Consensus Statement on the Management of Nonthrombotic Iliac Vein Lesions From the VIVA Foundation, the American Venous Forum, and the American Vein and Lymphatic Society.

A nonthrombotic iliac vein lesion is defined as the extrinsic compression of the iliac vein. Symptoms of lower extremity chronic venous insufficiency or pelvic venous disease can develop secondary to nonthrombotic iliac vein lesion. Anatomic compression has been observed in both symptomatic and asymptomatic patients. Causative factors that lead to symptomatic manifestations remain unclear. To provide guidance for providers treating patients with nonthrombotic iliac vein lesion, the VIVA Foundation convened a multidisciplinary group of leaders in venous disease management with representatives from the American Venous Forum and the American Vein and Lymphatic Society. Consensus statements regarding nonthrombotic iliac vein lesions were drafted by the participants to address patient selection, imaging for diagnosis, technical considerations for stent placement, postprocedure management, and future research/educational needs.

Inframalleolar access in endovenous treatment of venous ulcers and C5 disease with nonthermal nontumescent techniques.

PURPOSE: To evaluate the use of inframalleolar access for endovenous ablation when treating advanced venous disease with nonthermal nontumescent (NTNT) techniques. METHODS: This single-center retrospective study included 109 patients with advanced venous disease, treated using inframalleolar access between May 2018 and March 2020. NTNT techniques included ClariVein (Merit Medical Systems, South Jordan, Utah) and ScleroSafe (VVT Medical, Kefar Sava, Israel). Outcomes measured were postprocedure pain, leg edema, ulcer healing and recurrence rates, and venous insufficiency recurrence. RESULTS: Seventy-seven patients (70%) were treated with ClariVein and 32 (30%) with ScleroSafe. Postprocedure pain score (range, 0-10) after 1 week decreased from a preprocedure median of 5 (interquartile range, 3-6) to 1 ((interqartiel range, 0-2) (P = .0001). Complete wound healing was achieved in 38 patients (43.7%) after 30 days and in 71 patients (81.6%) after 90 days. One patient developed an ulcer recurrence and six developed venous insufficiency recurrence. There was no reported nerve or skin injuries. CONCLUSIONS: NTNT ablation techniques using inframalleolar access are effective and safe without risk of nerve damage. Their use facilitates ulcer healing and limits pain in patients with advanced disease.

Results of polidocanol endovenous microfoam in clinical practice.

BACKGROUND: Initial phase III clinical studies with polidocanol endovenous microfoam (PEM) demonstrated its safety and efficacy in the treatment of superficial venous reflux. In those studies, the primary outcome requirement was to assess the improvement in symptoms related to superficial venous disease. The goal of the present study was to evaluate the efficacy of PEM technology in routine clinical practice-specifically, the closure rates after treatment. METHODS: We performed an observational study during which data were prospectively collected from 2 vein centers using an electronic database. Patients with CEAP (clinical, etiologic, anatomic, pathophysiologic) class ≥2 and symptomatic superficial axial reflux (great saphenous vein, anterior accessory saphenous vein, and small saphenous vein) were included and followed up prospectively. PEM was used to treat the saphenous vein and varicosities. The CEAP classification was used to classify chronic venous disease, and the venous clinical severity score (VCSS) was applied to measure the disease severity. Pain and discomfort were assessed using a visual analog scale, and the residual veins were assessed by physical examination. RESULTS: PEM was used to treat superficial reflux in 60 patients. The CEAP classification was C2 for 32 patients, C3 for 14, C4 for 10, and C5 for 4 patients. The average pretreatment VCSS was 7.3. The saphenous vein diameter was 6.5 mm, and the average length was 31 cm. The average volume of PEM used to treat the saphenous veins was 9.3 mL. The closure rate at 3 and 6 months was 93% (54 of 58) and 93% (51 of 55), respectively. The VCSS had improved from 7.3 to 1.4. Complications included 1 case of deep vein thrombosis (1.7%), 5 patients (8.3%) with thrombophlebitis, and 4 patients (6.6%) with skin pigmentation. CONCLUSIONS: PEM is safe and effective for the treatment of saphenous reflux and varicosities. The early closure rates using PEM were maintained at 6 months and are comparable to the results reported with nonthermal, nontumescent technologies and thermal tumescent technologies.

A review of United States endovenous ablation practice trends from the Medicare Data Utilization and Payment Database.

