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Success of Endovenous Saphenous and Perforator Ablation in Patients with Symptomatic Venous Insufficiency Receiving Long-Term Warfarin Therapy page 6

Three-dimensional modelling of the venous system by direct multislice helical computed tomography venography: technique, indications and results page 9


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From the Editor-in-Chief Dr. Nick Morrison

jan-feb ‘13

contents

Success of Endovenous Saphenous and Perforator Ablation in Patients with Symptomatic Venous Insufficiency Receiving Long-Term Warfarin Therapy Contributing Editor/Reviewer: Jean-Jérôme GUEX, MD, FACPh

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Associate Editor: Jean-Jérôme GUEX, MD, FACPh

Three-dimensional modelling of the venous system by direct multislice helical computed tomography venography: technique, indications and results

Morphological and haemodynamic abnormalities in the jugular veins of patients with multiple sclerosis Contributing Editors/Reviewers: Erica Menegatti, PhD Paolo Zamboni, MD

Contributing Editor/Reviewer: Stephano Ricci, MD Associate Editor: Mitchel Goldman, MD, FACPh

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Associate Editor: Pauline Raymond-Martimbeau, MD, FACPh

Risk of recurrence in patients with pulmonary embolism: Predictive role of D-dimer and of residual perfusion defects on lung scintigraphy Contributing Editors/Reviewers: Kapil Baliga MS, DNBE Vasc. Ramesh K Tripathi MD, FRCS, FRACS Vasc. Associate Editor: Lowell S. Kabnick, MD, FACS, PACPh, RPhS

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disclosure of interests

Name

ACP Role

Date Submitted

Disclosure

Stephanie Dentoni, MD

Recruitment & Retention (Chair)

6/25/12

Nothing to Disclose

Mark Forrestal, MD, FACPh

ACP

6/25/12

New Star Lasers Cooltouch: Speaker, Trainer

Mitchel Goldman, MD, FACPh

Phlebology Forum Task Force

2/14/2013

American Society for Dermatologic Surgery, President-Elect; Merz Aesthetics/Kruesler, Consultant

Jean-Jerome Guex, MD, FACPh

ACP BOD, Communications, Standing Committee, Leadership Development, UIP 2013 Task Force, AMA HOD Task Force, International Affairs (Chair),

6/14/12

Kreussler: Speaker; Sigvaris: Speaker, Investigator, Consultant; Innotech: Principal Investigator; Pierre Fabre: Consultant; Boerighr Ingelheim: Consultant, Medical Writer; Servier: Investigator, Consultant, Speaker

Lowell Kabnick, MD, FACS, FACPh

UIP 2013 Task Force

7/17/12

Angiodynamics: Consultant, Shareholder, Patent; Vascular Insights: Scientific Advisory Board

Neil Khilnani, MD, FACPh

ACP BOD, Member Services (Chair)

7/24/12

Sapheon: Data Safety Board Member

Ted King, MD, FAAFP, FACPh

ACP BOD, Leadership Development, PES-QM Task Force, Public Education

6/14/12

BTG: Investigator; Merz: Speaker

Mark Meissner, MD

ACP BOD, Education Standing Committee

7/13/12

Nothing to Disclose

Nick Morrison, MD, FACS, FACPh

UIP 2013 Task Force (Chair), Phlebology Forum Task Force (Chair), Annual Congress Planning Committee (Chair)

6/13/12

Medi: Speakers Bureau; Merz: Speakers Bureau; Sapheon: Principle Investigator; VeinX: Scientific Advisory Board

Eric Mowatt-Larssen, MD

ACP CME Committee

6/25/12

BTG International, Inc.: Consultant

Diana Neuhardt, RVT, RPhS

ACP BOD, Member Services, Audit, UIP 2013 Task Force, Phlebology Forum Task Force, Veinline, Recruitment & Tetention, CME, Distance Learning, Public Education (Chair)

6/15/12

Nothing to Disclose

Pauline RaymondMartimbeau, MD, FACPh

UIP 2013 Task Force

6/22/12

Nothing to Disclose

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From the

Editor-in-Chief Dear Readers,

The first edition of Phlebology Forum of 2013 includes several articles of interest to those of us who treat patients with venous disease, both superficial and deep, with reviews that sometimes take a point of view different from that of the original author. This provides great perspective from a truly international viewpoint and affords us an in-depth analysis of each article with the opportunity to apply what works for our own venous practice. The articles of this edition range from the very practical problems of treating anti-coagulated patients with endovenous ablation and the quest to find an accurate predictor of recurrent deep venous thrombosis to the important association of multiple sclerosis with chronic cerebrospinal venous insufficiency, and finally a critical evaluation of the spectacular vascular images created by 3D CTV.

