Endovenous Thermal Ablation for Varicose Veins
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ISSN 1286-0107 Vol 19 • No.4 • 2012 • p161-204 Endovenous thermal ablation for varicose veins: . PAGE 163 strengths and weaknesses Renate R. van den BOS (Rotterdam, The Netherlands) Venous embryology: the key to understanding . PAGE 170 anomalous venous conditions Byung-Boong LEE (Washington D.C., USA) The “C0s” patient: worldwide results . PAGE 182 from the Vein Consult Program Jean-Jérôme GUEX et al. (Nice, France) Sclerotherapy in the patient with diabetes: . PAGE 193 indications and results Francesco FERRARA, Giovanni FERRARA (Naples, Italy) AIMS AND SCOPE Phlebolymphology is an international scientific journal entirely devoted to venous and lymphatic diseases. Phlebolymphology The aim of Phlebolymphology is to pro- vide doctors with updated information on phlebology and lymphology written by EDITOR IN CHIEF well-known international specialists. H. Partsch, MD Phlebolymphology is scientifically sup- Professor of Dermatology, Emeritus Head of the Dermatological Department ported by a prestigious editorial board. of the Wilhelminen Hospital Phlebolymphology has been pub lished Baumeistergasse 85, A 1160 Vienna, Austria four times per year since 1994, and, thanks to its high scientific level, was included in several databases. Phlebolymphology comprises an edito- EDITORIAL BOARD rial, articles on phlebology and lympho- logy, reviews, news, and a congress C. Allegra, MD calendar. Head, Dept of Angiology Hospital S. Giovanni, Via S. Giovanni Laterano, 155, 00184, Rome, Italy P. Coleridge Smith, DM, FRCS CORRESPONDENCE Consultant Surgeon & Reader in Surgery Thames Valley Nuffield Hospital, Wexham Park Hall, Wexham Street, Wexham, Bucks, SL3 6NB, UK Editor in Chief Hugo PARTSCH, MD Baumeistergasse 85 M. De Maeseneer, MD 1160 Vienna, Austria Department of Dermatology, Tel: +43 431 485 5853 Fax: +43 431 480 0304 Erasmus Medical Centre, BP 2040, 3000 CA Rotterdam, Netherlands E-mail: [email protected] A. Jawien, MD, PhD Editorial Manager Department of Surgery Françoise PITSCH, PharmD Servier International Ludwik Rydygier University Medical School, 50, rue Carnot Ujejskiego 75, 85-168 Bydgoszcz, Poland 92284 Suresnes Cedex, France Tel: +33 (1) 55 72 68 96 G. W. Schmid Schönbein, MS, PhD Fax: +33 (1) 55 72 56 86 E-mail: [email protected] Professor of Bioengineering and Medicine The Whitaker Institute for Biomedical Engineering, Publisher University of California San Diego, Les Laboratoires Servier 9500 Gilman Drive, La Jolla, CA 92093-0412, USA 50, rue Carnot 92284 Suresnes Cedex, France Tel: +33 (1) 55 72 60 00 Fax: +33 (1) 55 72 68 88 EDITORIAL MANAGER F. Pitsch, PharmD Servier International Indexed in EMBASE, PASCAL, Index Copernicus, and Scopus. © 2012 Les Laboratoires Servier - All rights reserved throughout the world and in all languages. No part of this publication may be reproduced, transmitted, or stored in any form or by any means either mechanical or electronic, including photocopying, recording, or through an information storage and retrieval system, without the written permission of the copyright holder. Opinions expressed do not necessarily reflect the views of the publisher, editors, or editorial board. The authors, editors, and publisher cannot be held responsible for errors or for any consequences arising from the use of the information contained in this journal. ISSN 1286-0107 CONTENTS EDITORIAL Hugo PARTSCH (Vienna, Austria) Page 162 PHLEBOLOGY Endovenous thermal ablation for varicose veins: Page 163 strengths and weaknesses Renate R. van den BOS (Rotterdam, The Netherlands) Venous embryology: the key to understanding Page 170 anomalous venous conditions Byung-Boong LEE (Washington D.C., USA) The “C0s” patient: worldwide results Page 182 from the Vein Consult Program Jean-Jérôme GUEX et al. (Nice, France) Sclerotherapy in the patient with diabetes: Page 193 indications and results Francesco FERRARA, Giovanni FERRARA (Naples, Italy) CONGRESS Congress and conference calendar Page 200 Phlebolymphology. Vol 19. No. 4. 2012 161 EDITORIAL Dear Readers, This issue of Phlebolymphology offers an exciting insight into some actual and very relevant fields of phlebology. Renate van den Bos and Marianne de Maeseneer, both working at the Dermatological University clinic in Rotterdam and outstanding experts in the field, discuss the strengths and weaknesses of the endovenous thermal ablation of varicose veins. They point out that Hugo Partsch duplex-guided endovenous procedures have widely replaced classical Editor in Chief stripping and that the newly developed steam ablation procedure has a promising future, being safer, faster, easier, and cheaper than endovenous laser and radiofrequency ablation (see also the article by René Milleret: Obliteration of Varicose Veins with Superheated Steam. Phlebolymphology. 