Isolated ter of CVD heredity. deep re#ux was infrequently reported [2.1-28.4% of limbs]. Previous DVT, reported in a median of 33% of patients, is likely underreported as DVTs may resolve without detectable damage. A Systematic Review of Quality of Life Scales for Conclusions. Insuf!ciency of the super!cial venous system Chronic Venous Disease of the Lower Limbs from the micro- to the macrovasculature has been frequently R. Launois, K. Katumba, J. Le Moine, L. Fiestas-Navarrete implicated in the development of venous ulceration. Surgical Rees France, Paris, France management in such cases has been found to have a high rate of healing and non-recurrence. Patients with both re#ux and Aim. We conducted a systematic review of the literature obstruction bene!t from surgical treatment of both disease about the quality of life (QOL) scales in chronic venous dis- processes.

18 INTERNATIONAL ANGIOLOGY October 2013 The Foam Sclerotherapy in Elderly Patients with Our aim was to assess early treatment ef!cacy and subsequent Severe And Disabling CVD (C4-C6 CEAP) recanalisation in patients with chronic venous ulceration fol- M. Gallucci1, P. Antignani 2, A. Carlizza 1, R. Boirivant 1, E. Schacter 1, lowing UGFS. L. La Bella1 Methods. Patients with open or recently healed leg ulcers 1S.Giovanni Hospital, Rome, Italy with super!cial venous re#ux were treated between July 2010 2Villa Claudia, Rome, Italy and Feb 2012.Venous duplex scans were performed on limbs 2 weeks and one year post treatment by an independent vascular Aim. The increase in the average age of the general popula- scientist. Recanalisation and re#ux patterns in the treated seg- tion has caused a continuous increase in the occurrence of severe ments were recorded. Recanalisation was classi!ed as ‘com- CVD among the elderly with serious effects on the quality of life plete’ when the lumen was patent in a previously occluded vein of these patients, who are frequently unwilling and/or have con- and ‘segmental’ when there was a reduction in the length of traindications to surgery (stripping, Linton procedure, SEPS). occlusion. One year ulcer recurrence rates were calculated us- Ultrasound guided foam sclerotherapy appears to be the most ing Kaplan-Meier survival analysis. promising alternative to surgery as it is minimally invasive and Results. Eighty two limbs were treated in 76 patients; 71 because of its reduced cost and favourable safety pro!le. Our were CEAP 5 and 11 CEAP 6. Of the segments treated 55 were study aims to assess whether foam sclerotherapy is able to im- truncal and 27 tributaries. Early occlusion was demonstrated prove the clinical conditions and quality of life of these patients. in 81/82 limbs; complete occlusion in 68/82 (83%) limbs, short Methods. Between December 2005 to May 2012 we per- segment occlusion in 13/82 (16%) limbs and 1/82 failed to oc- formed ultrasound guided foam sclerotherapy in 73 patients clude. At 1 year 4 patients were lost to follow up; complete with C4-C6 (CEAP classi!cation) CVD, with a mean age of 73.8 recanalisation with re#ux was seen in 10/77 (13%) limbs and years (range 68-85). All patients were evaluated before and af- segmental recanalisation with re#ux in 19/77 (25%) limbs. ter treatment and every year for 6 years through the Venous Overall recanalisation rate with re#ux was 38% (29/77). One Severity Score System (VSSS) and quality of life questionnaire year ulcer recurrence rate was 1.2%. (SF12). 22 patients (30,1%) had been suffering from one or more Conclusions. Recanalisation was present in nearly half the leg ulcers (C6 - CEAP) for an average period of 2,1 years; they suffered from physical disability and a poor quality of life. 33 legs treated by UGFS. Duplex surveillance enables identi!ca- patients underwent internal or external saphenous trunk treat- tion of further re#ux which may require top-up therapy to con- ment; as to the remaining 40 patients, incompetent perforating trol re#ux and venous hypertension with the aim of minimis- veins and relapsing collateral varices accounting for ulcers and ing ulcer recurrence. venous hypertension were treated. At the end of treatment, all patients were followed up with objective clinical exams, CDU, VCSS, VDS and SF12 questionnaire at 6-12-months and each year thereafter. The statistical evaluation of the SF12 question- Lateral Fasciectomy in Recalcitrant Lateral Leg Ul- naire and VCSS and VDS scores has been made. cers: Surgical Technique And Outcome In 44 Legs Results. During the 6-72 month follow-up period (mean/aver- 1 2 age, 31.9 months) symptoms improved or disappeared in all pa- F. Steinbacher , A. Obermayer tients. Ulcer healing was observed in 16 out of 22 patients (70.7%) 1Karl Landsteiner Institut für funktionelle Phlebochirurgie, Melk, Nied- with an average treatment time of 2.7 months. On average, VCSS erösterreich, Austria 2Karl Landsteiner Society, Institute of Functional Phlebologic Surgery, improved from a baseline value of 13.6 to an after-treatment value Melk, Austria of 4.1 (P<0.001); VDS score improved from 1,9 to 0.8 (P<0,001). We obtained a complete success in 65 patients ( 89,0%)(P<0,001), Aim. Crural fasciectomy in case of intractable laterally lo- a partial success in 5 patients (6.8%) and 3 failure (4.1%). No cated leg ulcers may be considered in cases of deep ulceration major or minor systemic side effects have been observed. The with a sclerotic and calci!ed wound base. statistical evaluation of the SF12 questionnaire ( Test Wilcoxon) Methods. In this study we present 44 legs which all under- 0-72 month period (mean/average 31,9 months) has showed the improvement of the quality of life for both the physical and men- went lateral fasciectomy, focusing on the postoperative heal- tal component. (PCS-12 - P<.001)(MCS-12 - P 0.018) ing rates. All patients who were treated during a period of 7 Conclusions. All patients expressed their gratitude and a years, were analyzed retrospectively. Furthermore we present high level of satisfaction for the functional, clinical improve- detailed operation procedure step by step, including the pros ment achieved after the treatment; especially patients with a and cons of preserving the terminal branch of the super!cial more severe CVI (C5-C6) could achieve a signi!cant improve- peroneal nerve. ment in their quality of life (SF12). In elderly patients, usu- Results. After a mean ulcer-duration of 3,5 years (0,1-43) ally reluctant to undergo surgery, we consider the foam scle- and a mean leg ulcer extension of 29 cm² (3-300), 91% ulcer- rotherapy as a treatment of !rst choice; it allows this group of ated legs healed after surgery. patients to hope for a cure and gain back, at least to a partial Conclusions. In cases of deep, non-healing lateral leg ul- extent, their autonomy with signi!cant positive repercussions ceration with surrounding dermatolipofasciosclerosis, fasciec- on a psychological and social level. tomy and mesh graft in one session is an excellent therapy option with good outcomes.

Ultrasound Guided Foam Sclerotherapy (UGFS) Treatment for Chronic Venous Ulceration: Is Duplex Surveillance Required? Larval Debridement Therapy in Sloughy Chronic J. Howard1, F. Slim 2, C. Wakely 3, C. Davies 4, S. Kulkarni 2, R. Bulbulia 4, Venous Leg Ulcers: A Randomized Controlled Trial M. Whyman4, K. Poskitt4 C. Davies, G. Woolfrey, N. Kenny, J. Dyer, A. Cooper, J. Waldron, R. 1Vascular lab, Cheltenham, Gloucestershire, United Kingdom Bulbulia, M. Whyman, K. Poskitt 2Vascular Department, Cheltenham General Hospital, Cheltenham, Unit- ed Kingdom Cheltenham General Hospital, Cheltenham, United Kingdom 3Vascular Lab, Cheltenham, United Kingdom 4Cheltenham General Hospital, Cheltenham, United Kingdom Aim. Slough in chronic venous leg ulcers may be associated with delayed healing. The purpose of this study was to assess Aim. Recanalisation following UGFS ranges between the ef!cacy of larvae to debride chronic venous leg ulcers and 8-47%. This may have detrimental effects on ulcer recurrence. to assess subsequent effect on healing.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 19 Methods. All patients with chronic leg ulcers presenting safe. Combined with the relative wound surface reduction of to the community-based leg ulcer service were evaluated for 43.78%, the novel EGF-containing wound dressing can be the study. Exclusion criteria were: ABPI <0.85 or >1.25, no regarded as an adequate and novel treatment option for pa- venous re#ux on duplex and <20% of ulcer surface covered tients with hard-to-heal venous leg ulcers. The reduction of with slough. Participants were randomly allocated to either 4 wound size needs to be con!rmed in a randomized controlled layer compression bandaging (4LB) alone or 4LB with larvae. trial. Surface areas of ulcer and slough were assessed at 4 days; 4LB was then continued and ulcer size measured every 2 weeks for up to 12 weeks. Results. 601 patients with chronic leg ulcers were screened Deep Venous Reconstruction – A Case Series between November 2008 and July 2012. Of these, 20 were randomized to 4LB and 20 to 4LB+larvae. The median (range) S. Kosasih1, H. Moore2, A. Davies2 ulcer size was 10.8(3-21.3) cm2 and 8.1(4.3-13.5) cm2 in the 1Imperial College London, London, United Kingdom 2 4LB and 4LB+larvae groups respectively (Mann-Whitney Academic Section of Vascular Surgery, Imperial College London, Lon- don, United Kingdom U, P=0.23). Median area of slough was 6.1cm2 (71.2%) and 4.9cm2 (64.4%) in the 4LB and 4LB+larvae groups respective- Aim. Deep venous surgery is challenging, performed in only ly (Mann-Whitney U, P=0.35). At day 4 the median percentage a small number of centres and outcomes remain variable. This area of slough reduced by 50% in the 4LB group and 84% in study presents a single consultant case series of deep venous the 4LB + larvae group (Mann-Whitney U, P<0.05). The 12- reconstruction procedures. week healing rate was 73% and 68% in the 4LB and 4LB+larvae Methods. A retrospective review of a single consultant’s groups respectively (Kaplan-Meier analysis P=0.66) deep venous reconstruction procedures and deep vein stenting Conclusions. Larval debridement therapy improves wound procedures was carried out and patient records and follow up debridement in chronic venous leg ulcers treated with mul- imaging reviewed for both clinical and radiological outcomes. tilayer compression bandages. However, no subsequent im- Results. Seventeen patients underwent deep venous pro- provement in ulcer healing was demonstrated. cedures (including deep venous reconstruction, deep venous bypass and vein transposition), of these, 16 were followed up. 8/16 had occluded in the intervening 12 years, and the remaining 8 were still patent at the last follow up. 1/16 still A Novel EGF-Containing Wound Dressing for the experienced symptoms despite a technically successful proce- Treatment of Recalcitrant Venous Leg Ulcers dure. For all other cases, patent grafts led to ulcer healing and M. Doerler1, S. Eming 2, J. Dissemond 3, A. Wolter 2, M. Stoffels-Wein- decreased leg swelling. Mean patency rates were 22 months, dorf3, S. Reich-Schupke1, P. Altmeyer4, M. Stücker1 ranging from 2 weeks to over 132 months with patency re- 1Vein Centre, Departments of Dermatology and Vascular Surgery, Ruhr- maining to the best of our knowledge. 17 deep venous stenting University Bochum, Bochum, Germany procedures were carried out, of which 1/17 failed at insertion, 2Department of Dermatology, Venereology and Allergology, University of Cologne, Cologne, Germany 8/17 occluded and 8/17 were patent at follow-up. 3Department of Dermatology, Venereology and Allergology, University of Conclusions. The outcomes of deep venous reconstructive Essen, Essen, Germany surgery and stenting are variable, particularly with regard to 4Department of Dermatology, Venereology and Allergology, Ruhr-Univer- technical success, however, given the good clinical outcome sity Bochum, Bochum, Germany following the procedures, it should still have a role in many patients, particularly in those that have failed other forms of Aim. To evaluate the ef!cacy, tolerability and safety of a treatment. novel wound dressing containing Epidermal Growth Factor (EGF) in a bovine collagen matrix for the treatment of recalcitrant chronic venous leg ulcers. Methods. Three specialized German wound centres included 33 ulcers of 31 patients with recalcitrant venous leg ulcers SOCIETY SESSION: into this study. The EGF-containing wound dressing was applied three times while best practice conservative wound treat- HUNGARIAN VENOUS FORUM ment was continued. The patients were followed up 1, 2 and 3 months after treatment to evaluate: a) the measured wound Immediate and Short-Term Duplex Ultrasound Out- size, b) the ease of application, c) the resorption of the dress- come of Endovenous Laser Treatment of Troncular ing, d) the wound dressing by means of a scale ranging from Varicose Veins - A Single Center Experience 1-5 (1 = best, 5 = worst) and e) the pain by visual analogue A. Puskas¹´², I.Gy.Fazakas², O. Melles², R. Eva¹ scale (0 = no pain, 100 = worst pain). ¹Department of Angiology, IInd Medical Clinic, University of Medicine Results. The protocol was completed by 25/31 patients. and Pharmacy of Targu Mures/Marosvasarhely, Romania The reasons for discontinuation were: wound infection (n=2) ²Angio Center Private Unite, Targu Mures/Marosvasarhely, Romania and pain (n=2). Two additional patients lost to follow-up after 2 and 3 months. At the end of the study, three ulcers were Aim. 1. To assess the “immediate” and “short term” duplex completely healed. Overall, the average wound surface de- ultrasound outcome of troncular varicose veins after endov- creased from 33.69 cm2 to 18.94 cm2 (relative wound surface enous laser ablation. 2. To follow-up the complications reduction: -43.78%). The wound dressing was evaluated as Methods. In this follow-up study preoperative DUS map- easy to apply (97.14%) and resorbable (98.11%) by patients ping and postoperative “immediate” (1-4 weeks) and “short and wound care specialists. More than 1/3 of the patients term” (1-12 months) examinations were performed. 94 limbs (35.7%) experienced no pain at all under treatment. The of 90 patients (67 women, 23 men, age 17-84) with GSV mean pain level on the VAS was 23. Subjective evaluations (N=84) or SSV (N=10) varicosity were selected for laser abla- of the novel wound dressing were 2.16 by average (median tion on an outpatient basis under tumescent local anesthesia. 2.0) for health care specialists and 2.40 (median 2.0) for the Saphenofemoral junction incompetence was treated by surgi- patients. cal ligation (85, 1%) and foam sclerotherapy was applied for Conclusions. Our results demonstrate that the novel EGF- the tributaries (81, 9%). A 1470 nm radial laser was used (pull- containing wound dressing was generally well tolerated and back velocity: 3 mm/sec; power: 10-15 W; average energy: 48 J/

20 INTERNATIONAL ANGIOLOGY October 2013 cm; average length of treated saphenous segment: 37 cm). The Endovascular and Surgical Management Options in occlusion rate, the ultrasonic appearance (hypo-echoic, hyper- Chronic DVT: Worth the Effort? echoic, iso-echoic or invisible/unidenti!able) and the progres- K.M. Rai sive venous diameter reduction in the two different control Director Vascular Surgery, Max Superspecialty Hospital. New Delhi, In- period were studied. The complications were also recorded. dia Results. The “immediate” DUS assessment identi!ed a 90, 6% complete occlusion rate. The later, “short-term” exami- Aim. Chronic deep vein thrombosis (DVT) is traditionally nation identi!ed a slightly different occlusion rate between managed conservatively; interventions are infrequently tried. saphenous segments: 97,5% at the upper third, 92,5% at the We reviewed the Endovascular and Surgical Management of mid third and 82.5% at the lower third. The complete disap- this condition at our institution in a selected group of patients. pearance of the vein was also frequently observed at differ- Methods. Retrospective review of prospectively treated pa- ent levels (17, 5% -25%-27,5%). In the “immediate” period a tients of chronic DVT treated with surgery/endovascular in- hypo-echoic aspect was more typical (63, 8%). In contrast, in terventions during a 3 year period (Jan 2010 to Dec 2012) in a “short term” period (1-12 months) the iso-echoic appearance single institution. Outcome measures were change in clinical predominated (77, 4%). The progressive diameter decrease at condition of the patient. different levels was signi!cant (p<0.05) between the preopera- Results. 43 patients of chronic DVT were treated with sur- tive and the post procedural examination periods, (32, 5% and gery/catheter based interventions. The age ranged from 24 – respectively 46, 3% reduction at “immediate” and at “short 66 years; there were 25 males & 18 females. Pre-procedure term”). The complication rate was low (6,3%) (local hemato- clinical status: C6 = 14, C 5 = 21, C 4= 4, C 3 = 4. 34 had iliac ma formation, seroma, super!cial thrombo#ebitis of the tribu- vein occlusion, and 9 SFV/ popliteal vein occlusion. A total of taries transitory paresthesia). 45 procedures were performed. 31 patients underwent iliac Conclusions. The ultrasonic evolution of laser-ablated vein stenting with a technical success rate of 93.5% (29/31). 5 saphenous segments con!rms the ef!cacy and safety of en- patients underwent contralateral GSV transposition for iliac dovenous laser therapy. We successfully documented the high occlusion. 5 patients underwent brachial vein transposition occlusion rate of the treated segments. The ultrasonic appear- and 4 ipsilateral GSV anastomosis to BK popliteal vein for ance was progressive from hypo/hyper to iso-echoic aspect femoro-popliteal DVT. Follow-up ranged from 3 – 38 months. and in considerable number of cases the complete disappear- Post-procedure clinical status improved considerably in 42/43 ance of the vein was found in the follow-up period. Duplex patients: C6 = 4, C 5 = 18, C 4 = 8, C 3 = 8, C 2 = 5. follow-up is a useful method to monitor the vein involution. Conclusions. Endovascular and Surgical Management of chronic DVT gives good results in selected cases. Meticulous assessment, planning, and appropriate selection of treatment modality are the keys to success. SOCIETY SESSION: VENOUS ASSOCIATION OF INDIA Single Center Experience of 6500 Cases of Endov- Prevalence of Chronic Venous Disease in India enous Ablation in last 10 years R. Pinjala S.F. Padaria Nizam’s Institute of Medical sciences, Hyderabad, Andhrapradesh, India Department of Cardiology, Jaslok Hospital, Mumbai, India

Aim. Chronic venous disease is common in India, but it is Aim. 1) To identify various anatomic subsets taken up for 1) under estimated and 2)Early detection will be helpful to re- Endovenous ablation with evolution of experience. 2) Evolu- duce the 3)morbidity due to venous disease. tion of Endovenous modalities of treatment over 10 years. 3) Methods. The risk of venous thrombosis, prevalence of Charting improvements in patient outcomes over a decade of color Doppler con!rmed venous thrombosis and chronic treatment venous insuf!ciency were studied in the ENDORSE study, Methods. We analyzed 6500 consecutive patients of Varicose PROVE study and RELIEF study which were part of the in- veins treated between 2003 and 2013 with Endovenous modali- ternational trials. The ENDORSE study was performed in 10 ties such as diode laser, Radiofrequency ablation and Foam Indian hospitals to assess the risk factors for DVT in patients Sclerotherapy. Over a decade there was a signi!cant change in in the acute care areas, in the PROVE trial duplex scan con- the treatment technique, as well as improvements in technol- !rmed DVT patients and their clinical pro!les were studied ogy. All patients were treated by the same physician at two cent- and in the RELIEF study the clinical symptoms and signs of ers, one a hospital based setting, and the other an outpatient patients with chronic venous suf!ciency were studied. clinic. While in the initial years, only patients with re#ux at the Results. In ENDORSE study it was observed that the risk of saphenofemoral junction or the sapheno-popliteal junction acute venous thromboembolism (VTE) in acute care patients were treated, later on even non- truncal varicosities were ad- according the ACCP guidelines was similar to that in the other dressed. In the last few years, closure of incompetent perforator countries, but the preventive measures were under-utilized. In veins has become standard practice procedure in all patients. the PROVE study Ultrasound detected DVT was also compa- Results. Patients treated with Diode laser demonstrated a rable to the other countries, though the incidence of proximal better outcome with the 1470 nm laser as compared to the 980 DVT was reported to be higher. The RELIEF study showed nm laser, both in permanent closure of the veins and lesser that chronic venous disease, was more common in those who patient discomfort. The radial laser !ber was found to be more were in 4th decade of their life with or without venous re#ux, effective than the bare laser !ber. Patients treated with Radi- though patients with demonstrable venous re#ux had more ofrequency ablation had less post operative discomfort, and signi!cant symptoms. quicker return to normal duties as compared to laser. Treat- Conclusions. We, in India need to perform larger epidemi- ment of incompetent perforator veins was easier using the ological studies to evaluate the prevalence of chronic venous bare laser !ber introduced through a simple venous cannula, disease and know the annual incidence of acute venous throm- and less painful than with using RFA stillete. Sclerotherapy bosis. Preventive measures and early detection can prevent using Sodium Tetradecyl Sulphate was more painful and asso- late complication such as chronic venous ulceration which is ciated with more complications than with use of Polidocanol. too dif!cult to treat in the later stages. Foam Sclerotherapy with Polidocal using concentrations vary-

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 21 ing from 0.5% to 3% depending on the vein size is extremely any procedure deviation from established protocols can result effective when used in conjunction with thermal ablation tech- in sub-optimal results. Perfect Planning Prevents Poor Per- niques, to deliver both a therapeutic and aesthetic result. We formance !. have never used any anti coagulant or anti platelet medica- Methods. Optimisation of results will be discussed in detail tions in our cases. under the following heads: Conclusions. Endovenous ablation of varicose veins has The !rst step is of knowing the patient and the pathophysi- undergone a signi!cant change in the last decade. Thermal ology of the process – in health and disease. It is imperative ablation using diode laser and radiofrequency ablation, and to be honest with the patient at the very start regarding the foam Sclerotherapy are today the cornerstones of treatment. results expected, the need for surveillance by regular Doppler Effective vein closure and minimal patient discomfort is pos- tests, the possibility of complications / side effects / recur- sible with current techniques. Operator experience plays a rence, the need for some lifestyle modi!cation and for possible signi!cant role in deciding outcomes as demonstrated by this staged additional procedures. large single operator series. The next step is to know the correct time to intervene and perhaps even more importantly – when not to intervene – ie indications and contra indications A clear understanding of the ‘nuts and bolts’ of the machines Role of Endovenous Procedures in Chronic Venous required ie the ultrasound machine and the RFA machine are Disease mandatory and need some special training. If possible it is ide- R. Varghese al for the surgeon to be able to handle and interpret the Dop- Department of Vascular Surgery, Jubilee Mission Medical College, Tri- pler himself. Exact anatomy, site of SFJ and SPJ, location of chur, Kerala, India large perforators, accessory venous channels etc is mandatory. The most vital for the surgeon is to know his own limita- Aim. Endovenous Procedures were traditionally consid- tions and level of training – nosce te ipsum ered expensive and high technology procedures not suitable The technique of the procedure - from preoperative prepa- for economically poor and inadequately equipped hospitals. ration, knowledge of endovascular techniques, asepsis and an- Methods. In the year 2005 we acquired a portable ultra- tisepsis, proper cannulation, adequate tumescent anesthesia, sound machine and started US guided foam sclerotherapy on a exact positioning of the catheter, and method of application day care basis. The Author underwent retraining in Endovenous of the pressure dressing. The devil is in the details. No step is procedures. The initial patients were those with C6 (ulcer) and minor or can be overlooked. soon patients with chronic healed ulcers (C5) consented to the Early postop ambulation, Class II compression stockings, new procedure. Endovenous Laser was introduced at three regular duplex scanning months as by then the patient load had increased and there An accurate documentation – the exact duplex !ndings with was the realization by the operating surgeon that large veins diagram, CEAP Class, length of vein ablated, the vein treated, needed a different procedure and we were able to convince the site of cannulation, duration of treatment, details of energy hospital authorities about the same. All the above patients were delivered, power settings, whether double energy was given at offered minimally invasive surgery or were failed surgery pa- some sites eg near SFJ should be clearly documented in the tients. Most common cause of surgical failure was poor skin patient charts condition, edema and below knee perforators with underlying Conclusions. By a meticulous approach the results of RFA deep venous hypertension. Most common reason for patients for varicose veins can be optimised. refusing surgery was, patients with chronic venous disease, who were fully aware of possible primary failure in C5, and C6 disease. Compression therapy was an adjunct in all these patients. Results. The whole team realized that use of perioperative Venous Thrombo-Embolism - 10 Year Indian Hospi- Ultrasound Doppler gave superior results even when used with tal Experience minimally invasive surgery (Even if Vein Mapping done Before). S. Agarwal, A.D. Lee, E. Stephen Day care Endovenous procedures under local tumescent an- Department of Vascular Surgery, Christian Medical College, Vellore, esthesia, with no sutures in groin was acceptable to almost all Tamilnadu, India patients and brought a paradigm shift in patient referrals from General practitioners and other Vein care professionals. Initially Aim. Venous thrombo-embolism(VTE) has traditionally we used Lignocaine based tumescent anesthesia. Now we use been considered rare in Asia. Recent reports from Hong Kong only cold saline tumescent anesthesia. Failures were again man- and Singapore indicate an increasing incidence of VTE. aged by same simple techniques as in the initial way. Compli- Objectives. To determine the incidence of VTE among hos- cations were statistically same as that for surgery. Costs came pitalised patients and study the predisposing factors and hence down to that of Surgery as volume increased and is now cheaper to increase the awareness of the need for VTE prophylaxis. than minimally invasive Surgery, overall results better than lat- Methods. This is a retrospective study carried out on all ter with regard to ulcer healing and Ulcer recurrence interval. patients diagnosed with VTE between 1996 and 2005 at our Conclusion. Endovenous Procedures is patient friendly hospital. In-patient records were used to collect data while and cost effective. Use of lignocaine is not a must and Cold out-patient records were used for follow-up outcomes. Normal Saline is an adequate substitute. Results. The incidence of VTE was 17.46 per 10 000 admissions. Malignancy (31%) was the most common predisposing factor, followed by postoperative status (30%). The incidence following surgery was !ve per 10 000 operations. General sur- Optimizing Results with RFA or Radiofrequency Ab- gery patients had the highest incidence of deep vein thrombo- lation of GSV - Review of Results of Last 5 Years sis (DVT; 40.3%), while the incidence in orthopaedic patients H.S. Bedi was 20.1%. Low-molecular- weight heparin (LMWH)has been Department of Cardio Vascular Endovascular & Thoracic Surgery, Chris- increasingly used therapeutically over the years. Pulmonary tian Medical College & Hospital, Ludhiana, Punjab, India embolism was diagnosed in 14.9% of the study patients. Mortality in those with con!rmed pulmonary embolism was Aim. Radio Frequency Ablation (RFA) is now an estab- 13.5%. lished endovascular method of treating varicose veins. As with Conclusion. VTE is no longer a rarity in India. General sur-

22 INTERNATIONAL ANGIOLOGY October 2013 gical operations are the most common causes of postoperative a combined re#ux (GSV + AASV). The reason for this could DVT. Pulmonary embolism continues to be ‘suspected’ more be the presence of a TV of the AASV too. Low lateral pres- often than it is diagnosed sure in a classic re#ux could preserve the terminal valve of the AASV and the same could occur for the PTV of the GSV when AASV is re#uxing. Therefore I think that there could be a sort of suction on these two valves owing to Venturi’s effect. Dialysis Access Angioplasty: Is it Worthwhile in In- Practical consequences of these observations are represent- dia? ed by the different therapeutic approaches in GSV treatment: V.M. Thakore, S.R. Kapadia modern endovascular procedures and actual surgical tech- Department of Vascular & Endovascular surgery, Angiocare - VINS hos- niques avoiding crossectomy should be con!ned, in my opin- pital, Baroda, India ion, to the cases of AASV absence. A precocious recurrence could be the result of a small AASV that enlarges because of Aim. To Access the feasibility, Safety, ef!cacy and durability the residual pressure in the GSV stump. of Dialysis Access Angioplasty (DAA) in Indian patients where Intermediate location of GSV is the rule in the cases of cost effectiveness is very prudent in decision making AASV absence: that’s to say that there is a different ride in the Methods. A Retrospective analysis of DAA in last 2 yrs. skin projection of the GSV in these cases. We must therefore Eleven patients were studied in last 2 yrs of a different age distinguish between the real AASV and the intermediate loca- group of 27 years to 63 yrs. DAA was performed for salvage tion of GSV before discussing about TV and PTV valves. of failing access in 7 pts and for refractory massive upper limb edema in 4 pts. All patients were evaluated by leg Dop- pler ultrasound & CT Venography was performed in 3 pts. All these patients had undergone multiple dialysis access operations viz. Radiocephalic AV !stula, Brachiocephalic Ultrasound Guided Foam Sclerotherapy of Recur- Av !stula, Basilic vein transposition and Dialysis access rent Varices of the Long and Short Saphenous Vein: graft surgeries.Salvage of !stula or graft was possible only 5 Years Follow Up through DAA. P. Pavei The most common lesions were as follows Inominate occlusion / Stenosis 3 pts. Multidisciplinary Day Surgery Unit, Azienda Ospedaliera of Padua, Pad- ua, Italy Subclavian Vein occlusion 4 pts Cephalic vein 1 pt Aim. To evaluate duplex ultrasound (DUS) outcomes after Access graft & vein Junction 4 pts ultrasound guided foam sclerotherapy (UGFS) of recurrent In most of the cases, access was taken under USG guidance, varices of the long and short saphenous vein. The aim of treat- through Av access graft in 4 pts., Basilic vein in 3 pts & Ce- ment was also to control varicose disease and its symptoms phalic vein in 4 pts. Plain balloon angioplasty was done in 3 and to prevent complications. pts & Stent were deployed in 8 pts. Methods. A consecutive series of patients presenting All the patient were followed up for 2 yrs. with a recurrent varicose disease emanating from a previ- Results. 1) Relief of edema and salvage of !stula was ously operated sapheno-femoral or sapheno-popliteal junc- achieved in 7 pts (66.6%). 2) Reintervention was required in 4 tion underwent serial DUS examinations following UGFS pts. (36.6%). 3) Poor result i-e immediate restenosis/occlusion with 1-3% Sodium Tetradecyl Sulphate (STS) or 0.3-1% Po- was observed in 2 pts.(18.8%) lidocanol. Conclusion. DAA is though feasible & Safe treatment op- Patients were divided into two groups: 1) neoangiogenesis tion but not very effective and durable treatment options in and 2) large recurrent varices emanating from a previously op- subset of Indian pts.Hence cost effectiveness is questionable. erated junction. From 2006 to 2012 we followed up 142 cases DAA should be offered where no other dialysis option is avail- of neoangiogenesis, 155 patients with large inguinal recur- able. rence and 28 popliteal recurrences. Results . 142 cases of neoangiogenesis (C 2/3 128 C 4 12 C 5 2 C6 0) received 1 - 3 sessions of foam sclerotherapy prepared by Tessari’s method with 4-10 ml of 0.3-1% Polidocanol with SOCIETY SESSION: 90.9% of good results at 3-5 years; 155 inguinal recurrenc- ASSOCIAZIONE FLEBOLOGICA ITALIANA es (C 2/3 126 C 4 19 C 5 8 C 6 2) underwent 1-3 sessions with 4-10ml per session of 1-3% STS with 87% of complete occlusions and no varices at 1 year, 85% at 2 years and 80.79% The Terminal and Pre-Terminal Valves of the Ante- at 3-5 years; 28 popliteal recurrences (C 2/3 24 C 4 2 C 5 1 C 6 rior Accessory Saphenous Vein 1) received 1-2 sessions with 4-10 ml per session of 1-3% A. Pieri STS with 60% of complete occlusions without varices at 3-5 Private Angiologist, Florence, Italy years. Complications were recorded: 0.2% gastrocnemial vein Thrombosis; 0.1% neurological problems, including CD Investigation: a real AASV is present in only 44-52% confusion, visual disturbance and headache; 2.8% super!- of normal people. A normal terminal valve (TV) of the AASV cial vein thrombosis; 3.9 % pigmentation; 16.5% pain along is very dif!cult to see with ultrasound (US) because it‘s usu- the treated vein. ally very little and its lea#ets are very close to the vein wall. Discussion. UGFS for recurrent varices is a safe, cheap and In these cases a small AASV trunk is visible (1-2 mm). In the repeatable technique with good medium-term results, similar AASV trunk there’s commonly visible a small dilation (about to those observed following other treatments. A single session 3-4 cm downstream) that represent the valvular pocket of the of UGFS can often eradicate these recurrences and possible repre-terminal valve (PTV). recurrence can simply be treated by further sessions. A higher It appears that a correct function of the PTV of the GSV incidence of recanalization related to a greater diameter of preserves GSV’s trunk from re#ux and only in these cases the vein was observed, suggesting that in these cases an as- we can observe a isolated AASV re#ux (if AASV is present). sociation with phlebectomies might be considered, but further Compared to a classic TV re#ux of the GSV we rarely observe studies will be necessary.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 23 LAFOS: Holmium Laser Assisted Foam Sclerother- — A saphenous vein incompetence associated to a perfora- apy tor with a bidirectional #ow in the lower third of the calf. In A. Frullini this situation a #ow towards the skin can occur during the contractive phase because the pressure in the deep system is Studio medico "ebologico, Figline Valdarno, Florence, Italy higher, but during the relaxation phase the pressure in the deep system drops while that in the super!cial system is higher, and In order to enhance the treatment of insuf!cient saphen- consequently an inward #ow occurs. The clinical execution of ous vein with sclerosing foam, we have used a new technique the Perthes test and the Doppler measurement of the inward called LAFOS (Laser Assisted Foam Sclerotherapy) in which a new speci!cally designed Ho:YAG laser has been used to and outward #ow show that in this pattern the inward #ow is shrink the vein immediately before sclerosing foam injection. the dominant event and the perforator has a non-pathogenic This laser pre-treatment is capable to signi!cantly reduce vein re-entry function. diameter thus less foam volume is necessary to ablate the vein with lower chance of complications. The procedure is performed in ambulatory setting as anesthesia is not required. We are presenting the short time results of the !rst 50 cases EndoTHeF: Endovascular Treatment of Hemor- treated by LAFOS. rhoids with Foam The laser system we used has a 5W max average power with M. Ronconi1, E. Cervi2, A. Frullini3 max 500 mJ per Pulse. 1Department of Surgery, Gardone Val Trompia Hospital, Brescia, Italy The treatment was performed on 38 with insuf!cient Great- 2Department of Surgery, Spedali Civili Hospital, Brescia, Italy er Saphenous Vein (GSV) and 12 Lesser Saphenous Vein (LSV) 3Studio Medico Flebologico, Figline Valdarno, Firenze, Italy LAFOS. The mean of maximum diameter of GSV was 9,17 and 7,91 for LSV. Two GSV were previously unsuccesfully treated Aim. The abstract describes a new conservative approach twice with two sessions of echoguided foam sclerotherapy. for the management of haemorrhoids. Vein shrinkage was easily achieved and the internal lumen Methods. From January 2009 to December 2012 we treated diameter was reduced in association with thickening of the 210 patients, 122 men and 88 woman, 48, 5 main age (range vein wall. 23-74) for proctorragy from hemorrhoids. Complete occlusion was always observed at one month, The technique provides the injection of a sclerosing foam even in the two cases resistent to conventional treatment with in the haemorrhoidal plexus (1) through a 10mm #exible en- sclerosing foam. doscopic instrument. No anaesthesia or sedation is needed. No complications due to foam sclerotherapy were observed Foam is prepared with Tessari’s method. Usually three haem- with the exception of minor bruisings that resolved unevent- orrhoids are treated every session. Two ml of foam are injected fully. Echoguided aspiration of intraluminal clots was routine- in each haemorrhoid (Fig 1), until the complete !lling of vein ly performed. (Fig 2). The injection is performed above the Parks’ line, where No pain was referred during the laser procedure and no pa- sensitive !bres of nervous systems are not present. tients required anesthesia. In 8 patients adjustment of laser Results. All the patients were observed every three weeks energy was necessary to avoid discomfort and most patients and then as needed. We carried out globally 765 procedures in were unaware of the laser action. 210 patients, with a mean of 3,3 sessions for each patient. In The immediate reduction of the vein caliber makes possible twelve cases we have carried out over !ve sessions for persist- treating of large veins (over 1,4 mm), with sclerosing foam. ent bleeding. In 83% of patients we assisted at the end of bleed- This was a true coartation proven by histologic study (not a ing after the !rst line of treatment. Thirty-two patients treated vasospasm). for a severe anaemia had a normalization of haematocrit with- We believe that LAFOS could represent a true enhancement in a month after the last session of sclerosis. There were no ma- of foam sclerotherapy allowing better immediate occlusion jor complications. Four patients referred only discomfort due rate and possibly better late outcome. to perianal itch and six patients referred local heaviness for a week after the procedure. After one year of follow-up most of patients have provided a positive feedback to the questionnaire on QoL after treatment with a high level agree. Hemodynamic Patterns of Calf Perforators Conclusion. Endovascular sclerotherapy of hemorrhoids S. Ermini with foam seems to be an useful tool for the management of haemorrhoids in order to achieve good control of bleeding and Private of#ce, v. Tizzano, 18 – 50012 Grassina, Firenze, Italy pain with a limited number of minority complications. Calf perforators in healthy subjects are less visible. Their number and visibility increase in athletes and in patients with permanent skin vasodilation, like those who take amlodipine. In CVI, calf perforators increase their caliber in relation to CONTROVERSY OF THE DAY deep ambulatory hypertension or to a super!cial venous incompetence, which gives origin to a vicious recirculation. By Controversy of the Day: There is a Clear Relation- increasing its caliber, the perforator loses its valve competence ship Between Multiple Sclerosis and CCSVI Which and the #ow only follows the pressure gradient. During the has Important Implications for Treatment Doppler check-up, in order to reproduce what happens when P. Zamboni a patient walks, we must perform the Doppler analysis using Director Vascular Disease Centre and Institute of Translational Medicine dynamic tests and not manual calf compression, to take a spe- and Surgery, Dept. of Morphology, Surgery, and Experimental Medicine, ci!c look at the #ow events during the contractive and relaxa- University of Ferrara, Italy tion phase of the muscle pump. We can analyze 2 different situations: Aim. To analyze the actual scienti!c controversy on Chron- — Obstruction of the popliteal vein with a perforator in the ic Cerebrospinal Venous Insuf!ciency (CCSVI) and its asso- mid calf that gives origin to a compensative #ow. In this per- ciation with both neurodegenerative disorders and multiple forator we will !nd a #ow towards the skin (a re#ux!!!) during sclerosis (MS). the contractive phase and no meaningful #ow during relaxa- Methods. We revised all published studies on prevalence tion. This is a re#ux, but it is not pathogenic. of CCSVI in MS patients, including ultrasound and catheter

24 INTERNATIONAL ANGIOLOGY October 2013 venography series, and also the press release of the recent The Ultrasound Pattern of Recurrent Varicose Veins COSMO study. Furthermore, we take into consideration other M. Grouden1, D. Moore2, P. Madhavan3, S. O’Neill4, M. Colgan5 publications dealing with the pathophysiologic consequences 1Hermitage Medical Center, Dublin, Ireland of CCSVI in the brain, as well as with the recent description of 2St James’s Hospital, Clane, Ireland CCSVI in Pathology. 3St. James’s Hospital, Ireland Results. Studies of prevalence show a big variability in 4Department of Vascular Surgery, Dublin, Ireland prevalence of CCSVI in MS patients assessed by established 5St. James’s Hospital, Dublin, Ireland ultrasonographic criteria. COSMO study despite the big sample and the blinded methodology appears to be inconclusive Aim. 1. Evaluate the ultrasound !ndings in patients with re- for 90% discrepancies between peripheral and central inves- current varicose veins. 2. Determine where possible the com- tigators. However, 12 studies, by the means of more objective pleteness of previous surgery. catheter venography, show a prevalence >90% of CCSVI in Methods. All consecutive patients presenting with recur- MS. Global hypo-perfusion of the brain, and reduced cerebral rent varicose veins were enrolled in the study. Patients are spinal #uid dynamics in MS was shown to be related to CCSVI. questioned on previous surgery and a complete ultrasound Postmortem studies show a higher prevalence of intraluminal venous evaluation performed. defects in the main extracranial vein in MS patients, as well an Results. To date 50 patients with recurrent varicose veins altered ratio type I\type III collagen in the vein wall in respect in 65 limbs have been enrolled. There are 14 males and 36 to controls. Finally both genetics and environmental factors females with a mean age of 57 years. Surgery varied from signi!cantly associated to MS were identi!ed. 25 years previously with a median of 10 years. The majority Conclusions. The origin of the controversy between the (80%) gave a history of previous high tie and strip while only 3 vascular and the neurological community is linked to the great limbs (5%) had undergone EVLT. Two limbs (3%) had previous variability in prevalence of CCSVI in MS patients by the means SPJ ligation and four limbs (6%) had both SFJ and SPJ liga- of venous ultrasound assessment, known to be a methodol- tion. The remaining three limbs (5%) had simple avulsions. Of ogy highly operator dependent. To the contrary, taking into ac- the 61 limbs who had previous stripping of the GSV, the GSV count the current epidemiological data, including studies on was present and incompetent in 36 cases (59%) and absent in catheter venography, the autoptic !ndings, and the relation- 25 (41%). The SSV was patent and incompetent in all cases of ship between CCSVI and both hypo-perfusion and cerebro- previous SPJ ligation. Truncal incompetence was found in all spinal #uid #ow, we conclude that CCSVI can be de!nitively cases where the patient had previous avulsions only. Two of inserted among the medical entities. Research is still incon- the three veins (66%)treated by laser were occluded. clusive in elucidating the CCSVI role in the pathogenesis of Conclusions. These !ndings suggest that incomplete sur- neurological disorders. The controversy between the vascular gery remains a major cause of recurrence. Treatment of vari- and the neurological community can be solved by the means cose veins should be carefully planned based on ultrasound of multimodality assessment of CCSVI. More reproducible !ndings. Hopefully with the newer ulrasound -guided treat- and objective CCSVI assessment is warranted also for plan- ments such as EVLT the incidence of recurrence will be re- ning treatments, in consequence of the inherent variability of duced in the future. the causes leading to restricted venous out#ow from the brain.

Segmental Biompedance Spectroscopy in Chronic FREE PAPER SESSION 4 Venous Disorders: Data on Resistance and Reac- tance Soft Sclerotherapy of the Hand Veins S. Urso1, F. Campana2, A. Cavezzi3 M. Valsamis1, M. Lefebvre-Vilardebo2 1Vascular Unit Hippocrates, San Benedetto del Tronto, Ascoli piceno, 1Private Practice, Athens, Greece Italy 2Of#ce of Surgical and Medical Phlebology, Paris, France 2Ospedale M. Bufalini” Cesena”, Forli-Cesena, Italy 3Poliambulatorio Hippocrates, San Benedetto Del Tronto, Italy Aim. Injection sclerotherapy is a widely used method of treatment for the varicose veins of the legs. We used the same Aim. To collect by means of bioimpedance spectroscopy technique for the reduction of the caliber of the very dilated (BIS) data on resistance (related to extracellular #uid content) hand veins and reactance (related to tissue composition) in patients af- Methods. In this non randomized prospective study, con- fected by chronic venous disorders (CVD) of the lower limbs. ducted between 10/2007 and 7/2012, 62 women with dilated Methods. 237 patients (77 M, 160 F, mean age 56,2 years) veins of the dorsum of the hand were treated for an aesthetic affected by CVD were investigated by means of BIS (U-400, improvement of their hands. Polidocanol 0.5-1.5%, Sodium Impedimed) with regards to resistance and reactance param- Tetradecyl Sulfate 0.25-1% and Scleremo 70-100%, were the eters. CEAP distribution in the 474 limbs was 78(16.5%) C1, sclerotherapeutic agents that we used in their liquid form. 96(20.3%) C2, 235(49,5%) C3, 65(13.7%) C4a or C4b. Absolute Various quantities were injected in each hand (max: 4cc), de- !gures and percentage differences for each parameter were pending on the size and the number of the veins we wanted to calculated: a) for each C stage, b) comparing different C stages treat. Both hands were injected in each session. No bandag- in the same patient, c) according to age groups. ing was applied after the treatment. No precautions and no Results. mean absolute !gures + standard deviation (SD) of restrictions were implied after the treatment. resistance were: 342.4(SD±31,1) in C1, 315.3(SD±33.5) in C2, Results. Minimum 1 and maximum 5 sessions were needed 249.9(SD±48.1) in C3, 222.6(SD±43.2) in C4. Reactance data for an overall satisfactory result. All our patients supported the were: 17.8(SD±2.9) in C1, 13.4(SD±3.2) in C2, 10.7(SD±4.6) in injections well. There were no complaints during or after the C3, 9.1(SD±3.3) in C4. Percentage difference of resistance and treatment and only very mild transitory oedemas were excep- reactance between limbs of the same patient were respectively: tionally noted. The achievement of a spasm immediately after 4.2% and 8.4% for C1 vs C2, 11.7% and 16.2% C1 vs C3, 15.1% the veins have been injected was a good prognostic factor, for and 18% C1 vs C4. Finally resistance and reactance values de- the outcome of the treatment. The treatment ended when the crease with patient’s age increase. result was regarded as satisfactory by the patient. Conclusions. BIS assessment of limbs affected by CVD Conclusions. Soft injection sclerotherapy of hand veins proved to be of help to assess #uid content and tissue compo- can give good aesthetic results with safety and relative ease. sition. Absolute !gures and comparative !gures of resistance

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 25 and reactance in C1-C4 CEAP stages showed a good correla- respect to frequency of phenotypes and similarities in veins tion; age strati!cation resulted in correlated data as well. and ulcers. Methods. We identi!ed bacterial cells and their DNA in varicous veins (C2 CEAP classi!cation) and venous ulcers (C5- Electro-Stimulation with Veinoplus. A New Method 6) with respect to frequency of phenotypes and similarities in veins and ulcers. for the Treatment of Chronic Venous Insuf#ciency Results. Bacterial isolates were identi!ed in varicous veins of the Lower Limbs in 40% of specimens and bacterial 16sRNA (DNA) in 52%. V. Bogachev Control veins were positive in 4%. Skin at disinfected incision RSMU, Moscow, Russian Federation site for vein harvesting contained proliferating bacteria in 4%. Venous ulcers were infected in 100%. Veins and ulcer granula- Aim. Electro-stimulation with VEINOPLUS has recently tion tissue were colonized by Staphylococci both aureus and emerged as a new technique to activate the calf muscle pump coagulase-negative, however, ulcers also revealed presence of and improve symptoms of venous disease. The aim of this gram-negative bacilli. Genetic similarities between skin and study was to determine in patients suffering from chronic vein staphylococci was found in 85%.Fifty-two percent of vari- edema of venous origin the ef!cacy of VEINOPLUS treatment cous vein specimens were in#itrated by granulocytes and mac- in terms of reduction of evening edema, diminution of pain, rophages. improvement of quality of life and also evaluate the durabil- Conclusions. Bacterial colonization may be a factor in the ity of the treatment and its impact on venous hemodynamics. pathomechanism of damage of lower limb super!cial veins Methods. 30 patients (32 legs) aged 19-50 (mean 45.2 ±1.3) (varices) and facilitating formation of venous ulcers. classi!ed CEAP C3 with chronic evening venous edema were recruited (22 limbs: C3SEp and 10 limbs: C3EsPr). All patients were treated with CE-registered VEINOPLUS neuromuscular stimulator during 30 days: 3 sessions per day (each session Effect of Shave Therapy and Split Skin Grafting on being 20 minutes) during 10 days, then 2 sessions per day dur- Healing and Recurrence of Large and Very Large ing 10 days and one per day during the last 10 days. Main criteria was the circumference of the supramaleoal shin seg- Vascular Leg Ulcers ment, measured with a tape in the evening, before treatment, H. Kittler1, K. Boehler2 daily and as control 5 days after treatment. As secondary cri- 1Medical University of Vienna, Vienna, Austria teria, patients were assessed on day 0 and 35 regarding pain 2Department of Dermatology, University of Vienna Medical School, AKH, on the Visual Analog Scale, Quality Of Life (QOL) according Vienna, Austria to CIVIQ questionnaire and venous Re!lling Time (RT) measured by PPG. Three months after the treatment, evaluation of Aim. To identify risk factors for ulcer healing and recur- symptoms was made again. No other means of treatment or rence after shave therapy and split skin grafting in addition to prophylaxis were used. correction of vascular insuf!ciency in patients with large and Results. VEINOPLUS treatment was well tolerated by pa- very large vascular ulcers. tients. There was not drop out and patients did not change their Methods. Single center, retrospective cohort study involv- lifestyle. After treatment, a total or partial reduction of evening ing 72 chronic leg ulcers with a mean area of 77±132cm². edema was shown in 93.8% of limbs, the circumference of the Healing and recurrence rates were determined using life-table supramalleolar shin diminished by 20,3mm (p<0.001), the analysis. Clinical, demographic and hemodynamic parameters number of painful legs reduced from 28 to 12 and the sever- were correlated with healing and recurrence using Cox regres- ity score was cut from 8.3 ±1.1 to 3.8 points ±0.9 (p<0.001), sion analysis. QOL was improved signi!cantly as the score dropped from Results. Sixty ulcers (83%) healed after a mean of 1.9 34.5 ±7.8 to 17.2 points ±4.6 (p<0.001) and RT increased from months, 15 ulcers (25%) recurred after a mean of 12.7 months. 17.3 ±0.9 to 21.5 seconds ±1.1 (p<0.001). Three months after Healing was positively associated with compression treatment VEINOPLUS treatment a total remission of symptoms was ob- (Hazard Ratio (HR) 2.02 [95% CI 1.14-3.59]) and negatively served in 50% of legs, despite absence of other treatment. associated with ulcer duration (HR 0.99 [95% CI 0.98-1.0]). Conclusions. VEINOPLUS stimulation is an effective and Male sex, ulcer duration and deep venous re#ux were identi- well-tolerated therapeutic method for the treatment of chronic !ed as signi!cant risk factors for ulcer recurrence (HR 0.14 venous disease when it comes to treatment of chronic edema, [95% CI 0.03-0.73]; HR 1.02 [95% CI 1.0-1.04]; HR 5.4 [95% CI for reducing pain and improving quality of life. VEINOPLUS 1.30-22.31]). Ankle brachial pressure index (ABPI) < 0.9 had can be used as additional means in the treatment and the pre- no signi!cant in#uence on healing or recurrence. vention of symptoms of chronic venous insuf!ciency. This Conclusions. Early surgical intervention improves healing study also reveals that stimulation of calf muscles with VEI- and reduces the risk of ulcer recurrence. NOPLUS can improve venous hemodynamics leading to a remission of symptoms. This !nding should be investigated and con!rmed in further studies. Skin Tissue Engineering Treatment R. Vellettaz1, L. Correa2, D. Dominici2, V Lavigne2 Bacteriology of Varicous Veins. Their Presumptive 1Clinica Colon CEVYL, Mar del Plata, Buenos Aires, Argentina 2Craveri SAIC, CABA, Buenos Aires, Argentina Role in Pathogenesis of Ulcer Formation W. Olszewski 1, M. Moscicka-Wesolowska 2, E. Swoboda-Kopec 3, M. Aim. Primary Objective To generate an arti!cial skin substi- 2 Zaleska tute DED (dermo-epidermal device) produced by a tissue en- 1Medical Research Center, Warsaw, Poland gineering. Secondary Objectives Secondary To analyze DED: 2Department of Surgical Research & Transplantology, Medical Research Center, Polish Academy of Scien, Warsaw, Poland - macro and microscopic characteristics - Immunohistochem- 3Department of Microbiology, Medical University, Warsaw, Poland, War- istry - Controls: microbiological purity identity saw, Poland Methods. We designed a preclinical study. We produced a surgical skin sharp lesion in a pig animal model. A biopsy was Aim. We identi!ed bacterial cells and their DNA in varicous taken from the pig skin to set a keratinocytes and !broblasts veins (C2 CEAP classi!cation) and venous ulcers (C5-6) with culture. A DED using a platelet poor plasma support was de-

26 INTERNATIONAL ANGIOLOGY October 2013 veloped. The DED were placed in the wound and skin biopsy In Vitro Effects of Detergent Sclerosants on White was taken at 14 and 21 days of implantation. We analyzed the Blood Cells macroscopic and microscopic characteristics of DED and the H. Moore1, T. Willenberg 2, P. Coleridge-Smith 3, C Chiappini 4, S Ber- tissue repair of the pig skin, studying the immunohistochemi- tazzo5, M Stevens4, A Davies6 cal pro!le. 1Academic Section of Vascular Surgery, Imperial College London, Lon- Results. Autologous DED demonstrated a complete don, United Kingdom epidermis,with more than !ve layers and rudimentary corni- 2University hospital Berne-CH, Berne, Berne !cation. DED analysis were performed: 1. Sterility controls: 3British Vein Institute, Amersham, United Kingdom All microbiological studies were negative 2. Purity exams were 4Imperial College London, London, United Kingdom 5Department of Materials, London, United Kingdom performed using the LALMethods. All paramethers were ac- 6Academic Section of Vascular Surgery, Imperial College London, Lon- cording to expected 3. Identity analysis a- Histological organi- don, United Kingdom zation was performed usig hematoxylin/eosin stains b- Immu- no histochemical analysis: Epithelium: positive for involucrin, Aim. This study aims to investigate the in vitro effect of the pankeratin (AE1, AE3), and negative for CD1A (indicating the sclerosants Sodium-Tetradecyl-Sulphate (STS) and Polidoca- absence of Langerhans cells) Dermis: positive for vimentin nol on white blood cells (WBCs). Basement membrane: positive for collagen type IV and lam- Methods. Blood was taken from subjects using a vacu- inin 4. Potency was evaluated though the immunohistochemi- tainer without tourniquet directly into a tube containing cal expression of TGF-b and Ki67 (expressed only in proliferat- EDTA. WBCs were isolated by differential lysis of red cells ing cells) The animals showed wound repair after 14 days. The and centrifugation and subjected to different concentrations control group had not healed completely in 21 days. of both polidocanol and STS ranging from 0.1-3% for 5 min- Conclusions. We generated a reproducible method, devel- utes with and without bovine serum albumin (BSA). Dead oping a DED that has structural and ultrastructural character- WBCs were labelled with a green #uorescent dead stain and istics compatible with skin grafting. It proved to be effective in #ow cytometry and scanning electron microscopy (SEM) the treatment of surgical wounds induced in pigs. In chronic was carried out. diseases, where cellular and molecular mechanisms of heal- Results. Increasing concentrations of both polidocanol and ing are disturbed, skin tissue engineering substitutes appear as STS decreased the number of events recorded during #ow cy- the most appropriate solution. We are now designing a clini- tometry. The presence of BSA had a protective effect, with a cal trial in venous ulcers, awaiting approval from the National higher number of events at the same given concentration of Regulatory. sclerosant in all cases. The presence of BSA did not have a signi!cant effect on the mean number of dead WBCs except at the 0.1% concentration of polidocanol. When compared to STS, polidocanol had a signi!cantly higher mean percentage How Should We Treat Complex Deep Venous Re"ux of dead cells at all concentrations above 0.2%, but a higher and Obstruction? A Survey number of total events. SEM demonstrated clumping of WBCs H. Moore1, I. Maththananda2, T. Lane3, I. Franklin1, A. Davies4 after exposure to polidocanol, and very few scattered WBCs 1Academic Section of Vascular Surgery, Imperial College London, Lon- after exposure to higher concentrations of STS. don, United Kingdom Conclusions. BSA seems to have a protective effect on 2Academic Section of Vascular Surgery, London, United Kingdom WBCs subjected to increasing concentration of sclerosant. 3London, United Kingdom STS and polidocanol have different effects on WBCs, as po- 4Academic Section of Vascular Surgery, Imperial College London, Lon- lidocanol increases the percentage of dead cells, and also caus- don, United Kingdom es clumping of cells. Aim. Vascular specialists manage patients with complex deep venous re#ux and obstruction. There are differing opinions and randomised trials are dif!cult. By performing a survey of venous experts, this study aims to guide management of Can Phlebectomy and Foam Sclerotherapy be Per- these challenging patients. formed Together? Methods. Ten complex cases were selected, all had C5-6 H. Gajraj disease and mixed super!cial and deep re#ux with/without The Veincare Centre, Dorset, United Kingdom chronic deep venous obstruction. An online survey program, distributed by e-mail to vascular specialists, was employed. Aim. Ambulatory phlebectomy is the treatment of choice The management options were ranked by the experts. for large super!cial varicose veins. However, usually only the Results. For patients with deep venous obstruction, to date, palpable portion of the non-saphenous tributary is extracted there have been 35 responses, including 25 Consultants. For and after phlebectomy large parts of the vein may be left in the deep venous re#ux survey, to date, there have been 77 re- situ. These residual veins could theoretically be the source of sponses, including 38 Consultants. The majority of cases had recurrence. Combining phlebectomy and foam sclerotherapy a clear preferred option for initial management, however, for in the same session to treat the same tributary may address a patient with unilateral proximal iliac obstruction, femoral this issue. However, it is not clear if such a combination might vein re#ux and previous super!cial vein ablation, the opinion lead to problems with healing at the phlebectomy sites. The was divided between compression alone and iliac vein stent. In aim of this study is to determine whether the foam sclerosant general, open surgical procedures were considered second or adversely affects the healing of phlebectomy sites as judged by third line. In the case of a young patient with subclavian vein wound infection, clinical appearance and patient satisfaction. thrombosis, the opinion was divided evenly between heparin Methods. Patients presenting with C2 disease to an ambu- alone and catheter directed thrombolysis, and for a patient latory vein clinic between 1st April 2010 and 31st March 2012 with IVC obstruction and intracranial bleed there was no out- were studied. Saphenous vein re#ux was treated by endov- right preferred option. enous thermal ablation and then the non-saphenous tributar- Conclusions. Preferred management options for patients ies were treated by a combination of phlebectomy and foam with complex deep vein re#ux, deep venous obstruction or sclerotherapy. Patients were reviewed at 48-72hrs, 6 weeks, 6 mixed re#ux and obstruction are variable across the world. A months and 12 months assessed for infection, hyperpigmen- consensus would be valuable to determine the best manage- tation and telangiectasias. Patient satisfaction questionnaires ment options for these patients. were completed at 12 months.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 27 Results. 379 legs were treated (298 patients; mean 49 years; (leading) end of lymphatic vessels. Block lymphatic drainage 212 women) by 2826 phlebectomies (median 9/leg; range in these patients, in an upright position, resulting in re#ux of 3 – 26). 8 patients were lost to follow up; 290 patients were lymph through the main lymphatic collectors. This was the ba- reviewed to 12 months. No phlebectomy wounds became in- sis for a modi!ed 10 operations - simultaneously draining the fected and all were closed at 72 hours. There were no cases of proximal and distal ends of the lymphatic vessels in the veins hypertrophic scarring, dyschromia or neotelangiectasia at the (bidirectional anastomosis). In all cases, surgical treatment phlebectomy site. 42 patients had brown discolouration over is complemented bandaging (sleeve «Sigvaris») and pneumo- the treated tributary which persisted to 6 months, but at 12 compression. months only 3 patients had pigmentation associated with the Results. Operational ef!ciency lymphovenous anastomosis sclerotherapy. Patient satisfaction questionnaires showed that was evaluated by the degree of reduction of the swelling of the at 12 months 288 patients were either very satis!ed or com- arm, by measuring the circumference of the forearm and up- pletely satis!ed with the appearance of their legs. 1 patient still per arm for 3 days after surgery, and 1, 3, 6, 12 months. Then had a prominent phlebectomy scar and 1 patient had brown 1 time a year. Analysis of the dynamics of various departments discolouration. of the circle hand held relatively original size in percent. Re- Conclusions. Foam sclerotherapy and phlebectomy can be gression of edema in standard operation after 1 month. aver- performed simultaneously in the same non-saphenous tribu- aged 65.6% and 28.2% in arm shoulder, when modi!ed - 69.1% tary without adversely affecting wound healing of the phlebec- and 62.7%, respectively. tomy site or the !nal overall cosmetic result at 12 months. Conclusions. Modi!ed lymphovenous anastomosis allows more than 2-fold decrease swelling shoulder, back through the drainage of lymph #ow, compared to the standard operation for patients with postmastectomy lymphedema. The Postural Compression of the Popliteal Vein J. Uhl1, J. Benigni2, C. Gillot3 1URDIA research unit, Paris, France 2NA, Saint Mandé, France 3University Paris Descartes, Paris, France THE BASIC SCIENCE OF THROMBOSIS

Aim. To study the anatomical parameters of the postural The Role of Tissue Factor in Venous Thrombogen- compression of the popliteal vein and show how to prevent esis thrombosis. N. Mackman Methods. Anatomical dissection of 100 lower limbs of fresh Department of Medicine, University of North Carolina at Chapel Hill, cadavers injected with neoprene latex make the basis of this Chapel Hill, USA anatomical study. 200 patients investigated by phlebography before or during varicose vein surgery were also analysed. Tissue factor (TF) binds factor VII/VIIa and activates the Results. Compression due to hyperextension of the knee: clotting cascade. It is essential for hemostasis but also con- compression by the femoral condyle (condylian gorge) Dur- tributes to thrombosis in many diseases. TF can be present ing knee #exion (> 90°) 3 kind of extrinsic compression in an active form and an encrypted form that has little to no can occur: High obstacle above the condyle: thin condylian procoagulant activity. In general, high levels of active TF are groove, venous kinking or volvulus of the popliteal vein. Mid- present in blood vessel walls and very low levels of encrypt- dle level obstacle: central stenosis or posterior notch of the ed TF are present in the blood itself. Some of this so-called popliteal wall Low obstacle: inprint of the popliteal muscle. “blood-borne” TF may circulate on microparticles (MPs), Entrapment syndrome of the popliteal vein is scarcely seen which are small membrane vesicles released from activated in practice. and apoptotic cells. Recent studies have shown that TF plays Conclusions. The postural compression of the popliteal an important role in deep vein thrombosis (DVT) in different vein or roots is underestimated and not diagnosed, but could mouse models involving the inferior vena cava (IVC). An early be easy recognized by Duplex ultrasound or even by simple study using an IVC ligation model found that the vessel wall continuous Doppler. This makes possible a prevention of DVT was the major source of TF that drove thrombosis. Similarly, for high risk patients: during operations, in bed or sitting posi- vessel wall TF but not leukocyte TF contributed to thrombo- tion during long distance #ights. sis in an electrolytic injury model. However, both models involve vessel damage and are not the best models of venous thrombosis in humans. Recently, a new IVC stenosis mouse model was developed that more closely mimics the endothelial activation without vessel damage that it thought to occur Modi#ed Lymphovenous Anastomosis in the Treat- in human DVT. Using this model, we found that mice with ment of Post-Mastectomy Lymphedema TF de!cient myeloid cells had reduced thrombosis compared S. Pryadko, A. Malinin with control mice, which indicated that myeloid TF contrib- Bakoulev Center for Cardiovascular Surgery Russian Academy of Medi- utes to thrombosis in this model. However, further studies cal Sciences, Moscow, Russian Federation are needed to determine if there are other cellular sources of TF contribute to thrombosis in healthy mice. Cancer patients Aim. More than half of women after mastectomy have have an increased risk for thrombosis. Importantly, tumor secondary lymphedema arm, which signi!cantly reduces the cells express high levels of TF and release TF+ MPs. We hy- quality of life. Lymphatic microsurgery can improve the pa- pothesized that tumor-derived TF+ MPs may trigger venous tient’s condition, but dissatisfaction result of the standard thrombosis. We found that mice containing TF-positive hu- lymph anastomosis requires a search for new approaches. man pancreatic tumors but not TF-negative tumors released Methods. Retrospective analysis of patients (N=31) treated TF+ MPs into the blood and activated coagulation. In addi- on department of venous pathology and microsurgery because tion, we found that injection of TF+ MPs into mice enhanced of post-mastectomy lymphedema in years 2003-2013. 22 op- thrombosis in the IVC stenosis model. This enhancement was erations were performed by standard methods, by proximal abolished by pre-incubating the MPs with an anti-TF anti- (outlet) ligation lymph vessels and implanted in a vein distal body. Currently, we are investigating how the tumor MPs are

28 INTERNATIONAL ANGIOLOGY October 2013 docking to the activated endothelium and other cell types to CHIVA – Technical Aspects and Evidence enhance thrombosis. Finally, we have found that elevated lev- E. Mendoza els of TF+ MPs are predictive of venous thrombosis in pancre- Venenpraxis, Wunstorf, Germany atic cancer patients. CHIVA stands for hemodynamic treatment of insuf!cient veins in ambulatory patients. It !rst described by Claude Franceschi in 1988. The aim of the method is to preserve the SAPHENOUS SPARING PROCEDURES saphenous veins for the venous drainage. The technique is based on four principles: Theoretical Considerations in CHIVA and ASVAL — Interruption of the veno-venous recirculation; F. Passariello — fragmentation of the hydrostatic column; Centro Diagnostico Aquarius, Napoli, Italy — preservation of the re-entry perforators; — deletion of the incompetent tributaries. CHIVA and ASVAL are conservative strategies for the treat- Leg veins are divided into a network of: N1 deep veins, N2 ment of chronic venous insuf!ciency (CVI), CHIVA being ap- saphenous trunks, and N3 epifascial tributaries. Correct blood plied also to deep veins diseases. drainage is from N3 to N2 and N1; in venous pathology this or- ASVAL has a shorter learning curve than CHIVA and is es- der is inverted. Recirculation is strati!ed into different Shunt- sentially based on tributary-phlebectomies. types, according to the re#ux source (the point where the CHIVA strategy can be applied by CHIVA-crossotomy, phle- blood #ow is reversed, to #ow from N1 to N2 or N3 and from bectomies, devalvulation and LASER (OBCHIVA, Passariel- N2 to N3). These #ows are analyzed with duplex ultrasound. lo,2010,2011,2013). Depending on the Shunt-type, different technical steps may The essential contraposition is ASVAL/CHIVA2, a special be chosen: in the case of a re#uxive saphenofemoral or saphe- strategy designed for the Shunt-III. nopopliteal junction with incompetent terminal valve and Both ASVAL/CHIVA2 perform a tributary disconnection, a draining perforator on the saphenous vein (Shunt-type 1) with temporary re#ux elimination. Without extra information, interruption of the junction is the basic element of the tech- no one will differentiate Muller-phlebectomy, ASVAL, CHIVA2 nique, followed or not by an interruption of re#uxive tributar- (Passariello,2010, The Phlebo-Turing-test). ies. If no perforator is found on the saphenous vein but only Differences can be found instead in the interpretation of on its re#uxive tributaries (Shunt-type 3), and depending dif- the re#ux elimination ASVAL deals with the abolition of the ferent parameters as the diameter of the saphenous vein, #ush “venous-reservoir”, super!cial dilated tributaries distrib- ligation of the tributary (with or without avulsion of the com- uted in zones (32_NZT).Re#ux is due to their “aspirating” plete tributary) may be suf!cient. As a result, the saphenous effect(Pittaluga,2009). vein is competent in 50 – 80% of cases. The same procedure CHIVA deals with the abolition of the re#ux reentry-point, may be applied in the case of a competent terminal valve and by limited phlebectomy or simple !nger compression, without incompetent pre-terminal valve, with re#ux from pelvic origin loss of venous-heritage. The tributary disconnection interrupts (pelvic shunt), again with a high incidence of competence in backward paths, leaving physiologic forward ones. the saphenous vein afterwards. CHIVA studies only the topographical properties of the net- Several studies have been published with long term results work, without any hypothesis on diameters or compliance, of CHIVA, with and without randomized comparison to other using a restricted set of hypotheses, while ASVAL requires a methods, specially compared with Stripping. Currently a Co- wider set of assumptions. CHIVA complies with an elementary chrane review is being reported, the results will be ready in application of the Ockham’s Razor (William of Ockham,XIV September. century,“entia non sunt multiplicanda praeter necessitatem”, In 3 randomized prospective investigations comparing the “entities must not be multiplied beyond necessity”) the aim of two methods for 5 – 10 years, the overall results in the two the procedure, in a relapsing re#ux ASVAL performs repeated methods were similar, with less pain after intervention in the phlebectomies, choosing saphenous ablative procedures when CHIVA Group and a higher rate of recurrence in the stripping phlebectomies are no more practicable. groups after 5 and 10 years (Carandina 2006, Iborra-Ortega CHIVA performs CHIVA2-1 st -step (like a phlebectomy), 2006, Parés 2010). Ulcer healing after CHIVA, as compared waiting for lower trunk valve incompetence.(Shunt-III-con- with compression alone, was signi!cantly higher and longer- version-Shunt-I, treatable with CHIVA1). lasting (Zamboni 2003). Some daily observations are against the reservoir hypothesis. During re#ux in the standing position no GSV/tributary caliber-variation occurs, while an almost !xed-caliber instead ASVAL Methods. Technical Aspects and Evidences is observed. P. Pittaluga, S. Chastanet Caliber increases instead when re#ux stops against a com- Riviera Veine Institut MC, Monte-Carlo, Monaco petent valve (Valsalva). During re#ux deep veins compliance !lls gradually, showing Therapeutic principle. The ASVAL method (Ambulatory an increased resistance, stopping the re#ux reentry, increasing Selective Varices Ablation under Local anaesthesia) is based the pressure, with super!cial veins dilatation. on the physiopathological ascending theory for venous insuf- This point of view remarks the importance of a reservoir !ciency with two consequences: not in the tributaries nor in the saphenous veins, located in- 1. If there is no saphenous re#ux, early treatment of vari- stead in the deep veins of the calf. In this view, the re#ux is cose veins (VVs) would be useful in order to prevent it spread- strictly connected with the alternate calf function. ing to the saphenous vein (SV). CHIVA/ASVAL refer respectively to descending/ascending 2. If there is saphenous re#ux, and up until a certain stage varicogenesis. However, once the re#ux develops, therapy of the disease, !rst-line therapy should include ablation of the doesn’t depend on the origin of the disease, but only on the varicose reservoir (VR) and not the ablation of the SV of which actual structure of the network. the re#ux is potentially reversible. Regarding the follow-up time sequence of segments involve- Saphenous stripping would only be indicated in cases ment, a false perception can derive from re#ux maneuvers be- where saphenous re#ux seems to be irreversible. The ASVAL ing negative in absence of reentry points. rejects the systematic crossectomy and stripping, by remov-

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 29 ing only the VR by phlebectomy, and preserving the re#uxing the calf, but it doesn’t give us any information about how the saphenous, in order to preserve the physiological role that the different compartments empty. SV could play in super!cial drainage. Moreover perforators analysis after stripping shows that Evidences. The medium-term results of a cohort of 303 they represent an hemodynamic spare system between the su- lower limbs treated by ASVAL showed a major improvement per!cial and the deep compartments !nalized to balance pres- in saphenous hemodynamics in 90% of cases compared to the sure, demonstrating the main role of the saphenous trunk in preoperative values up to 4 years of follow-up, with an im- the super!cial out#ow. provement or a disappearance of symptoms in 80 to 90% of cases, a cosmetic bene!t in 90% of cases, and a varicose recurrence rate of 11.5% at 4 years. In so much as the recurrence rate for the ASVAL method in the short and medium-term is not higher than for techniques that involve removal of the SV, when there is only partial SV re#ux and when the SV is only HANDS ON SIMULATION SESSION moderately dilated. Two prospective studies have shown the signi!cant effect of “Hands-On” Simulation Session: Compression phlebectomy on reduction of the diameter and the re#ux of the A.F. Brennan SV. In addition, the bene!t of the ASVAL for nullipara patients Lymphedema Management Program, HealthSouth Scottsdale Rehabilita- has been reported for the reduction of complexity, signs and tion Hospital, Scottsdale, USA symptoms in the event of VVs recurrence after pregnancy. A retrospective study of 1,010 lower limbs treated by ASVAL and Lymphedema is a chronic disease needing life-long treat- followed-up for a mean period of 36.6 months found that the ment. Among the different therapeutic modalities, compression limbs with recurrent VVs had a preoperative VR that was sig- is the single most important element of treatment for both the ni!cantly larger, especially below the knee. This observations initial phase of decongestion (Complex Lymphatic Therapy) as support the theory of the ascending development of varicose well as for long-term maintenance. Compression is vital in or- disease which is increasingly gaining ground in the scienti!c der to get the most effective clinical and cost effectiveness out- community. come of treatment and helping patients to maintain function However, the indications of ASVAL treatment require to be and have improved appearance. Management by proper com- more precise by longer follow-up and randomized controlled pression may be supplemented with other treatment modalities trials. including skin care, exercise and manual lymphatic drainage. An overview of the science behind compression bandaging for lymphedema and chronic edema will be discussed. Topics include effects of compression pressure and stiffness on venous Do We Need to Spare the Saphenous Vein? YES return, arterial circulation, and lymphatic drainage. Indications M. Cappelli for compression will be reviewed. Phlebology Private Of#ce, Florence, Italy Hands on demonstration of the various compression tools are the focus of this session. These tools will include: short Do We Need to Spare the Saphenous Vein ? YES stretch bandages, inelastic compression devices, and elastic Why? compression. For two main reasons: 1°) The saphenous trunk, even incompetent, can be used for arterial by-passes, as a !rst or second choice. This is the common experience of “arterial” vascular sur- J.A. Caprini geons and cardiovascular surgeons. Indeed, there is a !rm in Division of Vascular Surgery, NorthShore University HealthSystem, France that gathers stripped saphenous veins and sells them Evanston, IL, USA for by-pass use. We have to take into account that population age is increas- Compression therapy is one of the most important yet ing and therefore the probability of arterial disease raises up. poorly understood modalities for the treatment of a variety Furthermore, people are more sensitized to vein problems and of leg pathology. This workshop will consist of three mod- phlebologists will deal with vein disease more and more in the ules including stockings, Velcro devices, and compression early stage with small saphenous vein. bandages. The indications and contraindications for each of 2°) The treatment of primary varicose veins, preserving the these forms of therapy will be discussed and include hands- saphenous trunk, leads to a reduction of recurrences overtime, on techniques for application and removal. Stockings are as demonstrated by published RCTs. the mainstay in the treatment of leg swelling but are dif- It doesn’t just suf!ce to preserve a saphenous trunk to stabi- !cult to apply and remove in certain patient populations. lize the system, we have to preserve it as a draining saphenous The instructors will demonstrate innovative techniques in trunk as demonstrated by CHIVA procedures. application and removal of these stockings. The course will The retrograde #ow in the saphenous vein after CHIVA, as an also emphasize when stockings are inappropriate for an in- expression of its drainage, is, actually, a re#ux originating from dividual situation and how to take the next step in providing tributary out#ows once the original escape points is discon- appropriate edema control. What does one do when stock- nected and nevertheless it leads to low recurrences incidence. ings fail to control the patient’s edema? This may involve Therefore not all re#uxes are so pathogenic as thought, it the use of Velcro compression systems with or without liners depends on the developed pressure and speed. No study has and hands-on demonstration of the various products will be yet conclusively demonstrated that the direction of a #ow can included in the course. Compression bandages will be dis- be pathogenic “per se”. cussed including selection of the appropriate product based The role of the saphenous trunk, even if incompetent, as on the patient’s pathology. The concept of short-stretch ver- main path of the super!cial out#ow and how the super!cial sus long-stretch compression will be emphasized. The high- network empties, can be studied with the B-FLOW. light of this module will be demonstrations by the experts This technology allows us to overcame the limits of doppler of proper application techniques using these bandages. The effect for low speeds. instructors will guide the attendees through the hands-on The plethismography just measures the total emptying of application and removal of these bandages. The attendees

30 INTERNATIONAL ANGIOLOGY October 2013 will learn from the faculty !ner techniques regarding the use okines, and CSFs released in the culture media by multiplex of these products to successfully manage individual clinical ELISA assay (Bio-Rad 17-Plex, Bio-Rad, Milan, Italy). scenarios. Finally the latest techniques in measuring pres- Results. The pro-in#ammatory LPS stimulation of U-937 sures beneath any of these compression products will be macrophage-like cell line induced a signi!cant increase of C-C shown. and CXC chemokines, and colony stimulating factors compared to untreated cells. Speci!cally, LPS-treated macrophage- like U-937 cells showed increased levels of speci!c C-C (MCP- 1) and CXC (IL-8) chemokines (P<0.0001), and CSFs (GM-CSF FREE PAPER SESSION 5 and G-CSF) (P<0.0001). Treatment of U-937 macrophage-like cells with increased concentrations of SDX (0.12 and 0.24 Assessment of Cell Death Pattern of a Varicose Vein ULS/mL) signi!cantly down-regulated in a dose-dependent Organ Culture Model manner the differential release of C-C and CXC chemokines and CSFs (P<0.001). C. Lim1, S. Kiriakidis2, E. Paleolog2, A. Davies3 Conclusions. LPS stimulation of in#ammatory cell causes 1Imperial College London, London, United Kingdom the release of chemokines and CSFs. Treatments with SDX 2Kennedy Institute of Rheumatology, London, United Kingdom 3Academic Section of Vascular Surgery, Imperial College London, Lon- cause a signi!cant reduction in chemokines and CSFs expres- don, United Kingdom sion and/or secretion from the in#ammatory U-937 macrophage-like cells. This novel !nding of SDX underscores the Aim. The study investigated the viability of a commonly pleiotropic properties of SDX as not only an antithrombotic/ used varicose vein (VV) organ culture model that was based pro!brinolytic agent, but as a speci!c inhibitor of macrophage on a saphenous vein organ culture previously described by chemokines and CSFs with implications on mechanism of ac- Soyombo and colleagues. tion in the treatment of CVD. The clinical implication is that Methods. To assess cell death with time, VV organ cultures SDX-dependent anti-in#ammatory properties may counteract from 14 patients were incubated in normoxia for 14 days with the initiation and progression of CVD. culture medium changed every 48 hours. To demonstrate VV organ culture model contained viable cells, cell death of VV organ cultures from 4 patients treated with sodium azide 10mM and their untreated counterparts was assayed. Cell death was Mechanical Stretch Alters Metabolism of Vein Wall; assayed with Cell Death Detection ELISA Plus®. an Ex-Vivo Animal Study Results. Increased cell death was measured in VV organ M. Anwar1, P. Vorkas 2, L. Jia 2, O. Reslan 3, E. Want 2, J. Raffetto 4, R. cultures from day 0 to day 2. Cell death decreased gradually Khalil5, E. Holmes2, A. Davies1 after day 2 and plateaued off from day 8 to day 14. VV organ 1Academic Section of Vascular Surgery, Imperial College London, Lon- cultures treated with sodium azide demonstrated signi!cant- don, United Kingdom ly more cell death in tissue (P=0.001; two-way ANOVA with 2Imperial College London, London, United Kingdom Bonferroni post-tests). Cell death measured in VV organ cul- 3Division of Vascular Surgery, Brigham and Women’s Hospital, Harvard tures treated with sodium azide continued to increase until Medical School, Boston, MA, USA 4Vascular Surgery Division VA Boston Healthcare System Surgery 112, day 7. Whereas, cell death measured in tissue lysate of VV West Roxbury, MA, USA organ cultures not treated with sodium azide did not increase 5Division of Vascular Surgery, Brigham and Women’s Hospital, Harvard after day 1. Medical School, Boston, MA, USA Conclusions. This study demonstrated the viability of the VV organ culture model with most cell death occurred within Aim. Vein wall stretch, an etiological factor in the develop- the !rst two days of culture. The cell death then declined to a ment of varicose veins, may have an in#uence on the metabo- relatively low level and remained more or less plateau until at lism of the vein wall. The aim of this study was to investigate least day 14. The presence of viable cells supported the use of the the effect of ex-vivo mechanical stretch on the metabolism of organ culture to study in vitro VV behaviour within this period. the vein wall. Methods. Segments of male rat inferior vena cava (IVC) suspended in tissue bath were exposed to 0.5 g (non-stretch) or high 2 g tension (stretched) for short 4 or prolonged 18 hrs (5 vein segments in each group). The hydrophilic and organic me- Pleiotropic Properties of Glycosaminoglycan Sulo- tabolites were extracted using a bilayer extraction method and dexide in Chronic Venous Disease: In Vitro Modula- were run on 1-dimensional 1H Nuclear Magnetic Resonance tion of Chemokines and Colony Stimulating Factors (NMR) spectroscopy (800 MHz) and liquid-chromatography F. Mannello 1, D. Ligi2, M. Canale3, J. Raffetto4 coupled to Mass Spectrometry (LC-MS), respectively. Data ac- 1University “Carlo Bo” of Urbino, URBINO, Italy quired from NMR and LC-MS were mathematically modelled 2Dept Biomolecular Sciences, Section Clinical Biochemistry & Cell Biol- and statistically analysed using multivariate statistical models. ogy, University Urbino, Italy, Urbino, Italy Results. 1H NMR spectra of aqueous extracts of stretched 3Dept Biomolecular Sciences, Section Clinical Biochemistry & Cell Biol- ogy, University Urbino Italy, Urbino, Italy and non-stretched veins for 4 hrs revealed the presence of sev- 4Vascular Surgery Division VA Boston Healthcare System Surgery 112, eral metabolites including leucine, valine, creatine, myo-inosi- West Roxbury, MA, USA tol, choline, glucose and aspartate. Univariate analysis revealed increased concentrations of leucine and valine metabolites in Aim. 1. Analyze in vitro in#ammation-related chemokines IVC segments stretched as compared to non-stretched for 18 and colony-stimulating factors (CSFs) 2. Evaluate anti-in#am- hrs (p value range 0.01-0.004). Orthogonal partial least square- matory effects of glycosaminoglycan sulodexide (SDX) treat- discriminatory (OPLS-DA) analysis of LC-MS data identi!ed ment 3. Enhance the knowledge of pleiotropic properties of triglycerides moieties were present in higher concentrations SDX in chronic venous diseases (CVD) in stretched segments as compared to non-stretched vein seg- Methods. An in vitro study on human U-937 macrophage- ments for 18 hrs (p-value range 0.01-0.003). like cells. After in#ammatory stimuli with lipopolysaccharide Conclusions. This study has shown metabolic changes in (LPS), cells were treated with different concentrations of SDX rat vein wall under the effect of prolonged mechanical stretch. (a glycosaminoglycan mixture for the treatment of CVD) (Alfa- Elucidation of cellular pathways linked to these differential Wassermann, Bologna Italy). Analyses of C-C and CXC chem- metabolites should be the focus for future research.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 31 Detergent Sclerosants are Consumed by Circulating Measurements of Calf Muscle Oxygenation During Blood Cells Standing and Exercise in Patients with Chronic Ve- D. Connor1, K. Parsi2 nous Insuf#ciency 1St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, T. Yamaki Australia Tokyo Women’s Medical University, Tokyo, Japan 2St. Vincent’s Hospital, Bondi Junction, NSW, Australia Aim. Despite the established role of the calf muscle pump Aim. To investigate the effects of Sodium Tetradecyl Sul- for preventing chronic venous insuf!ciency (CVI), hemoglobin phate (STS) and Polidocanol (POL) on the viability of blood #ow in the calf muscle is poorly understood. Near-infrared cells, and the neutralisation of detergent sclerosants by cell spectroscopy (NIRS) provides continuous noninvasive moni- membranes toring of changes in tissue oxyhemoglobin (O2Hb) and deoxy- Methods. Whole blood samples and samples of isolated hemoglobin (HHb) levels. The purpose of this study was to leukocytes were incubated with various concentrations of scle- investigate the changes in calf muscle HbO2 and HHb levels rosants for 15 minutes. Cell counting was performed using a during standing and exercise in patients with CVI. haematology analyser. Blood smears were made and stained Methods. Seventy-four limbs in 73 patients with various using May-Grunwald and Giemsa dyes. Cell counting of iso- clinical stages of CVI were enrolled. Patients were divided into lated leukocytes and their viability was assessed by trypan blue early (C0-C3) and advanced (C4a-C6) according to the CEAP staining and using a haemocytometer. classi!cation. NIRS was used to measure changes in the calf Results. Detergent sclerosants induced the lysis of eryth- muscle HbO2 and HHb levels, and oxygenation index (HbD; rocytes, leukocytes and platelets. Different cell types exhib- HbD=O2Hb-HHb) while lying spine, standing, and then sub- ited different sensitivities to sclerosant, with erythrocytes sequently performing 10 tiptoe movements. more resistant to cell lysis than platelets and leukocytes. The Results. Among the 74 limbs evaluated, 47 had early and 27 concentration required to induce platelet lysis was higher for had advanced CVI. Standing caused increases in both O2Hb whole blood than for platelet rich plasma, suggesting that not and HHb levels. However, there were no signi!cant differences only plasma proteins compete for active sclerosant, but that in these increases, or HbD, between early and advanced CVI. cell membranes also compete for and therefore neutralise In contrast, the time elapsed until the maximum increase in sclerosants. The cell viability of leukocytes was reduced at O2Hb concentration was signi!cantly reduced in patients with concentrations of sclerosants that did not induce leukocyte advanced CVI in comparison with patients showing early CVI lysis. (55.5 ± 44.2, 32.6 ± 12.6 s, P=.025). During 10 tiptoe move- Conclusions. Detergent sclerosants induce cellular lysis, ments, a decrease in O2Hb concentration was observed, and however different cell types have different sensitivities to scle- there was no signi!cant difference in the reduction of O2Hb rosants. In addition to plasma proteins, cell membranes act to values between early and advanced CVI. In contrast, 10 tiptoe neutralise sclerosants. movements produced venous emptying (HHbE) and subsequent retention (HHbR), and the HHbR was signi!cantly increased in patients with advanced CVI compared with those with early CVI (6.0 ± 7.0, 9.0 ± 6.2 μmol/L, P=0.021). Further- The Effect of Distance from the Injection Site on more, HbD falls were more pronounced in patients with ad- Procoagulant Activity in Patients Undergoing Foam vanced CVI (7.4 ± 11.5, -5.9 ± 15.7 μmol/L, P=0.002). Sclerotherapy Conclusions. Changes in O2Hb and HHb concentrations differ between early and advanced CVI during standing and ex- K. Parsi1, J. Joseph2, D. Ma2, D. Connor3 ercise. Detailed investigation of the interrelationship between 1St. Vincent’s Hospital, Bondi Junction, NSW, Australia O2Hb and HHb during calf muscle pump function would lead 2St Vincent’s Centre for Applied Medical Research, Darlinghurst, New South Wales, Australia to a better understanding of the various clinical stages of CVI. 3St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia

Aim. To determine the effect of the distance from the injec- Histological Analysis of Sclerotherapy, Laser 940, tion site on the procoagulant activity of plasma obtained from Ohmic Thermolysis, and Intense Pulsed Light, on patients undergoing ultrasound guided Sclerotherapy Leg Vein Telangiectasias Methods. Foam sclerotherapy was peformed in 12 pa- R. Bush, P. Bush tients using STS and 9 patients using POL. Blood samples Midwest Vein & Laser Center, Cincinnati, OH, USA were collected from the target vein prior to sclerotherapy and 15cm, 30cm and 45cm from the injection site following Aim. This study examines vessel changes after sclerothera- the injection of 0.5mL of 3% sclerosant. Procoagulant activ- py, as well as three commonly used heat based modalities in ity was assessed using the Factor Xa Clotting Time (XACT) the treatment of leg telangiectasia. The three modalities are assay. laser 940, intense pulsed light (IPL), and ohmic thermolysis. Results. When compared to pre-sclerotherapy times, the Histological !ndings were correlated to clinical Results. injection of sclerosant foam signi!cantly shortened XACT Methods. Patient’s undergoing phlebectomy of a varicosity clotting times 15cm and 30cm from the injection site (p<0.01 underlying a pattern of super!cial telangiectasia form the pa- for STS and p<0.05 for POL). The shortest clotting times were tient population. After treating with the designated modality, recorded at 15cm. Clotting times began to normalise to pre- a 1mm punch biopsy was performed. A phlebectomy was then sclerotherapy levels 45cm from the injection site. In vitro stud- performed through the 1mm incision. Subsequently, the speci- ies of blood samples incubated in the presence of sclerosant men was sent for !xation and stained with hematoxylin and demonstrated that the majority of this procoagulant activity is eosin. A total of 25 evaluations were made; laser 940 (3), IPL located on phosphatidylserine exposing microparticles, shed (3), ohmic thermolysis (10), and sclerotherapy (9). from the membrane of cells. Results. Sclerotherapy causes profound cellular damage. Conclusions. The injection of sclerosant foam has a dis- There is complete endothelial loss and cell wall destruction. tance dependent effect on procoagulant activity, with the Acutely, the muscular layer is replaced with !brinogen. Vessel shortest clotting times detected 15cm from the injection damage is proportional to the concentration of sclerosant so- site. lution. 940 laser causes endothelial loss, isolated intraluminal

32 INTERNATIONAL ANGIOLOGY October 2013 thrombus, and collateral collagen denaturiation. The vessel Methods. This study used 336 limbs of 118 fresh, non- luminal size is unaffected acutely. The effect of ohmic thermo- embalmed cadavers. The technique included washing of the lysis is endothelial loss and vessel wall fusion (< 600 microns) whole venous system, latex injection, anatomical dissection, with minimal collateral damage. Intense pulsed light causes and then painting of the veins endothelial loss with minimal collateral injury. Results. The modal anatomy of the femoral vein was found Conclusions. All modalities effect signi!cant endothelial in 308 of 336 limbs (88%). Truncular malformations were loss. Proper application of all modalities requires knowledge found in 28 of 336 limbs (12%); unitruncular con!gurations of the size and depth of the telangiectasia, as well as the pain 3% ; axo femoral trunk (1%) and deep femoral trunk (2%). tients skin type and history of sun exposure. Optimal vessel Bitruncular con!gurations were found in 9% (bi!dity of the diameters for heat-based modalities are as follows: laser 940 femoral vein in 2%, femoral vein with axio-femoral trunk in (500 microns - 1mm), ohmic thermolysis (< 600 microns), 5%, and femoral vein with deep femoral trunk in 2%). IPL (< 300 microns). Use of any modality with sclerotherapy Conclusions. Truncular venous malformations of the femo- hastens resolution and decreases hemosiderin deposition by ral vein are not rare (12%). Their knowledge is important for reducing vessel size. the investigation of the venous network, particularly the venous mapping of patients with cardiovascular disease. It is also important to recognize a bitruncular con!guration to avoid potential errors for the diagnosis of deep venous thrombosis of Comparing the Haemodynamic Effect in Healthy the femoral vein, in the case of an occluded duplicated trunk. Subjects of a Neuromuscular Stimulation Device to Intermittent Pneumatic Compression K. Williams1, M. Ellis2, H. Moore3, A. Davies3 ABLATION TECHNIQUES 1Imperial College London, London, London, United Kingdom 2Academic Section of Vascular Surgery, London, United Kingdom FOR THE SAPHENOUS VEINS 3Academic Section of Vascular Surgery, Imperial College London, Lon- don, United Kingdom Endovenous ablation of the Small Saphenous Vein: Tips for Success Aim. This study compares the haemodynamic effect of IPC D.J. Moore, M. Grouden, S. Dundon, M.P. Colgan calf system (SCD Express™, Covidien, 11 second compression cycle/minute) to a novel neuromuscular electrical stimulation Dept Vascular Surgery, St James’s Hospital, Dublin, Ireland (NMES) device applied over the peroneal nerve (geko™, First- kind Ltd, setting: 27mA, 1Hz) in healthy subjects. Successful outcome in treating Small Saphenous Vein In- Methods. Ten healthy volunteers were randomised into competence (SSVI) is permanent ablation of the incompetent one of two equal sized groups. Baseline measurements of right segment, relief of symptoms, removal of all visible varices with super!cial femoral arterial and venous velocity and volume no adverse sequelae. Concern exists that the SSV responds dif- #ow were taken, then subjects received bilateral therapy with ferently to treatment compared with the great saphenous vein the two devices in an interventional cross-over trial. Measure- (GSV); it is a deep vein proximally, but review of current stud- ments were made after thirty minutes of therapy, devices were ies ( few compared to GSV) indicate endovenous ablation is as swapped, and measurements repeated after thirty minutes. good as conventional surgery in outcome and lack of compli- Results. 4 males and 6 females completed the study. Mean cations. Accurate pre-operative ultrasound mapping is essen- age 27.1, BMI 24.8, ABPIs all 0.9-1.1. Overall geko™ and IPC tial as is awareness of neural and venous anatomy. increased the venous volume #ow (46%, 7% respectively), peak Personal Observations. Access: The SSV is easy to access velocity (42%, 19%), and TAMV (12%, 27%); arterial values with the patient prone and all the vein can be treated. The SSV also increased for arterial volume #ow (22%, 0.6%), peak ve- can be accessed with the patient supine in combined GSV and locity (12%, -0.1%), and TAMV (30%, 6%). When IPC was used SSV incompetence. Simple measure such as GTN spray, a warm- !rst, enhancement of the venous/arterial effect of geko™ de- ing blanket and table tilt all help to ensure a large target vein. vice was seen (volume #ow +38/+37%, peak velocity +28/+20%, Nerve damage: Sural nerve injury is rare in the upper calf and TAMV +44/+47%). However, when geko™ was used before and increases lower down the leg as the nerve runs closer to IPC, measurements were reduced (-7/-20%, -48/-2%, -88/-10%). the SSV. Identifying the sural nerve and ablating the vein in the Conclusions. The geko™ device is non-inferior to IPC mid and upper calf helps avoid inadvertent damage. Possible at enhancing the haemodynamic ultrasound parameters in nerve damage in the popliteal fossa is avoided by beginning healthy people. The differences exhibited when devices are ablation at the junction of the SSV and intersaphenous vein. used consecutively may point to a different mechanism of ac- Dilute local anaesthesic (0.1% xylocaine) can affect the motion for electrical stimulation of the muscle pump over purely tor nerves producing worrying transient foot drop lasting a compressive methodologies. Studies into the effects on sub- couple of hours post treatment: It is judicious to check ankle jects with vascular pathology are indicated. movements before, during and after thermal ablation. DVT: We administer LMWH peri-operatively to reduce risk of DVT. Early mobilization is always encouraged. Additionally, it is important to ensure treatment of the SSV begins well be- Anatomical Variations of the Femoral Vein low the sapheno-poplitial junction. J. Uhl1, M. Chahim2, C. Gillot3 Thermal injury: Most studies showing successful long term 1URDIA research unit, Paris, France outcomes have used 810 or 980 nm laser. Concern exists about 2Paris, France postoperative pain with laser, but there is evidence that dis- 3University Paris Descartes, Paris, France comfort is related to the amount of energy delivered; lower watt energy may be less painful but may not be suf!cient to Aim. The venous anatomy is highly variable. This is due close the vein permanently. to possible venous malformations (minor truncular forms) oc- Recurrence: Pre-operative phlebitis is the most likely cause curring during the late development of the embryo that proof recurrent SSVI following thermal ablation. In our experi- duce several anatomical variations in the number and caliber ence the phlebitic SSV is dif!cult to close as scar tissue prevents of the main venous femoral trunks at the thigh level. Our aim thermal damage being applied evenly. Higher wattage and foam was to study the prevalence of the different anatomical varia- sclerotherapy judiciously applied may be more successful, but tions of the femoral vein at the thigh level patients should be warned in advance of likely recanalisation.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 33 CHRONIC ILIOFEMORAL OBSTRUCTION clinical signs and symptoms of CVI, while minimising the risk of recurrence. Characteristics of the Perfect Venous Stent: Do We Both radiofrequency and laser ablation have been shown Have It? to correct haemodynamic abnormalities of super!cial venous P. Neglen #ow as evidenced by duplex ultrasonography and air plethysmography, with bene!cial clinical outcomes even in advanced SP Vascular Center, Limassol, Cyprus stages of CVI. Venous !lling index increases with the number of re#uxing venous systems (super!cial, perforator and deep). It is well accepted that veins have very different physiologi- Consequently when large (>3mm) incompetent perforators cal, mechanical, and hemodynamic characteristics than do co-exist with incompetent saphenous veins, concomitant phle- arteries, so using “arterial” stents to treat venous disorders is bectomy may be of further clinical bene!t. Although limbs not adequate. Several companies have or are developing stents with super!cial re#ux have a lower venous !lling index than dedicated to the venous system. The main goal is to achieve those with deep re#ux, saphenous vein ablation can correct a good patency with little in-stent stenosis long-term. The deep re#ux in one-third of those with co-existent deep venous unique features of the venous system should be incorporated incompetence. Earlier reports suggest that surgical saphenec- into the stent design. On balloon dilation the typical arterio- tomy may reverse deep re#ux in the majority of patients with sclerotic lesions will remodel the artery wall. The subsequent- both super!cial and deep vein re#ux. However in the presence ly placed stent will have to override limited collapsing force. of three-system re#ux, surgical treatment of super!cial veins is The venous non-malignant obstructions are either due to !rm less successful at correcting perforator and deep re#ux. postthrombotic !brosis and/or sheath formation creating a Abolition of saphenous re#ux while sparing the saphenous high concentric radial compressive force, or a vessel crossing vein is the basis of both ASVAL and CHIVA treatment strate- creating a high local focal force, or a combination. The exter- gies, however with great disparity in resulting #ow dynamics. nal forces attempting to collapse the stent in such a vein are Borne of opposing theories of venous insuf!ciency, the long- much greater than in arteries. The venous lesions are usually term consequences of each remain to be established. more extensive. It is important to cover the entire venous ob- The pattern of haemodynamic abnormality may in#uence struction to create an optimal in- and out#ow. Some lesions the clinical severity of chronic venous insuf!ciency; accurate may, therefore, have the stent extended from the iliac vein into pre-operative assessment of re#ux is thus key to determining the common femoral vein underneath the inguinal ligament. the most appropriate treatment strategy for the patient. Scales The complex movement of the hip joint combined with the have been devised that assess the effectiveness of saphenous relatively !xed ligament may demand special properties to ablation using haemodynamic parameters, however the un- prevent compression, fracture and thrombosis at that site. The derpinning cause of the haemodynamic abnormality (i.e. wall iliac venous system includes 30-60 degrees angles of the vessel vs valve) remains elusive. Further studies are required to de- in its course from the IVC through the pelvis into the thigh. termine which disease pattern is best suited to one or a com- Migration in the venous system does not appear to be a major bination of therapeutic options, permitting individualisation problem if stents are placed using appropriate technique. and optimisation of treatment. Optimal design features would include: Suf!cient “resistance to concentric radial force” and “resistance to focal collapse” to prevent recurrent obstruction, but still be suf!ciently #exible to follow the vessel adequately Explanation of the SFJ Re"ux Patterns Preferably self-expandable in curved vessels, but balloon ex- M. Cappelli pandable allowed in straight segments, e.g., the IVC. Phlebology Private Of#ce, Florence, Italy Engineered to allow repeated shortening, twisting, and/or bending at the groin. The Saphenous Femoral Junction (SFJ), is the out#ow of Designed not to kink or “!sh-scale” at physiological angles. the Great Saphenous Vein (GSV) in the Femoral Vein (FV) and Longer and modular stents for lesions at the ilio-caval site. it is made up of: Any design of an optimal stent will inevitably need compro- — The saphenous arch mises, e.g., high resistance to collapse results in stiffer stents — The tributaries and dif!culty to crimp into a deliver device. Which compro- — The Terminal Valve (TV) mise is optimal is unknown. All features cannot be incorpo- — The Pre-Terminal Valve (PTV) rated in one stent and various stents may be necessary to ful!ll A Re#ux of the SFJ is the consequence of the incompetence the requirements. of one or two valves mentioned above, when a retrograde gradient is developed. The re#ux gradient can be present at rest or developed by Valsalva manoeuvre or compression/relaxation test (C/R test) HEMODYNAMIC CONSIDERATIONS or Dynamic test. IN VENOUS DISEASE Dynamic tests allow us to highlight the systolic and diastolic events. In other words what happen during the muscular Hemodynamic Effect of Abolition of Re"ux in Su- contraction and relaxation. per#cial Veins We can classify the SFJ re#ux in: A.H. Davies Pre-ostial re"ux (45%). When only the PTV is incompe- Head of Academic Section of Vascular Surgery, Imperial College London, tent no retrograde #ow through the ostium is detectable. United Kingdom The re#ux gets on below the ostium and it is fed up by tributary out#ows, is always diastolic and developed by muscular Prior to the emergence of minimally invasive treatment pump relaxation. The doppler sample must be placed distally for venous insuf!ciency, high ligation and stripping of the to the ostium. saphenous vein were the standard methods employed for the Valsalva manoeuvre is negative unless the presence of a pel- surgical management of super!cial venous disease. Despite vic escape point reaches the saphenous arch through one or current domination of radiofrequency and laser ablation, more tributaries. The pelvic escape point must be checked. and the advent of endoscopic and saphenous-sparing strate- Ostial re"ux (55%). When only the ostial valve or both gies, the primary aim of intervention remains the correction valves (TV and PTV) are incompetent, the Valsalva is positive of aberrant #ow to reduce venous hypertension, improving regardless of the presence of the femoral/iliac valve.

34 INTERNATIONAL ANGIOLOGY October 2013 Ostial Re#ux can be classi!ed in: Hemodynamic Effects of Compression in CVD A) CONTINOUS AT REST H. Partsch B) SYSTOLIC Emeritus Professor of Dermatology, Medical University Vienna, Austria Developed by the muscular pump contraction. Both conditions can coexist and be developed by a down- Aim. A review is given on the different tools of compression stream resistances increase at the iliac-cava level. They are an therapy and their mode of action. expression of the escape point of a vicarious open shunts Methods. Interface pressure and stiffness of compression C) DIASTOLIC devices, alone or in combination can be measured in vivo. Developed by muscular pump relaxation and detectable Hemodynamic effects have been demonstrated by measuring placing the doppler sample at the femoral side of the ostium venous volume and #ow velocity using MRI, Duplex and radio- D) DISSOCIATED (6%) isotopes, venous re#ux and venous pumping function using In this case the Valsalva is positive while the Dynamic test plethysmography and phlebodynamometry. Oedema reduc- is negative tion can be measured by limb volumetry. It can be due to: Results. Compression stockings exerting a pressure of ~20 a) A very small volume re#uxing throughout the ostium mmHg on the distal leg are able to increase venous blood #ow b) The Terminal Valve is strong enough to bear hydrostatic velocity in the supine position and to prevent and reduce leg pressure but it fails in hyper-pressure. Therefore it’s not com- swelling, especially after prolonged sitting and standing. In the pletely incompetent. upright position an interface pressure of more than 50 mmHg A pelvic escape point can be associated and detectable look- is needed for an intermittent occlusion of incompetent veins ing for a positive Valsalva at tributaries level. and for a reduction of ambulatory venous hypertension during walking. Such high intermittent interface pressure peaks exerting a “massaging effect” may rather be achieved by short Hemodynamic Shunts in Chronic Venous Disease stretch material and by multilayer, multicomponent bandages C. Franceschi than by elastic stockings. External pressure adds to the tissue Angiology Consultant Hospital Saint Joseph, Paris, France pressure which is the reason that in the same leg in the upright position relatively low pressure may narrow veins in the deep According to the dictionary, a shunt is a channel through muscle compartments, but not super!cial veins. Compression which blood is diverted from its normal path. Venous shunts has also major effects on the microcirculation, on the tissue are veins overloaded by blood diverted from its normal path. and on lymphatic drainage. Intermittent pneumatic compres- This overload increases the #ow and the transmural pressure sion, but also sustained inelastic compression with an interface responsible for vein dilation and tissue drainage impairment. pressure not exceeding 40 mmHg (“modi!ed” compression) in- This diversion relieves the drainage impairment of the tis- creases the arterial #ow in patients with mixed, arterial-venous sues when it compensates an obstructed collateral. We call it disease. All these effects are reinforced by (walking) exercises. Open Vicarious Shunt (OVS). Such a shunt is permanently Conclusions. Compression is a cornerstone in the man- overloaded with an increment during the systole of the mus- agement of venous and lymphatic insuf!ciency. Better under- cular pump. standing of the mechanisms of action will lead to an adequate- Conversely, the diversion dilates the veins and impairs the ly tailored use of this often underestimated and underused drainage when the shunting super!cial vein ( saphenous trunks treatment modality in individual patients. N2 or tributaries N3) is overloaded during the calf pump diastole by the #ow coming from the deep veins (N1) through a proximal re#uxing escape point N1>N2 or N1>N3 then return- Hemodynamic Effects in the Microcirculation ing into N1 through a distal perforator (re-entry), N2>N1 or J.D. Raffetto N3>N1. This concept of re-circulation was intuited by Tren- Assistant Professor of Surgery, Harvard Medical School, VA Boston HCS, delenburg as “Private circulation” 120 years ago. We call this Brigham and Women’s Hospital, Department of Surgery, West Roxbury closed circuit shunt, Closed Shunt (CS). It can be made of & Boston MA, USA various patterns according to its shunting paths ( (N1>N2>N1, N1>N2>N3>N1, N1>N3>N1, N1>N3>N2>N1, etc..) The perturbation in the microcirculation is a critical com- A shunt can exist in absence of re-circulation, or compensa- ponent in the pathophysiology of chronic venous disease. The tion and despite no N1>N2 nor N1>N3 escape point. Yet, an endothelium is a key regulator of vascular tone, hemostasis, incompetent N3 can recruit the normal #ows of other com- and coagulation. Injury, infection, immune diseases, diabetes, petent N3 (N3>N2) through its re#uxing connection (N2>N3 genetic predisposition, environmental factors, smoking, athero- escape point) and drain them distally through a N3>N1 re- sclerosis all have an adverse effect on the endothelium, which entry (N2>N3>N1 shunt) during the diastole. This N3 re#ux in turn must compensate to prevent further injury and maintain down to a distal re-entry perforator (N3-N1) is provided by integrity of the vascular wall. In chronic venous disease, the the powerful calf pump aspiration, and made possible by its sine qua non is persistent elevated ambulatory venous pressure. competence. That’s the reason why we call this shunt Open The effect on the microcirculation begins with altered shear Deviated Shunt (ODS), open because not recirculating and de- stress on the endothelial cells, causing endothelial cells to re- viated from its physiological path by a preferential pressure lease vasoactive agents, express E-selectin, in#ammatory mole- gradient through an incompetent N3. cules, chemokines, and prothrombotic precursors. Mechanical In the same patient one or more different types of shunts forces, low shear stress, stretch are sensed by the endothelial (OVS, CS and ODS) can be combined according to the ob- cells via intercellular adhesion molecule-1 (ICAM-1, CD54) structive and incompetent veins con!guration. These shunts and the mechanosensitive transient receptor potential vanil- can be reported and mapped in order to improve the diagno- loid channels (TRPVs) that are present in the endothelium. It sis and tailor an hemodynamic treatment of the chronic ve- is well known that patient with CVD have increased expression nous disease through a restore of an appropriate transmural of ICAM-1, which is expressed on endothelial cells, and activate pressure. CHIVA cure complies these requirements, discon- the recruitment of leukocytes and initiate endothelial transmi- necting the CS and ODS, respecting of the OVS, and frac- gration, setting up an in#ammatory cascade. In addition, the tioning the gravitational pressure column. Various RCTs have endothelial glycocalyx, composed of glycosaminoglycans, is an validated at the same time this method and its hemodynamic important structure that prevents leukocyte adhesion, in#am- concepts. mation and thrombosis. However, altered shear stress, me-

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 35 chanical forces on the vein wall cause leukocyte adhesion, and crovalves out to the third generation tributary (the boundary), in#ammation lead to injury and loss of the glycocalyx. A key was the resin able to penetrate deeper into the microvenous net- component of in#ammation is the expression of matrix metal- works of the dermis. In limbs with varicose veins and venous ul- loproteinases (MMP) which have signi!cant affects on the vein cers, re#ux into the small venous networks and capillary loops wall and venous valve and surrounding tissues. MMPs can be was more extensive with more dense networks and greater tor- released as a result of mechanical stretch and have signi!cant tuousity. In addition to super!cial axial saphenous vein insuf!- effects on the endothelium, venous smooth muscle, and adven- ciency, microvalve insuf!ciency also exist, and once it compro- titia. As a result of venous hypertension, in#ammation, and re- mises the third generation set of microvalves, there is a greater modeling, a key feature takes place in the post-capillary venule risks for the development of dermal venous ulceration. These where the !brin cuff a complex process involving !brin and !nding may help explain why some patients with longstanding collagen deposition is formed. The result is a major abnormal- varicose veins do not develop venous ulcers, since the microv- ity in dermal microcirculation with many components forming alves may be intact at the third generation network preventing the post-capillary cuff including collagen I and III, !bronectin, clinical deterioration. In addition, these !ndings may explain vitronectin, laminin, tenascin, !brin, TGF-b, a2-macroglobulin. why skin changes consistent with venous disease (hyperpig- Recently venous microvalves have been identi!ed in both con- mentation and even small skin ulceration) is seen clinically in trol specimens and in patients with chronic venous disease. patients with normal duplex ultrasound of the super!cial, deep, The interesting aspect of that study is a system of sequentially and perforator venous systems. Further research on the factors smaller generations of tributaries leading to a small venous responsible for initiating the altered shear stress and stretch on networks, with competent and incompetent microvalves. The vein walls will make it possible to have speci!c pharmaceutical regions are divided into 6 generations before reaching the small targets to restore the integrity of the microcirculation and treat venous network. In regions where incompetence existed in mi- the spectrum of chronic venous disease.

