Venous Disease: Use the Right Scoring Tool to Choose the Right Treatment

Endovenous interventions have revolutionized the treatment of venous disease, enabling many more physicians to effectively treat many more patients. But there’s a flip side to this valuable coin – one that will be explored in Thursday’s session “Venous Clinical Examination and Hemodynamics.”

“Since the advent of the endovenous revolution, the treatment of venous disease has become popular,” said Dr. Jose Almeida, who will moderate the session with Dr. Lowell S. Kabnick.  “But many physicians have only one tool in the toolbox – saphenous vein ablation. They have little understanding of the underlying pathophysiology, and therefore almost reflexively treat all patients whom they see with saphenous vein ablation. Physicians from disparate specialties are now treating venous disease; therefore, we are seeing great discontinuity in the care being rendered.”

The goal of the session, said Dr. Almeida, medical director of the  Miami Vein Center, is to get more physicians observing the guidelines put forth from the American Venous Forum and Society for Vascular Surgery.

He will discuss how to frame a treatment plan using two clinical assessment scores, both created by the American Venous Forum: CEAP and the Venous Clinical Severity Score (VCSS). The CEAP is a purely clinical measure, taking into account clinical manifestation, etiology, anatomy, and pathophysiologic dysfunction. The VCSS, on the other hand, describes the degree to which both the disease and its treatment affect the patient’s daily life. Given at baseline and after treatment, the VCSS focuses on the patient’s perspective of how treatment improved those symptoms.

Dr. Kabnick will discuss a new outcomes assessment tool in development – the Varicose Vein Symptom Quick (VVSymQ) score. VVSymQ  is a patient-reported electronic diary of five items that assess symptoms of varicose veins (heaviness, achiness, swelling, throbbing and itching). In practice settings, patients are asked to complete the entry daily for 10 days before and after surgery, Dr. Kabnick said.

All of these tools are meaningful ways to understand how venous insufficiency affects a patient, said Dr. Kabnick of New York Langone Medical Center. “One score allows us to understand disease severity, and the others let us see if we really helped the patient with our treatment.”

Dr. Neil Khilnani of Weill Cornell Medical Center, N.Y., will examine the use of duplex ultrasound mapping to identify venous reflux pathways. Dr. Andrew Nicolaides of  Imperial College, London, will touch on another imaging modality –- air plethysmography. This is most often employed in patients who have more advanced stages of venous insufficiency. It can help clarify the ultrasound exam when venous reflux or outflow obstruction are suspected but not clearly visualized.

“Air plethysmography is a research tool right now,” Dr. Kabnick said. “But we would like to see it adopted into mainstream testing.”

Dr. Raghu Kolluri, director of vascular medicine at Riverside Methodist Hospital, Columbus,Ohio, will discuss the symptoms of venous disease.

Dr. Seshadri Raju of the Rane Center, Jackson, Miss., will tackle the biggest controversy in venous insufficiency right now – the debate over where pathophysiology begins.

“This controversy really lies in the hemodynamics,” Dr. Kabnick said. The more traditional theory of descending pathology considers dilation and backward flow in the saphenous vein as the driving force behind varicosities.  An emerging school of thought, however, suggests an ascending evolution of disease, which begins in the smallest peripheral veins and progresses upward into the saphenous vein. This creates a backward flow that would be initially reversible.
“It will be interesting for the attendees to be introduced to these philosophies,”

Dr. Kabnick said. “In the United States, we generally believe venous insufficiency is a combination of ascending and descending pathophysiology, and we mostly try to treat what we think of as the underlying problem, which is a truncal vein.”

Outside the United States, two other techniques are often employed: ASVAL (ambulatory selective varices ablation under local anesthesia) and CHIVA (conservative hemodynamic treatment for chronic venous insufficiency). Both of these preserve the saphenous vein by targeting collateral veins for intervention (sclerotherapy, ligation, or removal). Dr. Sylvain Chastanet of the Riviera Vein Institute, Nice, France, will discuss the ASVAL technique, and  Dr. Paolo Zamboni of the University of Ferrara, Italy, will describe CHIVA.

Session 63: Venous Clinical Examination and Hemodynamics

7:30 a.m. – 8:30 a.m.