2011;19:174-187). In an extensive review article, Professor Byung-Boong Lee, George Washington University School of Medicine, shows that knowledge of embryology may be key to understanding vascular pathologies, for instance for the differentiation between truncular and extratruncular forms of vascular malformations. His article contains beautiful illustrations of clinical conditions: radiological, MRI, and nuclear medicine pictures and schematic drawings, which are helpful to understand this very complex topic. Jean-Jérôme Guex from Nice, together with a group of prominent coauthors working on the Vein Consult Program, a worldwide epidemiological survey (see the article by Francoise Pitsch in the last issue of Phlebolymphology; 2012;19:132-137), has analyzed a large group of symptomatic C0 patients, a cohort of patients that is well-known to every phlebologist. Out of a total of 91 545 subjects, 19.7% did not show any visible or palpable signs of venous disease—this is the definition of the C0 class according to the CEAP classification—but presented with subjective symptoms. Most of the 14% of patients who underwent a duplex scan examination had superficial reflux, and 18% had deep reflux. The authors suggest that an “inflammatory hypothesis” may be the cause of the symptoms, which include a reduced quality of life, and propose that venoactive drugs should be used for treatment. Based on their extraordinary experience with sclerotherapy using Sigg’s technique, Francesco and Giovanni Ferrara from Naples have showed, in a case series of 60 patients, that diabetes mellitus with good glycemic control (HbA1c<6.5%) is not a contraindication for this technique, but rather gives equally good results and no more complications than in nondiabetics. Have a great read! 162 Phlebolymphology. Vol 19. No. 4. 2012 PHLEBOLOGY Endovenous thermal ablation for varicose veins: strengths and weaknesses Renate R. van den BOS, ABSTRACT Marianne M.G. de MAESENEER Endovenous ablation is a frequently used method for treating varicose veins. Department of Dermatology, Endovenous laser ablation is the most frequently used technique, followed by Erasmus MC Rotterdam, The Netherlands radiofrequency ablation. Endovenous thermal treatments heat the vein, leading to thrombotic occlusion and finally fibrosis of the vein wall. Endovenous steam ablation is a new technique that has not yet been extensively studied. In this article, the procedures, strengths, and weaknesses of the currently available endovenous thermal ablation treatments are discussed. INTRODUCTION Endovenous treatment is currently one of the most frequently used methods for treating varicose veins. Varicose veins are manifestations of chronic venous disease (CVD), which may lead to serious complications. CVD is a common medical condition. The prevalence of varicose veins is estimated to range from 2%-40%.1-4 The prevalence of venous leg ulcers, the end-stage of CVD, is much lower. It is very difficult, if not impossible, to predict which patients with varicose veins will develop a leg ulcer. Nevertheless, it has been estimated that about half of venous leg ulcers are the result of superficial venous insufficiency.5 The cost of treating leg ulcers is very high; the treatment of varicose veins, which may reduce the incidence of leg ulcers by 50%, is therefore likely to be cost-effective. Treatment for varicose veins can roughly be divided into four categories: compression therapy, surgical treatment, sclerotherapy, and endovenous thermal ablation. Surgical ligation of the junction with or without stripping has been the standard of care in the treatment of insufficient great and small saphenous veins for more than 100 years. In the last decade, endovenous thermal ablation (EVTA) procedures have become the most frequently used therapy for saphenous varicose veins, Keywords: endovenous ablation treatments, saphenous especially in countries where reimbursement of the procedure has been insufficiency, thermal ablation, varicose veins introduced. Such minimally invasive techniques meet the demand for cosmetically superior, less invasive and more successful treatment modalities. Only introduced 10 years ago, these techniques have radically changed the Phlebolymphology. 2012;19(4):163-169. Phlebolymphology. Vol 19. No. 4. 2012 163 PHLEBOLOGY Renate R. van den BOS, Marianne M.G. de MAESENEER treatment of varicose veins.6 The EVTA techniques other laser kits the laser fiber is already inside the sheath. currently available are: endovenous laser ablation A crucial step in the EVLA procedure is the positioning (EVLA), radiofrequency ablation (RFA), and endovenous of the tip of the laser fiber 1 to 2 cm distally from the steam ablation. The advantage of EVTA is that it is junction