36 INTERNATIONAL ANGIOLOGY October 2013 WEDNESDAY, September 11, 2013

tively, of whom 58% were female, 8.4% obese, mean age was SEPTEMBER 11, 2013 50.6 and 55% were C1-C3. The mean (SD) AVVQ was 21.8 (11.7) median (IQR) VCSS 6 (3-9) and clinical CEAP 3 (2-4). WEDNESDAY Mean (SD) VD was 8.1 mm (3.9 mm). A weak signi!cant correlation was found between CEAP and VD (Spearman’s 0.169, p=0.001, R2 of < 0.1), and VD and VCSS (Spearman’s 0.163, p=0.002, R2 of < 0.1). No correlation was found between VD FREE PAPER SESSION 6 and AVVQ (Spearman’s 0.045, p=0.390). Male patients have a higher CEAP (p=0.026) and women worse QOL but there Validation of VVSymQ, a New Patient-Reported was no signi!cant difference in in VD or VCSS scores between Outcome Instrument for Measuring Symptoms in genders (p=0.140). All clinical and QOL parameters improved Varicose Veins Patients after treatment. Pre-operative vein diameter was signi!cantly J. Paty1, D. Wright2, C. Elash1, M. St.Charles-Krohe3 correlated with post-operative AVVQ and generic QOL ( R2 1ERT, Pittsburgh, PA, USA =0.025). 2BTG International Ltd, London, United Kingdom Conclusions. Patients with larger vein diameters presented 3ERT, Western Springs, IL, USA with worse clinical disease severity (CEAP and VCSS) but not with a worse quality of life. Aim. To demonstrate that patients !nd VVSymQ™ easy to use, that the instrument is reliable and sensitive to changes in symptoms, and to de!ne a clinically meaningful change in VVSymQ score. Comparing Endovascular Laser Ablation, Conven- Methods. VVSymQ is an electronic daily diary measur- tional Stripping and Ultrasound Guided Foam Scle- ing the most important symptoms of GSVI, developed in accordance with FDA’s Guidance to Industry. VVSymQ was rotherapy for Great Saphenous Varicose Veins evaluated in 3 studies of varicose veins patients: Forty pa- T. Nijsten 1, R. Van Den Bos2, M. De Maeseneer3, M. Neumann4 tients were treated with foam sclerotherapy in Study RS-002. 1Erasmus medisch centrum, Rotterdam, Netherlands Patients completed the electronic diary daily for 2 weeks at 23011 Ke Rotterdam, Netherlands 3Reet, Belguim baseline and for 10 days at 8 weeks post-treatment. In two 4Erasmus MC, Rotterdam, Netherlands Phase III studies totalling 511 patients, treatment with Po- lidocanol Endovenous Microfoam was compared to placebo. Aim. Many case-series have been published on treatments One week of baseline data and 8 weeks post-treatment data of varicose veins, but comparative randomized controlled tri- were collected. als remain sparse. Objective: to compare the anatomical suc- Results. Patient compliance was high (>90%) for com- cess rate, frequency of major complications and quality of pletion of scheduled diary entries. VVSymQ showed very life improvement of endovenous laser ablation (EVLA), ultra- high test-retest reliability with an intraclass correlation sound-guided foam sclerotherapy (UGFS) and conventional coef!cient of 0.96. VVSymQ demonstrated high construct surgery (CS), after one year follow-up. validity, con!rming appropriate measurement of symp- Methods. 240 consecutive patients with primary sympto- toms. VVSymQ was highly sensitive to treatment effect. In matic great saphenous vein re#ux were randomized to endov- the Phase III studies, subjects treated with PEM showed enous laser ablation, ultrasound-guided foam sclerotherapy signi!cant symptom reductions: 5.5 points from a baseline or conventional surgery, consisting of high ligation and short VVSymQ score of 9.0. In determining treatment bene!t, pa- stripping. Primary outcome was anatomical success de!ned tients reported a reduction of 4.6 points in VVSymQ score as as obliteration or absence of the treated vein on ultrasound clinically meaningful. examination after one year. Secondary outcomes were com- Conclusions. VVSymQ is an excellent PRO instrument for plications, improvement of the ‘C’ class of the CEAP classi!ca- measuring the clinical symptoms of varicose veins. VVSymQ tion and improvement of disease speci!c (CIVIQ) and general is validated, reliable and able to measure treatment success (EQ5D) quality of life scores. from the patient’s perspective. Results. More than 80% of the study population was classi!ed as C2 or C3 venous disease. After one year, the anatomical success rate was highest after EVLA (88.5%), followed by CS (88.2%) and UGFS (72.2%) (P<.001). The complication rate was low and comparable between treatment groups. All Size Doesn’t Matter - Patient Symptoms Do Not Cor- groups showed signi!cant (p<0.001) improvement of EQ5D relate with Vein Diameter and CIVIQ scores after therapy. 84.3% of all treated patients T. Lane 1, A. Shepherd2, M. Gohel3, I. Franklin1, A. Davies1 showed an improvement of the ‘C’ of the CEAP classi!cation. 1Academic Section of Vascular Surgery, Imperial College London, Lon- Conclusions. After one year follow up EVLA is as effective don, United Kingdom as CS and superior to UGFS according to occlusion on ultra- 2 Imperial College, Carshalton, United Kingdom sound duplex. Quality of life improves after treatment in all 3N/A groups signi!cantly. Aim. Vein diameter has been used as a rationing tool by healthcare providers and insurers. The aim of this study was to examine the relationship between vein diameter, clinical severity and disease speci!c quality of life (QOL) in patients with Complications of Venous Ablations: A Report from venous disease. the MAUDE Database Methods. Duplex scans from patients with truncal vein R. Malgor1, A. Gasparis2, N. Labropoulos1 re#ux awaiting intervention were assessed and the maximal 1Stony Brook University Medical Center, Stony Brook, NY, USA vein diameter (VD) was recorded. The Aberdeen Varicose 2Stony Brook Vein Center, Stony Brook, NY, USA Vein Questionnaire (AVVQ), the Venous Clinical Severity Score (VCSS), QOL (EQ-5D) and clinical CEAP grade was Aim. This study analysed the complications of endovenous recorded. ablation (EVA) using data from an open, voluntary national Results. Data were available for 429 patients pre-opera- database.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 39 Methods. We analysed 349 adverse events of endovenous One-Year-Follow-Up of the European Multicenter laser (EVL) and radiofrequency ablation (RFA) reported in the Study on Cyanoacrylate Embolization of Incompe- Manufacturer and User Facility Device Experience (MAUDE) tent Great Saphenous Veins database from January 2000 to June 2012. Outcomes of in- T. Proebstle 1, J. Alm 2, D. Sameh 3, L. Rasmussen 4, M. Whiteley 5, J. Law- terest were pulmonary embolism (PE), deep vein thrombosis son6, A. Davies7 (DVT), death, and device failures (i.e. broken laser tip, broken 1Dept. of Dermatology, University of Mainz, Germany, Mannheim, Ger- sheath). many Results. Two hundred and three (58%) reports were pa- 2Dermatologicum, Hamburg, Hamburg, Germany tient-related injuries and the other 146 (42%) device-related 3Spire Cheshire Hospital, Warrington, United Kingdom failures. More complications were related to RFA compared 4The Danish Vein Centres, Naestved, Denmark to EVL (216 vs. 133 procedures). Thirty (8%) non-fatal PEs 5The Whiteley Clinic at The Wimpole Clinic, London, United Kingdom 6Lawson B.V, Ouderkerk aan de Amstel, Netherlands and 123 (35%) DVTs were described. There were 7 (2%) peri- 7Academic Section of Vascular Surgery, Imperial College London, Lon- procedural deaths, all from PE. Of the 146 device failure don, United Kingdom reports, 41(28%) required surgical intervention. Despite an increasing number of procedures, reported events peaked Aim. Endothermal saphenous ablation requires the use of around 2008 and stabilized since then. Over the past 5 years, perivenous tumescent anesthesia and postinterventional com- the incidence of adverse events reported for EVL and RFA pression stockings, moreover, causing paresthesia in 5%-10% were 1 and 2 per 10,000 procedures. The complication ra- of patients. An embolization technique lacking theses needs tio over the years was <1:2,500 for DVT, <1:10,000 for PE, and complications would signi!cantly improve treatment. <1:50,000 for death. Methods. A prospective multicenter cohort study was Conclusions. EVA has gained high acceptance worldwide conducted in seven European centers between 12/2011 and but the risks tend to be overlooked. Despite a very low com- 07/2012. Incompetent Great Saphenous Veins (GSVs) re- plication rate, mortality has been reported. The complica- ceived endovenous embolization with a unique endovenous tions found in MAUDE represent only a fraction as the ma- cyanoacrylate (CA) adhesive implant. Neither tumescent an- jority of the practitioners do not even know this database. esthesia nor post-interventional compression stockings were Further investigation by a large prospective initiative is still used. Varicose tributaries remained untreated for 3 months. warranted to better de!ne the real magnitude of EVA com- Duplex ultrasound and clinical examination were performed plications. at 2 days and after 1, 3 and 6 months, which was the primary endpoint of the study. Results. 70 GSVs in 70 patients were treated, all followed- up for 6 months. At 2 day follow-up 69 of 70 patients (98,6%) showed complete occlusion. Partial recanalizations were observed at 3 months in 2 more cases and in one additional case at 6 months follow-up. Life-table occlusion rates were 98.6% Endovenous Laser Ablation Follow up Study (ELA- at 2 day follow-up (95%-CI:0.958-1.0), 95.7 % at 3 months FOS). A Prospective Trial to Assess Long Term EVLA (95%-CI:0,911- 1.0) and 94.3 % at 6 months (95%-CI:0.890- 0.999). Standard error was below 0.028 at all times. Phlebitis Results occurred in 6 cases (8.7%), 5 of whom received NSAIDs for D. Kontothanassis1, P. De Zolt2, N. Labropoulos3 an average of 7 days, no SAEs were observed. Average VCSS 1Istituto Flebologico Italiano-MediClinic Hospital, Pozzonovo, Italy improved from 4.3±0.3 at baseline to 1.3±0.16 at six months 2Istituto Flebologico Italiano- MediClinic Hospital, Pozzonovo, Italy 3 follow-up. Stony Brook University Medical Center, Stony Brook, NY, USA Conclusions. Transcatheter endovenous CA adhesive for closure of insuf!cient GSVs proved to be feasible, safe and ef- Aim. Determine the true long term clinical outcome of en- fective without the use of sedation, tumescent anesthesia or dovenous Laser ablation (EVLA). compression stockings. Side effects were mild, in particular Methods. Patients with chronic venous disease CEAP paresthesia was not observed. class 2 or higher that had EVLA and minimum 5 years follow up were included in the study. Clinical examination and duplex scanning were performed prior to treatment and at the last follow-up. All patients were selected to have re#ux in the great saphenous vein with a diameter of >5mm, re#ux Sclerosing Agents Binding with the Human Pro- duration of >2s and treatment length >20cm. Patients’ clini- teins: Electrophoretic Evidences, Clinical Conse- cal characteristics, saphenous closure rate, residual, recur- quences and Safety Pro#les rent and new disease, and clinical outcome were recorded L. Tessari 1, A. Cavezzi 2, M. Izzo 3, M. Ambrosino 4, F. ZINI 5, S. Ricci 6, M. in detail. Tessari 7, R. Fanelli8 Results. There were 59 patients, 45 females, mean age 1Bassi Foundation Trieste, 37019 Peschiera del Garda, Verona 51 years having a mean follow-up of 88 months (range 66- 2Casa di Cura Stella Maris, San Benedetto del Tronto, Italy 110). Duplex scanning showed immediate occlusion of all 3Math. Tech. Med. University of ferrara, ferrara, Italy 4centro duomo analisi, nola (napoli), Italy the ablated veins. At the !rst follow-up there were 2(3.4%) 5Casa di Cura Citta di Parma, Parma, Italy partial recanalisations whereas in the last follow up there 6Private practice, Roma, Italy were 2(3.4%) partial and 3(5.1%) complete recanalisations. 7Vascular Disease Center University of Ferrara- Italy, Ferrara, Italy Residual disease was detected in 7(11.9%) patients and new 8Istituto Ricerche Farmacologiche Mario Negri, Milan, Italy disease developed in 20(33.9%), thigh 2, calf 8 and both 10. There were 34 patients that regressed in class 0-1, 16 in class Aim. Investigations concerning the bubbles propagation 2 and the last 9 with C4-5 remained in the same class. De- and the interaction among the sclerosing agent (SA) and the spite the high incidence of new disease only 4 (6.8%) pa- blood need more evidences. Aim of our work was: 1. to iden- tients were symptomatic. tify SA ligands 2. to determine the binding time 3. to highlight Conclusions. EVLA of the great saphenous vein has very clinical consequences. good long term results with a low recurrence. New disease de- Methods. Thirtyone blood samples were tested by electro- velops in a third of the patients at long term but only a few phoresis. The control curve was compared after the SA (so- patients are symptomatic. diumtetradecylsulphate or polidocanol) addition. Six patients

40 INTERNATIONAL ANGIOLOGY October 2013 undergoing saphenous system sclerotherapy were divided in diameter between 5-10 mm receiving a pre-treatment size re- two groups. In group A (4 patients) a blood sample was ob- duction applying the principals of perivenous tumescent an- tained from the brachial vein before the injection (T0) of a esthesia (TA) followed by catheter-directed foam sclerotherapy varicose vein and at 1, 3, 5, 10 minutes. In group B (2 patients) (CDFS). The secondary objectives were the comparison with a the same procedure was performed with the same timing on control group, that received CDFS alone as well as the asses- the same side common femoral vein. Free STS (fSTS) and to- ment of patients satisfaction and cutaneous side effects. tal protein-bound STS (bSTS) were measured. Methods. 50 patients were included and randomized into two Results. In group A, the average bSTS concentration in µg/ groups. CDFS was performed in both groups assessing the GSV ml was 0, 1.62, 5.98, 6.91 and 7.2, respectively at T0, 1’, 3’, 5’, at knee level and applying 8 ml of 2% polidocanol-foam while the 10’. fSTS was always 0. In group B, bSTS average concentra- catheter was slowly withdrawn. Strictly perivenous TA with sa- tion in µg/ml was 0, 0.568, 13, 24.6 and 8.67, respectively at T0, line solution was additionally performed in group 1 (CDFS+TA), 1’, 3’, 5’, 10’. fSTS was always 0. At 8 seconds, electrophoresis before applying the sclerosant agent. Treatment was followed by demonstrated that sodiumtetradecylsulphate mainly binds Al- 24 hours eccentric compression and a thigh-lengths compression bumin and Alpha-globulins. Polidocanol binds beta-globulins. stocking class II for four weeks. During follow-up occlusion rates Conclusions. STS binds 73-83% of the plasma proteins, and clinical scores were assessed by blinded examiners. POL the 13%. Further studies are needed to con!rm a minor Results. At 12-months follow-up duplex ultrasound showed POL inactivation. At 8 seconds all the STS is already inactive. in the CDFS+TA group in 17/23 (73.9%) patients full occlusion, in At 8 seconds there is no fSTS in the systemic circulation, so 2/23 (8.7%) partial occlusion and in 4/23 (17.4%) treatment fail- causing no harm. Sclerotherapy side effects ethiology identi!- ure. In the CDFS alone group 15/20 (75 %) of the targeted GSV cation needs further evaluations. were fully occluded, 4/20 (20%) partially occluded and 1/20 (5%) were classi!ed as treatment failure. Both treatment arms showed a signi!cant (p<0.005) reduction of the treated GSV diameter of a mean of 2.76 (range: 0.3-7) mm in the CDFS+TA group and In vitro and in vivo Performance of Physician Com- 3.18 (range: 0.6-6.2) mm in the CDFS group. Patients satisfaction pounded Foams vs. Polidocanol Endovenous Micro- with the treatment was high in both study arms. Thrombophle- foam bitis and hyperpigmentation were less frequent in the CDFS+TA group (0/23 and 3/23) than in the CDFS alone group (2/20 and D. Wright 5/20). Overall there were no signi!cant inter-group differences. BTG International Ltd, London, United Kingdom Conclusions. In our cohort no bene!t could be found applying perivenous tumescent solution to reduce the vein diam- Aim. To compare clinically-relevant in vitro and in vivo per- eter before CDFS. Occlusion rates after 12 month were in the formance characteristics of physician compounded foams (PCFs) region of 74% in both study arms. Overall the study was able with proprietary Polidocanol Endovenous Microfoam (PEM). to demonstrate that CDFS is a safe and well tolerated treat- Methods. PCFs comprising Room Air (RA), CO 2 and CO 2:O 2 ment that goes along with a high acceptance by the patients. were evaluated vs. PEM for bubble size and stability using a variety of techniques. The ability to displace blood and contact the endothelial wall were examined in a biomimetic vein model. Cardiopulmonary effects of circulating microbubbles were examined in dogs. Long-Term (5-8 Years) Follow-Up after Ultrasound- Results. RA PCFs produced narrowest bubble size distribu- Guided Foam Sclerotherapy for Varicose Veins: Health-Related Quality of Life, Patient-Reported Out- tion and highest foam stability; PEM was similar. CO 2 PCFs were least stable, CO 2:O 2 PCFs had intermediate stability. PEM comes, Patient Satisfaction, and Re-Treatment Rates displayed slowest degradation rate (DR) in the vein model. K. Darvall1, G. Bate2, A. Bradbury3 PEM had statistically lower DR compared with CO 2-contain- 1University of Birmingham Dept of Vascular Surgery, Wellington, Somer- ing PCFs, regardless of preparation method, gas mixture or set, United Kingdom liquid:gas ratio. RA PCFs were also less cohesive and degraded 2University of Birmingham Dept of Vascular Surgery, Solihull, United more rapidly than PEM. Intravenous PEM was well-tolerated Kingdom 3University Department of Vascular Surgery, West Midlands, United compared with RA PCFs, with the latter leading to elevated Kingdom pulmonary artery pressure, peripheral vascular resistance and other adverse cardiopulmonary effects. Aim. To determine the long-term clinical effectiveness of Conclusions. PEM displays a unique combination of charac- ultrasound-guided foam sclerotherapy (UGFS) for CEAP C2-6 teristics relevant to clinical performance. PEM has a low nitrogen varicose veins (VV) in terms of health-related quality of life gas composition but displays bubble size distribution and stabil- (HRQL), patient-reported outcomes (PROMS), patient satis- ity parameters which are comparable to RA PCFs and greater faction, and re-treatment rates. than PCFs made with CO 2 or CO 2:O 2. PEM shows superior per- Methods. Consecutive patients undergoing UGFS between formance in a dynamic biomimetic model of #uid displacement April 2004 and May 2007 were invited for review at least 5 and retention. PEM was also better tolerated in vivo while RA years after treatment. Patients completed generic (Short PCF microbubbles were associated with adverse effects. Form, SF-12) and disease-speci!c (Aberdeen, AVSS) HRQL instruments, and questionnaires enquiring about lower-limb symptoms, lifestyle factors, and satisfaction with treatment. Data on re-treatments were prospectively recorded. Catheter-Directed Foam Sclerotherapy of Great Results. 391 limbs (285 patients) were reviewed (82% re- Saphenous Veins in Combination with Pre-Treat- sponse) at a median (IQR) of 71 (67-78) months following ment Reduction of the Diameter Employing the !rst UGFS treatment. 72% were CEAP C2-3; 22% had previ- Principals of Perivenous Tumescent Anesthesia ous surgery; 87% had GSV treatment and 20% SSV treatment. N. Devereux, B. Kahle Disease-speci!c HRQL scores signi!cantly improved at long- University Hospital of Schleswig Holstein, Campus Luebeck, Luebeck, term follow-up, with 89% having improved AVSS compared Germany with baseline. Symptom improvement and ‘meeting of expectations’ remained high at long-term follow-up: 63-94% of pa- Aim. The primary objective of this pilot study was to eval- tients had their pre-treatment expectations, in terms of lower uate occlusion rates of great saphenous veins (GSV) with a limb symptoms and lifestyle improvements, met or exceeded.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 41 Regarding satisfaction, 82% were very satis!ed with treatment (range, 6-96). Deep venous insuf!ciency in 14/197 limbs (7%). and only 3% were dissatis!ed; 91% would recommend the Prior DVT in 2/197 limbs (1%). VV associated with: untreated treatment to others. Kaplan-Meier analysis estimated the cu- distal saphenous vein re#ux (24%), recanalization in a treated mulative proportion requiring re-treatment at 5 years is 15%. saphenous vein (20%), accessory vein re#ux (19%), and de Conclusions. UGFS is highly effective with regard to novo saphenous vein re#ux (13%). Retreatment: EVA with PROMs, and the vast majority of patients remained very satis- phlebectomy and/or foam sclerotherapy in 52%; phlebectomy !ed with treatment and would recommend it to others. The and/or foam sclerotherapy in 40%. signi!cant improvements in HRQL seen early after UGFS are Conclusions. The presence of VV despite prior surgical or sustained to at least 5 years after treatment, and only 15% of endovenous intervention, occurs in a small number of patients limbs required re-treatment for recurrence. presenting for evaluation (16% overall, and 6% with prior EVA). In most cases, these VV can be attributed to: technical failure leading to saphenous vein recanalization, inadequate Clinical and Quality of Life Outcomes are Improved treatment manifesting as re#ux in untreated saphenous vein with Simultaneous Phlebectomies at 6 weeks - Early segments and de novo re#ux elsewhere, including other saphe- Results of the AVULS Randomised Clinical Trial nous or accessory veins. T. Lane 1, L. Varatharajan1, D. Kelleher2, I. Franklin1, A. Davies1 1Academic Section of Vascular Surgery, Imperial College London, Lon- don, United Kingdom Use of Transillumination Mapping Technique in Re- 2Department of Vascular Surgery, Royal Oldham Hospital, Oldham, Lan- ticular Veins cashire, United Kingdom R. Almeida Chetti1, G. Orallo2, D. Carraro3 Aim. The role of phlebectomies in the context of endother- 1Private practice, Capital Federal, Buenos Aires, Argentina 2Hospital Zonal De Agudos Domingo Mercante, Buenos Aires, Argentina mal ablation of truncal varicose veins is controversial with 3Hospital Zonal General De Agudos Gobernador Domingo Mercante, Jose only one previous trial examining the timing of intervention. C. Paz, Buenos Aires, Argentina Methods. Consenting patients attending for local anaesthetic endovenous ablation and varicosity treatment were Aim. To evaluate the use of the transillumination method to randomized to either delayed phlebectomies (>6 weeks) or locate feeder vein and morphology of reticular system in the simultaneous phlebectomies. Patients completed AVVQ, CES- treatment of varicose veins class C1 and C2 (CEAP). D, EQ-5D QOL and VAS questionnaires. Clinicians complet- Methods. A descriptive observational cohort study is pre- ed CEAP, VCSS and VDS classi!cation. Patients underwent sented, with a consecutive series of patients. January 2010 standard radiofrequency ablation and standard phlebectomy to December 2012. This report describes initial experience or foam sclerotherapy. Patients were then seen at 6 weeks and in evaluating and treating three hundred and forty patients the need for further treatment assessed. with reticular veins and telangiectasias (CEAP C1 y C2). We Results. 101 patients agreed to participate and were ran- excluded patients with incompetence of femoral saphenous, domized for treatment (50 Simultaneous and 51 Delayed). popliteal saphenous and/or perforating veins. For venous iden- Baseline data was collated – 41% were Male, mean age 51, ti!cation a direct visual marking was done, followed by the mean BMI 28.8, median CEAP 3, mean AVVQ 22.8, mean transillumination mapping. After that foam or liquid sclero- VCSS 6.4, mean VDS 1.24, mean EQ-5D QOL 0.728, EQ-5D therapy was performed. VAS 74.5 and CES-D 11.9. At 6 weeks post treatment, the si- Results. Two hundred thirty-eight patients underwent scle- multaneous group showed greater improvement compared to rotherapy with transillumination, hundred and two without it. the delayed group in all assessed areas. The mean VCSS was The average number of session’s in-group with transillumina- 3.0 vs 1.9 (p=0.032), VDS 0.75 vs 0.44 (p=0.014), EQ-5D QOL tion: Seven, media sessions In-group without transillumina- 0.879 vs 0.767 (p=0.048), EQ-5D VAS 83 vs 75.9 (p=0.039) and tion: 12.5. With transillumination technique, we observed bet- CES-D 6.0 vs 13.6 (p=0.002). ter visualization, up to 100% of cases, of the reticular venous Conclusions. 6 week results of the AVULS trial indicates system and feeder vein adjacent to telangiectatic vein complex, that simultaneous phlebectomies in the context of endother- mainly in skin types III and IV (Fitzpatrick Scale). mal radiofrequency ablation leads to improved quality of life Conclusions. Transillumination mapping technique better and clinical status. displayed the reticular and feeder veins adjacent to telangiectasias than direct view. Thus, considering the skin phototype, with this procedure the number of sessions and duration of Presence of Varicose Veins Despite Prior Endov- treatment could be reduced. We needed future controlled clin- enous Thermal Ablation of Saphenous Veins ical trials to evaluate the effectiveness of this procedure. P. Pal, J. Pal, R. Isaak Minnesota Vein Center, PA, North Oaks, MN, USA

Aim. To evaluate how often patients on their initial consul- SOCIETY SESSION: tation, present with varicose veins and a history of endovenous SOCIETY OF PHLEBOLOGY thermal ablation, and to determine the cause(s) of their vari- AND LYMPHOLOGY BONAERENSE cosities. Methods. A retrospective chart review of initial patient con- Removal Filters of Cave Vein in Thromboembolic sultations over a !ve year period (2007-2012) in a single Vein Disease Center was performed. Patients presenting with varicose veins G. Eisele, D. Simonelli, J. Neira, E. Malvino, M. Zilverman, H. Manos- (VV) and prior endovenous thermal ablation (EVA), radiofre- alva, O. Vargas quency or laser, were the subjects of this study. The cause(s) Interventional Radiology Services, Sanatorios Trinidad Palermo y Mitre, of the varicose veins was identi!ed by duplex ultrasound. Re- Clínica y Maternidad Suizo Argentina, Instituto Alexander Fleming and treatment methods were analyzed. CEMIC, Buenos Aires, Argentina. Results. 2347 patients were evaluated. 197 limbs in 150 (6%) patients, had prior EVA of a saphenous vein (great, small Aim. Evaluate the utility of retrievable vena cava !lters or accessory). Average age was 54.1 years (range, 22-88). 85% (VCF) in prophylactic treatment of deep vein thrombosis were women. Median time to presentation was 36 months (DVT) and pulmonary embolism (PE)

42 INTERNATIONAL ANGIOLOGY October 2013 Methods. Between May 1999 and May 2011, 511 adult pa- highly absorbs the 1470 laser wavelength, converts it into tients were treated for DVT and/or PE with implantation and steam, and produces the termal ablation of the endothelium, posterior retrieval of VCF in different private hospitals of Bue- selectively destroying the localized vascular defects. nos Aires. These patients (58% women) between 20 and 88 years The results were excellent in the super!cial lesions with old, received 515 VCF in inferior vena cava and 5 VCF in supe- transdermal in one sesion, the pain, tumor and cosmetic dis- rior vena cava. 296 FVC remained for de!nitive use and 218 orders were reduced. In the endoluminally treated it varied, VCF (42%) were retrieved after 31 days average of use. In this depending on the size and location of the disease. Due to the last group of patients, we retrospectively reviewed the medical high recurrence rate, it was necessary to re-treat some cases histories analyzing the indications, implantation, removal and after one year; being the second sessions simpler because of !ltering success, and the complications related to the VCF use. the smaller size of the lesions. Results. The main indication for retrievable VCF use was This technique is valid as an alternative therapeutic as a failure or temporal anticoagulation treatment contraindica- sole treatment or combined with pre or post surgery and scle- tion (91%). VCF implant and retrieval success was 100 and rotherapy. 90% respectively. Temporary !ltering success was de!ned when PE could not be detected clinically or in imaging studies during !ltering time and was obtained in 98% of patients; contrary !ltering failure was 2%. In 3 infected VCF, the device Our Experience in the Therapeutic of the Pelvic retrieval could achieve the infection control. Fifteen VCF had a Congestion Syndrome tilting position superior to 25º related to vena cava major axis. J.E. Paolini Complications consisted in impossible VCF retrieval (22 pa- Vascular Surgery Unit, Sanatorium Dr. Julio Mendez, CABA, Argentina tients), groin hematoma (1 patient), vena cava minor lesions (3 patients) and hemopericardium (1 patient) requiring surgical Congestive detecting pelvic syndrome has become more solution. prevalent due to the possibility of endovascular treatment. Conclusions. Retrievable VCF usually indicated in DVT or Thanks to training in endovascular techniques making our PE with temporary anticoagulation contraindication or fail- service is treating patients with congestive pelvic venous since ure, are effective in more than 95% PE prophylaxis. Compli- May 2012. Having treated 10 patients with symptoms of pelvic cations rate are low, without mortality nor risks of de!nitive varicocele using endovascular sandwich technique, achieving VCF implant. results comparable to the rest of the literature. Showing our In selected patients, prolongation the temporary !ltering experience in this !eld in the detection as well as in the treat- time could be necessary. ment of this disease.

Low Flow Vascular Malformations. Treatment with Phototermocoagulation SOCIETY SESSION: J.E. Soracco ASSOCIATION OF PHLEBOLOGY EL SALVADOR Phlebolymphology, Military Hospital, Buenos Aires, Argentina Radiofrequency in El Salvador It is the objective of this presentation to propose another L. F. Rodríguez application for the laser in endoluminal contact mode, as a Varicentro Clínica Flebologíca, San Salvador, El Salvador therapeutic alternative for the treatment of the slow #ow vascular malformations (VM). In 2007, Radiofrequency treatments applied in veins that The International Society for the Study of the Vascular suffer from venous re#ux began in El Salvador. Anomalies ( ISSVA ) classi!ed the angiodysplasias, vascular Now I present the experiences obtained in a cohort of 155 malformations or vascular anomalies in : hemangiomas and patients, treated from November 2007 to May 2012, in which VM. Being the latter slow-#ow or fast-#ow, troncular or extra- 139 patients were females and 16 were males. troncular, and capillary, venous, lymphatic or arterial malfor- All the patients underwent radiofrequency ablation pro- mations. cedures in major and minor saphenous veins, and accessory The diagnosis is clinical initially in the tumors of the skin veins under sedation and local outpatient anesthesia. In each and mucous membranes, or due to the complications that case, documenting the severity score, numerical pain scale, these produce, such as bleeding, infectious, pain or compres- and effectiveness of the ablation procedure, and the followed- sion in other locations. up of each case for a period of one year. During this time Laser devices operating at wavelengths of 810, 980 and interval, I strengthened the !nal results obtained from the 1470 nm were used, with optical !bers having radial or frontal analisis of the complete healing process, as well as the veri!ca- emission tip and a diameter of 400 and 600 µ. The lesion was tion of the differences obtained between the veins in which accessed percutaneously or transdermal. Radiofrecuency was preformed, complementary treatments In ambulatory surgery unit, under sedation or local anesthe- performed in some cases, and the early and late complications sia, ultrasound mapping is performed, in wich the best place observed in some of the cohort cases, as well as the improve- to access is located. This is performed under visual control on ment in their quality of life. the monitor, introducing the 18 or 16g needle into the cavity and inserting the optical !ber throught it which advances to the interior of the malformation. Laser energy is delivered in contact mode and continuosly, withdrawing the optical !ber and monitoring under visual display the phototermocoagula- Crossectomy and Foam in the Management of Pri- tion effect achieved. mary Varicose Veins Each laser wavelength is absorved by the tissues by a spe- E. J. Miranda ci!c cromophore, in our case we used those that are absorved Metropolitan Hospital, Managua, Nicaragua by hemoglobin and water, wich act as light targets. The indications for laser therapy are also based on the the- Aim. Over the past few years there has been a move towards ory of selective photothermolisis. Wherein water in the lymph different treatments for varicose veins. Besides ligation of the

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 43 saphenofemoral junction (SFJ) with or without stripping of very effective and can be performed in most patients with im- the great saphenous vein, today endovascular ablation tech- paired greater and lesser saphenous veins with few complica- niques are also gaining attention, e.g. endovascular laser or tions. radiofrequency ablation and ultrasound-guided foam sclerotherapy, UGFS. Sclerotherapy is used frequently because of its less invasive character, the highly successful occlusive percentage and to represent the least expensive modality for the treat- SOCIETY SESSION: ment of primary unilateral and bilateral GSV re#ux. The aim EUROPEAN VENOUS FORUM - of the present study is to report the clinical outcome of Cros- WHAT IS NEW IN THE sectomy and Foam three years following as an ideal treatment INTERNATIONAL GUIDELINES 2013 for primary varicose veins with safenous re#ux in a country with a very low per capita income. ON THE PREVENTION Methods. During the three-year period between Decem- OF VENOUS THROMBOEMBOLISM ber 2009 and December 2012, patients presenting re#ux in the great saphenous vein (GSV) Clinical severity (C-class) C4 Risk Assessment to C6 were included, 345 limbs on 304 patients were submit- J.A. Caprini ted to varicose vein surgery (same surgeon with preoperative Division of Vascular Surgery, NorthShore University HealthSystem, echo-guided mapping). Patients had Crossectomy and Foam Evanston, IL, USA applied directly by needle or catheter after ligation and prior to section on distal saphena. All of them with local anesthesia Individual risk assessment is an important tool to evaluate and ambulatory surgery. Remaining super!cial tributaries was thrombosis risk in patients. Prior to an operative procedure or treated in of!ce with Foam Sclerotherapy. treatment of a medical condition it is imperative to uncover any Results. After three years, a successful clinical outcome problem that might jeopardize the outcome of the procedure or was observed in 314 of 345 limbs (91%). Clinical recurrence dictate a change in the suggested treatment. The Caprini score was observed in 31. 25 of them (80.5%) was classi!ed previ- was developed in 1986 and consisted of a comprehensive list ously C5 or C6 and most of this limbs (19) had, previous- of risk factors that were weighted according to the probability ly recorded, some grade of re#ux in their deep venus sys- of each risk factor to cause a venous thromboembolism (VTE). tem. Recurrent saphenous re#ux was founded in 11 (3.1%) Formal validation of the model was !rst reported in 8216 gener- Redu crossectomy was conducted for angiogenesis on 6 al and vascular surgical patients at the University of Michigan. patients plus UGFS. The remaining 5 pattients were treated There was a statistically signi!cant correlation between score- with UGFS alone with successful results. Follow up time 5 derived level of risk and the incidence of clinically apparent months to 3 years. documented VTE events within 30 days of hospitalization. The Conclusions. The combination of crossectomy plus foam incidence of VTE events when the score was >8 was 6.5%. An- sclerotherapy produce much better results than crossectomy other study involving 1126 patients from !ve universities hav- or foam alone, with less recurrence, less thrombophlebitis and ing plastic surgery demonstrated a linear correlation between less probabilities of DVT. Is an effective method of eliminating score-derived level of risk and VTE. When the score was >8, pathological re#ux of GSV in the treatment of patients with 11.3% suffered a clinically documented VTE event within the chronic venous insuf!ciency and characterized by fast, low 60-day period. A third study involved 2016 adult patients admit- cost procedure that is associated with minimal discomfort for ted for ENT surgery who did not receive thrombosis prophy- the patient. laxis. A linear relationship existed between the scores and the incidence of clinically relevant VTE. Those with a score of >8 suffered an 18.3% incidence of clinical VTE and were more likely to develop a VTE compared to patients with a Caprini risk Endolaser in Saphenous Veins: Experience in El score of <8 (p<.001). In another study involving 4386 patients Salvador admitted to the surgical intensive care unit at the University A. Martinez Granados of Michigan a Caprini score was obtained. Linear correlation Private Practice, San Miguel, El Salvador between the Caprini risk score and the incidence of clinically relevant venous thromboembolism was seen and those with a Aim. To review the results of the use of Laser in Saphen- score >8 eight suffered an 11.46% incidence of VTE. In another ous Veins incompetence, realized in private consultory in El study involving 347 DVT patients, the Caprini score classi!ed Salvador. more patients into high and highest risk level compared to two Methods. Retrospective study of patients with great and other scores. Only 8.9% using the Kucher score and 23% us- small saphenous veins incompetence, diagnosed ultrasono- ing the Padua score were classi!ed as high or high risk. The graphically, operated under tumescent local anesthesia with Caprini score can be used to identify low-risk patients that may 810 nm Laser in clinic, from January 2006 to May 2012. be spared the risks of anticoagulation. This score can also iden- Results. 260 patients with postoperative ultrasound moni- tify those high and very high-risk patients where extended out- toring of at least one year, the mean age was 50 years with a of-hospital prophylaxis should be considered. range between 18 and 80 years. The average diameter of insuf- !cient terminal valve was 7.84 mm with range of 4.6 to 15.2 mm. CEAP grades 2-6, all laser treatments were completed in 1 session, additional sessions were required for sclerotherapy Prevention of Post-Thrombotic Syndrome treatment of super!cial varices. B. Eklöf Most frequent complications: bruising, postoperative pain, Lund University, Lund, Sweden and induration of treated vein. Less frequent fever (2), DVT (1), retained laser !ber (1). The post-thrombotic syndrome (PTS) is a signi!cant cause Satisfactory occlusion could not be achieved in 18 (6.9%) of chronic illness with considerable consequences for both the limbs, 10 with re#ux (3.8%) and 8 (3.1% with no re#ux). All patient and the society. The incidence of PTS following con- re#ux were treated with ultrasound guided sclerotherapy sat- !rmed deep venous thrombosis (DVT) is still controversial, as isfactory. the rate of postthrombotic sequelae reported has varied be- Conclusions. The procedure performed in clinic is safe, tween 20% and 100%.

44 INTERNATIONAL ANGIOLOGY October 2013 Iliofemoral DVT is associated with a higher frequency and varoxaban and Apixaban are available for different indications more severe PTS than distal DVT. Patients with extensive ili- in the European community, North America and other parts ofemoral DVT had signi!cantly worse PTS Villalta scores than of the world. Despite claims of superiority in terms of no re- those with distal or popliteal DVT. quirement for monitoring, predictable PK/PD and other safety Insuf!cient anticoagulation treatment is associated with an pro!les, these agents have certain drawbacks including lack of increased risk of thrombus propagation, pulmonary embolism antidote to neutralize bleeding and population based response (PE) and recurrent DVT. However anticoagulation alone im- differences. While Dabigatran, Rivaroxaban and Apixaban perfectly protects against the occurrence of venous obstruc- have been approved for DVT prophylaxis in Canada and Euro- tion and valvular destruction, resulting in ambulatory venous pean countries, only Rivaroxaban is approved for prophylaxis hypertension and potentially PTS. against DVT after orthopaedic surgery in the USA. Beside be- The effects of elastic compression stockings (ECS) following different from the conventional oral anticoagulant drugs, ing DVT have been well documented with reduction in venous the newer agents differ from one another in terms of pharma- hypertension, decreased edema, and improvements in tissue cokinetics, pharmacodynamics, bioavailability, mechanisms microcirculation. of action and drug interactions. These agents should be used In acute iliofemoral DVT early thrombus removal has been with caution in elderly patients especially those with compro- shown to decrease vein wall injury, preserve valve function and mised renal function. Patients with hepatic impairment as well ultimately decrease the occurrence of PTS. as those prone to bleeding have a greater risk of hemorraghic Recurrent ipsilateral DVT is a primary and probably the complications of these agents. While the observed bleeding most important etiologic factor in the development of PTS. complications are associated with the use of all of these agents, Reducing the rate of recurrent DVT will thereby decrease the Dabigatran in particular should be used with greater caution incidence of PTS. because of a reportedly higher risk of bleeding. Due to the lack Although it is not possible to foresee the development and of an antidote, the management of these bleeding episodes is course of PTS in the individual patient, clinical predictors of dif!cult. Currently several antidotes are in developmental stag- PTS are identi!able at the time of acute DVT. Clinical factors es. In addition Dabigatran is an absolute contraindication in at initial presentation and at 30 days, can allow categorization patients with mechanical heart valves. Since these agents pass of patients at risk for severe PTS. Proximal DVT involving the through placental barrier they are not useful in pregnancy. The common femoral or iliac veins, elevated BMI, previous ipsilat- clinical trials also reveal that these agents are relatively inferi- eral DVT, and older age are associated with the development or to standard of care in medical patients especially in cancer. of PTS. Cost considerations present an additional factor limiting their Recently the International Society on thrombosis and he- widespread use. Despite these limitations, these agents will be mostasis put forth recommendations, suggesting the Villalta useful in heparin compromised and conventional oral antico- PTS scale be used primarily, complimented by the CEAP clas- agulant compromised patients. si!cation when appropriate. Although it appears that early PTS symptoms after DVT correlate with poor long term outcome, we have yet to elucidate the underlying pathology of this process. The mechanism driving the progression of PTS, and SOCIETY SESSION: whether its course can be halted or even reversed is unknown. POLISH PHLEBOLOGICAL SOCIETY Chronic obstruction of the iliofemoral segment following acute DVT is common as only 20% to 30% of the iliac vein Primary VTE Prophylaxis in Cancer Patients thrombi recanalize with anticoagulation alone. Percutaneous Z. Krasiński1, D. Szpurek 2, M. Sanocki 1, R. Staniszewski 1, Ł. Dzieciu- endovenous angioplasty and stenting is the method of choice chowicz1, K. Pawlaczyk3, B. Krasińska3, T. Urbanek4 for venous out#ow obstruction with primary and secondary 1Department of General and Vascular Surgery, Medical University of patency rates of 57% and 80% at 72 months for postthrom- Poznań, Poznań, Poland botic disease. 2Departament of Gynecology, Medical University of Pozna ń, Pozna ń, Po- land 3Departament of Hypertension and Angiology, Medical University of Poznań, Poznań, Poland 4Department of General and Vascular Surgery, Medical University of Si- The Place of New Oral Anticoagulants lesia, Katowice, Poland J. Fareed Professor of Pathology and Pharmacology, Hemostasis and Thrombosis Aim. Ovarian cancer (OC) is associated with a high risk of Research Laboratories, Loyola University Medical Center, Maywood, IL, venous thromboembolism (VTE) both in pre- and postopera- USA tive period. The purpose of the study was to analyse the ef- !cacy and safety of an early prophylaxis with dalteparin inpa- The last century has witnessed the development of many tients with OC quali!ed for surgical treatment. newer oral anticoagulant agents for the prevention and treat- Methods. The study group consisted of 37 patients with ment of venous thromboembolism (VTE). Improved versions OC quali!ed for surgery in whom thromboprophylaxis was and formulations of conventional oral anticoagulants such as started at the moment of quali!cation for surgical treatment. warfarin have been introduced. The newer oral anticoagulants, The control group consisted of 61 OC quali!ed for surgery in representing anti-IIa (Ximelegatran and Dabigatran) and anti- whom thromboprophylaxis was started 12 hour before sur- Xa (Rivaroxaban, Apixaban) drugs were initially developed for gery. The duration of postoperative prophylaxis was 4 weeks in the management of post-surgical VTE. The earlier approach both groups. Dalteparin 5000 U/day was used in both groups. validated their effectiveness in the management of post-surgi- The primary end points were occurrence of VTE and major cal prophylaxis of DVT. These agents are claimed to have ease bleeding. The patients underwent full gynaecological exami- of administration without need of routine monitoring and re- nation, Duplex Doppler scan and D-dimer (DD) concentration portedly demonstrated additional advantages over warfarin, measurement at the moment of quali!cation for surgery, 1 day including predictable pharmacokinetics, infrequent drug and before and 7, 14, 28 days and 3 months after the surgery food interactions, relatively rapid onset and offset of action. Results. The total duration of thromboprophylaxis was Since warfarin has been used for stroke prevention in atrial 45,3 ± 10,7 days in SG and 27,9 ± 3,7 days in CG (p<0,0001). !brillation (SPAF), subsequently, these new oral anticoagulant The deep venous thrombosis rate was 2,7% in SG and 16,4% were developed for SPAF indication. Currently, Dabigatran, Ri- in CG /(p= 0,042/). Neither pulmonary embolism nor major

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 45 bleeding was observed. Median preoperative DD concentra- — tributaries represented by the Giacomini vein and the tion in all patients was 1700 ng/ml and was signi!cantly higher Thigh Extension of the Short Saphenous Vein; inpatients who developed postoperative DVT when compared — terminal Valve (TV); to those who did not 2556.8 and 1691,0 ng/ml, respectively — pre-Terminal Valve (PTV). (p=0.0009). A Re#ux of the SPJ is the consequence of the incompetence Conclusions. Early thromboprophylaxis with dalteparin in of one or two valves, mentioned above, when a retrograde gra- patients with ovarian cancer quali!ed for surgical treatment dient is developed. is safe, decreases the prothrombotic activation of haemostasis The re#ux gradient can be present at rest or developed by and the risk of thromboembolic complications. To determine Valsalva manoeuvre or compression/relaxation test (C/R) or indication, dosage and timing of such thromboprophylaxis in Dynamic test. this group of patients further studies are required. Dynamic tests allow us to highlight the systolic and diastolic events. We can classify the SPJ re#ux in: SOCIETY SESSION: Pre-ostial re"ux ITALIAN SOCIETY OF PHLEBOLOGY When only the PTV is incompetent. No retrograde #ow through the ostium is detectable. Differences Between ASVAL and CHIVA Method The re#ux gets on below the ostium. It can be: C. Franceschi SYSTOLIC when it’s fed by the anterograde #ow of the gas- Angiology Consultant Hospital Saint Joseph, Paris, France trocnemius veins. A common out#ow must be present. This hemodynamic pattern is found in 3% of the cases of primary According to their promoters ASVAL( Selective Ablation of incompetence of the SPJ. the Varices under Local Anesthesia) is an extensive phlebecto- DIASTOLIC when it’s fed by the tributaries out#ow or by my of the incompetent super!cial veins according to Muller’s the gastrocnemius vein. It’s always diastolic and developed technique in order to ablate the varicose veins they call “Reser- by muscular pump relaxation. The doppler sample must be voir”, responsible for the GSV re#ux because of their supposed placed distally with respect to the ostium. Valsalva is negative “!lling effect”. They set this method on the ascending theory of SYSTO-DIASTOLIC when both previous conditions are the varicogenesis, where the wall dilation of the distal super!- present cial veins by the hydrostatic pressure is supposed to be the primum movens responsible for the valve incompetence and pro- Ostial re"ux gressing upwards to the terminal valve of the GSV. When the When only the ostial valve or both valves (TV and PTV) are phlebectomies ablate the GSV re#ux and restore an antegrade incompetent. #ow, the GSV is spared. When the re#ux persists or recurs, the The Valsalva is positive regardless of the presence of a prox- GSV is destroyed. So far no validation by any long term RCT. imal popliteal valve. According to his promoter, CHIVA ( Conservative and Hemo- Classi!cation: dynamic cure of Venous Insuf!ciency in outpatients ) consists A) CONTINOUS AT REST in Hydrostatic column fractioning Closed and Open Deviated B) SYSTOLIC Developed by the muscular pump contrac- Shunts disconnection under local anesthesia. It’s theoretical tion background is that, secondary to the valve incompetence, the Both can coexist and are brought about by a downstream venous insuf!ciency ( veins dilation and drainage impairment) resistances increase at deep level. These hemodynamic pat- relates to an excess of trans-mural pressure due to the lack of terns are, much more frequent in a post-thrombotic syndrome pressure column fractioning and shunts diastolic aspiration or in case of a femoral vein aplasia than in a primary saphen- by the muscular pump (calf). Disconnections are tailored ac- ous incompetence. cording to the hemodynamic con!guration of the valve in- In primary SPJ incompetence a systolic re#ux lasting dur- competence and shunts. Some con!gurations ( Open Deviated ing all the systolic phase, is detectable in 15%. Shunts) need only disconnections of the tributaries and result It can be due to an ab-extrinsic compression, but not all in a GSV antegrade #ow restore. Others ( Closed Shunt) may the systolic re#uxes through the ostium are an expression of a need a sapheno-femoral disconnection, and doesn’t restore the vicarious shunt as they can depends also on the SPJ angle shot antegrade #ow. The remaining re#ux is not considered patho- with the popliteal vein and on the ostium size. logic because no more overloaded by the deep re#ux and the C) DIASTOLIC column is fractioned, so that the transmural pressure turns Developed by muscular pump relaxation and detectable normal. Several long term RCTs CHIVA vs Stripping validate placing the doppler sample at the popliteal side of the ostium. this method. CHIVA and ASVAL differ according to their he- It’s found in 82% of cases in primary SPJ incompetence modynamic concepts, strategy and technique and their conservative capabilities. Whereas CHIVA is conservative in every hemodynamic con!guration, ASVAL spares the GSV only in most of open vicarious shunts ( Shunt II pattern), few closed shunts (Shunt III pattern) and none of the other closed shunts Hemodynamic Assessment and Strategy Treatment patterns. of Giacomini Varicose Veins S. Ermini Private of#ce, v. Tizzano, 18 – 50012 Grassina, Firenze, Italy

Hemodynamic Patterns of the SPJ Incompetence Giacomini varicose veins are not commonly found, often M. Cappelli due to a less known physiopathology. They can originate from Phlebology Private Of#ce, Florence, Italy an upper placed escape point, e.g. a pelvic re#ux in the perineal region, or from the popliteal fossa. In the !rst situation Saphenous Popliteal Junction (SPJ), when present, is made the escape point has the same hemodynamic pattern as others, up of : like a re#uxing SFJ, and the blood #ows downwards during — “saphenous arch” that can have a common out#ow with the relaxation phase of the muscle pump. When the pathogen- gastrocnemius veins; ic #ow in the Giacomini v. originates from the popliteal fossa,

46 INTERNATIONAL ANGIOLOGY October 2013 the re#ux in the SPJ appears during the contractive phase of According to the Cochrane Library 2013 article, “Compres- the muscle pump and creates a centripetal #ow in the Giaco- sion increases the healing rates of venous leg ulcers compared mini v. If the re-entry point is placed higher, there is no #ow in with no compression. Multicomponent compression systems this pattern during the relaxation phase. If the re-entry point are more effective than single-component systems. Multicom- is placed lower than the escape point, a centripetal #ow occurs ponent systems containing an elastic bandage appear to be in the Giacomini v. also during relaxation and this is due to more effective than those composed mainly of inelastic con- a “pseudosyphon effect”. In this previous hemodynamic pat- stituents. Two-component bandage systems appear equivalent tern the circuit starts with a centripetal #ow from the SPJ and to the four-layer bandage (4LB) in terms of healing……The involves a visible varicose vein whose hemodynamic pattern performance of any type of compression bandage might be in- is not different from a classic one. A correct treatment can be #uenced by operator skill…” (The Cochrane Library 2013, Issue planned only if the correct physiopathology of this pathogenic 3; Compression for venous leg ulcers: O’Meara S, Cullum N, circuit is well checked with an US examination. Nelson EA, Dumville JC) Usually, in venous insuf!ciency ulcers, we are concerned with how many mmHg of pressure we exert on the sick limb and suggest bandages according to this parameter. There are other aspects of the limb affected by venous ulcers that must Mini-Invasive Treatment of Pelvic Escape Points be taken into account and that must in#uence the binding of L. Tessari a bandage to obtain results and not cause further inconven- Tessari Studi, 37019 Peschiera del Garda (VR), Italy iences and side effects. These aspects relate to the size of the limb, the skin type, Aim. Pelvic congestion syndrome is a recently recognized the presence or absence of in#ammation, pain and secretion, clinical picture due to pelvic vein insuf!ciency. Sometimes, bone structure with the presence or absence of bony ridges, propagation of venous re#ux into the lower extremities de- the presence or absence of ambulation and the type of gait, termines varicose veins and chronic venous disease (CVD). foot defects, type of plantar support, concomitant diseases, the Moreover, C. Franceschi and A. Bahnini reported that readily general condition of the patient, the patient’s mental status etc. visible varicose veins in the medial aspect of the thigh in the Therefore, these considerations all result in the need to use presence of a competent sapheno-femoral junction, are fed by different materials, various methods of stratifying these mate- re#ux through the vein of the Alcock canal. rials, the application of different levels of compression, as well The perineal site of re#ux (P point) pierces the perineal su- as, when needed, the use of appropriate cushions to increase per!cial fascia at the level of transversus perinei super!cialis or decrease the pressure in certain areas. All of the aforemen- muscle. It is associated with the junction of the perineal and tioned considerations must be taken into account when giving labial veins which are re#uxly !lled by the internal pudental patients instructions and advice about possible side effects, vein (Alcock canal). home care and patient behavior which must be carefully as- A surgical approach to the treatment of these two points of sessed from case to case. re#ux have been described. Those who apply the bandage must have considerable expe- To verify the effectiveness of ultrasonic guided foam sclero- rience and skill in order to apply the most appropriate band- therapy in treating re#ux of the Alcock canal vein, as well as age to each patient. This will consequently lead to the best pos- the consequent varicose veins of the lower limbs. sible healing in the shortest possible time. Methods. P Point is found by an echo-color-Doppler (ECD) This work consists in analyzing and making suggestions investigation in gynecological position. about the various possible solutions to these different aspects, Once P point is evinced, we proceed with a direct foam in- through cases and clinical examples. jection (Tessari method, Fibro Vein 2% plus a mixture of soluble and biocompatible CO2 70% + O2 30%). Eight-hundred-fortyseven consecutive female patients underwent both clinical and ECD, demonstrating in 95 cases (between the age of 32 and 66 years old) venous re#ux from SOCIETY SESSION: the Alcock canal vein. They underwent foam sclero-therapy, KOREAN SOCIETY OF PHLEBOLOGY followed in 22 cases, by a second shot injection after 8 weeks. F-up includes clinical as well as ultra-sonographic evaluation. Results. The mean follow-up lasted 13 months. Neither How to Manage the Congenital Venous Malforma- minor or major complications emerged. Patients’ compliance tion was optimal. Re#ux through the vein of the Alcock canal as D.I. Kim well as the connected varicose veins disappeared in the entire Div. Vascular Surgery, Samsung Medical Center, Sungkyunkwan Univer- cohort. sity School of Medicine, Seoul, Korea Conclusion. In the short term, foam sclero-therapy seems to be both effective and minimally invasive for treating such We retrospectively reviewed the data of 48 patients who peculiar pattern of re#ux. Further investigations will be neces- underwent surgical management for venous malformation sary in order to validate this technique in the long term. at our institute. The indications of surgeries were mass or swelling in 48 patients, intractable pain in 11 patients, limb length discrepancy in 7 patients, bleeding in 3 patients, and limitation of the range of motion in 1 patient. The locations of VM were head & neck in 17 patients, abdomen & pelvis Different Elastic Bandages Related to Different Ve- in 1 patient, perineum & genitalia in 3 patients, upper ex- nous Ulcers tremities in 12 patients, and lower extremities or buttock in R. Moretti 15 patients. Among the 48 operations for radical resection Private Practice, Florence, Italy and debulking, 25 of the surgeries resulted in “remission’, 11 resulted in “improvement” and 12 resulted in “no change”. The role of elastocompression is fundamental. It acts on the During follow-up (mean: 44.8 ± 36.6 months), recurrence af- transmural pressure and improves the microcirculation by re- ter radical excision occurred in 10% of the patients and size balancing it in almost every lesion of the lower limb, even in a increasement after debulking surgery occurred in 24% of the healthy subject! patients.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 47 The Short Term Result of Hybrid-Surgery (Cryo Ultrasonography, Computed tomographic angiography (CTA) Stripping with LASER) for Great Saphenous Vein and Magnetic Resonance Imaging (MRI) con!rmed the pres- D.M. Soh1, Y.K Shim2 ence of the !stulous tract between right popliteal artery and vein, and swollen subcutaneous fat and muscles of the right 1Department of General Thoracic and cardiovascular Surgery, Seoul, Ko- rea lower leg. The patient was admitted and endovascular stent 2Department of Plastic Surgery, Yonsei S Hospital, Seoul, Korea graft (diameter 9 mm, length 5cm, Viabahn stent graft) insertion was done. Duplex Doppler ultrasonography was repeated This is a randomized clinical trial compared cryostrip- on postoperative day one, and identi!ed the total occlusion of ping and EVLA of the great saphenous vein with cryostrip- the right dilated popliteal vein to below knee popliteal vein. ping only to determine the effect of surgery on results and The patient was discharged home on postoperative day seven quality of life. with signi!cant improvement. From June 2011 to July 2012, 317 patients with CEAP clinical severity class 2 to 4 were randomized to cryostripping and EVLT(143), and cryostripping only(174) with or without ambulatory phlebectomy. The primary outcome was The Effectiveness of Sclerotherapy on Reticular residual GSV after 6 months after surgery measured by ve- Varicose Veins and Telangiectasis nous duplex ultrasound imaging. Secondary outcomes were Y.W. Yoon quality of life, and postoperative neural damage. Durations Seoul Hajung varicose clinic, Incheon, Korea of follow-up were from 11months to 24 months. Result and quality of life was measured postoperatively with the venous The sclerotherapy is frequently used to treat the reticular clinical severity scoring (VCSS), venous segmental disease veins and telangiectasis. The aim of this study is to assess the score (VSDS), and venous disability score (VDS). Result effectiveness of sclerotherapy on reticular varicose veins and would be reported. telangiectasis in regard to its cosmetic and therapeutic effect. From January to august 2012, 74 patients were treated by foam sclerotherapy with sodium tetradecyl sulfate (STS) in author’s phlebology clinic. These Cryostripping: Above Knee or Below knee? Long patients were only had reticular veins or telangiectasis. The Term Follow Up of Cryostripping Surgery for Great patients combined with great saphenous vein (GSV) or small Saphenous Vein saphenous vein (SSV) trunk incompetence were not included. D.M. Soh1, K. Shim2 In total, 74 patients were had treated by sclerotherapy. There were 43 (58.1%) in symptomatic patients, 31 (41.9%) in cos- 1Department of General Thoracic and Cardiovascular Surgery, Seoul, Korea metic patients. Their symptoms were tingling (13), tightening 2Dept of Plastic Surgery, Yonsei S Hospital, Seoul, Korea (13), heaviness (8), fatigue (7), dull pain (6), cramping (6), and restless (2). Male patients were only two, the others female The length of the GSV of the stripping or Endovascular ab- were 72. There were symptom improved in 26 (60.5%) patients lation procedure is still questionable. Above knee procedures out of symptomatic cases. There were follow-up loss in 6 pa- are mostly recommended to prevent complications. This is tients. The sclerotherapy on reticular varicose veins and tel- a long-term follow up of randomized clinical trial compared angiectasis is effective not only cosmetics but also symptom cryostripping of the great saphenous vein above knee with cry- relief. ostripping below knee to determine the effect of surgery on results and quality of life. From January 2008 to Dec 2008, patients with CEAP clinical severity class 2 to 4 were randomized to cryostripping Ultrasound Guided Foam Sclrotherapy above, and cryostripping below knee with or without ambu- J.H. Jang latory phlebectomy. The primary outcome was residual GSV Dong-Seoul Vein Clinic, Seoul, Korea or recurrent varicosity after 6o months after surgery measured by venous duplex ultrasound imaging. Secondary out- Ultrasound Guided Foam Sclerotherapy (UGFS) is an injec- comes were quality of life, and postoperative neural damage. tion of foam sclerosing agent into the vessel direct ultrasound Duration of follow-up was 60 months. Result and quality visualization, it has new methods of treating venous disease of of life was measured postoperatively with the venous clini- lower extremity. cal severity scoring (VCSS), venous segmental disease score UGFS is used in the treatment of varicose veins (with or (VSDS), and venous disability score (VDS). Result would be without junctional incompetence), recurrent varicose vein, reported. low #ow congenital venous malformation, K-T syndrome, complicated chronic venous insuf!ciency (venous ulcer, lipodermatosclerosis and dermatitis), and unusual cause of varicose veins (vulvoperineal varicose vein). Treatment of Popliteal Arterio-Venous Fistula with The advantages of UGFS are avoidance of anesthetic and Stent Graft surgical intervention, earlier return to work, better cosmetic outcomes, suitable for those who are on the borderline of !t- D. H. Pyo, D.I. Kim ness or age. Div. Vascular. Surgery, Samsung Medical Center, Sungkyunkwan Univer- sity School of Medicine, Seoul, Korea

A 32-year-old man presented with a 7-month history of right lower extremity swelling. He had sustained posterior cruciate Femoral Nerve Block in Varicose Vein Surgery ligament (PCL) rupture of his right knee 7 months ago, so ad- G.W. Kim mitted to local orthopedic clinic and PCL reconstruction was Purum vein clinic, Seoul, Korea performed. At presentation, the patient’s right lower extremity was swollen, but it was not a pitting edema. Plantar #exion KPS members are using three types of anesthesia for vari- contracture of the right ankle was also seen. Duplex Doppler cose vein surgery. The three types are spinal anesthesia, re-

48 INTERNATIONAL ANGIOLOGY October 2013 sional nerve block, and local anesthesia occasionally combined signi!cantly reduces postoperative pain and hematoma forma- with IV anesthesia. Currently patients suffering from cardiac tion in patients undergoing GSV stripping for varicose veins. problem are increased. Spinal anesthesia has more of cardiac risk than resional nerve block. Success rate of ultrasound or nerve stimulation guided nerve block is 90%, when the success Effectiveness of Disposable Laser Fibers in EVLA rate of conventional nerve block is 70%. Ultrasound or nerve W.S. Chung stimulation guided nerve block is safe and has high succeed rate. I will explain about my method of ultrasound or nerve Varicose vein clinic, Yonsesarang Hospital, Seoul, Korea stimulation guided nerve block Utilization of single-use laser !bers by expert insertion into varicose veins can reduce reliance on introducer sheath sets and thereby lower costs for surgical procedures. Hemodynamic Changes after Varicose Vein Surgery In EVLA treatment, the Seldinger technique is most of- K.B. Lee1, D.I. Kim2 ten used to insert laser !bers into the varicose veins. Single- 1Department of Surgery, Seoul Medical Center, Seoul, Korea use !bers have rounded tips that allow for safe advancement 2Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan through slightly curved veins. However, it is dif!cult to ad- University School of Medicine, Seoul, Korea vance the !bers when the curves are too extreme. In these situations, we can re-insert the !bers at each of the extreme We retrospectively analyzed 1,756 limbs of 1,620 patients curves by needle point and reduce reliance on introducer who had undergone surgery for the limbs having a great saphe- sheath sets. nous vein (GSV) re#ux from January 1996 to June 2009. The At our varicose vein clinic, we evaluated 91 cases of patients venous hemodynamic changes were evaluated by performing receiving EVLA during a 10-month period. In 85 cases, we air plethysmography preoperatively and one month postop- managed to insert the laser !ber throughout the length of the eratively and assessing the venous volume (VV), the venous targeted vein without need for the introducer sheath set. We !lling index (VFI), the residual volume fraction (RVF) and the used the sheath sets in 6 cases. Over all, expert technique with ejection fraction (EF). single-use laser !bers allowed us to perform EVLA in 93.4% of Preoperatively, the median VV was 121.6 (94.7- 160.6)mL cases without requiring the introducer sheath set. and the median VFI was 4.8 (2.9-7.6)mL/s, the median RVF was Introducing the single-use laser !bers through needle point 40.6 (29.7-50.0)% and the median EF was 53.5 (44.3-64.1)%. at each extreme curve in the targeted varicose vein can reduce Postoperatively, the median VV was 90.6 (69.1-116.8) mL, the reliance on the introducer sheath system and therefore save median VFI was 1.4 (0.9-1.9)mL/s, the median RVF was 28.4 costs for the procedure. (17.5-38.7)% and the median EF was 65.2 (54.5-77.2)%. The VV, VFI and RVF were reduced 25.2%, 71.5% and 29.9%, respectively. The EF was increased 20.3%. The results were signi!cant for all four variables (p<.001). We compared the degree of hemodynamic changes according to the treatment modali- What is the Best Management for Recurred Varicose ties. The high ligation and stripping group of 1,578 cases, the GSV valvuloplasty group of 124 cases and the VNUS group of Vein: GSV Territory 54 cases. The reduction of the VV, VFI, and RVF was greater W.K. Jang in the GSV stripping group and the VNUS group than that in Dr. Kim varicose vein clinic, Incheon, Korea the valvuloplasty group (p<.001). Yet there was no difference of increasing the EF among the surgical modalities (p=.157). Recurrent varicose veins occur in 20% to 80% of patients following treatment. recurrent varicose vein after surgery or recurrent varicose vein after surgery is increased as time pass- Treatment of Varicose Vein by EVLA es. Four types of recurrent varicose veins have been reported: neovascularization, recanalization, residual stump, and dis- G.B. Kang ease progression. In treatment of recurrent varicose veins, re- Woorihangmaeg medical clinic Phlebologic department joongwhasan- do-open surgery is more dif!cult to perform than primary sur- Dong, Jeonju, Korea gery and can be associated with a higher risk of neurovascular Aim. To observe the effect of tumescent anesthetic solution injury and infection. Otherwise, minimally invasive therapy (TAS) #ush through the great saphenous vein(GSV) tunnel on such as endovenous thermal ablation and duplex guided scle- postoperative pain and hematoma formation after saphenous rotherapy can be safely performed. In conclusion, recurrence vein stripping operations. Design. Prospective, double-blind, is the usual problem from varicose veins treatment. Therefore, randomized, control trial we must have insight of recurrence in primary varicose veins Methods. One hundred patients were randomized to retreatment. And there is need of long term follow up after the ceive 50ml of tumescent anesthetic solution (0.05% lidocain treatment. + 1:1,000,000 epinephrin) or saline control #ush through the GSV tunnel after stripping in a double-blind study. Visual analogue pain scores were used to measure postoperative pain 3 days, 1 week, 2 weeks, 4 weeks. Patients were examined during 3 days, 1 week, 2 weeks, 4 weeks for hematoma formation Endovenous Laser Treatment with High Ligation of Results. In the control group the median postoperative Saphenous Vein pain score was 3(range 0-7) on day-3 compared to a median D.H. Kim 1(range 0-4) in the TAS group (p<0.001). The median pain Suwonhajung varicose vein clinic, Seoul, Korea score on 1 week was 1(range 0-5) (control) vs. 0 (range 0-5) (TAS group) (p<0.001, Mann whitney). And after 2 weeks, and Endovenous laser treatment (EVLT) has become a standard 4 weeks there was no different in two groups. Twelve patient therapy for the treatment of incompetent great saphenous vein (24%) developed a hematoma in the GSV tunnel in the control (GSV) and small saphenous vein (SSV). But EVLT may lead group compared to 3 patients(6%) in the TAS group (p=0.007) to some complications such as skin bruises, hematoma, skin Conclusions. Flushing of the GSV tunnel with tumescent burns, phlebitis, abnormal skin sensation, deep vein thrombo- anesthetic solution (0.05% lidocain + 1:1,000,000 epinephrin) sis and recurrence.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 49 In suwon hajung varicose vein clinic in Korea, we performed Clinical stage was C2 in all adolescent patients. 10 limbs of EVLT combined with ultrasound (US) – guided high ligation the 12 limbs (9 patients) had incompetent SFJ and 2 limbs had in patients with incompetent saphenous veins. US-guided high incompetent SPJ. All patients visited due to cosmetic prob- ligation was performed with 5 to 10 mm incision in the groin lems. 5 patients had no clinical symptom and the others com- (GSV) or popliteal area (SSV) to exposure the saphenofemoral plained minor symptoms such as heaviness and night clamps. junction or saphenopopliteal junction. Conclusions. Family history was well known risk factor of EVLT was combined with high ligation of the saphenous varicose vein. 9 adolescent patients with varicose veins didn`t vein, it was easier to obtain complete sclerosis of the saphen- have other risk factors such as obesity, prolonged standing, ous trunk, avoiding possible recurrence. It revealed satisfac- abdominal straining, trauma to the legs and pregnancy. Fam- tory results with a low complication rate and minimized the ily history is suggested to be a major factor of varicose veins in occurrence of nerve injury. 9 adolescent patients. The male-predominance in adolescent After proper high ligation, the results were very good. patients is unexpected feature of this study. Further investiga- Personal Experiences of Treatment of Varicose Vein tions will be needed. M.Y. Jang Hajung Surgical Clinic, Ilsan, Goyang, Korea

Aim. Family history has been suggested as one of the risk My Tips in the Treatment of Varicose Vein by Con- factors for varicose veins. ventional Surgery The aim of this study is to analyze the prevalence and risk C.H. Na factors of varicose veins in adolescent patients who have vis- Hajung Varicose Vein Clinic, Seoul, Korea ited in my clinic. Methods. Retrospective chart reviews from 2007 to 2010 The standard surgical method for varicose veins is consid- were done. Patients under age of 20 were investigated about ered as stripping of the saphenous vein and varicosectomy. their age, sex, family history, symptoms, site of varicose veins With the advance of medical devices, LASER or radiofrequen- and CEAP. cy ablation techniques are commonly used currently. Results. From May 2007 to May 2010, 1210 patients were The main concern of the patients is to get the good results diagnosed with varicose veins. cosmetically. So it is importance to minimized the scars along 9 patients were under age of 20. the varicosectomy site. We had a good cosmetical results using 7 patients were associated with family history. 8 patients Varady hook and cutting needles for varicosectomy. were male. The CEAP. The detail procedures will be presented during the congress.

50 INTERNATIONAL ANGIOLOGY October 2013 THURSDAY, September 12, 2013

and could be avoided by a precise mapping of the veins AND SEPTEMBER 12, 2013 of the nerves. 3) Anatomy of the foot venous pump. THURSDAY The location of the foot pump is not the “sole of Lejars” but the lateral plantar veins. They make a deep plexus located between the muscles of the sole. Their blood content, a volume of about 25 ml, is eject- ASK THE EXPERTS ed upwards at each step into the posterior tibial veins. This explains the role played by the foot static disorders Venous Anatomy during CVD, worsening the venous return by impairement of A. Caggiati the foot pump. Department of Anatomy, Sapienza University of Rome, Italy

Venous anatomy is the basis for any study on the physiol- FREE PAPER SESSION 7 ogy and pathophysiology of venous return, as well on the therapy of venous disease. The introduction of techniques Lower Extremity Venous Thrombosis in Elderly Pa- for vein imaging in living subjects has revolutionized cur- tients rent knowledge on venous anatomy. In fact, classic ana- R. Kreidy1, E. Stephan1, P. Salameh2, M. Waked1 tomic studies on cadavers could not evaluate morphological 1Saint George Hospital, University Medical Center, Beirut, Lebanon changes related to dynamic factors like breathing, orthos- 2Faculty of Pharmacy, Lebanese University, Beirut, Lebanon tatic forces and venous pumping. In turn, Duplex scanning, angioCT and angioMR allowed to evaluate the “dynamic ve- Aim. This study aims to de!ne risk factors for venous nous anatomy”. thrombosis among geriatric patients, to compare them with a Main improvements and re!nements in the knowledge of control group and to propose recommendations for manage- venous anatomy will be reported. Furthermore, some anatom- ment of venous thrombosis in elderly patients. ic topics related to the clinical and surgical approaches to ve- Methods. From January 2003 to January 2013, 189 consec- nous disorders will be discussed in detail. Between them, the utive geriatric patients older than 70 years (mean: 80.1 years; variable anatomy of the saphenous veins, of the venous valves, range: 70 to 97 years), diagnosed with lower extremity deep and of the pelvic veins. venous thrombosis by duplex scan in a university tertiary-care center, were retrospectively reviewed. Control group included 171 patients younger than 70 years (mean: 51.4 years; range: 21 to 70 years). J.F. Uhl Results. The most commonly reported risk factors in the URDIA research unit, University Paris Descartes, 45 rue des saints pères, geriatric group comparing to the control group are hospitali- Paris, France zation ( p<0.001 ), immobilization (p<0.001), history of venous thromboembolism (p=0.087), varicose veins (p=0.061), heart 1) Embryology of the veins of the lower limbs failure (p<0.001), chronic renal failure (p=0.03), hip fracture The aim of this talk is to focus on our knowledge of the ve- (p=0.018 ) and sepsis (p=0.07). Three and more risk factors nous embryology of the lower limbs. are more frequently observed in the geriatric group (p<0.001). In summary, it involves several steps:First a phase of so- Conclusions. The authors did not report statistically sig- called embryonic organogenesis (0-8 weeks) which is subdi- ni!cant variations between the two groups for history of ve- vided into:1. Reticular phase, or primitive vessels differentiate nous thromboembolism, varicose veins and sepsis. Whereas, into arteries, veins and lymphatics. Abnormalities at this stage advanced age was a major risk factor for venous thrombosis produce severe arteriovenous malformations.2. Truncal phase, essentially when associated with hospitalization, immobiliza- a rearrangement of the adult model already differentiated. Ab- tion, hip fracture, heart failure and chronic renal failure. Am- normalities at this stage produce minor malformations called bulation, aggressive treatment of hip fracture and heart fail- “truncular”Second, a fetal phase (8 weeks to 9 months). There- ure are recommended in the elderly patient to prevent venous in, it produces changes in size and structure of vessels, with thromboembolic complications. the appearance of the valves (3-4th month) and numerous individual variations and rearrangement of reticular network, connections and the saphenous fascia. Our research work in progress (URDIA, University Paris Prevalence of Deep Vein Thrombosis in Patients Descartes) provides realistic 3D vectorial models of the lower Undergoing Breast Reconstruction with Autologous limb of human embryos. The technique used is Computer As- Tissue Transfer sisted Anatomical Dissection (CAAD) with immuno markers H. Konoeda, T. Yamaki and manual segmentation. Tokyo Women’s Medical University, Tokyo, Japan This seems to con!rm the Gillot’s theory of the “angioguiding” nerves. One can observe the close relationship of the Aim. Evaluating the incidence of DVT in patients undergo- main venous axis with the nerves, suggesting the role of the ing breast reconstruction with autologous tissue transfer and endothelium growth factor to stimulate the vessel maturation to identify potential risk factors for DVT. along the nerve pathway. Methods. Nineteen patients undergoing breast reconstruc- 2) Anatomy of small saphenous vein (SSV), its thigh exten- tion were enrolled. The preoperative diameter of each deep sion (TE) and their companion nerves. venous segment was measured using duplex ultrasound, and The complex anatomy of the popliteal fossa is better under- near-infrared spectroscopy (NIRS) was used to measure calf stood by the embryology. muscle deoxygenated hemoglobin (HHb) levels. Filling index The true identi!cation of the several anatomical variations (FI-HHb), ejection index (EI-HHb), and retention index (RI- is possible thanks to the companion nerves of the venous axis. HHb) were calculated. Postoperatively, all patients received in- The vicinity of the nerve explains the high risk zones during termittent pneumatic pump and elastic compression stockings the treatments of varicose veins. The nerve trauma is the ma- for thromboprophylaxis. jor complication of SSV surgery and endovenous treatment, Results. Five (26.3%) had calf DVT. Of these, four received

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 53 free-#ap transfers and one had a latissimus dorsi pedicle #ap. Results. Of 325 patients treated operatively 25 had varicose There were no signi!cant differences in documented risk fac- veins without CVI. Among 300 patients with CVI we found as tors and type of #ap used between patients who did or did not follows: 1. No DVT in early and long-term follow-up in pa- develop DVT. In addition, there were no signi!cant differences tients treated with sulodexide or LMWH. 2. In 3 cases (1%) we in preoperative NIRS-derived parameters in patients with and con!rmed by US thrombotic changes in venous sinuses of gas- without DVT. However, the diameter of the peroneal vein was trocnemius muscle. These patients did not agree to the use of signi!cantly smaller in patients who developed DVT than in thromboprophylaxis with the exception of compression ther- those who did not (P < 0.05). apy. 3. We found statistically signi!cant (p<0.001) lower fre- Conclusions. The incidence of DVT in patients undergo- quency and extend of hematomas within the operated limbs. ing breast reconstruction using autologous tissue transfer is Conclusions. Use of the sulodexide and Low Molecular relatively high. Because only the peroneal vein diameter was Weight Heparin is fully effective in the antithrombotic pre- predictive of DVT developing in our study cohort, postopera- vention of DVT in varicose vein surgery in patients with CVI. tive pharmacologic thromboprophylaxis should be considered However, early and long-term follow-up showed statistically for all patients undergoing breast reconstruction. signi!cant sulodexide superiority over heparin in the form of lower frequency and lower extent of hematomas within the operated limbs. Epidemiology of Phlebitis (In"ammation of the Vein) D. Fiebig1, M. Gawlick2, A. Greiner3, S. Nikolaus4 Experimental Studies to Investigate the Relative 1Kompetenznetz Chronische Venenkrankheiten, Kiel, Germany Bleeding Effects of Dabigatran, Apixaban and Ri- 2Biobank popgen, Kiel, Germany varoxaban 3Capio MVZ Venenzentrum, Bad Bertrich, Germany 4University Clinic of Schleswig-Holstein Campus Kiel, Kiel, Germany J. Fareed1, W. Jeske 2, V. Escalante 2, D. Hoppensteadt 2, J. Walenga 2, R. Wahi 2 Aim. Phlebitis is an important characteristic of chronic ve- 1Loyola University Chicago Stritch School of Medicine, Maywood, IL, nous disease de!ned as in#ammation. Due to the fundamental USA 2Loyola University Medical Center, Maywood, USA advance by studying other in#ammation diseases we started an observational case-control study by genotyping genetic Aim. Despite the initial claims that the newer oral antico- makers. agulants such as the dabigatran, rivaroxaban and apixaban Methods. Beside broad epidemiological analysis about the are relatively safer and do not require monitoring and neu- risk factors we genotyped 2,388 cases with a phlebitis with and tralization, the use of these drugs is associated with signi!cant 835 controls with same genetic background from Germany. The genetic contribution was assessed by estimating the as- bleeding. At the present time there is no antidote available to sociation with disease versus a likelihood approach as imple- neutralize these drugs. Most of the neutralization approaches mented in the PLINK software package. The statistical signi!- require intravenous administration of the antagonists with cance was assessed by means of a likelihood-ratio-test. Logistic complex pharmacokinetics. A rat tail transaction model is uti- regression analyzes was performed using PSPP software. lized to compare the bleeding potential of various newer oral Results. We observed gender as a risk factor for phlebitis. anticoagulants. The genotyping results showed a clear signi!cant association Methods. Dabigatran, rivaroxaban and apixaban were ob- pLRT < 0.05 by the marker F2, F5 and F11. F5 showed un- tained from commercial sources and were diluted in saline to der a multiple model a p-value after logistic regression analy- obtain a 100ug/ml working solutions. Male sprague dawley sis (LRA) (correction for Bonferroni and multiple testing) of rats (250-400g) were injected in individual groups (6-8) via 0.62x10-2 by an OR 1.53 (1.13-2.06). F2 dominant model; p- intravenous route with the newer oral anticoagulants in the value LRA=0.87x10-3; OR 2.39 (1.43-4.01) and F11 dominant 50-600 ug/kg. Saline treated animals served as controls. At the model; p-value LRA=0.39x10-3; OR 1.4 (1.16-1.69). More in- completion of bleeding studies, blood samples were drawn formation is available from the table 1. from each group of rats and analyzed for the ex vivo antico- Conclusions. We identi!ed a statistically signi!cant associ- agulant effects. ation for three genetic makers towards phlebitis. An additional Results. All of the newer oral anticoagulants produced a relationship was observed between a higher CEAP grade and dose dependent increase in the bleeding time. The ED50 for female sex and a phlebitis. By around 15 % of our patients the dabigatran was 25ug/mg, for rivaroxaban it was 40 ug/kg and identi!ed F11 genetic maker could be found. More histological apixaban 90ug/kg. Ex vivo analysis of blood from various experiments are warranted. groups of rats did not reveal any relationships between bleeding and circulating levels of these agents. Conclusions. These studies suggest that at relatively low Sulodexide Versus Low Molecular Weight Heparin dosages, the newer oral anticoagulants are capable of prolong- ing the bleeding times. Dabigatran appears to produce the for the Antithrombotic Prevention in Varicose Vein strongest effects. The rat tail bleeding model provides a useful Surgery tool in the study of bleeding with these drugs. T. Drazkiewicz 1, A. Undas 1, J. Sadowski 1, T. Wilkosz 2, J. Krzywon 3, M. Ciesla-Dul1 1Dept. of Cardiac, Vascular and Transplant Surgery, Krakow, Poland Effect of Long-Term LMWH on Post-Thrombotic 2The John Paul II Hospital, Krakow, Krakow, Poland 3Dept. of Cardiac, Vascular and Transplant Surgeru, Krakow, Poland Syndrome in Patients With Iliac/Non-Iliac Venous Thrombosis: A Sub-Analysis from the Home-LITE Aim. To keep lower limbs free from thrombotic compli- Study cations in patients undergoing varicose vein surgery with or R. Hull1, J. Liang1, T. Merali2 without Chronic Venous Insuf!ciency (CVI) and with or with- 1University of Calgary, Calgary, Alberta out a history of varicophlebitis. 2Drug Intelligence, Toronto, Ontario Methods. Patients with varicose veins were treated operatively and pharmacologically. They were divided into two main groups: Aim. 1. Patients with iliac deep vein thrombosis (DVT) have with CVI and with CVI and history of varicophlebitis. Patients a poor prognosis and high incidence of post-thrombotic syn- were evaluated by ultrasound (US) before and after surgery. drome (PTS). 2. Evaluate the effect of long term low molecular

54 INTERNATIONAL ANGIOLOGY October 2013 weight heparin (LMWH) versus usual care on development of the thrombus resulting into effrective thrombolysis and pres- PTS according to DVT location (iliac/non-iliac). ervation of anatomy and function of the deep veins. Methods. We performed retrospective analysis of the mul- Methods. Retrospective analysis of 243 CASES OF DVT, ticenter, randomized, controlled trial of long-term LMWH treated between March 2007 to March 2013 with Urokinase. (Tinzaparin) with usual care (tinzaparin plus warfarin for ≥12 150 males and 93 females between age of 18 to 80years with weeks at home) for patients with DVT (Home-LITE) (Ref: Hull symptoms from 1 week to 4 months. USG guided puncture of RD et al AM J Med. 2009;122(8):762-9). Data were extracted Popliteal or PTV was done. Sheath placed, and a Multihole from 480 out-patients with documented, acute, proximal DVT catherter advanced intrathrombus. Thrombolysis done us- on January, 2011. ing Urokinase 250000units/hr. with adjuvant heparin. Check Results. Patients with iliac DVT had an overall odds ratio for progress #uoroscopy 12 hourly and catheter repositioning. PTS (including ulcer data) of 0.53 (95% CI 0.33, 0.83; P=0.0079) Procedure terminated at complete resolution or at 9 million in favor of tinzaparin. Patients with non-iliac DVT had a similar unit infusion. Post procedure oral anticoagulant given to set odds ratio (0.79 [95% CI 0.67, 0.93], P=0.0046) to that reported INR at 2.50. in the overall Home-LITE population (0.76 [95% CI 0.66, 0.89], Results. Complete Resolution occurred in 206 Cases, re- P=0.0004 (including ulcer data), both in favor of tinzaparin. sulting in softening of leg, patency of veins and preservation Conclusions. Long-term low molecular weight heparin of the valves. Partial Resolution in 33 Cases in which common may be a suitable alternative for the prevention of PTS in iliac vein did not open up but a large collateral #ow through patients with iliac DVT who are unlikely to undergo invasive the internal iliac veins occurred. All these cases also had leg thrombolysis. softening and valve preservation. Re-thrombosis occurred in 2 Cases with persistence of leg edema. No Result:2 cases. Fol- low up, 5 YRS. Post Thrombotic Syndrome none, Secondary Comparative Analysis Approach for Transcatheter Varicose Veins : 02. Directed Thrombolysis and Trans-Dorasalis Pedis Conclusions. DVT is recognized by painful and tender Vein Thrombolysis in Treatment for Deep Venous edema of the entire leg, and tender iliac fossa. Vascular Ultra- sonography is diagnostic. Untreated DVT may result in pulmo- Thrombosis of Lower Limbs nary embolism, pulmonary hypertension or Post thrombotic W. Zhang, X. Han syndrome. In CATHETER DIRECTED THROMBOLYSIS a The 1st af#liated hospital of Zhengzhou University, Zhengzhou, Henan, Tissue Plasminogen activator (TPA).( Urokinase, r-tpa or strep- China tokinase) is directly Delivered intrathrombus And Most Effec- tive thrombolysis achieved by recanalisation veins, preserva- Aim. To investigate the feasibility and ef!cacy of transcathe- tion of valves and prevention of post thrombotic syndrome. ter directed thrombolysis (TDT) approach in treatment for deep venous thrombosis (DVT) of lower limbs and as compared with trans-dorsal pedis vein thrombolysis (TPVT) approach. Use of IntraVascular Ultrasound IVUS in Phlebology Methods. The clinical data of 437 patients with acute DVT (184 males and 253 females) at the age of (43±12) years (range J. Hovorka 19-76 years) from July 2008 to January 2012 in the First Af- Valley Ambulatory Surgery Center, LLC, McAllen, TX, USA !liated Hospital of Zhengzhou University were analyzed retrospectively. Patients in the group TDT received TDT were 293 Aim. 1. Demonstrate how IntraVascular UltraSound (IVUS) cases, 32 inferior vena cava !lters were implanted. Patients in can be safely used in a clinic or of!ce based setting. 2. Report the group TPVT received TPVT were 65 cases, 4 inferior vena independent case series documenting a high incidence of Ilio- cava !lters were implanted. Femoral-Caval Venous lesions. 3. Initiate a discussion to de- Results. The resolution time of thrombus in the group velop a UIP consensus de!nition of these lesions. TDT was shorter than that in the group TPVT (6 d versus 9 Methods. IVUS has been used in patients with high sus- d, P<0.05). The circumference difference of leg or upper leg picion of proximal out#ow obstruction from 2009 to present. before and after treatment in the TDT group was signi!cant- Clinical criteria included CEAP score 3 or higher in addition to ly greater than that in the TPVT group (P<0.05). The rate of either Raju grade 3 edema and/or orthostatic venous pain with venous patency was (65.2±15.4%) and preservation rate of a score of 5 or greater on Visual Acuity Scale (VAS). 2009 IVUS valvular function was (78.2±12.6%) in the group TDT, and was performed at the time of diagnostic venography and/or which was (63.8±16.3%) and (91.1±10.7%) in the group TPVT, on intention to treat. 2010 began performing IVUS through respectively. The differences of venous patency rate was not saphenous at time of ablation as well as at time of venography. statistically signi!cant (P>0.05) between two groups, but the In 2011 began performing IVUS at time of saphenous ablation prevervation rate of valvular function was signi!cant differ- with or without venography/#uoroscopy in cases suspicious ence (P<0.05). Hematomas in 3 cases and gross hematuria in for proximal obstruction. Chemophrophylaxis with Low Mo- 4 cases were observed, and displacement of inferior vena cava lecular Weight Heparin was used. Outcome Measurements are !lter occurred in 1 patient in the group TDT. The gums bleed or presence or absence of venous obstruction greater than 50%. gross hematuria in 5 cases were observed in the group TPVT. Independent Variables include primary disease or secondary Conclusions. Both TDT and TPVT can effectively relieve disease. As noted in the objective there is currently no consen- symptoms. TDT can shorten the course of disease, but it in- sus regarding the signs, symptoms, anatomy and syndromes creases functional damage of the deep vein valvular. described and studied. Preliminary Analyses continue to con- !rm a high incidence of venous obstruction by IVUS. Lack of consensus de!nitions complicates further statistical analysis. Results. Out of 171 patients in the series >90% have had Catheter Directed Thrombolysis in Lower Limb obvious iliac lesions >50% by area; the remaining were border- Deep Venous Thrombosis, Technique and Results line. Iliac venous lesions were documented in the primary as Over Last Decade. well as secondary (thrombotic) groups. 5 limbs in the throm- D. Dekiwadia botic group were unable to be recanalized. There was no mor- Dekiwadia institute of vascular sciences, Rajkot, India tality. Femoral Venous access had minimal morbidity with the routine use of an access closure device and industry standard Aim. Intra Thrombus catheter directed thrombolysis with lymphedema bandaging (ISLB). Great Saphenous Vein GSV Tissue plasminogen activator-Urokinasse directly infused in access without an access closure device was without morbid-

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 55 ity using “crossed tape” technique and ISLB. GSV access with construction. Level of !brinogen and D-dimer was determined IVUS and ablation was without morbidity. Presence of Infe- by semi-quantitative method. rior Vena Cava IVC webbing at the diaphragm, hepatic veins, Results. We often visualized echopozitive formation in the Iliac Vein Con#uence and in cases of signi!cant scoliosis is re- niches of the venous valves. This formation consisted of many ported. Learning curve to perform IVUS through GSV without heterogeneous spot insertions caused by stasis of blood elements #uoroscopy was 100 cases for this practitioner and turbulence of blood. We speci!ed this ultrasound phenome- Conclusions. routine examination from right atrium to ac- non as the phenomenon of “sludge”. We’ve de!ned three degrees cess site is suggested given that IVC lesions are present and of sludge depending on spreading of stasis of blood elements in may account for symptoms in those with borderline iliac le- valve sinus. In the group of patients with sludge of III degree sions. Technically clinic based IVUS is possible with or without the level of D-dimer was increased in 100% of cases (mean 2,5 #uoroscopy. It can be performed without mortality and without ± 0,87 mg / ml). The level of !brinogen was 4,18 ± 1,37 g / liter. signi!cant morbidity. Given that proximal obstruction is com- Sludge of III degree indicates thrombosis of valve sinus. mon in this subset we recommend that the International Union Conclusions. In our opinion, the most clinical value is the of Phlebology pursue a consensus de!nition of May-Thurner identi!cation of sludge of II degree during screening ultra- Syndrome, Iliac Vein Compression Syndrome, Non-thrombotic sound investigation, as the one of the earliest predictors of the Iliac Vein Lesions (NIVLs), Orthostatic Pain, Grading of Ede- venous thrombosis development. ma, De!nition of Inferior Vena Cava subsegments.

Frequency of Below-The-Knee Deep Vein Thrombo- Iliac Stenting in Patients with Iliofemoral Deep Ve- sis in Japanese Residents: Control Study for Resi- nous Thrombosis Treated with Catheter-Directed dents in the Area Without Earthquake Thrombolysis K. Hanzawa1, S. Matsuoka 2, H. takahashi 2, H. Takekawa 3, M. Tsuch- ida4, T. Nakajima5, M. Ikura5 N. Baekgaard1, P. Foegh 2, L. Jensen 2, M. Joergensen 2, S. Just 2, R. Bro- 1 holm2, L. Klitfod2 Niigata University, Niigata, Japan 2Yokohama City, Yokohama, Japan 1Gentofte University Hospital, Copenhagen, Copenhagen, Denmark, Den- 3Dokkyo University, Mibu, Japan mark 4Niigata University Graduate School of Medicine, Niigaat, Japan 2Denmark 5Niigata National Hospital, Kashiwazaki, Japan

Aim. The iliac compression syndrome is a predominant ob- Aim. We reported that below-the-knee deep vein thrombo- structive lesion visualized during the treatment with catheter- sis (BKDVT) increased after earthquake in Japan. The purpose directed thrombolysis in patients with iliofemoral DVT. Inser- of this study is to elucidate the frequency of BKDVT in Japa- tion of a Wall stent is mandatory. Is this procedure performed nese residents living in the area without earthquake. in a suf!cient number of patients to obtain durable results Methods. Subjected were residents in Sakae-ku (Yokoha- compared to the group of patients without need for a stent? ma city), Izumi-ku (Yokohama city), Mibu town (Tochigi pre- Methods. A total of 192 consecutive patients with mean age fecture), Hiroshima city and Shibata city (Niigata prefecture). 30 years (range 14-74 years) involving 50 males (mean age 36 We performed the screening of BKDVT from September 2011 years) and 142 females (mean age 28 years) were treated in- to March 2013 for !ve times. We collected these residents for volving 195 limbs in the period 1999-2012. Stenting was per- screening of BKDVT by public information, radio and news- formed in 108 limbs (55%) mostly left sided. The duration of paper. BKDVT was determined by compression ultrasound ex- treatment was in mean 2½ days followed with AC and com- amination at the sitting position. pression stockings class 2. The patients were followed yearly Results. The total number of residents underwent ultra- with ultrasound sonography demonstrating patency of the sound was 827 (64±13.4 year-old). The total number of resi- lysed vein segments including the stent area and demonstra- dents with BKDVT was 34 (4.0%). However, the total number tion of valve suf!ciency as the major endpoints. Mean follow of residents without any disease or any DVT risk at the screen- up was 52 months. ing was 673, and they included 17 BKDVT (2.5%). Results. According to a Kaplan-Meier plot the estimated Conclusions. The frequency of BKDVT in case of collect- percent of competent veins (patent veins with normal valves) ing Japanese residents without earthquake by public informa- was 90 % in the stented group and 82 % in the group without tion, radio, or newspaper may be 2.5 - 4.0% (low risk – high a stent (log rank test, p=0.09) after 7 years. risk). The present data may be higher than that in previous Conclusions. It seems that the routine use of stenting of reports due to selection bias. In Japan, “economy class syn- any obstructive lesion in the iliac vein segment is suf!cient drome” is well known. Since many residents with leg trouble, with a high grade of durability. such as edema, eruption or varicose vein came to screen. How- ever, evacuee after earthquake often had bruised leg or edema. Since the frequency of BKDVT in evacuee after East Japan Great Earthquake (10% - 47%) or Mid Niigata Prefecture Preventive Ultrasound Diagnostic of Deep Venous Earthquake (5.8% to 35 %) was much higher than the present Thrombosis data, the present study shows that BKDVT increase in evacuee I. Ignatyev after earthquake. Further study is needed to clarify the fre- Interregional Clinical and Diagnostic Center, Kazan, Russian Federation quency of BKDVT in the other country without earthquake.

Aim. Objectives. Creation of a noninvasive screening method for the preventive diagnosis of venous thrombosis. Methods. We included 249 patients (average age 42±7,2 Management of Non Varicose Super#cial Vein years) who were divided into 2 groups. The !rst group in- Thrombosis: Single-Centre Experience cluded 100 patients with varicose vein with any degrees of T. Sultanyan, A. Avetisyan, T. Kamalyan, L. Manukyan chronic venous insuf!ciency. We included 99 patients with Medical center after Vladimir Avagyan, Yerevan, Armenia acute venous thrombosis in the second group. The control group consisted of 50 healthy men. Patients were examined by Aim. Very little information is available about the occur- color duplex scanning with B-#ow and three-dimensional re- rence of non varicose super!cial vein thrombosis (NV-SVT) in

56 INTERNATIONAL ANGIOLOGY October 2013 the general population and its appropriate management. The Concerning the effect on leg edema there is a correlation aim of this study was to show our experience in management between compression pressure and volume reduction up to of patients with NV-SVT, to improve our understanding of pre- a resting pressure of about 50 mmHg while higher pressures disposing risk factors for NV-SVT, to assess concomitant and (between 70 and 100mmHg) show an inverse correlation and recurrent thromboembolic events (DVT, PE, recurrence of the seem to be counterproductive. In patients with postmastec- NV-SVT) tomy arm-lymphedema bandages applied with a pressure < 30 Methods. Over a 5 year period, from January 2008 to Janu- mmHg were more effective than those with a pressure of >50 ary 2013, 22 patients (19 males and 3 females; mean age 38 mmHg. Taking the pressure loss of bandages into considera- years) were diagnosed with NV-SVT of lower limbs (LL). All tion these !ndings are especially relevant for the optimal tim- NV-SVT involved great saphenous vein (GSV) with proximal ing of bandage changes. level of acute thrombosis located in the upper third of the Conclusions. Compression therapy is one of the last areas thigh. Crossectomy was performed in all cases. After an ini- in practical medicine where the dose of the treatment (= in- tial course of intermediate-dose LMWH therapy patients were terface pressure) is widely ignored, especially in clinical trials. anticoagulated with VKA (INR 1,5-2) for at least 6 months. In Measuring different effects of compression in patients with the follow-up patients were assessed clinically and with duplex chronic venous incompetence there is a signi!cant correlation ultrasound (DUS) at least once a year. Investigation for risk between compression pressure and improvement of venous factors and thrombophilia was also carried out. pumping function. Concerning edema reduction such a posi- Results. At the time of presentation 5 patients had a his- tive correlation cumulates in an “optimal pressure range” be- tory of NV-SVT of the contralateral LL con!rmed by DUS. 2 yond which higher pressures are counterproductive. patients had concomitant NV-SVT of the contralateral distal GSV. No signs of concurrent DVT were found. After discon- tinuing of oral anticoagulation 3 patients developed NV-SVT in the contralateral LL, 1 patient had symptomatic DVT of The Microvascular Ulcer femoropopliteal segment. 1 patient with malignant neopla- K. Boehler sia died of possible PE despite anticoagulation. The most Department of Dermatology, University of Vienna Medical School, AKH, frequent risk factors observed in our study were: inherited Vienna, Austria thrombophilia-10 patients (heterozygous mutations of factor V(Leiden), prothrombin G20210A, MTHFR and their combi- The microvascular ulcer, also known as Martorell hyper- nations), Buerger’s disease-2 patients, antiphospholipid syn- tensive, ischemic leg ulcer is an underdiagnosed clinical entity drome-2 patients, malignant neoplasia-2 patients, contracep- characterized by extremely painful ulcers located preferably on tive use-1 patient. the dorsolateral aspect of the lower leg. It was !rst described by Conclusions. We propose active management of NV-SVT, Fernandes Martorell in 1945. The initial lesion, an extremely including screening for risk factors, surgical high ligation of painful eschar, matches skin infarction. All patients are hyper- super!cial truncal veins and prolonged anticoagulation, in or- tensive, more than 50% report diabetes in addition. As ulcers der to prevent the extension of thrombus into the deep veins, develope even if hypertension is well controlled by antihyper- as well as prevent recurrent thromboembolic events. tensive treatment it seems that the active process cannot be stopped with antihypertensive treatment alone. Histology reveals hypertrophic, stenotic, subcutaneous arterioles, hyaline degeneration and medial calci!cation. Extensive calci!cations SOCIETY SESSION: of the dermal vascular plexus can be demonstrated by low er- AUSTRIAN SOCIETY OF PHLEBOLOGY ergy x-ray. It can be assumed that Martorell hypertensive ulcer represents the most peripheral type of atherosclerosis. Periph- Dose Finding in Compression Therapy eral vascular occlusive disease or mediasclerosis might coexist H. Partsch but are not pathognomonic for Martorell hypertensive ulcer. Emeritus Professor of Dermatology, Medical University Vienna, Austria Several diseases raise considerable dif!culty in differential diagnosis: clinically Martorell’s ulcer resembles Calciphylaxis but Aim. To present data of some experimental studies in which renal and parathyroid function are normal. In addition due to different compression effects on venous parameters and on a strikingly in#ammatory wound border Martorell’s microvas- edema were related to the compression pressure (= dose of cular ulcer is frequently confused with pyoderma gangraeno- compression). sum or vasculitis. This can be deleterious, since management Methods. The interface pressure was measured by #at air- of these diseases requires steroid treatment which increases !lled pressure probes (Picopress®) allowing continuous and the risk of potentially fatal septicemia or amputation. Due repeated measurements under several compression devices, to increasing life expectancy and improved survival rates of mainly compression stockings and inelastic bandages. Venous patients with cardiovascular risk factors wound care centers parameters which were measured included leg MRI in lying will be more frequently confronted with microvascular ulcers. and standing position, venous re#ux (Duplex and air plethys- If Martorell’s ulcer is suspected we suggest a large and deep mography) and venous pumping function (phlebodynamom- enough biopsy to be taken from the healthy looking border etry, foot volumetry, strain gauge plethysmography). Extrem- leading into the wound as punch biopsies have been shown ity volumes were measured by water displacement volumetry. to inadequately re#ect micromorphologic characteristics of Results. Low compression pressure (<20 mmHg) reduces the disease process. In the vast majority of cases conservative the venous diameter in the lying position. Much higher pres- treatment will fail to heal the wounds. Lazareth et al were the sure is necessary to narrow leg veins in the upright position. !rst to point out the bene!cial effect of necrosectomy and skin A signi!cant reduction of ambulatory venous hypertension is grafting for the treatment of microvascular ulcers. Hafner et achieved by using inelastic compression in a pressure range al outlined re!ned treatment protocols in a large series of pa- of > 50 mmHg in standing, while elastic stockings are less tients which demonstrated that skin grafting done in addition effective. Applied with comparable pressure ranges inelastic to resection of necrotic tissue not only promotes healing but bandages are signi!cantly more effective in reducing venous also dramatically reduces pain. More recent reports stating re#ux. There is a signi!cant correlation between the compres- that intravenous use of sodium thiosulfat dissolves precipi- sion pressures (and of stiffness) with the ejection fraction of tated calcium in vessels and tissue of uremic and non-uremic the calf pump. forms of calciphylaxis might open new treatment options.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 57 SOCIETY SESSION: preventive measures for the prevention of DVT, such as antico- CANADIAN SOCIETY OF PHLEBOLOGY agulation and/or compression therapy in case of longer lasting immobility or after operative procedures. Uncommon Venous Lesions M. Zummo Centre de phlébologie, Montréal, Canada Super#cial Vein Thrombosis (SVT) as a Complica- In 30 years of phlebology practice, one encounters venous tion of Sclerotherapy problems that are unusual and challenging. Those are for the F.X. Breu most part congenital angiodysplasias that will progress in se- Private Practice, Tegernsee, Germany verity during the patient’s life span. Two cases will be presented. Both have capillary malforma- The aim of sclerotherapy is to destroy the entire wall of the tions and telangiectasias. They probably have some degree of vein leading to a transformation of the vessel into a !brous arterio-venous malformations. Both pathologies have been cord. From histological studies we know that this so called identi!ed has being a Klippel-Trénaunay syndrome. Both pa- chemical ablation is not possible completely without any tients have seen the appearance of their venous anomalies in thrombus (“sclerothrombus”). Even the strongest compres- their pre-teen years. They have noticed an increase in size of sion cannot prevent a thrombus formation due to the impos- their venous problems during their pregnancies, one single sibility of attaining a permanently “empty vein”. The sclero- and the other multiple, one with no return to her pre-preg- therapeutic reaction is limited in space and time of an induced nancy state after delivery. in#ammation which is a reaction of the denaturation of the One of the cases has been treated in her childhood and early vein wall components with an obstruction and shrinking of teen years with I.V. alcohol with partial resolution of the le- the varicose vein. sion. Most had recurred later. The other had not been treated We have to separate a sclerotherapeutic thrombosis, which prior to her consultation at our clinic. In both cases, ultra- is not avoidable and part of the therapeutic reaction, from the sound guided sclerotherapy with foamed sodium tetradecyl thromboembolic complication with its known sequelae, like sulfate failed to obliterate the lesions. Pelvic involvement was migration of the thrombus. suspected and the patients were both referred to our consult- The lack of this discrimination seems to be the main reason ing interventionist radiologist for his opinion. He proceeded for the wide range of the incidence of SVT in the international with the treatment of the pelvic venous anomalies. literature on sclerotherapy (from 0% up to 46% with a mean We will !rst present our diagnostic approach. The medica- of 4, 7%). The authors with a high rate of SVT or super!cial tion used and all the therapeutic options that have been and phlebitis seem to summarize many “successful” reactions in can be used will also be discussed. the list of complications. Authors with a very low rate of SVT assess any “sclerothrombus” irrespective of reddening and pain in the treated area, as a successful treatment. Neverthe- less there is a common rate of this complication in our and SOCIETY SESSION: some other studies of approximately 5%. GERMAN SOCIETY OF PHLEBOLOGY The risk factors for SVT in sclerotherapy are similar to those of deep vein thrombosis (DVT), additionally in#uenced by the used volume and concentration of the sclerosant. The Risk Factors for SVT role of compression therapy after sclerotherapy in order to M. Stücker, M. Doerler avoid this complication is still discussed controversially. The Vein Center, Departments of Dermatology and Vascular Surgery, Ruhr- application of Heparin (LMWH) or Fondaparinux is indicated University Bochum, Bochum, Germany according to the guidelines. LMWH-or Fondaparinux-prophylaxis in sclerotherapy is indicated in high risk patients for DVT Aim. Super!cial venous thrombosis (SVT) frequently and SVT equally. progresses to deep venous thrombosis (DVT) with the risk of A special entity of phlebitis is the delayed form after 4 weeks pulmonary embolism. Therefore, early identi!cation and – if after therapy, which has a self-limitation of approximately one possible – elimination of risk factors for SVT are essential. week under compression. Another fortunately rare entity of Methods. We performed a retrospective PubMed-based complication in sclerotherapy is the undesired extension and data analysis of known risk factors for SVT. migration of the sclerothrombus into the deep venous system Results. One can discriminate iatrogenic from non iatro- via the junctions or perforators, which ful!lls the de!nition genic SVTs. In iatrogenic SVTs acute in#ammation of the vein of a dangerous, maybe life threatening thromboembolic situ- wall due to mechanic or chemical irritation and the in#ux of ation, which needs full therapeutic anticoagulation for a lim- bacteria could be demonstrated. It remains unclear why SVT ited duration of time. may present without any clinical signs of in#ammation on the one hand and show severe clinical signs of in#ammation on the other hand. The risk factors for SVT resemble those of chronic venous SOCIETY SESSION: insuf!ciency. Women are more frequently affected (55-70% of LATIN AMERICAN VENOUS FORUM SVT patients). The median age is about 60 years. Obesity is present in 20% of the patients. Other risk factors include pregnancy, oral contraception, hormone replacement therapy, hy- Tactical Options in Laser Ablation in the Perforator percoagulability, cancer and a history of venous thromboem- Veins bolisms. More than 80% of the patients suffer from varicose O. Bottini, O. Gural Romero, M. Morales, J. Bercovich, R. La Mura veins. Acute triggers for SVT are long-distance #ights, long- Clinicas Hospital, José de San Martín, Buenos Aires, Argentina lasting immobility, recently performed operative procedures and injuries. Aim. Controversies exist about the participation of the per- Conclusions. Due to these risk factors the following pre- forator veins in the development of venous disease. Ablation ventive measures are particularly useful: a) therapy of varicose of longitudinal re#ux (GSV,SSV) reduce diameter and increase veins, especially of varicose veins with a preceding SVT, and b) valvular continence in perforator veins, in primary classes of

58 INTERNATIONAL ANGIOLOGY October 2013 CEAP classi!cation (C2 to C4). However, we have seen lipoder- Conclusions. Great vessels sclerotherapy is a positive matosclerosis and ulcer with exclusive insuf!ciency of perfo- method in 85% of the cases, is ambulatory, low cost and mini- rator veins. We have developed a technique called Echoassist- mal risk. ed Perforating Vein Laser Ablation (EPLA). Methods. Preliminary and prospective study from Decem- ber 2004 to September 2007 with a 5 years follow up, sample of 134 patients, 16 men with a mean age of 57 and 118 women Complications of Foam Sclerotherapy in the Treat- with a mean age of 48, distributed in C CEAP Classi!cation: ment of Great Saphenous Vein - Incidence DVT. C2: 52, C3: 32, C4: 28, C5: 16, C6: 6. We treated 302 insuf!- M. Avramovic cient perforators mainly in the inner side of the leg. We made echoassisted marking to set location, diameter and re#ux of Centro Flebología Avramovic, Buenos Aires, Argentina the perforator veins with measurements of security margins. (Margin 1: distance skin - aponeurotic hole. Margin 2: distance This presentations aim is to analyze the complications of aponeurotic hole - deep vessels). We used a Diode Laser of 980 foam sclerotherapy and compare with the treatment with scle- and 810 nm of wave length, with optical !bers of 400-600 mi- rosing liquid. crons, continous mode, 30-140 joules/cm.. Echoassisted pro- We performed a retrospective study of 958 medical records cedure with tumescent anesthesia. The echographic follow up of patients, treated with foam, from 2004-2012. The outcomes at 1st . week, 1 st , 3 rd , 6 th . month and 1 st , 2 nd ,3 rd , 4 th and 5 th year. were compared with another retrospective study that involved Repermeabilized perforators before the 1st week were consid- 1020 patients treated with liquid. ered persistent and recurrence after the 1st month. All patients were treated with 1% to 3% of Polidocanol Results. Aesthetic and symptomatic improvement. Ulcer foam, depending on the vessel caliber. The Tessari Method was healing in treated cases. Early occupational and social rein- used. A maximum of 6 cm 3 was injected per session. The same sertion. Persistence of 7 perforators after the procedure. Re- typical complications were observed between both treatments; currence of 15 perorators before the 6th . month ( occlusion but in the case of foam there were more super!cial throm- of 93%). No general complications. Other complications were bophlebitis (6,99%) and deep vein thrombosis (0,21%) than in assigned to combined treatments: erythema and local indura- the patients treated with sclerosing liquid. tion in 21 patients, pain in 9, paresthesia in 3, haematoma in We observed 67 cases of super!cial thrombophlebitis with 17, periphlebitis in 2, lymphorrhagia in 2, skin blisters in 2 foam and 32 cases with liquid. This cases were handled using cases. No evidence of infection, skin necrosis or deep venous NSAIDs, heparin gel or clot removal. Two cases of DVT were thrombosis. observed when using foam: one in Intergemellar vein and one Conclusion. Though today we prefer using 1470 laser, with in the Common Femoral vein. This cases were handled with radial !ber and 30 joules average in perforators of large ca- anticoagulant therapy. There were no cases of DVT with the liber, EPLA is a minimally invasive therapeutic option that use of the liquid. requires a learning curve, clear instructions, showing its ef- Conclusions. Foam therapy increases the risk of DVT, com- !ciency after a follow up of a year with the mentioned Results. pared with conventional treatments, requiring more Venous Doppler ultrasound control after sclerotherapy.