My best wishes for a safe, happy, and healthy New Year.

Nick Morrison, MD Editor-in-Chief Phlebology Forum

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Success of Endovenous Saphenous and Perforator Ablation in Patients with Symptomatic Venous Insufficiency Receiving Long-Term Warfarin Therapy Viktor Gabriel, Juan Carlos Jimenez, Ali Alktaifi, Peter F. Lawrence, Jessica O’Connell, Brian G. Derubertis, David A. Rigberg, and Hugh A. Gelabert, Ann Vasc Surg 2012; 26: 607–611 Summary and comments by Jean-Jérôme GUEX, MD, FACPh

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This retrospective review has the great merit of offering several possible answers to a question very frequently asked at phlebology meetings: how to treat patients under anticoagulation? In their collective of 781 patients (undergoing endovenous Closure Fast® radiofrequency (RF) ablations the authors analyzed the fate of the 45 patients of the collective who were receiving warfarin anticoagulation.

These patients were quite different from those not receiving warfarin since they obviously had a comorbid association: previous DVT for 36%, hyper-coagulable state for 20%, atrial fibrillation for 20%, prosthetic valve for 4%, and various reasons for the remaining 20%. They also differed from the clinical standpoint with 80% of them having severe chronic venous insufficiency (C4a-C6) and 59% suffering with an active ulceration. The responsibility of post thrombotic disease in the group is unfortunately not stated but remains likely. This point should have been taken into account since post thrombotic patients present with multiple threats: recurrence of DVT, development of varicose veins (because of frequent incompetent perforator), development of skin changes and ulcerations, hemorrhagic complications of warfarin.

Unfortunately, comparison of demographic and anatomic data is not presented between the anti-coagulated group and the others. Diameters of ablated veins were more or less what can be expected in such patients: GSV 7.7 ±3.8 mm, SSV 5.4 ±3 mm, incompetent perforators 3.4 ±0.9 m.

The exact protocol used in the RF ablation is not described or even summarized in the article, only indicated as a reference to another paper from the same team. It would have been interesting to know at least if they used tumescence, if they had determined an upper diameter limit for ablation at

The study reports what happens in real life... but some reservations remain.

the junctions, what was the applied compression regimen, etc …

Unlike what has been done in other studies, most patients stopped the anticoagulation 3-5 days preoperatively and resumed the same day after the procedure. Several patients received in addition LMWH or Fondaparinux after the procedure until the target INR was obtained. This may not be the protocol chosen by other teams and the rationale for such a program remains unclear.

Reported outcomes were:

»» The successful closure rate at 48-72 hours post operatively was 100% rate in great and small saphenous veins, 59% on IPV (increased to 77.3 after a second intervention). These results do not differ from what is

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observed in most studies on RF efficacy. »» No thrombotic events such as DVT or pulmonary emboli, other vascular events such as stroke, or myocardial infarction were observed. »» Hemorrhagic events: only 3 patients had a minimal hematoma, treated conservatively. All these observations are reassuring but it is our opinion that the follow up has not been completely satisfactory and that we lack figures to determine precisely the incidence of adverse events. It is obvious that this retrospective study relies on insufficiently documented files and that post-operative monitoring was not perfectly satisfactory if further analysis of data was considered. The study reports what happens in the real life and is probably sufficient to allow carrying out the procedure as described with minimal risks, but some reservations remain.

Assuming the rarity of complications, assessing the actual figures of incidence of thrombotic and vascular events in a prospective trial would require thousands of patients and above all systematic duplex and cardio-pulmonary evaluation at regular intervals, thus adding considerable expense.

The discussion provides some justifications to the topic and adds a number of relevant references.

