Marianne De Maeseneer

Treatment of superficial thrombophlebitis of the great saphenous vein

I read with interest the article by Hill et al. on superficial thrombophlebitis (ST) of the great saphenous vein (GSV). Based on the data of a retrospective analysis of lower extremity venous duplex scans carried out from 2004–2005, they recommend careful follow-up with repeat duplex scans to determine if there is propagation of the thrombus, and if thrombus is extending to within 5 cm of the saphenofemoral junction, to start full anticoagulation and/or surgical intervention. The authors correctly state that ascending ST is a serious illness as it may lead to deep vein thrombosis (DVT) and even pulmonary embolism. Therefore, duplex scan is mandatory to evaluate the extension of the thrombus and to detect a (non-) contiguous DVT. However, the initial strategy suggested by the authors – which is a vigorous treatment with heat, limb elevation, non-steroidal medications and antibiotics – is certainly open for discussion. First, the advice for bed rest and leg elevation in patients with ST is rather surprising since this constitutes an ideal method to further promote extension of the thrombus into the deep vein. Indeed, in the study of Hill et al. the follow-up duplex scan revealed cephalad progression of the thrombus to occur in 17 of 30 patients with ST of the GSV, and in eight patients there was extension of the thrombus into the common femoral vein. It is well known that bed rest and immobilization are major risk factors for venous thromboembolism due to venous stasis, one of the most important elements of Virchow’s triad. Venous stasis should by all means be avoided when there is already a thrombus in the superficial venous system. Moreover, mobilization might enhance fibrinolytic activity with reduction of thrombus. Therefore, the Belgian Thrombosis Guidelines Group (TGG) recommended immediate mobilization with elastic compression in all patients with ST. Secondly, thrombophlebitis is not caused by infection and therefore antibiotic treatment is completely unnecessary (except in rare cases of septic thrombophlebitis). Moreover, local heat is not indicated and patients with ST will benefit much more from local application of a cold-pack to reduce the local inflammatory signs. Thirdly, it is surprising that in the discussion of this paper initial treatment of extensive ST of the GSV with low molecular weight heparin (LMWH) is not discussed, although several recent papers (mainly from Europe) suggest that the latter treatment might be efficacious. The use of intermediate dosages of unfractionated heparin or LMWH for at least four weeks is recommended in the ACCP guidelines (Grade 2B), as well as in the TGG guidelines and in a recently published Cochrane Review on treatment of ST.

Rehabilitation of patients with venous diseases of the lower limbs: State of the art:

Background To date, no document comprehensively focused on the complex issue of the rehabilitation of chronic venous diseases of the lower limbs. Method This article overviews and summarizes current strategies concerning venous rehabilitation of lower limbs. Results Venous rehabilitation is based on four main strategies: (1) lifestyle adaptations and occupational therapies; (2) physical therapies; (3) adapted physical activities; (4) psychological and social support. Rehabilitative protocols must be tailored to the specific needs of each patient, depending on the severity of chronic venous disease and on the location and pattern of venous lesion(s), but also on age, motor deficits, co-morbidities and psychosocial conditions. Conclusions Venous rehabilitation consists of non-pharmacologic and non-surgical interventions aiming at prevention of venous disease progression and complications, reduction of symptoms and improvement of quality of life. Well-designed clinical trials are required to evaluate the efficacy of the described rehabilitative protocols in influencing the evolution of venous disorders.

Expert review on the VenaSeal® system for endovenous cyano-acrylate adhesive ablation of incompetent saphenous trunks in patients with varicose veins

ABSTRACT Introduction: The treatment of incompetent truncal veins has been innovated by the introduction of minimally invasive non-thermal non-tumescent (NTNT) techniques. One of these consists of the use of cyanoacrylate glue to occlude the vein lumen by means of the VenaSeal device. Areas covered: This expert-review aims to evaluate NTNT ablation of incompetent saphenous trunks using the VenaSeal device. Expert commentary: Cyanoacrylate adhesive embolization of incompetent truncal veins using the VenaSeal device is a safe and efficacious innovative technique. Further studies are needed to evaluate anatomical and clinical outcomes at long term.

What the phlebologist should know about local anesthetics

An increasing number of phlebological interventions are performed under local and tumescent anesthesia. Although the modern local anesthetic agents are generally perceived as being effective and safe drugs, the administration of these drugs may be associated with a number of adverse events. It is therefore mandatory that everyone who uses these compounds has insight into the pharmacological actions of these drugs and is capable of recognizing and adequately treating potential adverse events. The present narrative review summarizes the current knowledge on mechanisms of action of the most important local anesthetic drugs and reviews the potential adverse effects as well as their treatment.An increasing number of phlebological interventions are performed under local and tumescent anesthesia. Although the modern local anesthetic agents are generally perceived as being effective and safe drugs, the administration of these drugs may be associated with a number of adverse events. It is therefore mandatory that everyone who uses these compounds has insight into the pharmacological actions of these drugs and is capable of recognizing and adequately treating potential adverse events. The present narrative review summarizes the current knowledge on mechanisms of action of the most important local anesthetic drugs and reviews the potential adverse effects as well as their treatment.

Extensive Hematoma in the Superficial Posterior Compartment with Threatening Compartment Syndrome after Ambulatory Phlebectomy

e report a serious bleeding complication afterambulatory phlebectomy (AP) in a patientreceiving anticoagulant treatment. AP is a surgicaltechnique used to remove palpable and visiblevaricose veins. The Swiss physician Muller intro-duced it in its current form in 1956, using 2-mmincisions, no skin sutures or vein ligatures, localanesthesia, and immediate postoperative ambulatorycompression. This procedure is frequently used inthe treatment of superficial varicose veins.

Valsalva maneuver in phlebologic practice

Forced expiration against an airway obstruction was originally described as a method for inflating the Eustachian tubes and is accredited to Antonio Maria Valsalva (1666–1723). The Valsalva maneuver is commonly applied for different diagnostic purposes. Its use for phlebologic diagnosis is the object this review. Venous reflux is the most frequent pathophysiologic mechanism in chronic venous disease. Reflux is easily visualized by duplex ultrasound when properly elicited, in standing position. A simple way to elicit reflux is the so-called “compression-release maneuver”: by emptying the muscle reservoir, it determines a centrifugal gradient, dependent on hydrostatic pressure, creating an aspiration system from the superficial to the deep system. The same results are obtained with dynamics tests activating calf muscles. The Valsalva maneuver elicits reflux by a different mechanism, increasing the downstream pressure and, thus, highlighting any connection between the source of reflux and the refluxing vessel. The Valsalva maneuver is typically used to investigate the saphenofemoral junction. When the maneuver is performed correctly, it is very useful to analyse several conditions and different hemodynamic behaviours of the valvular system at the saphenofemoral junction. Negative Valsalva maneuver always indicates valvular competence at the saphenofemoral junction. Reverse flow lasting during the whole strain (positive Valsalva maneuver) indicates incompetence or absence of proximal valves. Coupling Valsalva maneuver to compression-release maneuver, with the sample volume in different saphenofemoral junction sections, may reveal different hemodynamic situations at the saphenofemoral junction, which can be analysed in detail.