SOCIETY SESSION: Therapeutics Re#nement in Microsclerotherapy SOCIEDAD ARGENTINA D.G. Balboni DE FLEBOLOGIA Y LINFOLOGIA Private Practice, Buenos Aires, Argentina

Advantages and Disadvantages of Foam Sclerother- From the beginning we have to know what kind of te- apy in the Treatment of Great Saphenous Vein langiectasias are we treating, because there are many types A. Avramovic that do not respond to microsclerotherapy or the outcome is Centro Flebología Avramovic, Buenos Aires, Argentina insuf!cient and therefore we must recognized the different anatomical patterns. The aim of this presentation is to list the pros and cons of The acknowledgment of different types of anatomic units the GSV and great tributaries treatment with foam. A retro- give us the recognition of what kind of connections they have spective study was performed; this involved 958 patients treat- and if they are associated with the most important cause of ed with foam from 2004 to 2012. The outcome of this study failure, the hyper#ux. was compared with another study in which 1020 patients were So, the therapeutical shortfalls are due to horizontal hyper- treated with sclerosing liquid (3% Polidocanol) between 1994- #uxes of an insuf!cient perforant as we see many times or in 2003. the vertical hyper#uxes due to great saphenous vein insuf!- All patients were injected with 1% to 3% of Polidocanol ciency. That´s frecuently the reasons of the failures. foam. Tessari Method was used. Concentration was increased Something similar happens in feet, the presence of tel- in proportion to the vascular caliber. angiectasias below and forward of the tibial malleolus tell us The 80% of patients required two sessions per each large of the insuf!ency of the greater saphenous vein or behind the vein caliber. malleolus the insuf!ciency of Cockets veins. Both reasons of We found that the advantages were: 1) positive outcome in failure if we can´t solve the hyper#ux. 2 sessions, 2) 30% more effective vs sclerosing liquid, 3) less A different condition is the presence of hormone agents. concentration and volume are needed, 4) lower recurrence The hormone stimulation because of high estrogen levels and rate in 3 years, 5) anesthesia is not required and 6) low cost the presence of estrogenic receptors produces the develop- and ambulatory method, being this last one an important is- ment of telangiectasias and the result more known is almost sue in South America. always the failure of the sclerotherapy and also the frequent The disadvantages were: 1) speci!c training is required, matting that appears after this treatments. 2) venous doppler ultrasound is needed, 3) limitation in the We know that all telangiectasias are of venous origin, there standarization of the method, 4) dif!culty in air sterilization, are some that are thin, have red brilliant colours, and with 5) higher rate of super!cial thrombophlebitis and deep vein an hyper#ow are called arterial telangiectasias. With sclero- thrombosis and 6) recanalization in 15% of cases. therapy their behavior is the relapse and the neoangiogenesis

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 59 can occur. Instead the blue ones respond successfully with this bination with enhanced technical safety making this an effec- treatment. tive, straightforward method with truly positive Results. Foam The most common causes of neoangiogenesis are the scle- sclerotherapy has provided several advantages to traditional rotherapy because of excessive in#ammation, the in#uence of sclerosing treatment: overweight and the estrogenic therapy. Angiogenesis depends — Lower sclerosing agent concentration. on in#ammation degree and to the extension of the thrombus, — Smaller amount of sclerosing agent. having as a result the release of angiogenics factors. — Greater contact time and larger contact surface area of And !nally in microsclerotherapy …………primum non the sclerosant and the vein endothelium. nocere — Fewer treatment sessions. — Increased treatment success rate. Brief general history Surgical Treatment Bene#ts of USF Insuf#cient in 1944 - Orbach: introduction of air prior to the injection of Laser Ablasion the GVS sclerosing agent - “air block” J.C. Krapp 1950 - Orbach: air block increases sclerotherapy success Service Phlebology and Lymphology, Central Military Hospital, Buenos rate by 10%. Aires, Argentina 1970 - 1980 – Martínez Lacabe (Argentina) employs sclerosing solution bubbles with detergent properties. The main objective of minimally invasive surgery is to 1993 - Cabrera Garrido (Spain) injection of physiological eliminate pathologic re#ux USF giving rise to varicose veins gas (CO2) in sclerosing agent solution. in a safe form, complete and !nal, with as little pain as possi- 1995: Monfreux (France) foam production using a glass sy- ble and that does not cause collateral damage. The procedure ringe and a sterile plug. should be functional and aesthetically improve the previous 1999: García Mingo (Spain) venous sclerosis with foam, de- state and be as ef!cient as possible, to minimize the variceal vice for generating therapeutic microfoam with Helium. recurrence. 1999-2000: Tessari (Italy) foam production with two syring- The systematized currently thermal ablation, either with es connected by a three-way stopcock. laser or RF, which ablates the saphenous conduit below the 2000: Frullini y Cavezzi (Italy) foam sclerosant in duplex- super!cial epigastric vein, has basically a large defect, leaving guided sclerotherapy. a stump of long saphenous vein, which has been described by 2000: Auad – Rosli – Tkach (Argentina) many authors as major fault causing recurrences postsurgi- Aneurisma of Saphenous Junction cal varicose followed by neovascularization, which develops mainly by individual factors, already described as vascular en- Techniques dothelial growth factor (VEGF) and other yet unknown, that Preparation of foam in TESSARI technique are present in the wall of primary and recurrent varicose veins. Two syringes and a three-way tap. The treatment we propose is a combination technique is Intravenous access via a Butter#y catheter approximately performed in two steps: the !rst is access to USF, through a 15cm. from the venous aneurysm. small incision of 2 cm, suprainguinal area, which allows ex- Leg elevated at a 45 degree angle. amination of USF and its tributaries. The saphenous femoral 15 cc. of Polidocanol 4% (Aetoxysklerol Kreussler Pharma) junction has great anatomical variability (double saphenous foam was applied or H and tributaries vein that can bind directly to the femo- A photo sequence of the patient showing the technique ap- ral or saphenous vein doubles, mainly AASV, the external pu- plied and results is presented. dendal vein and circum#ex vein). These are the main cause of recurrence on the groin to progression of the disease. Second step is effected saphenous duct ligation #ush with the USF when there terminal valve insuf!ciency and / or preterminal Laser Ablation and then performs laser thermal ablation of saphenous con- V. Spano, D. Carraro, J. Plaquin, A. Conde duit until the middle third of the calf, for avoid saphenous Phlebolinphology Service - Favaloro Foundation, Buenos Aires, Argen- nerve injury (paresthesia). tina Conclusions. Maintaining the bene!ts of a speedy recovery because injuries are minimal, as it is done the USF treatment, Aim. To provide security in the use of endoluminal laser for without making stripping, with minimal pain, with lower rates the treatment of super!cial venous insuf!ciency in order to of recurrent varicose to eliminate all possibilities of new re- decrease the production of complications. To obtain clinical currences from the disease progression and / or new tributary echo graphical parameters and the method of standardization. veins originated ebbs. There is no possibility of recanalization We believed the necessity not only of the systematization of saphenous conduit, maintaining a téchnique minimally in- but also of the standardization of methods to try to reduce vasive, safe about collateral damage as DVT or PE by Heit, complications. fewer recurrences for recanalization of saphenous veins and Methods. On using endoluminal laser technique, regard- progression of preexisting tributaries vein untreated, quick less of crossectomy, 147 insuf!cient saphenous conducts (os- and aesthetic recovery of the patient, with minimum post- tial incompetence in 2 seconds and re#ows ducts), and 112 of treatment pain. them were saphenous veins and Parvas 35 saphenous veins. Abstract: 2 methods comparing of the miter treatment: Method A: 30 seconds continuous laser shoots separated by 10 seconds break intervals. Sclerotherapy of Saphenous Junction Method B: 40 seconds continuous laser shoots separated by N.A. Rosli 40 seconds break intervals. Centro de Flebología Never Rosli, Córdoba, Argentina In both cases, laser shoots and breaks were repeated up to the “sign of investment bubbles” (S. I. S. BUR.) appeared. The transformation of the sclerosant into foam restricts its From that sign on distal duct treatment was done #uidity, therefore avoiding it from dispersing to unwanted ar- Echo Doppler color follow-up was made on 7, 30, 90 and eas and considerably increasing the sclerosing effect in com- 180 days.

60 INTERNATIONAL ANGIOLOGY October 2013 Results. 147 saphenous conduits were treated from 12 / and radical crossectomy of the great saphenous vein (GSV), to 2008 to 9 / 2011. 112 saphenous veins and 35 Parvas saphen- verify the importance of the collateral veins of S-F junction in ous veins. In 19 cases, the saphenous duct diameter was great- groin recurrences. er than 10 mm for saphenous veins in its entirety. The classic surgery of super!cial venous system has had With the method A, 4 laser shoots required to get SISBUR. many improvements, so the “traditional” idea of radical cros- With method, about 40% of the veins with diameter smaller sectomy (Babcock, 1907) has been won by the “new” selective than 10 mm were closed with two shoots and no and no one technique, which may be executed on traditional way or by the requires more than 3. new endovascular techniques. Conclusions. Knowing the patient’s path physiology, the Methods. Non-concurrent prospective study, the selected same positive results can be obtained using less supplied total casuistry concerns in 300 patients (220 F - 80 M, mean aged energy. 54 years, range 25-77), CEAP 2-S/3 Ep As(2/3) Pr, operated from January 2002 to December 2006, choosed with random method, divided in two groups (150 treated by selective crossectomy and 150 by radical crossectomy), 60 patients for every SOCIETY SESSION: year was considered. ITALIAN COLLEGE OF PHLEBOLOGY All the patients were operated of crossectomy by an unique surgeon for each group, in day-surgery and local anaesthesia. S-F. Junction: Haemodynamic models and Thera- All these patients were submitted to clinical venous examina- peutical Approach tion and to Duplex scanning of the lower limbs, by an independent operator, at different times from the operation (the L. Tessari follow-up is from 5 years for the patients operated in 2002 to 1 Tessari Studi, 37019 Peschiera del Garda (VR), Italy years for the patients operated in 2006). Results. On 300 patients controlled with Duplex has been The echo-color-Doppler allowed the phlebology world to get seen in the group of selective crossectomy 1 groin recurrence a deeper insight into the complex hemodynamic model of the (0,6%), in the group of radical crossectomy 14 groin recur- sapheno-femoral con#uence. rences (9,3%). In this setting, it was noted how different hemodynamic Conclusions. Based on the clinic experience done on ex- maneuvers are based on different hemodynamic principles: amined 300 patients, we can observe like the internal selective Valsalva on hyperpressure gradients, compression/relaxation crossectomy, saving the tributary veins coming from the ab- and other dynamic tests on the gravitational gradient. dominal wall, joint to the convenient treatment of saphenous A dissociation of the two tests outcomes can be explained insuf!ciency, revealed an ef!cacious therapy, giving results of by the above consideration: a valve can present a positive Val- undoubtable validity from the point of view prognostic and the salva and a negative compression/relaxation maneuver. rate of groin recurrences at 5 years. This kind of dissociation indicates higher chances of recovery in case of proper hemodynamic restoration. The vein caliber reduction following the tributary branch disconnection is the aim of such restoration and, at the same time, the basis for a further valvular recovery. What’s New in S-F Junction Valvuloplasty? In literature, it has been reported how 1294 incontinent S. Camilli sapheno-femoral con#uences actually presented a dissociated Private Surgery, Rome, Italy terminal valve in 45% of cases: in almost the half of the patient population a sapheno-femoral con#uence is avoidable. In the post-thrombotic syndrome (PTS) with secondary The beginning of this millennium has seen a huge expansion varicose veins (SVVs), the ablative strategy has commonly ap- in endovascular obliteration techniques (endovascular ELTV plied to SVVs and the greater saphenous vein (GSV). A new Laser, Radiofrequency VNUS Closure, Foam sclerosing trans approach is being proposed: the S-F junction valve repair to catheter, long or short CEST.). All these techniques can not treat preserve the GSV as a main vicarious draining conduit in PTS the sapheno-femoral con#uence and are therefore exposed to a with SVVs at early stage by the stretching valvuloplasty (StV) high recurrence risk, exactly as we have seen with surgery. technique. Considering the literature, we can assume that 45% of Aim. The patient suffering PTS may have had thrombophilia varicose patients with continent terminal valve and saphen- or trauma but he generally has no genetic hormonal or tissue ous truncal re#ux may be effectively treated by endovascular anomalies, like the varicose patient has; however he invariably techniques without any need of intervention on the sapheno- develops SVVs along the time. This is due to deep venous out- gfemoral con#uence. #ow impairment and hypertension which overload the super- In my opinion, concerning this re#ux pattern treatment, be- !cial system. This plays a vicarious function but, being over- fore choosing which endovascular technique is to be used, the loaded, it develops a progressive dilatation that leads, sooner operator must ask himself: “CUI PRODEST?” or later, to GSV incompetence and re#ux. Thus SVVs appear and a progressive decrease of the vicarious effect occurs. Methods. In case of SFJ incompetent valve with US-visible and mobile cusps, an oval shaped external support (OSES) is Selective vs . Radical Crossectomy of the Great permanently implanted around the valve to be repaired and Saphenous Vein in Primary Venous Insuf#ciency: is sutured onto the opposite inter-commissural walls in cor- Results at 5 Years. respondence of the opposite inter-commissural apices. Being F. Mariani 1,2, M. Bucalossi1,2, St. Mancini1,3 elastic and oversized against actual valve diameter, the device then exerts a stretching action. In so doing it extends the in- 1The Compression Therapy study Group (CTG), Colle Val d’Elsa, Siena, Italy ter-commissural diameter and consequently reduces the valve 2Valdisieve Clinic, Pontassieve, Firenze, Italy cusps loosening; so it restores the SFJ valve competence thus 3Department of General Surgery, Siena University, Siena, Italy regaining the GSV vicarious function. Among a cumulative personal experience of 41 SFJ-StV op- Aim. The aim of the study is to keep again the incidence erations, two patients with SVVs in PTS underwent the inter- of groin recurrences at 5 years follow-up, on two groups of vention. Both patients resulted in a regained SFJ valve compe- patients operated with a technique of selective crossectomy tence at the 16-20 mo. f-u.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 61 Conclusions. The SFJ-StV technique is safe, simple and SOCIETY SESSION: quick to doing; it is able to repair SFJ valves on the strict pre- AUSTRALIAN COLLEGE OF PHLEBOLOGY - condition they have US-visible and mobile cusps. The correct FRONTIERS IN PHLEBOLOGY RESEARCH planning and stitching onto the opposite inter-commissural apices are crucial points that affect the results. Combined interventions are commonly justi!ed to reduce venous obstacle Chronic Cerebrospinal Venous Insuf#ciency (CC- (by iliac vein clearance and stenting), venous re#ux (by discon- SVI), Multiple Sclerosis and the Role of Chlamydia nection of escape points), varicose private circulation volume Pneumoniae (by sclerosis and/or phlebectomy). At present, the SFJ-StV in- P. K. Thibault tervention is a bare proposal in PTS with SVVs at early stage; CCSVI Diagnostic Centre, Newcastle, Australia anyway we must consider that it doesn’t lose any therapeutical chance for the patient nor phlebologist. The overall strategy to The probability of a venous aetiology of MS remains strong be adopted and the obtainable bene!t are yet to be de!ned by based on evidence accumulated from the time the disorder clinical trial. was !rst described. Paolo Zamboni has proposed the concept of CCSVI where cerebral venous re#ux results from valvular obstructions probably created by congenital malformations. There is now suf!cient evidence to conclude that this mecha- Femoral Re"ux and Obstruction: Surgical, Endovas- nism is unlikely. cular and High Technology Approaches Epidemiological and geographical !ndings of prevalence of O. Maleti, M. Lugli MS indicate the involvement of an infective agent. A number Vascular Surgery, Hesperia Hospital, Modena, Italy of agents have been suggested but the respiratory pathogen Chlamydophila pneumonia (Cpn), has the most convincing Femoral re#ux means a re#ux from groin to popliteal vein evidence from a spectrum of medical disciplines. This over- that can be segmental or axial. In the axial re#ux the re#ux view of the venous pathology associated with MS proposes is extended from the iliac vein to calf. Femoral re#ux can be that the pathogenesis MS is initiated by Cpn, which causes a associated with proximal obstruction usually at common iliac speci!c chronic persistent venulitis affecting the cerebrospinal vein level. The associations of femoral re#ux and obstruction venous system. Secondary spread of the agent would initially can be primary (May Thurner syndrome associated with pri- be via the lymphatic system through infected lymphocytes and mary deep venous insuf!ciency) or secondary (PTS). monocytes to speci!cally involve the azygos, internal jugular Post thrombotic syndrome is the principal cause of chronic and vertebral veins. venous insuf!ciency and presents two principal hemodynamic The theory proposes mechanisms by which an infective alterations correlated to endoluminal and parietal !brosis. phlebitis could result in the speci!c neural damage, metabolic, The !brosis secondary to deep venous thrombosis provokes immunological and venous obstructions observed in MS. a destruction of the valves and creates an obstacle to normal The pathogenesis described provides a framework for fur- #ow. The re#ux and obstructed #ow are two elements that var- ther research into a venous aetiology for CCSVI and MS and iously correlated at different levels, are able to create various opens the pathway for alternative therapies. magnitude of post thrombotic syndrome. Usually the obstructive lesions are represented at ilio-caval and common femoral level, while re#ux represents the main element at the femoro- popliteal segment. Endoluminal techniques are mainly employed to restore The New Oral Anticoagulants - What is Safe? patency at ilio-caval level while open surgery is mainly em- J.P. Fletcher ployed to restore valve malfunction in the femoro-popliteal University of Sydney Department of Surgery, Westmead Hospital, Sydney, segment. The crucial meeting point between this districts is Australia the common femoral vein where frequently the restoration of patency and valve repair have to be applied in association. The Thrombosis initiates clinical events leading to most obstruction of femoral segment are usually well tolerated due deaths. Anticoagulants provide substantial bene!t in throm- to collateral pathways, conversely if common femoral vein is botic conditions, but the therapeutic window is narrow with occupied by signi!cant !brosis an endophlebectomy at this bleeding the commonest adverse outcome of anticoagulant level can improve considerably the leg’s conditions. therapy. There has been recent intensive activity towards the Endophlebectomy can be associated with proximal stenting development of new anticoagulants and several agents have or less frequently with distal stenting. been investigated in phase III clinical trials with demonstrat- When proximal patency is ensured and the re#ux is the ed therapeutic bene!t compared to low molecular weight principal cause of PTS symptoms, our purpose is to reduce heparin (LMWH) and warfarin. Dabigatran has equal ef!cacy deep re#ux. for the prevention and treatment of venous thromboembo- The techniques usually employed to correct these defects lism (VTE) and superior ef!cacy in stroke prevention in atrial are: !brillation (AF). Rivaroxaban has greater or equal ef!cacy in — Kistner valvuloplasty in primary disease, VTE prevention and treatment with equal ef!cacy for stroke — Vein transposition, transplantation and neovalve in sec- prevention in AF. Apixaban has equal ef!cacy in VTE preven- ondary disease. tion and superiority for stroke prevention in AF. Dabigatran, For planning a surgical strategy, an accurate diagnostic pro- rivaroxaban and apixaban are PBS listed for VTE prevention tocol based on duplex, pletismography, venography and IVUS following total knee or total hip replacement and rivaroxaban should be performed. is listed for treatment of symptomatic deep vein thrombosis Proximal obstruction must be treated !rst, given that al- and prevention of recurrent VTE. Indications for converting most half of the patients can improve considerably without from warfarin include patients unable to maintain a con- any additional procedure to correct re#ux. Residual symptoms sistent INR of 2-3 for 60-70% of the time; patients unable to or the worsening of them after proximal stenting require the undergo routine INR monitoring, and warfarin intolerance. correction of the re#ux. Endoluminal devices for correcting Successful use of anticoagulants requires careful patient se- the re#ux creating an antire#ux mechanism are subject to on- lection with monitoring to minimise the risk of thrombosis going research. and bleeding.

62 INTERNATIONAL ANGIOLOGY October 2013 CONTROVERSY OF THE DAY thrombosis involving at least the common femoral vein were included. They were followed-up with clinical examination Controversy of the Day: Both Theoretical Concerns and duplex ultrasound for a minimum of 5 years. Patients with and Clinical Evidence Support a Hemodynamic Ap- shorter follow-up, thrombolysis, previous history of thrombosis or chronic venous disease, peripheral arterial disease, vas- proach to Super#cial Venous Re"ux cular interventions were excluded. The CEAP classi!cation M. Cappelli and the VCSS were used to monitor the status of the lower Phlebology Private Of#ce, Florence, Italy limbs. Results. There were 214 patients of whom 165 were ex- The hemodynamic approach to the super!cial venous re#ux cluded leaving 49 patients (52 limbs) for analysis. The median is based on a conservative treatment of the saphenous trunk follow up was 71 months, range 60-107. Thrombosis in one and its major tributaries. vein segment was found in 9 patients and multi-segmental Why to preserve a re#uxing saphenous trunk ? involvement in 40, with the former having very good clini- For two main reasons: cal outcome. Only patients with multi-segmental deep vein 1°) The saphenous trunk, even if incompetent, can be used thrombosis (DVT) developed skin damage (25%) or venous for arterial by-passes, as a !rst or second choice. claudication (17%). This group fared the worst when com- This is the common experience of “arterial” vascular sur- pared to 3 other groups: isolated DVT, historical controls with geons and cardiovascular surgeons. Indeed, in France there is DVT below the common femoral vein and the contralateral a biomedical !rm (Bioprotec) that gathers stripped saphenous limb (p<0.001 for all comparisons). Recurrent ipsilateral DVT veins and sells them for by-pass use. occurred 8 times (16.3%) and was associated with clinical de- 2°) The treatment of primary varicose veins, preserving terioration (p<0.01). There were 167 affected vein segments of the saphenous trunk, leads to a reduction of recurrences over which 56 were fully recanalized, 78 partially and 33 remained time, as demonstrated by published RCTs. occluded. Patients with re#ux and obstruction had the worst Furthermore, the role of the saphenous trunk, even if in- outcome compared to those with re#ux or obstruction (p<0.01 competent, as a main path of the super!cial out#ow can be for both). demonstrated with the B-FLOW. Conclusions. Patients with multi-segmental iliofemoral On the contrary, the removal of a re#uxing saphenous trunk thrombosis treated with anticoagulation have poor long term provides the condition for: outcome. Ipsilateral recurrent DVT and the presence of com- Perforator veins dilation, as an expression of the activation bined re#ux and obstruction are important contributors for of the trans-fascial spare system the clinical deterioration. Appearance of recurrences without escape points that are not detectable after a conservative treatment How to preserve the saphenous trunk to obtain a system as stable as possible over time ? Direct Computed Tomography Venogram in the Di- It doesn’t just suf!ce to preserve a saphenous trunk to stabi- agnosis of May-Thurner Syndrome lize the system, we have to preserve it as a draining saphenous C. Hayes trunk as demonstrated by CHIVA procedures. The retrograde #ow in the saphenous vein after CHIVA, as Vein Center of North Texas, Sherman, TX, USA an expression of its drainage, is anyhow a re#ux originating from tributary out#ows once the original escape points is dis- Aim. 1. Determine the feasibility of direct Computed Tomo- graphic (CT) venography to detect May-Thurner Syndrome. 2. connected, and nevertheless it leads to low recurrence rate. Determine possible variables to increase sensitivity / speci!- Therefore not all re#uxes are so pathogenic as thought, it city of direct CT venography to detect May-Turner Syndrome depends on the developed pressure and speed. No study has Methods. We retrospectively evaluated 25 patients clini- yet de!nitively demonstrated that the direction of a #ow can cally suspected of having May-Thurner Syndrome from be pathogenic “per se”. 01/2011 to 04/2013. Contiguous axial tomograms of the pelvis Therefore we have to reduce the energy of the re#ux, and were taken after injection of Isovue 370 contrast via IV cath- then lateral pressure and speed, according to CHIVA principles eters placed in one of the super!cial veins of the left lower ex- that are made up of 2 main points: tremity. Scans were performed during the “!rst pass” of dye 1°) The reduction of the TMP developed by the re#ux: up the left lower extremity to create a “direct” CT Venogram. — Disconnecting the venous-venous Shunts, mostly Patients were referred from an independent vein center in a at the escape point level small city. The variables measured were the presence / ab- — Fractioning the hydrostatic pressure sence of compression of the left iliac vein by the right iliac The TMP reduction is proved by veins shrinking. artery as well as the presence or absence of !lling of pelvic 2°) The preservation of a draining system collateral veins. The system evolution is strictly related to drainage degree. Results. Ten of 25 patients were found to have signi!cant compression of the left iliac vein by the right iliac artery. Eight of 25 patients studied were found to have considerable collateral #ow from left to right. One patient had bilateral inguinal FREE PAPER SESSION 8 hernias with small and large bowel contained within them. Patients with signi!cant compression and collateral #ow were Prospective Evaluation of Patients With Iliofemoral felt to have high likelihood of having May-Thurner Syndrome. Venous Thrombosis Treated With Anticoagulation Conclusions. Direct CT venogram performed by placing C. Dias1, G. Spentzouris2, A. Gasparis3, N. Labropoulos2 the IV in the left leg and scanning during the !rst pass is a vi- 1The Aroostook Medical Center, Presque Isle, ME, USA able tool to screen for the presence or absence of May-Thurn- 2Stony Brook University Medical Center, Stony Brook, NY, USA er Syndrome. This technique may very well replace IVUS 3Stony Brook Vein Center, Stony Brook, NY, USA as the screening tool of choice to evaluate for May-Thurner Syndrome Further study is needed to determine the relative Aim. This prospective study was designed to determine the signi!cance of variables such as percentage stenosis, degree long term effects of iliofemoral venous thrombosis. of collateral #ow, presence or absence of acute or chronic Methods. Patients with documented diagnosis of acute DVT, etc.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 63 Transvaginal Duplex Ultrasonography is the Gold Results. Follow-up of 3 to 62 (median 13) months reveals Standard for Assessing Pelvic Venous Re"ux in the complete or nearly complete resolution of pelvic pain and dys- Ovarian and Internal Iliac Veins in Women pareunia except for one patient with signi!cant residual dys- M. Whiteley, S. Dos Santos, C. Harrison, J. Holdstock pareunia and one patient who is sexually inactive. Follow-up ultrasound shows the stents to be widely patent with antegrade 1 The Whiteley Clinic, Guildford, United Kingdom #ow in all 14 patients at 1 to 59 months post-op. The Venous Clinical Severity Score ranged from 0-9 (mean 7) preop and Aim. Assess the sensitivity and speci!city of transvaginal from 0-7 (mean 3) at one month post-op. duplex ultrasound (TVS) in identifying pathological re#ux in Conclusions. In addition to venous re#ux, Pelvic Conges- ovarian and internal iliac veins in women. tion Syndrome may result from out#ow obstruction of the ili- Methods. A retrospective study of patients treated in 2011 ac veins or inferior vena cava. Venous angioplasty and stenting and 2012 was performed in a specialised vein clinic. Diagnos- may be used to treat such patients with resolution of chronic tic TVS in women presenting with symptoms or signs of pelvic vein re#ux were compared with the outcomes of treatment pelvic pain and dyspareunia. Six of the seven patients with se- from pelvic vein embolisation. A repeat TVS was performed 6 vere left ovarian vein re#ux were not treated for the ovarian weeks later by a blinded observer and any residual re#ux was vein re#ux, but early results suggest that treatment of ovarian identi!ed. vein re#ux may be selective. Results. Results from 100 sequential patients were analysed. Mean age 44.2 years (32 – 69) with mode average parity of 3 (0 - 5 deliveries). Pre-treatment TVS identi!ed signi!cant re#ux in 289 veins (ovarian - 29 right 81 left; internal iliac - 93 right 86 left). Coil embolisation was successful in 88/100 Female Varicocele: Clinical-Therapeutical Correla- patients and failed partially in 14/100 - 5 due to failure to can- tions nulate the target vein. There were no false negatives and one false positive – PPV = 99.7%, NPV = 100%, Sensitivity = 100% P. Antignani, G. Calandra and Speci!city = 99.1%. Vascular Center Villa Claudia, Rome, Italy Conclusions. Currently there is no accepted gold standard for pelvic vein incompetence. Comparing TVS with the out- Aim. The presence of a vascular cause of pelvic pain was come from selectively treating the veins identi!ed as having !rst mooted in the late 19th century but it was not until 1948 pathological re#ux with coil embolisation, there were no false that Taylorproposed a connection between chronic pelvic negative diagnoses and one false positive in a right ovarian pain and the presence of pelvic varicose veins. The clinical vein. This study suggests TVS could be the gold standard in entity known as Pelvic Congestion Syndrome (PCS) may be assessing pelvic vein re#ux, being 100% sensitive and 99.1% described as the presence of pelvic varices, which to venous speci!c. stasis and congestion of the pelvic organs, and, in turn, lead to chronic pelvic pain. The aim of this paper is to present our experience in the clinical de!nition of disease and to report the results of treatment with sclerotherapy. Methods. We studied 59 women with typical symptoms and signs of PCS: chronic pelvic pain, dyspareunya, vulvar varices Venous Angioplasty and Stenting Improve Pelvic or legs varices. All patients were examined by means of echo Congestion Syndrome Caused by Venous Out"ow color duplex scanning of venous system of lower limbs and Obstruction transvaginal approach to evaluate the presence of pelvic varicocele and varicose veins. The protocol was: Medical Hystory S. Daugherty1, D. Gillespie2 – Clinical examination, Instrumental diagnosis (lower limbs 1VeinCare Centers of Tennessee, Clarksville, TN, USA and transvaginal color Duplex Ultrasound), Angio RM (in case 2Division of Vascular Surgery University of Rochester, Rochester, NY, USA of positive examen), Endovascular therapy (Transbrachial Endovascular Foam sclerotherapy). the followup of patients Aim. 1. Evaluate the hemodynamic abnormalities respon- was: 1st instrumental examination and symptoms evaluation sible for Pelvic Venous Congestion Syndrome, 2. Assess the at 2 months, 2nd instrumental and clinical examination at 6 response to treatment of iliac or inferior vena cava obstruc- months, further control at 12 months. Selective sclerotherapy tion for relieving pelvic pain and dyspareunia, 3. Assess the in- of pelvic veins with transbrachial access by means of 10 ml termediate-term patency of iliac and inferior vena cava stents of foam with 1 ml of sodium tetradecyl sulphate 3% with air placed for non-thrombotic obstruction. (Tessari method). Methods. We reviewed records from two institutions of Results. Clinical Results. complete resolution of symp- patients with venous out#ow obstruction and symptoms of tomatology in 58 patients (out of 59). Instrumental control: Pelvic Congestion Syndrome severely affecting quality of life. complete resolution of varicocele in 56, partial results in 2 cas- From January 2008 through January 2013, 14 patients were es. Further treatment after 12 months in 1 patient for persist- treated for Pelvic Congestion Syndrome associated with severe ent pre-mestrual pelvic pain and dispareunya. regarding the venous out#ow obstruction. Patient ages ranged from 22 to 46 lowerr limbs varicose veins, complete resolution of leg varices years. CT showed moderate to severe compression of the left in 49 patients, residual leg varices without symptoms in 10 common iliac vein in 13 patients and high grade stenosis of cases. the suprarenal inferior vena cava in the other. Extensive pelvic Conclusions. Given the pathophysiology of pelvic conges- varices were identi!ed in all patients. Venography con!rmed tion syndrome, the most promising treatment modalities have out#ow obstruction with extensive cross-pelvic venous collat- been those that target the ovarian veins speci!cally. Early se- erals. Seven patients were found to have severe left ovarian lective venography, as pre-treatment evaluation, can adequate- vein re#ux as well. IVUS con!rmed focal severe stenosis of the ly visualize the ovarian veins. Foam sclerotherapy has the ad- involved vein. Each patient was treated with angioplasty/stent- vantage over open surgery in that it leaves no obvious scar and ing of the left common iliac vein or inferior vena cava using can be conducted as an outpatient. It has been shown to be as self-expanding stents. One patient was treated concurrently effective, safety and ef!cacy as hysterectomy in treating the with left ovarian vein coil occlusion for severe left ovarian vein symptoms of pelvic congestion and this ef!cacy appears to be re#ux. sustained on long-term follow-up.

64 INTERNATIONAL ANGIOLOGY October 2013 Hemorrhoids are Associated with Pelvic Vein Re"ux venous forms with the increased risk of intraoperative blood in up to One Third of Women. Should Hemorrhoids loss was performed, 18 patients with venous forms underwent be Treated by Phlebologists? laser coagulation. Depending on location and area of the malformation at the closing wounds after the excision different J. Holdstock1, S. Dos Santos2, C. Harrison3, M. Whiteley3 methods of plastic surgery were used: local tissues, staged 1The Whiteley Clinic, Guildford, Surrey, United Kingdom 2The Whiteley Clinic/University of Surrey, Guildford, United Kingdom excision, tissue expansion, skin grafts, skin #aps on vascular 3The Whiteley Clinic, Guildford, United Kingdom pedicle or microvascular anastomoses.

Aim. Determine the prevalence of hemorrhoids in women with pelvic vein re#ux 2)Identify which pelvic veins are associ- Intraprocedural Complications of Sclerotherapy for ated with hemorrhoids 3)Assess if extent of pelvic vein re#ux Venous Malformations and Analysis of Patient-Re- in#uences the incidence of hemorrhoids ported Improvement Methods. Between January 2010 and December 2012 females presenting with leg varicose veins underwent duplex R. Clemens, C. Stamoulis, A. Lillis, A. Alomari ultrasound (DUS) to assess all sources of venous re#ux. Those Boston Children’s Hospital, Boston, MA, USA with signi!cant re#ux arising from the pelvis were offered transvaginal duplex sonogram (TVS) to evaluate re#ux in Aim. To assess the sclerosant, dosage and age-related risk Ovarian veins (OV), Internal Iliac veins (IIV) and associated of complications of sclerotherapy for treatment of spongiform varices in the adnexa, vulval/labial veins and hemorrhoids. venous malformations in children and adults and to evaluate Patterns and severity of re#ux were evaluated. the outcome as judged by patients. Results. 419 female patients had leg varicose vein patterns Methods. Medical records of patients who underwent arising from pelvic vein origin and underwent TVS. In 152/419 sclerotherapy of venous malformations over the past 8 years, (36.3%) hemorrhoids were identi!ed on TVS via direct trib- which contained information on intraprocedural complica- utaries from the Internal Iliac Veins. In 267/419 (63.7%) no tions (SIR classi!cation system), were reviewed. The corre- hemorrhoids were identi!ed The following table gives a break- lation between complications and sclerosants was assessed down of the patterns of re#ux associated with the hemorrhoid using a logistic regression model, with complications as the and non-hemorrhoid groups. outcome. The outcome of sclerotherapy as self-reported by pa- Conclusions. Hemorrhoids are associated with pelvic vein tients was assessed in a 21-item survey. re#ux in one third of females presenting with leg varicose Results. 166 patients (age 0.7 to 39 years) were treated veins. The incidence of hemorrhoids increases with number with 327 procedures. Mean age was 12.6 years. 59% of the pa- of pelvic trunks involved. Hemorrhoids are directly associated tients were female. Sodium tetradecyl sulfate 3% (292 proce- with internal iliac vein re#ux. Treatment of hemorrhoids, with dures), dehydrated ethanol (80), N-Butyl Cyanoacrylate (50) methods proven to work in conditions associated with pelvic and bleomycin (21) were used (33% combinations). Adverse vein incompetence, such as pelvic vein embolisation and foam effects occurred in 16 procedures (4.9%) including blistering sclerotherapy, could be considered. or ulceration of involved skin (n=8). There were no major complications. No correlation between complications and sclerosants (p>0.5 for all), age at procedure (p=0.67) or area treated (p=0.1) was found. >60% of patients returned the survey. Face and Neck Vascular Malformations – Modern Conclusions. Sclerotherapy for treatment of venous mal- Principles of Treatment With Application of Plastic formations is a safe procedure even when multiple sclerosants Surgery are combined. Minor complications, such as blistering or ul- V. Dan 1, S. Ilyin 2, S. Sapelkin 2, V. Sharobaro 2, I. Timina 2, V. Tsygankov 2, ceration are expected and are procedure related, but appear G. Va!na2 not to be related to age, dose or sclerosant. 1A.V.V Surgeryishnevsky Institute of, Moscow, Russian Federation 2A.V.Vishnevky Institute of Surgery, Moscow, Russian Federation

Aim. Patients with face and neck vascular malformations Vascular Anomalies Involving the Hand: Percutane- (VM) are dif!cult for treatment on account of anatomic pe- culiarities of this area. In some cases standard resections are ous Treatment Strategies and Outcomes absolutely impossible thus inducing to search new ways of D. Link wound surface closure with application of reconstructive sur- University of California Davis, Sacramento, CA, USA gery principles. Methods. A retrospective analysis and evaluation of results Aim. There are very few articles discussing the newer of treatment of 78 patients with VM was made (45 – arterio- percutaneous strategies for low #ow and high #ow vascular veous and 33 – venous forms). The age of patients varied from anomalies involving the hand or hand function. Direct punc- 14 up to 64 years (the average - 25,3 ± of 12,2). Diffuse affec- ture sclerotherapy and angiographic approaches are some- tion was revealed in 34, local - 44 patients. In 8 cases the dis- times not possible or ineffective. Direct ablation with laser of ease was complicated by bleedings from angiomatous tissues. lesion has been described for craniofacial anomalies but has Standard diagnostic complex was made to clarify the area and not been described for hand lesions. The purpose of this study angioarchitecture of malformation. is to evaluate the outcome of percutaneous therapies in terms Results. Preoperative x-ray controlled endovascular embol- of preservation of hand anatomy and function with minimally isation of afferent arteries at 32 patients with arteriovenous invasive techniques. forms with the increased risk of intraoperative blood loss was Methods. All patients with vascular anomalies involving performed, 18 patients with venous forms underwent laser co- the hand and hand function were evaluated. Patients evalu- agulation. Depending on location and area of the malforma- ated and managed in the vascular center were included in the tion at the closing wounds after the excision different methods lesion involved the hand or hand function. Lesions were classi- of plastic surgery were used: local tissues, staged excision, tis- !ed as high #ow, low #ow or Hemangioma. Functional Evalu- sue expansion, skin grafts, skin #aps on vascular pedicle or ations included strength, sensation and !ne motor function. microvascular anastomoses. Evaluations were logged at baseline, at treatment (sometimes Conclusions. Preoperative x-ray controlled endovascular multiple encounters), and at monthly intervals for a year and embolisation of afferent arteries at 32 patients with arterio- if no interventions yearly thereafter.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 65 Results. 30 patient were included in the study, there were center clinic were reviewed. Patients were selected on the ba- 12 patients with high #ow lesions, 15 patients with low #ow sis of 1, involvement of the foot and ankle, 2, intractable pain, lesions and 3 patients with a” Hemangioma”. All patients but 3, poor tissue nutrition, 4.functional de!cit. 8 patients were one retained function of the hand with treatment. Of the low enrolled. All records were reviewed. Lesion location was by #ow lesions 3 patients were complete responders all others division: fore-foot, mid-foot, and hind- foot. Lesions restricted were partial responders (slow growth). Of the high #ow le- to one division were Type A, two segments Type B and all three sions, there were no complete responders all high #ow pa- Type C (diffuse). Pain and functional scores were reviewed as tients receiving between 2 and 20 treatment sessions over values on an analog scale before and after treatment, Skin nu- a 10 year period of follow up. The Hemangioma were com- trition was not threatened, threatened, or ulcerated. pletely treated in the short term with laser ablation. Results. There were 4 high #ow lesions, on low #ow lesion, Conclusions. Percutaneous therapy with Angiographic and 3 venous malformations. Type A, 2 patients, both com- techniques and direct approach using sclerotherapy and laser plete responders; Type B 1 patient ulcerated skin, pain on am- ablations are very promising in maintaining hand function bulation, improved with treatment including physical therapy; without surgical resection. Type C4, one patient with ulceration and sepsis required amputation after attempted therapy, one patient had substantially improved, ongoing treatment and physical therapy. Conclusions. Therapy of vascular anomalies in the foot Under-Diagnosed Cause of Lower Extremity Venous should include image guided techniques. There need to be re- Thrombosis in the Young Patient porting standard developed along with an outcome data base R. Kreidy registry to further evaluate these lesions since they are too rare for level one studies. Saint George Hospital, University Medical Center, Beirut, Lebanon

Aim. Inferior vena cava congenital anomalies represent a rare cause of lower extremity venous thrombosis among young patients. The association of inherited thrombophilia Ethiodol in Sclerotherapy of Venous Malformations to these anomalies increases the risk of venous thrombosis R. Clemens, A. Lillis, A. Alomari several times. This study aims to evaluate the incidence of Boston Children’s Hospital, Boston, MA, USA inferior vena cava abnormalities with or without inherited thrombophilia among young patients with venous thrombo- Aim. To investigate the safety of ethiodized oil contrast in sis, to report clinical presentation and to discuss diagnosis and sclerotherapy for treatment of venous malformations in chil- management of these patients. dren and adults. Methods. From January 2003 to January 2011, 75 patients Methods. A review of the medical records of patients who younger than 50 years, diagnosed with lower extremity deep underwent sclerotherapy of venous malformations at our in- vein thrombosis by duplex scan in a university tertiary-care stitution over the past 8 years was performed. Intraprocedural center, were retrospectively reviewed. The presence of inferior complications were documented using the SIR classi!cation vena cava abnormalities and inherited thrombophilia was de- system. The correlation between complications and dose was termined among these patients. assessed using a logistic regression model with complication Results. Congenital inferior vena cava malformations (2 as the outcome. The model also included terms for age at pro- left-sided and 1 agenesis) were observed in three patients (4 cedure and area treated in order to assess their potential com- %) with spontaneous ilio-femoral venous thrombosis resist- binatorial effects on complications. ant to anticoagulants. The three patients were carriers for Results. 115 patients (age 1 to 35 years) had 202 scleor- inherited thrombophilia (one patient had severe multiple therapy procedures in combination with one or more of the pro-thrombotic polymorphisms, not yet reported in this con- following sclerosing agents: STS 3%, dehydrated ethanol, dition: heterozygote for pro-thrombin G 20210 A and factor glue or bleomycin. The mean age at procedure was 11.8 and V - Leiden, homozygote for MTHFR C 677 T with hyper-ho- the median 11 years. Dosage varied between 0.2 ml to 20 ml. mocysteinemia). There was no statistically signi!cant correlation between use/ Conclusions. Although uncommon, congenital inferior dose and complications (p=0.64) or age at procedure and area vena cava abnormalities combined with inherited throm- treated. Ethiodol dose was correlated with age at procedure bophilia should be excluded in young patients with sponta- (p=0.04) and area treated (p=0.0003) with smaller doses used neous ilio-femoral venous thrombosis, essentially when recur- for younger patients and smaller treatment areas. Only minor rent venous thrombosis or resistance to anticoagulants are complications (16) occurred. observed. Conclusions. Minor complications including skin blistering and hemoglobinuria are known side effects of sclerotherapy and are not speci!c to Ethiodol. The results of this study suggest that ethiodized oil contrast may be safely used in Arterial and Venous Anomalies in the Foot: Treated children and adults undergoing sclerotherapy for treatment of with Minimally Invasive Methods venous malformations. The dosage was found to be correlated D. Link with area treated and age at procedure. University of California Davis, Sacramento, CA, USA

Aim. The literature regarding vascular anomalies in the foot is sparse and treating physicians do not have adequate references to treatment planning o these dif!cult lesions. Im- Endovascular and Surgical Treatment of Pelvic Con- age guided direct and trans-catheter treatment (MIT) of vas- gestion Syndrome cular anomalies has been suggested with level 2 evidence. We I. Ignatyev review a small series of vascular anomalies in the foot speci!- Interregional Clinical and Diagnostic Center, Kazan, Russian Federation cally to evaluate treatment strategies and outcomes. Methods. A retrospective review of 65 patients actively be- Aim. Creation of optimal strategy of treatment patients ing treated with direct and trans-catheter treated in a vascular with pelvic congestion syndrome.

66 INTERNATIONAL ANGIOLOGY October 2013 Methods. 103 women (mean age 35,3±7,3 years) with Guidelines for Ef#cacy Studies of Venoactive Agents pelvic congestion syndrome were ex-amined and treated. All M. Perrin women underwent transvaginal and transabdominal color Lyon, France duplex scanning 52 women underwent CT angiography and phlebography. Reconstructive operations were performed on Aim. To raise key questions to be answered in order to im- the pelvic veins of patients: 17 women un-derwent applica- prove protocols for good clinical trials and to draw up future tions of the proximal ovarian-iliacal anastomoses. In one guidelines on the venoactive drugs (VADs). case prosthetics of left re-nal vein was made. And two women Methods. The literature has been reviewed using PubMed, underwent transposition of the left renal vein. In the case Embase, and Cochrane reviews. of idiopathic re#ux and presence of clinical pelvic conges- Results. Guidelines for testing VADs were updated to en- tion 19 patients underwent one-or two-sided embolization of able the pharmaceutical industry to invest the resources re- ovarian veins using “sandwich” method by combined appli- quired to perform large and de!nitive clinical trials, with a cation Gianturco spirals and 3% Polidocanolum solution. 15 view to improving the recommendations in the !eld of chronic patients underwent resection surgery: extraperitoneal resec- venous disorders (CVDs). Such guidelines could: tion of the egg-acoustic vein in 7 cases, laparoscopic resec- Reiterate the basic principles that should prevail when re- tion – in 8. porting (and setting up) a clinical trial, using the Consolidated Results. In 51 cases dilatation of ovarian veins till 5 mm, Standards of Reporting Trials (CONSORT) statement. This not accompanied by a syndrome of chronic pelvic pain was CONSORT statement is designed to help authors and investiga- revealed. 17 women had aorto-mesenteric compression of the tors #le reports, by the use of a published checklist and a "ow left renal vein (“nutcracker syndrome”) with apparent reno- diagram. ovarian re#ux and varicose of broad ligament varices. Major Include larger sample size according to the magnitude of and satisfactory results were obtained in 47 (90,1%) cases in the expected effect, having in mind the high incidence of pla- the group of women who underwent invasive diagnostic meth- cebo effect in the most important indications for VADS, i.e. ods. Recurrence of symptoms was diagnosed in 4 patients af- symptoms relief. ter resection operations and one patient after reconstructive Describe patients comprehensively at study selection, using surgery. the advanced CEAP classi!cation, which implies that not only Conclusions. Surgical and endovascular therapies are should the C of the CEAP be completed, but also items E, A, used as the most effective treatment of pelvic congestion syn- and P, together with mandatory color-coded duplex sonogra- drome. phy, with or without plethysmography (level 2 investigation). Despite its cost, such investigation might be insuf!cient to explore the super!cial venous network Perform long-term studies to examine the prevention of CVDs progression and the cost-effectiveness of VADs Promote the use of validated tools to assess symptoms, and THE ROLE OF VENOACTIVE DRUGS venous signs including ulcer. IN VENOUS DISORDERS Have a consensus on a standard treatment for dressings, compression therapy, and local antiseptics in venous leg ulcer. Impact of Venoactive Drugs on Venous Edema Conclusion. Much work remains to do to accord VADs the F.A Allaert role they deserve in the management of CVDs. ESC Cen Biotech, Dijon, France

Aim. To compare the reduction of venous ankle edema in randomized controlled trials of the main venoactive drugs versus a placebo or versus another venoactive drug and thereby GENERAL NURSING SYMPOSIUM #2 to con!rm or invalidate the existing recommendations on the pharmacological treatment of venous edema. Communication Matters Methods. Publications of randomized controlled trials of H.S. Fronek venoactive drugs versus either a placebo or another venoac- Department of Medicine, University of California – San Diego, La Jolla, tive drug on the reduction of ankle circumferences (AC) were USA searched through Medline and selected according to the Jadad and the Cucherat evaluation grids. The practice of medicine rests on four cornerstones: our Results. Ten publications dated between 1975 and 2009 fund of knowledge, physical examination technique, prob- including a total of 1010 patients were identi!ed for the me- lem-solving ability and communication skills. Good com- ta-analysis. Included were the following venoactive drugs: munication allows us to quickly develop rapport and trust, micronised puri!ed #avonoid fraction (MPFF), hydroxyethyl- which encourages sharing of information, decreases the risk rutoside, ruscus extracts and diosmin. The mean reduction of malpractice claims, and enhances our satisfaction with the in AC was -0.80 ± 0.53 cm with MPFF, -0.58 ± 0.47 cm with practice of medicine. Simple techniques such as knowing our ruscus extract, -0.58 ± 0.31 cm with hydroxyethylrutoside, patient’s name and how to pronounce it, having a plan for the -0.20 ± 0.5 cm with single diosmin, and -0.11 ± 0.42 cm with visit, and acknowledging that we can make a difference with placebo. The reduction in AC was signi!cantly superior to each patient lay the foundation for the relationship. Scanning that of placebo whatever the drug concerned (p<0.0001). The for the patient’s entire agenda, negotiating the agenda with comparison between MPFF, ruscus extract and hydroxyethyl- our patient, and involving the patient in all decision making rutoside on the reduction of ankle edema was in favour of increases patients’ satisfaction with their visit. Paraphrasing MPFF. Ruscus extract and hydroxyethylrutoside were also what the patient has said ensures that the history is being superior to placebo but not diosmin. This was signi!cant accurately communicated. Using visuals and “chunking and (p<0.0001), while the ef!cacy of the latter two venoactive checking” improves patients’ retention of what we say. Body agents was comparable. language and tone of voice convey more than our words and Conclusion. This meta-analysis con!rms the validity of the simple actions such as leaning forward, eye contact and not grade A assigned to MPFF in the management of symptoms crossing our arms can tell our patient that we are interested in and edema in recent international guidelines. and open to what they are saying.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 67 Cross-cultural issues are increasingly important as we care subjects with symptomatic chronic venous disease (CVD) in for an increasingly diverse patient population. Expressing in- presence of foot static disorders (FSD). terest in our patient’s culture, speaking slowly and pausing fre- Methods. A randomized control study included 24 patients, quently, and asking questions in several ways help to bridge with a symptomatic CVD and static foot disorders. The basic the cultural gap. The “4 C’s” are useful in understanding our CEAP was used to classify the patients. The venous symptoms patient’s cultural in#uence on their understanding of and in- were recorded using a 10-point VAS. Patient-reported QoL volvement with their illness: What do you CALL the problem? data were acquired using a CIVIC Questionnaire. We com- What do you think CAUSED the problem? How do you COPE pared 2 following treatments: -A compression stocking class with the problem? What CONCERNS do you have about the 2 French - and an insole made according to the sole print. To problem? compare the 2 treatments, we used the 4 following periods of Communication within a medical of!ce is just as impor- one week duration using cross-over technique. We randomly tant as that between practitioner and patient. Interpersonal shared the 24 patients in 2 arms of 12: For one arm: No treat- con#icts can decrease ef!ciency but can also result in serious ment, MCS, insole, both For the other arm: MCS / insole were medical errors. Simple skills such as contrasting, STATE, and applied in reverse order. using “I” messages can provide a framework for holding dif!- Results. 65% of the patients had a hollow foot and 6% had cult conversations and help to improve communication within a #at foot. We found a signi!cative improvement of the QoL the of!ce. with the MCS (p<.005) and the insole (p<.01) or both treatments p<.001) The symptoms were signi!cantly improved by the 2 treatments given separately or together. For QoL and symptoms, the difference between MCS and insole was not found signi!cant FREE PAPER SESSION 9 Conclusions. This study con!rms the crucial importance of the correction of the SFD in any patient with CVD: the in- Physiological Parameters for Effective Compression sole will improve the symptoms and also the QoL with an ef- Therapy of Swollen Lower Limbs- Tissue Fluid Pres- !ciency almost equal to the MCS, the best being to associate sure and Flow, Tonometry both treatments, but their effect is not additive. W. Olszewski 1, P. Jain2, M. Zaleska3 1Medical Research Center, Warsaw, Poland 2Benaras Hindu University, Varanasi,, Warsaw, Poland, 3Department of Surgical Research & Transplantology, Medical Research Center, Polish Academy of Scien, Warsaw, Poland Improved Patient Compliance with Compression Aim. Mechanical compression is an effective method ena- Therapy: The Results of a Compression Navigator bling tissue #uid (TF) to overcome tissue resistance and #ow Service to non-swollen regions. How high should be externally applied J. Lohr, G. Meister forces and timing of compression Lohr Surgical Specialists, LLC, Cincinnati, OH, USA Methods. We studied hydraulics of TF in swollen lower limbs using intermittent pneumatic compression of 30 pa- Aim. Background For a variety of reasons, patients do not tients with lower limb lymphedema stage II/III. In#ation pres- adhere to compression therapy. Vascular surgeons and com- sure ranged from 50 to 120mmHg, sequentially from chamber pression navigators can improve results by offering one-on- 1 to 8, in#ation time of each chamber ranged from 5 to 20 to one consultation regarding a diverse assortment of garments, 50sec. Skin tonometry was measured. TF pressure was meas- devices and ancillary services. ured in calf and thigh with use of subcutaneously placed pres- Methods. Methods Patients treated in our vascular practice sure sensor. Changes in circumference of compressed limb who were identi!ed as candidates for compression therapy, were measured continuously using a plethysmograph. returned for consultation with a certi!ed compression navi- Results. In#ation for 5 and 20 sec did not allow to reach TF gator. They were professionally !tted for the recommended pressure as in in#ated chamber. In advanced cases of lymph- compression devices. They were then surveyed about their use edema, to obtain the transmural pressure of 40 mmHg, pres- of the devices and their compliance with recommended use. sures in the sleeve had to be raised as high as 150 mmHg and Responses were received from 50 patients (mean age 72; 38 timing increased to 50 sec. Tonometry. Tonometer force of female). 1000 g/sq.cm generated average TF pressures of 25-40 mmHg, Results. Results Thirty-nine percent had never worn of 2000 g/sq.cm 50-60 mmHg, above 2000 g/sq.cm 70 mmHg.. compression garments; half had been professionally !t- TF #ow at in#ation pressure of 120mmHg and 50sec in#ation ted previously. Ninety-eight percent rated the compression ranged from 1 to 20 ml per in#ation cycle. navigator as very good or excellent in compression prod- Conclusions. The optimum in#ation pressures were 80- uct knowledge, product option explanations, and courtesy. 120mmHg and in#ation time of each chamber 50+ sec. Over 99% were surprised at the assistive devices available. Patients’ satisfaction with follow-up questions and returned phone calls was also excellent. Explanation of insurance bene!ts, coverage for compression garments, charges and payment collection all improved with one-on-one contact. Compression Versus Insole for CVD Patients with Eighty-three percent stated of!ce-based compression navi- Foot Static Disorders: A Randomized Controlled gator service increased likelihood of treatment compliance. Trial Comparing Symptoms and Quality of Life The median hours compression garments were worn per J. Uhl1, M. Chahim2, F. Allaert3 day was 12. 1URDIA research unit, Paris, France Conclusions. Conclusion Results indicate that of!ce-based 2Paris, France compression navigator service was helpful to our patients. 3Cenbiotech, Dijon, France Furthermore, the impression of compression therapy was greatly improved for most. One-on-one consultation with a Aim. To prospectively study quality-of-life (QoL) and symp- compression navigator is extremely helpful to patients, and toms bene!ts comparing compression stockings to insole in can result in improved compliance with prescribed compres-

68 INTERNATIONAL ANGIOLOGY October 2013 sion therapy. This service, also provided to in-house patients, Methods. Data collected included pre-/ post-procedural use ensures continuity of care. of compression therapy, baseline /post-procedural VCSS and type of venous ablation procedure. Also reviewed was information on compression devices, duration of use, compression- coverage, and strength. Compression Therapy (CT) in Endovenous Laser Results. 4,014 procedures were entered into the database Ablation of Great Saphenous Veins by 201 physicians from 42 medical centers, comprising 3,930 R. Vellettaz patients. Procedural types included endovenous laser ablation (60%), phlebectomies (34%), radiofrequency ablation (33%) Clinica Colon CEVYL, Mar del Plata, Buenos Aires, Argentina and sclerotherapy (16%), with 37% of treatments involving Aim. Primary To establish CT protocol To improve safety more than one modality. 26% of patients were compliant (dai- of procedure. Secondary To demonstrate decreased of minor ly use) with compression therapy prior to vein ablation. In the complications. To achieve better QOL and faster restarting of perioperative period, 95% of patients used some form of com- everyday and work activities pression therapy both day and night; 80% used a thigh-high Methods. Prospective randomized cohort -Group1: com- multilayered bandage. After 48 hours, 98% of patients used pression bandages concentric high extensibility for 7days, 30-40 mm Hg thigh-high compression during the daytime. then graduated compression stocking -Group2: Protocol GIC Clinical improvement in the VCSS score (3 or more) was seen Compression eccentric + stockings 30-40mmHg Hemicollant+ in 62%, while 23% improved their score by 1-2. compression bandages concentric low extensibility for 48 Conclusions. A minority of patients undergoing venous ab- hours, then graduated compression stocking Pneaumatic pres- lation therapy use compression therapy on a daily basis before sion sensor: Picopress B2:35 B3:45 Period: 4 months 25 EVLA the procedure. Most patients were compliant in the peri-oper- per group No differences in materials, surgical procedure, type ative and immediate post-surgical time period. Clinical out- of anesthesia, PO pain management. comes, as re#ected in improved VCSS scores, were excellent. Results. Picopress:adequate CT thigh in standing position > 30 mmHg Pain: temporality, G1 peak days 3; G2 plateau decreasing form day 1 to10th Average: 23.3(2-87) versus 13.1(0-63)mm p:0.014 Suspension of analgesic intake at 10th: Effect of Special Compression Stockings on the Per- 73vs91% Time of return: to usual activities 4vs2 days, to work formance of Athletes in Alpine Skiing activities 10vs7 days Ecchymosis: mild 72%vs 96%. Score: J. Strejcek, S. Strejcek 1.49(1.39-1. 62) vs 0.93(0.77-1.12) p:0.017. Induration:100% Center for Dermatologic Angiology, Ricany /Prague CZ - 251 01, Czech 2.17mm(1.73-2.49) vs 1.29mm(1.11-1.152) p:0.033 TFS:12%vs Republic 4% Pigmentation:4%vs 0% EHIT1: 96%vs100% 2:4%vs0% Questionnaire: good, 48%vs; very good, 56% Better Qol (CIV- Aim. It is generally assumed that graduated leg compres- IQ20) to the !rst month Best results showed in the question- sion reduces fatigue of the legs in athletes after training and naires completed by the patients signi!cantly reduces recovery time. We used the opportunity Conclusions. We detected in the G2: Ø Change in the tem- to equip the Czech national alpine skiing team with graduat- porality of pain. Ø Less Intensity of pain Ø Less intake of an- edcompressive stockings (GCS) designed by for this type of algesics Ø Lower rate of minor complications Ø Lower rate sport. Using different methods, we tried to evaluate the effect of progression of EHIT Ø Shorter time of return to usual and of so called Cell Energy Protection (CEP) sport stocking on work activities Ø Best results of the questionnaire completed training process, sports performance and recovery time. by the patients about procedure Ø Best results of the question- Methods. After determining the appropriate size of GCS naire of QOL type CEP / skiing race for individual members of the Czech national team (5 men and 3 women) were measured their initial compressive pressure at ankle region, the native muscle pump funcion (muscle pump test measured by digital photo- Use of Compression Therapy in Patients with Chron- pletysmography) in comparison with CEP’s stockings. Com- ic Venous Insuf#ciency Undergoing Ablation Thera- petitors during training stay on the glacier (Kaprun, Austria) py: A Report from the American Venous Registry trained three days without CEP stocking and then three days L. Kabnick1, T. Wake!eld 2, J. Almeida 3, J. Raffetto 4, R. McLafferty 5, P. with CEP stockings. Using a simple questionnaire of quality of Pappas6, J. Rectenwald 7, D. Gillespie 8, J. Blebea 9, U. Onyeachom 10 , B. sports life, by measurement of muscle venous pump test and Lal11 determining the number of circulating endothelial cells (CEC) 1NYU Langone Medical Center, New York, NY, USA in peripheral blood, we tried to evaluate the effect of compres- 2University of Michigan, Ann Arbor, USA sion on these parameters. 3Miami Vein Center, Miami, FL, USA Results. Stockings were included in the second compres- 4Vascular Surgery Division VA Boston Healthcare System Surgery 112, West Roxbury, MA, USA sive class. When comparing the “native” parameters of muscle 5Southern Illinois University Healthcare, Spring#eld, IL, USA venous pump with identi!ed parameters for compression, we 6Brooklyn, NY, USA found an increase in women by 23% in men by 17%. Specially 7University of Michigan, Ann Arbor, MI, USA modi!ed CIVIQ questionnaire showed Based on the indicative 8Division of Vascular Surgery University of Rochester, Rochester, NY, measurement (VARITEX System Holland) the CEP / skiing USA 9University of Oklahoma at Tulsa, Tulsa, OK, USA race enhanced quality “sports performance being” expressed 10 American Venous Forum, Boston, MA, USA by a standard coef!cient of quality of live (0 the best, 10 the 11 University of Maryland Medical Center, Baltimore, MD, USA worse) from 4,3 to 2,3 when using compression. Values of the number of CEC in peripheral blood, which are indicative of Aim. Compression therapy is an accepted therapy for pa- venous endothelial stability are during the use of compression tients with chronic venous insuf!ciency. Although widely rec- during sports activities improved (=reduced) This concurs ommended, there is limited consensus on the type and dura- with non-invasive measurement of endothelial activity (as a tion of such therapy. We analyzed data from the Varicose Vein pilot study). Module of the American Venous Registry (AVR) to evaluate the Conclusions. Our simple pilot study shows, that GCS dur- frequency, type and duration of compression therapy utilized ing sport activity can reduce fatigue, reduce recovery time, before and after endovenous ablation across the U.S. thus allow a higher training load.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 69 Can Micronized Puri#ed Flavonoid Fraction (MPFF) Conclusion: MPFF has a number of vein-speci!c anti-in- Improve the Outcome of Endovascular Treatments #ammatory effects that relieve symptoms at all stages of CVDs for Varicose Veins of the Lower Extremities? and other venous conditions. V. Bogachev RSMU, Moscow, Russian Federation

Aim. Evaluation of the improvement of postoperative symptoms and quality of life (QOL) by the micronized puri!ed RECURRENT VARICOSE VEINS #avonoid fraction (MPFF) in patients undergoing endovascular treatment (EVT) for varicose veins of the lower extremities REVAS/ PREVAIT: What Do We Need to Know, What Methods. A total of 230 patients with chronic venous dis- Do We Need to Report, and WHY ease (CVD) class C2-4sEpAsPr of the CEAP classi!cation and M. Perrin with at least three CVD-related symptoms were randomly as- Lyon, France signed to either the MPFF group (n=126) or the control group (n=104). Patients in the MPFF group received MPFF tablets, Recurrent varices after operative treatment are a common, 1000 mg daily for 2 weeks before and 4 weeks after EVT. Pa- complex and costly problem both for the patients and the phy- tients in the control group received standard compression sicians who treat venous diseases. To deal with this problem therapy. The Venous Clinical Severity Scoring (VCSS) and an international consensus meeting, held in Paris in 1998, pro- the 14 item-ChronIc Venous dIsease QOLQuestionnaire (CIV- posed guidelines for the de!nition, description and treatment IQ-14) were used pre- and post-operatively to assess symptom of recurrent varices after surgery (REVAS). intensity and QOL, respectively. Nevertheless, conventional surgery is no more the most Results. VCSS was signi!cantly decreased at 2 weeks after frequent operative procedure used for treating varicose vein. EVT in the MPFF group (P<0.00001), but not in the control Chemical and thermal ablation on one hand and mini inva- group (P=0.15). At 4 weeks after EVT, the reduction in VCSS sive surgery on the other hand have decreased tremendously score in the MPFF group was also markedly greater than in the use of high ligation (HL) + stripping. Consequently we the control group, although not statistically signi!cant. At 4 need to build new !les and elaborate documents in order to weeks after EVT, the patients’ QOL was signi!cantly improved determine whatever the technique used for treating varicose in both groups (P<0.00001) with a stronger trend observed in veins, which procedure according to the patient status might the MPFF group. Finally, the physicians’ overall satisfaction be recommended. To help we termed some de!nitions at the regarding the use of MPFF was signi!cantly greater at 4 weeks VEIN-TERM Transatlantic Interdisciplinary consensus meet- than at 2 weeks after EVT (P=0.000018). ing. Conclusions. Thanks to its vein-speci!c pharmacological Recurrent varices: reappearance of varicose veins in an area protection, MPFF can routinely be used in combination with previously treated successfully. varicose vein EVT. Residual varices: varicose veins remaining after treatment Prevait PREsence of Varices (residual or recurrent) After operatIve Treatment. This new term was created because it is frequently dif!- cult to classify correctly the results of initial procedures done A Review of the Ef#cacy of Micronized Puri#ed Fla- by others and consequently to differentiate recurrent varices vonoid Fraction in Reducing Venous Symptoms from residual varices as well as from disease evolution A. Mansilha In order to improve our knowledge we need to precise what Unit of Angiology and Vascular Surgery, Faculty of Medicine - University we are looking for and to report the precise information that of Porto, Portugal should help for avoiding PREVAIT In order to undertake prospective studies we suggest to Objective: To review clinical studies of the ef!cacy of mi- document before the initial intervention for every patient a cronized puri!ed #avonoid fraction (MPFF) in reducing symp- !le including Advanced CEAP classi!cation, a speci!c HRQoL toms associated with chronic venous disorders (CVDs) Questionnaire and a detailed ultrasound report on GSV and Methods: Randomized controlled trials and meta-analyses SSV in their major tributaries including presence or absence examining the effects of MPFF on the relief of venous symp- of re#uxive terminal and pre-terminal valve, perforator and deep systems toms in patients in CEAP classes C0s to C6s were reviewed. Results. In several placebo-controlled trials, MPFF was associated with a signi!cantly greater improvement in many of the symptoms of CVDs at the end of 2 months compared with placebo (P<. 001 MPFF versus placebo), or with nonmicro- nized diosmin (P<. 05 MPFF versus simple diosmin). Impor- Prevention and Management of VV Recurrences tantly, symptom relief with MPFF was achieved rapidly and M.G. De Maeseneer maintained in the long term. Phlebology, Department of Dermatology, Erasmus Medical centre, Rot- In a meta-analysis of 459 patients, MPFF signi!cantly re- terdam, Netherlands duced the symptoms associated with venous ulcers after 4 and 6 months of treatment. MPFF is also bene!cial on post-surgery Recurrence of varicose veins after treatment is due to one pain and in pain associated with pelvic congestion syndrome. or more of the following etiologic factors: tactical or technical Patients receiving MPFF 2 weeks before and continuing for failure, neovascularisation (mainly at the site of high ligation), 14 days after varicose vein surgery had signi!cantly less anal- recanalisation of a previously obliterated trunk, and progres- gesic use than a control group. In a cross-over study, women sion of the disease. Prevention of recurrence should therefore were randomized to receive either MPFF or placebo. After try to interfere with these factors. In the !rst place, a thorough- 6 months, mean pain scores were signi!cantly lower in the ly performed duplex ultrasound (DUS) should lead to a cor- MPFF group compared with placebo (P<.05). In recent guide- rect diagnosis of the varicose disease, to avoid tactical failure. lines for the treatment of CVDs, MPFF was assigned a high Further, the planned procedure should be performed correctly. level of recommendation as a !rst-line treatment for venous Training in DUS and ultrasound guided procedure is therefore symptoms at any stage of CVDs. the cornerstone of good clinical practice in phlebology. Neo-

70 INTERNATIONAL ANGIOLOGY October 2013 vascularisation, mainly at the saphenofemoral junction (SFJ) is a rare entity and the three techniques previously reported and saphenopopliteal junction (SPJ) remains a concern after are applicable in selected cases. surgical treatment of varicose veins. Some barrier techniques The indications to deep venous surgery are clinical class to mitigate the effect of neovascularisation have been tried out C3-C6, ethiology Er and absence or preliminary treatment of successfully. However, the best way to avoid neovascularisa- proximal obstructions. tion seems to be not to operate at the SFJ or SPJ. Nowadays, in Deep venous surgery is not indicated in severe tromb- many countries surgical high ligation and stripping has been hophilia, severe COPD, severe arteriopathy, impaired ambula- replaced by endovenous ablation techniques (chemical, ther- tion and contraindications to anticoagulant therapy. mal, glue). After these endovenous interventions recurrence Pitfalls may be link to various situations: may be due to recanalisation of the obliterated trunk, with or — underestimation of proximal obstruction without recurrent re#ux at the junction. Prevention of reca- — deep parallel re#ux or loop nalisation after thermal ablation is mainly a matter of using — dilatation of valve reconstruction site that can be control- good tumescence and a correct amount of energy, in view of led by means of a banding the vein diameter. The only factor we cannot really in#uence is — thrombosis of transplanted segment due to calibre inad- progression of the disease. equacy. Nowadays, management of varicose vein recurrence is Deep venous surgery is safe; mortality and thromboembolic changing, from a very invasive approach in the past towards complications have been rare in the 50 years of history report- the use of minimally invasive techniques. Extensive redo sur- ing from around the world. Deep venous surgery is able to im- gery, involving reoperation at the SFJ or SPJ, should be per- prove considerably the quality of life in patients affected by formed only in exceptional situations. Many less invasive al- severe chronic venous insuf!ciency. ternatives have now become available: phlebectomies without re-opening the groin, in some cases combined with operative foam sclerotherapy, endovenous ablation of a residual re#uxing saphenous trunk, or ultrasound guided foam sclerotherapy AN INTERNATIONAL PERSPECTIVE of a re#uxing trunk and/or tributaries. In addtion, embolisa- ON THE MANAGEMENT tion treatment of underlying pelvic vein incompetence and OF VENOUS ULCERATION treatment of a deep venous obstruction can be considered, if indicated. All these interventions can be performed in an am- South American Consensus Guidelines for the Pre- bulatory setting, without need for general anesthesia. Finally, adequate follow-up, including DUS, and a good vention and Treatment of Venous Ulceration communication between doctor and patient is essential in the O. H. Bottini, J. Hernando Ulloa, A. Orrego management of patients with recurrent varicose veins. Phlebology Unit, Department of Vascular Surgery, Hospital de Clínicas, Buenos Aires, Argentina

A group of experts in phlebology and vascular surgery DEEP VENOUS INTERVENTIONS from different countries in South America have been working in the development of a regional consensus guidelines for the management of the venous ulcer. The high incidence of the Management of The Deep Venous Re"ux disease, the lack until now of a document in the region based M. Lugli, O. Maleti on scienti!c evidence supported by specialists and the need Vascular Surgery, Hesperia Hospital, Modena, Italy of an easy tool for all kind of physicians, motivated this initiative. Previous guidelines and recent articles were reviewed After excluding proximal obstruction and having treated for evidence, and local studies, medical meetings and rec- the super!cial venous system re#uxes a surgical strategy for ognized opinions were also considered. The GRADE system correcting the deep venous re#ux may be considered. was used for the recommendations. Based on the strength of Deep venous re#ux can be related to three principal causes: evidence, different levels were considered for each topic. The — malfunction of the valves (primary insuf!ciency) main issues in the report included epidemiology, diagnosis, —destruction of the valves, usually post-thrombotic (sec- local therapy, compression, medical and pharmacological ondary insuf!ciency) treatment, and surgical approach of the underlying disease. — Congenital absence of the valves (valve agenesia) The main objective was to create a document common to all The valve malfunction can be related to two principal the countries of the sub continent, based on scienti!c data, events: including the regional diversity and with practical and use- 1°) functional malfunction due to super!cial venous insuf- ful information. The coordinating group was in Argentina !ciency determining an overload of the deep venous system. It and invited leaders from South America participated in the is a reversible condition were we can obtain the competence discussion and !nal approval of the document. This activity of the deep venous system after treating the super!cial system has the auspice of the UIP and local medical societies. Lack alone. of local good quality epidemiological data was a problem in 2°) altereted features of the valves determining a re#ux several countries. In the region there is an extremely broad more or less correlated with super!cial insuf!ciency and were variety of medical assistance, with high participation of pub- the correction of the deep re#ux is usually not obtained by lic hospitals, that implies the necessity of criteria uni!cation treating the super!cial system alone. with limited resources for the treatment of the venous ulcer. The surgical correction of the latter form is obtain by means Specialized advanced units in wounds management would of internal valvuloplasty. be required to improve the quality of medical control of the The valve destruction is characterized by the total destruc- disease. There are no direct or indirect costs regional analysis tion of the valve apparatus so valvuloplasty is not performable data about the venous ulcer burden. In conclusion, the pillars and the only available techniques are vein transposition, vein of the treatment are based on the traditional phlebological transplant and neovalve. approach: local treatment of the ulcer with simple and gener- The purpose of these three techniques is to create an antire- alized materials and the use of compression. The details and #ux mechanism in order to restore a re-equilibrium of the leg the recommendations will be presented and discussed in the when conservative treatments are not able to relief symptoms session of the international perspective of the management related to severe chronic venous insuf!ciency. Valve agenesia of venous ulceration.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 71

FRIDAY, September 13, 2013

scintigrams within 3h, (ii) fast growing edema after hyster- SEPTEMBER 13, 2013 ectomy or groin dissection not controlled by elastic support, (iii) hyperplastic lymphedema in children and teenagers, (iv) FRIDAY decompression of thigh lymph stasis before lower leg debulking.(ii). Contraindications: (i) lack of lymphatics on lymphoscintigraphy, (ii) in#ammatory changes in skin and lymphatics, (iii) idiopathic lymphedema. Postoperative evaluation: lymphoscintigraphy with liver scanning (time of appearance ASK THE EXPERTS of tracer in blood circulation), subsidence of DLA attacks, decreas of limb circumference. Ultrasound in Super#cial Venous Disorders Conclusions. The 5-year follow-up of patients operated in A. Pieri the 1960- and 70-ties showed evident ef!cacy of microsurgical Private Angiologist, Florence, Italy shunting. Todays’ evaluation is partly overshadowed by MLD, administration of long-lasting penicillin and elastic support, Colour Duplex Ultrasound Investigation (CDI) of the super- however, the results in patients who refused additional thera- !cial veins of the lower (and also upper) extremities represents py show at least lack of progression of lymphedema. Modi!ca- the most important progress in the knowledge of the super!- tions of lv shunt as interposition of vein graft or implantation cial venous system. to small subcutaneous veins reveal similar Results. A new functional anatomy of the super!cial venous nets was totally re-written and !nally saphenous veins could be differentiated at a glance by tributary veins. Venous valves became visible and their position, frequency and function could FREE PAPER SESSION 10 be investigated. Perforators were no longer a myth and they could be investigated in their physiology, pathophysiology and Chronic Cerebrospinal Venous Insuf#ciency is Un- position. likely to be a Direct Trigger Of Multiple Sclerosis Skin projections of the veins could be marked also for their M. Simka1, M. Kazibudzki2, P. Latacz2 intra-fascial courses. 1NZOZ Sana, Department of Angiology, Studzionka, Poland CDI allowed to detect different conditions in GSV truncu- 2EuroMedic Medical Center, Katowice, Poland lar re#ux and the extra-saphenous origin of pelvic re#ux. The variability of SSV termination became easy to detect by US Aim. Chronic cerebrospinal venous insuf!ciency, a vascular and the different origins of popliteal re#ux could also be in- pathology affecting the veins draining the central nervous sys- vestigated. tem can accompany multiple sclerosis and is suspected to be The proximal extension of super!cial venous thrombosis involved in its pathogenesis. This study was aimed at exploring became easy to investigate by US that offered the opportunity a potential role for chronic cerebrospinal venous insuf!ciency to overcome the limits of clinical diagnosis showing thrombus in triggering multiple sclerosis. If it were venous abnormali- extension inside the intra-fascial courses of saphenous veins ties responsible for neurological pathology, one should expect and even their extension into the deep veins. negative correlation, i.e. more severe vascular lesions in the CDI made also easy the project for therapeutic !stulas in patients with early onset of multiple sclerosis. the upper extremity. Methods. This survey was a post-hoc analysis of an initial study: open-label clinical trial on endovascular treatments for CCSVI. Patients’ age and duration of the disease were obtained while taking the histories. Localization and degree of venous blockages in 350 multiple sclerosis patients were assessed us- Lymphatic Microsurgery: Is There a Role? ing catheter venography. Statistical analysis comprised evalua- W. L. Olszewski tion of the correlations between severity of venous lesions and Department of Surgical Research & Transplantation, Medical Research patients’ age at onset of the disease. Center, Polish Academy of Sciences, Warsaw, Poland. Results. We found weak, yet statistically signi!cant positive Central Clinical Hospital, Ministry of Internal Affairs, Warsaw, Poland. correlations between patients’ age at onset of multiple sclerosis and accumulated and maximal scores of venous lesions. Aim. Clinical lymphatic microsurgery started in 1966 when The patients, also those with duration of multiple sclerosis not we performed in Warsaw, Poland the !rst microsurgical lym- longer than 5 years, who had their !rst attack of the disease at pho-venous shunts in the groin in 5 patients with lymphedema younger age, presented with less severe vascular lesions. after hysterectomy and irradiation. In course of time various Conclusions. Positive correlation suggests that venous modi!cations have been introduced. Today, lympho-venous lesions are not directly triggering multiple sclerosis. There shunts have established position in treatment of certain types should be another factor that initiates pathological processes of lymphedema in all parts of the world. Own experience. Over in the central nervous system. the last 45 we performed above 1000 microsurgical lymphovenous shunts (lymphnode-vein, lymphatics-vein) in patients with lymphedema of lower limbs. The follow-up was 5 to 40 years. Improvement criteria were: decrease in limb circumfer- The Prevalence of Venous Ulcers: The Olmsted ence (compared to contralateral normal limb), range of move- County Venous Ulcer Study ments in knee and ankle joints, no progress in hyperkeratosis, M. Gloviczki, P. Gloviczki, Y. Huang, H. Kalsi, M. Gibson, S. Cha, J. decrease in frequency of in#ammation attacks. Five years re- Heit sults were in postsurgical group 80% (cancer survivals), 40- Mayo Clinic, Rochester, MN, USA 50% in postin#ammatory, above 80% in inborn hyperplastic, and 5-10% in idiopathic lymphedema. Stabilization of limb Aim. In 2009, the American Venous Forum (AVF) set a goal volume and decrease in frequency of dermatolymphangioad- to reduce the prevalence of venous ulcers (VUs) in the US by enitis were obtained in all patients followed for 5-40 years. 50% within 10 years. The Olmsted County Venous Ulcer Study Present indications for shunts are: (i) at least one lymphatic was conducted to estimate the prevalence of venous ulcers and fragment of inguinal lymph node visualized on lympho- (VUs).

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 75 Methods. The Rochester Epidemiology Project and 18 VU standing position, 22 mm Hg MC signi!cantly reduced the cal- ICD-9 CM codes were used to identify unique residents with iber of deep calf veins but, paradoxically, did not affect super!- possible VU in 2010-2011 (n=1551). The medical records were cial varicose veins. Objective: To study the correlation between reviewed for a 15% random sample (n=227) of these patients. the interface pressure (IP) exerted by a bloodf pressure cuff Based on pre-speci!ed criteria patients were categorized as and the pressure in the muscular compartment. a VU or non-VU case. Continuous and categorical variables Methods. In ten healthy subjects, we used a pressure cuff were compared between groups using the two-sample t-test to study the effects of different pressures on the intramuscular and Chi-square test. pressure (IMP) of the medial gastrocnemius muscle. The IP of Results. Medical record review con!rmed VU (active or the cuff manometer was veri!ed by a Kikuhime® device with healed) in 93 cases (68 in 2010 and 90 in 2011, see Table). a small probe. The IMP of the medial gastrocnemius muscle Non-venous ulcers (ischemic, diabetic and others) occurred was measured with a 21G needle connected to a manometer in 46 and 74 cases, respectively, in 2010 and 2011. ICD-9 CM (Stryker® quick pressure monitor). Pressure data were record- code 454.0 best identi!ed VU cases (sensitivity=24%, speci!- ed in the prone position at rest with cuff pressures of 0, 10, 20, city=100%). Based on the random sample review an estimated 30, 40 and 50 mmHg. 635 patients had healed or active VUs. Results. At rest, the external pressure exerted by MC pro- Conclusions. VU patients were older, heavier and had more duces an IMP increase with a perfect linear correlation from frequently bilateral ulcers. The point prevalence of VUs in the 20 to 50 mm. In the standing position, the IMP reaches the Olmsted County population for 2010-2011 is estimated to be value of 60 mmHg for a compression of about 25 mm of Hg, 2.1/1000 person-year. because the spontaneous IMP is around 35 mmHg. The subcutaneous pressure is the only 25 mmHg, which is not suf!cient to #atten the saphenous and varicose veins. Conclusions. The values of pressure in the super!cial and muscular compartments at rest and in standing give us a good The Presence of Lower Extremity Venous Pulsatility explanation of the “paradox of compression”. is NOT Due to Cardiac Abnormality B. Schroedter, J. White Quality Vascular Imaging, Inc, Venice, FL, USA

Aim. The presence of peripheral venous pulsatility is commonly attributed to cardiac dysfunction, however we have Venous Out"ow Increases Signi#cantly with Below noted pulsatility in patients with no history of heart disease. Knee Compression Stockings in Healthy Subjects In a normal, high compliance venous system, cardiac pulsatil- C. Lattimer1, E. Kalodiki 2, M. Kafeza 3, M. Azzam 4, A. Nicolaides 5, G. ity is continually dampened with distance from the heart. We Geroulakos1 theorized that in a low compliance system, pulsatility would 1Imperial College, Ealing & Northwick Park Hospitals, Southall, Mid- be transmitted throughout and therefore its presence is solely dlesex, UK the re#ection of venous system hemodynamics. 2Imperial College & Ealing Hospital, Southall, Meddlesex, UK Methods. Using duplex ultrasound, we evaluated the right 3Imperial College & Ealing Hospital, Southall, Middlesex, UK 4Ealing Hospital, Southall, Middlesex, 5Vascular Screening and Diagnos- popliteal vein (PV) in 30 normal volunteers with no history of tic Centre, Ayios Dhometios, Nicosia, Cyprus heart disease and minimal venous disease in 2013. The right PV was chosen for its distal anatomic location and to avoid Aim. 1) Measure the effect of an occlusive thigh-cuff at potential left iliac vein compression. Three (3) spectral wave- hampering venous return. 2) Measure the performance of a forms were obtained: 1.) left lateral supine position with PV below-knee graduated elastic compression (GEC) stocking at at the level of the right atrium, 2.) after standing for >3” with overcoming this out#ow resistance. no weight bearing or muscle contraction, and 3.) following 10 Methods. The right leg of 20 healthy subjects was studied seconds of vigorous plantar / dorsi #exion. with air-plethysmography over a class I (18-21 mmHg) and Results. In a supine position, all 30 limbs had normal res- class II (23-32 mmHg) GEC. A 12 cm upper-thigh cuff was in- piratory phasicity. In every patient, following quiet standing #ated step-wise from 0-80 mmHg and de#ated suddenly whilst there was low velocity forward #ow with discernable pulsa- recording the calf volume. The following 3 measured venous tility. Immediately following dorsi#exion, #ow became highly return: Incremental thigh-cuff pressure causing the maximum pulsatile. increase in volume (IPMIV). Out#ow fraction (OF). Venous Conclusions. 100% of patients demonstrated highly pul- emptying time (VET90). satile #ow when the lower extremity venous system reached Results. The median (IQR) baseline values of IPMIV, hydrostatic pressure. While cardiac dysfunction may result in OF and VET90 without compression were 20(range:20-30) venous hypertension, the presence of pulsatile venous #ow in mmHg, 44(39-50)% and 13(8.8-15.9) seconds, respectively. the lower extremity is therefore 1. solely a function of venous With a class I stocking these improved to 50(range:30-70) hemodynamics and 2. should not generally be attributed to P<.0005, 64(52-67)% P<.0005 and 3.7(2.1-8) seconds P=.001, cardiac dysfunction. respectively (Wilcoxon). Similarly, with a class II stocking they improved to 50(range:40-80), 62(56-67)% and 3.5(2.3-8) seconds (P<.0005 for all 3 versus baseline). There was no difference between stocking class except in IPMIV which although Relationship Between Medical Compression and In- was signi!cantly higher with a class II (P=.005, Wilcoxon) its tramuscular Pressure-Explanation of a Paradox of correlation with stocking/ankle interface pressure was poor Compression (r=.360, P=.023, Spearman). J. Uhl1, J. Benigni2, A. Cornu-Thenard3 Conclusions. The pressure required to maximally restrict 1URDIA research unit, Paris, France venous emptying was 30 mmHg higher with GEC. After sud- 2Saint Mandé, France den thigh-cuff de#ation the venous emptying was 41-45% 3F-Saint-Antoine Hospital, Paris, France greater and 9-10 sec faster with GEC. This is a unique study which has quanti!ed the out#ow performance of a GEC in 3 Aim. The method of action of medical compression (MC) is different ways and concluded that below-knee GEC signi!- not well understood. We recently showed by MRI that, in the cantly improves the venous return in normal legs.

76 INTERNATIONAL ANGIOLOGY October 2013 Flow Visualisation of Sclerosant Foam Spreading in Outcome of a Retrieval Stent Filter and 30 Mm a Model of the Super#cial Veins Balloon Dilator for Patients with Budd-Chiari Syn- M. Behnia1, K. Wong2, D. Connor3, K. Parsi4 drome and Chronic Inferior Vena Cava Thrombosis: 1School of of Aerospace, Mechanical & Mechatronic Engineering, Univer- A Prospective Pilot Study sity of Sydney, Sydney, New South Wales, Australia J. Zhang, W. Zhang, X. Han, J. Ren 2St Vincent’s Centre for Applied Medical Research, Darlinghurst, New South Wales, Australia The 1st af#liated hospital of Zhengzhou University, Zhengzhou, Henan, 3St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, China Australia 4St. Vincent’s Hospital, Bondi Junction, NSW, Australia Aim. To evaluate the mid-term safety and efficacy of a retrieval stent filter and 30 mm balloon dilator in the treatment Aim. To visualise the effect of sclerosant type, concentra- of BuddeChiari syndrome (BCS) patients with chronic inferior tion and air ratio on foam sclerosant spreading in a model of vena cava (IVC) thrombosis. the Intersaphenous Vein system. Methods. Thirty-one consecutive patients with BCS and Methods. An experimental rig was constructed using 3mm chronic IVC thrombosis were treated with a retrieval stent filter PVC tubing !lled with saline to resemble the intersaphenous and a 30 mm balloon dilator, and subsequently underwent color vein system. A 25G needle was inserted 100mm away from the Doppler ultrasound follow-up at our hospital. Data relating to junction. A modi!ed Tessari Foam was produced using Sodi- the technical success, angiographic and ultrasound results, um Tetradecyl Sulphate (STS). The effect of sclerosant con- mortality, morbidity, and final clinical outcome were collected centrations (0.1% to 3.0%) and liquid air ratios (1+2 to 1+8) on retrospectively and follow-ups were performed 1, 3, 6, and 12 foam spreading was measured. months after placement of the stent, and annually thereafter. Results. Drier STS foams spread further than wetter foams. Results. Stent filter placement and balloon dilation were Lower concentrations travel further than 3.0%, presumably technically successful in all patients, with no procedure-relat- due to an increased saline content which is less viscous with ed complications. Removal of the stent filter was technically the exception of 0.1% case where bubble formation impeded successful in 22 of 23 attempts, yielding a technical success- foam spreading. ful rate of 95.7% (95% confidence intervals (CI): 87%, 105%). Conclusions. The concentration and liquid-air ratio of Inferior vena cavagrams performed immediately before stent sclerosant foam affect foam spreading length. Further ex- removal demonstrated that the IVC thrombus had completely periments are required to prove that reducing concentrations resolved in all patients without pulmonary embolism. The helps foam sclerosant spread further. mean primary patency rate 3, 6, 12, and 24 months after veno- plasty was 0.91(95% CI: 0.79-1.04), 0.87(95% CI: 0.72-1.02), 0.87(95% CI: 0.72-1.02), and 0.87(95% CI: 0.72-1.02), respectively. The secondary patency rates were 1.00 throughout the follow-up period. All patients are alive with resolution of the symptoms at the time of this report. Low Energy 1470 Laser Ablation of Saphenous and Conclusions. The preliminary results indicate that the re- Perforator Veins: 2 Year Follow-Up trieval stent filter and 30 mm balloon dilator are a safe and ef- D. Joyce fective treatment for BCS patients with chronic IVC thrombosis Joyce Vein & Aesthetics Institute, Punta Gorda, FL, USA

Aim. 1. Determine ef!cacy of low energy (LE) saphenous and perforator vein (IPV) laser ablation (LA). 2. Determine Traumatic Venous Injuries of the Lower Limbs. Li- complication rate with low energy SV and IPV LA. 3. Compare gation or Repair? LE with standard energy (SE) 1470 LA. C. Simkin1, A. Conde2 Methods. 912 patients, CEAP class (CC) 2-6, underwent 1Clinica Simkin-Varicocenter, Buenos Aires, Argentina 3533 procedures with 1470 nm LA over 39 months with bare 2Hospital Fiorito Buenos Aires Argentina, Buenos Aires, Argentina tip silica/silica !bers. 6W (targeted energy (TE) 30 J/cm) thigh SV (GSVT) and 4W (TE 20 J/cm) calf SV (GSVC) and Aim. 1-Integrate the management of venous traumatisms Small SV (SSV) were used for the !rst 138 cases. The next in the lower limbs. 2-To identify all the clinical presentation 3395 cases were 4W (TE 20J/cm) GSVT and 2W (TE 10J/cm.) with different chirurgical treatment. GSVC and SSV. IPV initially at 4W then 2W (15 - 105 J/IPV). Methods. Isolated venous injuries are infrequent and sub Success de!ned as occlusion at the last follow-up ultrasound diagnosticated. Our experience from year 2002 to 2012 in the (FUS). diagnosis, management and treatment of acute venous trau- Results. 644 females, 268 males. CC2:401, CC3:983, CC4- matisms of the lower extremities is presented. All 758 cases A:1470, CC4-B:252, CC5:148, CC6:279. FUS:88.7%. Inter- were classi!cated according to this classi!cation: penetrating/ val: 2 to 1050 days, mean:153.7 days, median:79 days. Suc- iatrogenic, blunt, pure ( only venous affection), A-V or Mixed cess GSVC: 2W:98.0%, 4W:97.3%. p>0.1 GSVT: 4W:97.1%, traumas (A-V, nerves, bones, soft tissue). Preop. arteriography 6W:100%. p>0.1 SSV: 2W:97.9%, 4W:100%. p>0.1 IPV: was done in all cases that hemodynamic situation allowed us to 2W:92.9%, 4W:97.1%. p>0.1 Total: LE:95.6%, SE:98.5%. do it. Diagnostic U.S was performed in 129 cases (17%) From p>0.1 Complications Cellulitis: LE:0.09% 1-GSVC, 1-IPV. 758 injuries, mostly were penetrating wounds (95.29%) as low SE:1.45% 1-GSVT, 1-IPV. p=0.014 Paresthesia: LE:0.47%. velocity !rearms, in men (98.02%), mean age 24 years old; in 6-GSVC, 6-IPV, 3-SSV, 1-GSVT. SE: 0/138 (0%). P>0.1 DVT: 26.4% was affected the venous system: alone 72 cases or as A-V LE:0.059% 1-GSVC, 1-IPV. SE:0% p>0.1 Totals: LE 0.68%, injuries 128 cases. Clinical presentation: 1° asymptomatic 2° SE 1.45%. p>0.1 Dark bleeding. 3° Hematoma 4° Compartment syndrome 5° Conclusions. 1470nm LA is effective and safe at SE of 4-7W, DVT ; 6° AVF; 7° Shock. Same surgical team, 100% open sur- TE 30-50 J/cm. We evaluated signi!cantly lower settings. Ef!- gery. Most affected veins: 1° SFV, 2° Poplitea, 3°popliteal distal cacy was excellent and complications rare with no statistically branches; 4° CFV. Treatment: lateral suture 64 (32%); ligation: signi!cant differences except cellulitis which decreased with 79 (39.5%) Complex repair techniques: contralateral GSV in- LE. Patient discomfort at procedure and post-operatively was terposition graft 57 cases (28.5%). Fasciotomies: 100 %cases. de!nitely decreased with LE. We conclude that LE is appropri- Primary Amputation: 55 cases (7.25%) Prophylactic anticoagu- ate and advisable for 1470 nm LA. lation: 87% cases. U.S follow up at 1, 6 months and yearly.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 77 Results. Scar infection:37%; Edema :100% ; Dvt : 6.2%: P.E 2 parts, due to the presence of a thick septum separating and death:1case. U.S Patency rate was: P.O 98.1%; 1;6 months: the muscle in the midline. The lateral part is the bigger one 94.3% and 89.6% ;at 1 year :74.2%. 65% of the cases were lost and contains longitudinal veins which are draining into the during the follow up at 3rd year P.O. !bular veins above the arcade of the hallux #exor longus Conclusions. Most venous injuries were combined with the muscle. Below this arcade, the !bular veins have a small ca- arterial ones (16.88%) Pure venous injuries were 9.52 % of our liber because they are located inside a !brous canal next to cases. It´s safe to ligate CFV ,SFV, Popliteal venous injuries in the !bula bone. Above the arcade, the !bular veins are much unstable patients. During the P.O and the follow up ,the repair bigger, fed by the huge soleus veins. In the medial part of patients presented less DVT comparing with the ligation ones the Soleus muscle, which is smaller, we can !nd horizontal and there was no difference regarding to the edema presenta- veins ending in the posterior tibial veins. In the upper part, a tion between them. vein frequently crosses the midline to join the !bular veins. Conclusions. The veins of the Soleus muscle are a frequent location for DVT. Most of these veins end in the !bular veins. This explains why the lateral root of the popliteal vein is often The Anatomy of Primary Venous Re"ux the bigger one. M. Qureshi, H. Moore, M. Ellis, I. Franklin, A. Davies Academic Section of Vascular Surgery, Imperial College London, London, United Kingdom Pulmonary Embolism or Ischemic Stroke Increase Aim. 1. Evaluate the anatomical distribution of venous re- 8-Year after Mid Niigata Prefecture Earthquake #ux in patients with primary CVD. 2. Determine the in#uence 2004 in the Residents with Asymptomatic Below- of DVI on saphenous, junctional and perforator re#ux. The-Knee Deep Vein Thrombosis Methods. Duplex ultrasonography reports of consecutive K. Hanzawa1, M. Ikura2, T. Nakajima3, T. Okamoto4, M. Tsuchida4 patients at one institution between 2000 and 2009 were re- 1Niigata University, Niigata, Japan viewed. Legs with secondary CVD, previous treatment, or no 2National Niigata Hospital, Kashiwazaki, Japan venous re#ux were excluded. Patients with inadequate data 3Niigata National Hospital, Kashiwazaki, Japan were not included. 4Niigata University Graduate School of Medicine, Niigata, Japan Results. 8654 legs were scanned; 3803 legs with primary CVD were included for analysis. DVI was present in 1081 legs Aim. VTE frequently occurred after Mid Niigata Prefecture (515 male; mean age 58 ± 17.95 yrs), of which 57% had saphen- Earthquake 2004 due to evacuating into small compact car for ous re#ux, 31% had saphenous and perforator re#ux, 1.7% had more than 4 days after the quake. 4 evacuees died from pul- perforator re#ux, 3.4% had isolated junctional incompetence, monary embolism (PE) in their own car within 10 days. We 0.83% had super!cial tributary re#ux only. DVI prevailed with- have screened below-the-knee deep vein thrombosis (BKDVT) out super!cial re#ux in 6.8% legs. In 2722 legs without DVI by ultrasound for residents living in the quake area every year. (901 male; mean age 52 ± 16.46 yrs), 69% had saphenous re- The purpose of this study is to elucidate whether asymptomat- #ux, 20% had saphenous and perforator re#ux, 3.1% had per- ic BKDVT induce PE or ischemic stroke (IS). forator re#ux, 3.9% had isolated junctional incompetence, and Methods. Subjected were residents in the area of Mid Niiga- 3.5% had super!cial tributary re#ux alone. The frequency of ta Prefecture Earthquake 2004 (Ojiya city and Tokamachi city). perforator re#ux increased signi!cantly with DVI (p<0.001; We collected the residents using public information or radio χ2), whereas the latter did not impact isolated junctional infor screening of BKDVT in 2012. BKDVT was determined by competence (p=0.49; χ2). The frequency of saphenous re#ux compression ultrasound examination. We asked the residents decreased with DVI (90% vs 87%; p=0.039; χ2); this weak sig- simultaneously whether PE or IS occurred after the quake. ni!cance may re#ect large sample size and type 2 error. Results. Total number of residents who had ultrasound ex- Conclusions. Saphenous re#ux with competent deep and amination was 1419 (68.5±10.0 year-old). 121 residents had perforating veins accounts for 50% legs with primary CVD. asymptomatic BKDVT, 6 residents had pulmonary embolism Perforator incompetence is signi!cantly increased in the pres- and 31 residents had IS after the quake. The positive rate of ence of DVI. Correlation with CEAP classi!cation is required pulmonary embolism (3.3%) in the residents with BKDVT was to determine the in#uence of patterns of re#ux on signs/symp- signi!cantly higher than that in those without it (0.13%)(Odds toms of CVD. ratio=7.8 %CI;3.0-10.0, p<0.0001). The positive rate of IS in the residents with BKDVT (9.3 %) was signi!cantly higher that that in those without it (1.5%) (Odds ratio= 3.4, %CI;1.5-7.2, p<0.01). Conclusions. Most BKDVT after the quake was asympto- Anatomy of the Veins of the Soleus Muscle matic and have remained now due to having no medical treat- J. Uhl1, M. Chahim2, J. Benigni3, C. Gillot4 ment immediately after the quake. It is important that asymptomatic BKDVT can not only induce pulmonary embolism, but 1URDIA research unit, Paris, France 2Paris, France also induce IS in longer period. BKDVT after earthquake is not 3Saint Mandé, France lethal, however we may detect and treat it more carefully to 4University Paris Descartes, Paris, France prevent secondary disease. Further study is needed to clarify whether BKDVT increase after earthquake in the other country. Aim. Although the calf muscle pump plays a crucial role in the venous return, the anatomy of the muscular veins of the calf is not well known, particularly the veins of the Soleus muscle, which is a frequent location of distal Deep Venous Comparison of Soft Tissue Grayscale Ultrasound Thrombosis (DVT). Objective: To propose a systematization of Findings in Patients with Chronic Venous Insuf#- the veins of the Soleus muscle. ciency and Lipodermatosclerosis Methods. 200 non-embalmed cadaveric subjects were stud- M. Stanbro1, S. Chastain2 ied using the technique of injection of the venous system with 1Vascular Health Alliance - Vein Center, Greenville, SC, USA Neoprene latex. The day after injection, an anatomical dissec- 2Greenville Hospital System, Greenville, SC, USA tion was done and a full colored segmentation was performed after venous identi!cation. Aim. 1. Objectively characterize lipodermatosclerosis (LDS) Results. The veins of the Soleus muscle are divided into as a manifestation of CVI through grayscale ultrasound !nd-

78 INTERNATIONAL ANGIOLOGY October 2013 ings; 2. Correlate ultrasound !ndings with a broad range of SOCIETY SESSION: CEAP clinical classes, speci!cally concentrating on CEAP clin- SOCIEDAD VENEZOLANA DE FLEBOLOGIA ical class 4b; 3. Examine the clinical utility of adding a brief soft tissue ultrasound exam to standing venous re#ux studies. Photodynamic Sclerotherapy Methods. After IRB approval and informed consent, subjects with CVI with LDS and normal comparators were re- R.D. Matheus cruited for imaging. A total of 55 legs were studied with the fol- Instituto de Atención Integral de Várices, Centro Médico Quirúrgico San lowing CEAP clinical class groupings: CEAP 0 (n = 10), CEAP 1 Ignacio, Caracas, Venezuela through 4a (n = 13), CEAP 4b through 6 (n = 32). By de!nition, It consists in using a prior injection of a substance hydroal- all patients in the latter group demonstrated LDS on physi- coholic hyperosmolar (polidocanol) as microfoam in the vein cal exam. Grayscale ultrasound imaging was performed with and subsequent immediate application on varices of an emis- a 10 MHz probe. After randomization, all studies were then sion of a laser that oscillates at a wavelength close to the reso- presented to a blinded phlebologist for analysis according to nant injectate (Nd: YAG). This method is useful for the treat- a staging system characterizing abnormal !ndings: indistinct ment of telangiectasias and reticular veins. interface between the dermis and subcutaneous tissues, in- The 0.25% polidocanol, in fewer steps can treat almost creased subcutaneous echogenicity, apparent loss of integrity all legs in a concentration insuf!cient to cause sclerosis by of fascial planes, and subcutaneous calci!cation. itself, without altering the effectiveness of 1064 nm laser. Results. The interpreter correctly identi!ed abnormal ul- Clinical results exceeded expectations. The #uence was de- trasound !ndings in all 32 patients with LDS. Overall agree- creased about 40%, with greater ef!ciency. A selected #u- ment between clinical exam and ultrasound !ndings was ences pain level previously injected into veins with polido- 84%. Ultrasound !ndings were interpreted as abnormal in 9 canol is lower than in non-injected. Success depends on the patients (16%) who were not judged to have LDS by physical speci!c increase of light absorption in the form of polydoca- exam. Within this group of patients, 4 individuals had been nol foam injection in contrast to the absorption in its liquid identi!ed as CEAP clinical class 4a, suggesting that soft tissue state injected. This allows increased speci!c absorption take abnormalities visualized by ultrasound may precede the clini- 90% of the energy emitted, instead of 30% using only the cal exam !ndings. laser, and the laser emission line leads to pronounced local Conclusions. To our knowledge, this is the !rst study ex- heating with a vasodilating effect and analgesic. Therefore, amining soft tissue ultrasound !ndings of the lower leg in a when choosing the Nd: YAG laser produces permanent and mixed population of patients with and without CVI. We dem- irreversible thermal damage in the vein recanalization limit- onstrate a high level of agreement between CEAP clinical ing the possibilities as with chemical sclerosis and the fo- class 4 and higher with grayscale ultrasound abnormalities. toesclerosis alone. This brief ultrasound exam adds meaningful information in This procedure is effective, outpatient, tolerable and does patients with CVI and would be a valuable addition to venous not require anesthesia, with side effects similar to or less than re#ux studies. any other method in use.

