Current perspectives on venous disease

Abstract

24th Annual Meeting of the American Venous Forum

Orlando, FL, USA, 8–11 February 2012

The American Venous Forum unites authorities on all facets of venous disease, the pathophysiology of venous disease and its treatment. The goal of this meeting was to educate attendees about current and novel clinical strategies to effectively manage venous disease.

Keywords::

• learning seminar
• novel therapies
• venous thromboembolism

Scientific sessions

Role of statins & aspirin therapy in deep vein thrombosis

The role of statin therapy for deep venous thrombosis (DVT) remains controversial. A recent retrospective cohort study reviewing 1795 patients over 5 years evaluated the effects of statins used with and without antiplatelet therapy. The incidence of DVT was significantly less in patients with both statin and antiplatelet therapy versus antiplatelet therapy alone. This study concluded that the use of statins and antiplatelet therapy is associated with a significant reduction in the occurrence of venous thromboembolism (VTE) in a dose-related manner. The potential antithrombotic nature of statins in the randomized controlled JUPITER trial showed that the incidence of DVT decreased with the 20-mg daily dose of rosuvastatin [1]. In a study by DeRoo et al. (University of Michigan, MI, USA), oral rosuvastatin in mice significantly decreased acute inflammation at the local and systemic levels, while also decreasing thrombosis 2 days after injury [2], suggesting a potential mechanism for rosuvastatin effects on DVT.

Strandness Memorial Lecture: venous & arterial thrombosis: is there a link?

Paola Prandoni (University of Padua, Italy) gave the Eugene Strandness Memorial Lecture this year. Prandoni is an international expert in the epidemiology of venous thrombosis. Prandoni spoke on the similarities and differences between venous thrombosis and arterial thrombosis. During his lecture, he presented data that linked unprovoked VTE with arterial cardiovascular events, and he demonstrated data for the first time which showed that small doses of aspirin can inhibit venous thrombosis after standard anticoagulant therapy. His data suggest that clinicians may be treating DVT patients similarly to how patients are treated with arterial disease.

Chronic cerebrospinal venous insufficiency

Molic et al. (Clinical Centre Nis, Nis, Serbia) discussed the Liberation procedure in the treatment of chronic cerebrospinal venous insufficiency – whether chronic cerebrospinal venous insufficiency related to brain congestive syndrome is rather than multiple sclerosis, highlighted chronic cerebrospinal venous insufficiency (CCSVI), which occurs due to compromised blood flow in the veins draining the central nervous system. This condition has been hypothesized to have a causal role in multiple sclerosis (MS). Currently, balloon angioplasty or stenting ‘liberation procedure’ has been the proposed treatment option for CCSVI in MS patients. Molic evaluated this procedure in patients with varying forms of MS with CCSVI. Patients were examined before the liberation procedure and at both 6 and 12 months postprocedure. Approximately 70% of treated patients showed an initial benefit, but more than 40% of the treated patients regained almost all of the preprocedural symptoms after 12 months. The author concluded that because blood biochemical parameters improved postprocedure, the liberation procedure had its greatest effects on relieving brain decongestion. This study suggests that CCSVI is related to brain congestive syndrome rather than MS.

New venous valve development & techniques

David Ku (Emory School of Medicine, GA, USA) has worked on developing prosthetic venous valves to treat chronic venous insufficiency in patients. Ku has developed a new valve design, which is naturally opened and impregnated with an anticoagulant agent to limit valve surface thrombogenesis [3]. This novel valve allows for low-resistance physiologic flow rates of 400–600 ml/min. In addition, no measureable thrombogenic potential in vitro blood was noted as seen in alternative biomaterials under identical conditions. This study was validated in a sheep external jugular vein animal model. Experimental valve patency was determined at 6 weeks, thus surpassing many autograft valves. This study demonstrates the translational effects of mechanical device testing in animals that directly benefits humans.

Aggressive treatments of venous thromboembolism & May–Thurner syndrome

May–Thurner syndrome is a thrombosis of the left iliac vein due to the compression of the common iliac vein by the right common iliac artery. The treatment of choice is endovascular, with thrombolysis followed by angioplasty with stenting [4]. Iliac vein compression syndrome has been implicated in the cause of iliofemoral DVT. Currently, noninvasive imaging modalities for visualizing compressed or obstructed vessels have clinically dependent limitations. Duran et al. (The Methodist DeBakey Heart and Vascular Institute, TX, USA) have demonstrated that dynamic magnetic resonance can diagnose May–Thurner syndrome by different available sequences throughout the cardiac cycle, unlike computed tomography (CT) [5]. However, the limitation of magnetic resonance is in detecting the syndrome where luminal disease is not evident.