However, several points are not clarified, including the cessation of warfarin before the procedure - which is not applied by other teams, the lack of monitoring of anticoagulation with  blood tests, the absence of routine postoperative Duplex control, and the fuzzy protocol for the choice of post-operative anticoagulation management.

From a technical point of view, the poor efficacy of RF regarding incompetent perforating veins ablation is also a problem since the learning curve explanation given should be supported by figures, which is not the case. These poor results do not allow one to draw the conclusion that anticoagulation has no impact on RF ablation of incompetent perforating veins.

The conclusion of the study is that the efficacy and the safety of the procedure in anticoagulated patients are good. We would rather say that they are likely and that the procedure is legitimate.

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Three-dimensional modelling of the venous system by direct multislice helical computed tomography venography: technique, indications and results J F Uhl Phlebology 2012;27:270–288 Contributing Editor/Reviewer: Stephano Ricci, MD Associate Editor: Mitchel Goldman, MD, FACPh

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ABSTRACT The spiral or helical computer tomography venography (CTV) scan is the result of two combined techniques : the rotation of an X-ray tube around the patient’s bed ( a multi-slice and multi-detector CTscan producing 600–1200 slices by series over about 30 seconds) and a continuous linear translation of the same bed. This enables the acquisition of spiral volumetric data, resulting in many slices, and 3D images by the use of dedicated reconstruction software so that rotation, tilt, pan, zoom and use of different transparencies of the tissues in real time is possible. CTV without contrast is sufficient for the superficial network, but not suitable for the perforator veins and the deep trunks. Contrast injection (20 mL in 180 mL of serum, at the rate of 2–3 mL/second should begin about 40–60 seconds before) has to be synchronized, in order that it finishes at the end of the acquisition.

Because of the exquisite depiction of venous anatomy it produces, CTV may help avoid the anatomical pitfalls of venous surgery, with some authors recommending CTV to investigate selected patients (SSV particularly) prior to surgery. CTV is proposed by the author for 10–15% of patients before surgery particularly in the following cases: neovascularization of the groin after great saphenous vein (GSV) surgery; postoperative recurrence of the popliteal fossa; small saphenous vein (SSV) high or abnormal termination; varicose veins of the great saphenous territory fed by ascending flow of the Giacomini vein via sapheno-popliteal reflux; large and complex varicose networks of the leg and foot; the course of perforator veins; sciatic nerve varices; venous malformations; acute DVT; and post thrombotic syndrome.

The main limitation is that CTV provides very little hemodynamic data, mainly because it can only be performed with subjects in the supine position. This means that DUS examination is mandatory in addition to CTV for the investigation of the superficial network as well as the deep system. This is particularly true for the patients with DVT. The main problem of CTV is the possible lack of visualization of some veins, to be differentiated from a venous thrombosis.

Radiation exposure to X-rays is the main criticism of CTV.

COMMENT JJean Francois Uhl is the true modern anatomist. Instead of using knife and forceps for cadaver dissection he investigates living subjects by CTV and VTR technique; instead of analyzing dead or formalin-treated tissues he can visualize the entire leg and thigh live from all angles, with virtual removal of skin, muscles and bones from veins and arteries. This modern anatomic model which produces exiting colorful pictures is easily understood and may be particularly appreciated by those operators that dislike or are not confident in echographic imaging. From the didactic point of view this virtual dissection imaging has no comparable methods as demonstrated by the 25 anatomical color pictures issued in the paper; each one “worth the price”. Dr. Uhl has been working on this subject for many years1 and his experience may be verified in Paris during his yearly Courses held with his senior master Dr.

1 Uhl JF, Verdeille S, Martin-Bouyer Y. Three-dimensional spiral CT venography for the pre-operative assessment of varicose patients. VASA 2003;32:91–4

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Claude Gillot, the last giant of traditional venous

Because of the exquisite depiction of venous anatomy it produces, CTV may help avoid the anatomical pitfalls of venous surgery.

anatomy2. (17th of January 2013 – Master class of venous anatomy).