The Venous Pro#le of Pregnant Women in the Vein SOCIETY SESSION: Consult Program ARGENTINIAN COLLEGE OF VENOUS D. Branisteanu AND LYMPHATIC SURGERY Iassy, Romania Our Experience in the Treatment of Vascular Mal- Aim. To compare the venous related history and clinical formations presentation of the pregnant women of the survey with these M. A. Dándolo, M. E. Pataro, J. M. Chica Muñoz, O. L. Ojeda Paredes of the nonpregnant women in child bearing age (between 18 Department of Vascular Surgery, Sanatorio Profesor Itoiz, Buenos Aires, and 49 years). Argentina Methods. The survey was conducted by general practitioners (GPs) as face-to-face interviews of consecutive patients Aim. Demonstrate the experience of our team in the em- seeking health care. History, risk factors, complaints likely to bolization of high-#ow and low-#ow vascular malformations be related with chronic venous disorders (CVDs) were report- and analyze their effectiveness in the short and medium ed by GPs together with the presence of CVDs signs. term. Results. Twenty countries completed the survey, in Eastern Methods. A cross-sectional retrospective analysis. Be- Europe, Western Europe, South and Latin America, and Mid- tween April 2000 and March 2012 we did 20 embolizations dle and Far East, totaling 1586 pregnant subjects who were in 10 patients, 6 angiodysplasias in women, with a mean compared with the 20 376 nonpregnant ones. Mean duration of age of 42 years. The locations of these were: 7 cases in the pregnancy was 5.3 ± 2.3 months. Compared with nonpregnant lower limb, 1 case in upper limb, 1 patient in the gluteal women, the pregnant ones were younger (30 vs 36 y, P<.0001), region and one in the shoulder region. The diagnosis was had less often positive personal history of thrombosis (2.6% performed by digital angiography, 8 cases corresponding to vs 6.3%, P<.0001), had lower frequency of self-reported CVDs high-#ow angiodysplasia, while two were of low-#ow. The signs such as swollen legs, spider veins, varicose veins (43% therapeutic by selective catheter-directed embolization was vs 49%, P<.0001), and were more often ascribed C0s (32% vs performed in 15 procedures and by direct puncture in the re- 22%, P<.0001) and C3 (19% vs 15%, P<.0001), but less C1 (18% maining !ve. Two patients had a history of surgical resection vs 26%, P<.0001) and C2 (7% vs 15%, P<.0001) by GPs. Preg- of arteriovenous malformation with complete recurrence of nant women also suffered less of venous symptoms than their the disease. A patient with an extensive arteriovenous mal- nonpregnant counterparts, except for heavy legs and sensation formation in the thigh, which required 10 procedures in a of swelling which were equally felt in both groups. period of 10 years. Cyanoacrylate was used in 18 procedures Conclusions. These results mainly mirror the younger age and polidocanol in two cases. A patient with a huge malfor- of pregnant women. Only edema and the related symptoms mation in the dorsal back needed embolization and surgical (heavy legs and sensation of swelling) might be speci!cally re- resection. lated to pregnancy. Results. The technical success of the embolization in the

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 79 nidus of angiodysplasia was achieved in all cases, obtaining Treatment in Vulvar Veins the complete disappearance of the signs and symptoms in 3 A. Kornberg patients. One patient had multiples symptomatic recurrences Vascular and Linphatic Argentine Surgeon College, Postgraduate teach- with embolization procedures, requiring 10 interventions in a ing Phlebolinfology Salvador University, Professor Pietravallo, Buenos period of 10 years. There were no adverse effects during ther- Aires, Argentina apy. There was loss of follow-up in a patient. Conclusions. Embolization of vascular malformations is Aim. While pregnant women more frequently suffer, vari- the best therapeutic method. The treatment is only palliative cose vulvar veins. But also in non-pregnant women ( 8 % ). in most cases, requiring strict monitoring for recurrences. Factors : hormonal, mechanical, multiparity, genetic, could be causing the main symptom, dyspareunia, secondarily vulvodynea. Endovascular Ablation of Saphenous Vein. Six Years Dyspareunia de!ned etymologically to “Greek bedfellows Experience. Learned Lessons that do not conform to each other” Concept: It is called dyspareunia sexual dysfunction im- H. Bauza Moreno, H.D. Martinez mediately manifested by genital pain before, during or after Phlebology Section, Department of General Surgery, Hospital Italiano de intercourse. It occurs in both sexes but is more common in Buenos Aires, Argentina women. Today it is accepted that there is a factor causing the pain initial which could then perpetuated by other physical, Radiofrequency ablation (RFA) and endovenous laser treat- mental or psychosocial. Patients may present well-de!ned and ment (EVLT) are the two most commonly minimally invasive localized pain or sexual dissatisfaction associated discomfort, thermal ablation methods, used to treat saphenous varicose which can disrupt the normal functioning and cause sexual veins, with high occlusion rates and very low side effects in problems. Vulvodynia is a strange pain syndrome, complex the short and the mid-term follow up period. We started with and unfamiliar to affect women between 20 and 65 years of these kind of procedures six years ago at the Hospital Italiano age. de Buenos Aires. Concepts such as energy dosing, tumescent Basically, vulvodynia is de!ned as vulvar pain. Women with anesthesia, dispositive position and new kind of complications this condition suffer from chronic pain, persistent irritation like the EHIT (Endovenous Heat Induced Thrombosys) will be of the genitals, and painful intercourse. Until recently, it was shown as well as some of the different lessons learned during thought that vulvodynia was a very rare disease. Over 50% the mentioned period. with vulvar varicose veins, have long chronic pelvic pain. The objective and protocol of work, According to our experience since in 2006 and 2013, determining a frecuency of symptoms (dyspareunia, vulvodynea), and appropriate treat- ALEAP (Echoassisted Laser Ablation of Perforator ment. Methods. semiology congestion, pains, (dyspareunia), Veins). Long term follow-up. (5 years) veins transvaginal doppler, doppler low member, hormonal O. Gural Romero, O. Bottini, M. Parodi, J. Bercovich, M. Morales, R. dosage: FSH. TSH, estradiol, NMR (Angioresonance) (subdia- La Mura phragmatic re#ux). Phlebology Section, Vascular Surgery Division. Clinicas Hospital “José de Results. Over 80 patients with chronic pelvic pain, ranging San Martín”, Buenos Aires, Argentina from age 28 to 42 years, 7 patients (5.6%) had varicose vulvar veins. Aim. Insuf!ciency of perforator veins by themselves or as- Made the diagnosis, and discarding subdiaphragmatic re- sociated to re#ux of saphenous trunks are responsible for the #ux in all patients was performed, sclerotherapy with sodium venous disease, they have been treated with conventional and teradesilsulfate 1 %, FOAM technique endovascular techniques. The present work details a technique Adverse effects occurred as 2% pain, erythema 1%. After called sclerosis with echoassisted laser of perforator veins sclerotherapy was placed Compression, with Panty Girdle, (Aleap), its follow up and long term evolution. “MIDENI” for 7 days. No relapse to date. Methods. From December 2004 to September 2007 a pro- Conclusions. Varicose vulvar veins develop in pregnant spective and close study was performed. women, but also in non-pregnant women, between 28 and 40 134 patients were operated, 302 perforator veins, 118 wom- years of age by 8%. The main symptom is dyspareunia and sec- en and 16 men. The mean age was 57 years. According to CEAP ondarily vulvodynea. Made the diagnosis, treatment, we have classi!cation, C2 52%, C3 32%, C4 32%, C5 16%, C6 6a%. The done with Sclerotherapy, Foam, with Sodium tetradedesilsul- main location was the middle and distal third of the leg. fate at 1%, and therapeutic compression with, Panty Girdle ALEAP as unique procedure in 10 cases, (7,46%) and com- Compression, “Mideni”. No recurrence at present. bined with treatment of saphenous trunks and epifascial veins in 124 cases (92,54%). High power diode laser of 980 – 810 nm of wave length, power of 6/14 Watts, time 5 seconds (mean), energy 30-140 joules/cm., continous mode, linear optical !bers of 400 microns were used. Echoassisted procedure with !xed The Impact of Endovenous Laser Therapy on the security margins 1-2 and tumescent anesthesia. Quality of Life of Patients with Chronic Venous Dis- Results. Inmediate occlusion in 295 perforators, 7 persist- ease ent and 15 recurrence within the !rst 6 months, no cases later M. Morales on. Follow up until March 2013 by ultrasound at 1st - week, 1 st . Bazurto Phlebology and Lymphology Dr. Bottini Medical Center, (SRL 3rd , 6 th . months, 1 st ., 2nd .,3rd .,4th .and 5th . years. Minor compli- Buenos Aires Estethics), Buenos Aires, Argentina cations as haematoma, induration, without evidence of deep venous thrombosis. Positive clinic and satisfaction evolution. Aim. This prospective study was designed to determine the Conclusion. This work is included in other multicenter effects of Endovascular Laser Therapy (EVLT) in the Qual- study with 973 patients, 2740 perforators, not included in this ity of Life of Patients with chronic venous disease and assess presentation. This technique with positive outcomes. appears the rate of occlusion of the Great Saphenous vein and Small effective, fast and replicable. Evolution exists, with the use of Saphenous vein, (GSV - SSV) after this procedure. 1470 nm.laser, it is possible without tumescent anesthesia, ex- Methods. Seventy six patients with stage C2-C6 of CEAP cept in isolated cases, reduction of surgical time, less recur- classi!cation were included. Clinical history was taken while rence and complications. physical examination and Duplex Scan were performed at

80 INTERNATIONAL ANGIOLOGY October 2013 baseline and during follow-up. All patients underwent EVLT to determine. In many cases SVT is a mild condition, which re- and were followed-up for a year. Forms of VCSS, AVVQ and solves spontaneously. A SVT occurs in two different forms: with SQOR-V were !lled before the procedure and at follow-up ex- varicose veins (V-SVT) and without varicose veins (NV-SVT). aminations. The diagnosis is based on the presence of erythema and tender- Results. The responses to quality of life questionnaires, ness in the distribution of the super!cial veins, with the throm- showed decreased the venous disease after treatment (p< bosis identi!ed as a palpable cord but extensive color #ow U/S 0.0001). The changing perception of the disease from baseline is mandatory for the precise evaluation of SVT: U/S evaluates compared to the !nal follow-up was change in favor of having the length of the thrombosis in the super!cial vein and also the less or no disease (p <0.0001). The rate of GSV occlusion was extension of thrombus into the deep venous system through 100%. In 88.5% of the cases only traces of the vein were seen in perforating veins or the saphenous-femoral junction SFJ and or the saphenous canal, while the remaining 11.5% the vein was saphenous-popliteal junction and/or SPJ. Bilateral compression seen in its entirety having smaller diameter and being !brosed. U/S may also reveal the presence of an associated DVT in The equivalent numbers for the SSV were 87.5% and 12.5% re- the contralateral limb. The treatment of V-SVT and NV-SVT is spectively. The diameter reduction from baseline to 12 months the same in the acute stage of the disease. If SVT involves SFJ, follow-up was signi!cant for both the GSV and SSV p <0.0001 SPJ or con#uences into the deep system through perforating for both veins. veins, anticoagulants must be used as like as for treatment of Conclusions. EVLT provides high rates of vein occlusion DVT. In case of NV-SVT it is mandatory to investigate and treat and signi!cantly improves the quality of life of patients with the underlying condition. Every patient with spontaneous NV- CVD and shortens the recovery time after the procedure. SVT or recurrent V-SVT must be investigate extensively for SVT risk factors, especially cancer and thrombophilia.

SOCIETY SESSION: SOCIETY SESSION: ITALIAN SOCIETY ACADEMIA MEXICANA DE FLEBOLOGIA FOR VASCULAR INVESTIGATION Y LINFOLOGIA - MEXICAN CONSENSUS OF SCLEROTHERAPY Chronic CerebroSpinal Venous Insuf#ciency E. Menegatti, S. Gianesini, P. Zamboni Background and Signi#cance of the 1st Mexican Vascular Disease Center-University of Ferrara Italy Consensus of Sclerotherapy F. Vega Chronic cerebrospinal venous insuf!ciency (CCSVI) is a syndrome that is characterized by stenoses or obstructions Clinica De Varices Y Ulceras De Mexico, Mexico D.F., Mexico of the internal jugular and/or azygous veins, leading to a disturbed #ow and consequent collateral circles activation. The Sclerotherapy is a procedure often used by doctors. In Mexi- brain drainage and perfusion impairment can follow. Venous co it was initially used by estheticians with cosmetic purposes, narrowings are primary obstructions, mainly related to seg- now it is recognized as a speci!c medical treatment for super- mental hypoplasia or, more frequently, to intraluminal defects !cial venous insuf!ciency. Although literaturemention indica- like webs, !xed valve lea#ets, membrane. Finally, obstruction tions, contraindications, materials, equipment and required tools for its implementation and used dose of administrated can be caused by extrinsic compressions. CCSVI has been par- sclerosing, every country should have a document which sum- ticularly studied in MS patients, where the majority of studies marizes all these aspects applied to local idiosyncrasy.There- indicate a higher prevalence respect to controls. fore a source document with the conceptual, legal, medical Ultrasound diagnosis is fast evolving. While the Consensus and ethical framework for sclerotherapy in Mexico is required. Criteria (UIP-ISNVD-UIA-ACP-EVF-AUACP) can be consid- Sclerotherapy should be considerate as an alternative medi- ered a good screening method, ultrasound technique is also cal procedure to treat varicose veins in all its forms and not moving toward a cerebral venous out-#ow quanti!cation in just as a cosmetic procedure, demystifying idea that “Veins relation to the cerebral blood in-#ow. New parameters can be are uncovered” or “washed” by sclerosing injection. In a docu- derived in order to assess the haemodynamic impact of CC- ment must be highlighted that the reason for the procedure, SVI more reliably. Moreover, muscular entrapment seems to its scope and its use as !rst option of medical care for varicose be an emerging cause of venous obstruction, and through ul- veins is scienti!cally supported and most be performed by a trasound technique it is possible to perform a new real time, trained physician, and should not be by persons not author- b-mode, dynamic test that is aimed to detect this abnormal- ized to do so (Technical, beauticians, etc..) ity. This presentation highlights all these emerging and recent Another important issue is the de!nition of the procedure technical ultrasonographic details, showing the potential con- itself, which give legal arguments to doctors who perform it, sequences determined by the CCSVI condition on the brain especially in the area of Thrombosis. It is common that doc- pathophysiology. tors without knowledge or ethic accuse other doctors of causing super!cial thrombophlebitis post sclerotherapy, judging it a non-conventional or even iatrogenic method, undermining it. Sclerotherapy itself implies vessel thrombosis as a conse- Management of SVT of Lower Limbs quence of endothelial injury, but the difference is that Phle- L. Aluigi bosclerosis provoke a “Controlled” thrombus, which become Center and school of Ultrasound, Internal Medicine A, Maggiore Hospi- unfunctional the affected vein. This is a key argument in the tal, Bologna, Italy legal defense of our colleagues. Other important point of consensus is the sclerosant, since Super!cial vein thrombosis (SVT) is an acute disease where in our country it is very dif!cult to acquire polidocanol or thrombus formation is connected with an in#ammatory re- sodium tetradecyl sulfate, besides the treatment of small tel- sponse of the venous wall. It is not easy to distinguish the degree angiectasias or reticular veins is usually practiced with glyc- of thrombosis and in#ammation, at the beginning of the disease erin, glycerine chromic or in institutional medium with hyper- but duplex ultrasound (U/S) may help in the diagnosis. SVT is tonic solutions of glucose or sodium chloride. We recommend a relatively frequent disease, but its exact incidence is dif!cult use concentrations accordingly to the international literature

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 81 and experience in Mexico, in order to standardize this practice Equipment required: and gradually !nd the best outcomes in our population, hop- 4.1 transilluminator ing to !nd soon polidocanol supported by health authority. It is generally agreed that there must be transillumination Establish the framework for the treatment of varicose veins team to successfully complete the sclerosis procedure, wheth- most commonly used in our country, would aloud growth of er !xed or portable type. phlebology and the application of the technique with better 4.2 dopplerr minidoppler or linear Results. Mini-Doppler (or Doppler Linear) Equipment is indispensable for diagnosis and veri!cation of the correctness of sclerotic veins re#ows. 4.3 Color Doppler Consensus General Results If Color Doppler equipment is available, it is convenient to N. Sanchez use the mini-Doppler and it is not always a complete study to Department of Vascular Surgery, Distrito Federal, Mexico City, Mexico the patient and it allows a quick veri!cation of the treatment. Aim. To Develop, based on world literature and the experi- 4.4 Oxygen tank ence of experts in Phlebosclerosis, a document that would co- Oxygen Tank with nasal prongs. ordinate concepts, preferences, differences and variations on To prepare foam and other uses. the axes of diagnosis, uses, treatment and other topics that in- The indications, contraindications, sclerosing, !tness, com- volving sclerotherapy, this document may have reference value pression, and other points, are similar to other published con- from the academic, medical, legal and practical standpoint. sensus. The concept of consensus: Our concept of consensus will be re#ected in two aspects: Consensus Additional Recommendations Consensus: Methods and conditions accepted unanimously. Variations: Methods and conditions that vary in relation to C. Ramirez the consensus set, in other words the variations permitted or Departament of phlebology, General Hospital of Matamoros, Tamaulipas, undertaken by the panelists in relation to the general consen- México sus. The treatment of Telangiectasias and reticular veins with This concept will allow us to establish general guidelines chromate glycerin has been accepted during decades. In our while handling the variations accepted in our country accord- experience we have been using simple glycerin without chrom ing to medical expertise and world literature. compounded with lidocaine for more than ten years. Concen- Topics of consensus: tration will be depending of the of the veins caliber. There is a 1. Overview: comparative study from Dr. M. Goldman where it talks about Telangiectasia treatment with simple glycerin and tetradecyl Prerequisites 1.1 sulfate of sodium, observing a better response and fewer com- 1.2 De!nition of sclerotherapy plications with the glycerin, the suf!cient amount can be di- 1.2.1 Physical application forms of sclerosing luted in order to inject micro telangiectasia (!nal touch) with 1.3 Indications 31 caliber needles. 1.4 Contraindications The transillumination as a support technique that is very 1.5 Sclerosing important to diagnose of reticular veins, telangiectasias pa- 1.6 Concentrations sclerosing thology and their perforating veins, the trasilluminacion has Sclerosing become in a fast, reliable and effective vein imaging technique, 1.7 Volumes (liquid and foam) allowing a perfect mapping for a surgical procedure and when 2. Material: we realize sclerosis supported with the transilluminator it al- 2.1 General lowing to see the sclerosing with a precise respond of the vein 2.2. Syringes to substance or agent, therefore the quality of the sclerosis is 2.3. Needles considerably elevated and the risk for complications is fewer. 2.4 Catheter It is an important tool to locate with precision the blood clots and drain them easily. For all the above we consider the Tran- 3. Patient: silluminator is an indispensable tool at the Phlebology profes- Position sionals’s of!ce. Compression We consider that the foot venous pathology is of paramount Equipment required: important, unfortunately for being the most distant part of our Transilluminator body it gets the most adverse effects of gravity and fewer stud- Minidoppler ies have been made, but deserve more attention. There is at Oxygen tank least a dozen of perforating veins, therefore We consider con- Usg doppler venient to add in the CEAP classi!cation in the Anatomy Sec- Recommendations: tion Num. 19. In some occasions the foot venous pathology is Thrombectomy equal or worst that the rest of the extremity, requiring a similar Type varices handling mostly with the use of Sclerotherapy. Are highlighted in a special way a few points: 1.2). De!nition sclerotherapy: It adopts C issued by Latin American in which our country Suggestions to Other Consensus participated. : R. Castaneda “Medical procedure that involves the introduction of a Department of Phebology, Centro Medico Monterrey, Monterrey Nuevo chemical intravenous produced by various mechanisms on the Leon, Mexico endothelium, lysis thereof and a thrombotic event, leading to obliteration of treated vessels and !brosis” As an opportunity to provide strategies to help in the Within the equipment needed for sclerotherapy include: treatment of some of the most persistent health condition

82 INTERNATIONAL ANGIOLOGY October 2013 around the world, the varicose veins, we created the mexican bolytic therapy venography almost always reveals a stenotic consensus of sclerotherapy. lesion just outside the subclavian jugular vein junction. This After evaluating the content of other consensus, we have lesion is thought to be the result of either anatomic compres- two suggestions: one, to improve the diagnosis and technique sion of the vein at that site or repeated damage from exces- methods and second, to start with low dosage of foam in the sive upper extremity activities or a combination of both. treatment of telangiectasias. What to do once patency has been restored to the vein is con- As a !rst suggestion, is the use of transilluminator. It has troversial and often center dependent. Removal of the !rst advantages for both, the patient and the treating physician rib is generally advocated to decompress the thoracic outlet to form a better picture of venous insuf!ciency. It is impor- and this may or may not be combined with various catheter tant to mention that in our consensus, we did not vote for or based or open surgical repairs of the vein. Very good results against having a transilluminator in of!ce, we decided that is in terms of relief of symptoms have been reported with many a tool necessary for the diagnosis and treatment of varicose combinations of techniques. There are no randomized trials veins. in this !eld and whether aggressive treatment really provides One of the main advantages of a transilluminator is the superior treatment in the long run to anticoagulation alone diagnsosis. We can see the trajectory of the varicose vein, whe- is really a matter of personal conviction and individual physi- re we can !nd the best spot to make the puncture, see the scle- cian prejudice. rosant runing into the varicose vein at its end, and !nd the best spot to make thrombectomy. With all this we can see that is a fundamental device that can facillitate the work and reduce the risk of extravasation. The second suggestion would be in the treatment of telan- Accreditation of Venous Centers giectasias. In our consensus we vote in favor to start with the J. Blebea use of 0.09% of polidocanol (foam) after the treatment of reti- Division of Vascular Surgery, Department of Surgery, University of Okla- cular vein. This dose can irritate endothelium, so it is effective homa College of Medicine, Tulsa, Oklahoma, USA and has the following advantages: it reduces the burning of the application, reduces in#amation of surrounding tissue (de- Aim. Up to two million Americans have venous disease creasing the risk of matting), and reduces the risk of necrosis with an estimated health care cost of $5 billion each year. The on skin. number of interventions performed for venous disorders have Wishing in the most humble way, that these suggestions been increasing dramatically, particularly with the advent of will help in the development of better treatments for varicose minimally-invasive procedures and the decrease in physician veins. re-imbursement for other medical care. Many of these procedures are now performed in independent outpatient centers, by physicians of multiple specialties with varying degrees of training and experience. There is therefore a need for accreditation of vein centers that includes evaluation of the training SOCIETY SESSION: and experience of physicians treating venous disease and the facilities in which procedures are performed to assure high AMERICAN VENOUS FORUM SYMPOSIUM quality patient care. Process. First established in 1990 for the purpose of ac- Effort Thrombosis - Evidence for and Against crediting non-invasive vascular laboratories, the Intersoci- G.L. Moneta etal Accreditation Commission (IAC) developed standards Professor and Chief, Vascular Surgery, Oregon Health & Science Univer- and guidelines for the performance of vascular testing and sity, Knight Cardiovascular Institute, Portland, USA quali!cations for vascular technologists and interpreting physicians. This has resulted in over 2,500 currently accred- Primary axillosubclavian vein thrombosis (axillosubcla- ited vascular facilities. This process has been extended to vian vein thrombosis not associated with a catheter) presents cover accreditation for echocardiography, nuclear medicine, with sudden onset of unilateral upper extremity swelling, CT and MRI facilities, and carotid stenting. Having identi- pain and cyanosis. Primary axillosubclavian vein thrombosis !ed a similar need in the care of patients with venous dis- has also been termed “effort thrombosis” or Paget-Schroetter orders, the process has now begun for the accreditation of syndrome. It is a relatively infrequent condition primarily af- vein centers. fecting younger individuals. Males are affected 4 to 1 over Results. Under the auspices of the IAC, nine professional females and the right upper extremity is affected 2 to 1 over organizations have sent 14 representatives as founding mem- the left. While repeated use of the upper extremities is a rec- bers of the Board of Directors of IAC –Vein Centers. After an ognized association with the condition, many patients have initial in-person meeting of all representatives to establish the no history of upper extremity activity beyond that of normal bylaws and organizational structure for the new organization, activities of daily living and it is unclear if the condition is regular bi-weekly teleconferences have been held during the activity induced or activity associated. Testing for hyperco- past year to develop the accreditation standards for the cent- aguble states is sometimes positive but hypercoagubility is ers, which include the required quali!cations of participating not generally considered a requirement for the disorder. Oth- physicians and ancillary personnel. This has included accredi- er than initial anticoagulation, treatment for acute primary tation for the treatment of super!cial and deep venous disease axillosubclavian vein thrombosis is controversial. Currently, to be followed by standards for lymphatic disorders. It is an- the most commonly recommended initial treatment in the ticipated that these standards will be !nalized by the summer U.S. is anticoagulation followed by catheter directed throm- of 2013 and implementation at three test centers begun this bolytic therapy. This is not necessarily the recommended year. It is planned that applications for accreditation will be- treatment in many other parts of the world with excellent come available by the end of the year. eventual relief of symptoms reported just with the use of an- Recommendation. With such a broad prevalence, high ticoagulation alone. Catheter directed thrombolytic therapy cost, and diversity of treating specialists, an accreditation (CDT), however, is highly successful in rapidly restoring pat- process for vein centers is being established to improve pa- ency to the axillosubclavian vein, especially if administered tient care. Accreditation should be supported by all physicians within 2 weeks of onset of symptoms. CDT can result in rapid and professional societies involved in the treatment of venous improvement of swelling and discomfort. Following throm- disease.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 83 SOCIETY SESSION: group were 91.9% and 58.2% and 2-year were 83.1% and CHINA ASSOCIATION OF PHLEBOLOGY 50.9%. Multivariate analysis showed that independent predictors for variceal rebleeding were TIPS treatment and de- Treatment of Acute Pulmonary Embolism with Ind- gree of superior mesenteric vein occlusion. Recanalization of portal venous system was realized in 23 (62.2%) patients in welling Catheter Thrombolysis TIPS group and 7 (19.4%) in EVL group. Multivariate analy- Z. Maoheng, Z. Qingqiao, G. Yuming, X. Hao sis showed that independent predictors for portal venous Department of Interventional Radiology, The Af#liated Hospital of system recanalization was TIPS treatment. 1-year and 2-year XUZHOU Medical College, China cumulative TIPS dysfunction rates were 91.7% and 80%. 1-year and 2-year cumulative hepatic encephalopathy rates Aim. To study the value of treatment of acute pulmonary were 16.2% and 41.8% in TIPS group and 17.4% and 40.2% embolism with indwelling catheter thrombolysis, To investi- in EVL group. There was no statistically signi!cance in he- gate the interventional integration diagnosis and treatment of patic encephalopathy rate between two groups. 1-year and deep vein thrombosis and pulmonary embolism (VTE). 2-year cumulative survival rates were 89.2% in TIPS group Methods. Pulmonary angiography inferior vena cavogra- and 86.1% and 80.4% in EVL group. There was no statisti- phy and suffered iliac-femoral venography were performed in cally signi!cance in survival rates between two groups. In a 645 patients, age 16-82 years old, mean 53.5 Yrs. High-risk multivariate analysis, higher Child-pugh score showed to in- pulmonary embolism were found in 105 patients and medium- dependently predict death. risk PE in 16 patients at pulmonary angiography. pigtail cath- Conclusion. These results suggest that TIPS is more effec- eter was indewellinged in pulmonary arterial after place !lter tive than EVL plus NSBB in preventing oesophageal variceal in IVC and UK was perfusion. and recanalizing the portal venous system, without increasing At regular time until PE dissolution. then thrombolysis hepatic encephalopathy rates. During a limited follow-up time, catheter was pushed into thrombose of femoral vein. UK was no statistically signi!cance in survival rates was observed be- perfusion via thrombolysis catheter and controlled angiogra- tween two groups. phy at regular time until thrombose of iliac femoral vein was dissolution. The !lter was withdrew after VTE dissolution. Heparin was injected in subcutaneous within thrombolysis. Results. Keeping catheter in pulmonary 5-14 days, mean 7.9 days,Urokinase dosage was 20-80 million units each day, the total amount of Urokinase 100-760 million units ,an aver- The Diagnosis and Endovascular for Iliac Vein Com- age of 3.36 million units. Thrombolysis effect in 119 patients pression Syndrome with PE was satisfactory, 2 older patients with PE died within J.P. Gu, W.S. Lou, X. He, L. Chen, G.P. Chen, H.B. Su, J.H. Song, T. PE thrombolysis, 119 !lters was withdrew, thrombolysis effect Wang, W.Y. Shi in 634 patients with satisfactory, The complication of blooding Department of interventional radiology, Nanjing #rst hospital, Nanjing happened in 14 cases with puncture site, in 4 cases with hema- Medical University, Nanjing, China turia in 5 cases with subcutaneous and intermuscular. Conclusions. Keeping catheter thrombolysis is a safe and Aim. Iliac vein compression syndrome (IVCS) is a clinical effective treatment for acute PE. interventional integration di- syndrome, which is characterized by pelvic and iliac vein out- agnosis and treatment of deep vein thrombosis and pulmonary #ow obstruction resulting from the compression of iliac vein embolism (VTE) is recommendable. by the overlying iliac artery, consisting of a myriad of symptoms and sometimes causing lower extremity deep venous thrombosis (LEDVT). In previously published articles, we reported an acceptable and encouraging short-term outcome of endovascular treatment for IVCS with or without LEDVT. Randomized Controlled Study of TIPS versus EVL Here we present and report our long-term follow-up data of plus NSBB for Preventing Oesophageal Variceal stented iliac vein in such patients. Methods. The demographic information, clinical presenta- Rebleeding in Cirrhotic Patients with Portal Vein tions, and treatment techniques were described in detail in the Thrombosis article published in KJR in 2009. Brie#y, percutaneous trans- L. Xiao, L. Xuefeng luminal angioplasty (PTA) and implantation of stents were Department of Interventional Radiology, West China Hospital, Sichuan performed for IVCS, but additional treatments including aspi- University, Chengdu, Sichuan, China ration and thrombectomy were used for those cases with fresh thrombus. A scheduled follow-up of lower extremity venogra- Aim. Portal vein thrombosis (PVT) is a common complica- phy at 1 year and 3 years was performed aiming to evaluate the tion of portal hypertension in cirrhotic patients. The present long-term patency of stented iliac vein. randomised controlled trial was designed to compare the tran- Results. During follow-up, venography of lower extremity sjugular intrahepatic portosystemic shunt (TIPS) versus endo- and pelvic veins were obtained in 78, 75 and 69 patients at the scopic variceal ligation (EVL) plus non-selective beta-blockers time of 6-months, 1 year and 3 years respectively. The 1 year (NSBB) in preventing oesophageal variceal rebleeding in in patency rate was 88.0% (22/25, group 1) and 81.82% (27/33, cirrhotic patients with PVT. group 2) and 41.18 % (7/17, group 3), and the 3-years patency Methods. Between January 2010 and December 2012 M, rate was 79.17% (19/24, group 1) and74.19% (23/31, group 2) 73 patients were randomly allocated to receive TIPS (n=37) or and 35.71 % (5/14, group 3), respectively with signi!cant dif- EVL plus NSBB (n=36). The groups were comparable regard- ference. Long-term patency rate in IVCS patients with or with- ing age, sex, etiology of liver cirrhosis, liver function, severity out fresh thrombosis were signi!cantly greater than that in and extent of PVT. IVCS patients with non-fresh thrombosis. Results. The mean follow-up time was 15.9±5.7 months Conclusion. Endovascular treatment for IVCS with or within TIPS group and 17.1±5.1 months in EVL group respec- out fresh thrombosis is technically feasible with an acceptable tively. TIPS technical success was achieved in all 37 patients and encouraging outcome of long-term in-stent patency. We and portal vein pressure gradient was reduced from 27.5±7.5 suggest that more attention should be paid to the evaluation of mmHg to 10.4±3.1mmHg. The 1-year probability of remain- iliac vein compression in patient with unilateral lower extrem- ing free of variceal rebleeding in the TIPS group and EVL ity edema and early recognition plus endovascular treatment

84 INTERNATIONAL ANGIOLOGY October 2013 of iliac vein compression could prevent a subsequent DVT and INVITED LECTURE improve clinical symptoms. The Basic Science of Primary Venous Insuf#ciency J.D. Raffetto Assistant Professor of Surgery, Harvard Medical School, VA Boston HCS, Agitating Thrombolysis Technique for the Treat- Brigham and Women’s Hospital, Department of Surgery, West Roxbury ment of Inferior Vena Cava Fresh Thrombus in Pa- & Boston MA, USA tients with Budd-Chiari Syndrome H. Xinwei, Z. Wenguang, W. Zhonggao The pathophysiology of primary venous disease is a com- Department of Interventional Radiology, the First Af#liated Hospital of plex entity with multifaceted stages leading to the dilated tor- Zhengzhou University, Zhengzhou 450052, China tuous, valve insuf!cient varicose veins, venous hypertension and the associated clinical manifestations seen with chronic Aim. To evaluate the therapeutic ef!cacy of agitating throm- venous disease. Several epidemiologic studies have assessed bolysis technique for Budd-Chiari syndrome complicated with the associated risk factors. Certainly genetic and environmen- fresh thrombus of inferior vena cava(IVC). tal factors in#uence the predisposition and perpetuation of Methods. From August 2005 to March 2012, 15 patients developing primary venous disease. Some important observa- of Budd-Chiari syndrome with fresh thrombus of IVC were tions are a family history, female gender, pregnancy, estrogen, treated with agitating thrombolysis technique, 9 males and 6 the latter three all associated with varicose veins clinically, female, the age ranging from 36 to 52 years-old. After venog- prolonged standing and sitting postures, and obesity. Genetic raphy and then recanalization for IVC was performed, which conditions such as Klippel-Trenaunay Syndrome, KTS, CA- was followed by agitating thrombolytic therapy used by a 5F DASIL, FOXC2 gene mutation, Ehlers Danlos syndrome all of pigtail catheter and a 0.035 inch guidewire. Finally, IVC was which display early onset of varicose veins. However, the vast dilated with percutaneous transluminal balloon angioplasty. majority of individuals with primary venous disease do not Clinical follow-up of IVC patency was implemented by color have the aforementioned genetic conditions, and a speci!c Doppler sonography. gene leading to primary venous disease and varicose veins Results. After agitating thrombolysis, the thrombus were has not been identi!ed, but it appears that the trait is auto- completely disappeared in all 15 patients without one case pul- somal dominant with variable penetrance. It is clear from monary embolism. In all patients, 14 patients IVC remained biochemical, immunohistochemical, and functional studies patency on color Doppler ultrasonograph after following up that both the vein wall and the valve are involved in the pri- for a mean period of 27.8 months. One patient follow-up color mary events leading to venous disease. Whether it is the vein Doppler ultrasonography at 14 months later showed that dom- wall changes preceding valve insuf!ciency or the valve insuf- inant stenoed. !ciency causing wall distension and wall changes, is a moot Conclusions. Agitating thrombolysis technique is a safe point. Importantly, evidence demonstrates that both vein wall and effective treatment for Budd-Chiari syndrome complicat- and vein valve are pathologically altered to cause primary ed with fresh thrombus of IVC. venous disease. Initiating events likely involve altered shear stress and mechanical stress forces on the endothelium and its glycocalyx, with perturbations on nitric oxide production, vasoactive substance release, expression of macrophage che- The Interventional Treatment of Pelvic Congestion moattractant protein-1 and vascular cell adhesion molecule-1 Syndrome (VCAM-1, CD-106), expression of L-selectins and E-selectins, Z. Jianhao, H. Xinwei intercellular adhesion molecule 1 (ICAM-1, CD54), with re- Department of Interventional Radiology, The First Af#liated Hospital, cruitment of leukocytes leading to leukocyte transmigration Zhengzhou University, China into the vein wall and valve, setting up an in#ammatory cascade and production of several cytokines (TGF-b, TNF-a, Pelvic Congestion Syndrome is also known as Ovarian IL-1) and increased expression of matrix metalloproteinases Vein Syndrome. It is caused by chronic obstruction, conges- (MMPs). Structural proteins have been analyzed in varicose tion, and engorgement of pelvic veins (varicose pelvic vein). veins and important !nding determined that overall colla- The degree of pelvic pain is related to the severity of the dis- gen is increased, and both elastin and laminin are decreased. ease. The etiopathogenesis include anatomical factors and me- When the collagen was examined in smooth muscle from chanical factors such as body posture, retroversion of uterus, varicose veins, the consistent !nding was that there was a early marriage, early pregnancy, multiple-pregnancy, multiple- signi!cant decrease of collagen type III and increased type I, delivery, constipation, lacerated wound of broad ligament and that interestingly was also observed in the dermal !broblasts so on. The distinctive symptoms are three kinds of pain such from varicose vein patients. These !ndings indicate a sys- as inferior abdominal pain, low back pain and dyspareunia. temic condition with strong genetic in#uences, and because Also include excessive menstrual bleeding, excessive Vaginal collagen I confers rigidity whereas collagen III is involved in secretions and presence of few masculine physical sign in the extensibility of a tissue, modi!cation of the collagen I/ gynecological examination. Auxiliary examinations include III ratio might contribute to the weakness and the decreased ultrasound Doppler, CT, MRI, DSA, Laparoscope and so on. elasticity of varicose veins. Interestingly, the transcription of There are many methods to treat pelvic congestion syndrome, collagen III is normal in smooth muscle cells from varicose including hysterectomy, surgical excision of ovarian vein, veins, and the activity of MMP-3 is increased leading to post- laparoscopic trans peritoneal gonadal vein ligation, ventrosus- translational modi!cation of collagen type III; these events pension, shortening of uterine ligament, broad ligament fascia are reversible when MMP-3 is inhibited in-vitro. MMPs are an patch and embolization of Ovarian Vein. Especially, coil em- important step in the development of primary venous disease; bolization of ovarian vein for treatment of PCS is an effective their implications are both early events affecting endotheli- and safe procedure, with high clinical success rate and degree um-smooth muscle interactions and venodilation, as well as of satisfaction. So it is an ideal treatment. At the same time late with extracellular matrix degradation, structural vein mental stress caused by embolization of Ovarian Vein is very wall changes and !brosis. MMPs have been demonstrated to slight. Especially it refers to patients with emotional strain be overexpressed with mechanical stretch and are regulated and sensitivity. Exairesis should be the last choice for patients by hypoxia inducible factors. Other potential mechanisms for of PCS the development of primary venous disease is hypoxia and

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 85 apoptosis of the vein wall; however, studies evaluating these 233.4±52.3 seconds and 91.2±33.8 seconds for SSVs. Mean de- pathophysiologic alterations are more likely associations, livered energy during the procedure was 2651.9±727.8 Joule with signi!cant variability in results and inconclusive. Meta- for GSVs and 932.8±386.3 for SSVs. Mean VCSS scores (Pr- bolic abnormalities may be critical to venous dysfunction and eoperative: 8.65±4.12, 1st month: 2.48±2.11, p<0.01) were im- lead to pathology. Metabonomics is the study of metabolism proved after the procedures. Most of the patients were satis- in biologic systems in response to pathophysiologic respons- !ed with the procedure. es, and in patients with varicose veins there are signi!cant Conclusions. EVLA with 1470 nm wavelength and 2-ring differences in three important metabolic products involving radial !ber for GSVs and SSVs is an effective and safe proce- creatine, lactate, and myoinositol metabolites. Analyzing the dure. This new !ber gives not only the advantage of decreasing cellular metabolism in varicose veins, with signature end delivered energy but also provides almost perfect occlusion products, re#ect the metabolism of the tissue and hold key rates and besides cause almost no pain and no adverse events. information to the disease processes. Further research in this exiting !eld is necessary to have a better understanding of the processes leading to primary venous diseases, in order to have targeted therapy in both the prevention and active treatment of varicose veins and their diverse clinical manifestations. Comparison of 1470 nm Laser with 980 nm Laser in Endovenous Laser Ablation of Saphenous Vein Varicosities M. Hirokawa, N. Kurihara, S. Suguru Ochanomizu Vacular and Vein Clinic, Chiyoda-ku, Tokyo, Japan FREE PAPER SESSION 11 Aim. The use of appropriate laser wavelength and optical New 2-Ring Radial Fiber Experience in the Endov- !ber may decrease major side effects after endovenous laser enous Laser Ablation of Varicose Veins ablation (EVLA) such as pain and bruising. This study was U. Demirkilic1, S. Doganci2 performed to compare outcome and side effects of two laser 1Varis Merkezi, Kavaklidere/Ankara, Turkey wavelengths using bare-tip or radial !ber in EVLA for primary 2Gulhane Military Academy of Medicine, ANKARA, Turkey varicose veins. Methods. This was a retrospective study of 1805 patients Aim. Endovenous laser ablation (EVLA) has been proven to operated for primary varicose veins between 2007 and 2011. be an ef!cient and safe treatment modality for varicose veins. 980nm laser and a bare-tip !ber was used in 1477 limbs (980BF According to the current guidelines endovenous thermal abla- group), 1470nm laser was used in 242 limbs with a bare-tip !b- tion is recommended over high ligation and stripping. Two- er (1470BF group) and in 211 limbs with a radial !ber (ELVES ring radial !ber as a new generation !ber splits the energy Radial TM , Biolitec AG, Germany) (1470RF group). The laser in two phases and leads to an effective vein closure with less was applied at 8-10W in 980BF group, 10W in 1470RF group, energy density. Aim of this study is to present our experience 6-12W in 1470BF group in continuous mode distally from the with 2-ring radial !ber in the treatment of varicose veins. sapheno-femoral junction under tumescent local anesthesia. Methods. Between January 2012 and September 2012, Postoperative follow-up was performed by clinical examina- !rst 80 patients (134 limbs and 173 veins) who had a six tion and venous duplex ultrasonography. month follow up treated for incompetent Greater Saphenous Results. The mean linear endovenous laser energy was Veins (GSV) and Small Saphenous Veins (SSV) included in signi!cantly lower in 1470RF group compared to 1470BF this study. All patients were treated with 1470 nm diode la- and 980BF group (81.4 vs. 85.1 vs. 85.9 J/cm: P<0.05). There ser plus 2-ring radial laser !ber. All the procedures were per- was no deep vein thrombosis except one case in 980BF formed under tumescent local anesthesia. Treatment param- group. Bruising (1.9 vs. 19.4 vs. 15.8%) and pain (0.9 vs. 7.4 eters were 12 Watts and 50 J/cm of LEED for GSVs and 10 vs. 6.2%) were signi!cantly lower (P<0.01) in 1470RF group Watts and 50 J/cm of LEED for LSVs. Cold tumescent local compared to 1470BF and 980BF group. Cumulative occlu- anesthesia was given under ultrasound guidance and with the sion rates by Kaplan- Meier method were signi!cantly high- help of a tumescent pump (10 ml/treated vein length). Vein di- er in 1470RF and 1470BF group compared to 980BF group ameters, treated vein length, total amount of delivered energy, (100% at 2 years 8 months vs. 99.5% at 4 years vs. 94.6% at amount of tumescent local anesthesia, duration of ablation, 2 years: P<0.05). occlusion rates, local pain, bruising, induration, paraesthesia Conclusions. The use of 1470 nm wavelength laser im- in the ablated regions, patient satisfaction and changes in VC- proved mid-term success rates after EVLA. Moreover, EVLA SSs (preoperative, postoperative 1st month) were recorded. using a radial !ber with 1470 nm laser minimized adverse ef- Additional phlebectomies were performed for all patients in fects compared to a bare-tip laser !ber with 1470nm or 980nm both groups. No heparin prophylaxis was used. Follow-up vis- laser. its were planned on the 2nd postoperative day, 7th day, 1st, 3rd, and 6th month. Results. Mean age of the patients was 46.3±13.7 (17-71). 67 of the patients were female. In 30 of the patients there were additional SSV ablations (39 veins). Three of the patients had iso- Prospective Randomized Trial of Endovenous Laser lated SSV incompetence. Mean GSV diameter at saphenofem- Ablation of Great Saphenous Veins with 1470 NM oral junction and the knee levels were 9.3± 4.2 and 6.9±3.1 Diode Laser And 2ring Fibers Comparing Compres- mm respectively. Mean SSV diameter at the level of junction sion Therapy 0 Days, 7 Days and 28 Days After Ther- and mid-calf level were 6.9±2.5 and 5.3±1.6 respectively. The apy: Preliminary Report initial success rate was 100% in all patients. All treated GSVs U. Maurins1, J. Rits1, E. Rabe2, F. Pannier3 and SSVs remained closed after 6 months. No major compli- 1Dr Maurins Vein Clinic, Riga, Latvia cation such as deep vein thrombosis and pulmonary embo- 2University of Bonn, Department of Dermatology, Bonn, Germany lism was observed. There were no local pain, no bruising, no 3Cologne, Germany induration and no paraesthesia in the ablated segment in both groups. Mean treated vein length for GSV was 46.8±9.6 cm Aim. To assess outcome one month after endovenous laser and 16.3±4.0 in SSV. Mean duration of ablation for GSVs was ablation (EVLA) of incompetent great saphenous veins (GSV)

86 INTERNATIONAL ANGIOLOGY October 2013 with 1470 nm diode laser (Ceralas E, biolitec) and a new 2Ring Echo-Sclerotherapy (ES) of the Small Saphenous !bers (biolitec) comparing compression therapy 0 days, 7 days Vein: A Cohort Study of 1411 Patients with a Mean and 28 days after therapy. Follow-Up of 6 Years Methods. 94 patients with primary incompetence of GSV M. Schadeck1, J. Uhl2 underwent EVLA with 1470 nm laser and 2Ring !bers. Ran- 1EEP, PARIS, France domisation was conducted immediately after EVLA in three 2URDIA Research unit, NEUILLY SUR SEINE, France groups: First, with compression stockings (23-32 mmHg), worn during the day for 1 week; Second, with compression Aim. Background : Sclerotherapy under echo control is a stockings (23-32 mmHg), worn during the day for 4 weeks revolution in the treatment of the saphenous trunks, particu- and third - without compression. The mean (s.d.) LEED were larly with the use of foam. Objective : To assess the technique 63(15) J/cm, 65(20) J/cm and 64(16) J/cm respectively. Follow- and long term results of ES of the SSV trunk. up investigations after 1, 7 and 28 days included complica- Methods. Material : 1411 patients with a mean age of 50 ( tions, occlusion rate, vein diameter, VCSS, QoL and pain on a 79% females and 19% males) were treated by echosclerother- scale between 0 and 10. apy from 1990 to 2010. The separation of patients into CEAP Results. After a mean follow-up period of 28 days, occlusion classes were C1 =6% C2 =90%, C3 and higher = 4% The mean rate was 100% in all three groups. No severe complications, age for the !rst ES was 52. The mean duration of the treat- such as deep vein thrombosis, occurred. Diameter of GSV 3 ment was 62 months (± 7).The mean number of ES episodes cm below saphenofemoral junction dropped 43% (0.7 to 0.4 per patient was 2.4 (1 to 18) The mean overall follow-up was cm), 39% (0.8 to 0.5 cm) and 39% (0.8 to 0.5 cm) respectively. 77 months (6 to 243) The mean (s.d.) post-intervention pain scores (scale 0-10) were Results. Techniques and Results The SSV trunk was treat- 0.4(0.7), 0.7(1.0) and 0.8(0.8) respectively. In al groups VCSS ed using liquid only in 32% and foam in 68%. The sclerosing improved from 6 to 3 after 28 days. The average (range) time agent used was STS in 49% and Polidocanol in 51%, the in- to return to normal activity was 0.5(0-3), 0.3(0-1) and 0.3(0-2) jected volume was usually 2cc (57%) and the concentration days respectively. The average (range) time to resume work always 3%. The mean caliber of the trunk treated was 6.3 mm was 1.3(0-10), 0.9(0-8) and 0.8(0-7) days respectively. (3 to 14) The average duration of the treatment was 62 months Conclusions. EVLA of GSV with 1470 nm diode laser and with an average of 2.3 sessions per limb performed (1 to 17) 2Ring !ber is a minimally invasive, safe and ef!cient treat- An in#ammatory reaction after injection was observed in 169 ment option with a high success rate. Use of compressions cases (12%): super!cial in 6.5%, excessive in 5.5%, and no stockings after EVLA with 1470 nm laser and 2Ring !ber has super!cial phlebitis. In only two cases was surgery required no additional bene!t to the following outcome measures: ef- for recanalization with persistent re#ux. Complications were !cacy, pain, vein diameter, time of work and normal activity, very rarely seen : 3 migraines, 6 reversible pigmentations, 1 symptoms, complications and VCSS. localized cutaneous necrosis, 15 DVT (1 super!cial femoral, 4 popliteal and 10 gastrocnemial). This represents 1% of the legs and 0.46% of the sessions Conclusions. Conclusion: Our results demonstrate that with an average of two episodes of ES over a 4 year period (0.4 Bipolar Radiofrequency Ablation of the Saphenous per year) we have achieved a safe and effective ablation of the Veins: A Series of 120 Patients With 2 Year- Follow- SSV trunk, which represents a cost-effective treatment option. Up C. Hamel-Desnos, P. Desnos French Society of Phlebology, Caen, France Routine Transcranial Doppler (TCD) Screening for Undiagnosed Right to Left Shunt Allows for Safe Aim. to investigate the effectiveness and the safety of bipo- Use of High Volumes of Foam Sclerotherapy (FS) lar radiofrequency-induced thermal-therapy (Celon-RFITT®) J. Albert, K. Dremstedt, J. Ochs for thermal ablation of saphenous veins (SV) performed in a Albert Vein Institute, Colorado Springs, CO, USA medical centre. Methods. Open monocentre prospective study. Between 2009 Aim. Neurologic injury and cerebral air embolism(CAE) and 2012,168 incompetent SV consisting of 126 great saphen- have been reported after FS (off-label use). Right to left cardi- ous veins (GSVs), 36 small saphenous veins (SSVs), 6 accessory ac and intrapulmonary shunt (RLS) must be present for CAE saphenous veins (ASVs) were treated in 120 patients (71% wom- to occur. Using <10ml of foam per session is recommended as en) whose average age was 58 and body-mass-index 25. The av- RLS is an accepted risk factor for neurologic injury during FS. erage trunk diameter was of 8 mm. Mean lengths (cm) of treated The purpose of the current study was to 1) Utilize TCD screen- veins were respectively: GSV 48, SSV 24, ASV 19. No sedation ing to identify undiagnosed RLS and determine usefulness of was administered and all procedures were performed strictly migraines as an indicator, 2) Determine if TCD was accepted under tumescent local anaesthesia. Since 2012 the settings rec- by patients, 3) Determine if patients without RLS could re- ommended by the manufacturer are a power (P) of 18Watts and ceive >10ml of FS without neurologic sequelae. an application time (T) of 2.5-6sec/ cm. In our study, started in Methods. From January 2008 to March 2013, 1,825 pa- 2009, on average, P used was 19W and T 6sec/cm. Average fol- tients underwent TCD screening before FS and provided mi- low-up was 28 months (>36 months for 41 patients). graine history. Signi!cant RLS was determined if >grade 2 at Results. By the end of the follow-up, 92% of SV were com- rest and >grade 3 with valsalva according to Spencer criteria. pletely occluded, 7.2% partially occluded; only one SV (0.6%) Patients with RLS received liquid sclerotherapy (LS) and all was totally permeable. Procedures and their postoperative others received FS limited by dose, not foam volume. Aver- course were uneventful and particularly well tolerated: mean age of 25.6ml for USGI FS(STS) and 18.5ml (Polidocanol) for pain score was 2 for the procedure (visual analogue scale 0-10, visual FS. 20% of patients received both sequentially. max=10) and 1 for 10 days after the procedure. Quality of life Results. No patients refused TCD because of invasiveness. survey showed that good resumption to normal life. Satisfac- 432 patients (29%) were found to have undiagnosed RLS. RLS tion score on average was 9.2 (max=10). was found in 35% of migraine positive and 25% of migraine Conclusions. The RFITT® procedure appears to be well- negative patients (P<0.01 Yates Chi Squared). No neurologic tolerated, safe, and effective for SV occlusion in the medium symptoms were reported after FS. term. For a P 18W, we recommend a basis of T of 5-6sec/cm. Conclusions. Use of TCD is easy to perform and accepted

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 87 by Phlebology patients. Absence of migraine suggests, but does Perineal varicose veins were present in 24.3% legs, but were not preclude, RLS. FS >10ml is safe in patients without RLS, the main origin of re#ux in only 12.4%. The rates of re#ux decreasing number of injection and compression sessions. originating from primary dystrophic networks in the inguinal lymphatic layer, from thigh perforators and from saphenopopliteal junction via the Giacomini vein were respectively 1.8%, 3.1% and 1.9%. Effectiveness and Clinical Outcome of Mechano- Conclusions. Two major lessons can be drawn from this chemical Ablation in Patients with Chronic Venous large study. 1. Only 53.2% ostial valves are incompetent, giving Disease a major argument for antegrade development of the varicose disease. 2. A treatment (and speci!cally the surgical resection) J. Koziarski1, M. Bishawi 2, R. Bernstein 3, M. Boter 4, D. Draughn 5, C. Gould6, C. Hamilton III7 of the sapheno-femoral junction is haemodynamically unnecessary in 46.8% of thigh GSV re#ux. 1Family Surgical, Battle Creek, MI, USA 2Stony Brook University, Stony Brook, NY, USA 3The Advanced Vein Treatment Center, Las Vegas, NV, USA 4Vein and Laser Center, Brooklyn, NY, USA 5Vein Specialists of the Carolina’s, Gastonia, NC, USA Perforating Vessels in the Medial Side of the Leg: 6Richmond Vein Center, Richmond, VA, USA 7Hamilton Vein Center, Sugar Land, TX, USA Anatomical Dissection and Duplex Ultrasound Study Z. Sammi1, C. Gillot2, J. Uhl3, F. Vin 4 Aim. 1. Evaluate the ef!cacy of mechano-chemical abla- 1University Paris V, Paris, France tion (MOCA) at 1 year. 2. Measure clinical ef!cacy of mech- 2Universié de Paris V, Paris, France ano-chemical ablation using VCSS. 3. Report closure rates of 3Unité de Recherche et de Développement en Imagerie et Anatomie, Paris, mechano-chemical ablation at one year follow-up. France 4 Methods. This was a prospective observational multicenter Neuilly Sur Seine, France report on the clinical outcomes of MOCA. Patient characteristics, clinical and procedural data were collected. The distribu- Aim. 1 To verify the hypothesis that a perforating vein is tion and extent of venous re#ux and the closure rate of the consistently accompanied by an arterial structure 2 To de- treated veins were evaluated with duplex ultrasound. Patients scribe the state of these perforating arteries in relation to the were followed-up with clinical examination and the CEAP and muscular fascia and the homologous perforating veins. 3 Sub- VCSS were used to evaluate outcome. stantiate the procedure of sclerotherapy in the light of results 4 Results. Data on 126 patients was collected. There were 81% To Improve knowledge on cutaneous vascularization of medial females, with a mean age of 65.5±14 years. The mean diameter side of the leg of the GSV in the upper thigh was 7.3mm. Closure rates were Methods. First, a duplex investigation on medial side re- 100% at 1 week, 98% at 3 months and 94% at 6 months. There gion was performed on 38 lower limbs of healthy subject with were no cases of venous thromboembolism. There was sig- an average age of 55.89. Then, an anatomic study on 5 cadav- ni!cant improvement in VCSS (p<0.001) for all time intervals. ers obtained from the Department of Anatomy at the Univer- These patients are being followed-up and the 12 month data on sity of Paris. 6 lower limbs were dissected, injected by latex clinical outcome and closure rate are being evaluated. and dyed under approved and controlled conditions. Conclusions. MOCA has the advantage of endovenous abla- Results. A perforating artery was found in the proximity tion without tumescent anesthesia, making it an almost pain- of the perforating vein in 100% of all cases. In 97.61% of the free procedure. High occlusion rates with signi!cant clinical cases, the perforating artery was visible under the deep fascia. improvement can be achieved at short-term and the durability The arteries accompany the perforating veins in their trajecto- of the procedure at 1-year will be reported. ry all the way into the subcutaneous tissue. Thus, they form an arterial network that is adjoined by arterial inter-perforating anastomoses that are modeled after venous anastomoses. Conclusions. The observations of our study con!rm the need of systematic use of ultrasounds during sclerotherapy Varicose Great Saphenous Vein: No Need for Treat- and of the remote and cautious injection of the perforating ing 50 % Junctions. From a Series of 1000 Legs channel in a tangential incident in order to avoid accidental M. Lefebvre-Vilardebo1, P. Lemasle2 intra-arterial injection. Better anatomical knowledge of the 1Of#ce of Surgical and Medical Phlebology, Paris, France perforating vein and artery pattern, but also better imaging, 2Cabinet d’Angiologie Nouvelle France, Le CHESNAY, France mapping and marking, provide scope for improvement. Aim. Treatments of varicose networks related to the great saphenous vein (GSV) incompetence tend towards preservation of the sapheno-femoral junction (ultrasound-guided Turned Down - Patient Preference in the AVULS foam sclerotherapy, endovenous techniques, crossectomy free Clinical Trial Setting saphenectomy) and even of the trunk (CHIVA, ASVAL). Objec- T. Lane 1, D. Kelleher2, I. Franklin1, A. Davies1 tives of the study: - to understand more acurately haemody- 1Academic Section of Vascular Surgery, Imperial College London, Lon- namics of GSV incompetence - to evaluate the risks of wrong don, United Kingdom evolution of these treatments - to try to speci!y indications. 2Department of Vascular Surgery, Royal Oldham Hospital, Oldham, Lan- Methods. 1000 legs with primary varicose veins linked cashire, United Kingdom to an incompetent thigh GSV were prospectively included. All legs required a !rst-hand surgery. They were investigated Aim. Patient preference and choice has become a key com- twice (initial consultation then pre-operative skin mapping) ponent of medical treatment and none more so than varicose using duplex- and color-coded scan. Investigations have spe- vein treatment. No funding for follow-up is available and paci!cally studied the origins of the saphenous re#ux. For each tient choice of treatment can be limited. This study aimed to leg, all sources of re#ux were noted with speci!cation of the assess patient preferences for treatment timing. main source. Methods. All patients undergoing local anaesthetic varicose Results. 79% of junctions were incompetent, but the ostial vein procedures from May 2011 to July 2012 were screened for valves were pathological in only 53.2%. The origin of re#ux inclusion in a randomized controlled trial assessing timing of was pre-terminal (coming from junction tributaries) in 25.8%. phlebectomies in the context of endothermal ablation (AVULS

88 INTERNATIONAL ANGIOLOGY October 2013 Trial). Reasons for declining participation were recorded if given. An exhaustive and bilaterally Duplex Ultrasound diagnosis Results. 376 patients were screened for inclusion in the is mandatory to certify age ,location, type and extension of the AVULS phlebectomy trial. Of these, 204 (54%) were suitable thrombus into the super!cial, perforator and/or the deep ve- for inclusion in the trial, 88 (23%) had isolated truncal re#ux nous system as a concomitant DVT ( 6 – 44% ). If the clot is lo- and 71 had isolated varicosities (19%). Of those suitable 87 calized at less than 2cm from the SFJ/SPJ it has to be consider participated in the trial (43%) and 117 declined, with desire as a DVT, and treated like one with anticoagulation. for 1 sitting treatment the reason in 95%, and wanting 2 sitting Progression of SVT to DVT was seen in 11% of the cases treatment in 5%. and the most common site was from the GSV- SFJ to the CFV. Conclusions. Patient preference is an important factor in 20-33% SVT is associated with symptomatic PE and 2-13% the treatment pathway with one-stop treatments favoured by with asymptomatic PE. the majority, even in the setting of clinical equipoise and in- There are no consensus in the treatment of SVT. creased access to specialist follow-up. This factor can prove The aim of the treatment is to prevent the extension of an obstacle for trial recruitment and is important when gener- SVT in super!cial and deep veins. Also to reduce vein and pe- alising reported clinical trial data. rivenous tissues in#ammation. There are different kind of surgical treatments depending on the localization of the SVT. Below the knee SVT in saphenous vein and/or tributar- Recurrent Varicose Veins after Vein “Stripping” Sur- ies epifascial veins can be treated with evacuation of the clot gery. Retreatment with Endovenous Laser Ablation (thrombectomy). P. Pal, J. Pal, R. Isaak Ligation and excision of the affected veins is suggested, in Minnesota Vein Center, PA, North Oaks, MN, USA the cases of recurrent bouts of SVT in the same vein, in spite of maximal medical management. Aim. To determine the incidence, cause(s) and treatment Above the knee SVT in saphenous vein and/or in tributaries of recurrent varicose veins in patients with prior surgical in- epifascial veins con be treated with thrombectomy. tervention. If the clot is very close to the saphenofemoral /popliteal Methods. A !ve year review (2007-2012) of initial patient junction, in acute, ligation should it be done. consultations in a single Vein Specialty Center. Patients with Division of the saphenofemoral / popliteal junction can be varicose veins (VV) and who had prior venous surgery or a his- performed simultaneously. tory of “stripping” after the year 2000, during the “endovenous From one week to 40 days after acute ligation was per- era” were the primary subjects of this study. We analyzed how formed, stripping or ablation of GSV/SSV is suggested. often these patients could be retreated with endovenous laser Conclusions. Surgical ligation of the SFJ / SPJ should be ablation (EVLA). performed only in acute SVT,because Results. 2347 patients were evaluated. 318 limbs in 219 It´s cheap and easy to perform. (9%) patients, had prior venous surgery (high ligation and/or Following the acute phase in patients with CVI, stripping / stripping, or phlebectomy). 144 limbs in 98 (4%) patients had ablation GSV/SSV can be performed. surgery after year 2000. 101 limbs were considered to have “stripping” of the great saphenous vein. Average age was 49.4 years (range, 32-74). 84% were women. Surgery occurred a median of 7 years previously (range, 1-12). Deep venous insuf- THE BURDEN OF VENOUS DISEASE !ciency in 24/144 limbs (17%). VV were associated with: pat- Mathematical Tools: HRQoL Derived Burden, QALY, ent great or small saphenous vein (47%), segmental/residual saphenous vein re#ux (18%), anterior accessory vein re#ux DALY, Burden (15%). EVLA with or without adjunctive treatment was feasi- H.M. Moore, T.R.A. Lane, A.H. Davies ble in 111/144 (77%) limbs. Academic Section of Vascular Surgery, Imperial College London, United Conclusions. During the endovenous era, there are pa- Kingdom tients whose primary treatment for varicose veins is still surgical “stripping”. A high percentage of these patients with vari- Venous disease is common. The majority of patients with cose veins and a history of vein “stripping”, have associated venous disease have super!cial venous re#ux alone with clini- saphenous or accessory vein re#ux. Retreatment with EVLA is cal manifestations including telangiectasia, varicose veins, possible in the majority of these patients. oedema and ulceration. Super!cial venous disease is not immediately life threatening, however, the treatment of varicose veins has been demonstrated to improve quality of life, alleviate symptoms of depression and treat the complications of TREATMENT venous disease. There is a disparity across developed countries OF SUPERFICIAL VENOUS THROMBOSIS between the predicted number of patients with varicose veins requiring treatment and the actual care given. How should we decide which patients should be treated? Surgical Ligation - When Should it Be Done? Methods of quantifying health status and its improvement C.G. Simkin with and without treatment of a disease have been used. Ge- Clinica Simkin – Varicocenter, Buenos Aires, Argentina neric health questionnaires including the Nottingham Health Pro!le or the General Health Questionnaire, and later quality Super!cial Venous Thrombosis (SVT) is clinically charac- of life tools such as the Short Form 36 (SF36) questionnaire terized by a red painful ,warm, tender and palpable cord-like series or the EuroQol 5 Domain questionnaire (EQ-5D) pro- structure along the course of a super!cial vein, usually located vide patient reported measures of their health at that point in the lower limbs, but it can occurs at any super!cial vein in These encompass the World Health Organisation’s de!ni- the body ( arms, abdomen, etc). tion that - “Health is a state of complete physical, mental Commonly occurs in varicose veins (62%) but occasionally and social well-being and not merely the absence of disease it may be found in healthy veins, secondary to the presence or in!rmity”. They allow the calculation of health economics of a hypercoaguable state, trauma (i-v canulae) ,pregnancy, measures such as Cost Effectiveness, Cost Bene!t, Cost Mini- obesity, prolonged bed rest or inactivity, infection and cancer mization and Cost Utility, and comparison between different (migratory SVT). treatments.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 89 Multiple options exist for disease speci!c quality of life FREE PAPER SESSION 12 scores, with the most commonly used English language questionnaire for varicose veins being the Aberdeen Varicose Vein Prevalence and Health Economic Impact of Lymph- Questionnaire (AVVQ) and the French language one being the edema in the USA ChronIc Venous Insuf!ciency Questionnaire (CIVIQ). These 1 1 2 3 4 are patient reported questionnaires, or PROMs, and provide S. Rockson , K. Brayton , A. Cheville , A. Hirsch , P. O’Brien key indicators of the symptomatic bene!t obtained by treating 1Stanford University School of Medicine, Stanford, CA, USA 2Mayo Clinic, Rochester, MN, USA patients. 3University of Minnesota Medical School, Minneapolis, MN, USA If the improvement in patients’ quality of life and the number 4University of Vermont College of Medicine, Burlington, VT, USA of years of reasonable quality of life gained by the undertaking of the procedure are calculated, the number of quality-adjust- Aim. To address: (i) the USA prevalence and health costs of ed life years (QALYs) can be calculated. Disability adjusted life lymphedema; (ii) characteristics of insured individuals using years (DALYs) are an alternative method of calculating health intermittent pneumatic compression (IPC); and (iii) the rela- expectancies, and are calculated by assessing the number of tive costs in patients utilizing IPC. healthy life years lost. Crucially, all treatment modalities for Methods. De-identi!ed patient data from commercially varicose veins have been shown to improve patients’ quality insured and privately managed Medicare patients were ana- of life in UK national non-selected patient reported outcome lyzed/adjusted to create prevalence estimates, with measure- measures and in the UK, all treatment modalities have been ments of health outcomes and costs for calendar year 2007 shown to be cost-effective in terms of QALYs gained relative to through 2011. Health care costs were aggregated for treatment conservative treatment. offered in home health, emergency, inpatient, outpatient, and of!ce sites; and for laboratory and pharmacy expenses. Costs were designated as lymphedema- or non-lymphedema-related, based on claim coding. Results. Approximately 3 million patients engage the U.S. What Have We Learned From Clinical Trials healthcare system for “edema” annually, including 200,000 E. Kalodiki with lymphedema; 900,000 with lower limb ulcers; and Vascular Surgery Department Ealing Hospital and Imperial College Lon- 800,000 with chronic venous insuf!ciency (CVI). 30,000 pa- don and Thrombosis, London, United Kingdom tients receive an IPC for home treatment annually. Average annual healthcare costs are highest in the year following di- There is considerable variation in how clinical trials are agnosis for lower limb ulcer patients ($4208), and less for reported. As a result meaningful interpretations of their con- lymphedema and CVI ($2400). Advanced IPC use for cancer- clusions are dif!cult. The American Venous Forum and the related lymphedema lowered annual costs when compared to Society of Interventional Radiology in 2007, published a joint traditional pumps ($925/year). Thus, the use of speci!c IPC statement on the recommended reporting standards for en- devices can signi!cantly impact lymphedema-speci!c treat- dovenous ablation (EVA) for the treatment of venous insuf- ment costs. !ciency. These include detailed population description, body Conclusions. The prevalence of lymphedema, as as- mass index, occupation and bilateral and staged treatment. sessed from administrative data, is high, as are associated The severity of the disease should be assessed by the CEAP costs. These treatment-related costs are accrued in diverse level II that includes duplex scanning. Validated scales like the care settings, spanning home health to inpatient sites. venous clinical severity score and various general and disease Treatment choices appear to have a significant impact on speci!c validated quality of life questionnaires should be re- subsequent healthcare costs. Patients utilizing IPC in the ported. A history of venous disease and co-morbidities may home experience improved outcomes and associated lower also in#uence the results of EVA. Clinical and duplex follow-up costs. should be at uniform intervals, typically within the !rst 3 days post-procedure, then at 1 month, 1 year after treatment, and annually thereafter. This VEIN-TERM consensus document of 2009 was devel- Genetic and Lymphoscintigraphy Study of Patients oped by a transatlantic interdisciplinary faculty of experts. It Affected by Primary Lymphedema Carrying VEGFR3 provides recommendations for fundamental venous termi- or FOXC2 Mutations: Comparison of Clinically Af- nology, focusing on terms identi!ed as creating interpretive fected and Unaffected Subjects problems, with the intent of promoting a common scienti!c S. Michelini1, M. Bertelli 2, F. Cappellino 1, S. Cecchin 2, D. Degiorgio 2, A. language in the investigation and management of chronic ve- Fiorentino1, A. Persi2, L. Pinelli2, V. Sainato1, M. Cardone1 nous disorders. 1Ospedale San Giovanni Battista, Roma, Italy The saphenous treatment score published by Lattimer in 2International Association of Medical Genetics, Rovereto, Italy 2012 is another approach which assesses the relative contribu- tions of re#ux, competency and occlusion above and below the Aim. Primary lymphedema is a lymphatic malformations knee in evaluating patients before and after treatment. developing in the later stage of lymphangiogenesis. The dis- Methods used in cost calculation have a profound effect ease develops clinically in different moments of life with the on cost-effectiveness analyses, thereby in#uencing healthcare appearance of an edema affecting the limbs or external geni- decision-making. As shown by Lattimer et al in 2013, national talia which tends to progress In familial forms, it is usually reimbursement data from payment by results should be com- inherited as an autosomal dominant disease linked to hetero- pared to service line reports and randomized controlled trials zygous mutations in genes involved in lymphangiogenesis, in- (RCT) micro-costing data. cluding VEGFR3 and FOXC2 genes. Due to its rarity, exhaus- Despite the heterogeneity of reporting standards in RCT of tive genotype-phenotype correlation studies are lacking and EVA for varicose veins that was reported by Thakur et al in lymphoscintigraphy studies have never been performed on 2010, clear messages are emerging. Surgery is no longer the subjects with inherited mutations but without clinical pres- gold standard. Between the EVA techniques there is great vari- entation. ation in the short and long term results. In conclusion in treat- Methods. We previously reported clinical and genetic anal- ing CVD one should adopt the dental approach i.e. to treat as ysis of 52 Italian probands screened for VEGFR3 and FOXC2 and when the problem arises. mutations [Michelini S. et al., 2012]. Here, we focus on the nine

90 INTERNATIONAL ANGIOLOGY October 2013 familial cases with positive molecular diagnosis (6 with muta- reduction 2. Patient reported outcomes 3. Clinician assessed tions in VEGFR3; 3 in FOXC2). These patients and their rela- outcomes tives also underwent lymphoscintigraphy. In one of the nine Methods. Utilizing patient records from 2009 to mid 2012, families we identi!ed a clinically normal subject carrying a a retrospective review of prospectively-collected data was FOXC2 heterozygous mutation. The same variant was detect- conducted on 196 lower extremity lymphedema patients who ed in his daughter, who has an overt phenotype. were prescribed an APCD. Pre and post treatment LVs were Results. The lymphoscintigraphic patterns of affected pa- calculated and clinical outcomes related to skin changes, pain tients in the same family proved to be very similar. The results and function were assessed. Patient reported outcomes and of the FOXC2 patient without clinical manifestations indicated satisfaction utilizing a pre and post treatment survey were also bilateral delay in lymphatic drainage through inguinal nodes. obtained. When major parameters (age of onset, clinically involved Results. 90% of patients demonstrated LV reduction; 35% limbs and evolution) were considered, a genotype-phenotype with reduction >10%. Mean LV reduction was 1150 mL (me- correlation was observed in patients carrying the same muta- dian 796 mL), or 8% of pre-treatment LV (P<0.0001). Greater tions from this and previous case studies. BMI and greater baseline LV were strong predictors of LV Conclusions. In conclusion, lymphoscintigraphic features reduction (P<0.0001). Clinician assessment indicated most of the clinically normal patient with FOXC2 mutation indicate patients experienced improvement in skin !brosis and func- that subjects without manifestations but carrying mutations tion. Patient-reported outcomes showed a statistically signi!- may have silent lymphatic insuf!ciencies. This suggests that cant increase in ability to control lymphedema through APCD in late forms, subclinical disease is already present at birth and treatment at home, increase in function with daily activities only manifests after physical trauma. Primary lymphedema and a reduction of pain interference. 66% of patients were should therefore be regarded as having variable clinical expres- “Very Satis!ed” with the APCD treatment. sion and not, as currently considered, incomplete penetrance. Conclusions. Our study demonstrated measureable and signi!cant reduction in LV with APCD treatment in the home combined with very favorable patient reported outcomes. The Formation of Tissue Fluid Channels in Lymphede- outcomes suggest that at home APCD treatment may be effec- matous Subcutaneous Tissue During Intermittent tive for lymphedema patients and their clinicians in achieving Pneumatic Compression Therapy treatment goals related to LV and pain reduction, functional improvement, and patient reported treatment satisfaction. M. Zaleska1, W. Olszewski2, M. Cakala-Jakimowicz3, P. Jain4 11Department of Surgical Research & Transplantology, Medical Research Center, Polish Academy of Scien, Warsaw, Poland 2Medical Research Center, Warsaw, Poland 31 Department of Surgical Research & Transplantation, Medical Research Addressing the Lymphedema Sequelae in the Se- Center, Polish Academy of Scie, Warsaw, Poland verely Overweight with an Innovative Pneumatic 4Benaras Hindu University, Varanasi, Warsaw, Poland Compression Therapy: A Pilot Study L. VanHoose, S. Kanaan, E. Haynes, T. Messer Aim. We observed formation of tissue channels during high pressure pneumatic therapy using lymphoscintigraphic and University of Kansas Medical Center, Kansas City, KS, USA biopsy histochemical methods in patients with lymphedema. Aim. The study’s objective was identi!cation of additive Methods. Ten patients with lymphedema stage II/III of bene!ts of a novel pneumatic compression therapy, the Lym- lower limbs were investigated. The parameters of compression phaPod, to a conventional therapy plan for the treatment of were: in#ation pressure 120-100mHg, sequentially from cham- lower extremity lymphedema and associated impairments in ber 1 to 8, in#ation time of each chamber 50’’, daily for 1 h and the severely overweight. for a period of 12 months. Lymphoscintigraphy with Nanocoll Methods. The 12-week, randomized, home-based pilot was performed before, after 6 and 12 months of treatment. study began in May 2011. Eligibility included BMI greater Skin and subcutaneous tissue biopsies were taken before and than 39 and lower extremity lymphedema. All subjects (n=10) after treatment. Specimens were injected with Paris Blue in received an adjustable static compression system. In addition, chloroform and made translucent to visualize spaces !lled pneumatic compression subjects utilized the LymphaPod for with mobile tissue #uid and subepidermal lymphatics. up to 3 hours daily. Outcome measurements included body Results. Lymphoscintigraphic imaging. After one year of weight, limb circumferences and volumes, Short Physical Per- massaging multiple wide channels !lled with tracer could be formance Battery (SPPB), and the Impact of Weight on QOL seen in the subcutis on the internal aspect of thigh and along questionnaire. large blood vessels running to the groin. There were no chan- Results. Four week analyses indicated the pneumatic com- nels around the hip, in hypogastrium and buttocks. Immuno- pression group had greater losses in body weight compared to histochemistry of biopsies revealed presence in subcutis and the static compression group (p=0.014). Average bilateral limb around veins of open spaces negative on staining with LYVE1. circumference reduction from pneumatic compression was These spaces were stained with Paris Blue and were of irregu- 1000 times greater with an average loss of 10±4% compared to lar shape with many interconnections. 0.01±0.1% with static compression therapy (p=0.008). A trend Conclusions. Long term high pressure pneumatic com- toward increased functional performance was observed in the pression brings about formation of multiple #uid channels pneumatic compression group compared to the static com- running to groin and femoral channel but not to the lateral pression group (p=0.08) based on SPPB summary scores. No parts of the limb. difference in quality of life was detected based on compression modality (p>0.05). Conclusions. Preliminary analyses indicated that the nov- Limb Volume Reduction Utilizing Advanced Pneu- el pneumatic compression therapy had an additive effect on matic Compression Treatment in the Home losses in body weight and limb measurements compared to S. Muluk, E. Taffe static compression alone. The sample size limited the effect West Penn Allegheny Health System, Pittsburgh, PA, USA size. Therefore additional research is needed. The impact of pneumatic compression usage on quality of life and functional Aim. Evaluate the effectiveness of an advanced pneumatic measures did not reach statistical signi!cance, but positive compression device (APCD) by assessing: 1. Limb volume (LV) trends were observed in the data.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 91 NEW ABLATION TECHNOLOGIES ergy density. The claim is that it diffuses the energy over a 2.2x larger area, causing a 56% lower energy density. Cyanoacrylate Adhesives: Will it Stick? Finally the “Radial tip”, is a quartz tip with a cone shape A.H. Davies, M.A. Anwar inside in order to re#ect the laser light in a radial direction and Academic Section of Vascular Surgery, Department of Surgery and Can- broaden the area. cer, Imperial College London, United Kingdom In some studies it has been shown that the use of those new !bers results in less side-effects, such as less postoperative Since it’s advent in 1960, cyanoacrylate has been used ex- ecchymosis, bruising and pain. However, for most new !bre- tensively in the medical !eld. Some of its common areas of use types, there still is a lack of randomized comparative clinical include repair of wounds, control of bleeding in gastric varices trials necessary to make any !nal conclusion. and treatments of endoleaks following endovascular abdominal aortic aneurysm repair, pelvic congestion syndrome and arteriovenous malformations with satisfactory outcomes. Cy- anoacrylate polymerizes when in contact with blood cells and MANAGEMENT OF PELVIC VEINS endothelium. Occlusion of the vessel wall occurs as a result of granulomatous response initiated by polymerisation and Pelvic Venous Re"ux: Diagnostic Strategies eventually resulting in vessel wall thickness and !brosis. The M. Greiner 1,2, M. Dadon1,2 Sapheon VenaSeal Closure System (Sapheon Inc, Santa Rosa, 1Vascular Pathology Unit, American Hospital of Paris, Neuilly/Seine, Calif) uses n-butyl cyanoacrylate with small volumes of bio- France 2Department of Vascular Interventional Radiology, Hôpital Unversitaire compatible additives (to slow down polymerisation). It has Pitié-Salpétrière, Paris, France been used for ablation of super!cial epigastric veins in animal models with complete occlusion of the veins at 30 and 60 days. If the testicular re#ux is well known, the diagnostic of the The !rst study of the use of cyanoacrylate in human (n=38 other pelvic venous re#uxes are more dif!cult to diagnose and patients) showed 100% occlusion rate at immediate post pro- codify. Two contexts have to be differentiated. cedure, 97% at 30 days and 92% at 1 year. Initially presented 1) The primary reason for consultation is a pelvic conges- data from the multi-centre eSCOPE study in seven European tion syndrome (PCS) (gynecological context): a venous ovari- centres including Germany, Denmark, UK and Netherlands an re#ux responsible for pelvic varicose veins has to be sought. (n=69 patients) presented occlusion rate of 94% at 3 months Trans vaginal and trans abdominal US are the !rst line tests with minimal complications. Another study using a new Ve- to be performed. If they show pelvic varicose veins second- TM naSeal closure procedure at Saphenion clinics in Germany ary to a simple re#ux (without obstruction of main draining (unpublished data) has shown occlusion rate of 99% at three veins), it’s an indication of pelvic phlebography associated months in 65 saphenous veins. with treatment if the diagnosis is con!rmed. If there is a suspi- Long term results of cyanoacrylate glue or adhesives are cion of truncular obstruction or local cause, it’s an indication still awaited nevertheless it is undoubtedly clear that cyanocr- of abdomino-pelvic MRI which may secondarily leads to phle- ylate adhesive does stick and short term results are compara- bography before the decision making. If the US is normal or ble with thermal ablation. Moreover, procedure is tumescent- shows another cause, a pelvic MRI has to be performed. less and no nerve damage is reported. 2) The primary reason for consultation is varicose veins of lower limbs (vascular context, in both women and men). Pelvic venous re#uxes need to be sought if the limb varicose veins are Endovenous Laser Ablation: Does Fiber Design Mat- associated with perineal/ genitals/ inguinal varicose veins and/ ter? or a PCS and/or atypical varices of lower limbs. Color Dop- M.E. Vuylsteke pler US in search of pelvic leak points (in particular perineal Department of Vascular Surgery, Sint-Andriesziekenhuis, Tielt, Belgium and inguinal points) must be performed as well as the Dop- pler of iliac veins, inferior vena cava and left renal vein. After Endovenous laser ablation has become a very popular tech- these tests, there are 3 possibilities: 1) The tests are normal or nique in the treatment of saphenous vein re#ux. Even if this the leaks are negligible: the lower limb varicose veins can be treatment obtains high occlusion rates, still some side-effects treated. 2) There is a suspicion of obstacle: it’s an indication of can be expected. Certain problems such as postoperative ecchy- MRI or CT scan. 3) The diameter of leak points is greater than mosis, bruising and pain jeopardise the recovery. In our opinion 3-4 mm or there are more than 3 leaks: it’s an indication of some of these side-effects can be explained by the use of a bare phlebography and embolization in order to avoid recurrences. !bre. The direct contact between the ‘bare‘ !ber-tip and the vein wall causes a very uneven energy distribution to the vein wall. This results in a destruction and ulceration or perforation of the vein while other parts of the vein wall are unaffected. The result- CONTROVERSIES IN COMPRESSION THERAPY ing uneven application of energy may be the cause of some of the complications of EVLA, such as postoperative ecchymosis, Venous Skin Changes: Static or Dynamic Compres- in#ammation around the treated vein and pain. sion? In order to have a more even energy distribution to the vein M.L. Flour wall, several new !bre designs have been developed. Dermatology Department, K.U.Leuven University Hospital, Leuven, Bel- First the “Tulip-tip” was developed to eliminate contact of gium the tip from the vein wall by means of geometric constraints. The ‘Tulip’-like petals act as an elastic resistance against the Trial data are lacking on the bene!ts of compression stock- vein wall and center the !ber-tip intraluminal. A histological ings in the management of venous eczema, atrophie blanche study showed that avoiding the direct contact between the !bre or lipodermatosclerosis (LDS). Since chronic ambulatory tip and the vein wall, and centring the !bre tip intraluminally, venous hypertension is the primary underlying cause in ve- results in a more homogeneous vein wall destruction, fewer nous disorders, compression treatment should be an effective vein wall perforations and less perivenous tissue destruction. conservative treatment option. The exerted pressure induces The “NeverTouch™ !ber” is similar to the bare !ber except increased subcutaneous pressures in patients with CVI, with a tube with a lens has been placed over the distal tip. This and without clinical oedema, and this is expected to counter- causes the light to be more divergent thus lowering the en- act capillary leakage.

92 INTERNATIONAL ANGIOLOGY October 2013 When evaluating clinical effectiveness of compression crucial factor is the stiffness of the compression material. The treatment in these cases, there are several clinical parameters higher the stiffness, measured by the static stiffness index, the to consider: like in#ammation, oedema, induration, pain, more effective is the compression therapy while the patient scarred atrophic areas in atrophie blanche and skin pigmenta- walks. In the last decade, several reports have shown that com- tion. Experimental data supports the effectiveness of distinct pression, in the form of multi-layer bandaging with stiff mate- levels of compression upon different aspects of LDS: oedema rial, is not only well tolerated in this group of patients, but may reduction has been shown both with bandages or with IPC improve the arterial-venous gradient by deceasing venous re- using pressures of 10-20 mmHg as well as 20-30 mmHg, and #ux and by increasing arterial #ow. The effect of compression improvement of microcirculation was achieved with bandages during walking in these patients mimics that of intermittent or IPC at 20-30 mmHg. Treatment with 35-45mmHg compres- pneumatic compression and the increase in arterial #ow may sion stockings for 6 months has been shown to reduce the area be due to release of nitric oxide and prostacyclin. A pressure of lipodermatosclerosis in patients with healed venous ulcers. range of 30-40 mmHg at the ankle is most likely the optimal Objective assessment of outcome parameters may be dif!cult, degree of compression in this group of patients. expensive, cumbersome, or not validated. The effect of compression is more than purely hemodynamic or mechanical, there is most probably an effect at the cellular/matrix level. In bio-engineering, experimental evidence Oedema Treatment: High or Low Pressure? shows that cells (e.g. !broblasts) behave differently when their H. Partsch 3D scaffold is stressed (static or dynamic) compared with a Emeritus Professor of Dermatology, Medical University Vienna, Austria lack of mechanical stimulation. Intermittent pneumatic compression (IPC) is an excellent model for ‘dynamic compres- Aim. To present data showing that low pressure is able to sion’ and under this modality release of vasodilating and anti- produce clinical effects regarding edema treatment, but also in#ammatory mediators from the endothelial cells has been regarding an improvement of the venous pumping function in shown. Similar effects may be expected by using stiff compres- patients with chronic venous insuf!ciency. sion material exerting high pressure peaks during walking. Methods. 1. Measurements of the leg volume using water In#ammation and pain may be severe in the acute phase, displacement volumetry were performed in volunteers inves- rendering compression treatment painful and so less likely to tigating the effect of stockings with different strength on the be tolerated. Several publications mention that compression occupational evening edema of the legs. 2. Leg volumetry in needs to be adapted at start, and supplementary treatment pre- patients with venous leg edema, comparing stockings with scribed like anti-in#ammatory agents (topical or systemic), or bandages. 3. Venous pumping function which also has an im- ‘!brinolytic’ medication (Stanazolol 2mg bid). Clinical experi- pact on edema formation was measured by a special plethys- ence of many is that stiff bandages (including wadding / pad- mographic technique in patients with severe super!cial re#ux ding) are well tolerated and very effective at reducing pain and without and with different compression devices exerting vari- in#ammation. No studies could be identi!ed on this subject. ous pressure ranges. 4. In order to check the in#uence of light compression on venous morphology MRI scans of lower and upper leg-segments were performed in the lying position without and after application of thrombo-prophylactic stockings. Which Compression in Mixed, Arterial-Venous Dis- Results. 1. Already pressures of less than 10 mmHg prevent ease? and reduce evening edema. The highest degree of satisfaction H.S. Fronek concerning subjective symptoms could be achieved in a pressure range between 15 and 20 mmHg. 2. In a recent study it Department of Medicine, University of California – San Diego, La Jolla, USA could be demonstrated that a so-called liner stocking with a pressure range between 20-26 mmHg worn day and night for The mainstay and !rst line of treatment for venous ulcera- one week produced a comparable reduction of leg swelling tion is compression therapy. The type of compression used as compression bandages applied with pressures between 55 often varies by geographic location of the practitioner. Pure and 70 mmHg. 3. Compression stockings (mean pressure 27 elastic compression is most commonly provided in the form of mmHg) led to an increase of the ejection fraction of the calf graduated elastic stockings and is available in several well-de- pump by 17%, inelastic bandages (29 mm Hg lying, 36 mmHg !ned strengths. Multi-layer bandaging incorporates both elas- standing) achieved an increase by 61%. 4. Thrombo-prophy- tic and inelastic components and the actual pressure provided lactic stockings narrow super!cial and deep veins in the su- depends greatly on the skill of the person applying the band- pine position in the lower and upper leg in spite of very low age and the number of layers of the bandage. Inelastic com- pressures, gradually decreasing to 6 mmHg at mid-thigh level. pression is available in the form of gauze or other wrapping Conclusions. Low compression pressure is effective in re- material, short-stretch bandages, and as a Velcro-fastened gar- ducing edema and leads to a reduction of venous calibre in the ment that is now easily applied to provide a pre-determined supine position. Although a more pronounced improvement and reproducible amount of pressure. Adequate compression, of venous pumping function is observed with higher pressures along with diagnosis and correction of venous re#ux, has been there is also a positive effect of low compression, especially shown to provide excellent ulcer closure rates in most uncom- when products with higher stiffness are used. plicated venous ulcers. However, it is estimated that 15-30% of patients with venous ulcers also have arterial insuf!ciency. While it is widely accepted that patients with an ABPI < 0.5 should undergo ar- COMPLICATIONS OF VENOUS INTERVENTIONS terial revascularization, the management of patients whose ABPI is between 0.5 and 0.8 is challenging. The time to ulcer Management of Post-Endovenous Ablation Venous healing is prolonged and many ulcers fail to close. Compli- Thrombosis cating the treatment is the long held belief that compression S.F. Daugherty is contraindicated in these patients. Of importance is the dif- VeinCare Centers of Tennessee, Clarksville, Tennessee, USA ferentiation of elastic compression, which applies high resting pressure, from inelastic compression, which applies low Venous thrombosis after endovenous thermal ablation resting pressure but results in high working pressure. Another (EVTA) is observed in a small number of cases. While most of

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 93 the reported thrombosis is endovenous heat-induced throm- !ed, the SFJ is ligated and either stripped or pin-inverted and bosis (EHIT), which may extend from the treated saphenous avulsed at about knee level. vein into the common femoral or popliteal veins, thrombo- Complications are classi!ed into minor and major. sis may involve veins contiguous to the saphenous vein such 1) Minor: as tributary varicosities or perforating veins. Occasionally, — Wound problems: including cellulitis, infection/abscess, thrombosis in veins remote to the site of the EVTA is identi- lymph leak, keloid scarring and formation of telangiectasia; !ed. Pulmonary embolism and ischemic stroke rarely are re- — Neurological; ported after EVTA. — bruising/haematoma; Recommendations for treatment of EHIT vary since few — missed veins. centers have reported more than a few cases. A commonly- 2) Major: used algorithm has evolved to treat EHIT 1 and 2 patients with — deep Vein Thrombosis (DVT) with or without pulmonary antiplatelet agents such as aspirin; class 3 patients with an- embolus (PE); tiplatelet agents or anticoagulation; class 4 patients with an- — death; ticoagulation. Some have suggested considering the new oral — amputation due to femoral arterial damage; anticoagulants for class 3 and 4 EHIT since management is — deep vein trauma requiring venous reconstruction; easier than low molecular weight heparin/warfarin and the du- — lymphoedema. ration of anticoagulation may be relatively brief. The literature suggests major complication rates of less Secondary thrombosis of tributary varicosities often is than 1% with almost 18% of patients suffering minor com- treated with antiplatelet agents such as aspirin, nonsteroidal plications. The commonest are cutaneous nerve issues and anti-in#ammatory agents, elastic compression, and warm wound infections. Recurrent varicose vein treatments have a compresses (if the patient desires). It is not clear whether anti- higher complication rate. coagulation is of much bene!t for this group of patients. Overall, it behoves the surgeon to evaluate all patients’ Extension of thrombus through a perforating vein into the symptoms carefully. Many treatments are sought for purely deep veins or deep vein thrombosis in a vein remote to the site cosmetic reasons so the potential for patients considering of the EVTA warrants full anticoagulation. If deep vein throm- themselves worse off after surgical ligation is considerable. bosis remote to the site of treatment is identi!ed, a throm- This, I believe is re#ected in rising surgical insurance premi- bophilia work-up is appropriate. ums for vascular surgeons. Pulmonary embolism requires therapeutic anticoagulation and a thorough lower extremity venous color duplex ultrasound exam to look for a source other than the treated saphenous vein. An intracranial ischemic event in the !rst several Anticoagulation and Venous Interventions: How weeks after EVTA should prompt echocardiography with bub- Can Complications be Avoided? ble testing to evaluate for a patent foramen ovale which may N. Khilnani be the pathway for an embolus from the lower extremity. Divison of Interventional Radiology, Weill Cornell Vascular, Department of Radiology, New York Presbyterian Hosptial- Weill Medical College of Cornell University, New York, NY, USA

Complications Associated with Surgical Ligation The use of anticoagulants is very common. As a result, physicians are frequently confronted with decisions related and Removal of the Great Saphenous Vein to managing anticoagulation before, during and after venous D.J. Moore procedures. Dept Vascular Surgery St James’s Hospital, Dublin, Ireland Venous thrombosis can occur after both deep and super- !cial venous interventions. In the deep system they are rep- Surgical treatment of varicose veins is perceived by the resented by acute thrombosis of vein segments previously public and the surgical fraternity as a minor procedure. Fre- stented or lysed and thrombosis or emboli that occur after quently treatments are delegated to less experienced members IVC !lter placement. Junctional extension of thrombus into of the team for training purposes. A review of surgical litera- the deep veins after thermal ablation saphenous ablation is ture and personal experience indicates that this perception is the most commonly discussed complication after super!cial inaccurate and the practice is at best unwise and unfair to the treatment. However, deep vein thrombosis can also occur after patient and junior surgeon. chemical ablation with visual or ultrasound guidance and su- Despite development of endovenous techniques, many per!cial thrombosis can occur after any super!cial treatment. surgeons have been slow to embrace them and !nancial con- During this presentation, evidence related to the safety of straints are also cited. As a result surgical ligation and strip- initiating, continuing or terminating anticoagulation around ping of the great saphenous vein (GSV) is still performed in the time of common super!cial and deep venous procedures over half of cases in Europe and the US, making this discus- will be reviewed. Where evidence is not available, anecdotal sion still relevant today. approaches commonly used will be reviewed and areas for fu- Surgical ligation and stripping is performed under gen- ture research highlighted. In addition the evidence regarding eral or spinal anaesthesia. An incision is made over the risk factors for thrombosis after venous interventions and the saphenofemoral junction (SFJ); the GSV and CFV are identi- value of various prophylactic strategies will be discussed.

94 INTERNATIONAL ANGIOLOGY October 2013 ELECTRONIC ABSTRACTS

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 95 96 INTERNATIONAL ANGIOLOGY October 2013 ELECTRONIC ABSTRACTS tional condition were used: Duplex ultrasonicgraphy, clinical analyze of movement, Xray-graphy and optic topography. CT Diagnosis of Chronic Compartment Syndrome of Results. Pathology of feet has 89% of patients, manifesta- Patients with C5-C6 Classes Venous Insuf#ciency tion of arthrosis of foot articulations has 45%. 56% of patients have deformation of spinal column.C3 and C4 classes of feet S. Katorkin, M. Melnikov, A. Zhukov deformation have 79,2% and 82,2%, arthrosis – 22% and 25%, Samara State Medical University, Samara, Russian Federation deformation of spinal column - 36,3% and 33,9%. Most often was revealed the combined platypodia in combination with Aim. One way of developing chronic ischemic mionevral- pes valgus and deformation of I toe. So was disorder of me- nogo de!cit is volume reduction of the compartment of the chanical suspension, balancing and jogging feet function.C5- scar tissue due to deformations of the circular distribution C6 classes of feet deformation have 95% of patients. Arthrosis of trophic venous leg ulcers, especially in combination with of talocrural articulation have 74% patients. Was found an evi- impaired blood circulation and lymph #ow. Lack of diagno- dent decrease of indices peak of gastrocnemius and anterior sis and correction of chronic compartment syndrome leads tibial muscles traction to 0,86±0,02 mv, 1,34±0,17 mv. Spatial to unsatisfactory results of treatment. Invasive measurement indices of speed were decreasing (68,2 ±1,05 step/min).There of pressure in musculoskeletal leg muf#er is not possible for was also tendention to base of step increase – 8,5 ±1.04 sm and expressed trophic inherent to C5-C6 class.To identify chron- abduction angle of affected extremity decrease -7,6 ±1,2º. Time ic compartment syndrome of patients with C5-C6 classes of roll over toe was decreasing to 16,2 ±1,3%. through the analysis of various parameters CT of the lower Conclusions. While chronic venous insuf!ciency goes with extremitie. concomitant pathology of musculo skeletal system, further in- Methods. Scanning was performed on multislice computed dividual tactic of treatment should be worked out together with tomography «Aquillion» company «Toshiba» with an effective orthopedist. Disorder of statodynamic function of patients with dose of 5.0 mSv and slice thickness of 3 mm. Determined: the chronic venous insuf!ciency should go under orthopedist cor- thickness of the skin, subcutaneous fat and fascia in millim- rection till main surgical operation and also in postoperative eters, the state of the periosteum and bone, density of sub- rehabilitation period. Such tactic helps to reduce rehabilitation cutaneous fat and muscles of the leg in three levels in terms course and to increase quality of patients’ life. of scale Hauns!lda (HU). We examined 58 patients, C5-C6 classes at the age of 20 to 78 years. In 12.2% of them the area of trophic ulcers was more than 20 cm2. Congestive Arthritic Syndrome in Patients with Results. There was a decrease in skin thickness and subcu- Combined Lesions of Venous and Musculoskeletal taneous fat to 6,31 ± 0,4 mm. There have been changes in the Systems Lower Extremities structure of subcutaneous fat in the form of multiple nodules and !brous bands with an increase in density up to 8,2 ± 0,16 S. Katorkin, E. Isaeva, M. Melnikov HU. The density of the muscles in the anterior fascial com- Samara State Medical University, Samara, Russian Federation partment in the lower third of the affected leg averaged -17,3 ± 0,17 HU, in the outer compartment 76,8 ± 1,4 HU, and the Aim. In the complex treatment of patients with chronic posterior surface and deep compartments, respectively, 41,4 ± venous insuf!ciency should be considered concomitant pa- 2,6 HU and -4,3 ± 0,18 HU. After a functional stress test in a thology of the musculoskeletal system. To improve treatment 10-minute step in the rate of 2 steps per second observed the outcomes of patients with C5-C6 classes chronic venous insuf- appearance of pain in the calf muscles calf and clinical mani- !ciency by identifying concomitant pathology of the locomo- festations of neuropathy. Observed phenomena of hypostesia tor system and the congestive arthritic syndrome. on the foot, which corresponds to compression of n. peroneus Methods. Were examined 160 patients with venous insuf- profundus and n. tibialis casings at leg. !ciency of the C5-C6 class. Of these, 65% were aged 40 to 60 Conclusions. Changing of the density of muscle tissue indi- years. The vast majority of patients had venous insuf!ciency cates the formation of chronic compartment syndrome. Should from 10 to 20 years. Clinical symptoms of C5-class had 102 be included in the complex treatment of patients with C5-C6 (63,8%), and C6 – in 58 (36,2%) patients. The diagnostic com- classes means of its relief: exercise therapy, antiplatelet, anti- plex included Duplex ultrasonicgraphy, Xray-graphy, fotoplan- hypoxants, antispasmodics, osmodiuretiki, magnetic therapy, tography and clinical analysis of motions (podometry, electro- ozone therapy, hyperbaric oxygen therapy. If there is no effect myography and goniometry in walking). considered to perfom an endoscopic decompression fasciotomy. Results. The pathology of the locomotor system was diagnosed in all patients with C5-C6 class. It is more often manifested in spreading ulcers in the ankle area, with a circular Functional Methods in Diagnostics and Treatment scar tissue deformation. Osteoarthritis of the ankle joint with severe pain syndrome was diagnosed in 79 (77,5%), and foot of Patients with Combined Involvement of Venous deformations II-III degree –in 97 (95%) patients with C5 class. and Musculoskeletal System of Lower Extremities In patients with C6 class, respectively, in 27 (46,6%) and 55 S. Katorkin, I. Losev, Y. Sysonenko (94,8%) cases. The most freguently detected combined with Samara State Medical University, Samara, Russian Federation valgus #at foot plant and toe deformity of I-type Hallux valgus in violation of the spring, balancing, and jog functions stop. Aim. In diagnostic and treatment of chronic venous insuf- Pronounced effects lipodermatosclerosis and deformation of !ciency often isn’t taken into account its combination with soft tissue of the shin with the transition to the ankle joint were different pathology of musculoskeletal system. To prove the observed in 84 (82%) and 82 (80%) patients with class C5 and importance of the use of functional method of planning of 100% and 96% - with the C6 class. If in the trophic process was treatment of patients with chronic venous insuf!ciency and engaged the bone, was developed ossi!cated periostitis with concomitant pathology of musculoskeletal system. areas of pronounced osteosclerosis. In goniometry indicated Methods. Were analyzed the results of examination and severely impaired locomotion of ankle on the affected side – treatment of 452 patients with chronic venous insuf!ciency up to 10,3±1,09º. Were signi!cantly decreased the parameters C3-C6 classes. 64% of them at the age of 40 to 60 years old. of maximums of gastrocnemius and tibialis anterior muscle 335 (75%)- the duration of disease is more then 5 years. Clini- contractions – up to 0,86±0,02 mV and 1,34±0,17 mV. Were de- cal symptoms of C3 have 168 (37%), C4- 124(27%), C5 – 102 creased the spatial performance speed rates – 68,2±1,05 a step/ (23%), C6- 58(13%) patients. For objective estimation of func- min, was increased database of step – 8,5±1,04 cm and was

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 97 decreased the angle of rotation of the foot on the affected limb agnosis of ADVT was set for 518 patients, among them 256 – 7,6±1,2º, indicating a severe antalgick immobilization of the (49,4%) men and 262 (50,6%) women. All of patients with joints of the lower extremities. The roll through the ankle joint ADVT got therapy with anticoagulants. Enoxaparin sodium was was increased to 37%, which was increasing its functional prescribed in 428 (82,6%) cases, UFH in 58 (11,2%) and in 20 overload (p<0,05). Time of rolling over the toe was decreasing (3,9%) – others LMWH. Were have analyzed ef!ciency and com- to 16,2±1,3% at a rate of 32,1% (p<0,05). plications after antithrombotical therapy in a hospital period. Conclusions. In patients with C5-C6 classes of venous in- Results. Results. Among patients with ADVT with prima- suf!ciency of involvement in the process of tissue trophic ul- ry localization in ileofemoral and popliteal segments which cer of the ankle joint in conjunction with concomitant diseases treated in the departments of vascular surgery prevailed sen- of the locomotor system lead to the development of congestive ior persons more than 60 years old (52,7%). In 83,8% cases the arthritic syndrome. This leads to a marked disruption evacua- most frequent symptoms of disease are an edema of extrem- tion function of the gastrocnemius muscle and the functional ity (in 80,1%) and pain syndrome 75,1%, which at a mono- insuf!ciency of the lower extremities. The therapeutic effect symptomal variant (34,4% patients) are marked in 64,6% and should be achieved through stimulation of the musculo-ve- 45,4% accordingly. Most frequent risk factors (RF) they had nous pump, the normalization of locomotion ankle, as well as the prolonged (more than 7 days.) immobilization and malig- the spring correction, balancing, and jog functions feet in their nant tumors. Ef!ciency of anticoagulant therapy (decreasing static and dynamic loading. of the number of ascending thromboses, recurrent DVT, and episodes of pulmonary embolism (PE) was identical at enoxaparin and UFH groups and was achieved in 95,6% and 91,3% Compression Therapy in Venous Leg Ulcers Treat- accordingly, however in cases of enoxaparin application re- ment. Twelve-Years Follow Up gress of clinical signs in was rapid 67,4% cases, while if UFH used only in 55,1% cases of with enoxaparin as compared to C. Sanchez Fernandez de la Vega UFH accompanied with reduced frequency of all hemorrhage Sergas, Lugo, Spain complications in 1,8 times, serious in 2,4 times and moderate in 2,8 times Aim. Physicians and nurses, trained in the technique of Conclusions. Conclusions: Therapy of UFH and LMWH compression bandaging and coordinated with other special- was effective (on the average a good result is got in more than ists, can heal venous leg ulcers in primary care, using a simple in 86 % cases) enough. Enoxaparin treatment was related to technique of compression therapy “Double focal compression considerably less of hemorrhage complications, than treat- bandaging”. ment of UFH (р<0,05), that concerned all of types of such Methods. One bandage is putting on the ulcer area (focal complications. compression bandage) and another for making a gradual external compression bandaging. We make a differential diagnosis with other ulcers, establishing the diagnose of venous ulcer. The material used is: A/ Gauzes for making a padded gauze The Role of Lymphoscintigraphy in the Differential used as focal compression. B/ Normal compression bandage Diagnosis of Popliteal Cysts for !xing the pad (focal compression) C/ Strong compression 1 2 elastic / inelastic bandage for using as gradual external com- E. Sanchez , M. Cook 1Cardiovascular & Vein Center of Florida, Bradenton, FL, USA pression. D/ Physiological saline solution / Scissors / Scalpel / 2 Adhesive tape. These are diagnostic tools: Hand held Doppler VA New Jersey Health Care System, East Orange, NJ, USA ultrasound device (measurement of the ankle-braquial-index) Aim. Popliteal cystic structures that develop following ar- / Camera / Tuning fork / 5.07 Mono!lament / Scales/ The Edin- throplasty could be related to the surgical procedure or due to burgh Claudication Questionnaire. unrelated pathology. Lymphoscintigraphy can be used to char- Results. The technique has been used for healing venous acterize post-operative popliteal cystic structures. leg ulcers since 15 years ago. Last !ve years, it was used in pa- Methods. A 74 year old man who had right knee arthro- tients who have been treated with different r treatments with- plasty two months ago complained of right lower leg swelling. out achieving to heal the ulcer. We report 58 patients (20 M Vascular sonography revealed a right popliteal cystic structure. /38 F), between 62 and 92 years old, and show (photographic A bilateral lower extremity lymphoscintigram was performed. sequences) the clinical course of the ulcer till healing. We have The images revealed a collection of tracer that corresponded not observed recurrences of the ulcer in the treated area. with the right popliteal cystic structure. 1.- It is an ef!cient and effective measure Conclusions. Results. The lymphoscintigram demonstrated that the considering the low cost, the resources used and the results right popliteal cystic structure accumulated the tracer and achieved. 2.- Patients are involved in the care of their ulcers. therefore represented a lymphocele. 3.- It is the safest treatment to be used in primary care, in the Conclusions. This case is interesting because the sono- treament of venous leg ulcers. graphic appearance of the popliteal cystic structure did not allow for differentiation. In this case, the popliteal cystic structure was initially thought to represent a synovial cyst (Baker’s Clinical Signs and Risk Factors of Deep Veins cyst). Lymphoscintigraphy established that the popliteal cystic Thrombosis of Lower Extremities. Ef#ciency and structure represented a lymphocele. Safety of Anticoagulant Therapy. (Retrospective Re- search) V. Mishalov, E. Amososva, N. Litvinova National Medical University, Kyiv, Ukraine The Role of Lymphoscintigraphy in Venous Ablation E. Sanchez1, M. Cook2 Aim. To conduct the retrospective analysis of clinical signs 1Cardiovascular & Vein Center of Florida, Bradenton, FL, USA and risk factors for patients with diagnosis of acute deep veins 2VA New Jersey Health Care System, East Orange, NJ, USA thrombosis (ADVT) of lower extremities, treating oneself in the departments of vascular surgery and to compare effective- Aim. To demonstrate a pitfall in the management and treat- ness and safety of therapy with LMWH enoxaparin and UFH. ment of venous insuf!ciency in the face of isolated pedal edema. Methods. Methods: For period from 2007 to 2012 the di- Methods. 47 year old woman who complained of leg dis-

98 INTERNATIONAL ANGIOLOGY October 2013 comfort with intermittent swelling of the lower left leg and to a consensus for this therapy. Varicosities left after catheter varicose veins in the right leg. The physical examination retreatments consist of sidebranches and perforators. The aim vealed normal arterial pulses in the legs, C2 disease in the right was to perform fewer incisions and avoid open surgery and leg and mild left pedal edema. Lower extremity and abdominal improve post procedural comfort venous sonography con!rmed super!cial venous insuf!ciency Methods. We used 2-ring radial - and slim single-ring ra- without evidence of iliac vein compression or deep venous in- dial laser catheters. Ultrasound was facilitated during treat- suf!ciency. ment with GE`s Venue40 and for the pre- and postprocedural Results. Lymphoscintigraphy demonstrated moderate left exams we used GE`s LogiQ-e. The treatment of a patient was leg back#ow of tracer and an enlarged popliteal lymph node. done with a single catheter so it was necessary to choose the Further inquiry into the lymphoscintigraphic !ndings revealed catheter of choice before. We used tumescent #uids with or that the patient had multiple episodes of “phlebitis” of the left without general anesthesia. Controls were made at day 1, 7 thigh as a child and teenager in her native Puerto Rico. and after 3months. Heparin was given as a single shot applica- Conclusions. Lymphoscintigraphy changed the course of tion after the procedure. All patients were admitted back home treatment. It revealed an explanation for the left pedal edema one hour after treatment. beyond super!cial venous insuf!ciency that would have been Results. There were no major complications. All perfora- treated by venous ablation. tors were closed except one located at the lower leg and closed after re-laser-treatment. Small bruising was common. There were no hematomas. There were no pigmentations due to treatment of super!cial branches. Diagnosis and Treatment of Saphenous Vein Aneu- Conclusions. Radial laser catheters offer a new range of rysms save treatment options for varicose veins as seen in their use R. Bush, P. Bush in ablation of trunk varicose veins. Midwest Vein & Laser Center, Cincinnati, OH, USA

Aim. Super!cial venous aneurysms of the greater saphenous vein (GSV), small saphenous vein (SSV), have been document- Endovenous Laser Versus Surgery - Who Won the ed and classi!ed as to anatomic presentation. This study docu- Race? ments aneurysms of the anterior accessory greater saphenous S. Jianu, E. Ursuleanu vein (AAGSV), posterior medial thigh circum#ex branch, as ProEstetica Medical Center, Bucharest, Romania well as variations of GSV aneurysms. Reclassi!cation of saphenous aneurysms is proposed, as well as treatment protocols. Aim. 1. implement the new endovenous laser treatment 2. Methods. In a 2-year period, records of patients (330), pre- evaluate and compare the new endovenous laser treatment senting at our center for evaluation and treatment of symp- with the old surgical method for incompetent great and saphe- tomatic venous disease were examined. Aneurysm criteria in- nous veins 3. propose a hierarchy in the wide accepted proce- cluded both dilatation of 2 times the size of the contiguous vein dures for varicose veins and 3 times the size of normal vein diameter. All aneurysms Methods. We designed this study in 2004 and we conducted were documented as to location, size, and clinical presentation. it until 2012.All the patients with incompetent great and small Histological evaluation of resected specimens was performed. saphenous veins were submitted to a complete phlebological Results. A total of 18 patients met the criteria for aneu- examination, including Duplex and were informed about both rysm, 4 males and 14 females. The mean age was 44, with a methods.Until 2008 we managed to randomize the patients by range from 16 to 75. Aneurysm location was GSV (9), AAGSV an unusual procedure- depending on their payment possibil- (6), SSV (2), and posterior medial thigh circum#ex branch (1). ity, laser treatment being considerably more expensive and not Treatment was determined according to location, aneurysmal accessible to almost a half of the patients (from 945 patients, neck size, and presence of collateral in#ow. Modalities of treat- 459 were treated with laser and 486 surgical).After 2008 it be- ment included foam sclerotherapy, surgical procedures, and came clear that the people, even it was already an economic thermal ablation either done alone or in combination. Aneu- crisis, were more and more reluctant to accept the surgery and rysm size is related to the degree of internal elastic membrane preferred the endovenous laser ablation.In 2009 we made 158 disruption. lasers and 103 crossectomies with saphenectomies for incom- Conclusions. Reclassi!cation of aneurysms should include petent saphenous veins (~1.5:1), in 2010 the change was obvi- standardized size criteria and should include AAGSV patholo- ous: 243 patients preferred laser treatment and only 62 surgery gy and GSV aneurysm classi!cation as to terminal and sub-ter- (~4:1) and in 2011 and 2012 the surgery became an exemption: minal valve involvement. Aneurysms of the AAGSV commonly 38 surgical operations versus 585 endovenous laser (~15:1 for present as acute thrombosis. Aneurysms involving the terminal laser). Now we have a total of 2134 patients in the study, 1445 valve, SSV aneurysms, and AAGSV aneurysms, with a commu- with endovenous laser treatments and 689 with crossecto- nication >4mm at the saphenofemoral junction (SFJ) should mies and saphenectomies. All the operations were performed be ligated to decrease the possibility of clot embolization. His- under tumescent anaesthesia and ambulatory. The patients tological evaluation of aneurysms reveal smooth muscle hyper- were monitorised clinically and and by Duplex at 7 days, one trophy and disruption of the internal elastic membrane. month, 3 months, 6 months, 1 year and every 6 momths after. Results. Clinical recurrence at 5 years was 4% for the laser group and 5% for the surgical group (P = 0.1). The morbidity rate was very low for the laser group: 4%-indurations, pain, New Treatment Options for Varicose Veins Others in#ammation on the route of the vein and small ecchymosis, than Trunk Insuf#ciencies Using the New Radial La- without super!cial burns, hemathomas or deep vein throm- ser Device bosis. The recovery for work was 2-3 days. For the surgical J. Boehme1, J. Alm2 group, the morbidity rate was around 10%- hemathomas, 1Vascular Department Dermatologikum Hamburg, Hamburg, Germany paresthesias, infection of the wound, deep vein thrombosis (1 2Dermatologicum, Hamburg, Hamburg, Germany case) and a lot of cases with ecchymosis and pain. The patients recovered for work at 5-7 days. Aim. The use of lasercatheters in the treatment of trunk Conclusions. The endovenous laser treatment brings less insuf!ciencies has become common and the data earned led complications than surgery and less days of recovery and it

