NEW GUIDELINES FOR TREATMENT OF VENOUS DISEASE

Peter Gloviczki, MD, Joe M. and Ruth Roberts Professor of Surgery,

Chair Emeritus, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN

From Foam to Filters: Whats New In Venous Disease in 2012? February 2-4, 2012, Durham, North Carolina

What is in, what is out?

Conflict of Interest

None

Varicose Veins and Chronic Venous Insufficiency

Evaluation perfected (Duplex scanning, MRV, CTV, IVUS)

Pathogenesis clarified (superficial, perforator and deep venous systems)

Treatment revolutionized (RF, Laser, Foam, Stents)

10. Compression therapy is suggested for patients with symptomatic varicose veins (GRADE 2C). 1. Palfreyman SJ, Michaels JA. A systematic review of

compression hosiery for uncomplicated varicose veins. Phlebology. 2009;24 Suppl 1:13-33.

2. Amsler F, Blattler W. Compression therapy for occupational leg symptoms and chronic venous disorders: a meta-analysis of randomised controlled trials. Eur J Vasc Endovasc Surg. 2008 Mar;35(3):366-72.

9. Foam sclerotherapy is suggested as an option for saphenous ablation (GRADE 2C)

1. Morrison N et al. J Vasc Surg 2006;44(1):224-5. 2. Wright D et al. Phlebology 2006;21(4):180-90. 3. Regan JD, Gibson KD, Rush JE, Shortell CK, Hirsch SA,

Wright DD. J Vasc Surg 2010.11 327. 4. Morrison N et al. J Vasc Surg 2008;47(4):830-13 6. 5. Luebke T, Brunkwall J. J Cardiovasc Surg 2008;49(2):213-33. 6. Jia X et al. Brit J Surg 2007;94(8):925-36. 7. Murad et al. J Vasc Surg 2011;53S:49-65.

73 patients All had high ligation Treatment equally effective at 3 and at 5 years at 5 years AVVQ better after standard surgery

580 legs randomized to laser, RF, FS or HLS At 1 year, 5.8%, 4.8%, 16.3% and 4.8% of the GSVs were patent and refluxing (P < 0001) One PE after FS, one DVT after HLS

All treatments were efficacious but the technical failure rate was highest after FS. Both RF and FS were associated with faster recovery and less pain than laser or stripping.

9. Foam sclerotherapy is suggested as an option for saphenous ablation (GRADE 2C)

Grade 2B Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011 Aug;98(8):1079-87.

8. The CEAP classification should be used to describe the severity of venous disease and the revised VCSS (Venous Clinical Severity Score) should be used to asses treatment outcome (GRADE 1B).

C2 C6

7. The guidelines recommend against compression therapy as the primary treatment if the patient is a candidate for saphenous vein ablation (GRADE 1B).

REACTIVE TRIAL 246 patients

At 2 years HLS and phlebectomy provided better symptomatic relief, cosmetic results and

significantly more improvement in quality of life than conservative

management

6. Compression therapy should be used as the primary treatment to aid healing of venous ulceration (GRADE 1B).

Ulcer Healing at 4 years ESCHAR Trial

Gohel MS et al, BMJ. 335(7610):83, 2007 Jul 14.

5. For treatment of the incompetent great saphenous vein (GSV), endovenous thermal ablation (RF or laser) is recommended over high ligation and stripping (GRADE 1B).

1. Darwood RJ, etal. Br J Surg. 2008 Mar;95(3):294-301. 2. de Medeiros CA et al. Dermatol Surg. 2005 Dec;31(12):1685-94. 3. Vuylsteke M et al. Phlebology. 2006 Jun;21(2):80-7. 4. Kalteis M, et al. J Vasc Surg. 2008 Apr;47(4):822-9. 5. Christenson JT, et al. J Vasc Surg. 2010 Nov;52(5):1234-41. 6. Pronk P, et al. Eur J Vasc Endovasc Surg. 2010 Nov;40(5):649-56. 7. Rasmussen HL et al. Brit J Surg 2011; 98: 10791087

Time to return to work was significantly less, quality of life and pain

scores were better after RFA

Improved QOL scores persisted at 2 years in the RFO group compared to

stripping and ligation

At 2 years recurrence rates (26% vs. 37%, p=NS), clinical severity score and improvement in QoL were

similar

4. Phlebectomy or sclerotherapy is recommended to treat varicose tributaries (GRADE 1B).

3. The committee recommended against selective treatment of perforating vein in patients with simple varicose veins (C2) GRADE 1B, suggested treatment of Pathologic Perforating Veins (reflux >500 ms, vein diameter >3.5 mm, located underneath healed or active ulcers, C5-C6) . GRADE 2B.

1. Kianifard B, et al. Randomized clinical trial of the effect of adding subfascial endoscopic perforator surgery to standard great saphenous vein stripping. Br J Surg. 2007 Sep;94(9):1075-80.

2. van Gent WB et al Conservative versus surgical treatment of venous leg ulcers: a prospective, randomized, multicenter trial. J Vasc Surg. 2006 Sep;44(3):563-71.

2. Evaluation of patients should include duplex ultrasound scanning of the deep and superficial veins (GRADE 1A).

Duration of Reflux:

Saphenous vein >500 ms

Femoral vein > 1 s

1. To decrease ulcer recurrence, ablation of the incompetent superficial veins is recommended in addition to compression therapy (GRADE 1A).

Ulcer Recurrence at 4 years ESCHAR Trial

Gohel MS et al, BMJ. 335(7610):83, 2007 Jul 14.

Scientific Evidence

(Guideline)

Physicians Clinical

Experience Patients

Preference

What is the Best Treatment of Superficial Venous Disease?

TREATMENT

Thank You !

Division of Vascular & Endovascular Surgery, Mayo Clinic, Rochester, MN