As underlined by the author CTV provides limited hemodynamic data (performed in lying position and not associated with dynamic flow-activating maneuvers like for DUS examination), so that DUS examination is always mandatory in addition; for this reason it would have been particularly interesting to compare 3D model pictures to US images of the same subjects to underline limits and advantages of the two imaging tools. In fact, in experienced hands DUS investigation is able to offer a complete analysis of the venous anatomic and physiologic status of the limb3 4 so that the need for further imaging investigation is very seldom needed. Consequently this makes CTV indication for superficial and deep vein network exploration quite rare (1-2% ?), possibly much less than 10-15 % as suggested by the author. 3D imaging may

simplify data transmission to the surgeon in particularly complicated cases when the surgeon is not used to doing US exploration on his own, but if we consider that many of these complicated cases could be treated in a non surgical way (sclerotherapy) or with limited surgery (phlebectomy/thermal ablation + sclerotherapy), the need for a specially detailed 3D anatomy is even lower.

So – as the author confirms- DUS examination remains the most important tool in particular for assessing superficial vein incompetence; but paradoxically DUS is even superior to CTV in imaging that particular aspect of the GSV anatomy, that is the “saphenous eye”3 4, immediately telling the observer if the vein being imaged is a saphenous stem or a more superficial tributary vein. Although indirectly suggested by 3D CTV this aspect is not as evident as with transverse scanning with ultrasound.

Finally, it should not be forgotten the high cost of the CTV compared to DUS, the need for a dedicated structure, and in particular the high exposure to radiation (about 100 chest Rx exposures). All this should today be avoided when not really necessary.5

2 Gillot C. Multimedia Atlas of the Superficial Venous Networks of the Lower Limb. EditionsPhle´bologiques Franc¸aises, 1994 3 Coleridge-Smith P, Labropoulos N, Partsch H, Myers K,Nicolaides A, Cavezzi A. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs e UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg 2006;31:83e92. 4 Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs e UIP consensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg 2006;31:288e99 5 http://xrayrisk.com/calculator/

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Morphological and haemodynamic abnormalities in the jugular veins of

patients with multiple sclerosis

Radak D, Kolar J, Tanaskovic S, Sagic D, Antonic Z, Mitrasinovic A, Babic S, Nenezic D, Ilijevski N. Phlebology. 2012 Jun;27(4):168-72. doi: 10.1258/phleb.2011.011004 Contributing Editor/Reviewers: Erica Menegatti, PhD; Paolo Zamboni, MD Associate Editor: Pauline Raymond-Martimbeau, MD, FACPh

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Summary It has been widely reported that the use of colour Doppler sonography is an ideal non-invasive method of assessment for Chronic cerebrospinal venous insufficiency (CCSVI). The aim of the present study was to evaluate the internal jugular vein (IJV) morphology and haemodynamic characteristics in patients with multiple sclerosis (MS) compared to a group of healthy controls (HC). Sixty-four patients with clinically defined MS according to McDonald criteria, subdivided into four subgroups (benign form, relapsing remitting, secondary progressive, primary progressive) and 37 HC matched for age and gender, were recruited. The entire cohort underwent an echo-colour-Doppler (ECD) examination aimed to identify the haemodynamic

In the MS group the rate of CCSVI positive was significantly higher compared to the HC group

diagnostic parameters of CCSVI. The presence of two or more parameters was considered positive for evidence of CCSVI. In the MS group the rate of CCSVI positive was significantly higher compared to the HC group, 42% vs 8% respectively (p<0.001). The majority of CCSVI presence was found in the relapsing remitting subgroup (28.1%), while in primary progressive and benign forms CCSVI presence was positive in 1.5% each. However, in both groups the most frequently observed criterion was abnormal IJV valves. The authors conclude that the internal jugular vein morphological changes and hemodynamic abnormalities were significantly associated with MS, while the same conditions were less frequently seen in the healthy individuals. Future studies are needed to explain a definite correlation between CCSVI and MS, and thus to elucidate the place for endovascular procedures as appropriate treatment for this severe disease.

COMMENTARY The article published by Radak et al, entitled “ Morphological and haemodynamic abnormalities in the jugular veins of patients with multiple sclerosis” is of course, a further contribution to the current scientific controversy about the prevalence of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis (MS) patients. The study was addressed to evaluate the cerebral venous return by means of echo colour Doppler sonography (ECD) in MS patients compared to healthy subjects according to Zamboni’s venous outflow criteria, in order to define the prevalence of CCSVI in both groups.