Endovenous interventions have revolutionized the treatment of venous disease, enabling many more physicians to effectively treat many more patients. But there’s a flip side to this valuable coin – one that will be explored in Thursday’s session “Venous Clinical Examination and Hemodynamics.”

“Since the advent of the endovenous revolution, the treatment of venous disease has become popular,” said Dr. Jose Almeida, who will moderate the session with Dr. Lowell S. Kabnick.  “But many physicians have only one tool in the toolbox – saphenous vein ablation. They have little understanding of the underlying pathophysiology, and therefore almost reflexively treat all patients whom they see with saphenous vein ablation. Physicians from disparate specialties are now treating venous disease; therefore, we are seeing great discontinuity in the care being rendered.”

The goal of the session, said Dr. Almeida, medical director of the  Miami Vein Center, is to get more physicians observing the guidelines put forth from the American Venous Forum and Society for Vascular Surgery.

He will discuss how to frame a treatment plan using two clinical assessment scores, both created by the American Venous Forum: CEAP and the Venous Clinical Severity Score (VCSS). The CEAP is a purely clinical measure, taking into account clinical manifestation, etiology, anatomy, and pathophysiologic dysfunction. The VCSS, on the other hand, describes the degree to which both the disease and its treatment affect the patient’s daily life. Given at baseline and after treatment, the VCSS focuses on the patient’s perspective of how treatment improved those symptoms.

Dr. Kabnick will discuss a new outcomes assessment tool in development – the Varicose Vein Symptom Quick (VVSymQ) score. VVSymQ  is a patient-reported electronic diary of five items that assess symptoms of varicose veins (heaviness, achiness, swelling, throbbing and itching). In practice settings, patients are asked to complete the entry daily for 10 days before and after surgery, Dr. Kabnick said.

All of these tools are meaningful ways to understand how venous insufficiency affects a patient, said Dr. Kabnick of New York Langone Medical Center. “One score allows us to understand disease severity, and the others let us see if we really helped the patient with our treatment.”

Dr. Neil Khilnani of Weill Cornell Medical Center, N.Y., will examine the use of duplex ultrasound mapping to identify venous reflux pathways. Dr. Andrew Nicolaides of  Imperial College, London, will touch on another imaging modality –- air plethysmography. This is most often employed in patients who have more advanced stages of venous insufficiency. It can help clarify the ultrasound exam when venous reflux or outflow obstruction are suspected but not clearly visualized.

“Air plethysmography is a research tool right now,” Dr. Kabnick said. “But we would like to see it adopted into mainstream testing.”

Dr. Raghu Kolluri, director of vascular medicine at Riverside Methodist Hospital, Columbus,Ohio, will discuss the symptoms of venous disease.

Dr. Seshadri Raju of the Rane Center, Jackson, Miss., will tackle the biggest controversy in venous insufficiency right now – the debate over where pathophysiology begins.

“This controversy really lies in the hemodynamics,” Dr. Kabnick said. The more traditional theory of descending pathology considers dilation and backward flow in the saphenous vein as the driving force behind varicosities.  An emerging school of thought, however, suggests an ascending evolution of disease, which begins in the smallest peripheral veins and progresses upward into the saphenous vein. This creates a backward flow that would be initially reversible.
“It will be interesting for the attendees to be introduced to these philosophies,”

Dr. Kabnick said. “In the United States, we generally believe venous insufficiency is a combination of ascending and descending pathophysiology, and we mostly try to treat what we think of as the underlying problem, which is a truncal vein.”

Outside the United States, two other techniques are often employed: ASVAL (ambulatory selective varices ablation under local anesthesia) and CHIVA (conservative hemodynamic treatment for chronic venous insufficiency). Both of these preserve the saphenous vein by targeting collateral veins for intervention (sclerotherapy, ligation, or removal). Dr. Sylvain Chastanet of the Riviera Vein Institute, Nice, France, will discuss the ASVAL technique, and  Dr. Paolo Zamboni of the University of Ferrara, Italy, will describe CHIVA.

Session 63: Venous Clinical Examination and Hemodynamics

7:30 a.m. – 8:30 a.m.

