Steven E. Zimmet

Endovenous laser treatment of saphenous vein reflux: long-term results.

PURPOSE To report long-term follow-up results of endovenous laser treatment for great saphenous vein (GSV) reflux caused by saphenofemoral junction (SFJ) incompetence. MATERIALS AND METHODS Four hundred ninety-nine GSVs in 423 subjects with varicose veins were treated over a 3-year period with 810-nm diode laser energy delivered percutaneously into the GSV via a 600- micro m fiber. Tumescent anesthesia (100-200 mL of 0.2% lidocaine) was delivered perivenously under ultrasound (US) guidance. Patients were evaluated clinically and with duplex US at 1 week, 1 month, 3 months, 6 months, 1 year, and yearly thereafter to assess treatment efficacy and adverse reactions. Compression sclerotherapy was performed in nearly all patients at follow-up for treatment of associated tributary varicose veins and secondary telangiectasia. RESULTS Successful occlusion of the GSV, defined as absence of flow on color Doppler imaging, was noted in 490 of 499 GSVs (98.2%) after initial treatment. One hundred thirteen of 121 limbs (93.4%) followed for 2 years have remained closed, with the treated portions of the GSVs not visible on duplex imaging. Of note, all recurrences have occurred before 9 months, with the majority noted before 3 months. Bruising was noted in 24% of patients and tightness along the course of the treated vein was present in 90% of limbs. There have been no skin burns, paresthesias, or cases of deep vein thrombosis. CONCLUSIONS Long-term results available in 499 limbs treated with endovenous laser demonstrate a recurrence rate of less than 7% at 2-year follow-up. These results are comparable or superior to those reported for the other options available for treatment of GSV reflux, including surgery, US-guided sclerotherapy, and radiofrequency ablation. Endovenous laser appears to offer these benefits with lower rates of complication and avoidance of general anesthesia.

Endovenous Laser Treatment of the Incompetent Greater Saphenous Vein

PURPOSE To assess the safety and preliminary efficacy of endovenous laser treatment (EVLT), a novel percutaneous technique for occlusion of the incompetent greater saphenous vein (GSV). MATERIALS AND METHODS Ninety GSVs in 84 patients with reflux at the saphenofemoral junction (SFJ) into the GSV were treated endovenously with pulses of laser energy and evaluated in a prospective, nonrandomized, consecutive enrollment multicenter study. Patients were evaluated at 1 week and at 1, 3, 6, and 9 months to determine efficacy and complications. RESULTS Eighty-seven of 90 GSVs (97%) were closed 1 week after initial treatment with endovenous laser. The remaining three GSVs were closed after repeat treatment. Eighty-nine of 90 GSVs (99%) remained closed for as long as 9 months according to serial duplex ultrasonography. Sonographic evaluation demonstrated 73% reduction in GSV diameter at 6 months (61 patients) and 81% reduction in GSV diameter at 9 months (26 patients) after EVLT. One patient developed a transient localized skin paresthesia. There have been no other minor or major complications. CONCLUSIONS EVLT of the incompetent GSV appears to be an extremely safe technique that yields impressive short-term results. Long-term follow-up is awaited.

Temperature changes in perivenous tissue during endovenous laser treatment in a swine model.

PURPOSE To conduct a pilot study to measure temperature at the outer vein wall during endovenous laser treatment (EVLT). METHOD Temperature at the outer vein wall was monitored during EVLT in a live pig ear vein (8 W: 1.0 and 2.0 seconds pulse duration; 10 W: 1.0 and 1.5 second pulse duration; 12 W: 0.5, 1.0 and 1.5 second pulse duration) and exposed hind limb vein (8 W: 0.5, 1.0, 1.5 second pulse duration; 12 W: 0.5,1.0, 1.5 second pulse duration with perivenous tumescent fluid (TF); and 15 W: 0.5 second pulse duration without and with TF, 1.0 second pulse duration with TF). RESULTS Peak temperatures, near the outer vein wall in an ear vein of a live pig, with laser fluence at 8 W were 40.8 degrees C and 48.9 degrees C (pulse durations of 1.0 and 2.0 seconds, respectively). At 10 W, peak temperature was 47.1 degrees C and 49.1 degrees C (pulse durations of 1.0 and 1.5 seconds, respectively). At 12 W, peak temperature ranged from 37.9 degrees C (0.5 second pulse duration) to 49.1 degrees C (1.5 second pulse durations). In an exposed hind limb vessel, at 8 W, peak temperature ranged between 34.6 degrees C to 38.5 degrees C (0.5, 1.0 and 1.5 second pulse durations). At 12 W and 0.5 to 1.5 second pulse durations, with TF, peak temperature ranged from 35.6 degrees C to 39.4 degrees C. At 15 W and 0.5 second pulse duration, peak temperature was 44.0 degrees C without TF and 34.5 degrees C with TF. At 15 W and 1.0 second pulse duration, with TF, pulse duration peak temperature was 37.0 degrees C. CONCLUSIONS In the model studied, peak temperatures of perivenous tissues generated during endovenous laser seem unlikely to cause permanent damage to these perivenous tissues. The peak temperature generated is reduced with the use of perivenous tumescent fluid.

