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International Angiology 2016 June;35(3):236-352

Copyright © 2016 EDIZIONI MINERVA MEDICA

language: English

Venous hemodynamic changes in lower limb venous disease: the UIP consensus according to scientific evidence

Byung B. LEE ¹, Andrew N. NICOLAIDES ^{2, 3}, Kenneth MYERS ⁴, Mark MEISSNER ⁵, Evi KALODIKI ^{6, 7}, Claudio ALLEGRA ⁸, Pier L. ANTIGNANI ⁹, Niels BÆKGAARD ¹⁰, Kirk BEACH ¹¹, Giovanni BELCARO ¹², Stephen BLACK ¹³, Lena BLOMGREN ¹⁴, Eliete BOUSKELA ¹⁵, Massimo CAPPELLI ¹⁶, Joseph CAPRINI ^{17, 18}, Patrick CARPENTIER ¹⁹, Attilio CAVEZZI ²⁰, Sylvain CHASTANET ²¹, Jan T. CHRISTENSON ^22-24, Demetris CHRISTOPOULOS ²⁵, Heather CLARKE ²⁶, Alun DAVIES ²⁷, Marianne DEMAESENEER ²⁸, Bo EKLÖF ²⁹, Stefano ERMINI ³⁰, Fidel FERNÁNDEZ ³¹, Claude FRANCESCHI ^{32, 33}, Antonios GASPARIS ³⁴, George GEROULAKOS ^{27, 35, 36}, Sergio GIANESINI ³⁷, Athanasios GIANNOUKAS ³⁸, Peter GLOVICZKI ³⁹, Ying HUANG ⁶, Veronica IBEGBUNA ⁶, Stavros K. KAKKOS ⁴⁰, Robert KISTNER ⁴¹, Tilo KÖLBEL ⁴², Ralph L. KURSTJENS ⁴³, Nicos LABROPOULOS ³⁴, James LAREDO ¹, Christopher R. LATTIMER ⁶, Marzia LUGLI ⁴⁴, Fedor LURIE ^{45, 46}, Oscar MALETI ⁴⁴, Jovan MARKOVIC ⁴⁷, Erika MENDOZA ^{48, 49}, Javier L. MONEDERO ⁵⁰, Gregory MONETA ⁵¹, Hayley MOORE ^{27, 52}, Nick MORRISON ⁵³, Giovanni MOSTI ⁵⁴, Olle NELZÉN ^{55, 56}, Alfred OBERMAYER ⁵⁷, Tomohiro OGAWA ⁵⁸, Kurosh PARSI ⁵⁹, Hugo PARTSCH ⁶⁰, Fausto PASSARIELLO ⁶¹, Michel R. PERRIN ⁶², Paul PITTALUGA ²¹, Seshadri RAJU ^{63, 64}, Stefano RICCI ⁶⁵, Antonio ROSALES ⁶⁶, Angelo SCUDERI ⁶⁷, Carl E. SLAGSVOLD ⁶⁸, Anders THURIN ⁶⁹, Tomasz URBANEK ⁷⁰, Andre M. VAN RIJ ⁷¹, Michael VASQUEZ ⁷², Cees H. WITTENS ⁴³, Paolo ZAMBONI ³⁷, Steven ZIMMET ⁷³, Santiago Z. EZPELETA ⁷⁴ ✉

