CHIVA strategy in chronic venous disease treatment: instructions for users

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

Internal Perivenous Compression for venous insufficiency at the Saphenofemoral Junction: Early and Midterm Results and Operative Pain

OBJECTIVES

To assess the postoperative pain and midterm results of patients undergoing internal perivenous compression with internal compression therapy (ICT) for venous insufficiency at the saphenofemoral junction (SFJ).

MATERIALS AND METHODS

Patients managed with ICT between April and October 2019 for grade 4 venous reflux at the SFJ were retrospectively evaluated. The venous clinical severity score (VCSS) was calculated preoperatively and 1, 3, and 6 months postoperatively. Postoperative pain was assessed with the visual analog scale (VAS). Control Doppler ultrasound imaging was performed 6 months postoperatively.

RESULTS

Forty-five patients [14 (31%) males and 31 (69%) females; mean age, 47 ± 13 years] were included. The median preoperative VCSS was 7 (5-8.5). The median VCSS at 1, 3, and 6 months postoperatively was 6 (4-7.5), 4 (3-5.5), and 3 (2-4), respectively, and these values were significantly lower than the preoperative score (p = 0,001, p < 0.001, and p < 0.001, respectively). The postoperative VAS score was 0 in 6 patients (13%), 1 in 17 patients (38%), 2 in 6 patients (13%), 3 in 15 patients (33%), and 4 in 1 patient (2%). At 6 months, reflux was absent in 9 (20%), grade 1 in 20 (44%), and grade 2 in 16 (36%) patients. A vena saphena magna diameter of >6.7 mm predicted grade >1 reflux at 6 months [87.5%, with an area under the curve of 0.78 (p < 0.001)]. No complications occurred.

CONCLUSION

ICT alleviated symptoms and reduced reflux grade in patients with venous insufficiency at the SFJ. This therapy can be applied with satisfactory patient comfort.

The Analysis of Selected Morphological and Hemodynamic Parameters of the Venous System and Their Presumable Impact on the Risk of Recurrence after Varicose Vein Treatment

INTRODUCTION

The current treatment of venous disease is focused on reflux elimination in main venous trunks, especially in the saphenous vein. However, a high recurrence rate, independent of the method of treatment, suggests that the reason of low effectiveness may be due to a strategy focused on symptoms, without considering their origin.

METHOD

The aim of study was the comparison of retrospective data from 535 women with venous disease, either after treatment (n = 183) or not treated before (n = 352). The analysis concerned clinical symptoms and the results of the extended diagnostics, including the examination of the lower limb, pelvic and abdominal veins either using duplex-doppler ultrasound as well as venography with computed tomography or magnetic resonance.

RESULTS

The comparison of selected venous system parameters revealed more advanced disease progression in previously treated patients, compared to non-treated individuals (e.g., ipsi- or bilateral incompetence of sapheno-phemoral junction-29.5% vs. 20.4%, at P < 0.05 and 13.6% vs. 7.7% at P < 0.05, respectively). This difference could be explained by post-treatment alterations in the venous system, an older age and the higher number of pregnancies in the recurrence group. However, both groups did not differ in regards to the symptoms of pelvic venous insufficiency or the frequency of relevant variants/abnormalities in venous system.

CONCLUSIONS

Based on the aforementioned findings, we postulate the revision of treatment strategy, which should consider abdominal and pelvic veins as the source of reflux in many female subjects.

Segmental saphenous ablation for chronic venous disease treatment

BACKGROUND

Endovenous thermal ablation for chronic venous disease treatment is recommended over traditional surgery. The present investigation compares endovenous laser ablation (EVLA) with radiofrequency (RF) for segmental endovenous sapheno-femoral junction ablation.

METHODS

This is a retrospective study in which 79 patients underwent a 6 cm great saphenous vein ablation by RF or by EVLA.Primary outcome was occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score, peri-procedural pain, aesthetic satisfaction.

RESULTS

At 12 ± 1 months recanalization of shrunk tract was recorded in 5/85 (5.8%) cases (2 RF, 3 EVLA) [OR: 1.6; 95%CI: 0.2-10.4; P = 0.6689]. Two cases (1/44 RF group and 1/38 EVLA group) also showed reflux recurrence [OR: 1.0; 95%CI: 0.06-17.8; P = 1.0000]. No significant differences between groups were found in AVVQ, VCSS, peri-procedural pain, or aesthetic satisfaction.

CONCLUSION

Saphenous sparing is feasible and effective by means of both EVLA and RF, representing a possible alternative to surgery.

Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019

Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.

Mini-invasive foam sclerotherapy-assisted ligation versus surgical flush ligation for incompetent sapheno-popliteal junction treatment

Objectives

Comparison of a flush sapheno-popliteal junction ligation versus a mini-invasive foam sclerotherapy-assisted ligation.

Methods

Forty-eight chronic venous disease patients underwent sapheno-popliteal junction flush ligation (group A). Forty-one patients underwent small saphenous vein ligation by means of mini-invasive incision with foam sclerotherapy of the popliteal stump (group B).