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 99 is preferred more and more by the patients. For us it is obvi- stent implantanción. Technical success 100%. Following by ous that the future in varicose veins treatment is not for the anticoagulation according to protocols. Monitoring was done surgery and we can see now very clear the winner of the race. with color dupplex and clinical symptoms in 70% of patients for period of 1 month to 72 months, with a mean of 14 months. During follow-up showed no recurrence of thrombosis or LASER versus Sclerotherapy for Telangiectasia and symptoms, which was ranked with score of Villata = 0. Aver- age length of hospital stay of 5 days. Reticular Veins Conclusions. The clinical characteristics of patients de- S. Jianu, E. Ursuleanu scribed here are agree to reported in the literature, the main ProEstetica Medical Center, Bucharest, Romania clinical manifestation was acute thrombosis ilio femoral segment. Short term follow-up showed no recurrence of throm- Aim. 1.evaluate the ef!cacy of LASER treatment and scle- bosis, there was preservation of valve apparatus competition rotherapy as a single treatment for telangiectasia and reticular and post-thrombotic syndrome wasnt presented. veins 2.compare the results of LASER treatment and sclerotherapy as single treatment for telangiectasia and reticular veins 3. evaluate the ef!cacy of combined method of LASER and sclerotherapy for telangiectasia and reticular veins 4.com- Metronomes & Metric Devices for Endovenous Ab- pare the results of combined method versus single method lation Methods. Since 1994 we utilized sclerotherapy with liquid R. Mueller, B. Mueller, J. Mueller (initially) or foam (in the last years) for treating reticular veins Cosmetic Vein Solutions, New York, NY, USA and telangiectasia. Since 2001 we began to use different types of lasers for the treatment of reticular veins and telangiectasia- Aim. 1) Review pullback rates’ crucial role in endovenous Argon laser, Diode laser 810 nm and 980 nm (with or without ablation safety and ef!cacy. 2) Summarize metronomes avail- cooling), Nd-YAG and IPL, as single treatment or associated able to time pullback rates. 3) Analyze the electronic metric with sclerotherapy. We analyzed retrospectively a group of devices that optimize pullback rates. 3620 patients which had at least one treatment for reticular Methods. Literature search, technologic review, and obser- veins or telangiectasia and we contacted them for a phone vational comparison of various metronomes & metric devices. selfevaluation or for a consultation for reevaluation. We had Challenges in timing pullback rates were identi!ed, and several in the !nal 3 subgroups, one of 2134 patients with at least one useful electronic and online metronomes were identi!ed, test- sclerotherapy, 1037 patients with at least one lasertherapy and ed, and features compared. Endovenous ablation procedures the smallest group of 449 patients with both, sclerotherapy in our private practice in 2012 were included. In-range linear and lasertherapy. endovenous energy density rates without and with metronome Results. We obtained statistically signi!cant ( P<0,05) bet- devices, ease of use, individual features were reviewed. ter results, aesthetic and functional, with sclerotherapy for Results. A technologic gap exists in providing optimal pull- reticular veins and telangiectasia than with LASER- sclero- back rates in endovenous ablation procedures, which deter- therapy was more effective than the vascular LASER in the mines linear endovenous energy density (LEED). Operators majority of the cases, being also a less expensive treatment. often must !nd their own timing devices. Four electronic The surprise was that better than the sclerotherapy alone were devices were identi!ed, tested, and corroborated against la- the results in the group with combined method-!rst sclero- ser console data. 2 devices are auditory: the M50 Meideal® therapy and after a while -LASER. metronome & the SilverDial® metronome online app. 2 are Conclusions. Sclerotherapy has better aesthetic and func- visual: the OsyPilot® running LED device and the EVLTrain- tional results than the LASER in the treatment of reticular veins ing® online app. All were found anecdotally to be equally very and telangiectasia but we can obtain even better results com- useful in standardizing and optimizing pullback rates in order bining the two methods- !rst sclerotherapy and then LASER. to achieve target LEED values. Conclusions. Digital physical and online metronomes and other devices are crucial to the safety and ef!cacy of endovenous ablation procedures. These cheap and easily operated Endovascular Treatment of May Thurner Syndrome devices, typically left to the practitioner to obtain, ensure accu- N. Hernandez-Cardenas, L. Cadavid-Velasquez, J. Gomez-Hoyos, J. rate catheter / !ber pullback speed, which is uniquely vulner- Tobon-Ramirez able to operator error in their absence. Several indispensable Clinica Cardiovascular, Medellin - Colombia, Colombia devices are available to the resourceful operator determined to optimize endovenous ablation pullback rates. (requested dis- Aim. Describe the clinical characteristics, presentation, claimer by a journal editor: “Full paper to be published in the treatment and follow up of goup patients at the clinica cardio- Journal for Vascular Ultrasound”) vascular with diagnosis of May Thurner syndrome. Methods. review medical records of patients diagnosed with may Thurner between 2000 and 2011. Variables assessed: age, sex, clinical presentation, previous history of deep vein Conservative and Surgical Treatment for Acute Vari- thrombosis, diagnosis, treatment, outcome and follow-up. cose Thrombophlebitis: Comparative Evaluation of Results. We describe 38 cases, 100% female, aged between the Results (Three-Year Prospective Study) 20-60 years, the initial presentation: acute venous thrombosis L. Markulan, S. Beichuk, D. Mirgorodskiy, V. Mishalov 90% of patients with ilio femoral segment involvement and Bogomolets National Medical University, Kiev, Ukraine 10% patients, symptoms of venous hypertension: edema, pain and varicose veins. Of the latter group 1 patient had history of Aim. Therapeutic approach to acute varicose thrombophle- deep vein thrombosis and 2 infrapopliteal super!cial venous bitis (AVTP) is not de!ned, although this condition can lead thrombosis, and history of varicectomia. The diagnosis was to deep-vein thrombosis (DVT) and pulmonary thromboem- performed in patients without thrombosis with ultrasound bolism. The aim: to improve the short-long term treatment re- dupplex which evidenced a decrease in vessel diameter greater sults in patients with AVTP than 70% and in all patients with measurement of gradients Methods. The study period was 2007 - 2012. 362 patients between the inferior cava vein and left common iliac. 100% with AVTP were studied: 243 patients (67.1 %) with type 1 by F. patients with acute thrombosis underwent thrombolysis and Verrel; 70 patients (19.3%) with type 2; 31 patients (8.6%) with

100 INTERNATIONAL ANGIOLOGY October 2013 type 3; 18 patients (5.0%) with type 4. 79 patients have under- and surgery, between the months of August 2010 and October gone conservative treatment (CT), 283 patients were operated 2012, 117 patients underwent surgery, 77 female and male. (O): 72 of them were performed palliative surgery (O-P); 211 In all cases, a protocol was proposed, pre, during and after of them - radical phlebectomy (O-R). The recurrence rate for surgery, in this type of surgical practice. All therapeutic pro- AVTP, DVT, severity of venous pathology on the VSS scale was cedures were performed under the prior written informed evaluated prospectively in a three-year period. consent. In all cases, preoperatively. The patients underwent Results. The cumulative recurrence rate for AVTP is venous Ecodoppler m.lower long standing : observeding, exist- 5.2%: CT - 14.6%, O - 2.2%, p=0,001 (O-P - 9.1%, O-R - 1.9%, ing diameters, gauges, characterization of tortous collateral, p=0,009). The cumulative rate for DVT is 1.9%: CT - 8.0%, O straight, perforating diameter, re#ux, perforator reentry, over- - 0.7%, p=0,003 (O-R - 0.0%, O-P-3.5%,p=0,01) The severity circulation, angiogenesis, and research variceal recurrence. of venous pathology decreased in the O-R group comparing Methods. Although, at present, we have changed the tac- with other groups (p<0,05): in three months it decreased by tics, and surgical technique ( of crosectomy, partial, total, 3.1 times, in six months - by 5.06 times, in three years - by treatment with shell perforator, cockett), laser technology, 11.46 times; O-P - by 1.49, 1.57 and 1.58 times, respectively; with or without crossectomy is a technique advocated by our CT - by 1.35, 1.28 and 1.1 times, respectively. group Surgical, not without complications. Never minimize Conclusions. Radical phlebectomy for AVTP performed the risks. The tactical procedure is that after anesthesia ( for during the three-year period provides a reliable prevention of blocking, spinal,general), we using percutaneous endovascu- DVT: 0% vs 4.3% and 8.0%, recurrence of VTP: 0% vs 10.6% lar laser Doppler, we used 980 nm laser beside 600 micron and 14.6%, it eliminates the necessity of re-operation and helps !ber.Initially we used sonosite 180 plus ultrasound with Color to reduce the severity of venous pathology on the VSS scale. Doppler Power and in the latter a Micromaxx sonosite ultrasound with color Doppler and power Doppler. Always with intraoperative measurement.By introducing the !ber with abocath 14, we arrived at 2cm below the saphenofemoral Thrombolysis as the Part of the Complex Treatment junction( reference epigastric vein ) otherwise we measure for Patients with Acute Lower Extremity Deep-Vein the distance in cm, we use the concept of ratio, taking as 1cm Thrombosis of Different Disease Duration away from the skin to the vein, in!ltration !siologic solution V. Mishalov, D. Mirgorodskiy, L. Markulan subcutaneous tissue. We believe that the in!ltrating with the cold solution, serves several purposes !rstly it lowers the tem- Bogomolets National Medical University, Kiev, Ukraine perature emitted by laser !ber secondly it treats the vein, and thirdly it decreases the initial temperature to the minimum. Aim. Effectiveness of thrombolytic therapy (TLT) for deep- This also contributes to the physical removal of structures ad- vein thrombosis persisting more than 10 days (DVT) was discussed. The aim was to evaluate the effectiveness of TLT for jacent to the treated vein. Used in the thigh, 8-10 watts, can patients with acute lower extremity DVT in the later periods. sometimes reach up to 12 watts –in leg 6-8 perforating watts, Methods. 81 patients with DVT were studied in the period 2-4 watts,our reference is based on Joules in relation to the of 2004 - 2012. The duration term for DVT was 1 - 28 days. The energy delivered for a !xed relation in a determined space, but comparative effectiveness evaluation of TLT (t-pa 100 mg) and we are aware that medicine and biology, there are no absolute heparin therapy (HT) (heparin 30000 U intravenously on a drip parameters. We use several reference situations relating to our for 48 hours, following Enoxaparin 2 mg/kg a day, moving to in- technique, wich the following: A ) Transilumination : The light direct anticoagulants) was performed. The TLT and HT groups of the laser !ber tip used as topographic reference to !nd in a were represented according to the terms of DVT. The !nal re- particular place andnever as real-time control of the delivery search stage was thrombosis recanalization (full and partial). of laser energy that is used to enable us to now wether the Results. The thrombosis recanalization was obtained in 15 laser is in the thigh or the leg. B ) Effect Laser : We can con- patients (100%) of TLT group with DVT less than 7 days and in trol laser ablation in real time through the ultrasound used 3 patients (21.4%) of HT group (p<0.05). No one had throm- intraoperator to verify the thermal effect by eye observation bosis recanalization in the HT group having DVT more than of the transversal sectional saphenous or by blind eye or eye 7 days, although positive dynamics was observed in every pa- –checking the venous obliteration (cloud effect). C ) Consistent tient: the reduction of pain and the affected limb excessive cir- with the two previous parameters a and b, we can control the cumference. Recanalization was obtained in 7 patients (78%) process endoluminal ultrasound technique in real time. We of TLT group with DVT duration 7 - 14 days, in 6 patients used to perform crossectomy, when after the measurement by (67%) with DVT duration 15 - 21 days, in 2 patients (35%) Doppler, the femoral saphenous was greater than 10mm. In with DVT duration up to 28 days. last six months we have expanded the saphenous arch calibre Conclusions. The TLT effectiveness in the complex treat- to 14mm, without conducting crossectomy.We now no longer ment for acute DVT reduces with the disease term prolonga- perform crossectomy.We !nally perform Muller technique tion. At the same time TLT provides venous blood #ow im- (varicose vein collaterals). provement for 67% patients with DVT up to 21 days, and in Results. In all cases we have followed a rigorous sched- 35% - up to 28 days, whereas the recanalization in that period ule, pre, intra, and postoperatory. The complications we had: for patients of HT group was not registered (p<0.05). 1) in 6 cases skin burns 2) in 15 patients with postoperative pain post laser thombophlebitis 3) in one patient varicorrhage After 90 days, the ultrasound showed, complete obliteration safenico shaft treatment and perforating vein. 4) 15 patients Our Combined Experience Treating Laser and Sur- underwent unilateral crossectomy, being !ve of them bilateral, and 5 cases with open ulcer, with proper insulation of the gery in Chronic Venous Insuf#ciency. Technical ulcer from the rest of the operating !eld to avoid contamina- LEPE.(Ecodoppler Adressed Endovascular Percuta- tion by covering the same with hydrocolloid membrane, this neos Laser) ablation helps to complete the remission ulcer with closure J. Segura in!ltration in open painfull ulcers. Tavoid pain suggested lido- Medico Cirujano Vascular, Bs.As, Argentina caine 2% and epinephrine, betamethasone deposit.To date we have 5 cases of recurrence which were treated with polido- Aim. The objective of our work is to provide our experi- canol or sodium tetradesilsulfate, technical Foam 1 %, with ence in private medical centers in Argentina, combinig laser excellent Results.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 101 Conclusions. The chronic venous insuf!ciency, with the stabilize pressures vulvoperineal endovascularhemodynami- combined treatment of partial crossectomy and laser is not cally altered. Venous insuf!ciency, does not end at the groin. considered an invased technique. We believe that the Laser We must break the wall into the abdomen.Pelvis there also. and ecogra!c control have changed the blind surgery technique. We never minimize the risk as ther mayalways bemedi- at and inmediat complications. The vertical re#ux treatment, as well as the perforating one is very important for the succes- Endovenous Saphenous Ablation in Patients with sof the ( LEPE). We think that the patients that come to our Acute Isolated Spontaneous Super#cial-Vein onsulting room with C2,onwars as a failure for the beginning Thrombosis of the neverending suffering of the patients. Moderm technol- W. Gradman ogy will allow us to !nd the desease in a subclinic state, univalvar re#ux, segmentary re#ux ,bilateral hereditary background Beverly Hills Vein Center, Los Angeles, CA, USA of phlebology desease, and patients will short medical history. Aim. No consensus has emerged for treating acute isolated We believe that those cases or any others, including the classic spontaneous super!cial-vein thrombosis (SVT) despite nu- and new ones, will probably be very useful, although here we merous proposed medical and surgical algorithms. This report have different situations and conditions. explores the possible role of endovenous saphenous ablation (EVSA) as primary treatment in patients with SVT and saphenous vein re#ux. Possible bene!ts of EVSA include (1) de!nitive treatment of the underlying pathology and (2) elimination Vulvar Vein Treatment of the saphenous vein as a path for pulmonary emboli, which A. Kornberg1, T. Mariana2 (3) may eliminate the need for anticoagulation. 1Colegio Argentino de Cirugia Venosa y Linfatica, Buenos Aires, Argen- Methods. 115 limbs with SVT were reviewed (2002-2012). tina Seventy-two (62.6%) limbs with saphenous re#ux were eligible 2Asociacion Argentina de Climaterio, Buenos Aires, Argentina for one of two treatments after the patient was given an explanation of the risks/bene!ts of each. Group I patients chose Aim. The aim of this work is a population of women with EVSA (laser or RF) ± phlebectomy if performed within a 45 pelvic chronic pain, (242) patients, between 23 and 45 years day treatment interval. Post-treatment anticoagulants were of age, in 10 % of the cases suffer of vulvar varicose veins and not given. Group II patients chose compression, re-Duplex at gluteal veins after the pregnancy. 30 % Whereas in 80 % of the one week, and anticoagulants if SVT extended into the thigh. cases after the pregnancy, they eliminated varicose veins vul- Group II patients were contacted in 2012 to determine the in- vares and gluteal veins, in 20 % there was persistence. In our cidence of late complications and treatments. The primary ef- casuistry 5 cases. In all the cases they presented dispareunia. !cacy outcomes were death, symptomatic VTE or bleed. (Pain forthwith sexual) The Syndrome of Pelvic Congestion, it Results. In Group I, mean interval from diagnosis to treat- is that one characterized for presenting expansion and or tor- ment was 13.7 days. After the 45-day treatment interval 12/29 tuosity of the veins uterus ováricas or his tributary ones, which (41%) Group II limbs underwent late EVSA [2.4-79.7 months]. heaviness, pain produces in the Pelvis and low members, sec- Overall, 53/72 (74%) limbs offered EVSA as primary treatment ondarily to the venous chronic éstasis. for SVT eventually underwent EVSA. Methods. The methodology of the study of the clinical pic- Conclusions. EVSA is both safe and ef!cacious, and may ture, was also of the gynecological checkup, make transvaginal be offered as primary treatment to patients presenting with venous eco doppler to measure the diameter, and re#ux of var- SVT and saphenous re#ux. icocele. We NMResonance, then solve the leackege points and subdiaphragmatic re#ux We classify the vulvar varicosities. 1. According to the etiology: A) No pregnant. B) Pregnant. C) During the puerperium. 2. According to factors Hematology: Our Experience in Vacuum Assisted Closure in Ar- A) thrombophilic. B) No thrombophilic. 3. According to Hor- gentina monale factors: A) with altered hypothalamic Pituitary FSH, A. Kornberg1, J. Segura2 TSH. B) No alteration of the hypothalamic Pituitary. 4. Ac- 1Colegio Argentino de Cirugia Venosa y Linfatica, Buenos Aires, Argen- cording to its topography: A) Infraisquiaticas. B) Supraisqui- tina aticas. C) gluteal. D) Perineal. E) Lip major, minor. F) suprapu- 2Medico Cirujano Vascular, Bs.As, Argentina bic. 5. According to size: A) greater than 1 cm. B) less than 1 cm. 6) Combined with PCS: A) Associated with PCS. B) Not Aim. The aim in this paper is to evaluate the ef!cacy of associated with PCS. 7. Combined with hemorrhoidal disease. VAC in lower limb ulcers,bilaterally, unilateral or over 1 A) With Hemorrhoids. B) Without Hemorrhoids. year of evolution, despite performing, debridement with lo- Results. In all cases, we try subdiaphragmatic re#ows in cal methods, creams,skin and circumscribed, grafts, hidro- the !rst instance, by coils embolization. In the second instance coloideas membranes, were not effective. VAC technique was in the 5 cases of vulvar varicesveins, sclerotherapy technique conducted (KCI) (negative pressure ulcers closure) in the 16 performed FOAM, with sodium tetradesilsulfato 1%. Then patients assisted in practice several private medical centers Panty Girdle Compression Vulvoperineal. Recommend it more in Buenos Aires, Argentina. Of the 16 patients, 10 female, than 6 hours standing or sitting, or postpartum, with varicoses 6 male, mean age 59 years, ulcers 12 lower limb unilateral vulvar veins. En the 5 cases decreased dyspareunia. and 4 bilateral, etiology: 10 PTS (CEAP 3), 2 peripheral ar- Conclusions. 1. Therapeutic compression placement vul- terial disease, 2 cases of diabetes,post.traumatico case. 50% var perineal post embolization helps correct venous pressures, of them with great secretion; 11 with infection, granulation hemodynamically altered in pelvic congestion syndrome. 2. average 56 days total. Vulvo perineal Girdle prior to the placement of coils, has a Methods. We evaluated 16 patients, 10 female, 6 male mechanism of: a) Containment of the pelvic #oor b) Decreas- (between March 2012 and February 2013), in private medi- ing Dyspareunia c) If the pressures in gonadal veins not exceed cal centers in Buenos Aires.Argentina. Clinical examination, 35 mmHg, decreases pelvic congestion sodium tetradesilsul- CEAP classi!cation, etiology of ulcers. Biochemical tests fate sclerotherapy is an indication for the treatment of V.Vulvar were performed to evaluate, diabetes, glucose tolerance test, veins, after treatment of subdiaphragmatic re#ows provided insulinemia, search coagulation disorders, is questioned by proximal to distal. We always use therapeutic compression to premedication as antihypertensives, beta blockers, I adjuvants

102 INTERNATIONAL ANGIOLOGY October 2013 metabolic diseases. In all cases underwent venous and arte- Five-Year Trends in Utilization of Inferior Vena Cava rial Ecodoppler colored, lower limbs to evaluate super!cial (IVC) Filters and deep system; perforating system, venous system reentry R. Tartaglione 1, A. Herr 2, L. Keating 2, K. Mandato 2, M. Englander 3, G. phlebothrombosis; Peripheral artery disease, mixed etiologies Siskin4 (arterial, venous) previous history of trauma. Treatment was 1Albany Medical Center Hospital, Albany, NY, USA performed, VAC, on an outpatient basis. weekly checks, to 30, 2Community Care Physicians, Albany, NY, USA 60 and 120 days according to protocol. De our team, once the 3Department of Radiology - Albany Medical Center, Albany, NY, USA diagnosis of the etiology of lower limb ulcers, evaluate size, 4Albany Medical Center, Albany, NY, USA location, edges, depth, local edema, infection. We washed, !rst with sc. physiological, put sponge dressing, with tubing 1cm, a Aim. Based on past reports and future projections regard- negative pressure device and reservoir. With self-adhesive !lm, ing increased utilization of IVC !lters, the present study was the wound is closed. Vaseline, I-shaped aluminum hydroxide performed to identify longitudinal trends in IVC !lter inser- peripheral. With an average of 56 days, lower costs of other tion practices at our institution. procedures without complications was obtained complete Methods. This retrospective study identi!ed all patients granulation in all treatment cases. En second instance, the undergoing IVC !lter placement procedures at our tertiary primary pathology treatment care institution during 18-month periods extending from Results. Of the 16 cases, with VAC technique, out patient, 2005-2007 and from 2010-2012. Procedural volume during full granulation was obtained. In 4 cases, 30 days was enough each time period was compared. A chart review identi!ed the granulation, but 2 to 45 days, 8 to 60 days, two in 120 days, indications for !lter placement, the referring service, and the given the characteristics of the ulcer, but even if it is unilateral type of !lter used. The number of inpatient admissions dur- or bilateral. In 10 cases with large secretion (60% of cases) ; ing each time period was compared. A trend analysis was then with treatment according to antibiogramy oral with suitable performed. bandage shaped to infection with 10 cases local. In 10 cases Results. The volume of IVC !lter insertions decreased syndrome, post thrombotic, perforating insuf!cient, 2 cases from 229 in 2005-2007 to 164 in 2010-2012. The number of arteriopathy hypertensive (Martorell ulcer), two cases with hospital admissions during the same time periods increased diabetes and insulin treatment case post traumatic. from 46,075 to 51,526. Based on the number of hospital Conclusions. According to our statistics, venous ulcers, ar- admissions, there was a 36% decrease in IVC !lter utiliza- terial, mixed or posttraumatic, occurs in the second stage of tion (X2=18.932; p<0.0001). The indications for !lter place- life, older than 55 years. Etiology ,thrombosis, DVT, arterio- ment and the change over time were as follows: DVT (40% pathies, diabetes and hypertension. In our environment, with increased to 48%), PE (37% to 37%), and PE prophylaxis many years of evolution, and methods of use from creams, (23% decreased to 10%). The referrals for !lter placement grafts membranes, high costs and relapses. The VAC method, by medical specialties increased from 41% to 46%; the refer- used since 1995, under barometric negative pressure increases rals by surgery decreased from 59% to 54%. The percent- the reepithelialization, granulocytosis, angiogenesis, decreas- age of cases referred by trauma surgery and neurosurgery es pain, lower costs, and outpatient technique. decreased from 31% to 15%. The use of retrievable !lters increased from 63% to 83%; retrievable !lters are now used exclusively at our institution. Given the changes in CPT coding, the volume change accounts for a 75% decrease in physi- How and Why the Endovenous Radio Frequency cian work RVUs. Ablation System Works: Histopathological Investi- Conclusions. In contrast to prior projections, the volume gations on the Great Saphenous Vein Treated with of IVC !lter insertion procedures decreased at our institution Endoluminal Ultrasonic Ablation over the course of 5 years. Notably, the percentage of !lters placed for prophylaxis decreased over time, which may corre- H. Bedi, N. Calton, K. Kwatra, V. Tewarson, A, Verghese late with the decrease in referrals initiated by trauma surgery Christian Medical College & Hospital, Ludhiana, Punjab, India and neurosurgery. As expected, retrievable !lter usage at our institution has increased in recent years. Decreased utilization Aim. The Radio Frequency Ablation (RFA) system is a may be attributed to a growing awareness of complications minimally invasive technique to generate heat to cause endo- reported in association with IVC !lters luminal ablation of the vein. In order to better understand the exact mechanism and sites of action we studied in detail the histological features of the greater saphenous vein subjected to RFA. Mechanism of Venous Recanalization after Post- Methods. Vein was obtained as a left over piece from a patient undergoing coronary artery bypass grafting (CABG) Thrombotic Syndrome or Endoluminal Therapeutic and one varicose segment removed by phlebectomy. The RFA Ablation probe (VNUS ClosureFast, Covidien, Mans!eld, USA) was J. Segura inserted into the vein, covered with warm packs (body tem- Colegio Argentino de Cirugia Venosa y Linfatica, Buenos Aires, Argentina perature) and the VNUS generator !red. The vein was then subjected to HPE. Aim. Submit a particular, individualized, and demonstrated Results. The vein immediately shrunk lengthwise and in di- through Color Doppler of venous recanalization of a light af- ameter. On histology - focal edema of the media, modi!cation ter an episode of DVT that generated the same total obstruc- of intercellular cement, loss of endothelium, separation and tion and occlusion or closure of saphenous vein or external disruption with hyperplasia of the intima, delamination of the trunk post. Endoluminal laser ablation by ultrasound-guided media, alteration of collagen, modi!cation of the cell nuclei of laser technique.We studied 1318 patients of both sexes (1089), the media and the heat induced thrombus were found – Figure (76.5%) women, 309 men (23.5%), and the age range 15-85 1 & 2. years old in women, and 36 -83, male. A surface phlebopaty Conclusions. The RFA technique causes a uniform and 1096. Chronic venous insuf!ciency and DVT patients and post transmural damage of the entire vessel wall. The process is not thrombotic syndrome 222 patiens limited to the intima but affects all layers. This study may help Methods. At follow-up by both the colored Ecodoppler ve- us in further improving our technique, hardware and results nous thrombosis (super!cial and deep) and l aablacion thera- of the procedure. peutic Endoluminal Laser Guided Ecodoppler of incompetent

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 103 saphenous veins, we veri!ed the presence of arteries within lares segments of internal saphenous veins. The goal here is to the previously occluded vessels such as either by DVT or laser prevent the evolutionary development of the disease. ablation therapy. Conclusions. We know that these re#ows Segmental can be Results. The angiogenic phenomenon detected by doppler a warning or the !rst step of the forward progression of super- color consists in !nding blood in the light signal of a venous !cial venous valvular disease. If these asymptomatic control vessel where it naturally should not be. Was detected the phe- other option would be evolutionary, and phlebotonics indica- nomenon of angiogenesis in 10 patients, 7 with diagnosis of tion. No doubt in these cases is imposed phlebologist tracking thrombosis, 4 surface 3 deep, and CVI, a diagnosis of TPS with handler. an Endoluminal Laser with postoperative Conclusions. We are facing a new situation Ecodoppler detected by color, that current knowledge of venous hemodynamic could correspond to a form of recanalization. Micro-Dose Lidocaine Tumescent Anesthesia for EVLA in the Drug Shortage Era R. Mueller Cosmetic Vein Solutions, New York, NY, USA Segmental Re"ux in Lower Limbs J. Segura Aim. 1) Assess very low concentration lidocaine’s ef!cacy in tumescent anesthesia (TA) for endovenous laser ablation Colegio Argentino de Cirugia Venosa y Linfatica, Buenos Aires, Argentina (EVLA). 2) Document this regimen’s pain during EVLA. 3) Consider TA’s necessity for local anesthetics. Aim. Take a sample population of 180 patients for the de- Methods. Non randomized, prospective, single arm, open tection of re#ux. Adult patients of both sexes. Purpose of the label trial of consecutive uncomplicated patients undergoing study: clinical examination, signs and / or symptoms of dis- EVLA for venous re#ux in of!ce setting 1-3/13. All received ease phlebology lower limbs. Equipment used: AU5 Esaote 0.025% lidocaine for TA with 8.4% sodium bicarbonate (1 ml Ultrasound and Color Doppler 10 MHz linear transducer 47.26 bicarbonate / 10 ml 1% lidocaine; no epinephrine). Outcomes cases negative re#ux 133.74 ebbs cases (positive) unilateral. ... measured & independent variables are standard intra-EVLA pa- 59...... 44% bilateral...... 74...... 56% Unilateral Re#ux...... rameters, including pain visual analog score (VAS) during EVLA. around the shaft. ... right 10, left 16. Segmental re#ux...... Results. Patients: 11 (6 male, 5 female) Veins treated: 20 (9 right. ... Arch 6, 6 trunk thigh, leg 3 Left...... Arch 8, 9 trunk Great Saphenous Vein, 7 GSV Accessory Vein, 2 Small Saphe- thigh, leg 7 Bilateral Re#ux...... Axis...... All right 37, left 33. nous Vein, 2 SSV Thigh Extension) Mean Values: Diameter: Re#ux...... segmental arch right. .. 9, 10 trunk thigh, leg 8 5.0 mm LEED: 79 Joules/cm Length: 23 cm TA Volume: 645 left. .. crook...... 10, 11 trunk thigh, leg 16. cc VAS: 0.15/10 In 95% of cases, laser treatment proceeded Methods. Esaote doppler 10MHz Ultrasound and Color without interruption or need to administer additional TA. One Doppler, linear transducer, This is to determine the limit of patient had 3/10 pain during the last 4 cm of treatment, which valvular incompetence May go unnoticed if the review is not responded to additional TA at same concentration. 95% of pa- exhaustive Ecodoppler. Mainly involving the VSI. In lower in- tients had VAS of 0 during EVLA. Acute occlusion rate 100%. cidence of major tributaries of the thigh, anterior accessory Conclusions. Micro-Dose Lidocaine (0.025%) can be used saphenous like and saphenous hamstring. They may have successfully in TA for EVLA. VAS pain score during EVLA was smaller diameter than the internal saphenous veins have val- 0.15/10, with 95% of patients in this small series having a score vular incompetence throughout its course. Sometimes it is not of 0. The lowest effective concentration of lidocaine for TA in easy to determine the limit of valvular incompetence. Valvular EVLA remains unknown and it appears likely that local anes- involvement may depend saphenous axis genuine, most inci- thetics are not essential ingredients in TA; more investigation dence, as well may correspond to ebb by tributaries of col- is needed. lateral. Results. Type A: Asymptomatic, no varicose veins and Re- #ux by Duplex. Type B: Asymptomatic, with varicose veins and Re#ux by Duplex. Type C: Symptomatic, no varicose veins and Re#ux by Duplex. Type D: Symptomatic, with varicose veins “Laser crossectomy”, a State of Art in EVLA. Single and Re#ux by Duplex. Type E: Symptomatic, with varicose Center Experience using Radial Fiber in more than veins, trophy disorders and Duplex re#ux. Type F: Syndrome 3000 EVLA Performed Piercing pure or associated with the above types Type A: (S-v- P. Dragic Dx +) In general, these young patients under 35 years. Heredity Private Clinic “Dr Dragic”, Belgrade, Serbia Tenard - here is vital. Re#ows found are rarely severe, <4 seconds. Re#ows found exceptionally super!cial and deep. May be Aim. We use our expirience of 3000 EVLA to improve proce- affected entire valve apparatus, as well as a single shell - Re#ux dure. Technological development of new generation of endov- univalvar. It is noted with some frequency overcirculation Phe- enous !bers with radial laser beam has led to the improvement nomenon. The sizes of the internal and external saphenous ves- of endovenous laser ablation technique (EVLA). Now it is pos- sels are often less than 4 mm. The saphenous axis is not always sible to place !ber top at the level of junction of vena safena entirely affected. Predominantly infrapatelares segments of the magna (VSM) and femoralis communis vein (VFC), which internal saphenous veins. The goal of treatment here is to pre- enables laser crossectomy - a total ablation of saphenous trunk vent the evolutionary development of the disease. There is also and saphenous junction branches. The effect of this technique the possibility of not treating the patient with the !rst !nding, could be compared to surgical crossectomy evading at the same but should be taken to Clinical follow-Ecodoppler. Type B: (s-v time surgical trauma complications. The aim of the paper is + Dx +) In general, these young patients under 35 years. Hered- de!ned as evaluation of safety and ef!ciency of endothermal ity is also of importance. The most frequently encountered re- ablation of saphenofemoral junction and saphenous trunk. #ux are severe. The super!cial re#uxes found are exceptionally Methods. We treated 100 incompetent VSM using EVLA deep. May be affected entire valve apparatus, as well as a single (radial !ber) procedure. All the treated veins showed total oc- shell. The phenomenon is observed overcirculation. The cal- clusion during the !rst as well as other ultrasound examina- iber of the affected vessels are 4 mm or greater. The saphenous tions. We observed no signi!cant differences in relation to clot axis may not always be fully affected. Predominantly infrapate- extension into the deep vein in the monitored groups. In 3 pa-

104 INTERNATIONAL ANGIOLOGY October 2013 tients from group I, we noticed a small clot extension in VFC canal, the vein can become very thin, between the adductors. (clot extension max.1.7 mm ranging from 0.2 to 1.7; mean 0.9 We observed similar signs on anatomical and phleboscan !nd- mm), while in two patients from group II we diagnosed clot ings. When a person is standing or walking, the action of the extension in VFC maximally up to 1.5 mm. It was noticed that 2 adductors cause an alternative compression-dilation on the in group I thrombotic masses were completely tied to VSM vein. Thus, Hunter’s canal could play a role in preventing re#ux. wall on saphenofemoral border, while in group II thrombotic Conclusions. Phlebologists should use ultrasounds to de- masses were tied to the wall distal from VSM junction, i.e. at tect re#ux of femoropopliteal axis. If there are signs of venous the place of catheter positioning. Proximal or extended clot return obstruction, it is indicated to investigate further to part was not tied to VSM wall. During control examination determine the obstruction level. Prevention is a priority and after four weeks in both groups a clot retraction from VFC phlebologists should give patients a notice to ensure they re- was noted. Mean time needed for endothermal ablation was ceive anticoagulation therapy in high risk events. around 8 minutes with no adjuvant procedures. The intervention was assessed as easily bearable (63 patients), moderate bearable (8 patients), dif!cult (1 patient), and unbearable (0 patient). Micronized Puri#ed Flavonoid Fraction Treatment Results. We treated 100 incompetent VSM using EVLA Improves Cutaneous Outcomes and Patients’ Satis- (radial !ber) procedure. All the treated veins showed total faction with Sclerotherapy for Super#cial Varicosi- occlusion during the !rst as well as other ultrasound examinations. We observed no signi!cant differences in relation to ties clot extension into the deep vein in the monitored groups. V. Crébassa 1, J. Kerihuel2 In 3 patients from group I, we noticed a small clot extension 1Clinique du Millénaire, Montpellier, France in VFC (clot extension max.1.7 mm ranging from 0.2 to 1.7; 2Vertical, Paris, France mean 0.9 mm), while in two patients from group II we diagnosed clot extension in VFC maximally up to 1.5 mm. It was Aim. To document the possible favorable impact of micro- noticed that in group I thrombotic masses were completely nized puri!ed #avonoid fraction (MPFF) on cutaneous results tied to VSM wall on saphenofemoral border, while in group following sclerotherapy of super!cial varicosities in a large II thrombotic masses were tied to the wall distal from VSM prospective cohort survey. junction, i.e. at the place of catheter positioning. Proximal or Methods. Adult female patients consecutively seen by extended clot part was not tied to VSM wall. During control 179 French angiologists for sclerotherapy of super!cial tel- examination after four weeks in both groups a clot retrac- angiectasias were included and followed up over one month tion from VFC was noted. Mean time needed for endother- after the last procedure. All were advised to take a daily treat- mal ablation was around 8 minutes with no adjuvant proce- ment with MPFF. Main study outcome was occurrence of any dures. The intervention was assessed as easily bearable (63 local cutaneous problem induced by the procedure. Binary patients), moderate bearable (8 patients), dif!cult (1 patient), logistic regression was used to identify prognostic factors of and unbearable (0 patient). cutaneous events. Conclusions. Clot extension within lumen VFC during Results. 1625 patients were evaluated (age 48 ± 12 years; EVLA (radial !ber) procedure on VSM with ≤ 1 cm diameter BMI: 22.9 ± 3.1 kg/m2; phototype I/II: 49.3%). 73.1% were is not related to the level of laser catheter positioning within treated for linear telangiectasias, 14.0% for reticular veins, VSM lumen. Clot extension was more signi!cantly dependant 4.0% for mattings and 8.9% for more complex problems. Lau- on blood #ow characteristics than on the level of catheter posi- romacrogol was used as sclerosant in 65.1% of the procedures tioning within VSM lumen. In order to con!rm the !nal state- and chrome alum in 22.9%. Overall adhesion to MPFF (mean ment, further examinations are needed. daily dose: 1000 mg) was poor/very poor in 9.4% only. A total of 704 cutaneous events (mainly bruising and erythema) were reported in 259 patients (15.9%; 95% CI: 14.2% to 17.8%). Cu- taneous problems were signi!cantly less frequent when treat- Hunter’s Canal: Implication in the Regulation of ing uncomplicated telangiectasias, when chrome alum was Femoropopliteal Venous Return? Interest for Phle- used (OR: 2.9; 95% CI: 1.6 to 5.1; p<0.001) and when adhesion bologist to MPFF was good (OR: 2.5; 95% CI: 1.3 to 4.9; p=0.009). Conclusions. Cutaneous complications of sclerotherapy C. Fortin were the main reason for patients’ dissatisfaction. MPFF treat- Canadian Society of Phlebology, Quebec, Canada ment appeared to limit the incidence of local adverse events of sclerotherapy. Aim. 1. State what happens to the vein in Hunter’s canal. 2. Explain if Hunter’s canal plays a role in venous return regulation. 3. Recognize why phlebologists should pay attention to Hunter’s canal. Methods. We present an observational study conducted Experiences with Hot Steam Treatment of Side- over a two-year period. The condition studied is venous femo- branches, Groin Recidives and Perforators in more ropopliteal obstruction. We studied the Hunter’s canal in 50 than 1500 Cases over Four Years cadavers and the serial data from 40 phleboscans and 40 phle- F. Netzer bographies. The cadavers were dissected utilizing a medial LBPS London Bridge Plastic Surgery and Aesthetic Clinic, London, Unit- approach of the thigh. We had injected the lower limb veins ed Kingdom beforehand. Phleboscans are from recurrences of SSV surgeries. Phleboscans and phlebographies were both performed in Aim. Hot steam seems to be a simple safe and effective a lying supine position. method to treat varicose veins especially in recurrent veins Results. The Hunter’s canal is formed of three musculo- and dif!cult situations such as groin recidives, insuf!cient tendinous components. The Hunter’s aponeurosis and 2 adduc- perforators in the hollow of the knee and venos aneurysma tor tendons: the adductor magnus opens the outlet of the canal Methods. Regarding the outcome of several hunderd pa- and the adductor longus closes it. At the outlet of the canal, tients treated with steam on the following veins - recurrent the femoropopliteal vein is often bent by the magnus adduc- varicose veins in the inguinal crossing - tributary veins in the tor or compressed by a calci!ed artery. Towards the end of the thigh - tributary veins in the lower leg - perorators in the thigh

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 105 - perforators in the lower leg short term and long term results worse quality of life (QOL) scores. Finally, the question raised regarding four years of follow up is ‘what should prevail when taking the decision to treat: re- Results. Hot sterile steam is a highly effective complemen- lieve patients’ sufferings or stick to physical signs only?’ tary method to treat sidebranches and recidives but is less ef- Conclusions. Even if further studies are needed to clear fective on perforators especially in the lower leg. up unanswered clinical questions, we should consider venous Conclusions. Further studies comparing steam with foam pain as part of CVD, since seeking symptoms may help detect sclerotherapy and mini-phlebectomy should follow as well as the disease, and pain relief leads to QOL improvement, which comparing steam and RFA and endoluminal laser on the GSV is meaningful to patients. and SSV.

Quality of Life and Costs Of Chronic Venous Disor- Cryoavulsion May Reduce Puncture Wounds in Con- ders: Worldwide Results from the Vein Consult Pro- ventional Varicosity Treatment gram J. Chung R. Launois Boramae Hospital, Seoul, Korea REES France, Paris, France

Aim. To treat varicose vein(VV) phlebectomy was added to Aim. To evaluate the impact of chronic venous disorders stripping of saphenous vein.Cryoavulsion(CA) had been intro- (CVDs) on costs and patients’ quality of life (QoL). duced as a new technique of VV treatment.It maybe performed Methods. Subjects found to have CVDs after examination multidirectionally by one stab wound to remove many tribu- by general practitioners were requested to !ll in a self-admin- tary varicosities minimizing numbers of wound.We applied istered questionnaire reporting features about their profes- CA to treat lower limb VV. sional activities and QoL (using CIVIQ-14 and scored 0 for bad Methods. From 2010/3/1 to 2012/2/28 among saphenous to 100 for very good QoL). stripping VV patients 31cases of miniphlebectomy (P-group) Results. A total of 35 495 questionnaires from 17 coun- and 85 cases of CA (C-group) were divided and evaluated tries (Armenia, Colombia, UAE, France, Georgia, Hungary, demographic factors,complications (No. of wound, hemato- Indonesia, Mexico, Romania, Russia, Serbia, Singapour, Slo- ma, neuralgia) and Aberdeen VV satisfaction score(AVVSS) vakia, Slovenia, Thaïland, Ukraine, Venezuela) were analyzed. change(preop/postop 2 mos). Seven percent of patients had been hospitalized and 4% had Results. Comparing P-group and C-group(P/C) 1. Demo- changed their professional activities because of CVDs. Loss of graphic factors such as M:F ratio (19:12/40:45) and mean work days was reported in 15% of patients. Number of lost age+SD (58.0+13.2/52.3+15.7) were similar. 2.VV clinical class work days did not exceed 1 week for most (40%), while 33% of in C2:C3:C4 were 19:5:7/68:12:52 and anatomical class in As: them lost more (21%>1 week and 12% > 1 month). QoL scores As+p:As+d were 22:7:2/64:18:3. Disease pattern was similar. 3. decreased with higher frequency of lost work days (from Mean numbers of stab wound (+SD) were 6.6+2.0/2.9+0.65 so 68.5+19.5 for 1 time to 51.2+22.9 for >3 times) and with dura- markedly fewer wounds in C-group were noticed (P<0.05). 4. tion of the absence from work (from 76.0+18.7 for <1 week to Incidence of hematoma were 87.1% (27/31) and 94.1% (80/85) 55.3+22.8 for >1 month). And so with increasing severity of and that of neuralgia were 16.1% (5/31) and 18.8% (16.85) and CVDs, ranging from 80.5+16.4 in patients with telangiectasias AVVSS were 7.19+1.09/2.23+0.7 and 7.85+1.43/2.24+0.79 in to 54.8+22.4 in those with an ulcer, and with the presence of a each(P>0.05). symptom (84.0+16.5 in patients without pain versus 67.8+19.9 Conclusions. Cryoavulsion had shown similar incidence of in those with pain) hematoma, neuralgia and patient satisfaction score as phle- Conclusions. CVDs worldwide are responsible for large pro- bectomy but was more pro!table on number of puncture ductivity losses, as well as for physical and psychological pa- wound and cosmetic result than phlebectomy. tients sufferings which are re#ected in worsened quality of life.

Should we Consider Venous Pain as Part of Chronic The Updated International Guidelines on ‘The Man- Venous Disease? agement of Chronic Venous Disorders of the Lower E. Rabe Limbs’ and the Place of Venoactive Drugs University of Bonn, Department of Dermatology, Bonn, Germany M. Perrin1, A. Nicolaides2 1Vascular Surgery, Chassieu, France Aim. De!ne whether venous pain is part of chronic venous 2Vascular Screening and Diagnostic Centre, Ayios Dhometios, Nicosia, disease (CVD) Cyprus Methods. An analysis of the literature regarding the pathophysiology, epidemiology, assessment methods of venous Aim. To update the central role that venoactive drugs symptoms, together with the link between symptoms and ob- (VADs) have in the management of symptomatic patients from jective CVD variables (signs, re#ux, markers) was performed. the earliest stages of chronic venous disorders (CVDs) to com- Results. Despite a systematic seek for venous symptoms plications. may help detect a CVD in 6 out of 10 subjects, mostly at the ear- Methods. A literature search of recent randomized con- lier stages, it appears that venous pain is often overlooked by trolled trials examining the effects of VADs on the relief of ve- physicians. The causes for such attitude might be that venous nous symptoms in patients in CEAP classes C0s to C6s was pain is common, mostly affects women, and is more impor- performed. tant to improve for the patient than the physician. In addition, Results. Recommendations are summarized in the table lower limb pain is not enough speci!c of CVD, or not system- below. It should be noted that the recommendation for mi- atically related to clinical signs or re#ux. This suggests that cronized puri!ed #avonoid fraction (MPFF) is strong, based venous pain may be related to disorders in the micro- rather on bene!ts that clearly outweigh the risks and evidence of than the macrocirculation, and we are just currently able to moderate quality (grade 1B) for the indication of relief of assess re#ux in large veins, not in smaller ones. There are also venous symptoms in C0s to C6s patients, including those signi!cant association with number of reported symptoms and with CVD-related edema. MPFF retains its strong recom-

106 INTERNATIONAL ANGIOLOGY October 2013 mendation for use as adjunctive therapy in treating venous home care regimens 4. Educate parents 5. Design patient and ulcers. age speci!c gradient compression garments Years Study Con- Conclusions. VADs may be the only alternative available ducted - April 1, 2001 thru present Disease Condition Studied when patients cannot comply with compression therapy. In - KT Syndrome and Primary Lymphedema Subject Studied - CVD complications, VADs and more particularly MPFF may 3 month old infant to present Setting in which subject stud- be used in conjunction with sclerotherapy, surgery and/or ied - Clinical and Home Care Interventions - Manual Lymph compression therapy, and be considered as adjunctive therapy Drainage Gradient Bandaging Intensive Skin Care Gradient in patients with active venous ulcers, especially in those with Compression Garments Monitor possible problems during large ulcers of long standing. growth and mobility Outcome Measurements - Patient’s Re- sponse - Minimal discomfort during treatment Independent Variables - Positive Effects: Reduction of #uid volume Healthy Skin Parents performing total home care Effective gradient compression garments Preliminary Analyses - Excellent total Advantages of Foam Sclerotherapy with Oxygen patient response And Polidocanol Results. Positive projected Results. - Parents’ acceptance F. Vega Rasgado 1, M. Vega Díaz2, M. Salinas P.3, L. Vega Rasgado4 of condition - Parents’ administering total home care - Re- 1Academia Mexicana de Flebología y Linfología, Tlalnepantla, Mexico duced swelling and minimal skin complications - Minimal 2E.N.C.B., I.P.N., México, Mexico discomfort during treatment - More mobile, independent, 3Clinica de Várices y Ulceras de México, México, Mexico compliant patient - Custom gradient compression stockings 4E.N.C.B., I.P.N., México, Mexico that !t Abstract text: At 18-20 weeks gestation, a malformation of Brandon’s left lower quadrant was detected upon rou- Aim. 1). Prevention of serious neurological effects post scle- tine ultra sound. Soon after his delivery on January 9, 2001, a rotherapy 2). To improve the quality of the micro bubbles re- thorough medical examination indicated Brandon had an ex- ducing gas solubility (O2) in blood 3). Inject higher volume of tremely large soft tissue overgrowth of the left foot, especially sclerosing agent safety the dorsum, with irregularity of the gluteal cleft. Phlebectatic Methods. Patients with multiple veins from Ambulatory blood vessels were detected within the small vascular stain Surgery Center were randomly selected. Patients were ana- overlying the left buttock. The affected left leg was 2 cm long- lyzed for HB, Ch, PT, EKG and chest x-ray. Procedure was er than the right leg. Large microcystic lesions containing performed in the surgical room with assistance of the anesthe- massive amounts of stagnant lymphatic #uid were present siologist and continuous monitoring Vein line was required in the foot and lower leg. MRI results indicated that Bran- and sometimes sedation The foam was prepared with Tessari don’s left lower quadrant lymphatic system was immature method using 1 part of liquid polidocanol at different concen- and inadequate. Our immediate concern was infection creat- trations and 4 parts of pure oxygen. The volumes used were ac- ing life-threatening conditions. Other critical isssues were: cording to the type and number of affected veins. The patients - The potential function of the affected left leg - To what de- were discharged after 3 Hrs with bandage and compressive gree was soft tissue and bone affected? - Status of lymphatic stockings connections/anastamosis between the left foot and lower leg Results. A concentrate of the results is as follows: Patients - How ef!ciently would #uids move through these affected = 500 Legs = 629 Right = 277= 44 % Left = 352 = 56 % Max. areas? - Effects of intensive gradient bandaging and gradient Volume= 60 ml Average Vol. = 19.5 ml Average polidocanol compression garments on an infant’s fragile skin and append- concentration = 2% Reticular and spider veins = 471 (74.88 %) ages - Availability of gradient compression garments to !t an Affected veins: Boyd perf. = 40 % Cockett I perf. = 195 (31 %) infant Saphenous veins = 125 (19.9) % Others = 30 % Adverse effects: Conclusions. This case study proves that if gradient direc- 0 The polidocanol concentrations were between 0.5-3% Here tional #ow garments are effective in treating this condition, we report just the most frequently affected groups of veins Our they could also be effective in treating other lower extremity study continues edema/lymphedema conditions: Positive !ndings: - Reduce in- Conclusions. The FOAM sclerotherapy performed with O2 #ammatory processes - Soften !brotic tissues - Reduce swell- is a good option to prevent and decrease the side neurological ing post-joint replacement - Alleviate sports injury trauma - effects. The FOAM performed with O2 is safe for high volumes Control effects of many blood vascular diseases - Adaptable injection when it is required. for aging population conditions Negative !ndings: - Treat skin as a wound - Need multiple non-custom gradient compression garments - Need supportive, adaptable shoes

Caring for an Infant with (KT) Klippel Trenaunay Syndrome Complicated by Microcystic Lymphatic Malformation of Left Lower Quadrant Vein Sparing Endovenous Laser Therapy P. Tubbs-Gingerich S. Doganci1, U. Demirkilic2 Ginger-K Lymphedema & Cancer Care Center, Morgan Hill, CA, USA 1Gulhane Military Academy of Medicine, ANKARA, Turkey 2Varis Merkezi, Kavaklidere/Ankara, Turkey Aim. Reduce/control edema and lymphedema when both the venous and lymphatic systems are compromised. Protect Aim. After gaining experience in the laser ablation of re- the integrity of an infant’s skin during long periods of gradi- sidual and/or recurrent veins, the idea of vein sparing endov- ent bandaging and wearing gradient compression garments. enous laser ablation has emerged. The aim of this study is to Educate both parents in administration of total home care. assess the ef!cacy, results, and adverse events of vein sparing Teach awareness of their infant’s future needs so they can, in endovenous laser ablation strategy. turn, prepare him as he grows, to care for himself. Prevent Methods. Between Februrary 2012 and September 2012 infection 18 patients with varicosities that caused by the Hunter per- Methods. Study Design: 1. Implement new ways to treat forators (n=7), tributary veins that arise form great saphen- complications of pediatric lymphedema 2. Design skin care ous vein (GSV) (n=7) or from Giacomini vein (n=2) included program for extremely fragile skin 3. Integrate cllnical and in the study. All patients treated with 1470 nm diode laser

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 107 and radial or slim radial !bers. All procedures were per- more potent. Safety was excellent; venospasm and failed ac- formed under local anesthesia. Endovenous laser ablation cess was rare in this small series. There was no signi!cant af- (EVLA) was performed using continuous pullback mode fect on heart rate or blood pressure of even combination forms with a power of 8 W. Linear endovenous energy density of nitroglycerin. (LEED) was decided as 50 J/cm regardless of the vein diameter. At the patients that do not have re#ux in saphenofemoral junction but re#ux in Hunter perforators, the GSV was in normal diameter excluding the segment in connection with perforator veins. In this situation we only ablated the Effects of Micronised Puri#ed Flavonoid Fraction distorted segment of GSV. For the tributary veins and Gi- on Symptoms and Quality of Life in Patients Suffer- acomini veins, we only ablated the related vein and did not ing from Chronic Venous Disease touch the GSV or small saphenous vein (SSV). Patients were A. Ramelet1, E. Rabe2 followed on the 2nd, 7th days and 1st and 6th month post- 1Dept Dermatology Inselspital Bern, Lausanne, Germany operatively. 2University of Bonn, Department of Dermatology, Bonn, Germany Results. The initial success rate was 100% in all patients. All treated veins remained closed after 1 month. No major Aim. The aim was to investigate the effect of Micronised complication such as deep vein thrombosis and pulmonary Puri!ed Flavonoid Fraction (MPFF; Da#on® 500mg) versus embolism was observed. At the beginning of the procedure, placebo, on pain and quality of life in patients with sympto- we hesitated about the propagation of the thrombus in the matic Chronic Venous Disease (CVD). proximal or distal part of the ablated segment. However, due Methods. A randomised, double-blind, placebo-control- to the !brotic occlusion caused by the 1470 nm diode laser, led, parallel-group study was conducted from 2003/06 to radial !ber, effective tumescent anesthesia administration evaluate treatment effects on vesperal oedema using water and trendelenburg position, the thrombus did not propogate displacement volumetry (WDV). Other criteria were leg pain\ anywhere and only the ablated segment remained occluded. heaviness assessed by visual analog scale (VAS) and quality There was no bruising, local pain, induration, and paraes- of life (CIVIQ-20). Tolerability was also assessed. Study treat- thesia. ments were administered for 4 months. The analysis focuses Conclusions. Selective, segmental vein ablation strategy on the subgroup of symptomatic patients having a baseline seems to be an effective method for sparing rest of GSV or VAS >4 cm. SSV. Since GSV is the most important graft for all vascular Results. The main study included 1137 patients classi!ed procedures, ablation of only distorted segments and sparing C3 or C4 according to CEAP class, with 572 in the sympto- the rest of it, may help us to preserve the valuable grafts. Al- matic subgroup: 296 randomised to MPFF and 296 to placebo. though these are promising results, these !ndings must be Patient demographics and medical history were well-balanced con!rmed by larger series. at baseline. The main study was inconclusive on WDV for methodological reasons. In the symptomatic subgroup, MPFF treatment was associated with a greater reduction in VAS score than on placebo treatment (between-group difference = -0.5 cm; p=0.031) and greater improvement in CIVIQ score Subcutaneous Nitroglycerin for Venodilation & Pre- (between-group difference = 3.1%; p=0.040). vention of Venospasm in Endovenous Ablation Pro- Conclusions. A 4-month treatment with MPFF signi!- cedures cantly reduced leg pain/heaviness and improved QOL when R. Mueller, J. Mueller compared to placebo and was well tolerated based on spontaneously reported adverse events, coded using the MedDRA Cosmetic Vein Solutions, New York, NY, USA dictionary. Aim. 1) Assess incremental ef!cacy of subcutaneous nitroglycerin (SC NTG) after topical dosing for venodilation in endovenous ablations. 2) Assess safety of nitroglycerin. 3) Assess ability of nitroglycerin to prevent venospasm related access failure. Sonothrombolysis – A Systematic Review of Throm- Methods. Non-randomized, prospective, single-arm, open bus Dissolution Using Microbubble Augmented Ul- label trial of SC NTG in consecutive re#ux patients undergoing trasound of!ce endovenous ablation 3/2013. 0.4 mg SC NTG injected B. Dharmarajah1, A. Thapar 1, V. Kasivisvanathan 1, E. Leen 1, A. Davies 2 in 2 aliquots on each side of the accessed vein, 20-30 minutes 1Imperial College London, London, United Kingdom after topical NTG applied (both unlabelled indications). Out- 2Academic Section of Vascular Surgery, Imperial College London, Lon- comes (inc. paired samples t tests, two-tailed): vein diameters, don, United Kingdom BP, HR before and after topical and SC NTG, toxicity, access failures, and venospasm. Aim. Post thrombotic syndrome (PTS) develops in 25-50% Results. Vein diameters - Baseline: 3.1 mm (SD. 89) Post of patients with DVT. Acute removal of venous obstruction Topical NTG: 3.5 mm (increase + 0.4 mm, SD. 53, p<.026, two- may preserve valvular function and reduce the incidence of tailed t test) 1 min. post SC NTG: 4.6 mm (increase + 1.1 mm PTS. Anticoagulation does not achieve thrombus dissolution, compared with topical, SD. 54, p<.001) SC NTG produced a therefore, novel percutaneous techniques such as catheter-di- 2.8 fold increase in vein diameter beyond topical NTG. 1 pa- rected thrombolysis and pharmacomechanical thrombectomy tient (8%) had vasovagal presyncope, responding immediately are being investigated as adjuncts in DVT therapy. This review to ammonia inhalant, venospasm & failed access. There were examines the experimental evidence for sonothrombolysis, a non signi!cant effects of SC or topical NTG on HR or BP, and non-invasive technique of microbubble augmented ultrasound no morbid events. for thrombus dissolution in the treatment of DVT. Conclusions. Subcutaneous nitroglycerin provided robust Methods. Two reviewers independently performed a sys- incremental venodilation (2.8 fold) of truncal veins at endov- tematic review of Pubmed and OVID databases according to enous ablation access sites, even after topical NTG pretreat- PRISMA guidelines for microbubble augmented sonothrom- ment. Topical nitroglycerin, an accepted strategy, delivered bolysis studies both in-vitro and in-vivo to assess the feasibility meager venodilation, while subcutaneous nitroglycerin was and safety for use in the treatment of DVT.

108 INTERNATIONAL ANGIOLOGY October 2013 Results. In-vitro, studies were performed both in non-#ow Comparison of 2-Ring Radial and Closurefast Fibers and #ow conditions using varied clot preparations. Ultrasound in the Treatment of very Large Diameter Veins with microbubbles showed increased thrombolysis over con- U. Demirkilic1, S. Doganci2 trol conditions. However, signi!cantly increased thrombolysis 1Varis Merkezi, Kavaklidere/Ankara, Turkey was observed in all but one study with addition of thrombolytic 2Gulhane Military Academy of Medicine, ANKARA, Turkey agents to ultrasound and microbubbles. In-vivo, studies consisted of animal thrombosis models using peripheral vessels. Aim. Endovenous thermal ablation methods have proven Increased thrombolysis with ultrasound and microbubbles was themselves as effective and safe treatment strategies in the again demonstrated. Additionally, disruption-replenishment ul- recent years. According to randomized trials ClosureFast trasound techniques using intermittent low mechanical index fiber is superior for early postoperative pain when com- (MI) imaging provided signi!cantly better thrombolysis compared to laser, and stripping. Two-ring radial fiber is a new pared to continuous high MI imaging. No evidence of clinically generation fiber. This fiber splits the energy in two phas- signi!cant emboli were observed as a result of sonothromboly- es and leads to an effective vein closure with less energy sis, however, local thermal effects were reported in some animal density. The aim of this study is to compare the efficacy, models. Signi!cant heterogeneity in methodologies did not al- adverse events, occlusion rates, patient satisfaction and low quantitative comparison of studies. changes in venous clinical severity scores in the treatment Conclusions. Sonothrombolysis appears a feasible and safe of very large diameter (>12 mm) great saphenous veins technique for thrombus dissolution but further experimental (GSV). work is required using speci!c models of DVT. Methods. Between September 2011 and September 2012, 40 patients (53 limbs) with GSVs lager than 12 mm randomized in two groups. Group 1 was treated with 1470 nm diode laser plus 2-ring radial laser fiber and Group 2 was treated with radiofrequency (RF) energy plus Clo- Effectiveness of Gebauer’s ® Mist Ethyl Chloride sureFast fiber. All the procedures were performed under Topical Anesthetic in Minimizing Pain Associated tumescent local anesthesia. In Group 1 treatment param- with Tumescent Anesthesia in Endovenous Ablation eters were 12 Watts and 70 J/cm of LEED. In the RF group Procedures treatment parameters were set by the RF generator. For T. Tran the proximal 3 segments double ablation of the same seg- Comprehensive Vein Center, The Villages, FL, USA ment was performed. In both groups cold tumescent local anesthesia was given under ultrasound guidance and with Aim. Tumescent anesthesia is the most painful and highest the help of a tumescent pump (10 ml/treated vein length). primary complaint of traditional Endovenous Ablation Proce- Vein diameters, treated vein length, total amount of deliv- dures. There is limited research in the use of topical anesthetic ered energy (in Group 1), number of segmental ablation (in to help patients alleviate the pain from instilling a large bore Group 2), amount of tumescent local anesthesia, duration needle for tumescent anesthesia. of ablation, occlusion rates, local pain, bruising, indura- Methods. Methods To determine the effectiveness of Ge- tion, paraesthesia in the ablated regions, patient satisfac- bauer’s® Mist Ethyl Chloride spray in diminishing the pain tion and changes in VCSSs (preoperative, postoperative related to tumescent anesthesia, we conducted a prospective 1st week and 1st month) were recorded. Additional phle- observational study on a convenience sample of patients un- bectomies were performed for all patients in both groups. dergoing Endovenous Ablation of the Great Saphenous vein. No heparin prophylaxis was used. Follow-up visits were Use of the spray prior to injection of tumescent and without planned on the 2nd postoperative day, 7th day, 1st ,3rd and was evaluated. Clinical and demographical data collected in- 6th month. clude age, sex, weight, and numeric pain scale 1-10. The pri- Results. Mean GSV diameter at saphenofemoral junc- mary outcome measures were the pain scale score differences tion and the knee levels were 17.3± 5.2 and 11.9±3.6 mm, with Mist Ethyl Chloride and without. and 16.8±4.1 mm and 11.5±3.1 mm respectively in Groups Results. Results Of the 71 patients, there were 22 (31%) 1 and 2. The initial success rate was 100% in all patients. males and 49 (69%) females, average age of 61.4 with a range All treated GSVs remained closed after 6 months. No ma- from 30 to 87, Average weight 170.8 lbs. with a range from jor complication such as deep vein thrombosis and pulmo- 110 to 280 pounds. The average pain without Ethyl Chloride nary embolism was observed. There were no local pain, is 6.309 with a min/max from 1 to 10, respectively. With use no bruising, and no paraesthesia in the ablated segment of Ethyl Chloride spray, the average pain scale is 2.633 with a in both groups. While there was no induration in group 1, min/max from 0 to 9, respectively. The spray does seem to have there were 2 indurations and phlebitis in group 2 (p>0.05). a signi!cant effect on the pain level of the patients. The results Mean treated vein length was 46.5 cm in group 1 and 45.9 show an estimated average difference of 3.6761 units of pain in group 2 (p>0.05). Mean duration of ablation was 198.2 lower when patients were given the spray. This result is highly seconds in group 1 and 191 seconds in group 2 (p=0.071). signi!cant with a p-value of <0.0001. No clinical signs of infec- VCSS scores were improved after the procedures and there tion or skin burn was identi!ed in any of the 71 patients. was no statistically significant difference between groups. Conclusions. Conclusion According to the pain scale There was also no statistically significant difference in pa- scores, use of Gebauer’s ® Mist Ethyl Chloride spray appear tient satisfaction between groups. to have a strong clinical signi!cance in reducing the pain as- Conclusions. Both treatment modalities are safe and sociated with tumescent anesthesia during Endovenous Ab- effective in the treatment of very large diameter GSVs. lation procedures. The study showed that there was a 58.2% 2-ring radial fiber also cause almost no pain as in the RF reduction in pain with use of the spray than without. A high- system. In very large diameter veins in order to increase er population study or multi-center trial would need to be occlusion rates double or sometimes triple ablations are done to accomplish even a stronger clinical signi!cance. In performed in RF. This situation unintentionally increases addition, there are multiple factors that can skew the pain the duration of the ablation procedure. From this point of scale such as age, sex, socioeconomic status, weight, small view, laser ablation with 2-ring radial fiber is also as fast saphenous vein treatment, costs, and co-morbidities that as RF system. There were 2 indurations and phlebitis in RF would need to be considered and further studied in a com- group. This may be related to vein diameter (diameters of parison analysis. these patients: 25 mm, 28.4 mm).

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 109 Endovesonus Laser Treatment of Recurrent and Re- permanent. 755-nm Q-switched laser is shown to be an ef- sidual Varicose Veins fective treatment to speed clearing. It is advisable to screen U. Demirkilic1, S. Doganci2 patients carefully for minocycline use and to discontinue the drug well in advance of sclerotherapy. 1Varis Merkezi, Kavaklidere/Ankara, Turkey 2Gulhane Military Academy of Medicine, ANKARA, Turkey

Aim. Recurrent varicose vein following previous surgery is relatively common and surgical reintervention to treat these recurrent varicosities is a cumbersome procedure. The aim of Five-Year Results Following Endovenous Laser Ab- this study is to asses the ef!cacy and safety of endovenous laser therapy in the treatment of recurrent varicose veins. lation of Great Saphenous Vein Varicosities Treated Methods. Between February 2010 and March 2012, 89 With 1470 nm Diode Laser and Radial Laser Fibers: limbs of 69 patients with recurrent varicose veins after pre- 1033 patients (1316 limbs) vious surgery were included in this non-randomized pro- S. Doganci1, U. Demirkilic2 spective study. Patients were evaluated by doppler examina- 1Gulhane Military Academy of Medicine, ANKARA, Turkey tion. Saphenofemoral junctions were carefully examined for 2Varis Merkezi, Kavaklidere/Ankara, Turkey stump, any residual side branch or neovascularization and re#ux. Then, presence of residual or dilated accessory axial Aim. The aim of this prospective study was to assess !ve- and association of perforator veins were determined. Venous year outcomes, adverse events, side-effects, recanalization clinical severity scores (VCSS) were recorded. Patients were rates after endovenous laser ablation (EVLA) of great saphe- treated with 1470 nm diode laser and radial !bers by using nous veins with 1470 nm diode laser and radial !bers by a 10 Watts and 50 Joule/cm of LEED. Postoperative morbidity, standardized duplex and clinical protocol. improvements of VCSS scores (determined at the 3rd month Methods. A non-randomized prospective trial was per- visit postoperatively), treated vein length and occlusion rates formed. We included a total of 1316 unselected limbs of 1033 were also recorded. Follow-up visits were planned as 1st week, patients with incompetent great saphenous veins (GSV), con- 1st month, 3rd, 6th and 12th months. !rmed by duplex ultrasound between September 2008 and Results. Mean age of the patients were 41.4±11.3 (23-71) April 2011. Patients with small saphenous vein insuf!ciencies years. 46 of patients were female. All patients were completed 1 did not included in this study cohort. EVLA was carried out year follow-up period. Mean recurrence time was 5,7±2,4 years with a 1470 nm diode laser and radial laser !bers in continu- (2-12). There were different types of recurrences. All patients ous mode and using ultrasound guided tumescent local an- were succesfully treated according to the recurrency type. VC- esthesia. Concomitant phlebectomies were performed in the SSs were improved in all patients. Signi!cant improvements same session. No heparin prophylaxis was given. Compres- in VCSS were determined when compared to preoperative val- sion therapy was applied to all patients. CEAP classi!cations ues at the third month follow-up. No adverse events such as of patients were determined. Venous Clinical Severity Scores ecchymosis, induration and paresthesia were detected at the (VCSS), and patient satisfaction were determined (preopera- early postoperative period. Patients complained minimal or tive and postoperative 3rd month). Side effects, adverse events no pain related with the procedure. No major complication were recorded. Patients underwent standard clinical and du- such as deep vein thrombosis and pulmonary embolism was plex follow-up examinations for recanalization, complication detected. such as deep vein thrombosis at postoperative 2nd day, 1 week, Conclusions. Surgical treatment of recurrent varicose 1 month, 6 month, 1 year and yearly thereafter. veins is a demanding procedure which is more dif!cult then Results. Re#ux was eliminated in all patients in the follow- the primary surgery according to the pattern of re#ux and re- up period (2 year- 54 months). 901 (87,2%) patients complet- current veins. Endovenous treatment as in primary interven- ed 2 years, 452 patients (43,7%) completed 3 years, and 216 tion provides an easy, safe and ef!cient treatment option in the patients (20,9%) (278 limbs) completed four years follow-up treatment of recurrent varicose veins. examinations. No re#ux and recanalization was recorded in any control point so far. Until a one-year experience we used 15 Watts and 90 Joule/cm of LEED as a treatment protocol, then we revized our protocol and gradually decreased watt and LEED levels. First we used 14W and 80 Joule/cm LEED and then for the last 20 months we are using 12 W and 70 Joule/ Minocycline Post-Sclerotherapy Hyperpigmenta- cm LEED energy for the treatment of GSV varicosities. 216 tion patients that completed 3 year follow-up were treated with 15 M. Isaacs Watts and 90 Joule/cm of LEED. There was 13 minimal ec- Vein Specialists of Northern California, Walnut Creek, CA, USA chymosis and 15 indurations and 4 transient paresthesias in the laser treated area. After decreasing the parameters to 14 W Aim. Raise awareness of minocycline related hyperpigmen- and 80 joule/cm LEED we treated 118 patients in a 5-month tation as a complication of sclerotherapy Educate regarding period. With this strategy 3 minimal ecchymosis and 3 indu- underlying pathophysiology Present approach to treatment of rations were seen in this group and no recanalization in the this complication follow-up visits. Then we decided to decrease to 12 W and 70 Methods. A case report will be presented demonstrating joule/cm LEED. 699 patients were treated with these parame- minocycline-related post-sclerotherapy pigmentation. This ters. With these parameters no ecchymosis, no induration and case will be used as the basis for discussing the underlying no paresthesia were recorded. Besides, these parameters did pathophysiology of this form of hyperpigmentation. Treat- not change the closure rate during the follow-up period. Al- ment with a 755-nm Q-switched alexandrite laser was shown though most of the patients were satis!ed with the treatment, to be an effective method of treatment to speed clearing of the satisfaction degree was even higher in the 12W and 70 Joule/ pigmentation. Photographs will be used to illustrate the nature cm LEED treated patients. VCSS scores were signi!cantly de- of the hyperpigmentation and treatment with laser. creased in all patients. Severe complications such as deep vein Results. (as previously described) thrombosis or pulmonary embolism did not occur in any of Conclusions. Minocylcine related hyperpigmentation can the treated cases. persist for years after appearing, and in some cases may be Conclusions. EVLA of the GSV with 1470 nm and radial

110 INTERNATIONAL ANGIOLOGY October 2013 laser !ber is a minimally invasive, safe and ef!cient treatment Ef#cacy and Safety of Cutting Balloons for the Treat- option. 1470 nm and radial laser !bers increased the success ment of Obstructive Lesions in the Internal Jugular rates while decreasing the early morbidity following EVLA. Veins Even lower energy levels did not change the closure rates. M. Simka1, T. Ludyga2, M. Kazibudzki2, P. Latacz2 1NZOZ Sana, Department of Angiology, Studzionka, Poland 2EuroMedic Medical Center, Katowice, Poland

Aesthetic Ambulatory Surgical Therapy of The Gi- Aim. Balloon angioplasty remains the main therapeutic ant Varicose Veins modality for the management of CCSVI. This method, howev- V. Ciubotaru er, was also reported to be associated with unacceptable rates Clinica Medicala FLEBESTET, Bucharest, Romania of restenoses, even as high as 50%. Although early results of stent implantations in CCSVI patients were promising, long- Aim. The aim of this paper is to present VANST (Varices’ term follow-ups have demonstrated frequent occlusions of Ambulatory Non-stripping Surgical Therapy)- a particular stents. These observations indicated that stentsʊat least cur- minimally invasive surgical method of treatment of the large rently available bare-metal devicesʊshould not be seen as a diameter varicose veins. preferred and routine treatment modality for CCSVI. Here we Methods. This retrospective study regards cases operated present the results of endovascular treatment for CCSVI with on between September 1998 - September 2012. Under local the use of cutting balloons, with focus on feasibility and safety anesthesia the varicose veins are intercepted, sectioned and of these endovascular devices. ligated. The same procedure is applied for pathologically di- Methods. We used cutting balloons (Peripheral Cutting lated collateral veins and for insuf!cient perforant veins. In Balloon®; Boston Scienti!c Corporation, USA) during 70 this manner both the venous #ux and re#ux are eliminated and procedures in 65 multiple sclerosis patients presenting with the varices are taken out of the circuit and become just empty strictures of the internal jugular veins, primarily at the level of nonfunctional tubes. jugular valves. These devices were used only in selected cases, Results. Veins of a diameter smaller than 40 mm. where following unsuccessful standard balloon angioplasty, and on excluded from the study. Number of cases in the study: 648 condition that commercially available devices could be applied limbs (623 patients – 166 women and 457 men). The struc- (currently they are maximally 8 mm in diameter). Borderline ture of the cases based on CEAP classi!cation: C2-53 ; C3-127 cases were treated using kissing balloon technique – cutting ; C4a-224 ; C4b-184 ; C5-19 ; C6-41. Postoperative closing up balloon together with a longer supporting standard balloon. of the varices takes place immediately in 100% of the cases. 5 Results. In all cases the perioperative course was unevent- years follow-up: recurrence after VANST occurs in 6.24% of ful, with no serious adverse events. Immediate technical success rate was 94.3%. In four cases (5.7%) cutting-balloon an- the cases. Improvement of the patients’ quality of life takes gioplasty alone was unsuccessful and stents were implanted. place in 2-4 weeks. Primary, assisted primary and secondary patency rates after 6 Conclusions. VANST is an excellent alternative to stripping months were: 88.1%, 94.1% and 98.5%, respectively. Follow- for treating large diameter varicose veins. The advantages of up has revealed that out of remaining 66 angioplasties four VANST are: - minimally invasive procedure - ambulatory treat- procedures failed (failure rate: 6.1%): in two patients stents ment (2-3 hours hospitalization) - no intraoperative bleeding, were implanted, in one patient successful redo cutting-balloon no postoperative echimosis or hematoma - postoperative evo- angioplasty was performed, in another case the treated seg- lution practically painless - aesthetic postoperative appear- ment of jugular vein totally occluded and was not feasible to ance. reopen endovascularly. Conclusions. Cutting balloons can be safely used for the management of stenosed internal jugular veins. These devices can replace stents in majority of cases, especially if standard Getting a Leg Up: Social Media that Works for To- balloon angioplasty is insuf!cient to restore proper out#ow. day’s Phlebologists However, the use of cutting balloons in this particular venous S. Peek territory is limited by the fact that currently only small diam- Incredible Marketing, Irvine, CA, USA eter devices are available. We also suggest that future clinical trials on the treatment for CCSVI should include cutting bal- Aim. Today, healthcare providers know that a social me- loons in the therapeutic armamentarium. dia presence is valuable, especially for specialized medical practices. The social sphere affords a venue for building and maintaining patient relationships, optimizing word of mouth exposure, pro!ling services and new technologies, generating Internal Laser Valvuloplasty and Endovascular Ve- disease awareness, and reinforcing brand identity. Creating ef- nous Remodeling with 1470 NM Laser. Initial Expe- fective social media efforts, however, requires a strategic ap- riences proach. E. Ferracani Ristenpart Methods. The purpose of this presentation is to demon- Instituto Privado de ecogra#a y Laser endovascular, Buenos Aires., Ar- strate how to build a successful and engaging social media gentina campaign that connects with patients, builds a specialized community, and generates business. With more than 1 billion Aim. #1 Investigate the ef!cacy of the use of laser 1470 active users on Facebook in 2013, connecting with patients for internal laser valvuloplasty of the saphenofemoral junc- requires skills of engagement, including a varied content mix tion with an innovative approach (ILV) internal laser valvulo- (blog, video, images, surveys, questions, articles, patient re- plasty #2 investigate endovenous laser remodeling with 1470 views), email and Website integration, and a regular social nm emission, (evlar) endovascular venous laser renodeling. #3 media presence that employs a patient-friendly tone. Evaluate the absence of complication with this new approach Results. A case study will be presented that documents the Methods. Prospective study.Study conducted 2012. Our impact of social media on the phlebologist’s practice. prospective initial experince comprised !ve patients done in Conclusions. Professional service options will be present- three phases. Phase 1; reduction of diameter and area phase ed. 2, reduction of diameter area and reduction of perioperative

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 111 re#ux phase 3, folow up control ,diameter and re#ux reduc- Epidemiology of CCSVI in MS using ECD-TCCS and tion, absence of complications. We used two !bers, a 6 mm Venography diameter radial !ber (elves radial) and a 4 mm diameter ra- A. D’Alessandro dial !ber (elves radial slim), inserted endoscopically trough Chief Dept. of Angiology S. Severo Hospital (FG), SAN SEVERO, Italy and angioscopy device for direct vision and perioperative ultrasonography. The primary ef!cacy endpoint of the study Aim. Chronic Cerebrospinal Venous Insuf!ciency (CCSVI) was ultrasound reduction and decreasing or abolition of os- are a recently described vascular clinical !ndings, character- tial saphenous vein re#ux by restoring the diameter of the ized by multiple stenoses of the major extracranial venous saphenous vein ef!cacy and further safety end points after a drainage pathways, particularly in the internal jugular veins period of six months were as follows:ultrasound absence or (IJV) and in the azigos vein (AZY), which cause intracranial decrease of re#ux, no deep vein thrombosis (DVT), no clini- hypertension. The activation of collateral circulation, clearly cal pulmonary embolism(pe or super!cial vein thrombosis identi!ed by selective venography, attempts to compensate for (SVT). the reduced venous return, however, the time of venous return Results. Ultrasound control was done intraoperative in is increased compared with control subjects. The hemody- four patients, one in phase 2 and three in phase 3.Elimination namic changes described in CCSVI, appear to be signi!cantly of re#ux was achieved in three patients one in phase 2 and two in phase 3. A 50% reduction was observed in the remain correlated with multiple sclerosis (MS). In this research we patient present all treated veins present stable results report our experience on the subject. Conclusions. Reduction of re#ux and functional recovery Methods. Non-invasive screening: was performed by of the vein could be achieved with this innovative approach ECD-TCCS examination according to the protocol de- and the results are stable a six month of follow up term follow scribed by Zamboni, considering the presence/absence of up and a larger amount of patients will enable an assessment !ve hemodynamic-ultrasonographic criteria required for of the durability of this new technique. the diagnosis of CCSVI: in order for a CCSVI diagnosis to occur, according to the protocol Zamboni, the patient should present at least 2 of the following 5 parameters: 1. Re#ux of internal jugular veins and/ or vertebral veins while in supine and sitting position; 2. Re#ux of DCVS (internal Improvement of Quality-of-Life after Endovascular cerebral vein, basal vein of Rosenthal, and the great cer- Treatment for Chronic Cerebrospinal Venous Insuf- ebral vein of Galen) 3. Presence of stenosis in the internal #ciency in the Patients with Multiple Sclerosis jugular vein after high-resolution B-mode examination; 4. M. Simka1, P. Latacz2, M. Kazibudzki2 Flow in the internal jugular veins and/or vertebral veins un- detectable with Doppler examination; 5. Inverse postural 1NZOZ Sana, Department of Angiology, Studzionka, Poland 2EuroMedic Medical Center, Katowice, Poland control of the main cerebral venous out#ow pathways. Phle- bographic diagnosis: 38 patients with CCSVI ultrasound Aim. The aim of this study was to evaluate an impact of diagnosis, underwent selective venography executed in a endovascular treatment for chronic cerebrospinal venous in- blinded fashion by two different teams. The former of insuf!ciency (CCSVI) on quality-of-life, chronic fatigue and heat terventional radiologists and the latter of vascular surgeons intolerance in multiple sclerosis patients. of IJV and AZY preoperative systems. Population Between Methods. In this open-label study we evaluated clinical January 2011 and January 2013, 137 patients were studied ef!cacy of endovascular treatment for CCSVI in a group of consecutively with US (90 females, 65,69%, and 47 males, 340 multiple sclerosis patients. These treatments were per- 34,30%), aged between 20 and 73, all related to various neu- formed in the years 2009-2011. We measured quality-of-life rological centers with clinically de!nite multiple sclerosis with Multiple Sclerosis Impact Scale-29 (MSIS-29) question- (CDMS), diagnosed according to the revised McDonald cri- naire, and severity of fatigue with Fatigue Severity Scale teria. Clinically, 80 patients (58,39%) had a clinical course (FSS). This assessment was done before endovascular pro- with exacerbations-remitting (RR), 38 patients (27,73%) cedure and after 6-months and 12-months follow-ups. We had a secondary progressive form (SP), and 11 patients also measured impact of the treatment for CCSVI on heat (8,02%) a primary progressive form (PP). intolerance. The treatments for CCSVI in these patients were Results. Of 137 patients with MS, 127 (92,70%) were diag- approved by the Bioethical Committee of the Regional Sile- nosed with CCSVI while 10 patients (7,29%) did not respond sian Board of Physicians in Katowice, Poland (approval No: to at least 2 Zamboni criteria, resulting in a negative diagnosis 7/2010). The study has been registered at ClinicalTrials.gov, of CCSVI. Among 40 patients studied with selective preopera- identi!er: NCT01264848. tive venography and positive to CCSVI, all had venous anoma- Results. We found statistically signi!cant improvement lies of the internal jugular veins and 19 patients (50%) had of some symptoms of multiple sclerosis. After the treatment venous anomalies of the azygos vein. mean FSS score dropped from 4.7 to 3.8 at 6-month follow- Conclusions. 1) the ECD-TCCS examination is an indis- up, and 3.7 at 12-month follow-up. Total MSIS-29 score pensable tool for the diagnosis of CCSVI for patients with S.M. dropped from initial average 86 points by 8 points after 6 However, the ECD-TCCS examination needs a new type of cul- months, and by 6 points after 12 months. Heat intolerance tural approach and requires an extended period for learning. did not change after the treatment. Interestingly, we did not Therefore it is of no surprise how the results of similar studies observe a “learning curve”, i.e. clinical outcomes were the can present signi!cant differences. 2) the ECD-TCCS examina- same throughout the study. tion is similar to selective phlebography (100% of patients) in Conclusions. Our results con!rm the !ndings of the pre- terms of diagnosis of CCSVI, while presenting signi!cant mar- vious studies that have found positive effect of endovascular gins of error when detecting concerned vessels. ECD-TCCS treatment on quality-of-life in multiple sclerosis patients. examination should therefore be entrusted with the diagno- Contrary to the others, we found that these clinical bene!ts sis of CCSVI without further specifying the nature of venous were not transient, but were still present after one year after anomalies and the vessels concerned. On the other hand, a endovascular procedure. However, even if these results are en- 100% sensitivity of the ECD-TCCS examination with respect couraging, a placebo effect playing a role cannot be ruled out. to selective phlebography in the diagnosis of CCSVI indicates Thus, better designed studies are warranted to validate such how the ultrasound examination is extremely reliable when treatments in multiple sclerosis patients. diagnosing CCSVI.

112 INTERNATIONAL ANGIOLOGY October 2013 3D Reconstruction of the Veins of the Lower Limbs nous band arose from the adductor magnus muscle, and in 3 Human Fetuses at 12-14 Weeks joined the adductor tendon to the vastus medialis, that the J. Uhl1, S. Rowland2, C. Gillot3 femoral vein was located more posteriorly and was frequently narrowed at this level. This was particularly true when the 1URDIA research unit, Paris, France 2London, United Kingdom artery was calci!ed. The resultant anatomical structure cre- 3University Paris Descartes, Paris, France ated a notch with venous stenosis frequently occurring at the lower part of the hiatus. In a majority of cases where such a Aim. The AIM of this study is to provide realistic 3D models stenosis was found, it was at the lower part of the canal, 13 to of the venous system of the lower limbs of human fetuses after 15 cm above the femoral condyle the organogenesis Conclusions. The action of the adductor muscles is mainly Methods. we used our technique of Computer Assisted Ana- to open and close the hiatus during ambulation. In addition, tomical Dissection (CAAD) (1) After embedding the two lower compression of the femoral vein in the adductor canal is an limbs of 3 embryos in paraf!n, slices of 5 micrometer thick- underestimated cause of venous obstruction and deep vein ness were performed divided into blocks of 10. The !rst 4 slices thrombosis. Ultrasound investigation of both limbs should of each block were studied by different staining and immuno systematically be carried out at this precise level to prevent markers as follows: -Hematein-Eosin-Safran (HES): This was future venous obstruction from occurring here. considered to be the reference section. -The trichrome of Mas- son to identify the collagen !bers, colored in blue by Aniline. -The protein S100 is a general immuno-labeling marker for the nerves. -D2-40 was used as an immuno-marker of the vascular system in the fourth slice. Digitalization of the stained slices were made with a 600 DPI scanner, providing 800 images. After Guidelines for Ef#cacy Studies of Venoactive Agents alignment and numerotation of the slices, the 3D reconstruc- M. Perrin tion technique was done by manual segmentation using the Servier, Chassieu, France Winsurf software to obtain a vectorial model of the structures of interest: Skin, bones, muscles, nerves, arteries and veins Aim. To raise key questions to be answered in order to im- Results. In all fetuses, we found a big axial vein in each prove protocols for good clinical trials and to draw up future sides, accompanying of the sciatic nerve, suggesting that it is guidelines on the venoactive drugs (VADs). the main vein of the thigh at the end of organogenesis. This Methods. The literature was reviewed using PubMed, Em- vein becomes hypoplastic in the adult, reduced to a small ar- base, and Cochrane reviews cade in 95% of the cases. Results. Guidelines for testing VADs were updated to en- Conclusions. The CAAD technique is unique in producing able the pharmaceutical industry to invest the resources re- such a realistic 3D model of the vascular and nervous system. quired to perform large and de!nitive clinical trials, with a It con!rms the theory of the “angioguiding nerves” (2): We view to improving the recommendations in the !eld of chron- observed the close relationship between the main veins and ic venous disorders (CVDs). Such guidelines could: § Reiter- nerves, supporting the theory of the important role of the ate the basic principles that should prevail when reporting vascular endothelial growth factor ( VEGF ) secreted by the (and setting up) a clinical trial, using the Consolidated Stand- nerves. This stimulates the maturation of the vessels along the ards of Reporting Trials (CONSORT) statement. § Include nervous pathway, and induces their specialization into arter- larger sample size according to the magnitude of the expect- ies, veins or lymphatics ed effect, having in mind the high incidence of placebo effect in the most important indications for VADS, i.e. symptoms relief. § Describe patients comprehensively at study selection, using the advanced CEAP classi!cation, which implies that not only should the C of the CEAP be completed, but also items E, A, and P, together with mandatory color-coded du- Venous Outlet Syndrome of Hunter’s Canal: A Major plex sonography, with or without plethysmography (level 2 Cause of Femoral DVT investigation). Despite its cost, such investigation might be J. Uhl1, C. Gillot2, C. Fortin3 insuf!cient to explore the super!cial venous network § Per- 1URDIA research unit, Paris, France form long-term studies to examine the prevention of CVDs 2University Paris Descartes, PARIS, France progression and the cost-effectiveness of VADs § Promote the 3Canadian Society of Phlebology, Quebec, Canada use of validated tools to assess symptoms, and venous signs including ulcer. § Have a consensus on a standard treatment Aim. “Adductor canal syndrome” (also called “Jogger’s syn- for dressings, compression therapy, and local antiseptics in drome”) has been described as an unusual cause of acute ar- venous leg ulcer. terial occlusion in younger men. It is also been identi!ed as Conclusions. Much work remains to do to accord VADs the a cause of compressive neuropathy of the saphenous nerve. role they deserve in the management of CVDs Nevertheless, femoral vein compression in the canal has never been described. Objective: To describe the anatomy and physiology of Hunter’s canal, and to show that the femoral vein is much more exposed than the artery to compression inside the adductor hiatus, particularly at the outlet. Methods. Fifty fresh cadavers were used to surgically ex- Management Issues in Female Klippel-Trenaunay pose the adductor hiatus for anatomical study. A series of 200 Patients Across the Generations phlebographies and 100 CT venographies were also used to J. Lohr1, S. McKeever2, A. Fellner3 study the morphology of the adductor hiatus. 1Cincinnati, USA Results. The anatomical dissections and cadaveric simu- 2Arizona College of Osteopathic Medicine, Midwestern University, Scotts- lations showed that contraction of the adductor longus closes dale, USA the hiatus, and the adductor magnus opens it. Our hypothesis 3TriHealth Hatton Institute for Research & Education, Cincinnati, USA is that Hunter’s canal prevents femoro-popliteal axis re#ux by synchronizing with calf pump ejection during ambulation. Aim. Background Klippel-Trenaunay Syndrome (KTS) is a Anatomically, in all cases where an abnormal musculotendi- congenital vascular anomaly characterized by varicose veins,

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 113 cutaneous capillary malformations, and hypertrophy of bone Anesthetic Management of Endovenous Laser Abla- and soft tissue. A series of three females is presented. tion of Great Saphenous Veins Methods. Methods These patients were initially diagnosed R. Vellettaz at ages 14, 26 and 30 and were followed for eight months, 14 Clinica Colon CEVYL, Mar del Plata, Buenos Aires, Argentina years, and 22 years, respectively. The changes during their lives will be presented along with the lessons learned. Aim. Primary To establish a perioperative anesthetic proto- Results. Results Hormonal changes of menarche were col To improve quality and safety of procedure. Secondary To associated with signi!cant upper extremity symptoms and assess compliance with discharge criteria To achieve satisfac- development of multiple varying-age DVTs and SVTs in the tion for patients and surgeons. 14-year-old patient. Infertility and gestational issues resulted Methods. • Study: prospective, observational • Materi- in signi!cant arteriovenous malformation (AVM) development als: Laser diode1470 nm Bare !bers Orchestra Base Primea with bleeding from a kidney, requiring multiple transfusions, • Period: 24 months • Population: 406 GSV Percutaneous, cessation of anticoagulation, and resulting in miscarriage at ecoguided, ambulatory Perioperative anesthetic protocol Pr- 21 weeks. Subsequently, the patient was successfully managed eoperative anesthetic interview Anesthetic technique: MAC through pregnancy and delivery. Intracranial AVMs in a pa- Endovenous conscious sedation: Propofol+ Remifentanil Tu- tient with a signi!cant hypercoagulable state have been suc- mescent anesthesia: Perivenous local anesthesia with modi!ed cessfully managed over 20 years. Klein’s solution, ecoguided Immediate postoperative manage- Conclusions. Conclusions KTS patients are at increased ment Discharge criteria Post Operative analgesia: multimodal risk of hypercoagulability. Indeed, postoperative throm- protocol Follow up:control 1st, 3rd,and 7thdays Questionary boembolism may be 10 times that of non-KTS patients. AVMs about satisfaction may lead to platelet sequestration and !brinogen consump- Results. Age: 53.72(21-79) Sex: F78% Procedure duration: tion, with a bleeding diaphysis ensuing and progressing to 37 minutes (31-44) Meeting the criteria of choice of outpa- intravascular coagulation following trauma. Genitourinary tients: 100% Intraoperative monitoring: 100% Intraoperative complications in KTS patients usually require intervention. control of intraoperative drugs:100% Orchestra® Base Primea: The obstetrical course of KTS is variable, requiring frequent Target Controlled Infusions [TCI] Intraoperative pain: not de- mother and fetal monitoring, and altering anesthetic choic- tected Post operative pain mild: 83.15% VAS below 40 NSAIDs: es for labor and delivery. Hormonal changes during the life diclofenac moderate: 6.85% VAS 40 to 70 Opioids: Tramadol cycle of KTS patients also alter disease processes and pain Physical means Few complications Involuntary movements: complaints. 4 p Respiratory depression or hypersensitivity reactions: no detected Discharge criteria Meeting: 12 from 14 points of fast-tracking: 100% Questionnaires completed by the patients Questionnaire completed by the patient: very good or excellent: >90% Questionnaires completed by the surgeon Very good or excellent: 100% Ef#ciency of Complex Application Kinesio Taping Conclusions. The expectations of the procedure were met: and Manual Lymph Drainage in Rehabilitation of absence of intra and postoperative pain, control Intraopera- Patients with Lymphedema of Lower Extremities tive of plasma concentrations drugs, awake patients, early dis- T. Apkhanova 1, I. Bobrovnitsky2, T. Knyazeva2 charge. EVLA is safe few complications High level of comfort- 1Federal State Institution «Russian Scienti#c Center of Rehabilitation ability for patient High level acceptability to surgeons MAC Medicine and Health Resort Sc, Moscow, Russia leads to better surgical conditions Best results of the satisfac- 2Federal State Institution, Moscow, Russia tion questionnaire The perioperative anesthetic management of EVLA must be supervised by anesthesiologists. Aim. To study the effectiveness of a rehabilitation complex, including Kinesio Taping and Manual Lymph Drainage (MLD) in patients with lymphedema of the lower extremities. Methods. We examined and treated 40 patients with lymphedema of the lower limbs of stages I-II, most of whom Endovenous Laser Ablation of Great Saphenous were women -89%, mean age 52 year. All patients by random Veins sampling were divided into 2 groups: Group 1 (n=20) received R. Vellettaz MLD, bandaging limbs, skin care, and medical gymnastics for Clinica Colon CEVYL, Mar del Plata, Buenos Aires, Argentina 2 weeks. Group 2 (n=20) consistently received MLD, skin care, kinesio taping and medical gymnastics during 2 weeks. Aim. Primary: To present a series of cases, personal experi- Results. Malleolar volume after treatment decreased in pa- ence in a private center Secundary: To demonstrate ef!cacy tients of group 1 by 9.6% of patients in group 2 to 3%. How- and safety of EVLA 1470 nm laser diode with bare !bers. ever, most of the patients in Group 1, although conducted with Methods. Materials: Laser diode:1470 nm. Bare !bers moisturizing lotions skin care, there was an increase dryness, Study: retrospective, nonrandomized, case series, observa- irritation and itching of the skin. In addition, the vast majority tional Period: 24 months Population: 406 GSV Technique: of patients experience psychological and physical discomfort percutaneous, ecoguided, in outpatient with local anesthetic associated with prolonged exposure to multi-band in which and sedation We protocolize: DUS pre, intra and post opera- patients were working, moving and sleeping. Patients in group tive. Anesthetic management: preoperative anesthetic inter- 2 did not experience physical and psychological problems as- view, anesthetic technique and immediate PO management, sociated with wearing the diurnal bandages, but at the same discharge criteria and post operative analgesia. Compression time in this group regression of edema was achieved by only treatment: GIC protocol. Inclusion and exclusion criteria 3% compared with group 1 (9.6%). Results. Age: 53.72 years old. Sex: F 78% CEAP: C3 56%. Conclusions. Thus, it is obvious that the kinesio taping can Severe re#ux: 89% LEED: 30J/cm. Withdrawal speed !ber 0.5 not be an alternative to banding, but in patients with “mild” cm/s Mean vein length: 47.7 cm (39.00-59.21) Success: 7 days swelling in the early stages of edema (I-II stages) when not 99.51% 24 months: 93.15%. Failures: 12 months 16 p Partial develop !brosis of the skin and subcutaneous tissue, kinesio Complications Pain: mild 90.14% Ecchymosis: classi!cation 5 taping can be used effectively after a session of MLD, without degrees: mild, 87 19%; moderate, 12. 81%. Induration: 100%. imposing bandages. TFS: 1.72% EHIT: “1” 0,49%; “2”, 99.51%; “3” and “4” not de-

114 INTERNATIONAL ANGIOLOGY October 2013 tected Pigmentation: 0.73% Evolutionary Control: Clinical nous pathophysiology, how it develops, and the true quality of improvement CEAP- SSVC. DUS: classi!cation SEACV. Im- life bene!ts of various treatment options are largely unknown. proved quality of life: CIVIQ20 Complementary treatment suc- A truly meaningful clinical data capture system speci!cally for cessive: (1 month post procedure). Collateral: Phlebectomy: venous disorder may provide answers to the paucity of data. 6%. UGFS 17%. Perforator: UGFS:7%. EVLA: 5% We describe a modern informatics system to capture research Conclusions. Effective and safe procedure The use of wave- and best practice data using the state of art information tech- lengths absorbed by water no increase ef!ciency but decreases nology to 1) compare effectiveness of various super!cial ve- complications The use of wavelengths absorbed by water al- nous treatments 2)capture patient reported outcomes after lows lower LEED Tumescent anesthesia and conscious seda- super!cial venous treatments and 3)perform quality of care tion improves tolerance, allowing adequate delivery LEDD assessments amongst phlebologists. The use of jaquet- tip !bers is controversia Theory of invagi- Methods. This is an on-going project started in Spring 2013. nation Cover tipped laser !ber is the most signi!cant variable It is an electronic health record (EHR) based patient-centered associated with the highest number of treatment failures registry whereby clinical data is automatically uploaded from individual EHR into the registry via cloud access without additional manual input. EHR templates are combined to a single form, then a standard and uni!ed document is formed. Temperature Pro#les of 980 nm and 1470 nm En- This super-template allows for quick navigation to appropriate dovenous Laser Ablation, Endovenous Radiofre- !elds for each and every visit. Ef!cient data collection may be quency Ablation and Endovenous Steam Ablation captured by many members of a health care team including W. Malskat the staff, the physician and others with output tailored to the speci!c date of service. Patient reported outcome data is cap- Erasmus MC, Rotterdam, Netherlands tured seamlessly through dedicated computer tablets or kiosks that walk patients through generic and disease speci!c queries Aim. Endovenous thermal ablation (EVTA) techniques are with little to no provider input. Ultimately, clinical data and very effective for the treatment of varicose veins, but their ex- patient reported outcome data can be analyzed. act working mechanism is still not well documented. The lack Results. The main outcomes of this project seek to 1) com- of knowledge of mechanistic properties has led to a variety of pare effectiveness of various super!cial venous treatments 2) EVTA protocols and a commercially driven dissemination of capture patient reported outcomes after super!cial venous new or modi!ed techniques without robust scienti!c evidence. treatments and 3)perform quality of care assessments amongst We aimed to compare temperature pro!les of 980 and 1470 nm phlebologists. endovenous laser ablation (EVLA), segmental radiofrequency Conclusions. The practice-based clinical registry holds ablation (RFA) and endovenous steam ablation (EVSA). enormous potential as a powerful tool to help measure, man- Methods. In an experimental setting, temperature meas- age and improve patient care. For a registry to ful!ll its poten- urements were performed using thermocouples; raw potato tial, stakeholders must work together to overcome the current was used to mimic a vein vall. Two laser wavelengths (980 and limitations in function and #exibility. 1470 nm) were used with tulip tip !bers, and 1470 nm also with a radial emitting !ber. Different powers and pullback speeds were used to achieve #uences of 30, 60 and 90 J/cm. For segmental RFA, 1 cycle of 20 seconds was analyzed. EVSA was performed with 2 and 3 pulses of steam per cm. Maximal tem- Value of CO2-O2 Based Foam in Sclerotherapy. A perature increase, time span of relevant temperature increase, German Prospective Multicenter Observational and area under the curve of the time of relevant temperature Study increase were measured. F. Breu Results. In all EVLA settings, temperature rise peaked and Kreussler, Rottach-Egern, Germany decreased rapidly. High #uence is associated with signi!cantly higher temperatures and increased time span of temperature Aim. This prospective multicenter observational study (OS) rise. Temperature pro!les of 980 and 1470 nm EVLA with tulip documented the ef!cacy and side-effects of ultrasound-guided tip !bers did not differ signi!cantly. Radial EVLA showed sig- polidocanol foam sclerotherapy (FS) with air and carbon di- ni!cantly higher maximal temperatures than tulip tip EVLA. oxide / oxygen foam (CO2-O2 FS) using the same evaluation EVSA resulted in mild peak temperatures for longer duration protocol in each center. than EVLA. Maximal temperatures with 3 pulses per cm were Methods. Eleven centers participated in this OS, nine signi!cantly higher than with 2 pulses. RFA temperature rises centers worked with air-based FS, two with CO2-O2 FS. Only were relatively mild, resulting in a plateau shaped temperature approved drugs were used. In 376 patients undergoing 553 pro!le, similar to EVSA. treatments, air-based FS was performed using 0.5% to 3% Conclusions. Temperature rises during EVLA are fast with polidocanol microfoam (Aethoxysklerol®, Kreussler). 125 pa- a high peak temperature for a short time, where EVSA and tients in 152 sessions were treated with CO2-O2-based foam RFA have longer plateau phases and lower maximal temper- using 1% to 3% polidocanol with seven parts CO2 (Laparox®, atures. Temperature pro!les of 980 and 1470 nm EVLA are Linde) to three parts O2 (Conoxia®, Linde). For the sterile dis- similar. Overall, differences in temperature levels of EVTA pensing of the CO2-O2 FS a mass #ow controller was used. techniques are minimal. Ef!cacy of treatment and side effects were assessed clinically and with duplex examination in the following visits after one week and 4-6 weeks after the last session. Results. Varicose veins larger than 3mm were treated with Chronic Venous Disorder Registry an average volume of 5.3mL in the air-FS and 8.2mL in the Y. Chi 1, M. Schul2 CO2-O2 FS. In the CO2-O2 -group clinical appearance and 1UC Davis Vascular Center, Sacramento, CA, USA venous occlusion rate documented by Duplex, treatment was 2Lafayette Regional Vein Center, Lafayette, IN, USA slightly more ef!cient (96,4% vs. 92,4%), most likely because larger volumes could be safely applied. In the CO2-O2 group Aim. Chronic venous disorders (CVD) represent one of the post-sclerotherpeutic compression therapy was performed in most prevalent medical conditions in the U.S. that carries sig- 97.6% of the cases, in the air group in 75.2%. In general more ni!cant economic and health burden. The knowledge into ve- side effects occurred after air in comparison with CO2-O2. The

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 115 differences were signi!cant (p<0.0001) for: Hyperpigmentation as well as close ultrasound inspection of the sheath tip. If 23.3% (air) vs. 13.6% (CO2-O2), and hematoma 14.4% vs. 2.5%. sheath thrombosis is found, the procedure should be aborted, The differences (air/CO2-O2) were not signi!cant for: Migraine anticoagulation instituted, and the patient should be tested 0.1%/0% Matting 1.4%/0% Burning sensation 11.7%/5.5% for thrombophilia, Subsequent vein ablations should be per- Thrombosis 1.1%/1.6% Visual disturbance 0.2%/1,8% No formed on anticoagulation, in the author’s opinion. group showed any permanent side effects on the central nervous system; all events of impaired vision were spontaneously reversible within 20 minutes without further treatment. Conclusions. The treatment with CO2-O2 FS is slightly Duplex Scan Aspect of the Sapheno-Femoral Junc- more ef!cient than air FS, especially in larger varicose veins and high volumes of foam. Maybe it CO2-O2 foam produces tion 6 Years after Endovenous Laser Ablation less side effects. But our results are no prove that it is de!nitely F. Vin safer. American hospital of Paris, Neuilly Sur Seine, France Aim. Objectives : show that the presence of a stump left in place at the sapheno-femoral junction after endovenous laser Pregnancy Does not In"uence Varicose Vein Laser ablation does not develop inguinal recurrence. Surgery Results Methods. Among 1222 endovenous Laser procedures conducted since January 2002 in patients with incompetence of I. Bihari1, G. Ayoub1, P. Bihari1 great saphenous vein, 220 patients with 6 years follow up Vein Center Budapest, Budapest, Hungary were randomized and reviewed for a clinical and ultrasound examination. The Duplex studies were focused to evaluate Aim. To examine the in#uence of pregnancy on the results the percentage of occlusion of the greater saphenous vein of laser surgery, knowing that following classic surgery about and the aspect of the stump at the sapho-femoral junction 50% recurrency is experienced (Fischer et al.). level. Methods. 7 varicose saphenous stems of 5 patients were Results. In 218 patients (99,1%), the GVS were closed from treated and followed. We used 1470 nm wavelength and higher the groin to the knee. In only 2 patients (0,9%) the greater laser energy than other colleagues (mean 158 J/cm). The tip of saphenous vein were incompletly closed without re#ux. The the !ber was 1 cm from the junction. Mean 7.6 months after surgery they became pregnant. stump length were ranged from 10 mm to 30 mm without re- Results. None of the treated 7 saphenous stems recanalised #ux. No inguinal recurrence through tributaries of the junc- during pregnancy. In 4 of them there were no clinical or US tion, no incompetent dystrophic lympho-nodal venous net- recurrencies, in 3 limbs C1 recurrent varicosities were found. work were found. The study of the junction with color doppler In 4 saphenous stems there were no stumps, in 3 cases there showed a Venturi effect of the blood coming from the tributar- were stumps of 6, 8 and 14 mm. In 2 of them patent tributaries ies of the junction to the fémoral vein. were found around the SFJ. Conclusions. The sapheno-femoral junction seems to play Conclusions. The laser technique described seems to be an important hemodynamic. Unlike the concept accepted by suitable for decreasing the recurrency rate of stem varicosity all the ligation division does not seem necessary and the pres- during pregnancy. ence of a short stump left in place will not relapse over the ligation junction of the #ush with the femoral vein.

Case Report: Unique Sheath Tip Thrombosis During EVLA In Patient With Occult Thrombophilia Diagnosis and Management of Left Renal Vein En- R. Mueller trapment – Nutcracker Syndrome Cosmetic Vein Solutions, New York, NY, USA T. Keith 1, J. Villavicencio2, S. Moser1 1Imperial College Healthcare NHS Trust, London, United Kingdom Aim. 1) Describe a unique case of a sheath tip thrombo- 2USUHS, Prof Surgery, Bethesda, MD, USA sis during a patient’s EVLA. 2) Diagnosed an occult thrombophilia. 3) Anticoagulated the patient; EVLA was performed Aim. 1. Report the !rst case of Nutcracker syndrome (NCS) later successfully under anticoagulation. treated with renal autotransplantation in the UK 2. Describe Methods. Case report of the clinical care of a patient with the presentation and diagnosis of NCS 3. Highlight the com- CEAP C3 super!cial venous re#ux disease treated in an of- plexities and controversies of managing NCS and analyze op- !ce based phlebology practice from February through March tions for treatment 2013. The patient was treated with endovenous laser ablations Methods. A 21 year old woman presented with left #ank pain. (1 aborted + 2 completed) as well as anticoagulation and mon- Thirty hospital admissions were all treated as pyelonephritis. itored with serial venous ultrasound and clinical examinations Multiple specialities “reassured” the symptoms were functional. as well as one chest CT and Emergency Department visit. Six years later imaging revealed left renal vein entrapment be- Results. During GSV EVLA, the sheath was placed just dis- tween the superior mesenteric artery and aorta (image 1). Reno- tal to the SFJ. It could not be aspirated, but it could be #ushed. caval pressure gradient of 7mmHg con!rmed diagnosis of NCS A large thrombus was noted at the tip (extending brie#y into (normal 0-2 mmHg). Renal autotransplantation was selected to the Common Femoral Vein), and through the thigh GSV. EVLA prevent further clinical deterioration in 2011. was aborted and LMWH was injected. The patient collapsed Results. Renal autotransplantation completely relieved all and was transported to the ED; pulmonary embolism was ex- symptoms. However, three months post-operatively hyperten- cluded. Heterozygous Factor V Leiden was diagnosed. Anti- sion (220/110) developed. Angiography con!rmed transplant coagulation was continued for 6 weeks with enoxaparin, then renal artery stenosis which was stented, normalising blood rivaroxaban. SVT resolved by week 4; EVLA was performed pressure (image 2). Three months post-angiography hyperten- without incident on rivaroxaban. sion returned; the stenosis had recurred. A second stent was Conclusions. This unique case urges new caution for EVLA placed (image 3). History repeated six months later. Autotrans- operators. Prompt sheath positioning, guidewire and dilator plant nephrectomy was selected to avoid hypertensive damage removal, and sheath #ushing should always be performed, of the fully functional right native kidney.