¹ Division of Vascular Surgery, Department of Surgery, George Washington University, Washington DC, WA, USA; ² Imperial College, London University, London, UK; ³ Department of Biological Sciences, University of Cyprus, Nicosia, Cyprus; ⁴ Victoria Vein Clinic, East Melbourne, Australia; ⁵ Department of Surgery, University of Washington, Seattle, WA, USA; ⁶ Josef Pflug Vascular Laboratory, Ealing Hospital and Imperial College London, UK; ⁷ Thrombosis and Hemostasis Research Laboratory, Loyola University Medical Centre, Maywood, IL, USA; ⁸ S. Giovanni Hospital, Rome, Italy; ⁹ Vascular Centre, Clinica Nuova Villa Claudia, Rome, Italy; ¹⁰ Vascular Clinic, Gentofte Hospital and Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; ¹¹ Division of Vascular Surgery and Department of Bioengineering, University of Washington, Seattle, WA, USA; ¹² Irvine3 Labs, Chieti-Pescara University, Chieti, Italy; ¹³ Department of Venous and Lymphedema Surgery, Guy’s and St Thomas’ Hospital, London, UK; ¹⁴ Department of Vascular Surgery Karolinska University Hospital Stockholm, Sweden; ¹⁵ Biomedical Center, State University of Rio de Janeiro, Rio de Janeiro, Brazil; ¹⁶ Private practitioner, Florence, Italy; ¹⁷ Division of Vascular Surgery, North Shore University Health System, Evanston, IL, USA; ¹⁸ The University of Chicago Pritzker School of Medicine, Chicago, IL, USA; ¹⁹ Department of Vascular Medicine, University Hospital, Grenoble, France; ²⁰ Eurocenter Venalinfa, San Benedetto del Tronto, Italy; ²¹ Department of Vascular Surgery, Riviera Veine Institut, Monaco; ²² Division of Cardiovascular Surgery, Venous Center, Department Of Surgery, University Hospital Of Geneva, Geneva, Switzerland; ²³ Faculty of Medicine, University of Geneva, Geneva, Switzerland; ²⁴ Venous Centre, Clinique Vert Pré, Geneva, Switzerland; ²⁵ Department of Vascular Surgery, “G. Gennimatas” General Hospital, Medical School, University of Thessaloniki, Thessaloniki, Greece; ²⁶ Department of Medical Imaging and Radiation Sciences, Monash University, Melbourne, Australia; ²⁷ Unit of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College School of Medicine, London, UK; ²⁸ Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands; ²⁹ Lund University, Lund, Sweden; ³⁰ Department of Hemodynamic Phlebology, University of Camerino, Camerino, Macerata, Italy; ³¹ Service of Angiology and Vascular Surgery, San Cecilio Clinical University Hospital, Granada, Spain; ³² Hôpital Universitaire Pitié-Salpêtrière, Paris, France; ³³ Saint Joseph Hospital, Paris, France; ³⁴ Division of Vascular Surgery, Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA; ³⁵ Department of Vascular Surgery, University of Athens, Athens, Greece; ³⁶ Department of Vascular Surgery, Attikon General University Hospital, Athens; ³⁷ Vascular Disease Center, University of Ferrara, Ferrara, Italy; ³⁸ Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; ³⁹ Division of Vascular and Endovascular Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA; ⁴⁰ Department of Vascular Surgery, University of Patras, Patras, Greece; ⁴¹ Department of Surgery, University of Hawaii, Honolulu, Hawaii, USA; ⁴² German Aortic Center, University Heart Center Hamburg, Hamburg, Germany; ⁴³ Department of Vascular Surgery and Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands; ⁴⁴ Division of Vascular Surgery, Department of Cardiovascular Surgery, Hesperia Hospital, Modena, Italy; ⁴⁵ Jobst Vascular Institute, Promedica, Toledo, OH, USA; ⁴⁶ University of Michigan, Ann Arbor, MI, USA; ⁴⁷ Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA; ⁴⁸ German Society of Phlebology, Wunstorf, Germany; ⁴⁹ German Society of CHIVA, Wunstorf, Germany; ⁵⁰ Department of Angiology and Vascular Surgery Unit, Ruber International Hospital, Madrid, Spain; ⁵¹ Division of Vascular Surgery, Department of Surgery, Oregon Health & Science University, Knight Cardiovascular Institute, Portland, OR, USA; ⁵² Registrar in Vascular Surgery, London Deanery, London, UK; ⁵³ Morrison Vein Institute, Scottsdale, AZ, USA; ⁵⁴ Department of Angiology, M.D. Barbantini Clinic, Lucca, Italy; ⁵⁵ Departments of Research & Development and Vascular Surgery, Skaraborg Hospital, Skövde, Sweden; ⁵⁶ Department of Vascular Surgery, Uppsala University, Uppsala, Sweden; ⁵⁷ Institute of Functional Vascular Surgery, Karl Landsteiner Society, Melk, Austria; ⁵⁸ Department of Cardiovascular Surgery, Fukushima Daiichi Hospital, Fukushima, Japan; ⁵⁹ St. Vincent’s Hospital, University of New South Wales (UNSW), Sydney, Australia; ⁶⁰ Dermatology, Medical University of Vienna, Austria; ⁶¹ Vasculab Foundation, Naples, Italy; ⁶² Department of Vascular Surgery, Lyon Hospital, Lyon, France; ⁶³ University of Mississippi Medical Center, Jackson, MS, USA; ⁶⁴ The Rane Center, Jackson, MS, USA; ⁶⁵ Private practitioner, Rome, Italy; ⁶⁶ Norwegian National Unit for Reconstructive Deep Venous Surgery (NOVI), Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway; ⁶⁷ Departments of Angiology and Vascular Surgery, Santa Lucinda University Hospital, Pontifical Catholic University of São Paulo (PUC-SP), São Paulo, Brazil; ⁶⁸ Department of Vascular Investigations, Oslo University Hospital, Oslo, Norway; ⁶⁹ Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden; ⁷⁰ Departments of General Surgery, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, Katowice, Poland; ⁷¹ Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; ⁷² Department of Surgery, The Venous Institute of Buffalo, The State University of New York at Buffalo, Buffalo, NY, USA; ⁷³ Zimmet Vein and Dermatology, Austin, TX, USA; ⁷⁴ Interventional Vascular Radiology Unit, Ruber International Hospital, Madrid, Spain