Recent evidence of the existence of CCSVI as a truly new pathologic entity described in pathology has been

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described.1 2 3 In clinical practice, unfortunately, it is difficult to accurately detect CCSVI using current MRI and ECD sonography techniques, something that has generated considerable scientific controversy. There is in fact significant heterogeneity in the different published studies: for instance studies coming from neurological centres show little or no prevalence of CCSVI, whereas studies coming from centres trained in the evaluation of the peripheral venous trunks show a much higher and significant prevalence. However, recently Laupacis et al. performed a meta-analysis presenting a positive association between CCSVI and MS, even after exclusion of the first study by Zamboni, considered as “hypothesis-generating” with an extremely high OR.4

Ultrasound is, of course, an ideal screening tool, because it is non-invasive and economical, and the reason for the great variability could be explained because of operator dependency, lack of proper training, and differences in protocols used.

To minimize errors and variability in study results, a group of societies including the International Society for Neurovascular Diseases and the American College of Phlebology, published a guideline protocol derived from a consensus conference.5

The investigation of Radak et al, is a strong confirmatory study reporting a significantly higher prevalence of CCSVI in MS patients.

In this regard, the authors report more abnormalities in cerebral venous outflow in the latter group compared to healthy controls. In doing this, they describe a list of 6 parameters which summarizes their own personal concept of cerebral venous outflow abnormalities, but they did not comply with the recommended criteria.5 6 This makes it impossible to include this study in future meta-analyses. It is mandatory to report data on CCSVI and ultrasound according to the guidelines in order to make the data comparable. The second reason to comply with a common protocol is linked to education in ultrasonic screening of CCSVI, a field where the need for specific training has been proven. Studies have shown that inter-operator variability decreases post-training, while agreement in trained operators was very good.7 8

1 Diaconu C, Staugaitis S, McBride J, et al. Anatomical and histological analysis of venous structures associated with chronic cerebro-spinal venous insufficiency. Abstract presented at: 5th ECTRIMS abstract book Amsterdam, published by ECTRIMS, 2011. 2 Baiocchini A, Toscano R, von Lorch W, et al. Anatomical stenosis of the internal jugular veins: supportive evidence of chronic cerebrospinal venous insufficiency? JNNP. Published 28 April 2011. Epub: http://jnnp.bmj.com/content/82/4/355.extract/ reply#jnnp_el_7244. 3 Coen M, Menegatti E, Salvi F, Mascoli F, Zamboni P, Gabbiani G,Bochaton-Piallat ML. Altered collagen expression in jugular veins in multiple sclerosis. Cardiovasc Pathol. 2013 Jan;22(1):33-8. doi:10.1016/j.carpath.2012.05.005. Epub 2012 Jul 5. 4 Laupacis A, Lillie E, Dueck A, et al. Association between chronic cerebrospinal venous insufficiency and multiple sclerosis: a meta-analysis. CMAJ. 2011;183(16):E1203–12. 5 Zamboni P, Morovic S, Menegatti E, et al. Screening for chronic cerebrospinal venous insufficiency (CCSVI) using ultrasound. Recommendations for a protocol. Int Angiol. 2011;30:1–2. 6 Radak D, Kolar J, Tanaskovic S, Sagic D, Antonic Z, Mitrasinovic A, Babic S, Nenezic D, Ilijevski N. Morphological and haemodynamic abnormalities in the jugular veins of patients with multiple sclerosis. Phlebology. 2012 Jun;27(4):168-72. doi: 10.1258/phleb.2011.011004 7 Menegatti E, Genova V, Tessari M, et al. The reproducibility of color doppler in chronic cerebrospinal venous insufficiency associated with multiple scleroris. Internl Angiol. 2010;29:121–6. 8 Zivadinov R, Ramanathan M, Dolic K, et al. Chronic cerebrospinal venous insufficiency in multiple sclerosis: diagnostic, pathogenetic, clinical and treatment perspectives. Expert Rev Neurother. 2011;11:1277–94.