116 INTERNATIONAL ANGIOLOGY October 2013 Conclusions. Diagnosis of NCS is often delayed due to lack works dissolved completely in 48 hours; cells pretreated with of knowledge or awareness of the condition. Autotransplanta- AMNA showed a signi!cant improvement and stabilization at tion completely relieved all symptoms of NCS but ultimately 48 hours as compared with controls both in number of meshes resulted in loss of a fully functional kidney. Surgery is recom- (p<0.01) and master segment lengths (p<0.01). mended when conservative management fails, however the Conclusions. AMNA signi!cantly improved stability viability of autotransplantation is questionable when other of endothelial cells organized in endothelial cell cords on surgical options exist such as renal vein stenting and reim- Matrigel; we are currently investigating if this effect might plantation. Increased awareness of the condition is essential be related to an integrin-dependent drug-matrix interaction to avoid a repeat of this case. or to a paracrine cytokine signalling phenomena. The in vitro Matrigel assay is a suitable method to test the effect of drugs on capillary-like structures fragility, especially after sclerotherapy.

Late Severe Infection on Leg after Endovenous La- ser Procedure of the Great Saphenous Vein A. Reichelt1, J. Ferreira2, L. Barreneche3, M. Goldani3 1Ponti#cia Universidade Catolica -PUCRS, Porto Alegre, RS, Brazil Bacterial Contamination Does not Necessarily Mean 2ponti#cia unidade catolica do rio grande do sul, porto alegre, Brazil Infection 3ponti#cia universidade catolica do rio grande do sul, porto alegre, Brazil C. Sanchez Fernandez de la Vega Aim. Report a case of infection on leg after endovenous la- Sergas, Lugo, Spain ser procedure of the great saphenous vein Methods. A 56 year old with re#ux of the great saphenous Aim. When clinical course of a venous ulcer is unfavour- vein ,history of varicose veins more then 20 years and CEAP able, physicians always ask for cell culture. Cell culture can classi!cation 4,was treated with endovenous laser ablation.Af- reveal the presence of the bacteria and probably, the physician ter thirtieth postoperative day start with intense pain on thigh will prescribe antibiotics. This is an error frequently commit- and 38°C temperature ted by physicians. They can identify !brin as a sing of infec- Results. Patient had a pos procedure until thirtieth day tion. Antibiotics only should be used, when we observe signs with no complains.After started with intense pain on thigh and symptoms of infection, such as cellulitis and / or fever. and fever of 38 ºC.Ultrasound !ndings: Interstitial edema and Methods. Based on my experience for treating venous leg blood analysis leucocyte counts 11000cells per microliter. He ulcers, for over 15 years, using only a graduated external com- was hospitalized and started with antibiotics.After 2 days ap- pression bandaging with focal compression on the surface of peared on thigh a large area of redness and continous with the ulcer, I never ask for a cell culture, whether clinical course fever.Ultrasound !ndings: Liquid collection. Surgical drainage of the ulcer is favourable. was performed, with output 150 cm3 of pus,culture grew sta- Results. My clinical practice over the past 15 years (58 pa- phyloccocus aureus.After 15 days patient was discharged and tients by other colleagues) treating venous leg ulcers, I never three months later he was complete recovered used antibiotics. My explanation is: Focal compression over Conclusions. Endovenous laser is a well established mini- the ulcer, produces pressure gradients in the area for improv- mally invasive tecnique to treat re#ux of the great saphenous ing tissue perfusion, so we have non-pathogenic bacteria. As vein,but all care must be taken like a surgery to minimize the an example, I show a photographic sequence of the clinical risk of an infection. course, with cell culture and antibiogram. As many patients, this patient there was treated, either orally or topically, with antimicrobial therapy. Bacteria have disappeared and we have resorted to the use of antibiotics. Conclusions. This fact should be suf!cient to re#ect about Endothelial Protection by Aminaphtone: A New Meth- the usefulness of antibiotic treatment in these cases. No antibi- od to Study Capillary-Like Structures Stability in Vitro otics should be administered, by the fact that we detect bacteria R. Di Stefano1, F. Felice2, R. Feriani3, A. Frullini4 in the wound. Focal compression in ulcer crater, improves tissue perfusion and prevents the pathogenicity of the bacteria. 1Vascular and Cardiothoracic department University of Pisa, pisa, Italy 2Vascular and Cardiothoracic department University of Pisa, Pisa, Italy 3Cardiovascular Research Laboratory, University of Pisa, Pisa, Italy 4Studio medico "ebologico, Figline Valdarno-Florence, Italy

Aim. To test the capability of Aminaphtone to stabilize three-dimensional capillary-like structures formed by endothelial cells in vitro when plated on Matrigel. Distribution of 1259 Patients with Budd-Chiari Syn- Methods. Human Umbilical Endothelial Cells (HU- drome in Henan Province of China VECs), grown for 48 hours in complete growth medium W. Zhang, X. Han (HCGM), were incubated for 24 hours separately with (1) The 1st af#liated hospital of Zhengzhou University, Zhengzhou, Henan, HCGM, (2) a solution of Aminaphtone 6µg/mL (AMNA) China in HCGM with 0.1% DMSO and (3) a solution of HCGM with 0.1% DMSO. Cells were then detached and seeded on Aim. To research the etiology and pathogenesis of Budd- Matrigel. Images were captured at different time-points Chiari syndrome by analyzing the clinical epidemic of patients with and morphometric analysis was performed with An- with Budd-Chiari syndrome in Henan province. giogenesis Analyzer. Methods. The clinic data of 1259 patients with Budd-Chiari Results. HUVECs when seeded on Matrigel formed capil- syndrome in Henan province from January 2003 to May 2010 lary-like structures. This process had a rapid onset, beginning were collected. The study of descriptive statistics was carried within 1 hour and was completed by 8-12 hours; after this on. time the network started to rearrange and completely disap- Results. Mean age was (41.14±11.88) years; the occupa- peared within 24-48 hours. In groups 1 and 2 capillary net- tion proportions of farmers took up 82.13%; there were more

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 117 patients in rural than urban; there were more patients in Endovenous Laser Ablation with 1470nm Diode La- eastern of Henan than western and northern of Henan; there ser and 2ring Radial Fiber: 1 Year Follow-Up were more patients in plain than mountain; the proportions of J. Rits1, E. Rabe2, F. Pannier3, U. Maurins1 mixed-type took up 75.9%. 1Dr Maurins Vein Clinic, Riga, Latvia Conclusions. The main etiological factor of Budd-Chiari syn- 2University of Bonn, Department of Dermatology, Bonn, Germany drome in Henan province may be environmental ingredient. 3Cologne, Germany

Aim. Endovenous laser ablation (EVLA) has become a most promising method of treatment for insuf!cient stump veins. Age Trends in the Prevalence of Budd-Chiari Syn- Recently Biolitec AG developed a new radial 2Ring laser !ber. drome in China Laser energy in this laser !ber has been divided into two equal X. Han, W. Zhang radially emitting portions. The aim of this study was to dem- The 1st af#liated hospital of Zhengzhou University, Zhengzhou, Henan, onstrate outcome and side effects after EVLA of GSV with a China 1470 nm diode laser (Ceralas E, Biolitec) using Radial 2Ring !bers. Aim. To analyze the changes in the age of patients with Methods. Non-randomized, prospective, single center Budd-Chiari syndrome in Henan Province, China between study was carried out. Fifty unselected limbs of 50 patients 1995 and 2009, and to analyze the possible etiological factors with a duplex sonographically veri!ed incompetent GSV were contributing to such changes. included. EVLA was performed with a 1470 nm Diode laser Methods. The clinical data for 909 patients with Budd- (Ceralas E, Biolitec) using Radial 2Ring !ber. All operations Chiari syndrome treated at the Department of Interventional underwent under local 0.05 % lidocaine tumescent anesthesia. Radiology of the First Af!liated Hospital of Zhengzhou Uni- Laser treatment was carried out in a continuous mode with a versity from 1995 to 2009 were analyzed using the SPSS 13.0 power of 15, 12 watts in the group 1 or 10 watts in the group statistical software. 2. The average linear endovenous energy density (LEED) and Results. The mean age of patients with Budd-Chiari syn- endovenous #uence equivalent (EFE) was 73 J/cm and 31 J/ drome is 39.17±11.40. An ascending trend was observed for cm2 respectively. Compression stockings (30 mmHg) for one the mean age of patients with Budd-Chiari syndrome in Hen- month were applied. Post-interventional checkups took place an Province from 1995 to 2009 (P<0.05). Patients aged 35-44 at day 1, 10, 30 and 1year. years accounted for 19.87% during 1995-1997, and 38.51% Results. No severe complications could be detected. In 1 during 2007-2009. The percentage of patients aged 35-44 years leg recanalization of 10 cm long distal GSV segment was ob- showed an upward trend. In contrast, the percentage of pa- served (group 2) at day 10 visit. Two distal paresthesia were tients aged 25-34 years showed a downward trend during this observed at 30 day visit (group 1). 78 % of treated patients did period. The percentages of other age groups of patients did not not take any painkillers postoperatively. In 94 % of the treated change greatly (all P>0.05). limbs no ecchymoses were observed at all. 46 patients attend- Conclusions. The age at diagnosis of patients with Budd- ed 1-year follow-up visit. All patients were clinically improved Chiari syndrome shows an upward trend in Henan Province comparing with there clinical status before treatment. from 1995 to 2009. Conclusions. EVLA of GSV with a radial 2Ring !ber by using a 1470 nm diode laser is a safe and ef!cient treatment option.

Agitating Thrombolysis Technique for the Treat- ment of Inferior Vena Cava Fresh Thrombus in Pa- tients with Budd-Chiari Syndrome Endovenous Laser Ablation in the Treatment of Pa- X. Han, W. Zhang tients with Super#cial Vein Thrombosis of Lower The 1st af#liated hospital of Zhengzhou University, Zhengzhou, Henan, Limbs China T. Sultanyan, T. Kamalyan, A. Avetisyan, L. Manukyan 1Medical Center after Vladimir Avagyan, Yerevan, Armenia Aim. To evaluate the therapeutic ef!cacy of agitating thrombolysis technique for Budd-Chiari syndrome complicated with Aim. The study was performed to evaluate the clinical ef- fresh thrombus of inferior vena cava(IVC). !cacy and feasibility of endovenous laser ablation (EVLA) of Methods. From August 2005 to March 2012, 15 patients saphenous veins in patients with super!cial vein thrombosis of Budd-Chiari syndrome with fresh thrombus of IVC were (SVT) of lower limbs. treated with agitating thrombolysis technique. 9 males and 6 Methods. A retrospective case-control study was per- female, the age ranging from 36 to 52 years-old. After venog- formed using clinical and duplex-sonographic follow-up data raphy and then recanalization for IVC was performed, which from 200 patients (204 lower limbs) with SVT or varicose vein was followed by agitating thrombolytic therapy used by a 5F disease (VVD) treated using a 940-nm laser. Patients were di- pigtail catheter and a 0.035 inch guidewire. Finally, IVC was vided into 2 groups (102 limbs in each group) matched for sex, dilated with percutaneous transluminal balloon angioplasty. age, clinical and anatomical classes (CEAP). Group I (main) Clinical follow-up of IVC patency was implemented by color included lower limbs with SVT. Group II (control) - lower Doppler sonography. limbs with VVD. Obligatory high ligation of saphenous veins Results. After agitating thrombolysis, the thrombus were was performed prior to EVLA in both groups. In the main completely disappeared in all 15 patients without one case pul- group washout of thrombi from truncal veins with catheter monary embolism. In all patients, 14 patients IVC remained was carried out to enable EVLA procedure. Incompetent or/ patency on color Doppler ultrasonograph after following up and thrombosed tributaries underwent concomitant mini- for a mean period of 27.8 months. One patient follow-up color phlebectomy. SVT of great saphenous vein was observed in Doppler ultrasonography at 14 months later showed that dom- 87% (n=93). Small saphenous vein was affected with throm- inant stenoed. botic process in 12,3% (n=9). Outcomes included postopera- Conclusions. Agitating thrombolysis technique is a safe tive complications, disease-speci!c quality of life (CIVIQ) and and effective treatment for Budd-Chiari syndrome complicat- recanalisation rates. ed with fresh thrombus of IVC. Results. In the main group we had 12,7% (n=13) technical

118 INTERNATIONAL ANGIOLOGY October 2013 failures related to an inability to washout thrombi in subacute objectives of this paper are: 1) Analyze closure rates. 2) Ana- stage of disease. Positive correlation was observed between du- lyze amount of energy used (parameters). 3) Identify major ration of SVT and feasibility of EVLA (p<0,01, ρ=0,51). No sta- complications. tistically signi!cant differences were seen between groups for Methods. Observational, Cross-sectional, Retrospective case complications (ecchymoses: 67,6% (n=69) and 69,6% (n=71) series of 885 patients with varicose veins of (1077 lower extremi- p>0,05, paresthesia: 25,5% (n=26) and 21,6% (n=22) p>0,05, ties) due to saphenous insuf!ciency of 910 GSV and 167 SSV wound infections: 6,9% (n=7) and 4,9% (n=5) p>0,05). At the consecutively treated at the Phlebology Unit of the Ponti!cia 1 year follow-up both groups demonstrated comparable im- Universidade Católica do Rio Grande do Sul from january 2009 provement in CIVIQ scores (p>0,05). Duplex ultrasonography to december 2012 by 3 different surgeons by Endovenous Laser revealed 14 cases (13,7%) of recanalisation in group I, and - 15 Ablation using a 1470nm 15W laser source (Ceralas E/1470 ®) cases (14,7%) in group II (p>0,05). delivered in continuos mode by radial !bres (ELVeS Radial ®- Conclusions. High ligation of saphenous veins combined CeramOptec GmbH) without Tumescent Local Anesthesia. The with thrombi washout can enable EVLA in patients with acute amount of energy criteria used was not following a mathemati- SVT (less than 14 days) cal model but !ve ultrasound markers of venous closure (“White line”, Pearl Sign, Bubbles going backwards, Incompressibility and no #ux with color doppler). Patients were evaluated to access results major complications and parameters. Prevalence of Chronic Venous Disease among Czech Results. Great Saphenous Vein. 735 patients - 910 Veins Primary Care Patients Bilateral 175 patients (23,8%) Age: Min: 24 Max: 86 Avg: 51 D. Karetova, B. Seifert, J. Vojtiskova Gender: Female 537 (73,06%) Male: 198 (27,93%) Side: Right Charles University, Prague, Czech Republic 436 (47,91%) Left 474 (52,08%) Diameter (mm): Min 2.4 Max 19.5 Avg 6.46 Leed (J/cm) Min: 7.47 Max: 269.13 Avg 59.38 Clo- Aim. Background: The management of chronic venous sure rate: 100% Small Saphenous Vein 150 Patients - 167 Veins disease (CVD) in primary care varies according to the com- Bilateral 17 patients (11,33%) AGE: Min: 22 Max: 82 Avg: 54 petence and engagement of general practitioners. An interna- Gender: Female 119 (79,33%) Male 31 (20.66%) Side: Right: tionally conducted Vein Consult Program is the global effort to 86 (51,49%) Left 81 (48,50%) Diameter (mm): Min 2.4 Max 5.6 raise awareness of CVD in different areas and to compare the Avg 3.9 Leed (J/cm) Min 19.88 Max 98.27 Avg 46.52 Closure management of the disease between countries. rate: 100% Major Complications Deep Venous Thrombosis: 2 Methods. Methods: As an adaptation of the Vein Consult Pulmonary Embolism: 0 Lymphatic damage (Lymphorraea): Program, a prospective observational survey was conducted 1 Infection: 1 Persistent Pain: 1 (Needed Neurolysis) Hyper in 80 general practices in the Czech Republic in 2012. 20 con- pigmentation: 2 Hypopigmentation: 0 phlebitis/periphlebitis: secutive patients aged over 40 years were included in a survey 0 induration 6 Burns: 0 Death: 0 in each practice. Risk factors, complaints of venous origin and Conclusions. This series showed that Endovenous Laser objective !ndings were registered. Ablation performed with a 1470 nm laser delivered with Ra- Results. Results. A total of 1 562 patients (mean age 61 yrs), dial Fibers, without use Tumescent Local Anesthesia follow- mostly women (61.2%) were screened. Reported symptoms in ing not mathematical models, but Ultrasound Criteria is a safe order of frequency were: heaviness in legs, pain, sensation of procedure with excellent results and low index of major com- swelling, cramps and burning or tingling sensations. Eight out plications (1,2%) to treat both GSV and SSV insuf!ciency. of 10 patients had a minimum 1 subjective complaint. Six out of 10 patients had at least one objective !nding of chronic venous disease. 22% of the patients with CVD reported a personal history of venous thrombembolic disease, while only 3% of Case Report: Successful EVLA Treatment of 28 mm the patients without CVD. Symptoms signi!cantly increased Diameter Type Va Venous Aneurysm of GSV Acces- with age and with severity of disease. sory Vein at the Saphenofemoral Junction Conclusions. Conclusions: The results of the survey in the R. Mueller, J. Mueller Czech Republic are consistent with the results of the Vein Con- sult Program internationally. Results indicate the need for an Cosmetic Vein Solutions, New York, NY, USA active approach to patients with symptoms of CVD in a general practice. Aim. 1) Describe a case: 28 mm diameter type Va GSV accessory vein aneurysm (18 mm diameter neck to SFJ). 2) Performed EVLA (with cold saline tumescent). 3) No DVT occurred. Endovenous Laser Ablation without Tumescent Lo- Methods. Case report - patient with symptomatic super!- cal Anaesthesia (TLA) - 1000 Legs Treated cial venous re#ux disease treated in private phlebology practice J. Ferreira1, A. Reichelt2, L. Narvaes3, M. Goldani3 12/2012. Patient refused surgery, requested EVLA treatment of 28 mm type Va GSV accessory vein aneurysm connecting 1Pontiac Catholic University (PUCRS) - Instituto Brasileiro de Flebolo- gia, Porto Alegre, Brazil to SFJ via 18 mm diameter wide neck. Treated with EVLA of 2PUCRS - IBF, Porto Alegre, Brazil aneurysm & GSV, with cold saline without lidocaine for tu- 3PUCRS, Porto Alegre, Brazil mescent anesthesia. Clinical and 2 month venous ultrasound follow up was conducted. Aim. Endovenous Laser Ablation (EVLA) is a well es- Results. Cold saline tumescent without lidocaine was tablished technique to treat varicose veins due to Saphen- used for tumescent anesthesia due to the patient’s use of ous Veins Re#ux. Traditionally this procedure is done under medications that inhibit cytochrome P450 3A4. EVLA was Tumescent Local Anesthesia (TLA) which provides excellent performed of the GSV accessory vein aneurysm as well as the anaesthesia, a buffer to prevent injuries in the surrounding GSV using separate !bers, sequentially, with acute occlusion tissues and to get full contact between the !ber and the vein of the distal 3/4 of the aneurysm sac. Follow up ultrasound wall. On the other hand, because the large amount of liquid at day 5 revealed total occlusion of the sac and the 18 mm injected around the vein, TLA dif!cult to follow the closure diameter neck, with partial occlusion at the saphenofemoral process in real time with Ultrasound. Recently new wave- junction, resolving at day 63. GSV ablation has been free of length (1470nm) and delivery system (Radial !bers) were in- re#ux and clinical improvement has been ‘miraculous’ by pa- troduced which allows to perform EVLA without TLA. The tient report.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 119 Conclusions. Venous aneurysms are an area of emerging in- ious patient perception of vein procedures under Tumescent terest in phlebology. This is an instructive case as optimal ther- Local Anesthesia (TLA) with or without oral Lorazepam. apy of large necked large super!cial venous aneurysms near the Methods. Prospective of!ce based vein procedure study with junctions is unde!ned, with real risks of deep venous thrombo- TLA with or without Ativan. PO comparing selective AITEE to sis with thermal ablation. The size of this successfully ablated MOPC. Consenting patients have one procedure with each mo- type Va venous aneurysm approaches the diameter of the larg- dality (clinician is blinded to modality). The study measures Bi- est known thermally ablated truncal vein to date (29 mm). Spectral Analysis (BIS) levels of Prefrontal Cortex EEG activity, vital signs and patient reported anxiety level. Results. Preliminary results of objective measures with the use of AITEE in n=9 patients have demonstrated lower BIS Perforator Treatment with Percutaneous Laser, levels with use of AITEE. All patients reported a more pleasant Control Eco Doppler experience than anticipated with less anxiety than expected. A. Kornberg, J. Segura Further results pending completion of study. Colegio Argentino de Cirugia Venosa y Linfatica, Buenos Aires, Argentina Conclusions. Auditory and Visual Somatosensory Stimu- lation (SSS) converges in the Ventrolateral Prefrontal Cortex Aim. The objective of this work is the treatment of insuf- (VLPFC) where auditory and visual neurons combine to recog- !cient perforating with Percutaneous Laser and control eco- nize objects. Mapping and monitoring of brain pathways allow doppler. His systematic methodology objective measurement of procedure anxiety. The BIS monitor Methods. We use a 980 laser, !ber laser of 400 or 600 mi- and Vital Signs are a reliable measures of anxiety and the ben- crons. For 400 micron !ber we make the needle 18 G x 1 ½ “and e!t of AITEE in vein patients. Studies con!rm that AITEE and 600 micron !ber Abbocath use a 14G. 1 - The patient should TLA with or without Lorazipam is reversible and lowers the be studied with precise topography of insuf!cient perforating stress of vein procedures. with “x “and “y” indicating the exact location of the emergency aponeurotic (ostium aponeurotic) treat the perforator 2 - OR is located precisely in the insuf!cient perforating ,supine patient Case Report on Repeated Bleeding Caused by Pul- with knee #exion slight downward leg inverted Trendelenburg angle of 45 ° downward. Indeed, look for the piercing with Dop- sating Varicose Veins pler and its respective function respecting this angle is essential L. Engels1, M. De Maeseneer2 because many perforating decrease its #ow and consequently 1Erasmus Medisch Centrum, Rotterdam, Netherlands its diameter in the supine position. That is why we do accu- 2Reet, Begium rately diagnosing days or weeks earlier with the patient standing, but we again make the operating room marked with this Aim. We report a case of an 83-year old woman with chron- angle. 3 - In the intraoperative Doppler image con!rms the in- ic venous insuf!ciency and repeated bleeding caused by pul- suf!cient perforating and notes how it gets to that perforating satile varicose veins related to severe tricuspid insuf!ciency. needle under the guidance Color Doppler. 4 - carries the laser Methods. Case report. !ber through the lumen of the needle 18 G x 1 ½ “Abbocath or Results. She was suffering from pain in the legs with ex- 14 wherein G is used for puncture. 5 - Once the needle is in the tensive varicose veins and had several episodes of varicose laser discharge perforating shows the image of the “bubble” in bleeding. Conservative treatment and attempts to perform am- the light of the perforator. 6 - Are downloads 3 “with power of bulatory phlebectomy failed. Duplex ultrasound revealed the 4 watts. Corresponds to 36 joules. 7 - The Eco Doppler image presence of pulsatile varicose veins and the relationship with shows how close the perforating at that level. 8 - putting pres- underlying tricuspid insuf!ciency became obvious. Finally the sure on the calf muscle is found that the re#ux is stopped in the patient could be treated successfully by the cardiologist and perforating closed. dermatologist. Results. We present the results of three years in each group Conclusions. In the rare case of pulsating varicose veins it of patients in the three periods that make up our sample. We is important to determine the underlying cause. If ultrasound believe that it is necessary for an accurate assessment of the investigation shows pulsating #ow in multiple deep veins, the results because in all series of other authors consulted con- cause is most likely cardial. !rmed that recurrences occur in the !rst 6 months post-treatment. Evaluated operated Relapses 1st series 2004-2005-2006 years 142 138 5% 2nd series Years 2007-2008-2009 128 115 4% 3rd series Years 2010 - until the end of June 2012 97 97 2% Up Fill & Aspirate Foam Sclerotherapy (FAFS): A New to December 2012 47 47 ------Total: 414 Approach for Sclerotherapy to the Large Super#cial Conclusions. 1 - High percentage of con!rmed closure of the perforator 2 - Excellent aesthetic result. Only punctate Varicosities at the Time of Endovenous Laser Abla- leaves a scar that over a week to ten days tends to go unno- tion (ELA) ticed. 3 - minimally invasive 4 - The postoperative period is M. Atasoy short, allowing comfortable and painless ambulation after to- Maltepe University School of Medicine, Istanbul, Turkey morrow. 5 - We have not recorded or indurative in#ammatory signs in the area of the puncture. Aim. 1. Implement the Fill &Aspirate Foam Sclerotherapy (FAFS) to the super!cial varicosities instead of ambulatory phlebectomy, 2. Perform the FAFS to the super!cial varicosities concomitant with Endovenous Laser Ablation(ELA) Voluntary Auditory Attenuation of Noxious Surgical 3.Assess the feasibility of the FAFS to the super!cial vari- Stimulation in Varicose Vein Procedures cosities. D. Hallstrand Jr1, T. Harper2, K. Harper2 Methods. Thirteen patients who refused to have phlebec- 1HI, LLC, Cartersville, GA, USA tomies with saphenous vein re#ux and large super!cial vari- 2Vein Specialists of the South, LLC, Macon, GA, USA cosities were included in the study. Both ELA and FAFS were performed concomitantly. Bulging varicosities with the diam- Aim. Analyze Auditory Isochronic Tone Entrainment eter of over 5 mm in supine position and extended to at least (AITEE) versus Music of Patient Choice (MOPC) effect on nox- 10 cm area at the limb accepted as large super!cial varicosity.

120 INTERNATIONAL ANGIOLOGY October 2013 Patients were excluded from the study if they had varicose ul- good early occlusion rates and major complications are rare if cer. After all ELA procedure is completed for FAFS multiple small volumes of foam are used. Compression therapy was not butter#y needles were placed into varicosities. While inject- able to lower the frequency of local side effects like pigmenta- ing the foam synchronously we aspirated the blood and foam tion or induration. The low price and easy repeatability make from the other site. We injected 11.2 ml of 1% Polidocanol so- this method an attractive alternative to varicose vein surgery lution for each patient. Following the treatment patients were and catheter vein ablation. reviewed at !rst and sixth months. Improvement in the CEAP, VCSS and the CIVIQ-2 (quality of life score) score at 6 month visit was investigated. Results. EVLA ablated the treated GSV in all limbs. Only 2 patient required sclerotherapy at 1st month visit. All scores An Ultrasound Model to Calculate the Brain Blood were improved at the sixth month visit. After the treatment Out"ow through Collateral Vessels average scores for CEAPS “C” 2.38 to 0.41, (p<0.01) and symp- E. Menegatti1, S. Francesco 2, S. Gianesini 3, M. Tessari 4, M. Zuolo 5, A. tomatic patients number 7 to 1, (p<0.01), VCSS 2.75 to 0.15, Taibi 2, M. Gambaccini2, P. Zamboni6 (p<.01),CIVIQ-2 54.31 to 22.38, (p<0.01). There were only 4 1Vascular Disease Center University of Ferrara- Italy, ferrara, Italy patients with mild pigmentation at sixth month visit and nine 2University of Ferrara, Ferrara, Italy patients had no pigmentation at all. 3Vascular Disease Center University of Ferrara- Italy, Ferrara, Italy 4Vascular Disease Center-Unversity of Ferrara, Italy, Ferrara, Italy Conclusions. FAFS was used for the great saphenous veins 5Center of Vascular Diseases, University of Ferrara (Italy), Ferrara, Italy and tributer veins. FAFS to the super!cial varicosities instead 6University of Ferrara, Ferrara, 44100, Italy of ambulatory phlebectomy is feasible and effective. Patients were very satis!ed with the aesthetic Results. Aim. 1. To develop a lumped model for quanti!cation of cerebral circulation by means of Echo-Color Doppler (ECD). 2. To preliminarily test the model in controls (HC) and in patients affected by Chronic Cerebrospinal Venous insuf!ciency (CCSVI). Prospective Observational Study on Patients with Methods. Case-control study, comparing 10 HC with 11 Varicose Veins Treated with Foam Sclerotherapy CCSVI. We assessed the head in#ow (HBinF) consisting in the B. Partsch overall #ow of common carotids and vertebral arteries, and Private Practice, Vienna, A-1180, Austria the cerebral blood #ow (CBF) consisting in the #ow with brain destination (internal carotid and vertebral arteries). We also Aim. 1. evaluate the ef!cacy and safety of foam sclerother- assessed the cerebral venous out#ow (HBoutF) consisting in apy using small volumes of foam (<10 ml) 2. investigate the overall #ow assessed in both internal jugular veins (IJVs) plus use of compression therapy in reducing side effects like in- vertebral veins. Finally, the lumped model allowed us to esti- duration, skin staining and super!cial vein thrombosis 3. !nd mate a number of indexes including the venous collateral #ow factors in#uencing the rate of sideeffects (concentration and (CFI) consisting in the rate of the in#ow which re-enters via volume of sclerosant, diameter of varicose veins collateral routes in the superior vena cava system. Methods. This was a prospective observational trial of con- Results. In HC the HBinF was 1040±125 ml/min, whereas secutive patients with large (C2) varicose veins treated by ul- the HBoutF was > 90% of the HBinF; the CFI value was 1% trasound guided foam sclerotherapy. The duration of inclusion of the HBinF, demonstrating a very small amount of blood into the study was 4 years. 402 patients (551 legs) with a mean drained by the collateral veins. When we applied the model age of 66,7 (22-90 years) were treated in a of!ce setting on to CCSVI, the HBinF was not signi!cantly different from HC. an ambulant basis. The clinical stages of the CEAP classi!ca- To the contrary, the #ow of CCSVI patients in the IJVs was tion were: C2 (33%), C3 (27%), C4a (19%), C4b (8%), C5 (4%) signi!cantly lower (p<0.001) while the correspondent CFI rate and C6 (9%). 44% of the patients presented with GSV vari- signi!cantly increased (61%, p<0.0002). cosities, 19% SSV. Isolated insuf!cient side branches like the Conclusions. Our preliminary application of the novel AASV, the PASV or the SASV were were found 19% of the pa- lumped model in the clinical setting suggests the pivotal role tients. An average of 2,8 sessions (1-6) were needed to achieve of the collateral network in draining the blood into the supe- the goal of complete varicose vein occlusion determined by rior vena cava under CCSVI condition. incompressibility of the vein and absence of blood #ow by duplex ultrasound. Post sclerotherapy compression was not routinely used. Only in patients with large super!cial varicosities, compression-therapy by bandages or graduated compression stockings was performed in order to reduce expected side ef- Vasodilation with Nitroglycerin will Improve Ve- fects nous Access during Endovenous Thermal Ablation Results. An occlusion of the varicose veins could be ac- F. Elmore, M. Gonzalez chieved in 99,3% of the treated patients. While typical sclero- Elmore Medical Vein & Laser Treatment Center, Fresno, CA, USA sing reactions with induration of super!cial varicosities were frequent, super!cial venous thrombosis was rare (0,8%). Com- Aim. a. Describe technique of cutaneous application of ni- pression therapy was not able to to reduce the rate of scleros- troglycerin (NTG) paste that through transdermal absorption ing reactions or hyperpigmentation. The rate of hyperpigmen- will dilate the saphenous vein prior to venous access. b. De- tions was neither in#uenced by concentration nor the volume scribe how reversal of vasospasm with an intravenous injec- of the sclerosant. Also the diameter of the varicose veins > 5 tion of NTG solution will allow successful venous access. c. mm was no independant risk factor. The only factor in#uenc- Describe the use of intravenous NTG to facilitate the passage ing local side effects was the super!cial location of the treated of laser or RF !ber. vein. There was 1 patient with a calf muscle vein thrombosis Methods. The diameter of saphenous veins are measured after sclerotherapy of a small sapenous vein varicosity resolving by duplex ultrasound (DUS) prior to Endovenous Thermal Ab- without sequelae after short term anticoagulant treatment. Side lation (EVA). Following cutaneous application of NTG paste effects of the central nervous system like visual disturbances over the vein, the increase in size of the vein is documented. If and migraines were seen with a frequency of 0,5%. vasospasm of the vein occurs during the procedure, this can be Conclusions. Ultrasound guided foam sclerotherapy shows immediately reversed by intravenous injection of dilute NTG

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 121 solution under DUS guidance. A small volume of intravenous dermatosclerosis. Although SEPS was initially performed us- NTG is utilized during EVA if vasospasm occurs after venous ing a one-port system, because of its poor visualization, SEPS access and complicates the passage of the laser or RF !ber. using a two-port system was introduced instead. However, the Solution concentrations and dosage size are documented. Side surgeon still had to perform the operation only with one hand, effects of the use of NTG are discussed. which made it dif!cult to have better visualization of the pe- Results. When the saphenous vein is stimulated during the ripheral vasculature and to detach or preserve the accompa- course of an EVA procedure, subsequent vasospasm can se- nying artery of incomplete perforating veins (IPVs). In such verely compromise the ease of venous access and/or passage of circumstances, we developed a three-port system using curved the energy !ber. NTG will consistently and quickly reverse this forceps and a dedicated #exible trocar to allow the surgeon vasospasm and greatly facilitate the performance of EVA. Veins to perform the operation with both hands and provide better as small as 2mm can readily be treated with this technique. The maneuverability of forceps, and reported the results of surgery usual dosages of NTG required are well tolerated by the patient. with a three-port system (UIP2011, Prague).The usefulness Conclusions. EVA is well established as the treatment of of a multi-port system was evaluated by comparing surgical choice for venous re#ux in the saphenous vein system. This outcomes with a two-port system SEPS with those with multi- re#ux often continues into distal segments of the vein that are port system SEPS. quite small, yet still require elimination. Veins often develop va- Methods. SEPS was performed using a high-vision cam- sospasm when the patient is nervous, or when stimulated during era system (Karl Storz) while carbon dioxide (8 to 12 mmHg) the course of EVA. This spasm can preclude the ability to ac- was insuf#ated through a rigid endoscope with 30-dgree view- cess a small vein and thereby limit the length of vein that can be ing angle type L lite-guide. EndoTIP® (Karl Storz, Tuttlingen, treated. Vasodilation with NTG utilizing a variety of techniques Germany) was used as the !rst port. Multi-port system SEPS can overcome these limitations and improve the success of EVA. was de!ned as a surgical technique which started with two- port system SEPS and it was replaced with three-port system SEPS using an additional #exible trocar (Aesculap®, B. Braun Melsungen AG) and curved forceps (Aesculap®) during surgery Prevalence of Chronic Venous Disease in India aiming to have better visualization and make it easier to de- R. Pinjala tach or preserve the accompanying artery. Nizam’s Institute of Medical sciences, Hyderabad, Andhrapradesh, India Results. Between March 2004 and March 2013, we performed SEPS on a total of 106 legs (in 102 patients) consisting Aim. Chronic venous disease is common in India, but it is of 53 legs in male patients (50%) and 53 legs in female patients 1)under estimated and 2)Early detection will be helpful to re- (50%). The mean age of patients was 61.9 ± 11.6 years old. Clini- duce the 3)morbidity due to venous disease. cal classi!cation was C4b for 42 legs (39.6%), C5 for 11 legs Methods. The risk of venous thrombosis, prevalence of (10.4%), and C6 for 53 legs (50%). The disease treated was pri- color Doppler con!rmed venous thrombosis and chronic mary leg varicose veins in all the legs except for four legs with venous insuf!ciency were studied in the ENDORSE study, post-thrombotic syndrome. SEPS systems used were one-port PROVE study and RELIEF study which were part of the in- systems in 18 legs, two-port systems in 69 legs, and multi-port ternational trials. The ENDORSE study was performed in 10 systems in 19 legs. The mean number of IPVs per leg dissected Indian hospitals to assess the risk factors for DVT in patients endoscopically was 2.3 veins (range: 1 to 4) and 2.9 veins (range: in the acute care areas, in the PROVE trial duplex scan con- 1 to 4) for two-port systems and multi-port systems, respective- !rmed DVT patients and their clinical pro!les were studied ly. SEPS success rates for two-port systems and multi-port sys- and in the RELIEF study the clinical symptoms and signs of tems were 93.2% and 100%, respectively, for Cockett perforating patients with chronic venous suf!ciency were studied. veins(p<0.01), and 93.3% and 100%, respectively, for paratibial Results. In ENDORSE study it was observed that the risk of perforating veins. The ulcer healing rate was 90.9% for both acute venous thromboembolism (VTE) in acute care patients two-port systems and multi-port systems. Accompanying artery according the ACCP guidelines was similar to that in the other preservation rates were 61.5% (32/52, n=37) and 96.7% (29/30, countries, but the preventive measures were under utilized. In n=19) for two-port systems and multi-port systems, respectively the PROVE study Ultrasound detected DVT was also compa- (p<0.01). No serious complications occurred in two-port system rable to the other countries, though the incidence of proximal SEPS or multi-port system SEPS. DVT was reported to be higher. The RELIEF study showed Conclusions. Compared with two-port systems, multi- that chronic venous disease, was more common in those who port systems provided signi!cantly higher accompanying were in 4th decade of their life with or without venous re#ux, artery preservation rates and SEPS success rates (Cockett though patients with demonstrable venous re#ux had more perforating veins) (p<0.01). This study shows that multi-port signi!cant symptoms. systems are useful because they allow the surgeon to perform Conclusions. We, in India need to perform larger epidemi- the operation with both hands and make delicate manipula- ological studies to evaluate the prevalence of chronic venous tions easier. disease and know the annual incidence of acute venous thrombosis. Preventive measures and early detection can prevent late complication such as chronic venous ulceration which is too dif!cult to treat in the later stages. Bacteria Colonize Vascular and Perivascular Tissues of Calf and Thigh in Atherosclerosis and Controls W. Olszewski 1, P. Andziak 2, M. Moscicka-Wesolowska 3, M. Zaleska 3, E. Swoboda-Kopec4, E. Stelmach3 1Medical Research Center, Warsaw, Poland Usefulness of Multi-port System Subfascial Endo- 2Dept. of Transplantation Surgery, Central Clinical Hospital, Ministry of scopic Perforating Vein Surgery Internal Affairs, Warsaw, Poland 3Department of Surgical Research & Transplantology, Medical Research H. Sugawara, M. Ichiki, K. Sai, K. Kamata, M. Ansai, Y. Nakano Center, Polish Academy of Scien, Warsaw, Poland Department of Surgery, Sendai Hospital of East Japan Railway Company, 4Department of Microbiology, Medical University, Warsaw, Poland, War- Sendai City, Japan saw, Poland

Aim. Subfascial endoscopic perforating vein surgery Aim. An unanswered question remains whether infection of (SEPS) was performed on legs with stasis skin ulcers or lipo- lower limb arteries by bacteria normally colonizing foot and

122 INTERNATIONAL ANGIOLOGY October 2013 calf may aggravate in#ammatory and occlusive atheromatous Is Intermittent Compression Effective in Moving changes and be a secondary destructive factor. Tissue Fluid in Legs with Ulcers? Methods. Atherosclerotic tibial, popliteal and femoral ar- M. Zaleska1, W. Olszewski2 terial walls were harvested from amputated limbs for iden- 1Department of Surgical Research & Transplantology, Medical Research ti!cation of bacteria and their DNA using PCR, targeting (i) Center, Polish Academy of Scien, Warsaw, Poland conserved region 16sRNA and (ii) CP and HP. Arteries from 2Medical Research Center, Warsaw, Poland organ donors were used as controls. Comparisons were made with thrombendarterectomized carotid plaques and punch Aim. Unknown remains how effective may intermittent fragments of thoracic aorta obtained during CABG operation. compression be in evacuating TF from in#amed regions and Moreover, bacteriological !ndings were correlated with im- whether accumulated TF forms natural subcutaneous chan- munohistochemical changes in arterial wall and periarterial nels crossing inguinal crease to hypogastrium and gluteal re- tissue. gion. Results. a) specimens of atherosclerotic calf and femo- Methods. We used lymphoscintigraphy to study pathways ral arteries contained bacterial isolates and/or their DNA, of lymph and mobile TF #ow in 30 posttraumatic lymphedema whereas, in normal cadaveric organ donors’ limb arteries or stage II and III pts during pneumatic massage of limb: a) from patients’ carotid arteries and aorta bacteria they were de- traumatized tissues to the inguinal region and b) across in- tected only sporadically, b) lower limb lymphatics contained guinal crease to healthy non-swollen tissues of hypogastrium bacterial cells in 76% of specimens, whereas controls in and gluteal region. 10%. c) isolates from limb arteries and lymphatics belonged Results. (i) in 21 pts pneumatic compression pushed iso- in majority to the coagulase-negative staphylococci and tope in lymph in few still functioning lymphatics and TF in S.aureus, however, other highly pathogenic strains were also interstitial space toward inguinal region and femoral channel, detected. d) immunohistopathological evaluation of limb ar- (ii) in none was isotope crossing inguinal crease or #owing terial walls showed dense focal in!ltrates of macrophages to gluteal area. Densitometry of lymphoscinitigraphic images showed increase in thigh isotope from mean 2.4% before ther- and granulocytes. apy, to 25.7% after 6 and 37.2% after 10 months of compres- Conclusions. Own bacterial isolates can be responsible for sion. dense neutrophil and macrophage in#itrates of atherosclerotic Conclusions. Intermittent pneumatic compression is effec- walls and periarterial tissue in lower limb and aggravate the tive in pushing mobile tissue #uid from the injured region and ischemic changes. relocating large #uid volumes toward groin. However, it does not cross inguinal crease. This needs redesigning of sleeves.

Italian Expert Opinion Survey in the Diagnosis and Treatment of Chronic Venous Disease (CVD) and the Post-Thrombotic Syndrome (PTS) Venous Thromboembolism Survey in Fukushima af- G. Agus ter East Japan Earthquake 2011 University of Milan, Milan. Italy, Milano, 20123, Italy H. Satokawa1, T. Fujimiya 2, S. Takase 2, H. Wakamatsu 2, H. Yokoyama 2 1Department of Cardiovascular Surgery, Fukushima Medical University, Aim. Study the latest updates on the diagnosis and treat- School of Medicine, Fukushima city, Japan ment of CVD and PTS. Collect, spread and compare the opin- 2Fukushima Medical University, School of Medicine, Fukushima, Japan ions of vascular Italian experts, leading to the writing of consensus national guidelines. Aim. The 2011 east Japan earthquake, tsunami and the Methods. In 2013 working group of representatives of the destruction of nuclear power plant caused a large damage to Italian scienti!c societies of phlebology and vascular surgery Fukushima. Many refugees developed and outbreak of venous studied, discussed and evaluated the statements of the recent thromboembolism (VTE) was feared. We performed VTE sur- literature and guidelines on CVD and PTS through a question- vey and report the result. naire sharing (0 = none, 1 = low, 2 = medium, 3 = high). The Methods. 1) We visited refuges and examined deep vein questionnaire was presented, discussed and evaluated by the thrombosis (DVT) for evacuees from March 28 to May 11 in group of experts and selected tutors throughout the Italian ter- Fukushima prefecture. The examination was performed at below knee the veins using ultrasound method. The staff team ritory. consisted of doctor, technologist and nurse. 2) Questionnaire The Survey involved around 400 vascular special- Results. survey was performed about the patient of pulmonary throm- ists. The different topics were synthesized in 25 statements/ boembolism (PE) in the same period to institutions in Fuku- questions. Among the key issues that emerged were the need shima. to better de!ne a common standard of diagnostic tests in the Results. 2238 refugees were examined in 79 facilities. There !rst visit of the patient, the importance of spreading and using were 210 patients with DVT (9.47%), in which most cases had the scores of clinical evaluation. Particular attention was given old and mural thrombus at the soleus veins. The fresh throm- to the various types of surgical treatment of varicose veins, the bus was observed in only 11 patients (0.50%). The age, refuge importance of the role of in#ammation as a marker and target stay days, tsunami, calf edema were signi!cant risk factors. of medical therapy and the possible role of an risk assessment The DVT incidences at each shelter were variable and might in PTS. depend on the quality of shelters. 21 institutions experienced Conclusions. A survey conducted in Italy to improve the 14 patients with PE. No PE occurred in evacuees and almost knowledge and management of CVD and PTS has been suc- PE patients were staying at own home. cessfully performed. The choice of selecting 25 items, propose, Conclusions. Fukushima DVT survey con!rmed the high discuss and assess through a questionnaire of consensus ex- incidence in 2011 east Japan earthquake and tsunami. Early ecuted in more steps, allowed to reach a level of quantity and intervention for VTE prophylaxis is required not only for evac- quality of participation of considerable importance. This ac- uees but also for peoples in own home. Further examination tivity provide the basis for a consensus vascular national Ital- and continuous long-term care are necessary for the suffered ian guidelines. people.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 123 Physiological Circadian Variability of Leg Volume in Congenital Venous Malformations Manifested as Different Postural Conditions Varicose Disease: Diagnosis and Treatment M. Tessari 1, S. Gianesini 1, E. Menegatti 1, M. Zuolo 2, A. Malagoni 1, P. Z. Maksimovic1, M. Maksimovic 2, M. Maksimovic 3, M. Dragas 4, M. Zamboni3 Paripovic4 1Vascular Disease Center University of Ferrara- Italy, Ferrara, Italy 1Clinic for vascular and endovascular surgery, Clinical center og Serbia, 2Center of Vascular Diseases, University of Ferrara (Italy), Ferrara, Italy Belgrade, Serbia 3University of Ferrara, Ferrara, 44100, Italy 2Ophtalmic Clinic, Clinical Center of Serbia, Belgrade, Serbia 3Clinic for Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade, Aim. 1. To establish variation in leg volume in healthy sub- Serbia 4Clinic for vascular and endovascular surgery, Clinical Center of Serbia, jects (HS) exposed to prolonged hydrostatic pressure. 2. To Belgrade, Serbia establish variation in leg volume in HS in the absence of gravitational gradient. Aim. Congenital vascular malformations are rare (1.5%). Methods. The study was carried out on two HS groups: the Venous malformations (VM) are 2/3 of all congenital malfo- group A (20 subjects, 12 females and 8 males, 32.8±7.8 y.o.) mations. Purpose is examination of the incidence, diagnosis were doctors and nurses who voluntarily submitted to water and choice of treatment VM manifested as varicose disease. plethysmography test pre and post eight hour standing in Methods. In the period of 1990 to 2012 at our clinic 2.557 surgery. The group B (20 subjects, 10 females and 10 males, patients (1.699 female, 858 male) suffering of chronic venous 24.1±3.9 y.o.) were volunteers assessed after 10 hours in su- diseases (CVD) were operated. Diagnosis is established by clin- pine position. ical picture and color duplex ultrasonography. In several states Results. Group A: leg volume at baseline was 1857.5 phlebography (include cavography) and magnetic resonance ml±196.9 on the right, and 1850 ml±194.7 on the left. After imaging prformed. At 61 suspicious intraoperative !ndings eight hours of exposure to hydrostatic pressure the volume surgeons demanded pathomorphological researches of the two lower limbs was signi!cantly increased to 1945 Results. Congenital vascular malformations with varicose ml±209.6, and to 1940 ml±216.2, respectively (p<0.0001). The manifestation were diagnosed in 28 patients: primary venous increased volume is signi!cantly correlated with time (R2= aneurysms (6), angiomzmatosis + venous aneurysm (2), ve- 0.95, p<0.0001). Group B: leg volume at baseline was 1875 nous hemangioma (5), malformations that drains into normal ml±175.1 on the right, and 1862.5 ml±166.9 on the left. Af- vein (4), A-V malformations (3), Klippel – Trenaunay disease ter ten hours the volume was 1770 ml±195.6, and to 1757.5 (2), isolated malformations (2), hypoplasia inferior cava vein ml±194.2, respectively (p<0.0001). The decreased volume (2) and AV malformations cum muscular hemangioma (2). is signi!cantly but inverted correlated with time (R2=-0.98, Surgical treatment is the method of choice for truncular forms p<0.0001). alone or after embolo/sclerotherapy. Endovascular techniques Conclusions. Both strong relationships clearly indicate hy- was used in conjunction with surgery, or as a sole. Conserva- drostatic pressure as the main actor in #uid accumulation over tive therapy is rarely used. time in the lower extremity. This represents a major risk factor Conclusions. Congenital venous malformations are rare in workers exposed to gravitational gradient. clinical entities and maybe similar varicose disease, but their pathohistological !ndings are different. The treatment should be performed in dedicated referral institutions which allow multidisciplinary team approach with participation of various specialists (vascular surgery, interventional radiology, pediat- rics, nuclear medicine, orthopedic surgery, plastic and recon- Effect of the Elastic Stoking on the Circadian Vari- structive surgery, physical therapy, psychological and family ability of Leg Volume in Healthy Workers Exposed counseling) in order to achieve optimal Results. to Prolonged Gravitational Gradient M. Tessari 1, S. Gianesini 1, E. Menegatti 1, M. Zuolo 2, A. Malagoni 1, P. Zamboni3 1Vascular Disease Center University of Ferrara- Italy, Ferrara, Italy Prevalence of Small Varicosities Among Patients 2Center of Vascular Diseases, University of Ferrara (Italy), Ferrara, Italy 3University of Ferrara, Ferrara, 44100, Italy with or without Telangiectasias on the Lower Limbs Estimated by Augmented Reality Examination Aim. To assess the effect of elastic stocking in Healthy Sub- K. Miyake ject (HS) exposed for working reason to hydrostatic pressure. Clinica Miyake, Sao Paulo, Brazil Methods. The cohort was composed by 20 HS (10 females and 10 males, 28.6±3.2 y.o.), doctors who voluntarily were Aim. The progress of the treatment for chronic venous disease measured by the means of water plethysmography test pre and has been supported by CEAP, REVAS and VCSS. The correlation post eight hour standing in surgery, respectively with and with- between the presence of vessels connected to resistant to sclero- out stockings exerting 20-30mmHg of pressure at the ankle. therapy telangiectasias has also been discussed. None of the above Results. In workers exposed to prolonged hydrostatic pres- described classi!cations evaluate the prevalence of small varicosi- sure the leg volume is signi!cantly different after 8 hours of ties under telangiectasias - “feeder vein”. Objective: 1. use Aug- exposure to gravitational gradient (p<0.0001); in addition, the mented Reality to search “feeder veins” in areas that the patient increased volume is strongly related to time of exposure (R2 = complained about telangiectasias 2. use the same method in areas 0.95). To the contrary, the baseline volume was paradoxically that the patient had no complaints about leg vein lesions increased respect to the end of the experiment, albeit not sig- Methods. - Case-control study - December 2012 to March ni!cantly, with elastic stockings. Finally, the decreased volume 2012 - Presence of small varicosities on the thigh with or with- is signi!cantly but inverted correlated with time (R2 = -0.99, out telangiectasias - 50 consecutive female patients - non- p<0.0001). invasive Augmented Reality examination - detection of small Conclusions. Our experiment demonstrates that elastic varicosities under telangiectasias - exclusion factor was the stocking may effectively counteract the increased leg volume presence of re#ux in any segment of the saphenous veins (ex- over time in workers exposed to prolonged gravitational gradi- amined by duplex scanning) ent. In perspective, this may correct one of the major risk fac- Results. At least one varicosity was detected in all areas tor for the development of chronic venous insuf!ciency. (100%) where the patient was complaining about telangiecta-

124 INTERNATIONAL ANGIOLOGY October 2013 sias. Prevalence of small varicosities in areas that the patient of venous patients using the C of CEAP. The objective was to considered normal was 26%(P<0.0001). We believe that the determine the level of agreement in the diagnosis of early or presence or not of a small varicosities under a telangiectagia advanced chronic venous disorder. affects the sclerotherapy result. Methods. Seven high-de!nition color photographs were Conclusions. This difference was considered to be extreme- taken of gaiter regions. These patients had venous disease ly statistically signi!cant. We conclude that the prevalence of con!rmed on duplex. The photographs were displayed with small varicosities estimated by augmented reality should be the revised CEAP as an aide memoire together with a ques- in the inclusion and exclusion factors of Sclerotherapy Treat- tionnaire (Fig. 1). Delegates familiar with CEAP were asked ment Studies to choose from 3 C class options for each photograph. The responses were summarized by grouping them into mild (C0- 3) or severe (C4-6). Results. 94% of the 117 delegates from 30 countries who Implementation of New Two-Ring Radial-Fiber completed the questionnaire had practiced phlebology for Combined with 1470 nm Diode Laser as Promis- more than 2 years. The percentage of delegates scoring mild ing Standard Treatment for Great Saphenous Vein (C0-3) and severe disease (C4-6) were: mild/severe, 3/96 (pho- Insuf#ciency (Diameter 3 cm Distal to Junction) of to 1), 65/33 (photo 2), 31/67(photo 3), 56/34(photo 4), 74/21 More Than 8 mm (photo 5), 89/10 (photo 6) and 37/59 (photo 7). The median D. Fiebig1, N. Frings2, K. Rass3, A. Greiner4 percentage agreement was 37(95% CI:25-49). The range was 23 (95% CI:11-36) to 95(95% CI:91-99), P<0.001/photo, Fish- 1Kompetenznetz Chronische Venenkrankheiten, Kiel, Germany 2Capio Clinic Bad Bertrich, Bad Bertrich, Germany er exact test). This indicates a signi!cant difference of per- 3Artemed, Simmerath, Germany ception in classifying pigmentation as mild or severe clinical 4Capio MVZ Venenzentrum, Bad Bertrich, Germany disease. Conclusions. Hyperpigmentation of the gaiter area de- Aim. Implementation of new two-ring radial-!ber com- !nes advanced chronic venous disorder. This is documented bined with 1470 nm diode laser as promising standard treat- from C4a in the CEAP classi!cation. This study has shown ment for great saphenous vein insuf!ciency (diameter 3 cm that recording pigmentation in the C class may be unreli- distal to junction) of more than 8 mm. able. This questions its use in clinical trials for grouping pa- Methods. Patients with great saphenous vein insuf!ciency tients into mild and severe disease. C4a in CEAP may require were assigned to endovenous laser treatment. Interventions revision. were performed on ambulatory patients at a specialized vein center in Germany. A pre-study with 226 patients has been concluded. The main-study with examination of 100 additional patients has started already. Main outcome measures: Occlusion-rate, venous clinical severity scoring, quality of life, biometrics data, energy density data and compression therapy. Anorrectal Venous Malformation Treated with Po- Results. Observation of 226 patients mean (SD) diameter lidocanol Microfoam 0.722 cm (0.178) 3 cm distally to junction. Sex speci!c: fe- A. Sierra Martinez1, J. Baixauli2, J. Cabrera Garrido3 males (n = 166) mean = (SD) 0.712cm (0.168) and males (n 1University Clinic Of Navarra, Pamplona 31004, Spain = 60) mean (SD) = 0.75 cm (0.201). Comparison of patients 2University Clinic of Navarra, Pamplona, Spain with diameter ≥ 8mm (subgroup A) versus < 8mm (subgroup 3Granada, Spain B). Observation subgroup A (n = 72): mean (SD) diameter = 0.923 cm (0.102) and for subgroup B (n = 154) 0.628 cm (0.13). Aim. Lower intestinal venous malformations (VM) are rare Occlusion-rate ≥ 99.1 % across all patients. Diameters were congenital anomalies that may give rise to massive bleeding measured in upright position sonographically. that threatens life. Their de!nitive treatment implies the ab- Conclusions. We demonstrate an effective method to treat dominoperineal resection of the rectum after controlling the large insuf!cient great saphenous veins (diameter above 8 blood loss. mm) by using the newly developed two-ring radial-!ber (Bio- Methods. A young male with anorectal, scrotal and sub- litec) laser. New construction needs less energy and results in cutaneous perineal VM that had bledding and hypovolemic optimal homogenous radiation. Patient satisfaction was high. shock was referred to our Phlebology unit. Radiographic In our main-study we will demonstrate additional Results. !ndings included signal T2 weighted enhanced abnormal modi!ed CEAP severity, postoperative pain and biometrics vessels on MRI affecting left lateral wall of the rectum and data. No difference in occlusion-rate between subgroup A and ischiorrectal fatty tissue. Colonoscopy showed a 4 cm sessile B could be observed. mass in the rectum 10 cm from the anus and inactive grade IV hemorrhoids Results. With the patient in a lithotomy position under lo- corregional anesthesia we injected 50 ml of 3 % polidocanol microfoam inside the anorectal VM with a 21G neddle under Pigmentation in the CEAP Classi#cation May Be Un- visual control checking the adequate !lling of the VM and the reliable as a Marker of Severe Chronic Venous Dis- hemorrhoid. There was no bleeding from the puncture site. The procedure was very well tolerated without pain or impor- order tant bleeding (just some stainning at the end of the deposi- C. Lattimer1, E. Kalodiki2, M. Azzam3, O. Albazde4, G. Geroulakos1 tion). He had one day hospital stay and returned to normal 1Imperial College, Ealing & Northwick Park Hospitals, Southall, Mid- activities the day after. In a follow-up inspection we evidenced dlesex, United Kingdom a marked reduction (60%) of the size of the VM and complete 2Imperial College & Josef P"ug Vascular Laboratory, Ealing Hospital, London, United Kingdom dissapearance of his hemorrhoid. 3Ealing Hospital, Southall, Middlesex, United Kingdom Conclusions. Anorectal abnormal vessels can be effectively 4Josef P"ug Vascular Unit, Middlesex, United Kingdom controlled by endochemical ablation with polidocanol microfoam injected through the anus, thus avoiding complications Aim. Delegates at 3 international venous conferences were derived from aggressive surgical procedures as well as a co- asked to classify different patterns of pigmentation in the legs lostomy.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 125 Feasibility and Safety of Lower-Calf and the Ankle cases (85%) with 72%(31/43) fully healed and only 2%(1/43) Region Puncture Site Following Endovenous Laser not improved. Ablation of the Saphenous Veins Conclusions. The management of lower extremity ulceration in community remains sub-optimal. Additional education M. Atasoy is required to ensure accurate diagnosis and management Maltepe University School of Medicine, Istanbul, Turkey When community ABIs are not available criteria for the safe use of compression should be available. Earlier referral of Aim. Assess the feasibility of endovenous laser ablation of non-healing ulcers should also be encouraged. Tertiary centers distal GSV and LSV at the ankle region. Determine the side must work with their community areas if a signi!cant impact effects of distal puncturing (close to the ankle) during laser ab- on ulcer treatment is to be made. lation. Assess the safety of low dose laser ablation with lower- calf access. Methods. Eighty-eight patients with Great Saphenous Vein(GSV) re#ux and 36 patients with Small Saphenous vein (SSV) re#ux were treated with endoveous laser ablation (ELA) Dynamically Cooled 1064-nm Nd:YAG Laser as a procedures using 1470 nm diode laser. Both GSV and the SSV Treatment Option for Facial Reticular Veins were canulated from the malleolar parts or the lower 1/3 calf D. Friedmann1, A. Liolios2, M. Goldman1 region. ELA procedures were performed by using 6 W energy 1Cosmetic Laser Dermatology, San Diego, CA, USA and linear endovenous energy density (LEED) of 30 J cm. Par- 2Goldman, Butterwick, Fitzpatrick, Groff, & Fabi: Cosmetic Laser Der- aesthesia and recanalisation in treated regions were recorded. matology, San Diego, CA, USA Folow-up visits were arranged on the 1st and 6th months, thereafter annualy. At 1st month visit complemtary sclerother- Aim. Facial reticular veins are a common cosmetic concern apy was performed to the lims if required. among patients. We evaluated the ef!cacy, safety, and patient Results. There was no recanalisation or re#ux in the treated satisfaction with a long-pulsed 1064nm Nd:YAG for the treat- GSV and SSV during the follow-up. Two patient from the GSV ment of periorbital and temporal reticular veins. re#ux group could not be reached at the 6th month follow-up. Methods. This is a retrospective study of 40 patients (36 Five patients (5/88, 0.5%) of GSV group and two patients (2/36, female, 4 male) who had facial reticular veins treated with a 0.5%)were describing mild paraesthesia when they were asked. dynamically cooled, 1064-nm Nd:YAG laser. Mean patient age Conclusions. GSV and SSV lies close relationship with the was 49.5 years (range 27-74 years), with skin types I-IV repre- nerves espicially at the lower-calf. Paraesthesia is the unde- sented. The length of follow-up from initial treatment ranged sired side effect of ablation espicially around the ankle region. from 3-88 months. Follow-up evaluation was performed in- Dilated varicose saphenous veins at the lower-calf is not un- of!ce or via telephone questionnaire. common. Treatment of the lower-calf saphenous veins by ELA Results. Patients in our practice required a mean of 1.63 using relative low doses is safe and effective. Paraeshesia is treatments. Most patients were very satis!ed with results, with rare and self-limitting side effect by this technique. the majority appreciating a 75-100% improvement of their facial reticular veins. The most common side effect reported was mild treatment site edema; however, 50% of patients reported no adverse effects whatsoever. The mean #uence used in our cohort was 191 J/cm2 (160-230 J/cm2) with a 3.5 mm spot size, 25-40 ms pulse duration, and 0-10/20-30 ms dynamic cryogen Chronic Lower Limb Ulceration – Much Progress to cooling. be Made? Conclusions. Use of a dynamically cooled, 1064-nm M. McCafferty1, Z. Martin 1, S. O’Neill 1, N. Haider 2, P. Madhavan 3, M. Nd:YAG laser is effective for the treatment of facial reticular Colgan3 veins with minimal side effects. The results of this treatment 1Department of Vascular Surgery, Dublin, Ireland are often immediate and tend to be long lasting. 2Dept of Vascular Surgery, Dublin, Ireland 3St. James’s Hospital, Dublin, Ireland

Aim. 1. Evaluate the assessment and management of chronic lower limb ulceration in the community. 2. Compare this to Social Media Marketing: Avoiding Legal Pitfalls the assessment, management and outcome in a tertiary vas- S. Peek cular center. 3. Identify areas where community care could be Incredible Marketing, Irvine, CA, USA improved. Methods. This is a prospective study of 51 consecutive low- Aim. Social media marketing has the potential to offer the er limb ulcer referrals to a vascular center over a four month phlebologist signi!cant bene!ts through digital connection period. A structured questionnaire was completed to evaluate and communication with existing and prospective patients. ulcer aetiology, relevant vascular history, clinical !ndings, an- However, marketing in the digital age doesn’t come without le- kle brachial indices (ABIs) and primary management before gal risk. Electronic communications and data privacy, security and after referral. laws by state, and sweepstakes promotions carry compliance Results. The male:female ratio was 1:2 and median age was obligations. 70yrs (33-90yrs). The mean time from ulcer management in Methods. This presentation will provide an overview of le- community to referral was 8 months (2 weeks – 60 months). gal risk and liability as well as how to implement safeguards Two-thirds did not have a working diagnosis on referral. and policies to manage potential legal pitfalls. Twelve patients (24%) had ABIs performed prior to referral, Results. Following this presentation you will (a) under- of which nine had normal pulses at their hospital visit. An ad- stand and be able to evaluate privacy policies on Linkedin, ditional six patient (13%) had reduced/absent pulses and ABIs Facebook and YouTube and perform a cost-bene!t analysis of were abnormal in four cases. Clinically, 31 ulcers (70%) were contractual terms for your practice; (b) know how to mitigate considered venous and treated in full compression. Twenty- publishing liabilities for images, video and other electronic three (74%) did not have compression prior to referral, two content; and (c) know how to create and implement an online had compression discontinued and !ve were in inadequate privacy policy. compression. Four month follow-up has been completed in 43 Conclusions. The Federal Trade Commission (FTC) Act,

126 INTERNATIONAL ANGIOLOGY October 2013 Controlling the Assault of Non-Solicited Pornography and Conclusions. The NeverTouch Direct laser !ber for the Marketing Act (CAN-SPAM), and the Telephone Consumer treatment of EVLA has proved to be safe and effective. It has Protection Act (TCPA) will be covered. excellent closure rates at three months and minimum post op pain. The elimination of the long wire and sheath saves time and steps during the procedure. The !ber tracts with almost zero risk of perforation.

Start to Finish: How to Create a Successful Market- ing Campaign in 3 Steps Protecting Your Online Reputation: 3 Things Every S. Peek Phlebologist Needs to Know Incredible Marketing, Irvine, CA, USA S. Peek Incredible Marketing, Irvine, CA, USA Aim. A successful marketing campaign has the power to transform today’s medical practice from relatively successful Aim. What is an e-reputation? Why does your online rep- into a pervasive, dominating force. Planning and implement- utation matter? What can you expect if !nd yourself with a ing a campaign can effectively position the phlebologist and bad reputation? The Internet is a mirror of your professional his or her practice in the overall marketplace, promote brand success-a vast collection of details that has the power to af- image, instill patient con!dence, expand the patient base, and fect how you look and how both you and your practice are boost the bottom line. While many will invest in marketing perceived. Search engines catalog everything, from blog posts efforts, however, few will achieve measured success without and social media updates to press releases. Doctor review sites strategic planning and implementation. exist by the dozens and it takes only one negative review to Methods. This presentation will describe in 3 steps-plan- potentially damage an otherwise stellar reputation. ning, content development, and execution-what the practicing Methods. The purpose of this presentation is to show you phlebologist needs to know to build a successful marketing how to manage your “e-reputation” by avoiding the most com- campaign from start to !nish. mon pitfalls that can negatively impact your professional pres- Results. Key points will include: understanding audience, ence. goal setting, brainstorming, messaging strategy and develop- Results. Learn how to set your own reputation, monitor ment, marketing mix selection, return on investment (metrics your presence, manage negative reviews, and secure your ac- and analysis), and when to seek out professional marketing counts. Are you virtually nonexistent? That can be detrimental assistance. too. Conclusions. A case study will be presented. Conclusions. Common reputation issues faced online as well as what you can do about it will be reviewed.

Treatment of Endothermal-Heat-Induced-Throm- Evaluation of Sheathless Laser Fiber for EVLA bus Using a Class-Speci#c Treatment Algorithm K. Goudarzi K. Harper, M. Kinney, E. Milligan Kamran Goudarzi, Wilmington, NC, USA Vein Specialists of the South, LLC, Macon, GA, USA

Aim. 1.Perform laser ablation of long saphenous vein utiliz- Aim. 1. Implement class speci!c treatment algorithm ing sheathless 1470 laser !ber to see if this causes less pain (CSTA) for Endothermal-Heat-Induced-Thrombus (EHIT). 2. and bruising than the currently available lasers. 2.Compare Report the overall and class speci!c incidence of EHIT in a the results with other laser !bers to see if the gold casing im- series of endovenous procedures. 3. Determine EHIT progres- proves performance. 3.Provide short term data for this newest sion to higher classi!cation using CSTA. 4. Establish time to of the 1470 !bers. resolution in patients with EHIT using CSTA. Methods. From September 2012 to February 2013 100 Methods. Conduct a retrospective chart review identify- patients scheduled for EVLA were treated with the AngioDy- ing patients with EHIT using the classi!cation established by namics NeverTouch Direct laser !ber in an of!ce setting. Kabnick et. al. Analyze the overall and class speci!c incidence Patients were selected based on the size and tortuosity of of EHIT and the incidence of progression and time to resolu- the vein for treatment of the GSV. Outcomes were de!ned tion with implementation of the CSTA. by ability to navigate targeted vein, closure of treatment seg- Results. 31 EHIT were identi!ed in 414 endovenous pro- ment, pain as reported by the patient post-procedure and no cedures (7.4%). EHIT by class is I- 26, II- 5, III and IV- 0. Pro- adverse events. gression occurred in 2 cases Class I to II (6.4%). Average time Results. Average patient age was 52, 84 Female 16 Male. to resolution was (24.6 days) for all classes was comparable to 52% Left GSV and 48% Right GSV were treated. Access sites prior to CSTA (26). Before implementing CSTA there was no varied from (60%) lower calf, (37%) mid-calf, and (2%) the standard protocol-all had compression and ambulation either knee area. All procedures started approximately 2.5cm from alone (10%), or with low-dose ASA (60%), or with anticoagu- the SFJ. A 1470 laser was set at 6 watts. Average Joules deliv- lants (30%). After implementing CSTA all were treated with ered was 1131.80. Average pull back time was 184.897s. Aver- compression and ambulation, either alone (20%), or with low age amount of tumescent anesthesia utilized was 321 ccs. All dose ASA (68%), or with anticoagulants (12%). !bers tracked up the targeted treatment area without the need Conclusions. The incidence of EHIT is not associated of a sheath introducer. Four required secondary entry points with a signi!cant risk of progression to VTE (no patients with due to tortuosity. Post-operative pain as reported by patients Class III or IV). CSTA proved safe and with a trend toward at one week visit rated less than one on an analog pain scale more conservative treatment. A larger multi-center center trial of 0 - 10. No adverse events were observed including: perfora- would help establish CSTA as a ‘best practice’ for EHIT. Kab- tion, DVT, PE, paresthesia, bruising, skin burns or infections. nick, L., et.al. (2011). Thrombus extensions at the SFJ after At three months the occlusion rate is 100%. endovenous thermal ablation: should we worry?

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 127 Foam Sclerotherapy for Reticular Veins of the Chest: The Use of Vibration for Pain Reduction in Sclero- A Retrospective Review of Ef#cacy and Safety therapy: Both Vibro-Anaesthesia and Vibrating Nee- D. Friedmann1, A. Cruz2, M. Goldman1 dles 1Cosmetic Laser Dermatology, San Diego, CA, USA J. Marx1, A. Granot2 2 Department of Dermatology, Mayo Clinic, Rochester, MN, USA 1Erase, Melbourne, Victoria, Australia 2The Ashley Centre, Melbourne, Australia Aim. No prior study has evaluated the use of foam sclerotherapy in treating clinically conspicuous reticular chest Aim. Objective Sclerotherapy is inherently a painful proce- veins. This retrospective study evaluates patient-rated effi- dure. The objective was to reduce this pain, using both Vibro- cacy, safety, and satisfaction following foam sclerotherapy anaesthesia and Vibrating Needles. for reticular veins of the chest. Methods. (1) Vibro-anaesthesia was applied to 18,000 scle- Methods. A telephone-based questionnaire was used rotherapy patients, over a 20 year period – to reduce the pain, for patient self-assessment of overall improvement, satis- and to prevent extravasation ulcers. (2) By copying the mos- faction, prevalence of adverse events, and willingness for quito’s precision technology, vibration has transformed the repeat treatment following foam sclerotherapy of reticular current conventional needle into a “high performance” nee- veins of the chest with sodium tetradecyl sulfate (STS). All dle. Since 2006, Vibrating Needles have now been used to treat patients had been treated with 0.25-0.50% foam STS using over 6,000 sclerotherapy patients. room air. Length of follow-up ranged from 3 months to 8 Results. A Testometric Force Rig quanti!ed a hypodermic years. needle’s performance. (a) Vibration reduced the force required Results. Twelve of 23 patients were successfully contact- to overcome the needle’s 2 performance-limiting factors : - 1. ed, with a total of 16 treatment sessions. Overall, patients Penetration Resistance by 57%. 2. Tissue Stiction by 36%. (b) reported scores of 2.28 ± 0.83 for overall improvement (0 After 13 consecutive skin penetrations, needle blunting had re- = none, 1= mild, 2 = moderate, 3 = complete resolution) duced the vibrating needle’s performance level down to that of and 1.71 ± 0.61 for satisfaction with results (0 = not satis- a brand new conventional needle. Visual Analogue Pain Scale fied at all, 1 = mildly satisfied, 2 = very satisfied), with few testing demonstrated signi!cantly reduced pain scores with significant treatment-related adverse events. The majority the new Vibrating Needles. Vibro-anaesthesia is now a very of patients stated they would undergo another treatment if well-documented anaesthetic technique. needed. Conclusions. These results suggest that a vibrating “high Conclusions. Foam sclerotherapy with STS is effective performance” needle can now deliver the higher level of pre- for the management of reticular veins of the chest with an cision required for sclerotherapy, and with signi!cantly less excellent safety profile and high long-term patient satisfac- pain. Vibro-anaesthesia can deliver instant and very effective tion. Pain Relief. When used together with Vibrating Needles, the result is a powerful pain-reducing combination.

Foam Sclerotherapy for Reticular Veins of the Dor- Varicose Veins and Morbidly Obese Patients – Treat- sal Hands: A Retrospective Review of Patient Out- ment Using Tactile Endovenous Ablation Technique comes and Adverse Events C. Lim1, S. Parsapour2, D. Greenstein3 D. Friedmann1, A. Tremaine2, M. Goldman1 1Department of Vascular Surgery, Middlesex, London, United Kingdom 1Cosmetic Laser Dermatology, San Diego, CA, USA 2Northwick Park Hospital, Middlesex, Greater London, United Kingdom 2Department of Dermatology, University of California, Irvine, Irvine, CA, 3London, United Kingdom USA Aim. High body mass index (BMI) has been reported to be Aim. Despite being the gold standard for lower extremity a risk factor of anatomical failure including increased non- reticular vein treatment, no study has yet evaluated foam scle- occlusion and early recanalization rate following endovenous rotherapy for hand veins. This retrospective study evaluates thermal and chemical ablation of varicose veins. Morbidly the safety and ef!cacy of foam sclerotherapy for reticular veins obese patients tend to pose more procedural challenges such of the dorsal hands. as inadequate compression following treatment and incom- Methods. A telephone-based questionnaire was used for plete obliteration of varicose veins. Despite challenging, there patient self-assessment of overall improvement, satisfac- are very few reports on ways to improve the occlusion and tion, prevalence of adverse events, and willingness for re- non-recanalization rate of varicose veins in morbidly obese peat treatment following foam sclerotherapy of dorsal hand patients treated with endovenous thermal and chemical abla- veins with sodium tetradecyl sulfate (STS). All patients had tion. We propose a tactile endovenous ablation technique to been treated with foam STS of 0.25-1.0% concentration us- improve the occlusion and non-recanalization rate of varicose ing room air. Length of follow-up ranged from 6 months to veins in morbidly obese patients. 9 years. Methods. Case series of 14 morbidly obese patients (BMI Results. Twenty-one out of 45 patients were successfully ≥40 kg/m2) with symptomatic primary or recurrent great and/ contacted, with a total of 54 treatment sessions performed on or short saphenous vein re#ux on duplex ultrasonography 38 hands. Overall, patients reported scores of 2.41±0.55 for (DUS). All patients were treated with tactile endovenous abla- overall improvement (0=none, 1=mild, 2=moderate, 3=com- tion technique using the 1470-nm diode laser and radial !bre plete resolution) and 1.73±0.45 for satisfaction with results slim (14 Watt). Vein closure was solely based on tactile feed- (0=not satis!ed at all, 1=mildly satis!ed, 2=very satis!ed), with back during a “rocking” pull-back technique. Tactile resistance few signi!cant treatment-related adverse events. The major- indicated vein closure. Minimal or no resistance indicated vein ity of patients stated they would undergo another treatment patency which would require further segmental ablation until if needed. resistance was felt. All patients were followed up for 6 months Conclusions. Foam sclerotherapy with STS is a safe and with DUS. effective treatment for reticular veins of the dorsal hands with Results. All patients were discharged on the same day with excellent long-term patient satisfaction. no immediate complication. Follow-up DUS in 6 months re-

128 INTERNATIONAL ANGIOLOGY October 2013 vealed complete occlusion of treated veins with no clinical re- pest, 1993); I. Bihari (Hungarian Journal of Vascular Diseases, currence. No deep vein thrombosis was reported. 1994, Hungarian Venous Forum, 1997); E. Monos (in#uence Conclusions. Using a tactile ablation technique, complete of gravity on the control of the lower limb venous system); A. occlusion of treated varicose veins for at least 6 months is Hetenyi ( book on Doppler investigation, re!nement of clas- achievable. sic varicose vein surgery); T. Sandor (thromboprophylaxis); G. Menyhei (surgery of CVI); G. Tasnadi (vascular malformations). Authors of books on venous diseases: G. Vas (1963), A. Nemes (1986) and I. Bihari (2004). Nowadays Hungarian phle- Flush Ablation of Short Stump Saphenofemoral bologists treat patients and carry out scienti!c activity all over Junction Recurrent Varicose Veins – A Method Us- the world: P. Gloviczki in the USA, Z. Varady in Germany, A. ing Endovenous Laser Puskas in Romania, P. Conrad and G. M. Somjen in Australia, and R. Varnagy and P-P. Komlos in South America. C. Lim1, S. Parsapour2, D. Greenstein3 Conclusions. It seems that Hungarians are ambitious to 1Department of Vascular Surgery, Middlesex, London, United Kingdom 2Northwick Park Hospital, Middlesex, Greater London, United Kingdom develop the discipline they have chosen, and many of them 3London, United Kingdom have been able to pro!t from the education they obtained in their home country. Aim. We present our experience with targeted endovenous laser ablation (EVLA) right at the saphenofemoral junction (SFJ) or “#ush ablation” with concomitant phlebectomies/ foam sclerotherapy in patients presented with complex recur- Anatomical Distribution and Physiological Impact rent varicosities arising very close to SFJ which would oth- of Venous Re"ux of Saphenous Tributaries in Pri- erwise not amenable endovenously if the conventional “2cm mary Varicose Vein rule” is followed. T. Ogawa Methods. Case series of 20 selected patients presented with Fukushima Daiichi Hospital, Fukushima, 960-8251, Japan symptomatic (CEAP C2-C6) recurrent varicosities, and treated with targeted EVLA with concomitant phlebectomies/foam Aim. Anatomical distribution and physiological impact of sclerotherapy by one clinician. Duplex ultrasonography (DUS) venous re#ux of saphenous tributaries in primary varicose of patients included revealed recurrent varicosities arose from vein are not clear. This study was to investigate venous re#ux tributaries feeding very close to short stump SFJ (≤6cm). of saphenous segments includes tributaries in primary vari- Results. The short stump re#uxing SFJ was cannulated cose vein. with a micropuncture set ≤6cm distal to SFJ. Following hy- Methods. This ongoing study was conducted prospectively drophilic wire and catheter insertion, a bare-tip laser !bre was from August 2012. 50 (63 legs) consecutive patients with great precisely positioned with the tip right at the SFJ just distal to saphenous varicose vein and without operation for varicose femoral vein under DUS guidance. Following tumescent in- vein were participated. Venous re#ux was assessed using du- !ltration, “#ush” EVLA was performed (1470 nm; 8-12 Watt; plex ultrasound and Air-phytismography. Venous re#ux seg- variable pull-back rate) from right at the SFJ under continu- ments were classi!ed into Anterior tributary vein (ATV), Great ous DUS vision of the !bre tip. The varicose tributaries were saphenous vein (GSVc), Posterior arch vein (PAV) at calf and treated with phlebectomies/foam sclerotherapy where appro- anterior and posterior accessory great saphenous vein (AA and priate. All patients were discharged on the same day with no PA) and great saphenous vein at thigh (GSVt). The relation immediate complication. Follow-up DUS in 6 weeks revealed between number of venous re#ux segments and venous !lling complete occlusion of recurrent varicosities right up to the index (VFI) were evaluated. SFJ without involving femoral vein in all patients. No deep vein thrombosis was reported. Results. Anatomical distribution of venous re#ux at calf Conclusions. SFJ “#ush ablation” with concomitant phle- in 63 legs was 10 ATV alone, 11 GSVs alone, 21 PAV alone, 2 bectomies/foam sclerotherapy of complex recurrent varicosi- ATV+GSVs, 2 ATV+PAV, 16 GSVs+PAV and 1 ATV+GSVs+PAV. ties arising close to short stump SFJ is safe and effective. How- Anatomical distribution of venous re#ux at thigh was 5 AA+ ever, such treatment strategy requires precise pre-operative GSVt, 5 PA +GSVt and 53 GSVt alone. The value of VFI in the planning and learning curves. group of 2, 3 and 4 re#ux segments from calf to thigh was 6.37, 7.32 and 6.90 ml/min respectively. There was no signi!cant difference in the VFI of 3 groups. Conclusions. The venous re#ux of posterior arch vein is easy to occur in great saphenous varicose vein. The number The History of Hungarian Phlebology of venous re#ux segments in great saphenous venous area did I. Bihari1, T. Sandor2, G. Bartos3 not affect to the value of venous !lling index. 1Vein Center Budapest, Budapest, Hungary 22nd Department of Surgery, Semmelweis University, Budapest, Hungary 3St Pantaleon Hospital, Dunaujvaros, Hungary

Aim. To show the development of phlebology in Hungary. Experience with 130000 Sclerotherapy Injections Methods. Authors gathered information from the litera- I. Bihari ture, and from colleagues who took part in the development Vein Center Budapest, Budapest, Hungary process. Results. Phlebology started with the work of K. Bugar- Aim. To show the changing methods and results since 1979, Meszaros, who wrote chapters on venous diseases in his book when the author was spurred to begin injection sclerotherapy on angiology (1944). A milestone in pharmacological phlebol- in spite of this being a banned treatment in Hungary. ogy was the discovery of #avonoids by A. Szentgyorgyi. After Methods. Experience is drawn from 130 000 injections giv- World War II, G. de Takats played an important role in the en to 4510 limbs of 3350 patients. The details of this method development of venous surgery in the USA. On the initiative of have changed a lot in this long period, regarding indications, L. Soltész, the Phlebological Section was founded in Hungary the amount and form of medicine, needles and syringes em- in 1979, chaired by G. Rado. Main contributors to the develop- ployed, the duration of compression and instructions to pa- ment: G. Acsady (1st European Congress of the UIP in Buda- tients.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 129 Results. Polidocanol sclerotherapy proved to be the best to avoid serious complications such as thromboembolism treatment for C1 cases. Foam sclerotherapy gave good long- cava !lter with the development of the NIP and the syndrome term results in the treatment of large tributaries, perforator of severe chronic venous insuf!ciency in the long-term and is and recurrent varicosities. Tetradecyl sulphate foam sclero- the method of choice. When embolism occurred in cava !lter therapy has had a good effect on stem varicosities for many should be considered thrombolysis with the high ef!ciency of years. In crural ulcer patients, the wound healed and remained the latter in comparison with conventional conservative meas- closed in every case, even if varicosities reappeared. Usually ures. there are some recurrencies after a few years which can be easily treated again. Firm bandaging improved the results. Complications and adverse reactions are rare (pigmentation, phlebitis, minor super!cial skin necrosis). We have not seen Femoral-Iliac Venous Graft Synthetic Bypass of the any serious complications. Unilateral Occlusion of the Iliac Vein in a Case of Conclusions. This method is of outstanding importance in Postthrombotic Disease of Right Leg with Nonheal- the treatment of varicosity. One of the main bene!ts is that ing Ulcer varicosity is a progressive disease and sclerotherapy can be 1 2 3 3 repeated unrestrictedly; the other is that sclerotherapy can be G. Khubulava , E. Gavrilov , I. Verzhak , I. Larin combined with surgical and conservative treatment modali- 1Advanced Surgical Department of Military Medical Academie, Saint- Petersburg, Russian Federation ties so that these together form a comprehensive treatment of 2Military Medical Academy, Cardiovascular Surgery Department, Saint- lower limb varicosity. Petersburg, Russian Federation 3Advanced Surgical Department of Military Medical Academia, Saint- Petersburg, Russian Federation

Cava Filter or Surgical Removal of Floating Throm- Aim. Femoral-iliac venous graft synthetic bypass of the uni- bi in Deep Venous Iliac-Femoral Segment - What to lateral occlusion of the iliac vein in a case of postthrombotic Choose? disease of right leg with nonhealing ulcer. Methods. To demonstrate the impact of surgical treatment G. Khubulava1, E. Gavrilov2, A. Shishkevich3, I. Verzhak3, I. Larin3 postthrombotic disease of the right lower limb veins with non- 1Advanced Surgical Department of Military Medical Academie, Saint- healing trophic ulcer leg. Methods: Patient K., born in 1975 Petersburg, Russian Federation was treated for advanced surgical department and clinic of 2Military Medical Academy, Cardiovascular Surgery Department, Saint- Petersburg, Russian Federation the Military Medical Academy from 22.05. to 02.06. 2012. 3Advanced Surgical Department of Military Medical Academia, Saint- Received routinely complained of the presence of nonheal- Petersburg, Russian Federation ing trophic ulcer right leg, lower leg and foot swelling, did not disappear during the night’s rest, varicose veins of right leg Aim. To improve the results of surgical treatment of the em- and suprapubic area. The diagnosis: post-thrombotic disease bolic dangerous thrombi in main veins legs through timely di- of the right lower extremity. Occlusion of the right external agnosis and surgical removal of #oating thrombus and throm- iliac vein. Mixed form (varicose-sclerotic). Sanitized trophic bolysis in case of embolism in cava !lter. ulcer of the right leg. Collateral: Viral Hepatitis “C” - carrier. Methods. We analyzed the results of treatment prostrate 87 In history - long (about 8-9 years) opioid addiction, repeatedly patients with #oating vein thrombosis of the lower limbs and practicing the introduction of drugs in the inguinal folds. The pelvis, were treated in advanced surgical department and clin- patient !nds himself in 5 years, when she became a mark of ic of the Medical Military Academy for the period 2005-2012. leg and foot swelling, varicose veins of right leg, and later ap- Patients with veri!ed #otation thrombotic masses venous ul- peared vein above the pubis, darkening of the skin seal right trasonography or venography are divided into three groups: leg about 9 months ago a trophic ulcer of the right leg. She one group of 14 patients for surgical prevention of pulmonary was treated with outpatient - took venotonics, used elastic embolism implanted cava !lter (Opt easy, Cordis), group 2 - compression, numerous external agents for the treatment of 67 patients also performed thrombectomy of the deep veins trophic ulcers. Local status: the right lower limb hyperpig- of the lower extremities, group 3 – 6 patients who only per- mented, Lipodermatosclerosis phenomena in the lower third formed thrombectomy of the deep veins of the lower extremi- of the tibia. On the medial ankle trophic ulcer measuring 9 x ties. Choice of tactics with isolated vena cava !lter implanta- 7 x 0.7 cm GSV trunk on the hip extended. GSV tributaries on tion was determined by: the reluctance of the patient to be the right lower leg varicose transformed. There varicose veins operated - 4, severe concomitant diseases (cancer status, heart above the pubis (v.epigastrica superfacialis). Peripheral pulse failure, respiratory failure) - 6, the size of the #oating element distinct.Achieved ultrasound scanning of the veins of the lower (up to 4 cm in length) - 4 cases. The evaluation criteria were: extremities and pelvis: Visualize main surface (GSV, SSV) and frequency of thromboembolism in cava !lter, the frequency deep (iliac, femoral, popliteal, tibialis) veins of right leg. When of pulmonary embolism, the degree of chronic venous insuf- imaging: ultrasound signs of postthrombotic disease: segmen- !ciently (CVI) class C of CEAP in the late (6 months or longer) tal occlusion of the right external iliac vein with preservation period. of valvular deep vein below the inguinal folds, varicose trans- Results. Patients in the !rst group of 5 cases (36%), patients formation GSV trunk on the thigh. Functioning varicose trans- of the 2 group in 1 case thromboembolism occurred cava !l- formed suprapubic shunt pool v.epigastrica superfacialis. GSV ter (1%), 3-th group – no cases. In 4 cases thromboembolism trunk on the left hip is consistent, with a maximum diameter cava !lter in a conservative treatment in 2 cases - catheter of 4 mm. 05/23/2012, bilateral femoral ascending venography: thrombolysis (alteplase 40 mg). In both cases, after cathteter occlusion of the right external iliac vein length of about 5.5 directed thrombolysis in thromboembolism cava !lter after 6 cm, varicose at the pool surface and exterior shameful epigas- and 12 months was observed C2 of CEAP. Cases of pulmonary tric veins, venous shunt suprapubic embolism was not in any group. Among the patients of group 1 Results. Given the indolent leg sores, failure of conserva- - CVI was C0-3 of CEAP was present in 6 patients (43%), grade tive therapy, there is a short external iliac vein occlusion, lack C4-6 of CEAP - 8 patients (57%). 2 groups of patients CVI 0-3 of suitability for autovenous bypass vein after preparation, CEAP degree was present in 63 patients (94%), grade C4-6 of was made the surgery 25/05/2012: linear femoral-iliac bypass CEAP - in 4 patients (6%). 3 group of patients – CVI C0-3 of right external iliac vein (reinforced PTFE graft 9 mm ) cros- CEAP degree was present in 6 patients (100%). sectomy, short stripping GSV in the thigh, the upper third of Conclusions. The timely removal of #oating leg vein clots the leg, separation ectatic suprapubic vein graft, removal of

130 INTERNATIONAL ANGIOLOGY October 2013 varicose veins of the right leg, the suprapubic region. Impos- Results. The surgical removal of the mass and histopatho- ing arteriovenous !stula has been made. In the postoperative logical examination con!rmed diagnosis of venous malforma- period carried painkillers, anti-in#ammatory, antibacterial, tion. vascular therapy, dressings. 6-8 day on leg ulcers !lled with Conclusions. In conclusion, in the differential diagnosis of granulation, the active edge epithelization, wrinkled skin limbs the soft tissue mass we have to take into consideration also against reduce swelling healing of venous ulcers against zinc- atypically located vascular malformation which needs proper gelatin dressing for 32 hours. Given the long-term drug abuse, evaluation before treatment. concomitant hepatitis C chronic administration appointed anticoagulant drug pradaksa (direct thrombin inhibitor) at a dose of 220 mg once a day. U.S. control over a 3, 5 weeks con- !rmed complete graft patency. 19/01/2013, the visual inspec- Transillumination in Telangiectasias Treatment tion: The patient concerned transient edema, the presence of R. Venesia intradermal veins on both legs as a cosmetic defect. Elastic Centro Quirúrgico Rosario., Rosario, Argentina compression uses periodically. The patient was married, pregnant. By ultrasound scanning of the shunt pass, recorded a Aim. To show evidence that the use of transillumination normal phase of breathing blood #ow data for the failure of (TI) for the aesthetic treatment of telangiectasias provides ac- the main veins not. The recommendations on the management curate anatomical and morphological information as regards of antenatal, delivery and postnatal periods. the size and degree of tortuosity of the veins of deep dermis Conclusions. This case report con!rms the high ef!ciency or hypodermis greater than 0.25 mm. and that this technique of surgical treatment of postthrombotic disease of veins of the helps simplify and optimize sclerotherapy. lower extremities by the operation of the linear PTFE femoral- Methods. Between January and December 2012, 488 pa- iliac bypass grafting. There was a complete healing of venous tients with lower limb telangiectasias were studied and treat- leg ulcers in the short term relief of the main symptoms of ment consulting for cosmetic reasons. 477 were women chronic venous insuf!ciency in the presence of shunt patency (97.74%) and 11, men (2,26%). We used a portable transillu- in terms of up to nine months, the psychological and social minator red and white leds and worked in a dark environment. rehabilitation of the patient. All cases were treated with sclerotherapy and in 292 cases (64,52%) this procedure was used to identify reticular veins and telangiectasias. Effectiveness of Single-Use Laser Fibers in Endov- Results. Out of the total of 488 patients, sclerotherapy was enous Laser Ablation used with TI 292 (64.52%) and without TI 198 (36.48%). In the !rst group, in 170 cases (59.10%) insuf!cient reticular veins W. Chung not visible to the human eye with morphological variety was Yonsesarang Hospital, Seoul, Korea observed. Such veins present variations, which range from an increase in the diameter to tortuosity. Reticular veins were Aim. Utilization of single-use laser !bers by expert inser- then injected as they were the leading cause of telangiectasias, tion into veins can reduce reliance on introducer sheath sets which initially motivated the consultation. and thereby lower costs for surgical procedures. Conclusions. We demonstrate the TI help in the treatment Methods. In Endovenous Laser Ablation(EVLA), the of varicose veins for cosmetic purposes as it enabled us to Seldinger’s technique is most often used to insert laser !bers make a direct puncture of reticular veins and telangiectasias into the varicose veins. Single-use !bers have rounded tips in which one can see the nutricia vein both sclerosis classical that allow for safe advancement through slightly curved veins. and foam, optimising the result. However, it is dif!cult to advance the !bers when the curves are too extreme. In these situations, we can re-insert the !bers at each of the extreme curves by needle point and reduce reliance on introducer sheath sets. Final 6-Month Results of the TAHOE II Study: Use Results. We evaluated 91 cases of patients receiving EVLA of a Novel Biodegradeable Implant to Treat Re"ux- during a 10-month period. In 85 cases, we managed to insert the laser !ber throughout the length of the targeted vein with- ing Great Saphenous Veins out need for the introducer sheath set. We used the sheath set J. Almeida1, E. Mackay2 in 6 cases. Over all, expert technique with single-use laser !b- 1Miami Vein Center, Miami, FL, USA ers allowed us to perform EVLA in 93.4% of cases without re- 2Edward G Mackay MD PA, Palm Harbor, FL, USA quiring the introducer sheath set. Conclusions. Introducing the single-use laser !bers Aim. Current endovenous thermal ablation techniques are through needle point at each extreme curve in the targeted performed using percutaneous delivery of perivenous tumes- varicose vein can reduce reliance on the introducer sheath set cent anesthesia. This study evaluated the feasibility of a novel and therefore save costs for the procedure. biodegradable implant to occlude incompetent great saphenous veins (GSV) without tumescent anesthesia. Methods. TAHOE II was a prospective, single-arm study. Patients (n=30) with symptomatic GSV re#ux were treated with the biodegradable implant and followed at 1 day, 1, 2 Case Report – Rare Wrist Venous Aneurysm and 6 weeks (wks), and 3 and 6 months (mos). Vein occlusion, K. Wasilewski1, G. Wasilewska2 re#ux status (duplex ultrasound), post procedure pain (0-10), 1Dubai Health Care City, Dubai, United Arab Emirates quality-of-life (CIVIQ2), venous clinical severity score, and ad- 2Rashid Hospital, DHA, Dubai, United Arab Emirates verse events were assessed at each visit. Results. Occlusion rate: 100% at 6 wks, 72.4% at 3 mos, Aim. The authors presenting a case of 37 years old male 68.8% at 6 mos. Re#ux-free rate: 100%, 75.9%, and 68.8% at patient with complain of a soft tissue mass lesion at the left same points. Pain (median (IQR)) was 2.5(0,5) at Day 1, 2(1,4) wrist for the last 4 years. at 1 wk and 0(0,0) from 2 wks-6 mos. CIVIQ2 change from Methods. 2012- The patient underwent Duplex Ultrasound, baseline (mean (SD)) was elevated (+12.9(16.0)) at 1 wk, neu- CT angiography and !nal surgical excision of the lesion with tral (-1.9(15.8)) at 2 wks, improved (-10.0(11.1))(p=0.001) by 6 histopathological examination. weeks, sustained to 6 mos. Adverse events: fever(17) and nau-

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 131 sea(16) resolved by 6 wks, erythema(15) by 3 mos, hyperpig- and tributary veins with a diameter at the saphenofemoral or mentation(6) remains at 6 mos, induration(18) and thrombus saphenopopliteal greater than 10 mm. extension(4) resolved by 6 wks. Methods. A cohort descriptive and observational study is Conclusions. The tumescent-free biodegradable implant presented evaluate foam ultrasound-guided sclerotherapy in resulted in a high initial GSV occlusion with recannalization a consecutive series of patients with chronic venous insuf!- appearing in some patients at 3 mos post-procedure. Initial ciency, for clinical ef!cacy and patient satisfaction at a mean in#ammatory response and post procedural pain occurred in 2-year follow-up. some patients, but resolved by 2 wks. This implant is prom- Results. We present a series of 97 patients with C3-C6 ising, but requires modi!cation to achieve higher long-term (CEAP) chronic venous insuf!ciency, treated in a period be- occlusion and re#ux-free rates, while mitigating acute in#am- tween 12/2007-12/2011. Selected patients: post-surgery recur- mation and pain. rences, post-sclerotherapy recurrences, presence of residual saphenous trunks, conventional surgery contraindications, laser contraindication, elderly patients, heart diseases, morbid obesity, and venous ulcers. One hundred thirty-six great saphenous vein (GSV) were treated. Eighty-eight GVS (64.7%) Venous Angioplasty in Chronic Cerebro Spinal Ve- presented a diameter between 10 and 15 mm. and 48 (35.3%) nous Insuf#ciency associated with Multiple Sclero- greater than 15 mm. Foam ultrasound-guided sclerotherapy was performed (tetradecyl sodium sulfate at 1% to 3%). Total sis: Results at 2 Years Follow Up occlusion was obtained in 84.6% (115 GSV) and partial occlu- G. Eisele1, A. Savino2, C. Schulte3, M. Cannellotto4, D. Simonelli4 sion in 15.4% (21 GSV). The mean treatment sessions were 1Sociedad de Flebologia y Linfologia Bonaerense, Buenos Aires, Argen- four, with an interval between sessions of 7-15 days. We per- tina formed an ultrasound scan at 12 and 24 months. 2Centro de Educacion Medica CEMIC, Buenos Aires, Argentina 3Instituto Argentino de Diagnostico y Tratamiento, Buenos Aires, Argen- Conclusions. Ultrasound-guided foam sclerotherapy is ef- tina fective in treating all sizes of varicose veins with high patient 4Centro de Educacion Medica CEMIC, Buenos Aires, Argentina satisfaction and improvement in quality of life. Could be a good therapeutic option in outpatient. Anyway, future control- Aim. Demonstrate feasibility, tolerance and results of ve- led clinical trials are needed to evaluate the effectiveness of nous angioplasty (VA) in patients with associated Chronic Cer- this procedure. ebro Spinal Venous Insuf!ciency (CCSVI) and Multiple Scle- rosis (MS) Methods. This case study include 19 patients with con- !rmed MS and CCSVI between September 2010 to January 2013 and selected for VA because a poor response and/or severe intolerance to medical therapies. 10 men and 9 women Outcome of Simultaneous Endovenous Laser Abla- presented with Recurrence-Relapse (n=14) and Secondary tion and Foam Sclerotherapy of the Saphenous Re- Progressive (n=5) MS con!rmed with Mc Donald revised crite- "ux: 3 Year Results ria. CCSVI lesions consisted in brain and spine venous drain- S. Kang age stenosis and slow #ow where the diagnosis was based on Seoul Sky Hospital, Seoul, Korea Clinic and Neurologic evaluation (CNE), cervical Color Dop- pler Ultrasound (CDU) and jugular (JV) and azygos (AV) veins Aim. To assess the ef!cacy of simultaneous endovenous phlebography (PH). Post VA controls between 1 and 24 months laser ablation (EVLA) with an 1470nm laser wavelength and include CNE and CDU evaluation. Complications related to VA foam sclerotherapy(FS) for treating saphenous re#ux associ- were described. Wilcoxon test was used for statistical analysis ated with varicose veins. in this preliminary ongoing study. Methods. Between October 2009 and December 2012, Results. CDU depicted 15 patients with JV lesions and PH con!rmed 13 stenotic JV and 8 AV patients. VA was performed in 568 (373 women, 195 men) patients with a mean age of in 33 JV and 8 AV. CNE tests improve soon after VA with maxi- 47.2(range 20-81) were treated, using a 1470-nm diode laser mum effect between 6 and 12 months. After 12 to 24 months, at 10 watts in continuous mode. The patients whose clinical a tendency to decrease and then to stabilize the bene!ts was CEAP categories C4-6 were excluded. EVLA with 80J/cm was observed in most patients. 8 patients presented JV restenosis used for proximal saphenous veins and FS for distal saphe- between 1 and 12 months without major complications. Toler- nous veins and tributaries under tumescent local anesthesia. ance was excellent and feasibility showed appropriate results They were evaluated clinically and by duplex at 1, 3, 6 month, in all patients. 1 year and 3years. Univariate Kaplan-Meier life table life ta- Conclusions. Patients with associated CCSVI and MS can ble analysis determined primary and secondary success rates. improve their clinical conditions with VA that demonstrate to Multivariate Cox regression analysis detected covariates that be safe and with and good tolerance. affected outcome. The postoperative follow-up was done by the same surgeon. Results. The primary and secondary successful occlusion rates of the GSV, de!ned as the absence of #ow on color doppler imaging, were 74.6% (95% CI 68-81%) and 88.7% (95% CI 85-94%) at 3 years for all veins. No patients were Foam Ultrasound-Guided Sclerotherapy Treatment included who were followed up for 1 year and then lost to for Varicose Veins of Saphenous Axes with Diameter follow-up. There was no deep vein thrombosis, super!cial Greater than 10 mm burns or thrombophlebitis that needed any kind of reopera- G. Orallo, R. Almeida, D. Carraro tion. Hospital Zonal General De Agudos Gobernador Domingo Mercante, Jose Conclusions. The simultaneous EVLA with an 1470nm C. Paz, Buenos Aires, Argentina laser wavelength and FS for treating saphenous re#ux associated with varicose veins is feasible and safe. However, the Aim. The objective was to analyze the effectiveness of foam short-term results for this treatment appears promising, long- ultrasound-guided sclerotherapy treatment in saphenous veins term result is needed.