Meisner et al. (University of Washington Medical Center, WA, USA) conducted a prospective study where 30 consecutive asymptomatic patients and 30 advanced venous disease patients were evaluated for proximal compression by CT [6]. By contrast, enhanced CT was used to survey the common iliac veins through the pelvis as they interact with the ileacarteries and the L5 vertebral body. No statistically significant area reductions of the iliac veins in the advanced disease patients versus asymptomatic controls were observed, indicating that CT as a method to quantify iliac vein compression has limitations. Of interest, 30% of the patients analyzed with CT displayed a non-May–Thurner compression in their iliac veins. This non-May–Thurner compression in patients with advanced venous disease is currently unknown.

The treatment of extensive DVT during pregnancy poses a significant patient risk. In a study by Herrera et al. (Toledo Hospital, OH, USA), 11 patients during 1999–2011 were referred to the Toledo Hospital for the management of extensive DVT during pregnancy [7]. Catheter-directed thrombolysis and pharmacomechanical thrombolysis and/or operative thrombolectomy were performed in nine patients. Each patient had rapid resolution of clinical signs postprocedure, eight patients delivered healthy infants and one infant died in utero due to complications of antiphospholipid antibody syndrome. Venous duplex ultrasound demonstrated patent veins and normal valve function in eight patients. Thus, the treatment of extensive DVT during pregnancy can be effective.

Villavicencio symposium on atrioventricular malformations/lymphology

The goal of this session was to educate attendees on the close physiological and pathological relationship between the lymphatic and venous systems. J Leonel Villavicencio (MD, USA) gave an outstanding overview on how congenital vascular malformations may involve arterial, venous and lymphatic structures, and can present in a variety of forms and many diagnostic and therapeutic challenges [8]. Villavicencio also educated listeners on the selected clinical reports that revealed the historical perspectives on the diagnosis and management of this disease. Lymphedema is the obstruction or blockage of lymph vessels that can be caused by surgery, cancer, injury and other medical conditions. Current therapeutic options for treating lymphedema and its clinical challenge were discussed by Thom Rooke (Mayo Clinic, MN, USA; manual lymphatic drainage).

Caroline Fife (The University of Texas Medical School at Houston, TX, USA) presented novel imaging techniques for the assessment of lymphatic function [9]. Near-infrared fluorescence imaging of the lymphatic system is an emerging technology that has allowed us to simultaneously study lymphatic structure, anatomy and function in patients with lymphedema of the upper and lower extremities, with microdosages of contrast agents.

Specialty symposia

Vascular medicine/thrombosis

The panel discussion gave attendees an interactive overview on the new oral anticoagulant (Jeff Weitz, Henderson Research Centre, ON, Canada), therapeutic methods used to treat iliofemoral venous thrombosis (Anthony Comerota, The Toledo Hospital, Jobst Vascular Center, OH, USA), venous thromboembolism and its interrelationship with inflammatory events (Thomas Wakefield, University of Michigan, MI, USA), and clinical management of chronic venous insufficiency (Susan Kahn, Jewish General Hospital, and Department of Medicine, McGill University, QB, Canada).

Biomechanics & bioengineering

This symposium addressed the translational roles of biomechanical research by exposing the gaps knowledge in venous pathophysiology (Seshadri Raju, River Oaks Hospital Flowood, MS, USA; Roger Kamm, Massachusetts Institute of Technology, MA, USA; Geert Schmid-Schonbein, University of California, CA, USA). Also, it revealed bioengineering solutions for the management of venous disorders (Fedor Lurie, Kistner Vein Clinic, HI, USA; Andrew Narracott, University of Sheffield, UK; David Ku, Emory School of Medicine, GA, USA; James More, Texas A&M University, TX, USA).

Wound care/compression

The goal of this symposium was to provide attendees with current and emerging information related to the treatment of venous leg ulcers (Robert Kirsner, University of Miami, FL, USA), the optimization of compression to maximize wound healing (Hugo Partsch, Medical University, Austria), the role of inflammation in the etiology and chronic venous ulcers and the use of adjunctive therapies to accelerate wound healing (William Enis, University of Illinois at Chicago, IL, USA; William Marston, University of North Carolina, NC, USA).

Venous ultrasound

During the symposium, attendees engaged in a live ultrasound demonstration identifying the main deep veins from the diaphragm to the inguinal ligament. In addition, the identification of key vascular landmarks and the demonstration of varying vascular reflux procedures were performed.

Conclusion

The 24th Annual Meeting of the American Venous Forum provided an academic setting in which clinicians and basic research scientists could exchange research findings and discuss current and best practice therapies for a vast number of vascular diseases. The next meeting of the American Venous Forum will take place in Phoenix (AZ, USA) 27 February to 2 March 2013 at The Wigwam Resort [101].

Financial & competing interests disclosure

DD Myers has received NIH funding (grant no. 1PO1HL089407). The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.