Results

At 4.1 ± 3.3 years mean follow-up, sapheno-popliteal junction recurrence was detected in four patients of group A (4/48; 8.3%) and in two cases of group B (3/41; 7.3%) ( P= ns). Mean procedural time was 36 ± 11 minutes versus 21 ± 6 minutes ( p<0.0001). A mild post-operative paresthesia lasting more than 24 h was reported in 6.3% (3/48) of group A versus 2.4% (1/41) ( p<0.009) of group B. At one-year check-up, Aberdeen Varicose Vein Questionnaire significantly improved in both groups with no significant difference between group A and B.

Conclusions

Foam-assisted mini-invasive sapheno-popliteal ligation represents a time and clinical-effective option, associated with a decrease in post-operative paresthesia risk.

Ultrasound-based topographic analysis of tributary vein connection with the saphenous vein during ambulatory conservative hemodynamic correction of chronic venous insufficiency

OBJECTIVE

Preoperative mapping of great saphenous vein (GSV) escape points to tributary veins (TVs) and targeted intervention of escape points may reduce recurrence rates of varicose veins (VVs) after endovascular treatment of saphenous veins and prevent saphenous nerve complications. The aim of this study was to perform an analysis of cartography after Doppler ultrasound mapping of escape points in patients with VVs and to suggest one point that may prevent recurrence and nerve complications.

METHODS

Ultrasound assessment of VVs was performed from March 4, 2016, to July 15, 2016, specifically focusing on the locations of escape points from the saphenous vein to TVs. The collected data were reviewed retrospectively. The topographic distribution of escape points was as follows: from inguinal ligament to midthigh; from midthigh to knee; from knee to midcalf; and from midcalf to heel.

RESULTS

Thirty patients (41 legs) with VVs underwent ultrasound examination. All VVs were characterized by reflux at the GSV. Topographic analysis revealed a total of 79 escape points in all patients. The most common location for escape points was the third part of the leg (from knee to midcalf), where 65.8% of escape points were located; 82.3% of all escape points were located below the knee. The mean diameter of the GSV at 3 cm and 15 cm from the saphenofemoral junction was 6.8 ± 1.6 cm and 5.5 ± 1.5 cm, respectively. Mean diameter of TVs was 5.1 ± 1.9 cm. The diameter was not significantly different between saphenous veins and TVs. The mean number of escape points in each leg was 1.9 ± 1.0.

CONCLUSIONS

Most escape points (65.8%) are located from knee to midcalf (third part of the leg), and 82.3% of all escape points are located below the knee. The diameter of TVs near the escape point is about 90% of that of the GSV. Thermal ablations of below-knee saphenous vein have potential nerve damage. Ablation of saphenous veins above the knee alone may result in residual shunting and formation of persistent reservoirs in TVs. These persistent reservoirs may be removed effectively with sclerotherapy or miniphlebectomy, especially trying to remove TVs near the escape point. Direct ligation of a TV near the escape point from the saphenous vein, just like saphenofemoral junction ligation, could be performed. These approaches may be able to prevent residual shunting and may reduce recurrence rates and nerve injury.

Altered velocity gradient in lower limb chronic venous disease

BACKGROUND

In physiology, velocity of the deep venous compartment is higher than the one in the saphenous compartment which is higher than the one in the tributaries. Considering that velocity variation is associated with changes in the pressure gradient, aim of the present study is to assess changes in venous kinetics in case of superficial chronic venous disease, so to provide further clues in venous drainage direction determination.

METHODS

Venous ultrasound scanning was performed on 40 lower limbs of 28 chronic venous disease patients (C2-6Ep,As,Pr). Velocities were measured in three different venous segments: great saphenous vein at 2 cm above the origin of the incompetent tributary (Group-A). great saphenous vein at 2 cm below the origin of tributary (Group-B). tributary at 2 cm from its origin from the great saphenous vein (Group-C.).

RESULTS

Diastolic time average velocity was higher in group-C (-21.3 ± 8.5 cm/s) than in group-A (-15.7 ± 5.2 cm/s; p = .0001) and group-B (-11.1 ± 2.9 cm/s; p = .0001), thus indicating an inversion of the physiological velocity gradient in chronic venous disease patients.

DISCUSSION

Chronic venous disease presents a subverted velocity gradient. These data introduce objective hemodynamics data, paving the way for further investigation in venous drainage direction determination.

Ligation of the saphenofemoral junction tributaries as risk factor for groin recurrence

OBJECTIVE

The aim of this study was to compare the recurrence rate after high ties performed with or without sparing of the saphenofemoral junction tributaries.

METHODS

There were 867 lower limbs enrolled. All patients underwent a high tie with (group A) or without (group B) ligation of all the junctional tributaries for a great saphenous vein reflux (C2-5EpAsPr). A duplex ultrasound examination detected recurrences.

RESULTS

Median follow-up was 5 years (interquartile range, 3-8 years). Group A had a higher recurrence rate than group B (odds ratio, 7.52; P < .001). Group A recurrences (7.4%), compared with group B (1.1%), presented with a more frequent direct stump reconnection (3.7% vs 0.2%; P < .001) or newly developed pelvic shunts (3% vs 0.5%; P < .001). No significant difference was reported between the two groups in newly incompetent perforating veins.

