Venous Insufficiency in 2019 – An Update on Interventional Medicines and Procedures

Highlights from the 15th annual Complex Cardiovascular Therapeutics: Advanced Endovascular and Coronary Intervention Global Summit (C3), Hilton Bonnet Creek, Orlando, FL, US, 23–6 June 2019 — Focus on venous insufficiency

Chronic venous insufficiency, resulting in abnormally high blood pressure in the veins of the extremities, leads to clinical outcomes associated with greatly reduced quality of life.¹ In Western countries, the prevalence of chronic venous insufficiency is relatively high (up to 40% of women and 17% of men); varicose veins, one of the most commonly associated conditions, may present in up to 76% of women and 56% of men.² Venous insufficiency and disease, often in combination with limb trauma, may lead to ulcers that are difficult to treat and slow to heal.³ Deep vein thrombosis is also more frequent in people with venous insufficiency, which has also been associated with post-thrombotic morbidity.⁴ Advancing age, obesity, female sex and prior or family history of venous disease or thrombosis are all risk factors for chronic venous insufficiency.^1,2

At the Complex Cardiovascular Catheter Therapeutics (C3) 2019 meeting, experts united at a summit on venous disease and shared insights and best practice on approaches to treating the associated conditions.

Endovenous laser ablation (EVLA) remains the gold standard for treating varicose veins and venous reflux; although endovenous radiofrequency ablation (RFA) is expected to become an increasingly used option. Non-thermal options may be less time consuming to perform and offer the advantage of nerve sparing treatment, and thus be preferable for some patients. However, for the majority of patients, thermal venous ablation has a long track record of success and can be used to treat relatively large veins (up to 16 mm diameter has be demonstrated with RFA and up to 40 mm with EVLA, compared with an ideal size of <12 mm with non-thermal ablation). Certain anatomy is not suited to thermal ablation: pelvic escape points, perforator veins, superficial veins next to nerves and very tortuous veins.

In EVLA treatment, both wavelength and fibre type are important, with jacketed fibres being associated with lower pain scores and improved post-operative recovery than bare fibres.⁵ In a review of a selection of recent studies and practical findings, Dr Lowell Kabnick noted that the incidence of endovenous heat-induced thrombosis (EHIT) was not significantly different between EVLA and RFA, and had a diminishing trend with increasing experience with using the techniques.⁶ Moreover, the majority of patients experienced moderate EHIT severity and were successfully treated with anticoagulation; none experienced severe experienced EHIT.⁶ Low competence with endothermal procedures was the most commonly associated cause of recurrent varicose veins.⁶ Best practice should include thorough duplex mapping and careful pre-operative marking. Special attention should be paid to accessory saphenous veins, pelvic sources, thigh extensions and perforator veins.⁶

The benefits of a CO₂ foam sclerosant for chemical ablation of abnormal veins up to 25 mm in diameter were discussed at this year’s C3 meeting. Carbon dioxide is highly soluble and, in past studies, has been associated with fewer adverse events than air foams in lower extremity venous sclerotherapy.⁷ Compared with a sclerosant alone (such as polidocanol or sodium tetradecyl sulfate]), a larger volume of CO₂ foam sclerosant can be delivered to a larger range of vein sizes, and with less force and with greater visibility on ultrasound imaging. Air emboli are avoided with CO₂. The relative efficacy and safety of this approach, compared with room air sclerotherapy, might be considered by physicians with an interest in chemical ablation.

For physicians performing venous stenting, best practice revolves around several key factors. The procedure should be performed with wires being inserted above the heart (or past the heart, if entering in the jugular) to reduce the chance of stent embolisation to the central system. Access points should be carefully considered on an individual patient basis, to encourage ‘healthy-to-healthy’ vein stenting and avoid diseased access points that may lead to complications. Stent size, especially with self-expanding stents, should be on a one-to-one basis with the target vein diameter; oversizing the stent may lead to complications, and remodelling can occur in dilatated segments. Where multiple stents are needed to create a long, tapered stent, it is important to avoid stent gaps. This is best achieved by having a larger diameter stent expand into the smaller diameter stent, creating a continuous pathway and avoiding flow disturbance.

