Venous Highlights of the 38th Annual VEITH Symposium

For Immediate Release
11/16/2011

By Lowell S. Kabnick, MD and Jose I. Almeida, MD

This was the sixth consecutive year that Venous and Endovenous Diagnosis and Treatment sessions have monopolized the Wednesday start of the 38th VEITH Symposium.  57 talks were given by 41 speakers, many of whom were American Venous Forum (AVF) members. Topics ranged from basics (anatomy) to advanced ("Chronic Cerebro Spinal Venous Insufficiency: Is This a Real Syndrome?"). There were two debates: "Hypercoaguable Testing is Needed in Most Cases" and "We Should Treat Calf Vein DVT with Standard Anticoagulation". We will attempt to summarize the salient points of the meeting.

Dr. Almeida initiated the conference with a talk on "Overview of Endovenous Surgery at a Glance" incorporating the present and a glimpse into the future with "tumescentless" venous procedures: glue, foam sclerotherapy, and pharmomechanical therapy. In addition, he touched on deep venous pathology and highlighted venous outflow obstruction, intravascular ultrasound (IVUS), and stents. We gained insight from Dr. Labropoulus during his discussion into how to perform diagnostic ultrasound testing for venous outflow obstruction and pelvic congestion syndrome and its significance. Dr. Mauriello, President of the American College of Phlebology, lectured on the value of tumescent anesthesia and knowledge of anatomy, to avoid saphenous, sural, and peroneal nerve injury. We heard Drs. Davies and Pittaluga disagree on the pathophysiology of varicose veins: ascending versus descending theory. Dr. Raju, President of the AVF, advocated stenting of the stenotic iliac vein and observation of concomitant femoral vein incompetence.  We can surgically intervene before ulcer healing by saphenous or perforator ablation, according to William Marston, MD. Dr. Rajasinghe, referencing THE ISOL-8 STUDY, stated that acute deep vein thrombosis (DVT) treatment appears to be gaining momentum with early pharmacomechanical thrombolytic therapy, however, there continue to be device limitations. Concerning inferior vena caval filters, "There is no question that in the USA, we are probably overusing caval interuption and not removing the majority of retrievable filters," said Dr. McLafferty, President-Elect of the AVF. Dr. Meissner made a cogent argument for not screening and Dr. Liem countered for screening hypercoaguable states; however, the audience was undecided. Dr. Kabnick, who continues to evaluate treatment for Endothermal Heat Induced Thrombosis (EHIT2) post ablation, still wavers about the necessity for anticoagulation.  Approximately 50% of the audience anticoagulated patients with EHIT2. Tom Wakefield discussed recommendations on the treatment of superficial venous thrombophlebitis (SVT) by reviewing guidelines. He gave his following recommendations: (1) If less than 5 cms of thrombus length - use NSAIDS, graduated compression hose, and warm compresses; (2) At least 3 cm distal to the saphenofemoral junction (SFJ) and greater than 5 cms of thrombus length - treat with fondaparinux or LMWH for 45 days; (3) Thrombus less than 3 cms from the SFJ needed therapeutic anticoagulation.  If the above are associated with venous insufficiency, Dr. Wakefield recommended medical management followed by interval GSV ablation. Dr. Lohr reviewed calf vein DVT data (tibial vessels only) and recommended standard anticoagulation. Dr. Sales looked at intramuscular calf vein DVT and recommended conservative measures; however, if the popliteal vein was involved he recommended anticoagulation. Dr Sales is now involved in a randomized controlled trial (RCT) comparing anticoagulation versus conservative measures for calf vein DVT.  Todd Berland concluded that efficacy, quality-of-life (QOL) measures, venous clinical severity scores (VCSS), and ecchymosis after saphenous vein thermal ablation is unaffected by postoperative compression hose; however, there was a small reduction of postoperative pain. Ed MacKay favored phlebectomy over sclerotherapy for bulging varicose veins; although, there were no RCT's discussing these treatments. On a different subject, Dr. MacKay concluded that there was no data to support non-nitrous gas mixtures were any safer than room air gas for foam sclerotherapy. Tom O'Donnell reviewed the literature on venous ulcer healing and concluded: "conservative treatment seems like a reasonable starting point, but after waiting for a period of time, surgical intervention may expedite the process."   After defining terminal interruption of the reflux source (TIRS) for venous ulcers using CO2 foam, Ron Bush concluded: (1) Patients can expect rapid pain relief; (2) rapid ulcer healing (8-10 weeks); but, (3) patients with deep venous insufficiency will have prolonged ulcer healing. Regarding the subject of other pelvic venous syndromes and treatment, Dr. Rosenblatt emphasized the management of patient expectations during the treatment of ovarian, internal iliac and venous malformations. Bo Eklof discussed RCTs concerning endochemical and endothermal ablations and concluded from a 1-year RCT from Copenhagen (Rasmussen) 2011: (1) all treatments were efficacious; (2) higher technical failure rates after foam; and (3) radiofrequency ablation and foam had a faster recovery rate.  Eberhard Rabe opinioned that C2 classification should be divided into C2a-nonsaphenous (extrafascial) varicose veins and C2b saphenous (intrafascial) varicose veins. He noted that there was higher incidence of clinical progression to advanced (C4) disease in patients who were C2b. Dr Sherif saw value in combining CEAP and VCSS scores, since CEAP alone is not a good metric for longitudinal follow-up.  Dr. Davies commented that QOL measures alone are not sensitive enough to ration varicose vein treatment.  Kabnick, in his pilot studies, concluded that both wave length (water-based) and non-contact fibers are important in improving postoperative recovery. Four-year registry of saphenous vein ablation with radiofrequency was presented by Dr. Dietzek; he noted 90% success and 19% complications. Dr. Gloviczki reviewed the consensus document on the treatment of superficial venous disease by the Society of Vascular Surgery (SVS) and AVF. Dr. Almeida concluded that pilot studies revealed the use of glue in saphenous vein closure is safe and effective.

For a review of all the lectures at the 38th VEITH Symposium, please go to VEITHsymposium™ or http://www.veithsymposium.org

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