CONCLUSIONS

Ligation of the junctional tributaries is associated with a higher recurrence risk. Further investigations are needed to determine the hemodynamic role of each single junctional tributary.

Femoral vein valve incompetence as a risk factor for junctional recurrence

Background

Recurrent varicose veins occur up to 80% of procedures. The sapheno-femoral junction can be involved in more than 50% of cases. A detailed pathophysiological explanation of the phenomenon is still missing. The aim of the present work is to evaluate the role of femoral vein incompetence as risk factor for sapheno-femoral junction recurrence.

Methods

Three-hundred-eighty-one patients presenting an incompetent great saphenous vein system and eventually also an incompetent femoral tract (C2-6EpAsdPr) underwent a great saphenous vein high ligation with flush ligation also of the incompetent tributaries along the leg, sparing the saphenous trunk. Pre-operatively, all patients underwent a sonographic evaluation assessing the superficial and deep venous systems, including a detailed analysis of the iliac-femoral vein tract above the sapheno-femoral junction. A retrospective statistical analysis assessed the recurrence risk associated with iliac-femoral vein tract incompetence.

Results

In a 5.5 ± 1.9 years follow-up, great saphenous vein trunk reflux recurrence was detected in 45/381 (11.8%) cases. The reflux source was found in a reconnected sapheno-femoral stump in 11/45 cases (24.5%), in the pelvic network in 8/45 cases (17.8%), in a neovascularization process in 7/45 (15.5%) and in a newly incompetent great saphenous vein tributary in 19/45 (42.2%). At the pre-operative assessment, iliac-femoral vein tract reflux was present in 7 (26.9%) of the 26 cases who developed a sapheno-femoral junction recurrence and in 25 (7%) of the 355 patients who did not demonstrate sapheno-femoral junction recurrence (odds ratio: 4.8; confidence interval 95%: 1.8–12.6; p < .003).

Discussion

Despite many technical diagnostic and therapeutic refinements, varicose veins recurrence remains a frequent event. The present investigation points out the association among iliac-femoral vein tract incompetence and sapheno-femoral junction recurrences after high ligation.

Lower limbs venous kinetics and consequent impact on drainage direction

Background

Literature concerning the lower limbs physiological venous haemodynamics is still lacking of reference velocity values and consequent impact on drainage direction. Aim of the present study is to assess the flow velocities in the different venous compartments, evaluating the possible Venturi effect role, thus finding clues for the identification of the physical model governing the flow direction.

Methods

Thirty-six lower limbs underwent a velocity and diameters echo-color-Doppler assessment in several anatomical point of analysis along both the deep and superficial venous systems. The investigation protocol included and compared two different manoeuvres to elicit the flow: manual calf compression/relaxation (CR) and active foot dorsiflexion (AFD). Both peak systolic (PSV) and time average velocities (TAV) were measured.

Results

The different venous segments demonstrated an overlap among the velocity values and the anatomical subdivision of the deep and superficial compartments. At the CR, TAV was 34 ± 12 cm/s in the deep venous system (N1), 15 ± 7 cm/s in the saphenous system (N2), 5 ± 2 cm/s in the saphenous tributaries (N3); PSV was 89 ± 35 cm/s in N1, 34 ± 16 cm/s in N2, 11 ± 4 cm/s in N3, p < 0.05. At the AFD, TAV was 33 ± 13 cm/s in N1, 15 ± 7 in N2, 9 ± 5 in N3; PSV was 83 ± 35 in N1, 32 ± 17 in N2, 15 ± 4 in N3, p < 0.05. A diameter decrease was reported from N1 to N3 ( p < 0.05).

Conclusion

This investigation provides evidences of the velocity decrease from the deepest to the most superficial compartments. These data introduce the Venturi effect as potential factor in the flow aspiration from the tributary to the deeper veins. The reported data represent a first step towards an objective evaluation of the physic laws governing the drainage. These values can constitute the basis for further investigations in pathological and post-procedural scenarios.

Mini-invasive high-tie by clip apposition versus crossectomy by ligature: Long-term outcomes and review of the available therapeutic options

Objective The aim of the present study is to compare a mini-invasive (smaller than 2-cm incision) sapheno-femoral high-tie by clip apposition (HT group) with a traditional high-ligation by ligature (HL group). Methods One hundred fifty chronic venous disease patients were included in group HT and compared with 150 cases constituting the group HL. The main outcome was the sonographic detection of saphenous trunk recurrences. Procedural pain, esthetic satisfaction, and disease specific quality of life were assessed. Results At 4.5 ± 2.4 years follow-up, 8 cases (5.3%) of Great Saphenous Vein reflux reappearance were reported in group HT vs. 19 cases (12.6%) (odds ratio: 2.6; 95% confidence interval: 1.1-6.1; P = 0.04) of group HL. Esthetic satisfaction was scored as high and very high in group HT and HL, respectively (P < .0001). Conclusions Proper high-ligation technique provides satisfying outcomes both in terms of recurrence rate and patient esthetic satisfaction. The different outcomes obtained by the two groups encourage further investigations regarding recurrence pathogenesis.