PURSUING NEW RESEARCH

As a part of the New Horizon Strategic Campaign, the AVLS formed committees to pursue new research projects and grants relevant to venous and lymphatic medicine. Many of these new studies use data from the PRO Venous Registry.

Phlebectomy Outcomes Study

Utilizing the thousands of data points on phlebectomy procedures from the AVLS PRO Venous Registry, Drs. John Blebea and Ken Harper are studying and comparing groups that initially underwent only phlebectomy, simultaneous phlebectomy, and venous ablation (laser and RFA) and groups that initially had only venous ablation. Examining both indications and clinical outcomes, they wish to better define optimal strategies for the use of phlebectomy and its contribution to patients who require combination therapy.

Venous Leg Ulcer Abstract

As the 2018 EVRA trial demonstrated that early intervention accelerates venous leg ulcer (VLU) healing and is proven cost-effective, has there really been a shift in care for those most in need of intervention? There remain structural barriers in place for many markets where no change in referral patterns has occurred. The following paragraph offers insight into nearly 2,000 leg ulcers entering vein practices pulled for analysis from the AVLS PRO 2.0 Registry. Data pulled for analysis included demographic variables, disease severity scoring, and duplex findings at presentation. To no one’s surprise, 83% had a superficial venous component (79% superficial ONLY, while the remainder had mixed superficial and deep vein pathology. 1.9% presented with post-thrombotic syndrome and ONLY deep vein pathology. An additional 278 patients presented with an absence of venous pathology yet an ulcer on the legs. In all, the VLU patients with superficial pathology presented at an average age of 65, proportionally more males vs. females. Those with mixed pathology demonstrated significantly younger ages. This manuscript is forthcoming, and we must ask ourselves, how can we disrupt the barriers to care so that those in need of our services have access to care? There is still much to do.

The Anterior Saphenous Vein

Last year an initiative was created by AVLS and AVF to demonstrate the importance of the anterior accessory of the great saphenous vein (GSV). Several scheduled meetings took place to determine the important issues and develop a plan to enhance our understanding and clarify all issues regarding this vein. All the anatomic and clinical work was collected, and our group of experts, Alberto Caggiati, Nicos Labropoulos, Mark Meissner, Antonios Gasparis, Edward Boyle, and Suat Doganci, removed the word accessory and proposed a new name: Anterior Saphenous Vein (ASV). This was done to indicate that ASV has its own distinct anatomy and pathology, producing signs and symptoms similar to those seen by the GSV. ASV starts from the dorsum of the foot and continues all the way to the thigh and groin area having connections with the GSV at various levels. It also often replaces the GSV in the thigh, and it is the main vein for drainage in the anterior and medial parts of the subcutaneous tissues.

Often the ASV has reflux on its own or together with the GSV, and thus it is very important to diagnose the exact pattern of the disease and plan the treatment. Other anatomic aspects of tributaries, lympho-venous networks, and connections with different veins will be described. We are preparing two separate papers. The first will demonstrate the clinical anatomy of the ASV and its complex and relevant pathophysiologic and therapeutic implications. The second paper is focused on the clinical presentation of patients with ASV reflux and the different patterns of the disease. It will also provide robust evidence against the claims of health insurances that inappropriately do not cover payment for procedures on this vein.

Clinical Research - Pelvic Varices (Pelvic Venous Disorders)

It has been estimated that almost 40% of all women will experience chronic pelvic pain during their lifetime and that 15% of all women between the ages of 18-50 experience chronic pelvic pain (CPP), accounting for 20% of outpatient gynecology appointments. Although more than 30 billion dollars are expended in the United States due to loss of work, family responsibility, and relationships caused by CPP, no cause is identified in up to 30% of patients. It is postulated that pelvic venous disorders (PeVD) account for 16-31% of cases of chronic pelvic pain, second only to endometriosis in prevalence. PeVD are also responsible for lower limb and vulvar varicose veins, left flank pain and hematuria, and lower limb pain and swelling without varicose veins. PeVD can lead to symptoms and signs as a result of the resultant pelvic venous hypertension caused by reflux of one or more gonadal or internal iliac veins as well as by obstruction of an iliac or the left renal vein. Consequently, PeVD can also be responsible for lower limb and vulvar varicose veins, left flank pain and hematuria, and lower limb pain and swelling without varicose veins. The current literature on outcomes for treatment of PeVD has limited acceptance by physicians and payers, resulting in poor access to treatment for patients and continued suffering from CPP. One of the largest limitations is the lack of a randomized trial of intervention proving efficacy. This project is planning to demonstrate change following treatment based on current real-world inclusion criteria for Ovarian Vein Embolization (OVE) by performing a randomized controlled trial of venography versus venography and embolization with adequate tracking of quality-of-life changes for six months following an intervention. In addition to validating OVE as a treatment option for patients with venous origin CPP, this will provide an assessment of the venous system in this unique patient population. This will also demonstrate change in the validated qualityof-life metrics as well as novel disease-specific quality-of-life tools that are in development.