Endovenous interventions have revolutionized the treatment of venous disease, enabling many more physicians to effectively treat many more patients. But there’s a flip side to this valuable coin – one that will be explored in Thursday’s session “Venous Clinical Examination and Hemodynamics.”

“Since the advent of the endovenous revolution, the treatment of venous disease has become popular,” said Dr. Jose Almeida, who will moderate the session with Dr. Lowell S. Kabnick.  “But many physicians have only one tool in the toolbox – saphenous vein ablation. They have little understanding of the underlying pathophysiology, and therefore almost reflexively treat all patients whom they see with saphenous vein ablation. Physicians from disparate specialties are now treating venous disease; therefore, we are seeing great discontinuity in the care being rendered.”

The goal of the session, said Dr. Almeida, medical director of the  Miami Vein Center, is to get more physicians observing the guidelines put forth from the American Venous Forum and Society for Vascular Surgery.

He will discuss how to frame a treatment plan using two clinical assessment scores, both created by the American Venous Forum: CEAP and the Venous Clinical Severity Score (VCSS). The CEAP is a purely clinical measure, taking into account clinical manifestation, etiology, anatomy, and pathophysiologic dysfunction. The VCSS, on the other hand, describes the degree to which both the disease and its treatment affect the patient’s daily life. Given at baseline and after treatment, the VCSS focuses on the patient’s perspective of how treatment improved those symptoms.

Dr. Kabnick will discuss a new outcomes assessment tool in development – the Varicose Vein Symptom Quick (VVSymQ) score. VVSymQ  is a patient-reported electronic diary of five items that assess symptoms of varicose veins (heaviness, achiness, swelling, throbbing and itching). In practice settings, patients are asked to complete the entry daily for 10 days before and after surgery, Dr. Kabnick said.

All of these tools are meaningful ways to understand how venous insufficiency affects a patient, said Dr. Kabnick of New York Langone Medical Center. “One score allows us to understand disease severity, and the others let us see if we really helped the patient with our treatment.”

Dr. Neil Khilnani of Weill Cornell Medical Center, N.Y., will examine the use of duplex ultrasound mapping to identify venous reflux pathways. Dr. Andrew Nicolaides of  Imperial College, London, will touch on another imaging modality –- air plethysmography. This is most often employed in patients who have more advanced stages of venous insufficiency. It can help clarify the ultrasound exam when venous reflux or outflow obstruction are suspected but not clearly visualized.

“Air plethysmography is a research tool right now,” Dr. Kabnick said. “But we would like to see it adopted into mainstream testing.”

Dr. Raghu Kolluri, director of vascular medicine at Riverside Methodist Hospital, Columbus,Ohio, will discuss the symptoms of venous disease.

Dr. Seshadri Raju of the Rane Center, Jackson, Miss., will tackle the biggest controversy in venous insufficiency right now – the debate over where pathophysiology begins.

“This controversy really lies in the hemodynamics,” Dr. Kabnick said. The more traditional theory of descending pathology considers dilation and backward flow in the saphenous vein as the driving force behind varicosities.  An emerging school of thought, however, suggests an ascending evolution of disease, which begins in the smallest peripheral veins and progresses upward into the saphenous vein. This creates a backward flow that would be initially reversible.
“It will be interesting for the attendees to be introduced to these philosophies,”

Dr. Kabnick said. “In the United States, we generally believe venous insufficiency is a combination of ascending and descending pathophysiology, and we mostly try to treat what we think of as the underlying problem, which is a truncal vein.”

Outside the United States, two other techniques are often employed: ASVAL (ambulatory selective varices ablation under local anesthesia) and CHIVA (conservative hemodynamic treatment for chronic venous insufficiency). Both of these preserve the saphenous vein by targeting collateral veins for intervention (sclerotherapy, ligation, or removal). Dr. Sylvain Chastanet of the Riviera Vein Institute, Nice, France, will discuss the ASVAL technique, and  Dr. Paolo Zamboni of the University of Ferrara, Italy, will describe CHIVA.

Session 63: Venous Clinical Examination and Hemodynamics

7:30 a.m. – 8:30 a.m.