OBJECTIVE: The growth of endovenous ablation in the United States over the last few years has raised concerns of overuse by many vascular societies and payers. Reasons for such growth are unclear (ie, increased awareness, less invasive procedure, or inappropriate overuse). The Medicare Provider Utilization and Payment database was analyzed to define metrics of current practice trends in Medicare patients by providers. METHODS: The Medicare Provider Utilization and Payment database was queried for endothermal ablation Current Procedural Terminology codes (36475, 36476, 36478, and 36479) from 2012 through 2015. These results were imported into a relational database program. Queries were designed to ascertain the practice trends of all providers, inclusive of all specialties, and the data were exported to a spreadsheet program for analysis. Analysis for ablations per patient was calculated by assessing the number of beneficiaries who underwent at least one ablation by a provider in relation to the total number of ablations performed by that provider. RESULTS: Most saphenous vein ablations were done by vascular surgeons (29%), cardiologists (21%), or general surgeons (14%). The remaining one-third was performed by 33 other provider specialties ranging from nuclear medicine specialists to ophthalmologists. Regional variation was significant with 51% of ablations being performed in the south (Florida, 15.7% and Texas, 11.4%). The Western region had the greatest percentage growth of 62% with the addition of 14,788 cases added between 2012 and 2015. Ablations per patient averaged 1.8 in the aggregate dataset. Over the 4-year period, there was a steady increase seen in the number of patients undergoing ablation, number of ablations performed, number of providers performing ablation, average amount of ablations being performed as well as the number and proportion of providers performing more than ablations per patient. The number of ablations per patient was higher than average in specialties without any formal vascular training. CONCLUSIONS: Endovenous ablation is performed by a wide variety of subspecialists with different levels of formal training for the management of chronic venous disease. This data analysis can help to establish better guidelines and governance over the use of endovenous ablation, but care should be taken to realize this is only an average and many patients will require more than two ablations for appropriate care. As our health care system shifts from a fee-for-service to a value-based system, and taxpayer-funded resources in Medicare patients become less available, it is important that practice trends be scrutinized using data-driven initiatives so that the appropriate physician treats the appropriate patient for the appropriate reasons.

Present and future options for treatment of infrainguinal deep vein disease.

OBJECTIVE: Management of chronic deep vein disease focuses on the alleviation of reflux and obstruction. For the suprainguinal veins, the main underlying pathologic process is obstruction, which has been recognized as a significant contributor to chronic venous insufficiency. This is currently being addressed with venous stenting and the development of dedicated stents designed for this segment of the venous system. Treatment of the femoropopliteal vein (FPV) is far more challenging because of the idiosyncratic anatomy, the hemodynamic physiology, and the technical aspects of size mismatch and valve flow dynamics in managing deep venous reflux. This review article discusses traditional and emerging technologies to treat infrainguinal disease. METHODS: Previous and current articles addressing this issue were reviewed. Emphasis was placed on emerging techniques and technologies. RESULTS: Significant bench work, in vitro and in vivo studies, have been conducted over the last 40 years addressing the issue of infrainguinal reflux and obstruction. Historically, open procedures to address FPV reflux and obstruction have had variable success in a few centers around the world. The significant increase of emerging endovascular therapies may allow more appropriate, reproducible, widespread treatment of infrainguinal deep venous disease. CONCLUSIONS: Adequate and durable therapies for infrainguinal venous disease represent one of the greatest challenges for a vein specialist. Recently, a cluster of interest and techniques/technologies have been developed. The endovascular management of arterial disease is mature. The endovenous management of infrainguinal disease is on the cusp of meaningful innovation. The purpose of this evidence summary is to describe the options for the management of chronic FPV disease, with emphasis on emerging technologies and techniques.

Current techniques to treat pathologic perforator veins.

Pathologic perforating veins have become an interest to the venous specialist caring for patients with CEAP 4 to 6 disease. Historically, open perforator ligation and then subdermal endoscopic perforator ligation was described. These methods had clear shortcomings. More recently, thermal ablation techniques, including radiofrequency ablation and laser ablation, have been described. Ultrasound-guided sclerotherapy has also been used as a possible means to treat pathologic perforator veins. This report describes and summarizes the updated techniques to treat perforating veins in a challenging patient population.

Ultrasound-guided percutaneous ablation for the treatment of perforating vein incompetence.

Recent advances in catheter-based endovenous interventions have broadened our understanding in the pathophysiology and therapeutic strategies of chronic venous insufficiency, a condition that can be caused by abnormality of various lower extremity venous structures, including superficial or deep vein reflux or incompetent perforating veins. This article reviews the history and therapeutic principles of percutaneous ablation of perforators (PAPs). Discussions related to treatment strategies and procedural techniques of PAPs using radiofrequency ablation, laser energy, and sclerosant injection are provided. Current clinical results of PAPs with radiofrequency and laser energy ablation as a treatment modality of chronic venous insufficiency are also discussed.