132 INTERNATIONAL ANGIOLOGY October 2013 A New Method for Endovenous Laser Ablation – Conclusions. High PP more than 1000W showed clinical “Clear Tip Mode” effectiveness and less USEs compared with 980nm, because of N. Sakakibara1, R. Kansaku 1, M. Sueishi 2, H. Yamaoka 1, A. Amano 3, H. much shorter pulse duration. The thermal-relaxation-time of Inaba3, Y. Yokoyama3 water could be a crucial parameter. In addition, since high PP 1Department of Cardiovascular Surgery, Edogawa Hospital, Edogawa- adds non-thermal vein damage with shock wave, this technol- Ku, Tokyo, Japan ogy would establish a new frontier for the future. 2Shinagawa Heart Medical Clinic, Minato-Ku, Tokyo, Japan 3Department of Cardiovascular Surgery, Juntendo University School of Medicine, Bunkyou-Ku, Tokyo, Japan

Aim. We developed a new concept using “Clear Tip Mode” (CTM) to avoid carbonized coagulum and thrombus forma- How to Reduce the Postsclerotherapy Pigmentation tion on the !ber tip during EVLA. This study evaluated the Using a Special Microcompression System contribution of high peak power to CTM. J. Strejcek, H. Prochazkova Methods. A 1320 nm Nd:YAG pulsed laser with selectable Center for Dermatologic Angiology, Ricany /Prague CZ - 251 01, Czech pulse duration (PD) was utilized. Laser emission in water and Republic blood was performed with PD of 100-500 µsec with power varying from 12 to 18W. Observation of water and blood at the Aim. Microsclerotherapy is the common name for injec- !ber tip was imaged by ultrasound and coagulum formation tion treatment of microvarices. It is a technique used for many was compared. Ex-vivo vein ablation was performed to verify years for the treatment of cosmetically disturbing small varic- the safety of a maximum peak power (PP) of 5000W. es. Typical for this approach is the use of very thin needles, Results. Higher PP in water shows greater amounts of low concentrations of sclerosing agents, and short-term com- laser induced bubbles (LIBs) and streaming from the tip pression after treatment. One complication of this treatment was more vigorous. PP higher than 1500W demonstrated is postsclerotherapy pigmentation of treated veins. In addition photoacoustic signal surrounding LIB. In blood, LIBs were to many standard recommended procedures, the authors de- reduced and slower streaming was observed. Lower PP veloped a special system for targeted compression of treated showed #ow stagnation. PP less than 1000W, 500 µsec PD veins, which signi!cantly reduces the incidence of pigmenta- shows coagulum formation, however PP more than 3000W tion. with 100 µsec PD shows no coagulum. Minimal coagulum Methods. We compared the incidence of postsclerotherapy was observed with 300 µsec, but clinically acceptable. PP pigmentation recorded from 2009 - 2010 with patients treated of 5000W with 100 µsec PD shows no vein perforation and in 2012 for which we have used this system (MCS). All pa- carbonization. tients underwent standard clinical examination, muscle pump Conclusions. CTM takes advantage of the shock wave-in- test (digital photoplethysmography, D-PPG) and duplex ultra- duced !ber tip #ash phenomenon, which is produced by high sound examination. The study enrolled patients with microv- PP. PP higher than 1500W yields effective #ash streaming on arices (leg teleangiectasias) and reticular varicose veins only. the !ber tip, and produces a clean tip without carbonized co- The largest diameter of the treated vein was 5mm. Podocanol agulum. In addition, since shock wave affects the non-thermal in concentrations from 0.25 to 0.5% was the sclerotherapy damage on the vein wall, CTM would establish a new standard solution. To precisely localize the injection site the lighting of EVLA without undesired thermal effects. system Veinlite LEDX was used. The MCS was applied at the injection site and subsequently class II graduated compression stockings were applied. MCS was removed 10 days after the treatment. If present, the small coagula were drained and patients wore stockings for a further 10 days. Finally we evalu- First Clinical Experience of Endovenous Pulsed La- ated the incidence of pigmentation after 6 weeks. ser Ablation with High Peak Power Results. Newly developed MCS, as well as cushioning ma- N. Sakakibara1, R. Kansaku 1, M. Sueishi 2, H. Yamaoka 1, A. Amano 3, H. terial used were very well tolerated. Only in rare cases was Inaba3, Y. Yokoyama3 slight redness and mild itching observed. When comparing the 1Department of Cardiovascular Surgery, Edogawa Hospital, Edogawa- group of patients without MCS (n = 34) with the group where Ku, Tokyo, Japan MCS was used (n=37), we observed a signi!cant reduction in 2Shinagawa Heart Medical Clinic, Minato-Ku, Tokyo, Japan 3Department of Cardiovascular Surgery, Juntendo University School of the incidence postsclerotherapy pigmentations. The group Medicine, Bunkyou-Ku, Tokyo, Japan treated without MCS had anincidence of pigmentation of 17%. In patients with MCS, the incidence of pigmentation was 3%. Aim. A 1320 nm Nd:YAG pulsed laser system which can Conclusions. Postsclerotherapy pigmentation is a very “un- generate more than thousand watts of peak power (PP) was popular” adverse sequalae of microsclerotherapy. To obtain developed. The objective is to evaluate the clinical ef!cacy and the reduced incidence the microcompression system can be undesired side effect (USE) after high PP EVLA. sucsesfully used. Methods. 92 patients were treated by 1320nm pulsed laser with high PP of 1000 W (n=47) and 1250 W (n=45). Patient demographics were mean age 63 years, 58 female and CEAP of 3.0. GSV occlusion rate and USEs are compared with the of!cial clinical data of 980nm approved by Pharmaceuticals Anatomy of the Pelvic Veins and Medical Devices Agency of Japan. J. Uhl1, M. Chahim2, V. Delmas3, C. Gillot4 Results. The average energies were 59.9 J/cm and 75.2 J/ 1URDIA research unit, Paris, France, cm. GSV occlusion rates in high PP group at one month were 2Paris, France, 100 %, but were not signi!cant with 980nm. Postoperative 3URDIA research unit, Paris, France pain score (range: 0-10) were 0.54 and 1.59 (p<0.01). Pain 4University Paris Descartes, Paris, France score more than 3 are less frequent in high PP group than in 980nm (p<0.01). Bruising score 0 (0-3) at treated segments Aim. Provide an educational DVD describing the pelvic ve- after one week were more often by 44 (93.6%) with 1000W nous network, for a better understanding of the pelvic conges- and 39 (86.4%) with 1250W than the 43.5% using 980nm tion syndrome, and derivative routes appearing in case of an (p<0.01). ilio-caval obstruction.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 133 Methods. 300 investigations by occlusive and selective Endovascular Aortic Stenting in a Patient with phlebography and anatomical techniques (injection and cor- Chronic Traumatic Aortocaval Fistula rosion) are the basis of this study. This includes CT venogra- K. Rerkasem1, T. Srisuwan1, R. Kanjanavanit1 phy with 3D reconstruction. Chiang Mai University, Chiang Mai, Thailand Results. The description is in 4 chapters: 1- The pelvic veins with 3 origins: a. The internal iliac vein - visceral and Aim. We aimed to present and review the treatment of a parietal branches and their variations b. The ovaric veins rare case of delay presenting of traumatic aortocaval !stula (left ending in the left renal vein, right in the vena cava) c. (ACF) by using endovascular approach and its effect on hemo- The superior rectal veins (belonging to the portal and not dynamic problem. to the caval system) 2- The derivative routes in case of ilio- Methods. A 59-year-old male came to hospital with pro- caval obstruction: Internal vertebral venous plexuses and gressive dyspnea and peripheral edema starting 7 years ago Azygos system. By the ascending lumbar vein, the ilio-lum- with recent history of frequent hospital readmisssion with bar vein joins the lumbar veins, the Azygos system and the chest discomfort and congestive heart failure (CHF) Physical internal vertebral venous plexuses. 3- The pelvic leak points examination revealed severe tricuspid regurgitation and atrial feeding varicose veins of the lower limbs (C Franceschi) : !brillation. Ill-de!ned pulsatile mass at right paraumbilical 6 points could feed on both sides: the points P(udendal) area with continuous abdominal bruit was also detected. His ,O(bturator), I(nguinal), two G(luteal) and C(litoridian). 4- oxygen saturation was 90% at room air. Chest x-ray showed The results of radiolological assessment of the pelvic veins increased pulmonary blood #ow compatible with left to right is shown as well as the classi!cation of the pelvis venous shunting. Pulmonary hypertension and patent foramen ovale insuf!ciency (M. Greiner). Clinical case reports of pelvix re- (PFO) with right to left shunting was noted with echocardio- #ux are reported (L. Monedero) gram. Also thrombocytopenia and renal insuf!ciency was de- Conclusions. Pelvic vein anatomy is useful to better under- tected. Forty-one years ago,he had a stab wound at right lower stand the multiples network connections of the pelvic venous quadrant. He was taken to the operating room, where an ex- system vertically and transversally, and helps for the diagnosis ploratory laparotomy was performed to repair only bowel lac- of pelvic congestion syndrome. eration. Results. The computed tomography scanning was performed and showed aortocaval !stula in the infrarenal part. The diameter of IVC and renal vein was 10 and 2 cms respectively. The endovascular abdominal tube stent graft (Endurant) was advanced under #uoroscopy and deployed to cover the !stula. Postoperatively, the patient was returned A Novel Hybrid Adaptive Compression Device in- to the critical care unit, where his hospital course was com- cluding Pneumatic Compression: A Phase 2 Study plicated by severe bradycardia and torsades de pointes and H. Partsch1, W. Vanscheidt2, A. Comerota3 excessive diuresis. Temporary pacemaker was placed. Oth- erwise he recovered uneventfully. The cardiac, renal and 1Emeritus Professor Medical University Vienna, Wien, Austria 2Practice for Dermotology, Freiburg, Germany thrombocytopenic problem was improved in the !rst week 3Jobst Vascular Institute, Toledo, OH, USA after intrevention. With decrease in venous pressure, PFO was spontaneously closed with normalized systemic oxygen Aim. To present a new self-applicable and adjustable de- saturation. vice for leg compression providing standardized, graduated Conclusions. The endovascular mean provides an at- pressure chambers (“sustained pneumatic compression, SPC- tractive alternative to open surgical methods for repair of mode”) in addition to an intermittent pneumatic pressure chronic ACF. However in chronic case, complications such pump (“IPC mode”). as severe bradycardia (Nicoladoni-Branham sign) and exces- Methods. Two preclinical dose-response relationship stud- sive diuresis must be anticipated and readily addressed after ies considering the combination of tolerability, comfort, and ACF closure. ef!cacy were performed in 12 (SPC-study) and 15 (IPC-study) patients with chronic venous edema respectively and leg volume was measured before and after application using different pressure combinations in the chambers. Additionally clinical pilot studies using the 4-chamber device providing treatment Anatomical Dispositives of the Lower Limbs Against from the foot to upper-calf in SPC- mode for 12 hours/day the Venous Re"ux and in IPC- mode for 2 hours were performed in patients with 1 2 3 4 chronic venous leg ulcers. J. Uhl , M. Chahim , J. Benigni , C. Gillot Results. Based on the combination of tolerability, comfort, 1URDIA research unit, Paris, France 2Paris, France and ef!cacy, 30-40 mmHg graduated SPC, 30 mmHg nongrad- 3Saint Mandé, France uated SPC, and 50 mmHg graduated IPC showed to be the 4University Paris Descartes, Paris, France most ef!cient methods to reduce edema. The pilot studies revealed no statistically signi!cant differences between a 4-layer Aim. The venous valves of the venous network of the lower compression system and the novel device except quality of life, limbs are the main mechanism against the re#ux due to hy- which was signi!cantly improved with the hybrid compres- drostatic pressure in standing position. Objective: To describe sion system. the other anatomical dispositives of the lower limbs against Conclusions. The novel hybrid system ful!lls some re- venous re#ux. quirements for an ideal compression device: 1) Pressure in Methods. 200 non-embalmed cadaveric subjects were stud- the chambers, corresponding to the dosage of compression, is ied using the technique of injection of the venous system with preset and will be kept constant during treatment. 2) The in- Neoprene latex. The day after injection, an anatomical dissec- elastic system can be changed and self- applied by the patient. tion was done and a full colored segmentation was performed 3) Additional massaging by using the IPC mode is especially after venous identi!cation. effective during sitting phases. 4) Ease of use and comfort was Results. There are 4 dispositives against re#ux: 2-The main rated very high by the patients. dispositive are the VENOUS VALVES. Located in the super!-

134 INTERNATIONAL ANGIOLOGY October 2013 cial system, along the perforator veins and mainly in the DEEP The static stiffness index is egal to WP minus RP. A value of SYSTEM. A precise description of the femoro-popliteal valves more than 10 de!ne a stiff device. 3) The perfect location of is given with their common locations. 2-The HUNTER’s ca- compression is the calf, due to the action on the calf pump nal is a regulator of the femoro-popliteal #ux. During walk- muscles. (foot pressure and thigh pressure have no clinical ing, the action of Adductor longus muscle (opening the canal) impact). 4) The ideal compression is a low resting pressure and Adductor magnus (closing the canal) are antagonists and and a high working pressure: for that, inelastic material like regulate the column of blood together with the femoral valves short stretch or multilayer bandages are more ef!cient, pro- 3-The plexus shaped dispositive of the posterior tibial veins viding a better effect on the ejection fraction and on the calf avoids the re#ux at the lower leg level. 4-The arcade of the pump. A good solution could also be the superimposition of Hallux #exor longus is located at the lower third of the leg elastic stockings. along the !bula bone: below this arcade, the !bular veins have Conclusions. The compression therapy is made to walk a small caliber, limited by the size of the !brous and bony ca- with, in order to activate the calf pump with a high pressure nal along the !bula. acting on the deep and muscular veins. Conclusions. These anatomical dispositives are complementary to the main role of the venous valves. This enables the full ef!cacy of the muscular pumps to activate the venous return. Changes of the Re#lling Time in Healthy Subjects and Chronic Venous Insuf#ciency F. Passariello Case Series of Persistent Sciatic Vein without Klip- Centro Diagnostico Aquarius, 80127 Napoli, Italy pel-Trenaunay-Weber Syndrome: Femoral Vein Dose Matter Aim. Veins re!ll in a forward direction through the normal K. Rerkasem, T. Srisuwan, S. Arworn capillary system and in a backward direction through re#uxing veins. The Re!lling Time (RT) is measured in seconds by means Chiang Mai University, Chiang Mai, Thailand of several types of plethysmography (PPG,LRR,SGP,APG). Aim of the present paper is to show how to measure RT using Aim. To present a short series of persistent sciatic vein BMode Ultrasound. without Klippel-Trenaunay-Weber syndrome (KTWS), a rare venous variation and to review anatomical consideration of Methods. 30 limbs in 17 people, healthy volunteers(HV) deep venous system. and C1-C4 chronic venous insuf!ciency (CVI), were examined Methods. From January 2012-April 2013, computed tomo- in standing position in a 1-year study designed to assess the graphic venography of lower extremity of non-KTWS-cases ef!ciency of the calf muscle pump. As part of this complex were retrospectively reviewed. protocol, a separate study was reserved to RT measures, taken also applying a tourniquet at the lower thigh(RT L), at the Results. Three cases of lower type persistent sciatic vein L were found. A combination of May-Thurner syndrome with ankle(RTL) and at both sites(RT L). A Parana maneuver was persistent sciatic vein was noted. Non-hypoplastic femoral performed and the BMode Ultrasound of the Medial Gastroc- veins, normal and duplicated, were found in two cases. nemius veins(MGs) (generally double, choose the greater one) Conclusions. In this rare entity, associated non-hypoplastic was acquired in the diastolic phase. Images were re-winded femoral vein is not uncommon and this condition should be in cine-loop, previously !xed to last more than 10 seconds. A concerned during ultrasonographic examination for unusual complete squeeze of MGs during Parana was considered the causes of chronic venous insuf!ciency, and also other coexist- prerequisite check to get a reliable measure. ing venous anomaly should not be overlooked. To our knowl- Results. The analysis of data is in progress, so that only edge, no studies present persistent sciatic vein without KTWS preliminary qualitative results can be given. RT shortens as the before. CVI class increases in line with classical results in literature. RT values are much smaller than values reported with APG. As L L to the effect of tourniquets, RT L<= RT <= RT while RT L has a not !xed relationship with the other measures. Conclusions. RT L – RT gives a rough estimate of the im- What are the Main Ingredients of Medical Compres- portance of re#ux and is related to the clinical C class. The sion Therapy? interpretation of the RT Lbehaviour at the moment isn’t clear J. Uhl1, J. Benigni2, A. Cornu-Thenard3 and additional studies are needed. A comparative analysis is in 1URDIA research unit, Paris, France progress with data from segmental Bioimpedenziometry. 2Saint Mandé, France 3F-Saint-Antoine Hospital, Paris, France

Aim. The medical compression is the cheapest and the most ef!cient treatment of the CVD. objective: Highlight the main Immediate and Short-Term Duplex Ultrasound Out- rules of compression on the basis of the international recom- come of Endovenous Laser Treatment of Troncular mandations Varicose Veins-A Single Center Experience Methods. Papers published under the auspices of the ICC A. Puskas1, I. Fazakas2, O. Melles2, R. Eva3 (international Compression Club) founded by Partsch in 2006. 1 Results. 1) The PRESSURE is the !rst ingredient of com- IInd Medical Clinic, Dep. of Angiology, Univ of Targu Mures/Maros- vasarhely, Angio-Center priv. unit, Targu Mures, Romania pression, acting like the posology of a drug. The severe stages 2Angio Center Private Unit, Targu Mures, Romania of CVD require a higher interface pressure to be measured 3University of Medicine and Pharmacy Targu Mures/Marosvasarhely, at the apex of the calf (B1 point) The pressure of stockings Targu Mures, Romania should be evaluated in mm of Hg. 2) The STIFFNESS (or ineslasticity) is the second ingredient of compression. Can Aim. 1. To assess the “immediate” and “short term” duplex be assessed by measuring the pressure at rest (RP) and work- ultrasound outcome (occlusion rate, ultrasonic appearance ing pressure (WP) during muscular contraction (standing). and diameter decrease of treated segments) of troncular vari-

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 135 cose veins after endovenous laser ablation. 2. To follow-up the RCT. Mechanochemical ablation was performed by ClariVein complications. and the sclerosant dosage was randomized in 3 treatment Methods. In this duplex ultrasound (DUS) follow-up study arms: intermittent 1% POL foam and, 2% liquid POL, 3% liq- in order to monitor GSV and SSV changes after endovenous uid POL. Primary endpoint was the anatomical success which laser ablation, preoperative mapping and postoperative “im- is de!ned by >85% closure of the GSV. mediate” (1-4 weeks) and “short term” (1-12 months) exami- Results. 19 patients were treated with 1% POL foam and nations were performed. Between February 2011 and Janu- completed 6 weeks follow-up. Duplex scans revealed 16% ary 2013, 94 limbs of 90 patients (67 women, 23 men, age anatomical success in the treated GSVs. No major complica- 17-84, average 47, 7) with GSV (N=84) or SSV (N=10) vari- tions have been detected. All complications were minor and cosity were selected for laser ablation on an outpatient basis improved quickly. under tumescent local anesthesia. Saphenofemoral junction Conclusions. Mechanochemical ablation of the GSV using incompetence was treated by surgical interruption (85, 1%) ClariVein and 1% POL foam after 6 weeks is safe but not effec- and foam sclerotherapy was applied for the tributaries (81, tive for closure of the GSV. The research to determine the ideal 9%). A 1470 nm radial laser was used (pull-back velocity: 3 Polidocanol dosage with ClariVein will be continued with 2% mm/sec; power: 10-15 W; average energy: 48 J/cm; average and 3% liquid. length of treated saphenous segment: 37 cm). By postoperative DUS the occlusion rate, the main ultrasonic appearance (hypo-echoic, hyper-echoic, iso-echoic or invisible/unidenti!- able) and the progressive venous diameter reduction in the two different control period were studied. The complications Fate of Great Saphenous Vein and Saphenofemoral were also recorded. Junction Tributaries after Laser Ablation Results. The “immediate” DUS assessment identi!ed a 90, S. Kaspar1, I. Steiner2 6% complete occlusion rate with no difference at the level of 1Flebocentrum, Hradec Kralove, Czech Republic different segments. The later, “short-term” DUS examination 2FN, Hradec Kralove, Czech Republic identi!ed however a slightly different occlusion-disappearance rate between saphenous segments: 97,5% at the upper third, Aim. Unlike traditional surgery, endovenous laser ablation 92,5% at the mid third and 82.5% at the lower third. In this abolishies great saphenous vein (GSV) re#ux without speci!c “short term” follow-up period the complete disappearance of interruption of GSV tributaries at the groin. The fate of these the vein (unidenti!able on DUS) was also frequently observed tributaries and GSV itself was assessed in this study. (27, 5 % at the upper third, 25 % at the mid and 17, 5 % at the Methods. 1028 limbs after endovenous laser ablation of lower third). In the !rst 1-4 postoperative weeks a hypo-echoic GSV were assessed with colour #ow duplex ultrasonography aspect was more typical (63, 8%). In contrast, after months of and saphenofemoral junction re#ux and tributary patency intervention (1-12 months) the iso-echoic appearance predom- were recorded (follow-up 4 to 7 years). Ultrastructural analysis inated (77, 4%). The progressive diameter decrease at different with transmission electron microscopy and histopathological levels was signi!cant (p<0.05) between the preoperative and examinations of ablated saphenous veins just after and 6 years the post procedural examination periods, (32, 5% and respec- after original procedure were performed. tively 46, 3% reduction at “immediate” and at “short term”). Results. In 4.9 % recurrence with re#ux in GSV was detect- The complication rate was low (6,3%) and consisted of local ed. In 17.8 % of cases we found #ush GSV occlusion with the hematoma formation in one case, one seroma formation, two saphenofemoral junction and no tributaries were detectable. super!cial thrombophlebitis of the tributaries and two cases In 71.2%, one or more tributaries were visible without GSV re- with transitory paresthesia at the level of external malleola #ux. Only in 6.1% we found proximal stump ( with or without (both after SSV ablation). visible tributaries) extending less than 5cm of GSV length. Ul- Conclusions. The ultrasonic evolution of laser-ablated trastructural analysis with transmission electron microscopy saphenous segments con!rms the ef!cacy and safety of en- showed denaturation of collagen !brillar structure dependent dovenous laser therapy. We successfully documented the high on power used and the histopathological examination of GSV occlusion rate of the treated segments with a progressive oc- 6 years after laser ablation found multiple small vessels and clusive characteristic of upper segments and a low tendency to carbon deposits in !brotised vein. partially reopening of the lower thirds. The ultrasonic appear- Conclusions. Persistent non-re#uxing GSV tributaries at ance was also progressive from hypo/hyper to iso-echoic as- the saphenofemoral junction did not appear to have a nega- pect and in considerable number of cases the complete disap- tive impact on clinical outcome of endovenous laser ablation. pearance of the vein was found in the follow-up period. Duplex Fate of multiple small vessel channels found in ablated veins follow-up is a useful method to monitor the vein involution should be further determined. and to identify those cases which need retreatment in the short term postoperative period.

Why is High Ligation not Mandatory in the Great Saphenous Vein Surgery? J. Uhl Mechanochemical Ablation of the GSV Using Clar- URDIA research unit, Paris, France ivein and Polidocanol Foam: Preliminary Results of the Dose-Finding Study Aim. The investigation by hemodynamical venous map- Y. Lam 1, C. Wittens2 ping brought us a revolution in the !led of varicose veins 1Maastricht UMC+, Maastricht, Netherlands surgery, and opened the way of the new endovenous and con- 2Eben Emael, Belgium servative techniques. objective: to analyse the advantages and reasons of preservation of the saphenous femoral junction Aim. To determine the ideal Polidocanol dosage with Clar- (SFJ). iVein catheter for successful closure of the GSV. Methods. Based on our experience of 1200 surgical abla- Methods. Between September 2012 – February 2013, 87 tions of the great saphenous vein (GSV) without high ligation, patients (87 limbs) with primary incompetence of the GSV our papers and the analysis of the literature (C2-4,Ep,As,Pr) were included in a double blind multicentre Results. Firstly, several epidemiological studies1 show the

136 INTERNATIONAL ANGIOLOGY October 2013 ascending evolution of CVD from the branches to the trunk, tion of the channels of their !lling up; both the venous #ux and lastly reaching the SFJ. Secondly, in about 2/3 of the patients, re#ux where eliminated and varices become just empty non- the inguinal re#ux pattern does not justify a high ligation functional tubes. The patient is immediately mobilized after (Capelli2). This is con!rmed by the late results of endovenous the operation and live the clinic after 30 minutes. treatment by RF3 showing a competent thumb of the GSV in Results. The study included 5 cases (one woman and four 90% of the cases. The invagination of the GSV without high men). 4 cases where work related accidents and one was do- ligation has been shown to be simple with a similar outcome mestic related. Surface of the burned areas was between 34% and the same advantage of a low rate of neovascularization of and 76% of the skin. After the intervention the varicose veins the groin3,4 Lastly, the RCT of Casoni5 with 7 years FU (un- closed in 100% of the cases. 92% of the incisions resulted in per published), shows similar results with a lower rate of recur- primam cicatrisation. One case was in C6 CEAP classi!cation rence even for patients presenting a terminal re#ux. stage and the leg ulcer healed in 14 days after the operation. Conclusions. In the majority of cases, including number of Conclusions. Treatment dif!culties of varices following terminal re#ux, the preservation of the SFJ is possible during skin burns are: - the abnormal anatomical disposure (mostly the surgical treatment for GSV truncal incompetence. 1 Lab- non-saphenian) - the extremely tortuous aspect - the !rm ad- ropoulos JVS J Vasc Surg 2005;41:291-5. 2 Capelli Int Angiol. herence of the veins to the surrounding tissues - the hyper- 2004;23:25-8 3 Merchant et al. JVS 2005;27:42-502-9 4 Pittalu- trophic or retractile scars; skin grafts. The employment of ga et al. JVS 2008, 47, 6 :1300-1304 5 Lefebvre-Vilardebo, Uhl VANST in cases with skin burns related varicose veins proved et al. Abstracts college Français de Pathologie Vasculaire 2010 a high degree of ef!ciency. Correctly treated skin burns related 6 Casoni Abstracts EVF 2009 varices show a minimal recurrence rate.

The Relationship between Dressing Changes and Echo-Sclerotherapy (ES) of the Great Saphenous Blister Formation Vein (GSV) : A Cohort Study of 5211 Patients with a 1 2 W. Chung , H. Kang Mean Follow-Up of 5 Years 1 Yonsesarang Hospital, Seoul, Korea 1 2 2Yonsei University College of Medicine, Seoul, Korea M. Schadeck , J. Uhl 1EEP, PARIS, France Aim. Some patients develop blisters near the treatment site 2URDIA Research unit, Neuilly sur Seine, France for varicose veins. We attempted to determine whether performing dressing changes on the day of surgical treatment for Aim. Sclerotherapy under echo control is a revolution in varicose veins decreased the formation of blisters. the treatment of the saphenous trunks, particularly with the Methods. We assessed 299 patients receiving EVLA and use of foam. Objective: To assess the technique and long term ambulatory phlebectomy at a single clinic within a one year follow-up of ES of the GSV trunk. period. One group was discharged immediately post-treatment Methods. 5211 patients with a mean age of 50 (80% females after receiving a single dressing while the other was asked to and 20% males) were treated by echosclerotherapy from 1990 wait several hours for a dressing change before being allowed to 2010. The separation of patients into CEAP classes were C1 =6.3% C2 =90%, C3 and more= 3.7% The mean patient age to leave. We compared the frequency of blister formation for the !rst ES was 50. The mean duration of treatment was between these two groups. The assessment was performed 40 months (± 1.5) The mean number of ES episodes per limb through the SPSS 18.0 statistical analysis program. was 4.2 (1 to 18). The mean overall follow-up was 58 months Results. Of the 231 individuals receiving only a single dress- (6 to 261) ing, 20 cases (8.7%) of blister formation was observed. Individ- Results. The GSV trunk was treated using liquid only in uals receiving a second dressing before discharge (n=68) had 47% and foam in 53%. The sclerosing agent used was STS only 2 cases (2.9%) of blister formation. Bivariate analysis by in 39% and Polidocanol in 61%, the most frequently injected chi-square test showed a p-value of 0.183. volume was 2cc (60%) and the concentration always 3%. The Conclusions. The number of blisters developed on indi- mean caliber of the trunk treated was 6 mm (3 to 16) An in- viduals receiving a second dressing was lower than the rate #ammatory reaction after injection was observed in 679 cases of blister formation on individuals discharged immediately (13%): super!cial in 7% excessive in 6%, super!cial phlebitis (2.9% vs 8.7%). Unfortunately, there was no signi!cance in 0.07% Other complications were very infrequently seen : 5 found between these two groups by chi-square analysis(p- migraines, 12 reversible pigmentations, 1 sepsis and 11 DVT (2 value=0.183). We believe the limited number of cases was a posterior tibial, 1 popliteal and 8 gastrocnemial). This repre- constraining factor. sents 0.21% of the legs and 0.049% of the episodes. Conclusions. Our results show that with an average of 4 episodes of ES over 40 months (1.3 treatments per year) we have achieved a safe and effective ablation of the GSV trunk, which represents a cost-effective treatment option. Ambulatory Surgical Treatment of the Varicose Veins Following 3rd or 4th Degree Burns V. Ciubotaru Clinica Medicala FLEBESTET, Bucharest, Romania Investigating Peripheral Haemodynamics during Aim. The purpose of this paper is to present our experience Neuromuscular Stimulation in treatment of patients with varicose veins which evolved af- L. Varatharajan, H. Moore, K. Williams, A. Davies ter 3rd or 4th degree burns located at different levels of the Academic Section of Vascular Surgery, Imperial College London, London, inferior limbs. United Kingdom Methods. In all the cases we used an ambulatory minimal traumatic surgical method called VANST (Varices’ Ambulatory Aim. Determine the effect of Neuromuscular stimula- Non-stripping Surgical Therapy). VANST is a procedure of tak- tion (NMS) of calf muscles on peripheral haemodynamics in ing the varicose veins out of the circuit through the intercep- healthy individuals.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 137 Methods. In this pilot study carried out in 2013, electrical Anterior Accessory Great Saphenous Vein Treated stimulation of calf muscles was applied to 10 volunteers us- with Endovenous Laser ® ing a device (Revitive ) with two large footpads through which S. Kaspar stimulation is delivered to the sole of the feet. The blood #ow and TAMV of the super!cial femoral vein was measured us- Flebocentrum, Hradec Kralove, Czech Republic ing ultrasound before (baseline), 15 minutes during and after Aim. Endovenous laser ablation of great saphenous vein electrical stimulation had stopped at 30 minutes. Data was (GSV) represents well established technique of radical thera- analysed using a Student’s paired t-test. py of varicose veins of lower extremities with excellent long- Results. 10 patients (6 males, 4 females) were included in term results. However, the laser ablation of anterior acces- the study (mean age 34 years; range 21-63). All participants sory GSV (AAGSV) remains infrequent in everyday surgical had ABPI values >0.9 and no signs of venous disease. At 15 practice. This study assesses the ef!cacy of this unusual pro- minutes of stimulation, there was a signi!cant increase in cedure. mean blood #ow and mean TAMV compared to baseline by Methods. From April 2003 to December 2012 we performed 88.1cc/min (41.2% increase; p=0.02) and 1.17 cm/s (34.1% in- endovenous laser ablation of 125 AAGSV. Before surgery, all crease p=0.04), respectively. There was no signi!cant differ- patients were assessed with colour #ow duplex ultrasonogra- ence in #ow (p=0.25) or TAMV (p=0.26) at 30 minutes in com- phy and re#ux pattern and diameter of the truncal vein (3.5 parison to baseline. The mean decrease in #ow at 30 minutes to 22.8 mm) were recorded. The endovenous procedures were in comparison to 15 minutes was 160.6 cc/min (52.6% reduc- performed using 980 nm diode or 1320 nm Nd:YAG lasers tion; p=0.025). There was no signi!cant difference in TAMV at combined with 600 microns bare !ber. In the follow-up (1 30 minutes compared to 15 minutes (p=0.914). month to 10 years post op) patients were asssessed clinically Conclusions. Blood #ow and TAMV increased during NMS and with duplex ultrasound. but returned to baseline once stimulation had stopped. By improving blood #ow, NMS has the ability to enhance venous Results. No deep venous thrombosis, nor pulmonary em- return and counteract venous stasis. These results prompt fur- bolism were recorded. In majority of patients we found bruis- ther studies to investigate the role of NMS in patients with ing and/or indurations along the treated veins which resolved chronic venous insuf!ciency. within 2 to3 weeks. Once, the neovascularisation was found in the groin and the total occlusion rate was 92%. Conclusions. Even technically more dif!cult and delicate, endovenous laser therapy of AAGSV can be performed safely and !naly with excellent results comparable to well established ablation of GSV.

A Review of Genetics Component to Primary Venous Disease and the Direction for Future Research M. Anwar, K. Adesina-Georgiadis, A. Davies Academic Section of Vascular Surgery, Imperial College London, London, Eighteen Month Single Center Experience on Cy- United Kingdom anoacrylate Embolization of N = 200 Incompetent Great and Small Saphenous, Tributary and Perfora- Aim. Empirical evidence suggests that there is a sig- tor Veins ni!cant familial association of varicose veins (VV) disease. T. Proebstle 1 , M. Schimpf 2 , C. Meergans 3 , T. Moehler 4 Alongside familial risk, a number of environmental risk factors are also involved in disease development which may 1Dept. of Dermatology, University of Mainz, Germany, Mannheim, Ger- many in#uence the methodologies employed to identify the actual 2Private Cllinic Proebstle, Mannheim, Germany genetic component to the disease. We present the current un- 3Dept. of Dermatolgy, University of Mainz, Germany, Mainz, Germany derstanding of the genetic contribution to VV disease, while 4Dept. of Dermatolgoy, Mainz, Germany also summarising current approaches, their problems and Aim. A novel endovenous embolization technology based possible solutions. on N-Butyl-Cyanoacrylate (CA) has been approved in Europe Methods. PubMed and Medline search was performed us- in September 2011. Clinical experience in treatment of routine ing the terms: “genetics” or “inheritance”or “heritability” or cases has been very limited until now. Particularly the treat- “heredity” and “varicose veins” or “chronic venous disease” or ment of small saphenous veins (SSVs), larger tributaries like “chronic venous insuf!ciency”. The Preferred Reporting Items accessory saphenous veins and perforator veins has not been for Systematic Reviews and Meta-Analyses methodology was reported. applied to systematically identify relevant articles. Methods. Routine patients with clinically relevant venous Results. Association of several genes have been noticed with re#ux willing to cover the costs of this new technology were VV disease, however, it is unclear whether this is the cause or treated with CA embolization. Tumescent local anesthesia and the effect of the varicosities. Mutations in some genes includ- post-interventional medical compression stockings were not ing desmuslin thrombomodulin and FOXC2 can directly affect used. Additionally visible varicose veins either were left un- vein function. Genetic single nucleotide polymorphism array treated or were subject to adjunct foam sclerotherapy with 1% analyses have shown some indirect role of genetics in VV for- polidocanol. mation. Similarly, there are some hereditary single gene disor- Results. Two hundred incompetent veins were treated in ders and genetic syndromes, which may include VV as part of 107 patients. In detail, n=144 GSVs, n=30 SSVs, n=18 accesso- the (often complex) clinical presentation. However, there are ry saphenous veins and n=8 other veins, consisting of smaller inherent limitations with the strategies which are routinely be- tributaries and perforators received CA embolization. Patients ing used to characterise genetic factors. median age was 55 years [range 24–87], median treatment Conclusions. It is apparent that there is a limited under- length was 37cm [1-70], corresponding to a median deliv- standing of the complex underlying genetic factors contrib- ered CA volume of 1.26 ml [0.09-2.25]. Median follow-up was uting to VV formation. The simultaneous use of alternative 6 months [0-18]. Immediate successful closure of all treated emerging technologies including genome wise association veins was demonstrated by duplex control ultrasound at 24h, analyses and metabonomics analyses may provide a compre- no glue or thrombus extensions into the deep vein system were hensive picture of disease genotype and elucidate its associa- noted. In general, side effects were moderate, no paresthesia tion with the phenotype. and no severe adverse events were observed.

138 INTERNATIONAL ANGIOLOGY October 2013 Conclusions. Endovenous CA embolization for incompe- treatment of incompetent greater saphenous vein in 80% of the tent saphenous, tributary and perforator veins proved to be cases at 6 months when the diameter is less as 7.5 mm. The oc- safe and effective for routine patient treatment. clusion is observed in 76% and 74% at 1 and 2 years follow up. There is no difference and possibility of recanalisation when an aspect of withe scar is observed in the saphenous compartment. The Extrinsic Compression Syndromes of the Deep Abdominal Veins J. Uhl1, J. Benigni2, C. Gillot3 Mechano-Chemical Endovenous Ablation of Great 1URDIA research unit, Paris, France Saphenous Vein Insuf#ciency Using the Clarivein™ 2Saint Mandé, France Catheter: Registry Study 3University Paris Descartes, Paris, France D. Boersma1, R. van Eekeren2, D. Werson1, J. de Vries1, M. Reijnen2 1St Antonius Hospital, Nieuwegein, Netherlands Aim. To describe the main causes of the extrinsic compres- 2 sion of deep pelvic and abdominal veins Rijnstate Hospital, Arnhem, Netherlands Methods. 300 investigations by occlusive and selective Aim. The objectives of this study: 1. Measure clinical and phlebography and anatomical techniques (injection and cor- anatomical success after 12 months 2. Describe complications rosion) are the basis of this study. This includes CT venogra- 3. Evaluate quality of life (QoL) phy with 3D reconstruction. Methods. A total of 105 consecutive patients treated for The anatomical description includes 2 types of Results. GSV insuf!ciency (C2-C5) with MOCA™ using the ClariVein™ extrinsic compression: 1- The main venous compression syn- device (Vascular Insights, USA) were included in a prospective dromes: for these 2 syndromes, it should be underlined that study between September 2011 and January 2012. Follow up the compression is mostly related to the position of the spine at 6 and 12 months included assessment of QoL by Aberdeen (hyperlordosis) a. The Nut cracker syndrome: compression Varicose Vein Questionnaire (AVVQ), clinical evaluation by Ve- of the renal vein between the aorta and the superior me- nous Clinical Severity Score (VCSS) and duplex ultrasound to senteric artery. b. The Cockett or May-Thurner syndrome: objectify anatomical success. is commonly the classic type of the compression of the left Results. Clinical success was obtain in 95%. VCSS decreased common iliac vein by the right iliac artery. But several other signi!cantly from 4 (IQR 3-5) before treatment to 1.0 (IQR 0-2) types could be found: 2- The external compression of the at 6 months and 1.0 (IQR 0-1) at 12 months (p<0.0001). AVVQ- vena cava. a. By an abdominal tumor or metastatic nodes. score decreased from 11.1 (IQR 8.1-19) to 2.2 (IQR 0.3-6.1) b. By the lumbosacral disc due to spinal osteoarthritis. c. at 12 months. At 6 month follow-up anatomical success was By a pregnant uterus: very common in lying position and 93% (95/102). After one year 88% ) of the GSVs (88/100) were responsible for the delelopment of a collateral route by the occluded. In 7% recanalisation of the proximal segment had internal vertebral venous plexuses. This explains some sci- occurred. No major complications occurred. Local hematoma atic syndromes during pregnancy by a venous compression was seen in 8% and super!cial trombophlebitis in 13%. in the vertebral foramina. Conclusions. Mechanochemical endovenous ablation of Conclusions. The frequency of these venous abnormali- GSV incompetence is feasible and a safe treatment. The ex- ties, whether permanent or positional suggests that proxi- cellent clinical success is well illustrated by the signi!cant mal deep venous obstructions are often ignored or mis- improvement in VCSS and QoL. Anatomical success at 6 and diagnosed. We believe that CVD patients should be more 12 months was respectively 93% and 88%. Recanalisation lim- precisely investigated, in particular by color duplex and CT ited to the proximal segments was seen 7% at 12 months. This venography. could be an important lead for improvement of anatomical success.

Duplex Scan Evaluation of the Ef#ciency of Greater Saphenous Vein Foam Sclerotherapy Assessment of Jugular Endovascular Malformations F. Vin in Chronic Cerebrospinal Venous Insuf#ciency: American hospital of Paris, Neuilly Sur Seine, France Comparison between Colour-Doppler Scanning and Catheter Venography Aim. Check in the greater saphenous vein by duplex scan 2 years after injection sclerotherapy to demonstrate than re- M. Resta1, A. Galeandro 2, A. Zito 3, P. Livrea 4, M. Trojano 4, M. Ciccone 3, D. Monaco1 canalisation is not possible when the vein appear like a white scar. 1ss Annunziata Hospital, Taranto, Italy 2Centro Diagnostica Globale, Taranto, Italy Methods. 264 incompetent greater saphenous vein diam- 3Deto, Bari, Italy eter less as 7.5 mm were treated by foam injection with Lau- 4Department Neurology, Bari, Italy romacrogol 400 3% 3cc under ultrasonic guidance. Duplex scan examination was performed before inclusion.Patients Aim. Chronic cerebrospinal venous insuf!ciency (CCSVI) with deep venous thrombosis story and with deep venous re- is a malformative condition characterized by several anoma- #ux were not included in the study. All the patients were evalu- lies of the azygos and/or internal jugular veins (IJVs). Recom- ated at 6 months, 1 year and 2 years follw up. mended diagnosis of CCSVI is performed with colour-Doppler Results. 264 incompetent greater saphenous vein ,210 (CD) sonography. Though catheter venography (CV) is consid- patients, range 28-82 years old, 76% female and 24% male. ered as the gold standard for determining vascular anatomy. Greater saphenous vein diameter at J0 was range 4-7 mm The lacking literature data do not allow us to have an idea of (mean 6.1). At 6 months the saphenous vein is occluded in variability between the two methods. For this reason we tried 80%, 76% at 1 year and 74% at 2 years. The diameter was 4.77 to compare the values coming from two techniques The aim mm ± 1.84 at 6 months, 0.57mm ±1.49 in 27.9% after 1 year. of this report is to evaluate, in patients with multiple sclerosis After 2 years the saphenous vein is not visible in 85% and size (MS), the accuracy of CD sonography versus CV in estimating 0.55 mm ± 1.6 in 15 %. the agreement between the twoo techniques Conclusions. Injection sclérothérapy is ef!cient for the Methods. Nine patients with clinically proven MS were

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 139 included in our study. In all patients, IJV morphology and Heterogeneity of Clinical Outcome Measures in haemodynamic characteristics were evaluated by colour Chronic Cerebrovascular Venous Insuf#ciency Doppler sonography as well as venous #ow disorder. After S. Onida1, A. Thapar2, T. Lane3, R. Nicholas2, A. Davies1 these patients were submitted to catheter venography (CV). 1Academic Section of Vascular Surgery, Imperial College London, Lon- Results. Two experienced operators (one for colour Dop- don, United Kingdom, pler sonography and the other one for catheter venography) 2Imperial College London, London, United Kingdom evaluated 9 consecutive patients independently from each oth- 3London, United Kingdom er. McNemar test allowed us to consider comparable the data coming from the well-trained operators: every characteristics Aim. The aim of this study was to review the published lit- and parameters showed no statistical differences between erature on intervention in Chronic Cerebrovascular Venous themselves (p=ns). This result is a novelty in the literature Insuf!ciency (CCSVI) and Multiple Sclerosis (MS), focussing background cause of the lacking data about the reproducibil- on reported clinical outcome measures. ity of the technique in clinical settings. Methods. We performed a Pubmed and EMBASE literature Conclusions. McNemar test con!rmed the strong repro- review using the terms Chronic Cerebrovascular Venous Insuf!- ducibility of the procedure (p=ns). Doppler sonography has an ciency and Multiple Sclerosis. Articles describing endovascular important value for the detection of IJV anomalies in patients intervention in CCSVI by means of percutaneous angioplasty with MS, with good agreement with catheter venography (CV). (PTA) or stenting were reviewed and outcome measures noted. Of these, only papers reporting clinical outcome measures as primary or secondary endpoints were included. Results. A total of 14 articles published between Decem- ber 2009 and April 2013 ful!lled the entry criteria, including two case reports. Patient numbers were variable (1 – 259) and measures of disease severity were heterogeneous. Primary Ef#cacy of Foam Ultrasound Guided Foam Sclero- outcome measures were clinical in 50%, and included the therapy of Varicose Small Saphenous Veins, Mid- Expanded Disability Status Scale (EDSS), Multiple Sclerosis and Longterm Results Impact Scale (MSIS 29), Multiple Sclerosis Functional Com- R. Murena-Schmidt posite (MSFC), relapse rate or separate functional measures. 1Medical Practice, Cologne, Germany Secondary outcome measures were clinical in in 71%, often in conjunction with radiological measures. Aim. Occlusion rate after UGFS of the SSV found by duplex Conclusions. The published literature on the effect of inter- scan at 6, 12, 24, 36, 48 and 60 months documentation of side vention in CCSVI is extremely heterogenous. There are differ- effects questionnaire about patients satisfaction ences in the recruited patient populations, diagnostic criteria Methods. 100 consecutive patients with 103 previously for CCSVI and clinical outcome measure assessment, making untreated varicose SSV (re#ux >0,5 sec extended at least to direct comparison between articles dif!cult. In light of these midcalf, mean SSV diameter was 0,61 cm ) were included. con#icting results, it is important to interpret the literature on Patients were treated with UGFS between november 2005 this controversial subject with caution. This study also high- and january 2012 and followed up until april 2013 ( mean lights the need for uniform reporting standards. follow-up was 48 months) A single injection of foam ( Tes- saris method 1+4)1-3 % polidocanol 1 to 5 ml (mean 2.61 ml ) was given under ultrasound guidance. Retreatments were allowed and documented. The !rst clinical and complete duplex control was done after 1 week, then after 6, 12, 24, Thermal Ablation of Saphenous Veins in Elderly 36, 48 and 60 months C. Hamel-Desnos1, P. Desnos2, F. Allaert3, P. Kern4 Results. Complete SSV occlusion was achieved in 90 % with the 1st and in further 9.8 % with the 2nd injection with- 1French Society of Phlebology, CAEN, France 2French Society of Phlebology, Caen, France in the !rst month. Complete occlusion was observed in 75% 3French Society of Phlebology, dijon, Bourgogne, France of the patients at 6, in 77% at 12, in 83 % at 24, and 69% at 4Private of#ce of Vascular Medicine and Service of Angiology, University 36 and 67,4 % at 60 months. 24 % of the patients needed a Hospital Lausanne, Vevey, Switzerland retreatment after 6 months, 14,3% after 12 months, 4 % after 24 months, 12% after 36 months, 11,1% after 48 months and Aim. To investigate feasibility, tolerance and safety of thermal 13 % after 60 months. Side effects were a local tenderness ablation (TA), i.e. radiofrequency (RFA) or endovenous laser was found in 12 patients (12,2%), none requiring analgetics (EVLA), of saphenous veins (SV) in elderly (group1≥75years), or further consultation. One patient experienced an episode compared with a control-group (group2<75years). of dizziness lasting 15 min and recovererd completely, one Methods. Observational multicenter prospective study thrombophilic patient had a thrombus extending into SP- conducted, under the aegis of the French and Swiss junction which disappeared within 1 week under full anti- Societies of Phlebology (18 centers SFP, SSP). Ninety pa- cogulation. tipical complaints were improved in 70 % of the tients (69% women in both groups) were included in group1 cases and 80% of the patients would repeat the procedure if and 617 in group2 (mean age 80-y and 53; mean BMI 26 needed. and 25), representing 863 SV. Mean trunk-diameters were Conclusions. In previous studies SSV treatment with UGFS similar in both groups (small-SV:6mm; great-SV:7mm). In were reported to have worse results compared to GSV9,10. group1, comorbidities were more frequent, particularly Other studies report good outcome after UGFS of SSV vari- cardiac insufficiency (p<0.01) diabetes (p<0.0001), history cose veins up to 12 months follow up. In my experience UGFS of thrombosis (p<0.001), and CEAP clinical class was sig- of insuf!cient SSV is safe and effective with high patient’s sat- nificantly higher. isfaction, good longterm results and improvement in quality Results. The most used technique was EVLA (86%; ra- of life. UGFS can be used in all age groups. UGFS has the ad- dial-!ber 67%). Settings used were similar in both groups ditional bene!t that repeated treatments are easy to perform if for each technique. Only 6% of TA were performed in an needed and that this method is very cost effective. Treatment operating-room for group1 (14% group2). The anaesthesia sessions last 20 to 30 minutes so that patients do not need sig- consisted of tumescent local anaesthesia (TLA) alone in 91% ni!cant time off work. of cases in group1 (85% group2). Procedures were particu-

140 INTERNATIONAL ANGIOLOGY October 2013 larly well tolerated in both groups: mean pain-score was 1.6 Methods. We report an otherwise healthy 39-year-old male for the procedure (VAS 0-10) and 1.4 for the 10 days follow- who initially tolerated an injection of liquid polidocanol well. ing the procedure. Side effects were few with no difference He was four days symptom-free, then suddenly developed the between both groups, but rate of paraesthesia was higher classic pain and pathognomonic skin changes associated with when general anesthesia was used (7.5%) compared with Nicolau’s syndrome. He opted for conservative treatment in- TLA alone (0.9%). At 3 months, 100% of SV were occlud- cluding compression, heat and ambulation; no steroids, blood ed in group1 (99.5% group2), with high satisfaction score thinning agents or nitrates. (9.3/10). Results. After three months he healed without sequela. Conclusions. TA must be performed strictly under TLA to Previous reports have theorized that this phenomena is more minimize side effects. It is safe and effective in elderly. common in hyper-vascularized areas, yet in this instance the injection was on the anterior shin. Conclusions. The purpose of this report is to add to the world’s knowledge base regarding this undesirable outcome.

Venous Paediatric Trauma: Systematic Review of In- juries and Management S. Rowland, B. Dharmarajah, H. Moore, A. Davies Academic Section of Vascular Surgery, Imperial College London, London, Endovenous Laser Ablation (1470 NM) of the Small United Kingdom Saphenous Vein: Outcomes and Assessment of Pa- tient Satisfaction Aim. 1. To investigate the prevalence of non-iatrogenic paediatric venous injuries 2. To identify clinical presentations and L. Narvaes1, J. Ferreira2, A. Reichelt3, M. Goldani4 complications of paediatric venous trauma 3. To discuss man- 1Hospital São Lucas PUCRS, Porto Alegre, Rio Grande do Sul, Brazil 2Pontiac Catholic University (PUCRS) - Instituto Brasileiro de Flebolo- agement options in paediatric venous trauma gia, Porto Alegre, Brazil Methods. A systematic review of published literature 3PUCRS - IBF, Porto Alegre, Brazil, 4PUCRS, Porto Alegre, Brazil (Medline) describing non-iatrogenic traumatic venous injury in the paediatric population (<17 years) was performed ac- Aim. Endovenous laser ablation (EVLA) for incompetent cording to PRISMA guidelines. The prevalence of venous in- saphenous vein is a widely accepted form of treatment. Few jury and affected vasculature was identi!ed. Mechanisms of data are available on small saphenous vein (SSV) laser abla- venous injury were summarized and prognostic factors identi- tion. This study aims to demonstrate the treatment outcomes !ed. Evidence regarding the ef!cacy of diagnostic modalities of EVLA of incompetent SSV with a 1470nm diode laser in our available was summarised and surgical options for repair re- single center experience. viewed. Methods. Between January 2009 and December 2012, Results. More than 160 paediatric traumatic venous in- 150 patients (167 limbs) with varicose veins and re#ux in the juries were identi!ed between 1989 and present day. Mecha- SSV on duplex ultrasound (US) examination were treated nisms of injury included blunt trauma from seatbelt related with a 1470nm diode laser and radial !bers under local an- injury and fall from height, or penetrating trauma from gun- aesthesia (no tumescence). EVLA was performed using con- shot and foreign object. Injuries were sustained throughout tinuous mode and LEED appropriate to SSV closure under the venous tree, complicated by severe haemorrhage, aneu- US guidance. Patients had clinical follow-up visits at 1 day, rysm, thrombosis or venous infection with signi!cant mor- 1 week, 1 month, 6 months and every 12 months after treat- bidity and mortality. Diagnostic investigations were incon- ment. sistent but included venography and CT venography and in Results. Initial technical success rate was 100% in 167 some cases, laparotomy. Interventions included primary re- limbs treated. SSV remained closed in all limbs after follow- pair, venous ligation, saphenous vein interposition grafting, up period. Major complications have not been detected and, lateral suture, end-to-end anastomosis and deep venovenous in particular, there was no deep venous thrombosis (DVT). Ec- bypass. chymosis were seen in 60% with median duration of 2 weeks. Conclusions. Traumatic venous injury in the paediatric Temporary paresthesia was observed with a median duration population is uncommon but may be associated with sig- of 4 weeks. No skin discoloration, super!cial burn, throm- ni!cant morbidity and mortality. Diagnostic and therapeutic bophlebitis or palpable induration was observed. Patient satis- intervention is rarely evidence based. Paediatric trauma reg- faction (functional and aesthetics) was high. istries should be developed worldwide to record details of pae- Conclusions. EVLA of the incompetent SSV with 1470nm diatric venous trauma in order that evidence based manage- diode laser is highly effective and appears to be a safe tech- ment plans can be developed. nique, with low rates of complications and affording symptomatic relief and aesthetics satisfaction. Studies with larger samples are indicated to con!rm these observations.

Nicolau’s Livedoid Dermatitis Delayed Onset after Ultrasound Guided Liquid Polidocanol Injection C. Asbjornsen Vein Healthcare Center, South Portland, ME, USA To Evaluate the Ef#cacy of Adjunctive Treatment with Endovenous Thermal Ablation: A Comparative Aim. Nicolau syndrome, livedoid dermatis, or embololia Study cutis medicamentosa, is a potentially devastating complication T. King 1, R. Guptan2 of sclerotherapy. It is characterized by acute pain at the site of 1Vein Clinics of America, Oakbrook Terrace, IL, USA injection followed by the occurrence of a livedoid plaque that 2Vein Clinics of America, Downers Grove, IL, USA ultimately results in skin and tissue necrosis. This report is the !rst account of delayed Nicolau’s livoid dermatis after liquid Aim. Controversy exists as to when adjunctive treatment polidocanol. However, there has been one similar case report for residual symptomatic varicosis should be used after ETA. after polidocanol foam injections. Insurers often mandate compression, only, for the !rst 6-12

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 141 weeks post ETA. We prospectively studied whether there is any Treatment of the Small Saphenous Vein Using advantage in delaying adjunctive treatment (sclerotherapy), 1470nm Diode Laser and the Radial Fiber after ETA and whether a delay has any effect on a patient’s T. King 1, R. Guptan2 health related quality of life (HRQL) 1Vein Clinics of America, Oakbrook Terrace, IL, USA Methods. 156 consecutive patients with GSV re#ux receiv- 2Vein Clinics of America, Downers Grove, IL, USA ing ETA were prospectively divided into two groups. Group 1 received delayed adjunctive treatment with ultrasound-guided Aim. To report on our experience in using 1470nm diode (foam) and visual (liquid) sclerotherapy. These patients’ insur- laser and radial !ber in treating saphenopopliteal junction in- ers required that they wait 4-6 months post ETA to receive ad- competence and small saphenous vein re#ux. junctive treatment. Group 2 received simultaneous adjunctive Methods. Eighty-!ve (85) small saphenous veins in seven- treatment with their ETA. They received the same treatment as ty-three (73) patients with symptomatic small saphenous vein the delayed group but were not required to wait. All patients re#ux were treated over a sixteen month period. Patients were in both groups were seen at 1, 3, 6 and 12 months after their evaluated clinically and Duplex ultrasound evaluation was initial ETA and their HRQL was assessed using the Aberdeen performed at 3-7 days, four weeks, three months, six months, Varicose Vein Questionnaire (AVVQ). and twelve months after endovenous laser treatment. Results. The demographic pro!le of the two groups was Results. Successful occlusion of the small saphenous vein, comparable, as were their SFJ sizes and CEAP clinical class as shown by lack of #ow on Duplex ultrasound and pulsed at baseline. Both groups started with comparable AVVQ color Doppler imaging, was demonstrated in all but !ve (5.9%) scores (13.5±6.2 vs. 12.9±5.8, p=NS). These were signi!cantly treated veins at one month. With observation, these junctions improved in Group 2 at 3 months (p <0.001) and 6 months were seen to be closed at three months. There was one small (p<0.05). The patients in Group 1 had a remarkable improve- saphenous vein (1.1%) with #ow at three months that had ment after undergoing delayed adjunctive treatment, and at previously been seen to not have #ow. This was successfully 12 months the AVVQ scores in both groups became compa- treated with ultrasound-guided foam sclerotherapy. To date, rable. successful occlusion has been seen in all patients who have Conclusions. Based on HRQL assessments, patients re- completed their six and twelve month follow-ups. Patients ex- ceive no bene!t from delaying adjunctive treatment for the perienced minimal bruising at the laser !ber access site and management of residual symptomatic varicosis after ETA. reported negligible discomfort along the treated vein at one week. No patient had swelling or tenderness. No nerve injury or skin burns occurred. There was no evidence of deep venous thrombosis. Conclusions. Short and intermediate term results of en- Low Predictability of Thrombotic Risk following dovenous laser ablation of the small saphenous vein with the Endovenous Laser Ablation for Chronic Venous Dis- 1470nm diode laser and radial !bre appears to be highly safe ease and effective in the elimination of small saphenous vein re#ux. T. King 1, S. Vayuvegula2, C. McGreevey3, A. Davis3 1Vein Clinics of America, Oakbrook Terrace, IL, USA 2Vein Clinics of America, Orland Park, IL, USA 3Vein Clinics of America, Downers Grove, IL, USA Phlebologic Rehabilitation J. Chunga Prieto Aim. To assess the incidence of venous thromboembolism Glomach Medic S.A., Lima, Peru (VTE) following endovenous laser treatment (ELT). Methods. A retrospective case series of thrombotic compli- Aim. To establish the clinical bene!ts of the exercises we cations after ELT collected over a twenty-seven month period teach our patients of venous ulcer by improving the range of from a 41 of!ce phlebology group. All included patients had ankle movement (ROAM), and demonstrate the bene!ts in undergone ELT for symptomatic, Duplex ultrasound proven, wound healing. saphenous truncal re#ux (>500 milliseconds), and were CEAP Methods. Study Design: Case series. Year(s)/Month(s) C2-6. Study Conducted: April 2012 to December 2012 Disease/Con- Results. Detailed Duplex ultrasound deep venous system dition Studied: patients with leg ulcers caused by venous in- investigation of the treated limb was performed 3-7 days af- suf!ciency that came to our practice. Subjects Studied: 27 pa- ter 21,041 consecutive saphenous truncal ELT procedures. tients with venous leg ulcers (9 males, 18 females); 35 limbs; Sixty-one (0.29%) VTEs were reported in 54 patients. There 42 active leg ulcers. Sizes of the ulcers: 20 cm2. to 100 cm2. were 27/61 (44%) deep vein thromboses (DVT), 15 being en- (Media of 60 cm2). Setting in Which Subjects Studied: We dovenous heat induced thrombosis (EHIT) Class 2-4. There teach our patients and a family member a series of exercises in were 27/61 (20 GSV/7 SSV) cases (44%) of EHITs: Class I-12, our private practice, to be performed at home or at workplace. Class II-10, Class III-5, Class IV-0. There were 15/61 (23%) Intervention(s): Series of exercises perform which include: 15 super!cial vein thromboses (SVT). Three involved untreated minutes work 3 times per day; alongside with compression saphenous tributaries; the rest were in the treated saphen- therapy and sclerotherapy. Outcome Measurement(s): ROAM, ous trunks. There were 7/61 (11%) pulmonary emboli (PE). Wound healing time. One PE was associated with an SVT but no DVT was found. Results. ROAM was reduced in all patients with venous Two PEs were not associated with an identi!ed SVT, DVT or leg ulcers (22°+-5) and patients with long time ulcers, showed EHIT. Three PEs were associated with DVT. One PE was as- lower levels of ROAM. After doing this exercises as scheduled, sociated with an EHIT 1. One was associated with an EHIT patients improve their ROAM (30°+-5) and also has a lesser 1 and bi-lateral SVTs. Patients with documented femoro- time in healing their ulcer (1 to 4 months with a media of 2 popliteal DVT, Class III EHIT, and/or PE were treated with months). The exercises are better performed with elastic com- anticoagulation. pression. Patients with venous leg ulcers are often told to rest Conclusions. Investigators found a low incidence of VTE, in bed, when we tell them to do this exercises and walk, they and a very low level of predictability of thrombotic risk, fol- feel better with themselves becoming our best allies in healing lowing ELT. Currently the data is undergoing multivariate their ulcers analysis to assess whether there are factors which are predic- Conclusions. The objective of the study was to demonstrate tive of that risk. our exercises program improves healing rates in patients with

142 INTERNATIONAL ANGIOLOGY October 2013 venous leg ulcers. In conclusion this research has shown that very often these procedures are affected by recurrences, phlebologic rehabilitation improves ROAM which alongside whose gold-standard treatment remains a controversy sub- sclerotherapy and compression therapy heals venous leg ul- ject. The main cause of these unsatisfying outcomes seems cers faster and also improves our patient’s psychology because to be an inappropriate groin dissection, leading to a residual they can walk and be ef!cient again. too long saphenous stump. This anatomical recurrence-fa- vouring factor is reported in percentages up to the 26% and it has remained the same for the last decades. Aim of this work is: 1) to compare the effectiveness of surgery versus Randomized Study to Determine Body Mass Index sclerotherapy in the sapheno-femoral recurrent incompe- as an Isolated Risk Factor for Saphenous Re"ux Di- tence management. agnosed with Vascular Ultrasound in the Spanish Methods. We analysed 433 chronic venous disease patients Hospital of Mexico City (C1-6EpAs,p,dPr) who presented a recurrent incompetent I. Leon, J. Paz, V. Perez, P. Rojas sapheno-femoral junction: 182 underwent echo-guided-foam Hospital Español de México, Mexico City, Mexico sclerotherapy, 251 were operated on always by the same surgeon who performed a Lì procedure. Clinical and echo-color- Aim. To describe the real relationship between body mass Doppler measurements assessed the outcome. index (BMI) as an isolated risk factor for mayor and minor Results. The mean follow up lasted 10 years. The sapheno- saphenous re#ux. Determine the incidence of re#ux in saphen- femoral junction showed incompetent recanalization signs ous veins for body mass index in one or two limbs in all symp- in 22 % of the sclerotherapic cases versus 3% of the surgical tomatic patients. To integrate an speci!c BMI and vein re#ux group. The clinical outcome showed no statistically signi!cant and initiate medical treatment in patients to prevent the de- differences among the two groups. velopment of chronic venous disease. All data is obtained and Conclusions. Re-do surgery on the inguinal region can diagnosed with vascular ultrasound. vein re#ux is de!ned as easily become challenging because of scars and neo-vas- blood return of valves of the saphenous vein of more than 0.5 cualrization. In 1975 Arthur Lì described an effective high seconds with a valsalva maneuver. ligation surgical approach based on the identi!cation of the Methods. Randomized study realized in the vascular labora- femoral arterial pulse to get to the junction by dissecting tory of the Spanish hospital in México city, using a 7.5 Mhz Ul- through a scar-less tissue. The procedure is accessible to all trasound with Doppler duplex triplex, with the patient standing vascular surgeons. The present study demonstrates its feasi- up, all studies with re#ux of the minor and mayor saphenous bility and effectiveness compared to the traditional sclero- veins were located and called randomized the patients, until we therapic approach. got 50 patients with our inclusion criteria, and ask their weight and height to calculate their body mass index, with that data we made some statistical analysis using SPSS program using x2 and t student for the variables. Inclusion Criteria: All patients of any age with re#ux of saphenous veins diagnosed in our vascular labortory. Re#ux of more than 0.5 seg. Exclusion criteria: Omohyoid Muscle Entrapment of the Internal Jugu- Women using oral hormones or history of using them, history lar Vein in CCSVI Patients: Clinical and Operative of pregnancy, family history of venous disease. Consequences Results. Fifty patients with saphenous re#ux 41 (82%) S. Gianesini, E. Menegatti, M. Zuolo, M. Tessari, S. Occhionorelli, S. women, 9 (8%) men (p<0.05), average age 56 years (27- Ascanelli, P. Zamboni 91 years). BMI of 30 kg/m2 or more in 43 (86%) of patients Vascular Disease Center University of Ferrara- Italy, Ferrara, Italy (p<0.05), with an average BMI of 31.8 Kg/m2, we found unilateral saphenous re#ux of 100% (p< 0.05), and bilateral mayor Aim. Omohyoid muscle (OM) compression on the internal saphenous re#ux in 38 (76%) patients (p<0.05), bilateral mi- jugular vein (IJV) constitutes a possible venous obstruction nor saphenous re#ux in 16 (32%) (p> 0.05). No Statistically cause. This study describes 6 CCSVI cases which presented difference between age was found and women were the most an IJV OM entrapment impacting on the therapeutic strategy. affected and the ones who searched for medical help earlier Pertinent anatomical, pathophysiological and clinical conse- than men. quences are reported. Conclusions. BMI of 31.8 Kg/m2 ( obese class I or moderately obese) is an isolated risk factor for saphenous re#ux in Methods. Six CCSVI patients who underwent a percuta- all symptomatic patients that come to the vascular laboratory neous angioplasty (PTA) treatment presented clinical and for venous re#ux diagnosis in saphenous veins and an inte- imaging signs of recurrence at 1 year follow-up. Echo-color- gral approach to the patient must be done to have a successful Doppler assessment and magnetic resonance venography co- treatment and good clinical outcomes, and we better initiate herently identi!ed an OM entrapment of the IJV. An OM sur- treatment before venous re#ux is present in all of these patents gical transection and venous angioplasty were performed. to prevent chronic venous disease and improve quality of life Clinical, neurological and imaging follow up data were rein all of our patients, and maybe if we act early, surgery will be corded. avoided in many of our patients. Results. The surgical exploration con!rmed the IJV extrinsic compression by the OM. Anatomical variants were observed on the same muscle. At 1 year mean follow up the surgical procedure lead to an IJV #ow improvement from a pre-operative The Recurrent Sapheno-Femoral Incompetence 52.6+32 mL/min to a post-procedural 403.6+141.9 (p=0.0079). Treatment: Surgery Wins against Sclerotherapy The mean neurological disability score (EDSS) improved from F. Zini 1, L. Tessari2, R. Torre3 3 to 2.5. Conclusions. OM compression on the IJV can impact the 1Casa di Cura Citta di Parma, Parma, Italy 2Bassi Foundation Trieste, 37019 Peschiera del Garda, Verona, Italy CCSVI clinical and therapeutic course. Several anatomical 3Casa di Cura Privata Piacenza SpA, Piacenza, Italy and pathophysiological aspects need further investigations. Such condition may cause PTA failure and needs to be preop- Aim. In Europe, high ligation and stripping for varicose eratively considered. Open surgery seems to offer an effective veins remains the most popular procedure. Nevertheless, therapeutic option.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 143 A UK View - Where Does Venous Disease Fit in the vein valve distal to the con#uence of FV and DFV in normal Vascular Surgeon’s Workload? subjects. The information obtained can be compared to other A. Thapar, J. Salem, H. Moore, A. Davies imaging modalities to assess its reliability. Academic Section of Vascular Surgery, Imperial College London, London, United Kingdom

Aim. In the UK, the number of venous procedures per- The in Vitro Effects of Detergent Sclerosants on In- formed has been markedly reduced over the last 5 years. The "ammatory and Angiogenic Cytokines aim of this study was to identify trends in index procedures K. Parsi1, O. Cooley Andrade2, D. Du2, A. Jothidas2, D. Connor2 performed over the last 5 years and the proportion of endovas- 1St. Vincent’s Hospital, Bondi Junction, NSW, Australia cular cases performed. 2St Vincent’s Centre for Applied Medical Research, Darlinghurst, New Methods. Hospital episode statistics data for !nancial years South Wales, Australia ending 2007-2011 was obtained via an open access internet portal. Data for aortic, carotid, infrainguinal arterial, venous, Aim. To investigate the effects of detergent sclerosants So- renal access and amputations were retrieved using pre-spec- dium Tetradecyl Sulphate (STS) and Polidocanol (POL) on the i!ed three point codes and analysed in Prism v5 (GraphPad release of in#ammatory and angiogenic cytokines from leu- Software). Proportions of open and endovascular operations kocytes were compared using the chi-squared statistic, taking p<0.01 Methods. Whole blood, platelet rich plasma and isolated as statistical signi!cance. leukocyte samples from normal donors were incubated with Results. In 2011, amongst all vascular procedures, 30% of varying concentrations of STS or POL (0.0%-1.2%). The re- the workload was treatment for varicose veins, 18% infrain- lease of in#ammatory cytokines IL-1α, IL-1 β, IL-6, IL-8, IL-17, guinal arterial, 9% renal access, 7% aortic, 5% carotid and CD40L, IFN-gamma and TNF-alpha and angiogenic cytokines 4% major amputation. The proportion of endovascular pro- VEGF and bFGF were analysed by enzyme linked immuno- cedures increased signi!cantly over 5 years from 33 to 53% sorbent assay. (p<0.0001) for aortic work and from 13 to 42% (p<0.0001) for Results. CD40Ligand was released by both platelets and super!cial venous work. The only index procedure showing leukocytes following STS and POL incubation. STS incuba- sustained year on year increases in numbers was renal access tion stimulated the release of IL-1α, IL-1 β, IL-6, IL-8, IL-17, from 9207 cases in 2007, to 11, 780 cases in 2011. There were CD40L, IFN-gamma, TNF-alpha from polymorphonuclear no clinically signi!cant trends in other index procedures. cells (neutrophils, eosinophils or basophils), whereas POL Conclusions. There is a growing need to prepare the vas- stimulated the release of IL-8. Both STS and POL stimulated cular specialists of tomorrow for greater pro!ciency in the the release of VEGF from leukocytes. endovascular treatment of super!cial venous disease. Those Conclusions. STS stimulates the release of in#ammatory managing vascular budgets and applying for vascular special- cytokines, whereas both STS and POL stimulated the release ist training should be aware of this change in practice, and it of the angiogenic cytokine VEGF. can be used to guide those designing curricula.

The UK Varicose Vein Story 1989-2010 H. Moore, K. Head, J. Shalhoub, T. Lane, A. Davies Academic Section of Vascular Surgery, Imperial College London, London, Haemodynamic Measurements around a Femoral United Kingdom Vein Valve by Duplex Ultrasound H. Moore, B. Dharmarajah, M. Ellis, M. Gohel, A. Davies Aim. The aim of this study was to analyse changing prac- Academic Section of Vascular Surgery, Imperial College London, London, tices in the treatment of varicose veins in the UK over the last United Kingdom 20 years using nationally compiled data. Methods. Centrally-compiled Hospital Episode Statistics Aim. A detailed dynamic assessment of deep vein #ow pat- (HES) data for varicose vein procedures carried out within the terns is required to understand venous valve haemodynamics. NHS from 1989-2010 was obtained from the HES data ware- The aims of this study were to evaluate haemodynamic vari- house for England. The numbers of different procedures car- ables in subjects with normal deep veins. ried out was calculated for each year. Methods. A prospective observational study evaluating Results. The mean age of patients undergoing varicose vein subjects with normal deep veins was carried out. The !rst vis- intervention in the UK has increased from 46.2 years in 1989 ible valve distal to the con#uence of the DFV and FV was lo- to 51.3 years in 2010. The mean waiting times for these pro- cated. Images were acquired with combinations of the subject cedures has decreased from 250 days to 78 days. The mean in standing and semi-recumbent positions, with respiration duration of each episode has decreased from 2.2 days to 0.2 or held expiration and with/without a standard calf squeeze. days. Ligation of the great saphenous vein (GSV) was the most Readings were taken proximal, distal and within the valve leaf- commonly performed procedure in 1989, peaking at 35,067 lets, and recorded for assessment of#ine using Image-J. procedures in 1995 and declining to a low of 530 in 2010. The Results. Seven normal subjects were studied. The maximum number of GSV stripping procedures in 1989 was 4,803, peak- velocities obtained in the lying position ranged from 51.43- ing at 23,423 in 2002 and subsequently declining to 173 in 127.06cm/s and in the standing positions from 29.37-59.00cm/s. 2010. Endovenous procedures were de!ned separately in 2006 Velocity tended to increase within and proximal to the valve and both laser and radiofrequency ablation have increased lea#ets. Overall, the average maximum velocity increased from annually since then, and recently combined procedures are 39cm/s anatomically distal to the valve lea#ets, to 45cm/s within increasingly common. The relative number of bilateral proce- the lea#ets, to 47cm/s anatomically proximal to the lea#ets. The dures has decreased over time. average mean velocity increased from 13cm/s anatomically dis- Conclusions. Varicose vein practice in the UK has changed tal to the valve lea#ets, to 16cm/s within and proximal to the considerably over the last 20 years. The lengths of hospital lea#ets. The mean duration of calf squeeze was 2.32s. stays have been reduced as practice moves away from open Conclusions. This study investigated the use of ultrasound surgery towards endovenous techniques, which can be per- imaging to provide the #ow pro!le around the !rst femoral formed in an of!ce-based setting.

144 INTERNATIONAL ANGIOLOGY October 2013 Sclerosant Foam Structure is Strongly In"uences by verity of venous diseases and can be used as criteria for diag- the Liquid Air Fraction and the Use Of Filters nosis and documentation. Duplex !ndings were con!rmed by D. Connor1, M. Behnia2, E. Cameron3, T. Chen3, K. Parsi4 phase-contrast MR imaging. 1St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, Australia 2School of of Aerospace, Mechanical & Mechatronic Engineering, Univer- The Effect of Temperature on Sclerosant Foam Sta- sity of Sydney, Sydney, New South Wales, Australia 3St Vincent’s Centre for Applied Medical Research, Darlinghurst, New bility South Wales, Australia M Behnia1, G Valenzuela1, K Wong2, D Connor2, M Behnia1, K Parsi3 4 St. Vincent’s Hospital, Bondi Junction, NSW, Australia 1School of of Aerospace, Mechanical & Mechatronic Engineering, Univer- sity of Sydney, Sydney, New South Wales, Australia Aim. To determine the effects of sclerosant foam composi- 2St Vincent’s Centre for Applied Medical Research, Darlinghurst, New tion on foam structure, coarsening and liquid drainage. South Wales, Australia Methods. Sodium tetradecyl sulphate (STS) and polidoca- 3St. Vincent’s Hospital, Bondi Junction, NSW, Australia nol (POL) foams were investigated at a range of concentrations (0.5%-3%) and liquid air fractions (LAF, 1+2-1+8). Foam Aim. The aim of this study was to investigate the effects was prepared neat using a 3-way stopcock with or without of temperature on sclerosant liquid surface tension and foam 5μm !lters and injected into a 3mm PVC vein model !lled with half-life and viscosity. either saline or blood. Liquid drainage and bubble count and Methods. Sodium Tetradecyl Sulphate (STS) and Polidoca- size were documented by serial photography. nol (POL) foams were prepared in syringes and immersed in Results. Liquid drained from foam more rapidly in verti- a water bath at temperatures ranging between 10-40°C, with cal compared to horizontal syringes. All variations gener- the foam half-life calculated. Liquid surface tension was meas- ated foam comprising small bubbles (<30μm) initially, with ured using a tensiometer for temperatures between 15-35°C. bubbles coalescing to form mini-foams (>250μm) within 3 Foam viscosity was measured with a rheometer for a shear minutes and macro-foams (>500μm) within 7.5 minutes. De- rate of 0.02s-1 at either 25 or 35°C. creased air content and the presence of !lters produced signi!- Results. Foam half-life was decreased at higher tempera- cantly smaller bubbles. The inclusion of !lters had a greater tures when compared to lower temperatures. Liquid surface effect for POL than STS in reducing the bubble size. Following tension was higher in POL than in STS, and the surface ten- injection into the vein model, upper regions of foam coars- sion of both decreased when temperature was increased. POL ened more rapidly while liquid drained to the bottom of the foam was more viscous than STS for this particular shear rate, vessel. Foam coarsening was fastest at lower STS and higher but these trends cannot be con!rmed for higher shear rates. As POL concentrations. 0.5% POL produced signi!cantly higher concentration and temperature increased, the viscosity of STS bubble counts than 0.5% STS. decreased, whereas in POL the viscosity increased. Conclusions. Foam structure is in#uenced by LAF and the Conclusions. Foam drainage was prolonged at colder tem- presence of !lters. peratures, and surface tension increased at colder temperatures. POL foam was more viscous and stable at colder temperatures than STS at high concentrations.

Severity Scoring of Venous Insuf#ciency using Computational Fluid Dynamics (CFD) Modelling of Phase-Contrast MR Imgaging and Duplex Ultra- Sclerosant Foam Behaviour sound M Behnia1, K Wong2, T Chen2, D Connor2, K Parsi3 B. Kahle, P. Hunold, P. Rudolphi 1School of of Aerospace, Mechanical & Mechatronic Engineering, Univer- University Hospital of Schleswig Holstein Campus Luebeck, Luebeck, sity of Sydney, Sydney, New South Wales, Australia Germany 2St Vincent’s Centre for Applied Medical Research, Darlinghurst, New South Wales, Australia Aim. To con!rm duplex !ndings of volume #ow measure- 3St. Vincent’s Hospital, Bondi Junction, NSW, Australia ments in the common femoral vein and artery by phase-contrast MR Imaging. 2.To quantify the severity of venous insuf- Aim. To construct a computational #uid dynamics (CFD) !ciency by the ratio of venous and arterial volume #ow data. model of a vein and needle to simulate the injection of either Methods. In 40 limbs with different types of varicose veins liquid or foam sclerosant and to compare this to an experi- volume #ow in the common femoral vein and artery were mental model. measured by duplex ultrasound in relaxed supine position. Methods. The density and rheological data were deter- Volume #ow (mL/min) was calculated as the product of mean mined experimentally and imported into the CFD model. blood #ow velocity (cm/min) and the cross section (cm²) of the Two vein systems were tested: a horizontal straight vein vessel. The ratio of the venous and arterial volume #ow was and a model of the saphenofemoral junction. A commercial calculated by division of the venous by the arterial data. Then CFD package (ANSYS-FLUENT v13.0) was used. Parameters all patients underwent phase-contrast MR #ow measurement tested included the effects of vein pressure on injection #ow, of the common femoral vein and artery. The veno-arterial ratio the injection of sclerosant into saline or blood, the angle of was calculated by division of the venous by arterial volume injection and the difference in sclerosant spreading between #ow. We used ANOVA to determine stastical correlation be- liquid and foam tween duplex and MR volume #ow data. Results. Compared to experimental results, the modelling Results. In all limbs the ratio and volume #ow data as- with liquid sclerosant proved more reliable than the modelling sessed by duplex ultrasound could be con!rmed by phase- of foam sclerosant. The outlet pressure, injection angle and contrast MR imaging. Corresponding to the clinical severity injection of sclerosant into blood or saline had minor, but cal- the ratio of venous and arterial volume #ow increases signi!- culable differences in sclerosant spreading. Further modelling cantly. In healthy limbs and in C1 varicose veins the ratio was is being performed to produce a more reproducible model of lower than 1.1. In contrast to signi!cant varicose veins the ra- foam spreading. tio was higher than 1.2 (P<. 001). Conclusions. CFD simulations provide a quick, cost effec- Conclusions. The ratio of volume #ow in the common tive determination of the impact of different parameters on femoral vein and artery characterizes the hemodynamic se- sclerosant #ow and spreading.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 145 Altered Elastase - Alpha-1-Antitrypsin Balance in Results. At 1-weak follow-up complete occlusion (total non- the Blood of Patients with Chronic Venous Insuf#- compressibility) of the femoral segment of GSV was found in ciency (CVI) 129 cases (97.7%). Re#ux > 1 sec was observed in 2 cases and antegrade #ow without re#ux (< 0.5 sec) in 1 case. The mean M. Iskra1, W. Turkiewicz2, M. Budzyń-Napierała1 size of the internal diameter of the vein was decreased by 1 - 1Department of General Chemistry, Poznan University of Medical Sci- ences, Poznan, Poland 4,5 mm (44.8%). The distal segment of GSV and its tributaries 2Department of General Surgery, Medical Center HCP Poznan, Poznan, were empty due to compression of the crus. These veins were Poland treated during the next session of the sclerotherapy. Conclusions. Using required measure of the procedure Aim. Leukocyte elastase (LE) is one of the proteases char- (60° elevation of the leg, bandage of the crus, use of cold scle- acterized by broad range of substrate speci!city that is sus- rosant) allow to achieve the occlusion of the femoral segment pected to participate in the vein wall damage during CVI. The of GSV almost in 100% of cases after !rst treatment. aim of the present study was to determine the relationship between LE and its inhibitor – alpha-1-antitrypsin (AAT) in the blood of patients with CVI. Methods. The concentration and the activity of LE along The Effect of Dilution of Sclerosants with Water or with the activity of AAT were evaluated in the serum/plasma of Saline on the Critical Micelle Concentration CVI patients. CVI patients were divided according to disease D. Connor1, K. Wong2, M. Behnia3, K. Parsi4 severity (group M – mild symptoms of CVI, group S – severe 1St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, symptoms of CVI) and duration (≤ 10 years, > 10 years). The Australia results were compared with those obtained for 33 healthy age 2St Vincent’s Centre for Applied Medical Research, Darlinghurst, New and sex-matched volunteers. South Wales, Australia 3School of of Aerospace, Mechanical & Mechatronic Engineering, Univer- Results. Concentration of LE in plasma of CVI patients sity of Sydney, Sydney, New South Wales, Australia was observed to be not different in compared with a healthy 4St. Vincent’s Hospital, Bondi Junction, NSW, Australia control [CVI patients: 52,5 (17,38 – 87,63) ng/ml vs control group: 44 (26 – 85) ng/ml, p=0,993]. A signi!cant decrease in Aim. Low concentration commercial detergent sclerosants the elastase-like activity and an increase in the AAT activity are available in a pre-diluted format, diluted using sterile wa- were found in patients with mild clinical symptoms of CVI and ter, however sclerosants may also be diluted in-house, often shorter duration of disease (≤ 10 years) [elastase-like activi- using normal saline. The objective of this study was to deter- ty: group M - 0,422 (0,174-0,785) U/l vs control group - 0,736 mine whether the dilution of sclerosant in water or saline af- (0,447-1,253) U/l, p=0,004; ≤ 10 years - 0,557 (0,248-0,785) U/l fects the critical micelle concentration of the sclerosant. vs control group - 0,736 (0,447-1,253) U/l), p=0,018; AAT activ- Methods. The detergent sclerosants sodium tetradecyl sul- ity: group M - 1,085±0,533 U/ml vs control group - 0,805±0,205 phate (STS) or polidocanol (POL) were diluted using either U/ml, p=0,046; ≤ 10 years - 1,111±0,524 U/ml vs control group water or normal saline (0.9%w/v). The surface tension of the - 0,805±0,205 U/ml, p=0,036]. Moreover, in these groups of sclerosant liquid was determined using the Du Nuoy ring patients, a signi!cant negative correlation between AAT and method. Using this data, the critical micelle concentration elastase-like activity was noticed [group M – elastase-like (CMC) was determined. activity:AAT activity r=-0,443 p=0,018; ≤ 10 years – elastase- Results. The CMC of STS was higher than POL (0.2% vs like activity:AAT activity r=-0,422 p=0,040]. 0.002%, respectively). The dilution of STS with saline signi!- Conclusions. The results obtained in the present study are cantly decreased the CMC of STS, when compared to STS di- mostly contradictive to the hypothesis on the potential role luted with water (0.075% vs 0.2%, respectively). The dilution of LE in the proteolytic degradation of the vein wall, as they of POL with saline had no effect when compared to POL di- have not shown any increase in the concentration or activity luted with water (both 0.002%). of LE in blood of CVI patients. Reversible correlation between Conclusions. The dilution of sclerosants in-house with sa- elastase-like activity and AAT activity suggests that LE-AAT line as opposed to a commercially available dilution in sterile balance is rather shifted towards antiprotease, especially in water may have signi!cant effects on the activity of the sclero- early stage of CVI development. Although the excess amount sant for STS, but not for POL. of inhibitor probably protect from proteolytic action of LE, this disproportion could also have negative consequences. It may cause an inappropriate metabolism of extracellular matrix components leading not to their degradation but abnor- Use of a New Device for Lymphoedema Treatment: mal accumulation in the vein wall. Preliminary Study S. Michelini1, M. Cardone 1, E. Dimakakos 2, L. Michelotti 1, A. Pissas 3, W. Olszewski 4 UGFS of Great Saphenous Vein: How to Make Im- 1Ospedale San Giovanni Battista, Roma, Italy 2University of Athens “Sotiria”, Athens, Greece mediate Results Better? 3Centre Hospitalier de Bagnols-sur-Cèze, Bagnols sur. Ceze, France A. Baeshko, N. Shestak 4Central Clinical Hospital, Warsaw, Poland Belarussian State Medical University, Minsk, Belarus Aim. The need to respect the EBM in the treatment of Aim. The objective of these case series is to present imme- lymphedema let think about the fact that the manual lym- diate results of the occlusion of great saphenous vein (GSV) phatic drainage is too operator-dependent; pressure actually with axial re#ux using UGFS with speci!ed parameters of the exerted by the physiotherapist on the underlying tissue is vari- technique. able depending on the individual skills and experience gained Methods. A group of 117 patients (132 GSV, the mean di- in various and different retraining. ameter was 6.7 mm) comprised these case series (2013 year). Methods. From these considerations, the idea of creating UGFS using 1-3% cold polidocanol was employed. For ideal a new device whose operation is linked with the work of the exsanguination of the vein and prevention of the migration of physiotherapist was borne. This new tool, where we !nd a roll- foam to the distal stream, 60° elevation and bandage of the er handpiece, is connected with a software that controls the crus before injection was applied. The patients were examined pressure actually exerted on the tissues. It is possible, through with DUS before treatment and after 1 weak. audible and visual signals, maintain a constant pressure in the

146 INTERNATIONAL ANGIOLOGY October 2013 various maneuvers performed with predetermined layouts, al- woven cotton bandages, inital as a spiral second as a “her- lowing you to perform maneuvers in a standardized way be- ringbone pattern” and third as a spiral, then sequred with ei- tween different operators. Patients were studied with values by ther tape or velcro apparatus. Outcome was ability of patient limb measurements, using the formula of the truncated cone, and/or provider to reproduce the initial manual lymphatic before and after 8 sessions therapy: We studied 50 patients, drainage as well as compression bandage. This time period aging from 15 to 72, and comprehending 22 primary and 28 was chosen as the phlebologist had completed a 135 hour secondary lymphedema certi!cation course in lymphedema consistent with the Na- Results. The !rst clinical results demonstrate the effective- tional Lymphedema Network guidelines for the training and ness of the technique in the reduction of volume and consist- education of Lymphedema Therapists in December of 2010. ency of the tissues and the possibility that the same is uniform- These techniques were studied and taught at the initial visit ly applied in the real centers in which the preliminary study is of new patients with phlebolymphedema and/or signi!cant conducted. In particular, the easy feasibility and accuracy of edema due to chronic venous insuf!ciency. the system are associated with clinical evident improvements, Results. Out of the 175 patients one patient left the clin- veri!able with an average reduction in the volume of the limbs ic without participating. The others at least tried the treat- (calculated automatically by the computer after you enter the ments. Two patients reported no signi!cant bene!t and the data) by 39% compared to baseline values. rest at least were able to participate with greater than 90% Conclusions. Such a device appears to be useful, allowing reporting signi!cant bene!t. A majority were able to be man- us to perform maneuvers in a standardized way between differ- aged with simple spiral alone. While management of others ent operators, and giving us the possibility to compare results, often allowed decrease in the amount of padding required at in order to respect the EBM in the treatment of lymphedema. subsequent visits. Conclusions. We were able to demonstrate ability to teach basic safe Manual Lymphatic Drainage techniques to patients in one visit. The maneuvers able to be reproduced included Introduction of Complete Decongestive Therapy “short short neck” and “anterior thigh sequences.” Bandag- Principles to the Phlebology Clinic ing to the knee sometimes included sheets of 1/2 inch gray foam in order to comply with the law of La Place. It is rec- J. Hovorka ommended that interested phlebologists pursue a 135 com- Valley Ambulatory Surgery Center, LLC, McAllen, TX, USA plete decongestive therapy training course in Lymphedema management in order to better serve their patients. Referral Aim. 1) Introduce basic principles of Complete Decon- to a Certi!ed Lymphatic Therapist whom is also a Physical, gestive Therapy (CDT) de!ned as the safe, effective use of Occupational or Speech Therapist may have a waiting list of manual therapy as well as compression bandaging to control up to 6 months. We suggested that the general everyday phle- edema, lymphedema and swelling. 2) Illustrate the perform- bologist should be able to be introduce two MLD techniques ance of manual therapy techniques taught to the patient at as described and add gray foam bandaging to the armamen- the initial visit in the clinic. 3) Integrate standardized tech- tarium of bandages in order to better serve the patient popu- nique of foam for bandaging using multi-layer compression lation. and short stretch bandages to begin at the initial patient visit in the clinic. Methods. Study is designed as a retrospective review from January 2011 to the present June 2012. Disease/condition Spectrum of Congenital Anomalies of the Inferior studied included is phlebolymphedema. Search through the Vena Cava and their Clinical Manifestation registry for lymphedema and varicose veins as well as pa- A. Baeshko, D. Bogodyazh, N. Shestak tients having had multilayer compression bandaging at the Belarussian State Medical University, Minsk, Belarus initial visit revealed 175 patients. Interventions performed included teaching of two manual lymphatic drainage tech- Aim. An analysis of the features of clinical symptoms hypo- niques. First is “short short neck sequence” using simple plasia and aplasia of the inferior vena cava (IVC) in the acute circle technique. Second is “anterior thigh sequence” using and long-term periods of the disease was the purpose of the simple circle and pump techniques. Setting is the clinic. research. Outcome measurement is demonstration by patient and/or Methods. Analyzed survey contains !ndings obtained by fol- caregiver of ability to perform manual lymphatic drainage lowing an examination and dynamic observation (from 2003 to introductory techniques as well as ability to apply multilayer 2012) of twenty one 15- to-55-year-old male patients (average compression bandaging. Independent Variables include clini- age 25.9±2.6 years) with congenital abnormalities of the IVC. cal stage of lymphedema as well as presence or absence of ul- The diagnosis was veri!ed in 19 patients by means of the spiral ceration. CEAP-Venous Clinical scores were class 3 through non-enhanced and contrast-enhanced computed tomography 6. Clinical Lymphedema stage was stage 2 and stage 3 in the with using of axial sections and their three-dimensional recon- patients reported. CEAP-L clinical stage included 3 Edema structions. Two patients had the MRI-phlebography data. that persists with night rest, 4 Fibrotic edema, 5 Elephan- Results. In 16 patients the disease !rst manifested as pe- tiasis with skin lesions (no C6 in CEAP-L). Complete De- ripheral thrombosis; fever, chill and subsequent edema of both congestive Therapy is de!ned as the safe and effective use legs !rst appeared in 5 patients. The unilateral iliofemoral of manual techniques and compression bandaging to control thrombosis appeared in 9 patients (right – 6, left – 3) and bi- swelling and edemas. Manual Lymphatic Drainage taught at lateral in 4. In 1,5-12 months after the acute period of disease the initial visit included “short short neck” as well as “An- the signs of the IVC syndrome had appeared in every patient. terior Thigh sequence.” Compression bandaging in all cases Extensive collateral #ow was observed in all our patients. The included the use of short stretch woven cotton bandaging. A azygos and hemiazygos, ascending lumbar veins and left go- majority of patients were able to be managed with a “simple nadal vein were the most dilated. spiral” bandage consistent with the package insert from the Conclusions. Conclusion. Congenital anomalies of the manufacturer and described by Partsch. patients with irregu- IVC !rst appear clinically as deep vein thrombosis (usually by lar shaped limbs required the use of foam. 1/2 inch gray foam the right iliofemoral thrombosis). An anomaly of this vessel sheets obtained in 3 foot by 6 foot sheets were cut into shape should be suspected if thrombosis involves the right iliac veins to provide a cone shaped appearance in all cases up to the in 30-year- old patients or younger. For the diagnosis these knee and secured with three 10 cm width x 5 meter in length anomalies need to perform SCT– or MRI–phlebography.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 147 Detergent Sclerosants Induce in Vitro Platelet Ac- From the year 2007 to the end of 2012 with have treated 151 tivation, but Inhibit Aggregation by Inhibition of patients with 189 extremities. GpIIb/IIIa Results. Results. In the !rst series of 1998 we saw several perioperative complications, !ve patients with hypesthesias D. Connor1, J. Low2, D. Ma3, A. Pilotelle3, S. Watson4, J. Joseph3 and one patient with a skin burn which was related to the non 1St Vincent’s Centre for Applied Medical Research, Darlinghurst, NSW, use of tumescent anesthesia. In this series we have a mean Australia 2Sydpath, St Vincent’s Hospital, Darlinghurst, New South Wales, Aus- follow-up of 80 months with excellent long term results, only tralia in one case we a saw recanalisation of the GSV 14 month post- 3St Vincent’s Centre for Applied Medical Research, Darlinghurst, New operatively. All other veins were occluded, in one case we saw South Wales, Australia a recurrence at the SPJ 160 months postoperativly. In the sec- 4Centre for Cardiovascular Sciences, University of Birmingham, Bir- ond series from 2004 to 2007 we didn’t see any severe perioper- mingham, United Kingdom ative complications and the long term results were good with an occlusion rate of more than 90%. A few of the patients we Aim. To investigate the in vitro effects of detergent scle- had to reoperate with a high ligation due to a recurrent varico- rosants Sodium Tetradecyl Sulphate (STS) and Polidocanol sis of the anterior accessory vein in the groin. The results with (POL) on platelet activation and aggregation. Closure Fast improved signi!cantly also in this series from Methods. Whole blood and platelet rich plasma samples 2007 we didn’t see any severe perioperative complication and were incubated with sclerosants. Platelet and platelet micro- the occlusion rate was greater than 95%. particle (PMP) counts were measured by #ow cytometry. Plate- Conclusions. Conclusion: RFA is a very safe procedure. let activation was examined by ELISA for soluble factors (sP- The perioperative complication is rate is very low if you apply selectin, von Willebrand factor, sCD40L and serotonin) and by tumescent #uid around the treated vein. RFA is also a durable #ow cytometry for membrane-bound markers (CD62p, CD63) procedure the long term occlusion rate is excellent, even up and cytoplasmic calcium. Platelet aggregation was assessed by to 10 years PFA-100®, light transmission and impedance (Multiplate®) aggregometry, and by #ow cytometry for glycoprotein (Gp)Ib and GpIIb/IIIa subunits, heterodimer expression and activation (PAC-1 binding). Results. Both agents lysed platelets at high concentrations (≥0.1%) but induced platelet activation at lower concentrations Plication Femoral Vein Resorbable Thread - Alter- as evident by a rise in membrane-bound and soluble markers, native to Surgery Linton with Open Thrombectomy cytoplasmic calcium and release of phosphatidylserine+ PMP. Platelet activation (CD62p expression) following STS (but not in Patients with Deep Vein Thrombosis of the Lower POL) incubation was inhibited using dasatinib (a src pathway Limbs inhibitor). This inhibition was not seen in platelets incubated S. Pryadko with PRT318 (a syk pathway inhibitor). Agonist-stimulated Bakoulev Center for Cardiovascular Surgery Russian Academy of Medi- platelet aggregation was inhibited by both sclerosants. Mem- cal Sciences, Moscow, Russian Federation brane expression of GpIb and GpIIb/IIIa individual subunits or heterodimer was not affected by sclerosants but the activa- Aim. Open thrombectomy of the femoral vein is widely tion of GpIIb/IIIa was suppressed. used for the treatment of deep vein thrombosis of the lower Conclusions. Low concentration sclerosants activated limbs in Russia (more than 500 operations per year). In this platelets and released microparticles. This occured via a Src- case, for the prevention of pulmonary embolism used femoral dependent pathway for STS, but not for POL. Both sclerosants vein ligation (Linton operation) or installation of cava !lter. inhibited platelet aggregation due to suppression of GpIIb/IIIa An alternative to these procedures can be plication femoral activation. vein absorbable thread that keeps the lumen femoral vein and serves cava !lter. Methods. A retrospective analysis of 15 patients with acute occlusive thrombosis of the tibial-femoral-popliteal segment, with the presence of #oating thrombus in the de- 15 Years Experience with Radio Frequency Ablation partment operated venous pathology from 2007 to 2013. The operation involves the removal of the #oating segment of (RFA) thrombus and thrombectomy of the super!cial femoral vein, T. Noppeney, J. Noppeney depending on the method of prophylaxis of thromboembo- MVZ Obere Turnstraße, Nuremberg, Germany lism patients were divided into three groups. Group I - resection of the femoral vein - 2 patients, group II - ligation Aim. The aim of this retrospective analysis was to describe of the femoral vein (Vicryl 2/0) - 4 patients and a group III our experiences with RFA the development of the technique - plication femoral vein by suturing (Vicryl 4/0) “U”-shaped and the improvement of the results over the years. suture - 9 patients. Postoperative therapy consisted of direct Methods. Methods: We started using RFA in the year and indirect anticoagulants, #ebotoniki, compression ho- 1998 when the device received the CE-Mark in Europe and siery «Sigvaris». Comparative analysis of treatment was 18 Germany. In a !rst series we treated 12 patients, mainly the months after surgery, every 3 months, on the basis of clinical GSV. In all these cases we combined the RFA procedure with symptoms and duplex scanning. Maximum period of obser- the high ligation and interruption of side branches of the vation of 5 years. sapheno-femoral junction. We didn’t apply tumescent an- Results. retromboz and thromboembolism was observed in esthesia and treated the vein in the whole length down to any of the groups. Progression of venous insuf!ciency - limb the ankle. We restarted our program in the year 2004, then edema, secondary varicose saphenous veins, trophic disorders we performed the RFA procedure without high ligation and were observed in all patients I and II. Analysis of the results of stopped the thermal ablation of the GSV just below the knee duplex scanning and control #eboga!i showed no reduction in and performed all the procedures with tumescent anesthesia. the lumen of the vein group II in all phases of observation. In Through the year 2007 we treated 61 patients 85 extremities group III cross the femoral vein in the plication recovered after with RFA ablation. RFA device was developed further on to recanalization of the super!cial femoral vein in 3-6 months. the Closure Fast catheter with segmental thermal ablation. after surgery. It was noted that the patients in Groups I and II

148 INTERNATIONAL ANGIOLOGY October 2013 femoral vein recanalization rate was minimal and amounted Results. 4,509 ELA procedures were performed. 23.7% pa- to 6 months. 25-30% after surgery. In group III recanalization tients were male; mean age was 54.6±20.1 years. A mean of was 55-60% for the same period (a year complete recanaliza- 60.3±38.2 J/cm energy was delivered per procedure. 1.1% of tion recorded in 6 cases). patients had a periprocedural complication. The overall mean Conclusions. ligation and resection of the femoral vein pre- preoperative VCSS was 7.9±4.7, which decreased to 4.8±3.9 vent thromboembolism, but lead to the progression of venous at 35 days following ELA. Each wavelength used resulted in a insuf!ciency. Plication femoral vein preserves cross veins, ve- signi!cant reduction in VCSS score. nous insuf!ciency reduces by at least 50%, and as reliable in Conclusions. ELA of all different wavelengths improve the prevention of thromboembolism. clinical symptoms after endovenous ablation. Longer term follow up is needed to determine if the ELA wavelength applied continues to impact VCSS over the long term. Kilt Syndrome and Antitrombin III De#ciency J. Pereira Albino, L. Castro e Sousa, P. Amorim, G. Sousa, J. Vieira, M. Teresa Vieira, N. Meireles European Guidelines for Sclerotherapy in Chronic Vascular S. II H Pulido Valente - CHLN, Lisbon, Lisbon Venous Disorders Part 1: Indications, Contraindica- Aim. The absence of the inferior vena cava with bilateral tions and Results venous thrombosis and renal anomalies in young patients, F. Pannier 1, E. Rabe 2, F. Breu 3, A. Cavezzi 4, P. Coleridge-Smith 5, A. 6 7 8 9 10 11 are a rare association recently described as the Kilt syn- Frullini , J. Gillet , J. Guex , C. Hamel-Desnos , P. Kern , B. Partsch , A. Ramelet12 , L. Tessari13 drome. 1 Methods. The authors describe the case of a family in Cologne, Germany 2University of Bonn, Department of Dermatology, Bonn, Germany which two sisters (29 and 32 years old) reveal repeat venous 3Kreussler, Rottach-Egern, Germany thrombosis, and Antitrombin III de!ciency associated in one 4Poliambulatorio Hippocrates, San Benedetto Del Tronto, Italy of them an inferior vena cava agenesis 5British Vein Institute, Amersham, UK Results. In one of them the diagnosis was possible thanks 6Studio medico "ebologico, Figline Valdarno-Florence, Italy to a iliofemoral deep venous thrombosis that was related to the 7Vascular Medicine, Bourgoin-Jallieu, France 8Cabinet de Phlebologie, Nice, France pattern of mesenteric venous thrombosis. The other younger 9French Society of Phlebology, CAEN, France patient, besides having bilateral repetition venous thrombosis, 10 Private of#ce of Vascular Medicine and Service of Angiology, University we detected an inferior vena cava and a left kidney agenesis Hospital Lausanne, Vevey, Switzerland which shapes the clinical condition known as the Kilt Syn- 11 private practice, Vienna, A-1180, Austria drome. 12 Dept Dermatology Inselspital Bern, Lausanne, Switzerland 13 Conclusions. In conclusion, the authors claim it is manda- Bassi Foundation Trieste, 37019 Peschiera del Garda, Verona, Italy tory a study be carried out on the possibility of existing thrombophilia, in case of venous thrombosis recurrence in young Aim. Sclerotherapy is the targeted chemical ablation of patients, besides the determination of inferior vena cava and varicose veins by intravenous injection of a liquid or foamed kidney anomalies. sclerosing drug. The aim of this guideline is to give evidence based recommendations for liquid and foam sclerotherapy. Methods. This guideline was drafted on behalf of 23 Euro- pean Phlebological Societies during a Guideline Conference Endovenous Laser Ablation and the In"uence Of on 7th - 10th May 2012 in Mainz. The conference was organ- Wavelength on Venous Outcomes: s Report from the ized by the German Society of Phlebology. These guidelines American Venous Registry (AVR) review the present state of knowledge as re#ected in published medical literature. The recommendations of this guideline J. Raffetto1, J. Almeida 2, L. Kabnick 3, T. Wake!eld 4, U. Onyeachom 5, R. McLafferty6, P. Pappas 7, J. Rectenwald 8, J. Blebea 9, D. Gillespie 10 , are graded according to the GRADE recommendations. This B. Lal11 guideline focuses on the two sclerosing drugs which are li- 1Vascular Surgery Division VA Boston Healthcare System Surgery 112, censed in the majority of the European countries, Polidocanol West Roxbury, MA, USA (POL) and Sodium tetradecyl sulphate (STS). Other sclero- 2Miami Vein Center, Miami, FL, USA sants are not discussed in detail. 3NYU Langone Medical Center, New York, NY, USA Results. The guideline gives evidence based recommenda- 4University of Michigan Hospitals & Health Centers, Ann Arbor, MI, USA 5American Venous Forum, Boston, MA, USA tions concerning indications, contraindications and effectivity 6Southern Illinois University Healthcare, Spring#eld, IL, USA of liquid and foam sclerotherapy of varicose veins and venous 7Brooklyn, NY, USA malformations. 8University of Michigan, Ann Arbor, MI, USA Conclusions. We recommend sclerotherapy for all types 9University of Oklahoma at Tulsa, Tulsa, OK, USA of veins. We recommend to consider the following absolute 10 Division of Vascular Surgery University of Rochester, Rochester, NY, USA contraindications (GRADE 1C): o Known allergy to the scle- 11 University of Maryland Medical Center, Baltimore, MD USA rosant o Acute deep vein thrombosis (DVT) and/or pulmonary embolism o Local infection in the area of sclerotherapy Aim. Endovenous laser ablation (ELA) with a variety of or severe generalised infection o Long-lasting immobility wavelengths is used commonly in the treatment of varicose and con!nement to bed For foam sclerotherapy in addition: veins. Most studies report clinical outcomes of a single wave- o Known symptomatic right-to-left shunt (e.g. symptomatic length compared to non-ELA treatment modalities. We evalu- patent foramen ovale) We recommend liquid sclerotherapy ated the impact of different laser wavelengths on clinical out- as the method of choice for ablation of telangiectasias and comes in patients undergoing ELA. reticular varicose veins (C1) (GRADE 1A). Foam sclerother- Methods. The Varicose Vein Module of the AVR is a coop- apy of C1 varicose veins is an alternative method (GRADE erative registry of multiple specialties. De-identi!ed data was 2B). We recommend foam sclerotherapy over liquid sclero- obtained from 49 participants at 44 sites in 25 states across therapy for the treatment of saphenous veins (GRADE 1A), the US, on 6,253 vein ablation procedures between 2007-2012 venous malformations (GRADE 2B) and recurrent varices in 6,149 patients. Patient demographics, indications for proce- after previous treatment, accessory saphenous varices, dure, laser wavelength and clinical outcomes were assessed at non-saphenous varices and incompetent perforating veins. 35 days utilizing the Venous Clinical Severity Score (VCSS). (GRADE 1C).

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 149 What Triggers Venous Symptoms? Results. The guideline gives evidence based recommendations N. Labropoulos concerning side effects of liquid and foam sclerotherapy of vari- University, Stony Brook, NY, USA cose veins and venous malformations and their management. Conclusions. If anaphylaxis is suspected we recommend Aim. Patients with venous disease may experience symp- stopping the injection immediately and to follow with standard toms of different intensity dependent upon the extent and type emergency procedures including the administration of epine- of pathology they suffer. This report addresses the factors that phrin when appropriate. (GRADE 1A). To prevent inadvertent are responsible for triggering pain paravenous or intraarterial injection we recommend using Methods. Data collected from our institution and relevant ultrasound guidance for both foam and liquid sclerotherapy literature reports were used to elucidate the factors that trig- when the target vein is not visible or palpable (GRADE 1C). ger pain. The macro- and micro-hemodynamic changes and To reduce the risk of skin necrosis we recommend to avoid their effects on the vein wall and peri-venous space were ana- high volume injections. The sclerosant should be injected with lyzed in detail. minimal pressure. (GRADE 1C). To improve general safety of Results. Various hemodynamic changes involving both the foam sclerotherapy we recommend: • Injecting a highly vis- macro- and microcirculation were identi!ed. Venous pain is cous foam into varicose veins (C2) (Level 1C) • Avoiding pa- linked to the activation of the nerve endings located on the tient or leg movement for a few minutes after injection, avoid- vein wall and could be present without marked hemodynamic ing an Valsalva manoeuvre by the patient (Level 1C). changes. Changes in the vein wall and peri-venous space are more common in advanced vein disease. Dilation and local venous hypertension in the microcirculation are necessary for developing signs and symptoms. Re#ux in smaller veins can Association of Radiofrequency Ablation (RFA) of be independent of the main trunks while re#ux in the third the Great Saphenous Vein (GSV) and Ambulatory generation tributaries can lead to signi!cant changes into Phlebectomy (AP) of Collateral and Perforating venules and capillaries. In parallel to the histological studies Varicose Veins in an Outpatient Setting For a Better we have observed changes in veins <2mm with high resolution Functional Result ultrasound. We identi!ed marked re#ux, wall thickening and F. Artale, C. Steinweg dilation and tortuosity that are not usually appreciated on a Vein Clinic Genève, Genève, Switzerland routing venous imaging. Conclusions. Pain and other symptoms are associated with Aim. Nowadays RFA is a valid alternative to the traditional the changes seen in the microcirculation. These are more evi- stripping intervention when there is an insuf!ciency of the dent when bigger veins are involved. The strength of the asso- great saphenous vein (GSV). There are different opinions con- ciation and the number of factors need in order to trigger pain cerning whether it is good or not to associate an intervention is not well understood. for the phlebectomy of collateral varicose veins and the interruption of perforating veins. Some authors suggest waiting a few months before treating varicose veins and remaining perforating veins; others believe that the elimination of the saphe- European Guidelines for Sclerotherapy in Chron- nous re#ux only is enough, and therefore it is unnecessary the ic Venous Disorders Part 2: Side Effects and their intervention on the remaining varicose veins. The authors of Management this research propose the association of the two methods (RFA J. Guex1, E. Rabe 2, F. Breu 3, A. Cavezzi 4, P. Coleridge-Smith 5, A. Frul- + AP) at the same time. lini6, J. Gillet 7, C. Hamel-Desnos 8, P. Kern 9, B. Partsch 10 , A. Ramelet 11 , Methods. 30 patients, who suffered from insuf!ciency L. Tessari12 , F. Pannier13 of the great saphenous vein (GVS) with the presence of col- 1Cabinet de Phlebologie, Nice, France lateral varicose veins and incontinence of perforating veins, 2University of Bonn, Department of Dermatology, Bonn, Germany have been treated. All patients were submitted to evaluation 3Kreussler, Rottach-Egern, Germany of venous valvular re#ux with duplex ultrasound scanning. 4Poliambulatorio Hippocrates, San Benedetto Del Tronto, Italy 5British Vein Institute, Amersham, UK The procedure of thermal ablation was performed in an out- 6Studio medico "ebologico, Figline Valdarno-Florence, Italy patient setting with a VNUS ClosureFAST Procedure, under 7Vascular Medicine, Bourgoin-Jallieu, France tumescent local anesthesia. The phlebectomy was performed 8French Society of Phlebology, CAEN, France immediately after using the Müller technique, still under lo- 9Private of#ce of Vascular Medicine and Service of Angiology, University cal anesthesia. An elastic compression was constantly applied Hospital Lausanne, Vevey, Switzerland 10 private practice, Vienna, A-1180, Austria with an adhesive bandage for 24 hours and subsequently an 11 Dept Dermatology Inselspital Bern, Lausanne, Switzerland elastic stocking (KII) for one week. In any case a low-molecu- 12 Bassi Foundation Trieste, 37019 Peschiera del Garda, Verona, Italy lar-weight heparin prophylaxis was performed for 7 days. All 13 Cologne, Germany patients were controlled with duplex ultrasound scanning after 7 days, after 3 months, after 6 months and after 1 year fol- Aim. Sclerotherapy is the targeted chemical ablation of lowing the treatment. varicose veins by intravenous injection of a liquid or foamed Results. After 7 days 100% of patients had an occlusion sclerosing drug. The aim of this guideline is to give evidence of the GSV with the complete elimination of the re#ux. After based recommendations for liquid and foam sclerotherapy. 6 months 100% of patients had a complete resorption of the Methods. This guideline was drafted on behalf of 23 Euro- GVS without re#ux. After 1 year only 2 cases out of 30 (6,7%) pean Phlebological Societies during a Guideline Conference had a partial re-canalization and re#ux of collateral varicose on 7th - 10th May 2012 in Mainz. The conference was organ- veins, which made a further phlebectomy intervention nec- ized by the German Society of Phlebology. These guidelines essary. The Venous Clinical Severity Score signi!cantly im- review the present state of knowledge as re#ected in published proved at three months (P < 0.001). No serious complications medical literature. The recommendations of this guideline were observed. are graded according to the GRADE recommendations. This Conclusions. The results show that a combined treatment guideline focuses on the two sclerosing drugs which are li- of radiofrequency ablation (RFA) and ambulatory phlebectomy censed in the majority of the European countries, Polidocanol (AP) brings about a more complete and de!nitive result, along (POL) and Sodium tetradecyl sulphate (STS). Other sclero- with an obviously better tolerability for the patients, who can sants are not discussed in detail. solve their functional problems with one treatment only.