For the management of venous ulcers, compression is key, with an increasing evidence base favouring compression bandages and stockings for improved healing, rather than no compression.⁸ Compression is also associated with lower rate of ulcer recurrence than management with no compression.⁸ The addition of oral pentoxifylline to compression has been associated with better healing than placebo.⁸ There is no clinical trial evidence base for the benefits of leg elevation; however, there is merit to the approach because venous insufficiency is corrected when the limb is elevated above the heart. Advantages of elevation, so as increased venous return and reduced oedema, should be considered for each patient – for example, is the cardiovascular system of the individual healthy enough for a sudden increase in circulating volume?⁸

When the superior vena cava is compressed – often by a lung tumour, lymphoma, thrombosis or aneurysm – a patient may develop superior vena cava syndrome (SVCS). The majority of SVCS cases (85%) are associated with malignancies, most commonly lung cancer; overall, around 4% of patients with lung cancer develop SVCS.⁹ Often most noticeable in the morning, following horizontal sleeping, SVCS has a gradual, insidious onset, with swelling of the face and neck, dyspnoea, and a dry cough as the most common symptoms. Rapid and accurate diagnosis is important to reduce the risk of death from laryngeal swelling and cerebral anoxia. Venography is the gold standard for diagnosis confirmation; X-ray, MRI and CT scans can be used to detect the obstruction and associated mass.⁹ Electrocardiogram or echocardiogram can help detect any cardiac causes for obstruction. Treatment focuses on resolution of the underlying condition and eliminating the obstruction to relieve symptoms – this would typically include cancer treatment as appropriate, along with anticoagulation and endovascular stenting, with the option of surgery to bypass the superior vena cava.^10,11 Long-term anticoagulation therapy or platelet inhibition is required if a stent is used; in non-stent treatment strategies (e.g. angioplasty, recanalisation) there is debate as to the benefits of anticoagulation versus antiplatelet therapy. Effective therapy should provide adequate tissue perfusion and oxygenation, maintain airway patency and relieve symptoms, improving quality of life. Endovascular therapy is associated with decreased morbidity and mortality in patients with SVCS.

Continued optimisation of management strategies, alongside medical, procedure and device developments are welcomed as physicians seek to continually improve patient outcomes across the varied presentations of chronic venous insufficiency.

References

1. Lozano Sánchez FS, Sánchez Nevarez I, González-Porras JR, et al. Quality of life in patients with chronic venous disease: influence of the socio-demographical and clinical factors. Int Angiol. 2013;32:433–41.
2. Beebe-Dimmer JL, Pfeifer JR, Engle JS, et al. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol. 2005;15:175–84.
3. Kelechi TJ, Johnson JJ, Yates S. Chronic venous disease and venous leg ulcers: An evidence-based update. J Vasc Nurs. 2015;33:36–46.
4. Shaydakov ME, Comerota AJ, Lurie F. Primary venous insufficiency increases risk of deep vein thrombosis. J Vasc Surg Venous Lymphat Disord. 2016;4:161–6.
5. Kabnick LS, Sadek M. Fiber type as compared to wavelength may contribute more to improving postoperative recovery following endovenous laser ablation. J Vasc Surg Venous Lymphat Disord. 2016;4:286–92.
6. Kabnick LS. 20 Years of Venous Thermal Ablation: Tell it like it is. Presented at: Complex Cardiovascular Catheter Therapeutics (C3), Orlando, USA, 23–26 June 2019.
7. Morrison N, Neuhardt DL, Rogers CR, et al. Comparisons of side effects using air and carbon dioxide foam for endovenous chemical ablation. J Vasc Surg. 2008;47:830–6.
8. Nelson EA, Adderley U. Venous leg ulcers. BMJ Clin Evid. 2016;2016: pii: 1902.
9. Jawed M. SVC Syndrome, Occlusion and Recalization. Presented at: Complex Cardiovascular Catheter Therapeutics (C3), Orlando, USA, 23–26 June 2019.
10. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology for Palliative Care; Version 1.2017. Available at: www.nccn.org/professionals/physician_gls/default.aspx (accessed 23 April 2019).
11. Kvale PA, Selecky PA, Prakash UB, et al. Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:368S.