Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023.

BACKGROUND: Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events. OBJECTIVES: To categorise contraindications to sclerotherapy based on the available scientific evidence. METHODS: An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited. RESULTS: Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes. CONCLUSIONS: Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of 'no intervention as a treatment option' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.

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.

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.

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.

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.

Classification of compression bandages: practical aspects.

BACKGROUND: Compression bandages appear to be simple medical devices. However, there is a lack of agreement over their classification and confusion over the use of important terms such as elastic, inelastic, and stiffness. OBJECTIVES: The objectives were to propose terms to describe both simple and complex compression bandage systems and to offer classification based on in vivo measurements of subbandage pressure and stiffness. METHODS: A consensus meeting of experts including members from medical professions and from companies producing compression products discussed a proposal that was sent out beforehand and agreed on by the authors after correction. RESULTS: Pressure, layers, components, and elastic properties (P-LA-C-E) are the important characteristics of compression bandages. Based on simple in vivo measurements, pressure ranges and elastic properties of different bandage systems can be described. Descriptions of composite bandages should also report the number of layers of bandage material applied to the leg and the components that have been used to create the final bandage system. CONCLUSION: Future descriptions of compression bandages should include the subbandage pressure range measured in the medial gaiter area, the number of layers, and a specification of the bandage components and of the elastic property (stiffness) of the final bandage.

Sclerotherapy treatment of telangiectasias and varicose veins.

Telangiectasias and/or varicose veins are present in about 33% of adult women and 15% of adult men. Although they may be only of cosmetic concern, superficial varices often cause significant symptoms such as pain, aching, heaviness, and pruritus. Venous ulceration is commonly caused solely by superficial venous insufficiency. Superficial thin-walled veins may rupture and hemorrhage. Sclerotherapy is a nonsurgical procedure that can be used to treat both small and large varices of the superficial venous system and perforators. This involves injecting a sclerosant intraluminally to cause fibrosis and eventual obliteration of a vein. The most common sclerosants used in the U.S. include sodium tetradecyl sulfate, polidocanol, 23.4% saline, and a combination of 25% dextrose with 10% saline. Treatment generally proceeds from proximal to distal and largest to smallest vein, based on a reflux map developed from physical examination, Doppler, and duplex ultrasound. Sclerotherapy results can be optimized and the risk of complications minimized by choosing the proper sclerosant, sclerosant concentration, sclerosant volume, and injection sites for the vein(s) being treated. Post-treatment instructions, particularly compression and ambulation, are designed to improve the results and safety of sclerotherapy. Adequate understanding of an appropriate history and physical, ultrasound evaluation, anatomy, pathophysiology, knowledge of sclerosing solutions, patient selection, and post-treatment care, as well as the ability to prevent, recognize, and treat complications are required before embarking on treatment.

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.

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.