There are excellent guidelines for clinicians to manage venous diseases but few reviews to assess their hemodynamic background. Hemodynamic concepts that evolved in the past have largely remained unchallenged in recent decades, perhaps due to their often complicated nature and in part due to emergence of new diagnostic techniques. Duplex ultrasound scanning and other imaging techniques which evolved in the latter part of the 20th century have dominated investigation. They have greatly improved our understanding of the anatomical patterns of venous reflux and obstruction. However, they do not provide the physiological basis for understanding the hemodynamics of flow, pressure, compliance and resistance. Hemodynamic investigations appear to provide a better correlation with post-treatment clinical outcome and quality of life than ultrasound findings. There is a far better prospect for understanding the complete picture of the patient’s disability and response to management by combining ultrasound with hemodynamic studies. Accordingly, at the instigation of Dr Angelo Scuderi, the Union Internationale de Phlebologie (UIP) executive board commissioned a large number of experts to assess all aspects of management for venous disease by evidence-based principles. These included experts from various member societies including the European Venous Forum (EVF), American Venous Forum (AVF), American College of Phlebology (ACP) and Cardiovascular Disease Educational and Research Trust (CDERT). Their aim was to confirm or dispel long-held hemodynamic principles and to provide a comprehensive review of venous hemodynamic concepts underlying the pathophysiology of lower limb venous disorders, their usefulness for investigating patients and the relevant hemodynamic changes associated with various forms of treatment. Chapter 1 is devoted to basic hemodynamic concepts and normal venous physiology. Chapter 2 presents the mechanism and magnitude of hemodynamic changes in acute deep vein thrombosis indicating their pathophysiological and clinical significance. Chapter 3 describes the hemodynamic changes that occur in different classes of chronic venous disease and their relation to the anatomic extent of disease in the macrocirculation and microcirculation. The next four chapters (Chapters 4-7) describe the hemodynamic changes resulting from treatment by compression using different materials, intermittent compression devices, pharmacological agents and finally surgical or endovenous ablation. Chapter 8 discusses the unique hemodynamic features associated with alternative treatment techniques used by the CHIVA and ASVAL. Chapter 9 describes the hemodynamic effects following treatment to relieve pelvic reflux and obstruction. Finally, Chapter 10 demonstrates that contrary to general belief there is a moderate to good correlation between certain hemodynamic measurements and clinical severity of chronic venous disease. The authors believe that this document will be a timely asset to both clinicians and researchers alike. It is directed towards surgeons and physicians who are anxious to incorporate the conclusions of research into their daily practice. It is also directed to postgraduate trainees, vascular technologists and bioengineers, particularly to help them understand the hemodynamic background to pathophysiology, investigations and treatment of patients with venous disorders. Hopefully it will be a platform for those who would like to embark on new research in the field of venous disease.