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Risk of recurrence in patients with pulmonary embolism: Predictive role of D-dimer and of residual perfusion defects on lung scintigraphy. Daniela Poli; Caterina Cenci; Emilia Antonucci; Elisa Grifoni; Chiara Arcangeli; Domenico Prisco; Rosanna Abbate;Massimo Miniati Thrombosis Centre, Department of Heart and Vessels, AOU-Careggi, Florence, Italy; Department of Medical and Surgical Critical Care, University of Florence, Florence Italy; Department of Heart and Vessels, AOU-Careggi, Florence, Italy Thrombosis and Haemostasis 109.2/2013 Contributing Editor/Reviewers: Kapil Baliga MS, DNBE Vasc.; Ramesh K Tripathi MD, FRCS, FRACS Vasc. Associate Editor: Lowell S. Kabnick, MD, FACS, PACPh, RPhS

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The prediction of recurrence risk after an episode of venous thromboembolism (VTE) is of great value as it can save unnecessary burden of prolonged anticoagulation and its attendant iatrogenic bleeding complications. This study aims to consider D-dimer levels, residual venous obstruction (RVO) and scintigraphic pulmonary perfusion defects (PD) following a PE event and draw conclusions using either of the above modalities to predict a recurrence. Two hundred thirty-six patients who survived a first episode of PE were prospectively followed. After a minimum 3 months of oral anticoagulation therapy (OAT) in 139 patients D-dimer levels, RVO by compression ultrasound and PDs by perfusion lung scans were obtained. In the follow-up period, 20 patients (14%) had a recurrent VTE. Recurrence correlated favorably with elevated D-dimer (p=0.003). RVO also showed a predictive value (p=0.07) though not statistically significant. No major association could be drawn between PD >10% and VTE recurrence, D-dimer or RVO. In conclusion, D-dimer correlates positively with VTE recurrence but residual PD on lung scintigraphy is neither predictive nor associated with elevated D-dimer.

COMMENTary The impact and overall burden of VTE is being increasingly recognized around the world. Incidence of PE is 66 per 1,00,0001 with 25% of them presenting as sudden death.2 The need for immediate anticoagulation is well established as there is a 50% recurrence, 25% of which are fatal if the patients are not adequately anticoagulated.3 Since the risk of recurrence is greatest in the first 6 to 12 months after the initial episode and gradually diminishes thereafter4 the benefit of an extended course of anticoagulation may be offset over time by the risk of clinically important bleeding.5 6 7 8 Pulmonary embolism, in survivors, carries two serious long-term sequelae; recurrence and chronic thromboembolic pulmonary hypertension (CTEPH). In the event of an unprovoked VTE, the need for long-term (read: life-long) anticoagulation exists in patients with low risk for iatrogenic bleeds. Therefore, there is a need for a gold standard marker to predict either of the two dreaded events mentioned above.

Sequential ventilation-perfusion scans (V/Q) have been useful in predicting the subsequent onset of CTEPH if there were large perfusion defects consistently. Many markers have been postulated to predict recurrence of VTE including residual perfusion defects (PD), D-dimer levels and residual vein obstruction (RVO). Of course stopping anticoagulation in patients at obvious high risk of recurrence would raise ethical questions. Any study design naturally rules out thrombophilia patients, strong family history of VTE and patients who need life long anticoagulation for other medical reasons. These markers may further be applicable in situations where thrombophilia workup is either not available or results equivocal.

RVO, though a modest marker for limb DVT recurrence may not be a perfect tool to recognize PE recurrence; also the associated varied ambiguous criteria and inter-observer variation make RVO an unlikely perfect tool to predict VTE. Moreover, in this study the sample size was low due to enrollment of mostly PE patients rather than DVT patients. PD >10% represents a significant PE but follow-up reveals no difference in onset of recurrence in these cases, drawing us to conclude in many ways that the amount of clot burden per se does not correlate with recurrence. D-dimer on the other hand correlates well with any acute VTE event and can also help predict recurrence. It is necessary to stop anticoagulation for one month to check the D-dimer.

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The major advantages of this study are the deficiency in knowledge that it addresses and its aim to answer the questions on the use of D-dimer, scintigraphic perfusion defects and RVO. The findings in the study are in agreement with the existing evidence, reinstating the positive predictive value of elevated D-dimer levels to predict recurrence.9 Also, RVO may be a modest marker of recurrent VTE. It adds that residual perfusion defects, irrespective of size, don’t correlate with recurrence or elevated D-dimer levels.

The design of this study does not designate a uniform proper timing of the perfusion scans and only 60% of the patients could

There is a need for a gold standard marker to predict recurrent VTE and chronic thromboembolic pulmonary hypertenstion

be evaluated in the final analysis as the rest had to be on OAT continuously. Also, there was only 1 death due to hemorrhagic complications of anticoagulation while there is no mention of incidence of major bleed. The question that could be raised is: whether leaving all patients on long-term anticoagulation is the best alternative?

The arrival of newer oral anticoagulants in the market, the safety and non-requirement of PT-INR monitoring could well persuade physicians to maintain patients on long term anticoagulation rather than rely on non–RCT trials to select a perfect marker to predict recurrences in VTE. Moreover the use of aspirin following completion of the mandatory period of anticoagulation can be an effective substitute in selected cases. As the ASPIRE study concluded, there was a significant reduction in the rate of major vascular events with improved net clinical benefit even though aspirin did not decrease the VTE recurrence per se.10

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1 Silverstein MD,Heit JA ,Mohr DN et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism : a 25 year population based study. Arch Intern Med 1998 Mar 23;158 (6):585-93 2 John A.Heit. The epidemiology of venous thromboembolism in the Community. Arterioscler Thromb vasc Biol 2008; 28:370-372 3 Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled Trial. Lancet 1960; 1:1309-1312 4 Heit JA, Mohr DN, Silverstein MD, Petterson TM, O’Fallon WM, Melton LJ III. Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. Arch Intern Med 2000; 160: 761-8. 5 Schulman S, Rhedin AS, Lindmarker P, et al. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. N Engl J Med 1995; 332:1661-5. 6 Kearon C, Gent M, Hirsh J, et al. A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism. N Engl J Med 1999; 340:901-7. 7 Agnelli G, Prandoni P, Santamaria MG, et al. Three months versus one year of oral anticoagulant therapy for idiopathic deep venous thrombosis. N Engl J Med 2001;345:165-9. 8 Pinede L, Ninet J, Duhaut P, et al. Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circulation 2001; 103:2453-60. 9 Douketis J, Tosetto A ,Marcucci M et al. Patient level meta-analysis: effect of measurement timing , threshold , and patient age on ability of D-dimer testing to assess recurrence risk after unprovoked venous thromboembolism Ann Intern Med. 2010 Oct19; 153(8): 523-31 10 Timothy A. Brighton, John W. Eikelboom, Kristy Mann et al. Low-Dose Aspirin for preventing Recurrent Venous Thromboembolism. N Engl J Med 2012; 367:1979-1987

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intellectual capital

/// UIP 2013 Call for Abstracts

World Meeting of the International Union of Phlebology /// September 8–13, 2013

Call For Abstracts The Scientific Committee of the International Union of Phlebology invites you to submit an abstract for consideration at the 2013 World Congress of the International Union of Phlebology, September 8–13, 2013 in Boston, MA. Please submit an abstract on any of the following topics:

+ BASIC SCIENCE + CCSVI + CHRONIC VENOUS INSUFFICIENCY AND VENOUS ULCERATION + COMPRESSION THERAPY + DEEP VENOUS THROMBOSIS + EPIDEMIOLOGY + LYMPHADEMA + MISCELLANEOUS

+ PELVIC VENOUS DISEASE - REFLUX & OBSTRUCTION + PHLEBOLOGIC NURSING + SUPERFICIAL VENOUS DISEASE » Venous Ablation » Sclerotherapy » Miscellaneous + VENOTONIC DRUGS + VENOUS DIAGNOSTICS + VENOUS MALFORMATIONS

Deadline for Submission is April 15, 2013 Abstracts must be submitted online and are limited to 250 words. For additional details and to submit an oral or poster abstract for presentation at UIP 2013, please visit http://ww4.aievolution.com/acp1301/

510.346.6800 | www.uip2013.org | www.phlebology.org


Phlebology Forum January-February 2013