150 INTERNATIONAL ANGIOLOGY October 2013 European Guidelines for Sclerotherapy in Chronic Registry databases were searched from January 2000 through Venous Disorders Part 3: Principles of Liquid and January 2013 for RCTs and large CS employing EVA or FS as Foam Sclerotherapy a single modality for treatment of GSI, with concomitant postoperative duplex scanning. Pooled (strati!ed) incidence of VTE E. Rabe1, F. Breu 2, A. Cavezzi 3, P. Coleridge-Smith 4, A. Frullini 5, J. Gil- let6, J. Guex 7, C. Hamel-Desnos 8, P. Kern 9, B. Partsch 10 , A. Ramelet 11 , with 95% con!dence intervals was estimated using the DerSi- L. Tessari12 , F. Pannier13 monian-Laird procedure for random effects meta-analysis. 1University of Bonn, Department of Dermatology, Bonn, Germany Results. Twelve RCTs and 19 CS investigating EVA (radi- 2Kreussler, Rottach-Egern, Germany ofrequency ablation [RFA] with VNUS® ClosureFAST™ cath- 3Poliambulatorio Hippocrates, San Benedetto Del Tronto, Italy eter only, endovenous laser ablation [EVLA], or both) were 4British Vein Institute, Amersham, UK included. Data from 5 RCTs and 6 CS investigating nonpropri- 5Studio medico "ebologico, Figline Valdarno-Florence, Italy etary foam preparations were analyzed. For context, incidence 6Vascular Medicine, Bourgoin-Jallieu, France 7Cabinet de Phlebologie, Nice, France of VTE in the ligation and stripping arms of EVA RCTs was 8French Society of Phlebology, CAEN, France assessed. All VTE classes were rare for each modality [Table]. 9Private of#ce of Vascular Medicine and Service of Angiology, University Estimated incidence rates were similar in RCTs and CS, except Hospital Lausanne, Vevey, Switzerland those for thrombus extension and overall VTE, which were 10 private practice, Vienna, A-1180, Austria signi!cantly more common in RFA CS than RCTs (P<0.001 11 Dept Dermatology Inselspital Bern, Lausanne, Switzerland 12 Bassi Foundation Trieste, 37019 Peschiera del Garda, Verona, Italy and P=0.005, respectively). 13 Cologne, Germany Conclusions. Treatment of GSI by EVA or FS is a common vascular intervention. The strati!ed incidence of VTE appears Aim. Sclerotherapy is the targeted chemical ablation of to be low as reported in both RCTs and CS investigating these varicose veins by intravenous injection of a liquid or foamed modalities. Observed incidence was also low with ligation and sclerosing drug. The aim of this guideline is to give evidence stripping. Although duplex scans were obtained postoperative- based recommendations for liquid and foam sclerotherapy. ly, a minority of studies speci!ed protocols for VTE detection. Methods. This guideline was drafted on behalf of 23 Euro- pean Phlebological Societies during a Guideline Conference on 7th - 10th May 2012 in Mainz. The conference was organ- European Guidelines for Sclerotherapy in Chronic ized by the German Society of Phlebology. These guidelines review the present state of knowledge as re#ected in published Venous Disorders Part 4: Diagnostic evaluation be- medical literature. The recommendations of this guideline fore and outcome evaluation after sclerotherapy are graded according to the GRADE recommendations. This F. Breu 1, E. Rabe 2, A. Cavezzi 3, P. Coleridge-Smith 4, A. Frullini 5, J. Gil- guideline focuses on the two sclerosing drugs which are li- let6, J. Guex 7, C. Hamel-Desnos 8, P. Kern 9, B. Partsch 10 , A. Ramelet 11 , L. Tessari12 , F. Pannier13 censed in the majority of the European countries, Polidocanol 1Kreussler, Rottach-Egern, Germany (POL) and Sodium tetradecyl sulphate (STS). Other sclero- 2University of Bonn, Department of Dermatology, Bonn, Germany sants are not discussed in detail. 3Poliambulatorio Hippocrates, San Benedetto Del Tronto, Italy Results. The guideline gives evidence based recommenda- 4British Vein Institute, Amersham, UK tions concerning principles of liquid and foam sclerotherapy 5Studio medico "ebologico, Figline Valdarno-Florence, Italy of varicose veins and venous malformations. 6Vascular Medicine, Bourgoin-Jallieu, France 7Cabinet de Phlebologie, Nice, France Conclusions. We recommend the use of a three-way-stop- 8French Society of Phlebology, CAEN, France cock (Tessari method) or two-way connector (Tessari-DSS 9Private of#ce of Vascular Medicine and Service of Angiology, University method) for the generation of sclerosant foam for all indica- Hospital Lausanne, Vevey, Switzerland tions. (GRADE 1A) We recommend air as the gas component 10 private practice, Vienna, A-1180, Austria for generation of sclerosing foam for all indications (GRADE 11 Dept Dermatology Inselspital Bern, Lausanne, Switzerland 12 Bassi Foundation Trieste, 37019 Peschiera del Garda, Verona, Italy 1A) or a mixture of carbon dioxide and oxygen (GRADE 2B). 13 Cologne, Germany We recommend a ratio of liquid sclerosant to gas for the production of a sclerosing foam of 1 + 4 (1 part liquid + 4 parts Aim. Sclerotherapy is the targeted chemical ablation of air) to 1 + 5 (GRADE 1A). When treating varicose veins (C2), varicose veins by intravenous injection of a liquid or foamed viscous, !ne-bubbled and homogenous foam is recommended sclerosing drug. The aim of this guideline is to give evidence (GRADE 1C). Increasing the proportion of the sclerosant is based recommendations for liquid and foam sclerotherapy. acceptable, especially with lower concentrations of sclerosant Methods. This guideline was drafted on behalf of 23 Euro- drugs. We recommend that the time between foam production pean Phlebological Societies during a Guideline Conference and injection is as short as possible. (GRADE 1C). We recom- on 7th - 10th May 2012 in Mainz. The conference was organ- mend a maximum of 10 mL of foam per session in routine cas- ized by the German Society of Phlebology. These guidelines es (GRADE 2B). Higher foam volumes are applicable accord- review the present state of knowledge as re#ected in published ing to the individual risk-bene!t -assessment (GRADE 2C). medical literature. The recommendations of this guideline are graded according to the GRADE recommendations. This guideline focuses on the two sclerosing drugs which are li- censed in the majority of the European countries, Polidocanol Thromboembolic Complications of Endovenous (POL) and Sodium tetradecyl sulphate (STS). Other sclero- Thermal Ablation and Foam Sclerotherapy in the sants are not discussed in detail. Treatment of Great Saphenous Vein Insuf#ciency Results. The guideline gives evidence based recommenda- M. Dermody1, M. Schul2, T. O’Donnell1 tions concerning diagnostic evaluation before and outcome 1Tufts Medical Center, Boston, MA, USA evaluation after liquid and foam sclerotherapy of varicose 2Lafayette Regional Vein Center, Lafayette, IN, USA veins and venous malformations. Conclusions. We recommend diagnostic evaluation includ- Aim. Examine the incidence of venous thromboembolism ing history-taking, clinical examination and Duplex ultrasound (VTE) following treatment of great saphenous insuf!ciency investigation before sclerotherapy. In telangiectasias and retic- (GSI) by endovenous thermal ablation (EVA) or foam scle- ular varicose veins, cw-Doppler instead of Duplex ultrasound rotherapy (FS) using meta-analysis of published randomized may be suf!cient. (GRADE 1C). We strongly recommend duplex controlled trials (RCTs) and case series (CS). ultrasound prior to sclerotherapy in patients with recurrent var- Methods. Medline, Embase, Cochrane, and Clinical Trials icose veins after previous treatment and in patients with vascu-

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 151 lar malformations. (GRADE 1B). We recommend against rou- Foam Sclerotherapy with Enoxaparin Prophylaxis tine investigation for right-to-left shunts or for the presence of in Patients at High Risk for Thromboembolic Events thrombophilia factors in the coagulation system. (GRADE 1C). S. Reich-Schupke1, M. Doerler1, P. Altmeyer2, M. Stücker1 To assess the outcome after sclerotherapy we recommend clini- 1Vein Centre, Departments of Dermatology and Vascular Surgery, Ruhr- cal outcome evaluation in telangiectasias and reticular varicose University Bochum, Bochum, Germany veins (C1) and clinical and ultrasound outcome assessment in 2Department of Dermatology, Venereology and Allergology, Ruhr-Univer- varicose veins (C2) and venous malformations. (GRADE 1C). sity Bochum, Bochum, Germany Aim. Hypercoagulability and thrombophilia with or without deep venous thrombosis are relative contraindications for Venous Ulcer Treated by Laser Ablation Only sclerotherapy according to the current German guidelines. K. Goudarzi However, patients suffering from these conditions are often in need of sclerotherapy. Recommendations for prophylactic Kamran Goudarzi MD, PA, Wilmington, NC, USA anticoagulation under sclerotherapy are missing. Methods. In this retrospective analysis (2009-2010) we Aim. There is no literature of venous ulcers healing utiliz- included 54 patients who had foam sclerotherapy of truncal ing laser ablation. or tributary veins with a deep venous thrombosis and/ or pul- Methods. The patient came in with a venous ulcer. She was monary embolism in medical history and no permanent anti- treated with laser ablation. The wound was kept clean. 20/30 coagulation. Additionally to the compression treatment with mm/hG of Compression Stocking was utilized. The patient 23-32mmHg for 3 weeks patients received Enoxaparine 40mg had multiple ultrasound guided sclerotherapy, in addition. once a day for 3 days after sclerotherapy. Clinical and duplex- Both the long and short saphenous veins were laser ablated. sonographic controls were conducted before every treatment The ulcer itself was not treated by any topical medication. It and 2-3 weeks after the last injection. was kept clean by regular washing only. No Phlebectomy was Results. Sclerotherapy was either performed on one (30/54) utilized. The ulcer healed on its own. or on both (24/54) legs. A truncal vein was treated in 2/54 pa- Results. The ulcer healed on its own following laser abla- tients. All patients received foam sclerotherapy of tributaries. tion procedure. The volume per treatment session was 3.3ml foam on average Conclusions. This is proof that laser ablation can heal ve- (2-6ml). The patients had an average of 4.9 treatments (1-11). nous ulcers. Altogether 262 treatments were performed. No deep venous thrombosis or symptomatic pulmonary embolism occurred. In 7/262 treatments (2.7%) there was a symptomatic phlebitis in the treated area, in 2/262 treatments (0.8%) patients developed an ascending phlebitis beyond the sclerotherapy region. Venous Aneurysms of the Lower Limbs Personal Ex- Conclusions. According to the current data, foam sclero- perience therapy with a co-treatment of compression (23-32mmHg) J. Pereira Albino, J. Vieira, P. Amorim, L. Castro e Sousa, G. Sousa, G. and Enoxaparin 40mg once per day for 3 days after sclerother- Sobrinho, N. Meireles apy can be regarded as safe in patients with thromboembolic Vascular S. II H Pulido Valente - CHLN, Lisbon, Lisbon events in medical history. The current study is the !rst with a standardized regimen. Further prospective and randomized Aim. Venous aneurysms of the lower limbs are a rare clini- controlled studies are necessary to verify the tolerability and cal entity sometimes associated with congenital venous mal- safety of sclerotherapy in patients with a high risk for throm- formation. The diagnosis may be associated with symptoms boembolic events. like profound venous thrombosis and/or pulmonary thromboembolism or it may just be accidentally found out within the scope of hemodinamyc studies to assess chronic venous disease. A New Method for the Production of Foam Sclero- Methods. The authors present 7 clinical cases of venous an- therapy eurysm of the lower limbs, in a 13-year retrospective study. In F. Casals-Sole six cases there was popliteal vein aneurysm, whose diagnosis Hospital Clinic, Barcelona, Spain happened by accident in the progress of an ultrason study of the inferior limbs for chronic venous disease. In one of the cas- Aim. Foams are produced by supersaturating the liquid es, the manifestation was pulmonary thromboembolism and with gas or by mechanical means. In phlebology, several me- the study of the lower limbs revealed aneurysms of the femoral chanical methods are employed to produce a foam sclerosant and popliteal veins. 5 patients were submitted to surgical cor- drug, essentially by beating or using high pressure hydrody- rection, through exclusion and direct closure, or bypass tech- namic forces. The foam thus obtained is heterogeneous and niques. In 4 cases the existing super!cial insuf!ciency was also unstable. We propose a new mechanical method to produce cared for. Two patients refused surgery. more homogenous and stable foam and able to be employed Results. All the operated patients were followed during as a “point-of-care”. one year after the surgery. Their profound venous system was Methods. Different concentrations of a non-ionic sur- found permeable and non-dilated in 4 cases. The case in which factant (polidocanol) in 5% glucose or physiological serum a PTFE interposition was done it was thrombosed after two were prepared. Branson 450W Sonicator®, operating a 20 years of the surgery and the patient revealed post-thrombot- kHz frequency ultrasound, delivering 23-25 watts over 2 ml ic symptoms. In one of the patients who refused surgery the samples of these solutions of Polidocanol, across a tapered aneurysm was asymptomatic 5 years after the diagnosis and microtip of 3 mm, placed at liquid/gas interface, was used. other was lost for follow-up. Foam obtained is transferred to a 3 ml plastic syringe (Teru- Conclusions. Venous aneurysms, particularly when they mo®), and maintained plate, at room temperature. One drop are saccular, may be a source of venous thromboembolism is placed between a slide and a cover-slide, and microscopi- and should be corrected. The classical surgical repair with cally observed. recession of the aneurysm area and direct closure produces Results. In less than four seconds, with amplitude of 60 %, rather satisfactory results and should be the preferential tech- is it possible to induce a transient cavitation, with apparition nique to use. of white foam at concentrations as low as 0.10 % of Polido-

152 INTERNATIONAL ANGIOLOGY October 2013 canol. Thirty percent of foam volume is immediately drained !ciency in the population evaluated 2- evaluate treatment out- in 30 seconds, but 80% of remainder foam persisted for ten come 3- evaluate complications minutes, in the microscope different distributions of uniform Methods. Case report of 195 patients consecutive patients round microbubbles were observed. in a private phlebology clinic focused on aesthetic result Con- Conclusions. With this new method we can standardize ducted between August 2011 and June 2012 All patients were the foam production, obtaining a signi!cant amount of micro- evaluated/treated by the author following the sequence: history, bubbles, in a short time, allowing decreasing signi!cantly the examination, duplex scanning, photoplesitmography, augment- polidocanol concentration, and suf!ciently persisting in time ed reality, photo documentation (25-50 photos every session/ before injection, enabling a more reproducible treatment. consultation), transdermal laser shots with cold air skin cooling followed by Dextrose75% sclerotherapy also with skin cooling and Augmented Reality Guidance. Results were evaluated by patient’s satisfaction and before and after photo comparison Results. 195 patients were evaluated and treated. 18 male and 177 female (92%). Average age was 50.95. 33(17%) complained Improvement in Foam Sclerotherapy with the Ex- about pain and/or edema. 63(32%) had indication of Endo Ve- ternal Application of Ultrasounds: Preliminary Re- nous Laser Ablation (had insuf!ciency on saphenous veins seg- sults ments). 138(70%) had indication of Cryo-Laser and Cryo-Scle- F. Casals-Sole rotherapy. 138(100%) of the treated patients had feeder veins Hospital Clinic, Barcelona, Spain under augmented reality visualization. 6(3%) didn’t treat complaining about the cost. Average number of sessions was 2.15. Aim. Local drug delivery has been approached with the Average number of laser shots per session was 652 (min 10, max intravenous administration of microbubbles loaded with the 2950). 31(61%) had improvement above 75%. 101(39%) had im- therapeutic agent, which respond to the pressure of externally provement between 50-75%. 2 patients complained about hyper- applied ultrasounds, causing resonance and destruction of pigmentation (1%). There was no other complication. these bubbles allowing drug release to the target tissues. We Conclusions. Duplex Scanning and Augmented Reality apply local ultrasounds over foam !lled varicose veins, to prof- evaluation helps on diagnostic accuracy. All patients had feeder it as a core for triggering phenomena of acoustic re#ections veins under the telangiectasias. Cryo-Laser and Cryo Sclero- and sharing forces reinforcing endothelial wall disruptions; therapy (D75%) guided by Augmented Reality is a new, effec- moreover allowing to reduce the sclerosant concentrations to tive and safe method. As soon as other groups starts to use the occlude large veins. method in different populations it will be possible to have more Methods. Polidocanol in CO2/O2 (70%/30%)-based foam conclusions about advantages and disadvantages (such as price is injected in varicose veins. Veins !lled with bubbles were of the devices). The lack of use of augmented reality in sample sonographically detected, and while the patient remains selection may be a bias to all telangiectasia treatment trials. with the legs elevated, we applied externally over this area a beam of continuous 3 MHz ultrasound of moderate intensity (30sec/cm2). Patients wear elastic stockings for three The Value of Early Thromboprophylaxis with weeks. Dalteparin in Patients with Ovarain Cancer Quali- Results. In !ve patients we have treated nine varicose veins #ed to Surgical Treatment segments: one great saphenous vein (ø=1.8 cm), six accesso- Z. Krasinski1, D. Szpurek 2, R. Staniszewski 3, Ł. Dzieciuchowicz 3, B. ries great saphenous veins in the thigh (two with ø>1.5 cm) Krasinska4, K. Pawlaczyk4, T. Urbanek5 or leg, reticular veins and telangiectasias, at 1.5%-0.5% po- 1Univerity of Medical Sciences Poznan Poland, Poznan, Poland, lidocanol concentrations. Ultrasounds were applied for 8-18 2Clinic of Gynecology, Univerity of Medical Sciences Poznan Poland, minutes. No secondary effects were reported, exception one Poznan, Select, Poland intravascular hematoma. At month, with the exception of tel- 3Univerity of Medical Sciences Poznan Poland, Poznan, Select, Poland angiectasias, we found the segment treated incompressible in 4Clinic of Hypertension, Univerity of Medical Sciences, Poznan, Select, Poland all cases. In two cases, the above segment was found occluded. 5 Deep vein system was unaffected. Medical University of Silesia, Katowice, 40-635, Poland Conclusions. The use of ultrasounds as an adjuvant to pro- Aim. Ovarian cancer (OC) is associated with a high risk of duce re#ections and shearing stress in injected foam, improve venous thromboembolism (VTE) both in pre- and postopera- the effects of the varicose vein treatment, allowing using low tive period. The purpose of the study was to analyse the ef- sclerosant concentrations, besides providing a new pharmaco- !cacy and safety of an early prophylaxis with dalteparin inpa- dynamical explanation of foam treatment. tients with OC quali!ed for surgical treatment Methods. The study group consisted of 37 patients with OC quali!ed for surgery in whom thromboprophylaxis was started at the moment of quali!cation for surgical treatment. Case Report of 195 Patients Classi#ed by Duplex The control group consisted of 61 OC quali!ed for surgery in Scanning and Augmented Reality, and Treated by whom thromboprophylaxis was started 12 hour before surgery. The duration of postoperative prophylaxis was 4 weeks in Cryo-Laser & Cryo-Sclerotherapy: Results and Com- both groups. Dalteparin 5000 U/day was used in both groups. plications The primary end points were occurrence of VTE and major K. Miyake bleeding. The patients underwent full gynaecological exami- Clinica Miyake, Sao Paulo, Brazil nation, Duplex Doppler scan and D-dimer (DD) concentration measurement at the moment of quali!cation for surgery, 1 day Aim. Duplex Scanning and Augmented Reality (projection before and 7, 14, 28 days and 3 months after the surgery of infra-red image of veins onto the skin) are new semiotic Results. The total duration of thromboprophylaxis was tools to a phlebology clinic. Transdermal laser is now capa- 45,3±10,7 days in SG and 27,9±3,7 days in CG (p<0,0001). The ble of selective photothermolisis and the synergy with Dex- deep venous thrombosis rate was 2,7% in SG and 16,4% in CG trose75% sclerotherapy allows a more effectiveness. This tech- /(p=0,042/). Neither pulmonary embolism nor major bleeding nique was designed to be free of anaphylaxis and embolism. was observed. Median preoperative DD concentration in all pa- Objective: 1- calculate the prevalence of saphenous vein insuf- tients was 1700 ng/ml and was signi!cantly higher inpatients

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 153 who developed postoperative DVT when compared to those Conclusions. In our multicenter cohort study, CDU inves- who did not 2556.8 and 1691,0 ng/ml, respectively (p=0.0009). tigation showed incompetence of SSV associated with com- Conclusions. Early thromboprophylaxis with dalteparin in petence of terminal valve at SPJ in one third of the cases. Re- patients with ovarian cancer quali!ed for surgical treatment cruitment-based re#ux has been highlighted in popliteal and is safe, decreases the prothrombotic activation of haemostasis femoral vein above incompetent SPJ, with 98% abolition of and the risk of thromboembolic complications.To determine this re#ux after SSV surgery/foam sclerotherapy. indication, dosage and timing of such thromboprophylaxis in this group of patients further studies are required

Relationship between Circumstances of Evacuation Chronic Venous Leg Ulcers Bene#t from Abolition of Facility and Deep Vein Thrombosis after East Japan “Sourcing-Positive“ Re"ux Routes and Ulcer Surgery Great Earthquake A. Obermayer K. Hanzawa1, M. Shibata 2, S. Ueda 3, M. Ikura 4, T. Nakajima 5, T. Karl Landsteiner Society, Institute of Functional Phlebologic Surgery, Okamoto6, M. Tsuchida7 Melk, Austria 1Niigata University, Niigata, Japan 2Miyagi Cardiothoracic vascular Center, Kurihara, Japan Aim. We developed “duplex-sourcing” to determine re#ux 3Ishinomaki Red Cross Hospital, Ishinomaki, Japan routes causing venous hypertension in ulcerated legs and 4National Niigata Hospital, Kashiwazaki, Japan propose a three-step-therapy for successful management. We 5Niigata National Hospital, Kashiwazaki, Japan present our principles and outcomes. 6Niigata University Graduate School of Medicine, Niigata, Japan 7Niigata University Graduate School of Medicine, Niigaat, Japan Methods. For the last 16 years our procedure for intractable venous leg ulcers included three main steps: 1. Abolishment of Aim. In East Japan Great Earthquake, 15,883 people died super!cial and perforator venous re#ux with particular focus and 2681 people still have not been recognized. 600,000 peo- on „sourcing positive” re#ux routes. Therefore we performed ple evacuated immediate after the quake. We have investigated surgery of insuf!cient saphenous trunks, side branches and below-the-knee DVT (BKDVT) in evacuation facilities since 4 perforators. Since 13 years we also use endoluminal techniques days after the quake. There were many evacuation facilities such as radiofrequency, LASER and foam-sclerotherapy. 2. Sur- in disaster area, however the circumstances of them were dif- gery of the ulcer: Debridement, shaving or fasciectomy followed fered in each place. When we examined at an evacuation facil- by mesh graft in the same session. 3. Compression therapy. ity with severe circumstances in tsunami area, many BKDVT Results. Ulcer healing was achiefed in 87% of the cases. The were determined in evacuees. The purpose of this study is to mean time of healing was 6 weeks. A total of 13% of the ve- elucidate the relationship between BKDVT and the circum- nous ulcers never healed but improved, recurrent venous ulcers stances of evacuation facility. occurred in 5%. The mean size of ulceration was 12cm² (0,25- Methods. We examined 2500 evacuees in 220 evacuation 500). Before surgery the patients were resistant to treatment for facilities after East Japan Great Earthquake from March to a period ranging from 4 weeks to 30 years (median 1 year). December 2011. BKDVT was determined by compression ul- Conclusions. This strategy of ulcer treatment results in a trasound examination in sitting position. We delivered evacu- signi!cant improvement of ulcer healing rate, reduction of re- ees graduate stocking to prevent pulmonary embolism. currence rate and an impressive increase in quality of life in Results. In tsunami area in Miyagi prefecture (Minami- comparison with data from the literature. A crossover re#ux Sanriku town, Ishinomaki city, Higashi-Matsushima city), cir- pattern or a small diameter of the causal vein may lead to inac- cumstances of evacuation facilities were so sever, shortage of curate treatment and early recurrence. food or water, no electricity, no gas, very cold #oor. All evacuees slept directly on the #oor without bed or mattress, only they used blanket more than 7 days. The frequency of BKDVT Sapheno-Popliteal Junction Hemodynamics and in tsunami area 7-14 days after the quake was more than 35% Variations in Femoral and Popliteal Vein Hemody- (30-47%). In inland area in Miyagi prefecture (Tome city, Kuri- namics after Small Saphenous Vein Treatment: A hara city), circumstances of evacuation facilities were better Colour-Duplex Ultrasound Observational Study than that in tsunami area. There were food or water, mattress, F. Campana 1, A. Cavezzi2, S. Urso3 electricity, gas, etc. However, evacuee slept directly on the #oor using mattress or Futon. The frequency of BKDVT in inland 1Bufalini Hospital Cesena, San Benedetto del Tronto, Ascoli Piceno, Italy 2Poliambulatorio Hippocrates, San Benedetto del Tronto, Italy area was about 10% (9-15%). 3Vascular Unit Hippocrates, San Benedetto del Tronto, Ascoli Piceno, Italy Conclusions. The frequency of BKDVT correlated with circumstances of evacuation facilities. Severe circumstances of Aim. to assess hemodynamics of sapheno-popliteal junc- evacuation facility induce stress and immobility following BK- tion (SPJ) and of popliteal and femoral vein after small saphe- DVT. However BKDVT in evacuation facilities without sever nous vein (SSV) treatment circumstance was high (10%). We suspect that the reason of Methods. 241 patients, (75 M et 166 F, mean age 54 years), that is sleeping directly on the #oor. Further study is needed to for a total of 280 limbs with SSV incompetence were investi- clarify the reason of that. gated with colour-duplex ultrasound (CDU) immediately before and six months after SPJ ligation+stripping and phlebectomies (162 limbs), ultrasound-guided foam sclerotherapy (86 limbs), long catheter foam sclerotherapy (32 limbs). Results. Pre-operative CDU investigation showed re#ux in Response to Lymphedema Treatment Assessed by the distal thigh segment of femoral vein and in popliteal vein Ultrasound above SPJ in 185 limbs (66%), whereas in 95 limbs (34%) no E. Iker deep venous re#ux was highlighted (SSV terminal valve com- Lymphedema Center, Santa Monica, CA, USA petence). Six months after treatment the re#ux in popliteal and femoral vein completely disappeared in 142 cases (77%) Aim. The objective of this study was to assess the response and it was below one second in 39 cases (21%), !nally in 4 to treatment of lymphedema using quantitative measurements limbs (2%) re#ux persisted unchanged. with ultrasound.

154 INTERNATIONAL ANGIOLOGY October 2013 Methods. The study included 16 patients with lymphedema Results. All patients demonstrated clinical evidence of of the lower extremities: 9 with primary lymphedema and 7 with lymphedema of lower extremities, pelvis and/or genital ar- secondary lymphedema. 23 edematous lower limbs were evalu- eas. The onset of lymphedema varied from several days to !ve ated. Epifascial thickness (skin to fascia) was measured with ul- years after surgery. The clinical presentation of lymphedema trasound prior to the treatment at the ankle, calf and distal thigh was correlated with the !ndings by lymphoscintigraphy and in each edematous leg. Measurements were repeated at identical TERASON Ultrasound System t3000. locations after 30 minutes of manual lymph drainage (MLD) and Conclusions. Several distinct patterns of altered lymphatic again after an additional 30 minutes of pump treatment. #ow were demonstrated, and they correlated with the location Results. Mean reduction of epifascial space thickness of and character of clinical signs and symptoms. The importance the lymphedematous limbs after just one session of MLD was of early identi!cation and treatment of lymphedema, and the 16.9%, (ankle site 13.1%, calf 14.9% and thigh 15.8%). After correlation of radiographic and clinical !ndings are discussed. additional pump treatment the mean reduction compared to baseline was 29.6%, (ankle 24.0%, calf 23.5% and thigh 26.0%). Conclusions. Ultrasound is easily performed and provides Minimally Invasive Endovenous Laser Ablation with quantitative measurements of volume and thickness of epifas- a 1320nm laser in the Treatment of Lower Extremity cial space. It allows objective measurements of the severity of Venous Disease and Venous Ulcers disease and response to treatment in patients with lymphedema. V. Mishra 1, L. Miller2, S. Alsaad2, H. Greenway2, L. Housman3 1Scripps Health, Nashville, TN, USA 2Scripps Health, La Jolla, CA, USA Endovenous Laser Treatment for Small Saphenous 3Scripps Clinic Medical Group, San Diego, CA, USA Vein Re"ux: Effectiveness and Safety Aim. Venous disease is one of the most commonly report- 1 2 2 3 2 V. Mishra , L. Miller , S. Alsaad , L. Housman , H. Greenway ed chronic medical conditions and a substantial source of 1Scripps Health, Nashville, TN, 2Scripps Health, La Jolla, CA, USA morbidity in the USA. Venous ulceration is a severe clinical 3 Scripps Clinic Medical Group, San Diego, CA, USA manifestation of chronic venous insuf!ciency resulting in signi!cant pain, disability, decreased quality of life for the pa- Aim. Venous re#ux is a relatively common problem causing tients and increasing healthcare expenditure. Our cases series decreased quality of life for many patients. Due to local anato- reports on the safety and ef!cacy of treatment of 36 venous my, ablative treatment of the small saphenous vein (SSV) may ulcers at Scripps Clinic with the 1320nm laser with 1 month, 6 result in a number of complications, including: sural nerve in- month, 1 year, 18 month, and 2 year follow-up data. jury, deep vein thrombosis, and damage to the overlying skin. Methods. A retrospective chart review was performed of all Safety and effectiveness of endovenous laser treatment (EVLT) EVLT cases performed for the venous ulcers from March 2007 has been well characterized for treatment of the greater saphe- to April 2013. Charts were reviewed for treatment complica- nous vein, but not so for the SSV. This study reports one in- tions as well as resolution and recurrence of venous ulcers. stitution’s data regarding the effectiveness and safety of EVLT Results. Of 36 patients with documented venous disease speci!cally for SSV re#ux using a 1320nm wavelength laser. and venous ulceration, all were treated with EVLT using a Methods. A retrospective chart review was performed of 1320nm wavelength laser. A combination of EVLT and Endov- all EVLT cases performed for the SSV from June 2009 to April enous Chemical Ablation (ECA) treatments resulted in com- 2013. Charts were reviewed for complications, closure of treat- plete resolution of the venous ulcers without any recurrence. ed vein, and re-canalization. No deep vein thrombosis, nerve injury, or cutaneous damaged Results. Of 343 patients with documented small saphen- occurred in our series of 36 patients. Percentage closure, per- ous vein re#ux, 342 were treated with EVLT using a 1320nm centage re-canalization, and complications will be reported for wavelength laser. One treatment was terminated for failure 6-, 12-, 18-, and 24-month follow-up. All procedures have been to pass the guidewire. No deep vein thrombosis, nerve injury, performed by the same team in an of!ce setting with minimal or cutaneous damaged occurred in our series of 343 patients. recovery time and side effects. Percentage closure, percentage re-canalization, and complica- Conclusions. When properly performed, endovenous laser tions will be reported for 6-, 12-, and 18-month follow-up. treatment using a 1320nm wavelength laser is a safe and effec- Conclusions. When properly performed with avoidance of tive treatment option for venous disease and ulceration. the sural nerve, endovenous laser treatment using a 1320nm wavelength laser is a safe and effective treatment option with low risk of complications for small saphenous vein re#ux. A Novel Vapor Method for Saphenous Vein Ablation in the Caprine Model: Science and Histology L. Kabnick, H. Rana, T. Berland, M. Sadek Pelvic Lymphadenectomy Resulting in Lymphedema NYU Langone Medical Center, New York, USA E. Iker Lymphedema Center, Santa Monica, CA, USA Aim. Since 1999, disruptive technologies are the standard to ablate re#uxing truncal veins. However, integral parts of the Aim. The objective of this study is to assess alterations of method theory are focused on the thermal reactions leading lymphatic anatomy and physiology resulting from pelvic lym- to steam destruction. The purpose of this animal study is to phadenectomy. observe the effects of vapor/steam ablation on the venous wall Methods. Forty-two patients who presented with sympto- and to understand steam as the sole energy source. matic lower extremities swelling following pelvic surgery un- Methods. Two studies were performed. Saphenous veins derwent whole body lymphoscintigraphy. Symptoms included were percutaneously accessed and vapor was delivered through uncomfortable pelvic and lower extremity swelling, and/or a novel RF catheter placement. Pre and post treatment vein di- genital discomfort, recurrent infections, skin breakdown, im- ameters were measured by ultrasound. Necropsy and histopa- paired wound healing, limited range of motion, and alterations thology were performed. In study one, 6 animals (12 limbs) of cosmesis. Pelvic lymphadenectomy had been performed for were treated: 1 acute and 5 chronic (42days). All veins received management of uterine cancer (12 patients), cervical cancer tumescent anesthesia. Power was set at 60W and delivered by (8 patients), ovarian cancer (5 patients), prostate cancer (6 pa- continuous or intermittent pullback rate of 1cm/6sec. In study tients), bladder cancer (3 patients), and melanoma (8 patients). two, 2 limbs were treated with and without tumescent. Power

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 155 was set to 60W and the catheter was held stationary for 20s. used for the non-purpuric treatment of a variety of vascular le- Points proximal and central to the catheter tip were evaluated. sions including facial telangiectases, rosacea and other micro- Results. Treatment resulted in lumen reduction, low depth vasculature disorders. of thermal penetration, and full-thickness circumferential ef- Results. The near-infrared 1064 nm Nd:YAG laser is not as fect. The !nal set of chronic animals showed persistent closure well absorbed by hemoglobin as the 532 nm KTP laser, but there at 6wks. In study 2: there were minimal proximal histological is almost no melanin competition at this longer wavelength. The changes in the limb with perivenous tumescent; however, no longer wavelength leads to deeper penetration and targeting of such histological changes were observed in the limb without deeper, blue spider veins of up to 3 mm. The results that can be tumescent. reached for small leg telangiectasias are comparable with those Conclusions. EVAT (Endovenous Vapor Ablation Treat- reached by sclerotherapy. The results can be further improved ment) appears to provide even convective-heating of the vein when these two modalities were combined. Postsclerotherapy- wall without perforation. In theory, the safety pro!le and ef- induced matting as well as diffuse #ushing syndromes can also !cacy could be equal or better than current energy-based mo- effectively be treated by the 1064 nm Nd:YAG laser. dalities. Conclusions. Side effects of laser treatments for vascular lesions are uncommon but may include burns and pigment dyschromia. High Frequency of Arteriovenous Fistula in Chronic Venous Ulcers B. Hoyle1, A. Strauss2, M. Thein2, I. Gordon3 Five Year Result of Endovenous Radiofrequency 1Advanced Vein Care, Orange, CA, USA Ablation for Super#cial Venous Insuf#ciency of the 2VALBHCS, Long Beach, CA, USA Great Saphenous Vein 3VA Medical Center Long Beach, Long Beach, CA, USA W. Kim Aim. While studying sclerotherapy of chronic venous ul- National medical center, Seoul, Jung-gu, Korea cers, duplex ultrasound (DUS) of the skin surrounding the patients’s wounds was performed. We observed a surprising- Aim. Endovenous radiofrequency ablation( VNUS®Closure ly high incidence of super!cial arteriovenous !stulae (AVFs) fast) of super!cial saphenous vein insuf!ciency have replaced close to the ulcer margin. Stimulated by excellent results in conventional ligation and stripping as a alternative technique. several patients who rapidly healed after sclerotherapy of their The purpose of this study is to evaluate the long term treat- AVFs, we studied the frequency of AVFs detected close to ul- ment outcomes of endovenous radiofrequency ablation. cers in a consecutive series of patients since April 2012. Methods. A single center retrospective review of great Methods. Retrospective review of clinic records for sub- saphenous vein insuf!ciency treated with radiofrequency ab- jects at two institutions with chronic leg ulcers undergoing lation between July 2007 and July 2012. Radiofrequency abla- DUS of the skin within 5 cm of the wound margin. DUS was tion was performed on 281 limbs in 246 patients with symp- considered positive for AVF if the following were present: 1] at tomatic varicose vein under tumescent anesthesia without least one vein with arterial waveform; 2] the vein(s) with arte- general anesthesia or regional anesthesia. Post-operative fol- rialized #ow demonstrated augmentation with compression, low up was perfomed after 1week, 6 month, and then yearly. and 3] a feeding artery very close to or directly communicating Results. The mean age of patients was 55.71±12.24 years with the pulsatile vein(s). (range: 19-89 years) and 133 (54.06) % were woman. The av- Results. 36 patients with 39 ulcerated limbs were identi!ed erage body mass index was 23.15±2.89 kg/m2. Mean length (3 women, mean age = 64; mean size =23.4 cm2; mean dura- of ablated vein was 24.73±4.68 cm and mean diameter 2cm tion = 4-.6 months). Super!cial AVFs were present in 9 of 34 distal from SFJ was 6.37±2.12mm (range: 2.6-21.2 mm). The patients (26.5%) and in 11 of 39 limbs (28.2%). There were occlusion rate at 60 month was 93.59 % and re#ux free rate no signi!cant differences in wound size or duration between at 60 month was 96.09% by Kaplan-Meier analysis. No major limbs with or without AVF. complications occurred. However 17 patients had induration Conclusions. The frequency of super!cial AVF near venous with skin pigmentation. ulcers is much higher than generally described in the litera- Conclusions. Our 5-year experience suggests that endov- ture. Further study is warranted to con!rm these !ndings and enous radiofrequency ablation is a effective and durable treat- to evaluate the causal relationship between super!cial AVFs ment modality in super!cial saphenous vein insuf!ciency with and leg ulceration. low complication rates.

A Combination Bimodal Wavelength and Vary Pulse Endovenous Radiofrequency Ablation in Old Pa- Duration Laser Approach to Treat Vascular Disor- tients with Varicose Vein: Clinical Analysis of Ef#- ders cacy and Safety N. Sadick W. Kim Sadick Aesthetic Surgery & Dermatology, P.C., New York, USA National medical center, Seoul, Jung-gu, Korea

Aim. Vascular lasers use light to target and destroy un- Aim. Generally saphenofemoral junction re#ux is the main wanted small telangiectasia of the skin. The laser wavelength cause of chronic venous insuf!ciency. Because of the symptoms is chosen to selectively target the abnormal blood vessels only, from the re#ux, the elderly patients may experience reduced sparing the surrounding normal skin structures. For effective quality of life. Due to the possible complications after the surgi- treatment the laser needs to penetrate to the depth of the tar- cal intervention, most of the elderly patients tend to reluctant get vessel. In addition laser exposure needs to be long enough to receive surgery and only visit the clinic after symptoms more to cause suf!cient slow coagulation of the vessel effecting pan- aggravated. A variety of minimally invasive methods have been endothelial sclerosis. invented over the last decade. In this study we used endovenous Methods. A new approach combines a 532nm KTP and a radiofrequency ablation, (VNUS®Closure fast) to demonstrate 1064 nm Nd:YAG laser in one device to treat all type of cutane- the clinical outcome in the elderly and younger groups. We ana- ous vascular lesions. The 532 nm green light laser wavelength lyze the ef!cacy and complication rates in each group. is near the !rst absorption peak of hemoglobin and can be Methods. Between July 2007 and July 2012, endovenous ra-

156 INTERNATIONAL ANGIOLOGY October 2013 diofrequency ablation was performed in patients 65 limbss in Methods. This 43 year old security guard has a 26 year his- the elderly group (over 65-year-old) and in patients 181 limbs tory of varicose veins and stasis skin changes, including ulcers, with ages under 65-year-old. We retrospectively compare the in his left leg. Associated symptoms have gradually increased both group with CEAP classi!cation, Occlusion rate, re#ux free over time despite daily use of high grade graduated compres- rate, co-morbidities and complications after the procedure. sion hose. Duplex ultrasound revealed the presence of saphe- Results. All patients had symptomatic varicose vein and nopopliteal insuf!ciency and a large incompetent perforator underwent level 2 clinical classi!cation with color duplex vein in the medial ankle area. The re#uxing small saphenous scan. There was no signi!cant difference in 5-year occlusion vein was successfully treated with radiofrequency ablation, rate between them. Pre-op and follow up VCSS did not show but an attempt to ablate the incompetent perforator with laser any difference between groups. Minor complications such as abalaton as unsuccessful. A second attempt of ablation with a skin burn, ecchymosis, and tenderness had no signi!cant dif- 3 cm radiofrequency catheter is described. The catheter was ference between groups. introduced into the perforator under ultrasound guidance, Conclusions. Endovenous radiofrequency ablation is safe then advanced to the level of the fascia. Because of its unu- and effective methods in the elderly group. sual length super!cial to the fascia, 8 cm of the vein could be treated with a total of !ve 20 second cycles. Follow-up duplex at !ve weeks showed complete closure of the perforator associated with excellent symptom resolution. Results. Follow-up duplex at !ve weeks showed complete Klippel Trenaunay Syndrome (KTS). Global Treat- closure of the perforator associated with excellent symptom ment resolution. C. Simkin1, R. Simkin2 Conclusions. In this patient radiofrequency ablation was 1Clinica Simkin-Varicocenter, Buenos Aires, Argentina shown to be a viable alternative to endovenous laser ablation 2University of Buenos Aires (UBA),Clinica Simkin, Buenos Aires, Argen- as a method of incompetent perforator treatment. tina

Aim. 1-Integrate the management in the treatment and in the follow up of the KTS patients. 2-Understand that KTS has Signi#cance of Epigastric Vein in Laser Ablation of multiple clinical presentation with different treatment. Great Saphenous Methods. From year 2001 to 2012.Our experience in the K. Goudarzi treatment of angiomas,troncular varicose veins ,and a recur- Kamran Goudarzi MD, PA, Wilmington, NC, USA rence of a diffuse micro-arteriovenos !stulae pattern in the Aim. To point out importance of saving Epigastric Vein dur- infrapopliteal distal branches in the internal tight of the leg ing Laser Ablation of Great Saphenous Vein. Epigastric Vein is presented. The cases were classi!cated according Simkin´s is commonly sacri!ced during vein stripping or laser ablation. KTS classi!cation in pure KTS. Diffuse and Mixed KTS (ar- I believe this is a mistake, since in the majority of cases, this terial, lymphatic and vein component). U.S pre, intra and vein is competent, hence preventing recurrent disease in fu- postoperatory was performed.Microsurgery. 4 cases endolaser ture. 980nm, 3 cases endolaser radial !ber 1470nm. Arteriography Methods. During several thousand laser ablations over and venography was also done in the cases that we performed the past twelve years, we have had the opportunity to observe regional segmentary skeletisation in the deep venous system competent valves inside epigastric. years before. 1Case GSV +surgical treatment in pelvic veins (15 Results. The poster submitted shows a competent valve in years after we did the regional segmentary skeletisation tech- Epigastric Vein just proximal to the incompetent preterminal nique). 1 case 1470 nm endolaser SSV in perforators ,epifascial valve. veins of the tight. Transdermal P.O laser in the diffuse angi- Conclusions. During vein stripping or laser ablation of the omatosis, pigmentary nevus and Polidocanol 2% UFGS was Great Saphenous Vein, every attempt should be made to save performed. U.S Follow up at 1 week, 1 ,3, 6 months and yearly. the competent epigastric vein. Results. 5 cases closed.2 cases UFGS as secondary procedure was done. MicroAVF was closed, compresion stocking was indicated With excellent tolerability. Conclusions. Long term follow up (15-24 years) of the “Re- Current and Future Approaches to Neutralize the gional segmentary skeletization” technique presents good re- Bleeding Effects of Dabigatran, Rivaroxaban and sults ,the different measure and length of the legs doesn´t exist any more. Diffuse microAVF pattern can also be closed with Apixaban Endolaser. J. Fareed1, W. Jeske 2, D. Hoppensteadt 2, J. Walenga 2, R. Wahi 2, B. Lewis2, J. Cho2 1Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA 2Loyola University Medical Center, Maywood, USA Treatment of a Large Incompetent Perforator Vein with a Three Centimeter Radiofrequency Catheter; Aim. Currently there are three newer anticoagulants approved globally for various indications, including post surgi- Case Report cal management of DVT, atrial !brillation and acute coronary M. Isaacs, M. Gardner syndrome. The approved indications for each of these agents Vein Specialists of Northern California, Walnut Creek, CA, USA are product speci!c and each agent exhibits a distinct pharmacologic pro!le. At this time there are no antidotes available Aim. Endovenous ablation techniques have proven to be to reverse the bleeding effects of these agents. Prothrombin enormously successful in treating re#ux in the super!cial venous complex concentrates (PCCs), activated prothrombin complex system. Incompetent perforator veins, particular those in the dis- concentrates (APCCs), Factor VIIa and modi!ed Xa and IIa tal leg, remain a challenging problem. Endovenous laser abla- are evaluated in various systems. tion has been used successfully, but in the case being presented Methods. Commercially available PCCs and APCCs were endovenous laser ablation failed. Repeat treatment with a small, tested in the whole blood and plasma systems to determine 3 cm radiofrequency catheter was successfully accomplished. the neutralization pro!le of these agents. The bleeding pro-

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 157 !le of each of these newer drugs were tested in animal mod- great saphenous vein got endovascular treatment without pr- els of bleeding and their potential reversal. Drug interactions eoperative congestion. To evaluate the success of the therapy, with each of these agents were studied to determine the rela- each patient got lymphszintigraphies pre- and postoperative. tive contribution of !brinolytic agents, antiplatelet drugs and The dynamic lymphatic #uence and leg circumferences were heparins on the bleeding pro!le. recorded and compared Results. Because of the compositional differences, various Results. Patients with combined edema of the lower ex- PCCs exhibited different pro!les. In the global test such as tremity and varicose vein disease of the great saphenous vein, the PT and APTT, no major neutralization was observed with treated by endovascular procedure do not have new injuries of any of the agents. All agents produce concentration depend- the lymphatic vessels postoperative. The postoperative dynam- ent bleeding effects in the order of dabigatran > rivaroxaban > ic lymphatic #uence is better than before treatment. The meas- apixaban. PCC combination with EACA showed improved he- ured leg circumferences are smaller than before treatment mostatic pro!le. Different degrees of interactions were noted. Conclusions. The therapy of patients with combined ede- Conclusions. The bleeding complications associated with ma and varicose vein disease of the great saphenous vein is not newer agents are multifactorial. Such factors as adjunct drugs only possible by conservative, non-operative treatment. The and patients own predispositions contribute to bleeding. The operative therapy is necessary, the endovascular treatment is newer approaches using modi!ed enzymes and antibodies can the therapy of the !rst choice. be further improved by using external devices to avoid systemic complications.

Case Report: Congenital Anomaly of the Inferior Laser Ablation: Hybrid and Minimally Invasive Pro- Vena Cava in Young Patient with Deep Vein Throm- cedures in Varicose Veins bosis and Super#cial Vein Thrombosis of the Lower R. Simkin1, C. Simkin2 Extremity 1University of Buenos Aires (UBA), Buenos Aires Argentina D. Steffen 2Clinica Simkin, Varicocenter, Buenos Aires, Argentina Capio Klinik im Park, Hilden, Germany

Aim. To Present our experience in the combined treatment Aim. Identi!cation of a congenital anomaly of the inferior with endolaser in the GSV,SSV,Vv in the foot, vulvar and per- vena cava as incidental !nding in a young male patient with- forators veins. out pre-existing diseases. Resuming the diagnostic cascade in Methods. U.S guided Endovenous laser plus the applica- patients with deep vein thrombosis. Ways to identify the proxi- tion of tumescent anesthesia was made in1389 cases, as- mal end of the thrombus. sociated With the Mûller´s technique in epifascial veins. In Methods. Anamnesis: Young 25 years old man, pain in low- GSV: 923 cases were bilateral (66,45%), 566 were unilateral er limb since 1 day, swelling of the lower extremity, no other (40,74%). In SSV: 103 cases were bilateral (7,41%) and 74 uni- diseses. Diagnostic: General Examination, blood sreening, lateral (5,32%). 547epifacial veins (39,38%), 99 perforators ultrasound screening, phlebographic examination, computed vein (7,12%), 25 AASV (2,21%) Giacomini veins 37 (2,66%), tomography and 173 foot vv (15,28%). 58 cases (4,58%) were not evaluated Results. Clinical improvement of the swelling after 2 days. yet. All patients were evaluated with a pre operatory U.S du- Long time anticoagulation. Discussion of lytic therapy. plex scan, as well as with all of the tests needed for a standard Conclusions. Agenesis of the inferior vena cava is a rare surgery. Post op. U.S follow up was performed at one week, 1, disease, most known cases are combined with deep vein 3,6 months and 1 year, and yearly. thrombosis of a lower extremity. The diagnostic pathway is Results. Oedema in 235 (16,91%) cases, lymphorrhea in important to identify the disease. A life-long anticoagulation is 6 cases (0,43%), neuralgia in the long saphenous area in 34 necessary. A thrombolytic therapie depends on the swelling of cases (2,44%), paresthesia in 13 cases (0,93%), ulcer in 3 cases the lower extremity. (0,27%), pain in 343 cases (24,69%), and infection in 1 case (0,07%). The neuralgia disappeared in all cases one week after the surgery Conclusions. The advantages of performing the endoluminal laser plus micro surgery at the same chirurgical time is that we resolve the hole problem in only one session. CO2 Foam Sclerosant in Venous Insuf#ciency: A Large Series Comparing Side Effects and Complica- tions to Room Air Foam Sclerosant M. Walters1, J. Stallone1, I. Schur2, E. Koh3 Using Endovascular Treatment for the Therapy of 1American Access Care, New York, NY, USA Great Saphenous Vein in Patients with Combined 2AAC, New York, NY, USA 3Access Care Physicians, c/o Verona Veins at Access Care Physicians, Ve- Edema without Pre-Operative Decongestion rona, NJ, USA D. Steffen Capio Klinik im Park, Hilden, Germany Aim. To retrospectively analyze and evaluate complications and side effects during and following administration of CO2 Aim. Performed therapies in patients with combined ede- foam sclerosants and compare them to room air foam scle- ma and venous disease of the greater saphenous vein are in rosant. most cases conservative using lymphatic drainage. Operative Methods. From 12/09-02/13, 649 CO2 foam sclerotherapy therapies are often rejected by therapists because of possible cases were performed. F:M=3.4/1. Average age 53 yrs. CEAP injuries of lymphatic vessels by performing open surgery in average=C3.8. Standard Tessari technique (4:1 ratio) was used. patients with combined edema. This can be shown by lym- Vein size=1-23 mm. CO2 volumes 2-40 ccs (average 11 ccs). phography. Using endovascular treatment of the great saphen- Vital signs, side effects, and complications were tabulated and ous vein in patients with combined edema can avoid damages compared to our own room air foam series of 290 cases from in lymphatic vessels 11/03-10/06. Air volume average 6.5 ccs. Chi square analysis Methods. Patients with combined edema and disease of the was performed.

158 INTERNATIONAL ANGIOLOGY October 2013 Results. No signi!cant change in vital signs including BP, Excision of Spontaneous Palma and Other Second- pulse, ECG, O2 saturation was observed during or following ary Varicose Veins in the Absence of Patent Deep the procedure in either series of patients. In the room air foam Axial Veins group, there were a total of 17 complications, including dizzi- I. Bihari1, Z. Varady2, G. Tasnadi3, P. Bihari1 ness (5), scotoma (1), migraines (2), panic attack (1), ulcera- 1 tion (5), and transient dry cough (3). In the CO2 foam group Vein Center Budapest, Budapest, Hungary 2Venenklinik Frankfurt, Frankfurt am Main, Germany there were only 2 complications (p <. 0001), both of transient 3Heim Pal Hospital, Budapest, Hungary dry cough (< 5 seconds). No neurological side effects were seen in the CO2 foam group. Aim. To show that in some deep vein occlusion cases, re- Conclusions. This retrospective review of CO2 foam and moval of secondary varicose veins improves the venous circu- room air foam in the treatment of venous insuf!ciency dem- lation of the limb. onstrates that CO2 foam is extremely safe and effective. The Methods. Since 1981 in 92 patients both the spontaneous use of CO2 foam should be the preferred method, given the Palma venous arch (19 cases) and lower limb varicosity (73 reported complication rate in our series and that in the his- cases) were removed. In 7 of them, deep vein aplasia was the torical literature for room air foam, especially given the rare, reason for the absence of deep vein circulation. In 11 cases, but catastrophic neurological complications that have been crural ulcer was the main complaint. To select patients, du- reported. plex ultrasound examination, venous pressure measurement, compression test and phlebography were performed. Radical varicectomy (crossectomy, stripping, phlebectomy, laser ablation) was carried out in every post-thrombotic and aplasia case. Results. Patients’ complaints decreased or disappeared, Endovenous Laser Ablation: Damage of Venous Wall crural ulcers healed (11 cases), in 86 cases there was signi!- Treated in Vivo with Radial Fiber and 1470 NM Di- cant pain relief, venous clinical severity score decreased by ode Laser mean 43 %, and did not increase in any case. There were no circulatory complications during or after the operation. Re- M. Parikov current varicosity could be observed in 58 cases (63.0 %) with- Innovative vascular centre, Saint-Petersburg, Russian Federation in 3 years, without ulcer recurrence. This means that these tests proved to be reliable in the detection of the presence of Aim. Today the best model for evaluation of laser action on an additional drainage system of the limb, the subfascial col- the venous wall is «in vivo model» with stripping of GSV after laterals in the muscles. EVLA. Damage during stripping can’t be good for study of ad- Conclusions. Traditionally the veins of the lower limbs are ventitia (G.Sprea!co, 2011). The number of such experiments classi!ed as super!cial and axial veins. We prefer to say epi- is limited. We developed and used « in vivo model» for studies fascial and subfascial vascular beds. In these cases there was of endovenous. no axial venous circulation, but a subfascial collateral system Methods. We performed endovenous laser ablation in had developed which could maintain the venous drainage of patients with S-type of incompetent GSV. After EVLT of in- the limb. trafascial part of GSV we performed laser treatment short segment of extrafascial part on the thigh (length 2-4 cm) and then performed miniphlebectomy this segment for examination. We used the laser with wavelength 1470 nm, radial !bers, automatically pull-back, tumescent anesthesia with Case Report: Successful EVLA Occlusion of Both pomp. Before each procedure we measured the power of laser Channels of a Great Saphenous Vein Bisected Longi- energy with powermeter by «Ophir». In the study included tudinally by Chronic Super#cial Venous Thrombosis 25 patients (F-19, M-6, mean age 42,1±12,1 y) with varicose R. Mueller disease with C2-C3 class CEAP without previous phlebitis Cosmetic Vein Solutions, New York, NY, USA or sclerotherapy. A total of 29 venous segments. In all cases incompetent GSV was determined by ultrasound. Mean di- Aim. 1) describe a case of chronic super!cial venous throm- ameter of extrafacsial part was 6,3±1,0 mm (range 4,8-9,3). bosis synechia bisecting the proximal GSV 2) describe occlu- We used continuous mode with power range 2,9-10,5 Watts: sion of both GSV channels with EVLA 3) describe occlusion at 2,9-3,5W (n=3), 4-4,9W (n=6), 5-5,9 W (n=6), 6-7W (n=10), short term follow up 9-10,5W (n=3, only with 2ring !ber), pull-back 0,7 mm/sec, Methods. Case report - patient with super!cial re#ux LEED 41,8-150 J/cm, EFE 20,5-95,5 J/cm2. After miniphle- treated in private practice 3/2013. Patient had super!cial ve- bectomy we performed macroscopic evaluation of inner and nous thrombosis of varicose GSV tributaries that propagated external layers. During evaluation we marked signs damage to common femoral vein, treated with warfarin. Thromboses of vein: gummy consistency, thickened wall, reduced caliper, retracted, leaving synechia bisecting the GSV longitudinally. loss typical pink color and appereance grayish-white color EVLA performed after 5 months of anticoagulation to prevent (external layer) or white color (inner layer). In cases com- recurrent propagation. Cold saline without lidocaine for tu- plete laser action, damage should be uniform, widespread mescent anesthesia. Clinical and 65 day venous ultrasound fol- and constant around the whole vein wall circumference. In low up conducted. case of insuf!cient severity of these signs, we considered that Results. The patient had a treacherous SVT, arising within damage of venous wall was incomplete. In addition we per- calf varicose GSV / accessory GSV tributaries. After several formed microscopy. weeks of conservative therapy, sudden propagation to SVT of Results. Incomplete damage of venous wall was in 8 cas- the thigh GSV and DVT of the common femoral vein ensued, es. Power in this cases was 2,9-5,0 W (mean 3,9±0,67), LEED requiring enoxaparin and warfarin. DVT & SVT retracted, 41,8-71,8 J/cm (mean 55,68±10,17), EFE 20,52-32,5 J/cm2 leaving a synechia type chronic SVT bisecting the thigh GSV (27,73±3,99). In 21 cases damage was complete: power 4,2- longitudinally. EVLA was performed, accessing one GSV chan- 10,5 W (mean 6,28±1,63), LEED 59,93-150,00 J/cm (mean nel, with successful ablation of both channels at 65 day fol- 89,79±23,35), EFE 26,83-95,54 J/cm2 (47,43±15,20). lowup. Cold saline without lidocaine used for tumescent an- Conclusions. When applying 1470 nm laser and radial !ber esthesia due to use of medication inhibiting cytochrome P450 complete damage of venous wall occurs when LEED is more 3A4. 72 J/cm, EFE – more 32,5 J/cm2. Conclusions. This instructive case illustrates the feasi-

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 159 bility of occluding via EVLA both lumina of a truncal vein arthritis, 6 had ankle joint arthritis ,and 20 had unexplained bisected longitudinally by a chronic SVT. Despite the pres- !ndings. ence of a stiff immobile synechia bisecting the vein, thermal Conclusions. B-mode US can replace CFD in rapid assess- energy was able to be transmitted by convection and/or con- ment of most cases presented by acute lower limb pain and duction to close both channels effectively, at least by short save time for the physician in decision-making. term followup. Objective was to prevent recurrence of SVT propagation to DVT. The Pathophysiology of Chronic Venous Ulceration R. Velineni, K. Spagou, M. Anwar, M. Gohel, E. Holmes, A. Davies Experiences of Balloon Dilatation and Thrombus Academic Section of Vascular Surgery, Imperial College London, London, Extraction for the Treatment of Cerebral Venous Si- United Kingdom nus Thrombosis X. Han1, T. Li2, S. Shao-Feng3 Aim. Chronic venous ulceration (CVU) remains a scourge of developed healthcare systems consuming approximately 1The 1st af#liated hospital of Zhengzhou University, Zhengzhou, Henan, China 1-2% of the healthcare budget and generates signi!cant physi- 2Interventional Radiology,, zhengzhou, China cal and psychological morbidity. Our understanding of the 3First Af#liated Hospital of Zhengzhou University, Zhengzhou, Henan, relationship between chronic venous insuf!ciency and the China microcirculatory changes underpinning CVU is incomplete. Objectives 1. Identify methods of assessing CVU pathophysi- Aim. This study aimed to investigate the ef!cacy and safety ology. 2. Identify speci!c factors implicated in the genesis or of balloon dilatation and thrombus extraction for the treat- progression of CVU. ment of cerebral venous sinus thrombosis (CVST). Methods. A literature review undertaken in April 2013. A Methods. Twenty-six cases of DSA-con!rmed CVST were Search undertaken of the PubMed database with the following treated with balloon dilatation and thrombus extraction. Ac- MeSH terms; 1 “Varicose Ulcer/enzymology” 2 “Varicose Ulcer/ tive treatment of primary disease was carried out after cer- etiology” 3 “Varicose Ulcer/immunology” 4 “Varicose Ulcer/me- ebral venous sinus recanalization, and subsequent anticoagu- tabolism” 5 “Varicose Ulcer/pathology” 6 “Varicose Ulcer/phys- lant therapy lasted for 6 months. iology” 7 “Varicose Ulcer/physiopathology” Titles and abstracts Results. Recanalization of the cerebral venous sinus was of studies were reviewed. Articles needed to report !ndings achieved in all 26 patients, and no endovascular treatment rein English to be included. After review of titles and abstracts, lated complications occurred during or after the procedure. studies were included if they demonstrated primary evidence At discharge the Glasgow Coma Scale (GCS) of the patients in the biological mechanisms of chronic venous ulceration. had improved from an average of 12.3 points to 15 points, Results. Searching PubMed obtained 530 studies. After re- and clinical symptoms were improved in 100% of the patients. view of titles and abstracts, 108 relevant articles were iden- Follow-up times ranged from 12–62 months (mean follow-up ti!ed. Sampling and selection of substrate were found to be time of 42.3 months) and no thrombus re-formation or new heterogenous such as sampling of wound #uid directly or by neurological de!cits occurred during that time. !lter disc absorption, tissue biopsy and blood from the af- Conclusions. Based on our small study population, balloon fected limb or distant sites. Studies have examined the role dilatation and thrombus extraction appears to be a safe and ef- of cytokines, protein synthesis, proteases and their inhibitors, fective treatment for cerebral venous sinus thrombosis. How- cellular function and coagulation cascade. ever, further research is needed to con!rm this. Conclusions. There is signi!cant heterogeneity in the sampling, assaying and targeting in the bid to understand the pathophysiology of CVU. In addition, there appears to be no standard animal model representative of CVU. Prior ap- Validity of B-Mode Ultrasound in Assessment of proaches have tended to examine single factors in isolation. It Acute Lower Limb Pain may be useful to examine the process of CVU from a different O. Ismail1, S. Rezk2 perspective such as a top-down systems biological approach in order to develop a more global view. We have recently com- 1Souhag faculty of medicine, Souhag, Egypt 2Alazhar, Assiut, Egypt menced a study in which CVU #uid shall be obtained and a multivariate metabolic pro!le will be generated. The global Aim. Acute lower limb pain represents one of the most view of metabolism has the potential to deepen our under- common presentations at emergency department. Its rapid standing of CVU pathophysiology. diagnosis is needed for rapid and proper treatment. The availability of B-mode US machines should help in their diagnosis. 1) clearing up of most common causes that lead to acute lower limb pain, 2) assess the role and accuracy of B-mode US in Single Center Initial Experience in Endovascular diagnosis of acute limb pain with absence of CFD units at ED, Treatment for Obstructive Venous Pathology primary health care units and urban areas 3) Applying a diag- V. Rubio, G. Rubio, E. Gaxiola, C. Gutierrez nostic protocol for acute limb pain including physical exami- Ceten, Guadalajara, Jalisco, Mexico nation, B-mode U/S and D-dimer assessment. Methods. Subjects: 200 patients were presented by acute Aim. Several studies have demonstrated the bene!ts of lower limb pain at emergency department. Methods: A pro- thrombus removal in decreasing severity of post thrombotic spective study from January 2011 to February 2012, 200 pa- syndrome, and venous stenting has proved excellent in main- tients presented by acute LL pain to ED were subjected to taining patency. This article presents our initial experience re- clinical examination, B-mode U/S by a radiologist and further stablishing out#ow in patients with severe obstructive venous speci!c assessment according to US Results. disease. Results. 86 patients had thrombosed veins, 32 had cellulli- Methods. Retrospective, observational, single center study tis, 14 had acute ischemia, 20 hade acute leg hematoma, 8 had in a two year period in 29 patients with venous obstructive ruptured Baker’s cyst, 6 had leg abscess, 4 had acute tenosyn- disease of several etiologies and chronicity: !ve patients with ovitis of peroneii and tibialis posterior tendons, 4 had knee subclavian venous obstruction and 24 patients with iliofemo-

160 INTERNATIONAL ANGIOLOGY October 2013 ral disease. Procedures performed included catheter directed because it was investigated in the differential diagnosis of legs’ thrombolysis, percutaneous mechanical thrombectomy, an- swelling. Distal DVT cannot produce any swelling but leg pain gioplasty, and stenting. Results were determined by imaging, and is usually asymptomatic in bedded patients (mostly surgi- and the Villalta score. Chronicity in#uenced success. cal patients). Well’s score and Dimer test are confusing in most Results. Flow restoral was achieved in 27 of 29 patients cases, looking for a distal DVT. with general improvement of symptoms and imaging. Catheter Methods. A normal CD machine and a good anatomic sche- directed thrombolysis combined with mechanical thrombec- ma of the calf veins, as the one published by Marie Thérèse tomy accounted for 90% clot removal in acute cases, and an- Barrélliér in Artères et Veines 1991; 10(6):440-1 is perhaps gioplasty and stenting completed treatment of the initial cause enough to understand and diagnose distal DVT. Distal DVT of the obstruction. Flow restoration improved edema, pain, investigation often requires the sitting position of the patient movility, and morbidity. with depending legs just to relax the posterior muscular com- Conclusions. Stenting is an ef!cient technique to treat ob- partment of the leg. Probe compression is not painful in this structive venous disease after reducing clot burden in deep position as well as squeezing manoeuvres. Pay attention: do venous thrombosis and to improve venous out#ow in chronic not perform CUS in standing position...!!! severe post thrombotic syndrome. Results. Distal DVT always occurs in stasis conditions and it’s easy to detect by US, even in B/W mode, because the interested vein segment enlarges until its maximal compliance. By Colour mode we can detect #oating thrombosis. Time for a EndoTHeF: Endovascular Treatment of Hemor- bilateral complete limbs investigation doesn’t exceed 15 min. rhoids with Foam Convex probe may be needed in obese patients. CD investiga- M. Ronconi1, E. Cervi2, A. Frullini3 tion still represents the gold standard in DVT detection (MT Barrélliér 1998). Distal DVT must be carefully researched in 1Ospedale di Gardone Val Trompia, Brescia, Italy 2Azienda Spedali Civili, Brescia, Italy bedded surgical patients, mailny orthopedic, and following 3Studio medico "ebologico, Figline Valdarno-Florence, Italy muscular traumas (syndrome of “pedrada” included) because it is asymptomatic. Symptomatic patients are represented by Aim. The abstract describes a new conservative approach any, otherwise unexplained, painful legs without swelling. In for the management of haemorrhoids. swelling legs a secondary distal DVT can take place and its’ Methods. From January 2009 to December 2012 we treated only clinical symptom can be the changing site of the pain. 210 patients, 122 men and 88 woman, 48,5 main age (range Hypotheses about the genesis of distal DVT: No genetic or 23-74) for proctorragy from hemorrhoids. The technique pro- acquired coagulation problems were demonstrated in distal vides the injection of a sclerosing foam in the haemorrhoidal DVTs: we think that the soleal veins enlarge in bedded patients plexus (1) trough a 10mm #exible endoscopic instrument. No because the soleum, the main muscle of posture, is totally out anaesthesia or sedation is needed. Foam is prepared with Tes- of its tasks. Enlargement means #ow velocity reduction in the sari’s method. Usually three haemorrhoids are treated every deep veins leading to stasis with subsequent thrombosis. A session. Two ml of foam are injected in each haemorrhoid (Fig similar mechanism is hypothesizable also in traumas because 1), until the complete !lling of vein (Fig 2). The injection is the interested leg is only used as a stick without any #exion- performed above the Parks’ line, where sensitive !bres of nerv- extension movements. ous systems are not present Conclusions. Distal DVTs are a frequently ignored reality Results. All the patients were observed every three weeks but they can be easily explored by US investigation. Distal DVT and then as needed. We carried out globally 765 procedures usually represent the mother of proximal DVT and it’s clinical in 210 patients, with a mean of 3,3 sessions for each patient. presentation may even be PE. Dimer Test and Wells’ score are In twelve cases we have carried out over !ve sessions for per- not useful in distal DVT investigation. sistent bleeding. In 83% of patients we assisted at the end of bleeding after the !rst line of treatment. Thirty-two patients treated for a severe anaemia had a normalization of haematocrit within a month after the last session of sclerosis. There Use of Phlebolymphology Ultrasound in the Man- were no major complications. Four patients referred only agement of the Patient in Phlebolgy clinic with Co- discomfort due to perianal itch and six patients referred lo- morbid Lymphedema cal heaviness for a week after the procedure. After one year of J. Maples1, J. Hovorka2 follow-up most of patients have provided a positive feedback 1Valley laser surgical solutions, McAllen, TX, USA to the questionnaire on QoL after treatment with a high level 2Valley Ambulatory Surgery Center, LLC, McAllen, TX, USA agree. Conclusions. Endovascular sclerotherapy of hemorrhoids Aim. 1. Implement a protocol for Phlebolymphology Ul- with foam seems to be an useful tool for the management of trasound in the clinic to help monitor and manage patients haemorrhoids in order to achieve good control of bleeding and with Lymphedema. 2. Demonstrate how Phlebolymphology pain with a limited number of minority complications. Ultrasound (PLUS) can be used to mintor progress and enable access to care in th phlebology and therapy clinic. 3.Initiate a discussion regarding multidisciplinary care of the Lymph- edema patient including ultrasound Phlebolymphology Ultra- Distal DVT sound (PLUS). A. Pieri Methods. For patients in 2012 the Registry in the electronic Private Angiologist, Firenze, Italy medical record was searched for 457.1 Lymphedema, as well as subsets inidcating diagnoses that would commonly be found Aim. Distal DVT is de!ned by its location, infra-popliteal, in a phlebology clinic such as 454.1 varicose veins with in#am- mainly at the calf level. Actual literature plays against its’ in- mation, 454.2 varicose veins with ulcer, and 454.8 varicose vestigation because US demonstration may be dif!cult and veins with other complication. The Institutional Review Board time consuming and because they usually evolve into sponta- approved the search noting that this is a pilot study using dei- neous resolution (75%). But in 25% of the cases their evolution denti!ed patient.161 patients were found with a diagnosis of proceeds into proximal DVT and even into PE. We think that lymphedema. 135 of these patients had what is termed as a the actual literature approach to distal DVT is totally wrong PhLeboLymphology UltraSound (PLUS). The clinical protocol

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 161 is as follows. 1. Medial anterior 24 cm from the sole of the for Results. In 2012 161 patients were found with a diagnosis dermal thickness as well as dermal to fascia measurement not- of lymphedema. 135 of these patients had what is termed as ing if dermal stranding is evident as well as hyperechogenicity a PhLeboLymphology UltraSound (PLUS). Out of these pa- is noted if evident of greyscale imaging. 2. medial anterior 6 tients 44 patients also had an ICD-9 code of 454.1, 99 had an cm from the sole of the for dermal thickness as well as dermal ICD-9 code of 454.8 and 77 had a ICD-9 code of 454.2. Out to fascia measurement noting if dermal stranding is evident as of the patients that had PLUS performed 53 were referred to well as hyperechogenicity is noted if evident of greyscale im- one outpatient physical therapist (Certi!ed Lymphatic Ther- aging. 3. Posterior tibial and Peroneal veins are identi!ed with apist). Without information from the PLUS more than the and without external compression to see if they are abnormal standard episode of complete decongestive therapy (2 weeks if not identi!able due to swelling being so signi!cant dermal !ve days per week and two weeks three days a week) has not thickness and dermal to fascia measurements should be taken been possible. Further when patient returned to clinic noted to display the severity of swelling. 4. Popliteal vein should be with Phlebolymphology ultrasound (PLUS) free #uid edema identi!ed on greyscale with and without external compression to see if it is abnormal. 5. circumference of the leg is measured 6 decreased as shown by the Phlebolymphology ultrasound cm from the sole of the foot and 24 cm from the sole of the foot study. unless swelling is displayed in another area then the circumfer- Conclusions. In patients that have lower extremity lymph- ence of the leg should be measured at the site of swelling also. edema the PLUS has given objective reproducible medical evi- Incidental !ndings include veins that appear to be enlarged per- dence that our Certi!ed Lymphatic Therapist on an outpatient forant vessels breaking through the fascia should be assessed basis needs to complete treatment for patients. We recom- with color doppler to see if re#ux is present upon which com- mend to pursue an objective of building consensus regarding plete venous duplex should follow. Intervention include decon- different protocols for patients that have a low Well’s score and gestive therapy by certi!ed lymphatic therapist also multilayer still are in need of ultrasound information for management of compression bandaging elastic compression stocking. phlebolymphedema.

162 INTERNATIONAL ANGIOLOGY October 2013 INDUSTRY SPONSORED SYMPOSIA

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 163 164 INTERNATIONAL ANGIOLOGY October 2013 BAUERFEIND SYMPOSIUM: Use of Medical Compression Hosiery: Patient and RELEVANT BENEFIT Practitioner Obstacles in the USA OF COMPRESSION HOSIERY T. Morrison IN ACUTE AND CHRONIC VENOUS DISEASE CEO Morrison Vein Institute, Delegate of ACP for the International Com- pression Club (ICC), Consultant for Morrison Training Institute, Scotts- Compression Hosiery in Patients with Venous Ulcers dale, AZ, USA W. Blättler, F. Amsler, E. Brizzio, M. Jünger Background. Graduated compression socks and hosiery Clinical and Interventional Angiology, University Hospital Bern, Swit- have been a proven prescription in the prevention, manage- zerland ment and treatment of the many stages of venous insuf!ciency. There are no US government standards for compression; no Aim. High level lower leg compression is regarded the key national standard guidelines for healthcare professionals or- therapeutic intervention in patients with venous leg ulcers. dering compression stockings. How can we be sure the sizing Correction of chronic venous hypertension is the motive. Fea- !ts Today’s population and !nd con!dence in !tting a wide tures beyond pressure may be as important. variety of sizes and shapes of patients. Methods. Studies on issues of pathophysiology and clinical Methods. Studies on issues of pathophysiology and clini- ef!cacy of compression will be reviewed. cal ef!cacy of compression will be reviewed. Techniques of Results. The in#ammatory soup of chronic wounds is mod- donning and dof!ng different compression modalities can en- i!able by compression and pain reducible with interface pres- hance patient compliance and treatment outcomes. sures below those improving phlebodynamics. High pressure Results. Clinical ef!cacy, in several indications, has been does not accelerate healing but may impair it in patients with proved by randomized controlled trials. Standards rest in the genetic polymorphisms of hemochromatosis and coagulation hands of registered compression stocking !tters and the phy- factor XIII. sician or health care professionals who prescribe them. Test- Conclusion. Best clinical results are obtained using two- ing methods (compatible to the European ITF method which component compression stockings. provides curves and values) for better analysis of compression delivery and hands on compression workshops will teach providers how to order and how to apply functional compression Methods. Conclusion. Best clinical results are obtained using a combination of elastic compression stockings, inelastic bandages, Velcro compression devices, and medical com- Compression Stockings for the Treatment of Super- pression devices by vendors who follow strict testing rou- #cial Vein Thrombophlebitis of the Leg tines, use the best yarns and state of the art technologies to K. Boehler, S. Tzaneva, S. Stolkovich and H. Kittler insure medical ef!cacy. Fitting our patients from young to Department of Dermatology, Division of General Dermatology, Medical old with extreme size ranges in compression devices is an art University Vienna, Austria as well as a challenge.

Objective. The purpose of this study was to evaluate if compression stockings class II are superior to no compression in: reducing disease related pain, promoting thrombus and erythema regression, improving quality of life Methods. Controlled clinical trial performed between 2010 and 2012 assigning 80 out-patients with super!cial Thigh Compression after Endovenous Thermal Ab- thrombophlebitis to wearing compression stockings class II lation for three weeks or no compression (control group). Systemic S.E. Zimmet thromboprophylaxis was basic treatment for all patients, American Board of Venous & Lymphatic Medicine. Austin, TX, USA non steroidal anti-in#ammatory drugs were allowed. Main outcome variables were: reduction of pain (VAS, Lowenberg Compression stockings are routinely used following endov- test), additional outcome variables were reduction of ery- enous thermal ablation. Postoperative pain has been common- thema and thrombus length, analgetics consumption and ly reported in the initial postoperative period despite the use of quality of life. stockings. There are recent preliminary reports of the utility of Results. VAS score documented no signi!cant difference additional thigh compression after endovenous thermal abla- in pain reduction between the compression(C) and no com- tion with regard to reduction of postoperative pain. pression group (NC) (C: 5,1 to 0,8; NC:4,4 to 0;9; p=0,32) as Subsurface pressure measurements were obtained with did the Lowenbergtest ( C:49,7 to 7,0; NC 51,8 to8,8; p=0,8). a Kikuhime pressure sensor in mid-thigh with the subject Reduction in weekly analgetics consumption was similar in active standing while using a supplemental bandaging in group C and NC (C: 5 to 2; NC 6 to 2 ; p=0,6) as was system (inelastic bandage over pads) applied underneath a reduction in thrombus length (p=0,07) and skin erythema 30-40 mmHg compression stocking. The mean pressure re- (p=0,61). There was a tendency towards faster pain recovery, corded was 55.8mmHg (44-68mmHg). The mean pressure less pill consumption and reduction in thrombus length in of a class II compression stocking alone is about 15mmHg the compression group within the !rst 7 days of treatment. at the thigh level. A pressure of 40mmHg has been found Conclusion. The results of this study suggest that the to signi!cantly reduce the diameter of the great saphenous therapeutic effect of compression stockings class II on su- vein in the thigh. The increased thigh pressure achieved with per!cial vein thrombophlebitis has been overestimated. Still this bandaging system may explain the apparent reduction when weighing the minor discomfort of wearing compres- in post-operative pain and bruising seen with this and other sion stockings against the advantage of faster recovery and similar systems. less analgetic consumption, it is justi!ed to recommend Even in this era of high-tech innovation, compression re- stockings to patients suffering from super!cial throm- mains a fundamental and essential treatment modality that bophlebitis. requires much more study and wider utilization.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 165 BSN MEDICAL SYMPOSIUM chronic wounds on the lower legs. The chronic venous insuf- !ciency (CVI) is in at least 50% of the patients the most often How to Assess Venous Insuf#ciency diagnosed underlying disease, followed by peripheral arterial J.A. Caprini occlusive disease (PAOD) and the combination of both each Division of Vascular Surgery, NorthShore University HealthSystem, in about 15%. Other rarely diagnosed causes are for example Evanston, IL, USA vasculitis, metabolic causes like calciphylaxis, neutrophilic diseases like Pyoderma gangrenosum or infections like leish- Venous insufficiency is a very common but poorly un- maniasis. In addition to the clinical examination with typical derstood condition that represents a major cause of chron- clinical appearance of the ulcers and the surrounding skin and ic venous disease. In 1994 the American venous forum the palpation of the pedal pulses especially the ultrasound is created the “CEAP” classification to fully characterize im- essential for the diagnostic of the vascular system. Moreover, if portant aspects of chronic venous disease (CVD). The clas- a rare cause including a neoplasia is suspected a biopsy should sification includes C, clinical; E, etiology; A, anatomy; P, always be taken. pathophysiology. This system distinguishes primary from Even if in approximately 80% of patients with chronic leg secondary and from congenital causes of the problem. It ulcers a CVI and/or PAOD are by far the most causally relevant distinguishes reflux from obstructive pathophysiology and factors, the summation of the rarer causes with up to 20% of identifies the precise anatomic segments affected by reflux the patients are still a very relevant proportion of all patients. or obstruction through 18 named segments of the lower Therefore it is central important to diagnose or exclude vas- extremity venous tree. Each of these elements of CVD are cular diseases in all patients with chronic leg ulcers. Espe- specifically defined from within the classification in order cially in so-called hard-to-heal wounds or clinically atypical to achieve uniform reporting wherever the classification wounds rarely diagnosed etiologies should also be considered is used. The full classification system is used for scientific because a successful treatment of patients with chronic leg journal articles while a basic version is commonly used in ulcers must obligate based on a correct and comprehensive clinical practice. Methods of investigation may be divided diagnose. into three levels. Level I consists of an office visit with history and clinical examination which may include the hand- held Doppler. Level II includes noninvasive vascular laboratory examinations such as duplex color scanning and plethysmography. Level III involves more complex imaging A New Approach to Combining Moist Wound Care studies including varicography, ascending and descending and Compression Therapy for Successful Venous venography, venous pressure measurements, IVUS, spiral Leg Ulcer Treatment CT scan, or MRV. The basic clinical classification includes C0 representing no visible or palpable signs of venous J.B. McGuire disease; C1 telangiectases or reticular veins; C2 varicose School of Podiatric Medicine, Temple University, PA, USA veins; C3 edema; C4a pigmentation and or eczema; C4b lipodermatosclerosis and/or atrophie blanche; C5 healed Successful healing of venous leg ulcers can only be achieved venous ulcer; C6 active venous ulcer. This basic clinical by compression therapy in combination with moist wound classification is commonly used in conjunction with a his- healing. This combined treatment is acknowledged as one of tory, physical exam and venous insufficiency examination the most effective for treating venous leg ulcers. to create a short and long-term treatment plan for the pa- However, it is widely believed that implementing this com- tient. This examination includes a combination of real- bined treatment in daily practice can be complicated and even time B – mode ultrasonography, pulse wave Doppler and impossible. Further, the trend towards shortened hospitals color flow to evaluate the lower extremity veins for evi- stays and ambulant treatment for wound patients has in- dence of valvular incompetence. The overall venous anato- creased the need for simpli!ed treatment approaches. my as well as the presence of obstruction and/or reflux in It is our observation that an easy to understand therapy ap- the venous system is assessed. Based on this information proach leads to a high patient compliance and physician’s ac- a decision can be made to treat surface and or perfora- ceptance, especially when a well-rounded range of mutually compatible compression and wound care products are includ- tor reflux with ablation techniques or foam sclerotherapy. ed in the therapy plan. Patients with deep venous reflux all require compression To effectively combine moist wound healing with com- therapy and superficial and/or perforator ablation can be pression therapy, it is important to select wound care prod- done in some of these individuals to improve their clinical ucts that are reliable under compression, for example, symptoms. Long-term compression therapy is required for super-absorbent polyurethane foam dressings. The wound most individuals with C3 disease and beyond. care products must maintain a moist wound environment, even under compression of 40 mmHg (good moisture management, no maceration). Also key to a successful outcome is ensuring the compression products exert the required pressure. Several compression tools are available including How to Distinguish a Venous Ulcer From Other Ul- short stretch bandages, which can be used for reduction of cers? extensive oedema. These can later be replaced by two-layer J. Dissemond stocking systems. The liner of the two-layer stocking sys- Dept. of Dermatology, Venerology and Allergology, University of Essen, tems exerts 15mmHg, which is appropriate for night wear. Germany For day time compression, the liner and upper stocking worn together exert 40mmHg together. The incidence of chronic wounds is reported in Western The compression stocking systems, were also reported as industrialized nations with 1-2% of the adult population. Al- easy to apply, delivering exact and constant pressure, and though representative current epidemiological data are lack- greatly appreciated by both the patients and physicians. Fur- ing, it can be assumed that chronic wounds mostly manifest as ther clinical evidence is needed to increase the number of ad- leg ulcers, diabetic foot ulcers or pressure ulcers. There exists equately treated venous leg ulcers, but the results so far are a variety of causes that may be responsible for the onset of promising.

166 INTERNATIONAL ANGIOLOGY October 2013 Compliance in Compression Therapy SERVIER SYMPOSIUM: T. Morrison UNDERSTANDING VENOUS PAIN CEO Morrison Vein Institute, Princess Dr., Scottsdale, AZ, USA What Triggers Venous Symptoms? Aim. “Compression of the lower limb can be provided by N. Labropoulos the use of hosiery, bandages, inelastic or elastic wrapping sys- Division of Vascular Surgery, Stony Brook University Medical Center, NY, tems, and intermittent pneumatic compression; all offer clini- USA cal bene!ts over the use of no compression in the management of a range of lower leg circulatory problems. Compression is Aim. Patients with venous disease may experience symp- the standard in treating venous leg ulcers. Minimally invasive toms of different intensity dependent upon the extent and type procedures combined with effective compression for CVI can of pathology they suffer. This report addresses the factors that heal leg ulcers faster and with fewer recurrences.” Dr. G. Mosti. are responsible for triggering pain. International standards in compression (class, stiffness, Methods. Data collected from our institution and relevant elastic/inelastic, bandaging techniques) are advancing with literature reports were used to elucidate the factors that trig- the help of industry, the ICC and national/international peers. ger pain. The macro- and micro-hemodynamic changes and Methods. Studies on issues of pathophysiology and clini- their effects on the vein wall and peri-venous space were ana- cal ef!cacy of compression will be reviewed. Understanding lyzed in detail. the compression device materials and their correct application Results. Various hemodynamic changes involving both the will enhance all the sophisticated interventions and assist with macro- and microcirculation were identi!ed. Venous pain is the “hard to !t patients” or “hard to heal” leg ulcers. Improved linked to the activation of the nerve endings located on the vein application techniques increase the number of better patient wall and could be present without marked hemodynamic chang- outcomes. Further studies comparing ef!cacy, side effects, sat- es. Changes in the vein wall and peri-venous space are more isfaction scores, symptoms and QOL are required to get more common in advanced vein disease. Dilation and local venous hy- insides in compression therapy. pertension in the microcirculation are necessary for developing Results. Standards rest in the hands of registered compres- signs and symptoms. Re#ux in smaller veins can be independent sion stocking !tters and the physician or health care profes- of the main trunks while re#ux in the third generation tributar- sionals who prescribe them. Various studies will be presented ies can lead to signi!cant changes into venules and capillaries. that evaluate compression vs. no compression after venous In parallel to the histological studies we have observed changes procedures and for leg ulcer treatment. Moreover, this paper in veins <2mm with high resolution ultrasound. We identi!ed gives data for compression compliance. Are there any com- marked re#ux, wall thickening and dilation and tortuosity that pression studies giving observance data? Compression compli- are not usually appreciated on a routine venous imaging. ance is not a simple problem, neither is its analysis. We look at Conclusions. Pain and other symptoms are associated with “true life” patients of all sizes and shapes and diseased states the changes seen in the microcirculation. These are more evi- and determine realistic approaches for patient compliance. dent when bigger veins are involved. The strength of the asso- Conclusions. Fitting our patients from young to old with ciation and the number of factors need in order to trigger pain extreme size ranges in compression devices is an art as well is not well understood. as a challenge. The advantage of compression to improve pain and clinical in#ammation in case of occurrence of phlebitis (so better comfort for the patient); compression garments combined with compression decongestive therapies manage lymphedema; Compression bandaging is a major cornerstone A Review of the Ef#cacy of Micronized Puri#ed Fla- in the treatment of CVI with leg ulcers; the ef!cacy consider- vonoid Fraction in Reducing Venous Symptoms ably depends on the applied pressure and is therefore largely A. Mansilha dependent on the individual applying the system. Teaching Unit of Angiology and Vascular Surgery, Faculty of Medicine - University Sub-Bandage pressure measurement with simple interven- of Porto, Portugal tions can improve ef!cacy in compression bandaging as well as evaluating elastic compression stocking prescriptions for Aim. To review clinical studies of the ef!cacy of micronized individual body types of various ages. puri!ed #avonoid fraction (MPFF) in reducing symptoms associated with chronic venous disorders (CVDs) Methods. Randomized controlled trials and meta-analyses examining the effects of MPFF on the relief of venous symptoms in patients in CEAP classes C0 s to C6 s were reviewed. Results. In several placebo-controlled trials, MPFF was as- BTG SYMPOSIUM sociated with a signi!cantly greater improvement in many of the symptoms of CVDs at the end of 2 months compared with Shaping Our Destiny: Impact of Patient-Reported placebo (P<. 001 MPFF versus placebo), or with nonmicro- Outcomes on Varicose Vein Treatment and Reim- nized diosmin (P<0.05 MPFF versus simple diosmin). Impor- bursement tantly, symptom relief with MPFF was achieved rapidly and maintained in the long term. The Affordable Care Act will impact many facets of health- In a meta-analysis of 459 patients, MPFF signi!cantly re- care in the USA, including reimbursement criteria and the link duced the symptoms associated with venous ulcers after 4 and between performance/quality measures and payment. In the 6 months of treatment. MPFF is also bene!cial on post-surgery realm of venous disease, quality metrics will likely incorpo- pain and in pain associated with pelvic congestion syndrome. rate patient-reported outcomes (PROs). This symposium will Patients receiving MPFF 2 weeks before and continuing for review the implications of the Affordable Care Act on the treat- 14 days after varicose vein surgery had signi!cantly less anal- ment of varicose veins, the growing importance of PROs, the gesic use than a control group. In a cross-over study, women use of PROs and physician-reported outcome instruments in were randomized to receive either MPFF or placebo. After the management of venous disease, and offer a panel discus- 6 months, mean pain scores were signi!cantly lower in the sion on how venous healthcare professionals and societies can MPFF group compared with placebo (P<.05). In recent guide- work together to proactively shape healthcare policy. lines for the treatment of CVDs, MPFF was assigned a high

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 167 level of recommendation as a !rst-line treatment for venous nous symptoms, together with the link between symptoms symptoms at any stage of CVDs. and objective CVD variables (signs, re#ux, markers) was per- Conclusion. MPFF has a number of vein-speci!c anti-informed. #ammatory effects that relieve symptoms at all stages of CVDs Results. Despite a systematic seek for venous symptoms and other venous conditions. may help detect a CVD in 6 out of 10 subjects, mostly at the earlier stages, it appears that venous pain is often overlooked by physicians. The causes for such attitude might be that venous pain is common, mostly affects women, and is more important to improve for the patient than the physician. In Is Venous Pain Reduction a Meaningful Treatment addition, lower limb pain is not enough speci!c of CVD, or Outcome? not systematically related to clinical signs or re#ux. This sug- P. Neglen gests that venous pain may be related to disorders other than SP Vascular Center, Limassol, Cyprus those of the macrocirculation. It might stem from venous obstruction or from functional anomalies such as those associ- It is well known that physicians underestimate the degree ated with obesity, prolonged standing or sitting, lack of regu- of pain a venous patient have and also its impact on his/her lar exercise, etc… It may even be related to microcirculatory quality of life. This is even more accentuated, when no un- disorders; however, we are currently unable to assess re#ux derlying venous pathology can be identi!ed. In venous disease in smaller veins. There are also signi!cant association with that usually means that the duplex ultrasound study (DUS) is number of reported symptoms and worse quality of life (QOL) negative for re#ux. Furthermore, it has been well documented scores. Finally, the question raised is ‘what should prevail that there is no relationship between clinical severity (C-class when taking the decision to treat: relieve patients’ sufferings in CEAP) and magnitude of venous pain. Similarly, it is also or stick to physical signs only?’ shown that there is poor correlation between the presence of Conclusion. Even if further studies are needed to clear up re#ux and pain. unanswered clinical questions, we should consider venous There is no doubt that venous pain in the CEAP- classi!ca- pain as part of CVD, since seeking symptoms may help detect tion and the VCSS are undervalued. The classi!cation does not the disease, and pain relief leads to QOL improvement, which include any assessment of degree of pain; the classes are only is meaningful to patients denoted as being symptomatic or asymptomatic. The addition of the use of the validated Visual Analogue Scale as a base assessment of pain has been very useful in our service. It has helped us !nd patients with severe pain (>5/10), which has not been proportionate to the clinical or initial DUS !ndings. It has prompted us to proceed with further investigation, espe- VASCULAR INSIGHTS SYMPOSIUM cially of the iliocaval venous out#ow tract. The venous pain of out#ow obstruction can be a true “venous claudication” with bursting pain on walking with a long Cost-Effectiveness of Varicose Vein Treatment: resolution time at rest. Probably venous hypertension due to Where does ClariVein® #t in? the out#ow obstruction may cause in#ammatory pain. This A.H. Davies, H.M. Moore would be the visceral type of pain, which includes discomfort, Academic Section of Vascular Surgery, Imperial College School of Medi- tightness and heaviness not necessarily accentuated by walk- cine, Charing Cross Hospital, London, United Kingdom ing. When out#ow obstruction is corrected by stenting, the improvement in pain (VAS) is consistently substantial, uniformly Varicose veins are a common condition that requires treat- resulting in complete freedom of pain in 75-85% of stented ment. Truncal varicosities can be treated by surgery, endother- patients in all C-classes. Swelling is usually less impacted mal ablation, MOCA, foam sclerotherapy and ClariVein®. To (freedom of swelling in appr. 45% of patients). The residual justify the use of any of the techniques, the cost-effectiveness swelling is usually easier to control when the pain has been needs to be evaluated. relieved. The National Institute of Clinical Excellence (NICE) has To conclude, it is important to think pelvic out#ow obstruc- just evaluated the cost effectiveness of the management of tion and not only rely on an infra-inguinal ultrasound investi- varicose veins. It has shown that it is cost-effective to treat gation in patients with suspicion of venous pain. Venous pain patients with symptomatic varicose veins. The most cost-ef- is a meaningful and important outcome measure in patients fective option was endothermal ablation, followed by foam with CVD, often underestimated. The improvement of pain sclerotherapy, followed by surgery. The recommendations also and its effect on the patient is not optimally revealed by CEAP stated that compression hosiery should only be offered if inter- or VCSS. A better measure is to utilize the VAS and different ventional treatment was not suitable or declined. ClariVein® validated questionnaires to measure the impact by pain on being a new technology was not part of the scope of this guide- quality of life. line. The 2013 NICE recommendations will be presented in abbreviated form. For ClariVein® to be recommended as being as cost-effective as endothermal ablation, it needs not only to have comparable patient outcomes in terms of quality of life gains, recurrence Should we Consider Venous Pain as Part of Chronic rates and adverse event pro!le, but also needs to have the same treatment cost as endothermal ablation. The potential savings Venous Disease? in terms of not requiring a generator or tumescent anaesthesia E. Rabe need to be taken into consideration. Department of Dermatology, University of Bonn, Germany In conclusion, providing the long term results with Clar- iVein ® are comparable to those of endothermal ablation and Aim. De!ne whether venous pain is part of chronic venous the cost equivalent, then there is no reason why it could not disease (CVD) become the treatment of choice. However, it should be noted Methods. An analysis of the literature regarding the that all patients gain signi!cantly by whichever interventional pathophysiology, epidemiology, assessment methods of ve- modality of treatment that is used.

168 INTERNATIONAL ANGIOLOGY October 2013 Bene#ts of MOCA Over Thermal Ablation for Treat- of leg which has undergone signi!cant change due to chronic ing Venous Stasis Ulcers insuf!ciency, including hyperpigmentation, lipodermatoscle- S.K. Subramanian rosis and stasis dermatitis. This makes the use of tumescent anesthesia in these areas very dif!cult and impractical due to Southern Regional Medical Center Henry Hospital Medical Center, At- lanta, GA, USA the sensitive and painful nature of the skin and around the ulcer itself not possible. Endovenous treatment of venous insuf!ciency of the great At our center, we have elected to use mechanico-chemical saphenous vein and small saphenous vein has traditionally ablation (clarivein) for these challenging cases. The clarivein been performed by the use of thermal ablation with either ra- catheter allows us to treat below the ulcer (which is not pos- diofrequency or laser ablation techniques. However the limita- sible with thermal techniques) and gives us the ability to close tions and risks become signi!cant when these modalities are the main vein as well as tributary branches (from the slceros- used when the GSV is in close proximity with the saphenous ant) which course underneath the ulcer itself. For those in- nerve (as seen near lower third of the leg below the knee) and stances where we are unable to access by the ankle or upper when performing ablation of the SSV which is in close prox- foot we can access just below the knee and pass the catheter in imity of the sural nerve. a retrograde fashion below the ulcer to the ankle allowing for The limitations become increasingly evident when treating the most bene!cial and complete treatment. venous insuf!ciency as it pertains to venous stasis ulcers. Of- We have found that our results with ulcer healing are more ten these ulcers are present in the gator regions, speci!cally effective and durable the more distal we can ablate the associ- in the medial aspect of the ankle and lower leg (due to GSV ated incompetent truncal and tributaries veins. insuf!ciency) as well as in the lateral ankle and leg (due to The clarivein catheter allows us to treat many of these ul- SSV insuf!ciency). The challenges with thermal ablation is cer patients which thermal ablation techniques could not. The not only due to the veins course below the ulcer but include clarivein catheter also eliminates the risk for nerve damage to the skin surrounding the ulcer or often the entire lower part the saphenous and sural nerves due to thermal injury.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 169

Authors’ Index

A Bottini O., 58, 71, 80. Cooper A., 19. Fellner A., 113. Bradbury A., 41. Cornu-Thenard A., 76, 135. Feriani R., 117. Adesina-Georgiadis K., 6, 138. Branisteanu D., 79. Correa L., 26. Ferracani Ristenpart E., 111. Agarwal S., 22. Brayton K., 90. Crébassa V., 18, 105. Ferreira J., 117, 119, 141. Agus G., 123. Brennan A. F., 30. Cruz A., 128. Fiebig D., 8, 54, 125. Akavov A., 10. Breu F. X., 58. Fiestas-Navarrete L., 18. Aksoy M., 11. Breu F., 115, 149, 150, 151. D Fife C., 10. Albazde O., 125. Brien P. O., 90. Fiorentino A., 90. Albert J., 87. Brizzio E., 165. Fletcher J. P., 62. Aldrich M., 10. Broholm R., 56. D’Alessandro A., 112. Flour M. L., 7, 92. Allaert F., 18, 67, 68, 140. Bucalossi M., 61. Da Pozzo E., 4. Foegh P., 56. Dadon M., 92. Alm J., 40, 99. BudzyĔ-Napierała M., 146. Fortin C., 105, 113. Almeida Chetti R., 42. Bulbulia R., 19. Dan V., 65. Franceschi C., 35, 46. Almeida J., 4, 69, 131, 149. Burchielli S., 4. Dándolo M. A., 79. Francesco S., 121. Almeida R., 132. Bush P., 32, 99. Darvall K., 41. Franklin I., 27, 39, 42, 78, 88. Alomari A., 3, 65, 66. Bush R., 32, 99. Daugherty S., 64, 93. Friedmann D., 126, 128. Alsaad S., 155. Davies A., 3, 6, 20, 27, 31, 33, Frings N., 125. Altmeyer P., 20, 152. C 34, 39, 40, 42, 78, 88, 89, 92, Fronek H. S., 67, 93. Aluigi L., 81. 108, 137, 138, 140, 141, 144, Frullini A., 4, 12, 24, 117, 149, Amano A., 133. Cabrera Garrido J., 125. 160, 168. 150, 151, 161. Ambrosino M., 40. Cadavid-Velasquez L., 100. Davies C., 19. Fujimiya T., 123. Amorim P., 149, 152. Caggiati A., 53. Davis A., 142. Amososva E., 98. Cakala-Jakimowicz M., 91. De Maeseneer M., 39, 70, 120. Amsler F., 165. Calandra G., 64. de Vries J., 139. G Andziak P., 122. Calton N., 103. De Zolt P., 5, 40. Ansai M., 122. Cameron E., 145. Degiorgio D., 90. Gajraj H., 4, 27. Antignani P., 19, 64. Camilli S., 61. Dekiwadia D., 55. Galeandro A., 139. Anwar M., 31, 92, 138, 160. Campana F., 25, 154. Delmas V., 133. Gallucci M., 19. Apkhanova T., 114. Canale M., 17, 31. Demirkilic U., 86, 107, 109, 110. Gambaccini M., 121. Artale F., 150. Cannellotto M., 132. Dermody M., 151. Gardner M., 157. Arworn S., 135. Cappelli M., 30, 34, 46, 63. Desnos P., 87, 140. Gasparis A., 18, 39, 63. Asbjornsen C., 141. Cappellino F., 90. Devereux N., 41. Gauw S., 5. Ascanelli S., 10, 143. Caprini J. A., 30, 44, 166. Dharmarajah B., 108, 141, 144. Gavrilov E., 130. Askerkhanov G., 10. Cardone M., 90, 146. Di Stefano R., 4, 117. Gawlick M., 54. Atasoy M., 120, 126. Carlizza A., 19. Dias C., 63. Gaxiola E., 160. Avetisyan A., 56, 118. Carraro D., 42, 60, 132. Dimakakos E., 146. Geroulakos G., 76, 125. Avramovic A., 59. Casals-Sole F., 152, 153. Dissemond J., 20, 166. Gianesini S., 10, 81, 121, 124, Ayoub G., 116. Castaneda R., 82. Doerler M., 20, 58, 152. 143. Azzam M., 76, 125. Castro e Sousa L., 149, 152. Doganci S., 86, 107, 109, 110. Gibson M., 75. Catarinella F., 5. Dominici D., 26. Gillespie D., 4, 64, 69, 149. B Cavezzi A., 25, 40, 149, 150, 151, Dos Santos S., 64, 65. Gillet J., 149, 150, 151. 154. Dragas M., 124. Gillot C., 28, 33, 78, 88, 113, 133, Baekgaard N., 7, 56. Cecchin S., 90. Dragic P., 104. 134, 139. Baeshko A., 146, 147. Cervi E., 24, 161. Draughn D., 88. Gloviczki M., 75. Baixauli J., 125. Cha S., 75. Drazkiewicz T., 54. Gloviczki P., 75. Balboni D. G., 59. Chahim M., 33, 68, 78, 133, 134. Dremstedt K., 87. Gohel M., 39, 144, 160. Barreneche L., 117. Chastain S., 29, 78. Du D., 144. Goldani M., 117, 119, 141. Bartos G., 129. Chen G. P., 84. Dundon S., 33. Goldman M., 126, 128. Bate G., 41. Chen L., 84. Dyer J., 19. Gomez-Hoyos J., 100. Bauza Moreno H., 80. Chen T., 145. Dzieciuchowicz Ł., 45, 153. Gonzalez M., 121. Bedi H., 22, 103. Cheville A., 90. Gordon I., 156. Behnia M., 77, 145. Chi Y., 115. E Goudarzi K., 127, 152, 157. Beichuk S., 100. Chiappini C., 27. Gould C., 88. Benigni J., 28, 76, 78, 134, 135, Chica Muñoz J. M., 79. Eisele G., 42, 132. Gradman W., 102. 139. Cho J., 157. Eklöf B., 11, 44. Granot A., 128. Bercovich J., 58, 80. Chung J., 106. Elash C., 39. Greenstein D., 128, 129. Berland T., 155. Chung W. S., 49. Ellis M., 33, 78, 144. Greenway H., 155. Bernstein R., 88. Chung W., 131, 137. Elmore F., 121. Greiner A., 54, 125. Bertazzo S., 27. Chunga Prieto J., 142. Eming S., 20. Greiner M., 92. Bertelli M., 90. Ciccone M., 139. Engels L., 120. Grouden M., 25, 33. Bihari I., 116, 129, 159. Ciesla-Dul M., 54. Englander M., 103. Gu J. P., 84. Bishawi M., 88. Ciubotaru V., 111, 137. Ermini S., 24, 46. Guex J., 149, 150, 151. Black C. M., 13. Clemens R., 65, 66. Escalante V., 54. Guggenbichler S., 12. Blättler W., 165. Coleridge-Smith P., 27, 149, 150, Eva R., 20, 135. Guilliod R., 10. Blebea J., 4, 69, 83, 149. 151. Guptan R., 141, 142. Bobrovnitsky I., 114. Colgan M. P., 33. Gural Romero O., 58, 80. Boehler K., 26, 57, 165. Colgan M., 25, 126. F Gutierrez C., 160. Boehme J., 99. Comerota A., 134. Boersma D., 139. Conde A., 60, 77. Fanelli R., 40. Bogachev V., 26, 70. Connor D., 32, 77, 144, 145, 146, Fareed J., 45, 54, 157. H Bogodyazh D., 147. 148. Fazakas I. Gy., 20. Boirivant R., 19. Cook M., 98. Fazakas I., 135. Haider N., 126. Boter M., 88. Cooley Andrade O., 144. Felice F., 4, 117. Hallstrand D. Jr., 120.

Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 171 Hamel-Desnos C., 87, 140, 149, Kang S., 132. Lim C., 31, 128, 129. Moretti R., 47. 150, 151. Kanjanavanit R., 134. Link D., 65, 66. Morrison T., 165, 167. Hamilton III C., 88. Kansaku R., 133. Liolios A., 126. Moscicka-Wesolowska M., 26, Han X., 55, 77, 117, 118, 160. Kanth A., 18. Litvinova N., 98. 122. Hanzawa K., 56, 78, 154. Kapadia S. R., 23. Livrea P., 139. Moser S., 116. Hao X., 84. Karetova D., 119. Lohr J., 68, 113. Mueller B., 100. Harper K., 120, 127. Kasivisvanathan V., 108. Losev I., 97. Mueller J., 100, 108, 119. Harper T., 120. Kaspar S., 4, 136, 138. Lou W. S., 84. Mueller R., 100, 104, 108, 116, Harrison C., 64, 65. Katorkin S., 97. Low J., 148. 119, 159. Hayes C., 63. Katumba K., 18. Ludyga T., 111. Muller S., 8. Haynes E., 91. Kazakmurzaev M., 10. Lugli M., 17, 62, 71. Muluk S., 91. He X., 84. Kazibudzki M., 75, 111, 112. Murena-Schmidt R., 140. Head K., 144. Keating L., 103. Heit J., 75. Keith T., 116. M Hernandez-Cardenas N., 100. Kelleher D., 42, 88. N Hernando Ulloa J., 71. Kenny N., 19. Ma D., 32, 148. Herr A., 103. Kerihuel J., 105. Mackay E., 131. Na C. H., 50. Hirokawa M., 86. Kern P., 7, 140, 149, 150, 151. Mackman N., 28. Nakajima T., 56, 78, 154. Hirsch A., 90. Khalil R., 31. Madhavan P., 25, 126. Nakano Y., 122. Holdstock J., 64, 65. Khan S., 18. Makhatilov M., 10. Narvaes L., 119, 141. Holmes E., 31, 160. Khilnani N., 94. Maksimovic M., 124, 124. Neglen P., 34, 168. Hoppensteadt D., 54, 157. Khubulava G., 130. Maksimovic Z., 124. Neira J., 42. Housman L., 155. Kim D. H., 49. Malagoni A., 124, 124. Netzer F., 105. Hovorka J., 55, 147, 161. Kim D. I., 47, 48, 49. Maleti O., 17, 62, 71. Neumann M., 39. Howard J., 19. Kim G. W., 48. Malgor R., 39. Nicholas R., 140. Hoyle B., 156. Kim W., 156. Malinin A., 28. Nicolaides A., 76, 106. Huang Y., 75. King T., 141, 142. Malskat W., 115. Nijsten T., 39. Hull R., 54. Kinney M., 127. Malvino E., 42. Nikolaus S., 54. Hunold P., 145. Kiriakidis S., 31. Mancini St., 61. Noppeney J., 148. Kittler H., 26, 165. Mandato K., 103. Noppeney T., 148. Klitfod L., 56. Mannello F., 17, 31. I Knyazeva T., 114. Manosalva H., 42. Koh E., 158. Mansilha A., 70, 167. O Ibañez V. J., 17. Konoeda H., 53. Manukyan L., 56, 118. Ichiki M., 122. Kontothanassis D., 5, 40. Maoheng Z., 84. O’Donnell T., 151. Ignatyev I., 56, 66. Kornberg A., 80, 102, 120. Maples J., 161. O’Neill S., 25, 126. Iker E., 154, 155. Kosasih S., 20. Mariana T., 102. Obermayer A., 8, 19, 154. Ikura M., 56, 78, 154. Koziarski J., 88. Mariani F., 61. Occhionorelli S., 10, 143. Ilyin S., 65. Krapp J. C., 60. Markulan L., 100, 101. Ochs J., 87. Inaba H., 133. Krasinska B., 45, 153. Martin Z., 126. Ogawa T., 129. Isaacs M., 110, 157. Krasinski Z., 45, 153. Martinez Granados A., 44 Ojeda Paredes O. L., 79. Isaak R., 42, 89. Kreidy R., 53, 66. Martinez H. D., 80. Okamoto T., 78, 154. Isaeva E., 97. Krzywon J., 54. Marx J., 128. Olszewski W., 26, 68, 75, 91, Iskra M., 146. Kulkarni S., 19. Matheus R. D., 79. 122, 123, 146. Ismail O., 160. Kurihara N., 86. Maththananda I., 27. Onida S., 140. Izzo M., 40. Kurtoglu M., 11. Matsuoka S., 56. Onyeachom U., 69, 149. Kwatra K., 103. Maurins U., 86, 118. Orallo G., 42, 132. McCafferty M., 126. Orrego A., 71. J McGreevey C., 142. L McGuire J. B., 166. McKeever S., 113. P Jain P., 68, 91. La Bella L., 19. McLafferty R., 4, 69, 149. Jang J. H., 48. La Mura R., 58, 80. Meergans C., 138. Padaria S. F., 21. Jang M. Y., 49, 50. Labropoulos N., 5, 18, 39, 40, 63, Meireles N., 149, 152. Pal J., 42, 89. Jensen L., 56. 150, 167. Meister G., 68. Pal P., 42, 89. Jeske W., 54, 157. Lal B., 4, 69, 149. Melles O., 20, 135. Paleolog E., 31. Jia L., 31. Lam Y., 136. Melnikov M., 97. Pannier F., 86, 118, 149, 150, Jianhao Z., 85. Lane T. R. A., 3, 89. Mendoza E., 9, 29. 151. Jianu S., 99, 100. Lane T., 6, 27, 39, 42, 88, 140, Menegatti E., 10, 81, 121, 124, Paolini J. E., 43. Joergensen M., 56. 144. 143. Pappas P., 4, 69, 149 Joseph J., 32, 148. Larin I., 130. Merali T., 54. Parikov M., 159. Jothidas A., 144. Latacz P., 75, 111, 112. Messer T., 91. Paripovic M., 124. Joyce D., 77. Lattimer C., 76, 125. Michelini S., 90, 146. Parodi M., 80. Jünger M., 165. Launois R., 18, 106. Michelotti L., 146. Parsapour S., 128, 129. Just S., 56. Lavigne V., 26. Miller L., 155. Parsi K., 32, 77, 144, 145, 146. Lawson J., 5, 40. Milligan E., 127. Partsch B., 121, 149, 150, 151. Le Moine J., 18. Miranda E. J., 43. Partsch H., 6, 35, 57, 93, 134. K Lee A. D., 22. Mirgorodskiy D., 100, 101. Passariello F., 29, 135. Lee K. B., 49. Mishalov V., 98, 100, 101. Pataro M. E., 79. Kabnick L., 4, 69, 149, 155. Leen E., 108. Mishra V., 155. Paty J., 39. Kafeza M., 76. Lefebvre-Vilardebo M., 25, 88. Miyake K., 124, 153. Pavei P., 23. Kahle B., 41, 145. Lemasle P., 88. Moehler T., 138. Pawlaczyk K., 45, 153. Kalodiki E., 76, 90, 125. Lemoine Piñones C., 8. Monaco D., 139. Paz J., 143. Kalsi H., 75. Leon I., 143. Moneta G. L., 83. Peek S., 111, 126, 127. Kamalyan T., 56, 118. Lewis B., 157. Mooij M., 5. Pereira Albino J., 149, 152. Kamata K., 122. Li T., 160. Moore D., 25, 33, 94. Perez V., 143. Kanaan S., 91. Liang J., 54. Moore H. M., 6, 20, 27, 33, 78, Perrin M., 67, 70, 106, 113. Kang G. B., 49. Ligi D., 17, 31. 89, 137, 141, 144, 168. Persi A., 90. Kang H., 137. Lillis A., 65, 66. Morales M., 58, 80. Pieri A., 23, 75, 161.

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Vol. 32 - Suppl. 1 to No. 5 INTERNATIONAL ANGIOLOGY 173 turn your home or office into a campus. introducing the American College of Phlebology’s Online Education Center.

Whether it’s at work, home, or on the go, you now have the convenience and efficiency of earning continuing medical education credit and improving patient care with the American College of Phlebology’s (ACP) Online Education Center. Courses cover a wide range of topics related to venous and lymphatic disease. Course discounts apply to ACP members.

some of our most recent offerings include: CCSVI: To Treat or Not to Treat Cosmetic Treatment of Facial Veins and Telangiectasia Duplex Ultrasound- Why and How Electronic Health Records and Your Bottom Line start today To access the ACP’s Online Education Center, visit www.education.phlebology.org advancing vein care www.phlebology.org 510.346.6800

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advancing vein care Vein Care Continues its Ascent

ACP 2014 28TH ANNUAL CONGRESS

November 6 – 9, 2014 JW Marriott Desert Ridge Resort Phoenix, AZ

The ACP’s 28 TH Annual Congress will provide vein care practitioners with the latest techniques, innovative content, interaction with internationally recognized faculty and opportunities for all levels of skill to gain the tools needed to improve patient care. Join us November 6 – 9, 2014 at the JW Marriott Desert Ridge Resort in Phoenix, AZ for this important meeting.

PLAN AHEAD FOR THE 2015 ANNUAL CONGRESS November 12 – 15, 2015 Hilton Bonnet Creek Orlando, FL

advancing vein care www.phlebology.org | 510.346.6800