Core content for training in venous and lymphatic medicine

The major venous societies in the United States share a common mission to improve the standards of medical practitioners, the educational goals for teaching and training programs in venous disease, and the quality of patient care related to the treatment of venous disorders. With these important goals in mind, a task force made up of experts from the specialties of dermatology, interventional radiology, phlebology, vascular medicine, and vascular surgery was formed to develop a consensus document describing the Core Content for venous and lymphatic medicine and to develop a core educational content outline for training. This outline describes the areas of knowledge considered essential for practice in the field, which encompasses the study, diagnosis, and treatment of patients with acute and chronic venous and lymphatic disorders. The American Venous Forum and the American College of Phlebology have endorsed the Core Content.

Curriculum of the American College of Phlebology

T Nguyen , J Bergan-, R Min, N Morrison and S Zimmet *Dermatology, Mohs Micrographic & Dermatologic surgery, Procedural Dermatology, University of Texas-MD Anderson Cancer Center, Houston, TX, USA; -Department of Surgery, UCSD School of Medicine, San Diego, CA, USA; +Department of Radiology, Cornell University School of Medicine, New York, NY, USA; Morrison Vein Institute, Scottsdale AZ, USA; Zimmet Vein and Dermatology, Austin, TX, USA

Exploring the value of vein center accreditation to the venous specialist

Whereas advancements in medicine offer potential alternatives for better treatment outcomes, these additional therapeutic options can make health care decision-making more difficult for patients, referring physicians, payers, and policy makers. In a complex and ever-changing medical world, quantifying quality care is a challenge, while the need to promote higher quality care is even more important. Many of the key developments in the field have come into common use without the opportunity for formal training for physicians already in practice, regardless of specialty background. These techniques are often learned through postgraduate educational experiences. As a result, it is likely that there is a wide range of knowledge, skill, and experience among physicians offering vein services. Given that many of these services are provided in the office, there is no hospital or institutional supervision or accreditation. In an effort to improve quality of venous care, the Intersocietal Accreditation Commission (IAC) established accreditation standards for superficial vein centers. This review discusses the process used to create the IAC Vein Center guidelines; summarizes important requirements for accreditation and their impact on quality of care; and examines the potential impact of IAC accreditation on patients, providers, and payers.

Program requirements for fellowship education in venous and lymphatic medicine

Background In every field of medicine, comprehensive education should be delivered at the graduate level. Currently, no single specialty routinely provides a standardized comprehensive curriculum in venous and lymphatic disease. Method The American Board of Venous & Lymphatic Medicine formed a task force, made up of experts from the specialties of dermatology, family practice, interventional radiology, interventional cardiology, phlebology, vascular medicine, and vascular surgery, to develop a consensus document describing the program requirements for fellowship medical education in venous and lymphatic medicine. Result The Program Requirements for Fellowship Education in Venous and Lymphatic Medicine identify the knowledge and skills that physicians must master through the course of fellowship training in venous and lymphatic medicine. They also specify the requirements for venous and lymphatic training programs. The document is based on the Core Content for Training in Venous and Lymphatic Medicine and follows the ACGME format that all subspecialties in the United States use to specify the requirements for training program accreditation. The American Board of Venous & Lymphatic Medicine Board of Directors approved this document in May 2016. Conclusion The pathway to a vein practice is diverse, and there is no standardized format available for physician education and training. The Program Requirements for Fellowship Education in Venous and Lymphatic Medicine establishes educational standards for teaching programs in venous and lymphatic medicine and will facilitate graduation of physicians who have had comprehensive training in the field.

Editors' note regarding Blood pressure normalization post-jugular venous balloon angioplasty.

10.1177/(0268355515575882) Blood pressure normalization post-jugular venous balloon angioplasty, by Zohara Sternberg, Prabhjot Grewal, Steven Cen, Frances DeBarge-Igoe, Jinhee Yu, and Michael Arata, Phlebology 0268355513512824, first published on 19 November 2013 as Epub, DOI: 10.1177/0268355513512824.

Venous Disease A–Z

We, the Editorial staff, are very pleased to announce the start of a new series in Phlebology, entitled ‘Venous Disease: A–Z’. This series consists of invited papers on important topics in phlebology by recognized experts. With the exception of the annual Special Issue, one paper from the series will be published in each issue for many months to come. The initial plan is for 24 topics each with a special author. Here are just a few examples of the upcoming papers: