Update of the SFMV (French society of vascular medicine) guidelines on the conditions and safety measures necessary for thermal ablation of the saphenous veins and proposals for unresolved issues.

Venous insufficiency is a very common disease affecting about 25% of the French population (if we combine all stages of its progression). It is a complex disease and its aetiology has not yet been fully elucidated. Some of its causes are well known, such as valvular dysfunction, vein wall defect, and the suctioning effect common to all varicose veins. These factors are generally associated and together lead to dysfunction of one or more of the saphenous veins. Saphenous vein dysfunction is revealed by ultrasound scan, a reflux lasting more than 0.5 seconds indicating venous incompetence. The potential consequences of saphenous vein dysfunction over time include: symptoms (heaviness, swellings, restlessness, cramps, itching of the lower limbs), acute complications (superficial venous thrombosis, varicose bleeding), chronic complications (changes in skin texture and colour, stasis dermatitis, eczema, vein atresia, leg ulcer), and appearance of unaesthetic varicose veins. It is not possible to repair an incompetent saphenous vein. The only therapeutic options at present are ultrasound-guided foam sclerotherapy, physical removal of the vein (saphenous stripping), or its thermal ablation (by laser or radiofrequency treatment), the latter strategy having now become the gold standard as recommended by international guidelines. Recommendations concerning thermal ablation of saphenous veins were published in 2014 by the Société française de médecine vasculaire. Our society has now decided to update these recommendations, taking this opportunity to discuss unresolved issues and issues not addressed in the original guidelines. Thermal ablation of an incompetent saphenous vein consists in destroying this by means of a heating element introduced via ultrasound-guided venous puncture. The heating element comprises either a laser fibre or a radiofrequency catheter. The practitioner must provide the patient with full information about the procedure and obtain his/her consent prior to its implementation. The checklist concerning the interventional procedure issued by the HAS should be validated for each patient (see the appended document).

[Ultrasound screening of abdominal aortic aneurysm: Lessons from Vesale 2013]. / Dépistage échographique de l'anévrisme de l'aorte abdominale - les enseignements de Vésale 2013.

Although aneurysm of the abdominal infra-renal aorta (AAA) meets criteria warranting B mode ultrasound screening, the advantages of mass screening versus selective targeted opportunistic screening remain a subject of debate. In France, the French Society of Vascular Medicine (SFMV) and the Health Authority (HAS) published recommendations for targeted opportunistic screening in 2006 and 2013 respectively. The SFMV held a mainstream communication day on November 21, 2013 in France involving participants from metropolitan France and overseas departments that led to a proposal for free AAA ultrasound screening: the Vesalius operation. Being a consumer operation, the selection criteria were limited to age (men and women between 60 and 75 years); the age limit was lowered to 50 years in case of direct family history of AAA. More than 7000 people (as many women as men) were screened in 83 centers with a 1.70% prevalence of AAA in the age-based target population (3.12% for men, 0.27% for women). The median diameter of detected AAA was 33 mm (range 20 to 74 mm). The prevalence of AAA was 1.7% in this population. Vesalius data are consistent with those of the literature both in terms of prevalence and for cardiovascular risk factors with the important role of smoking. Lessons from Vesalius to take into consideration are: screening is warranted in men 60 years and over, especially smokers, and in female smokers. Screening beyond 75 years should be discussed. Given the importance of screening, the SFMV set up a year of national screening for AAA (Vesalius operation 2014/2015) in order to increase public and physician awareness about AAA detection, therapeutic management, and monitoring. AAA is a serious, common, disease that kills 6000 people each year. The goal of screening is cost-effective reduction in the death toll.

[French Society of Vascular Medicine good medical practice guidelines on safety and environment in vascular medicine: Treatment of varicose veins]. / Recommandations de bonne pratique concernant la sécurité et l'environnement en médecine vasculaire, notamment pour le traitement des varices, proposées par la Société française de médecine vasculaire.

These guidelines proposed by the French Society of Vascular Medicine define the optimal environment for vascular medicine practice: outpatient clinic; equipment, layout and maintenance of the care center; infection risk prevention (hand hygiene, individual protective measures, exposure to blood, ultrasound apparatus, etc.); common interventions and techniques (liquid and foam sclerotherapy, endovenous thermal treatments). These guidelines do not include phlebectomy and use of ultrasound contrast agents.

[Quality standards for ultrasonographic assessment of peripheral vascular malformations and vascular tumors. Report of the French Society for Vascular Medicine]. / Standards de qualité pour la pratique de l'examen écho-doppler dans l'étude des malformations et tumeurs vasculaires. Rapport de la Société française de médecine vasculaire (SFMV).

THE QUALITY STANDARDS OF THE FRENCH SOCIETY OF VASCULAR MEDICINE FOR THE ULTRASONOGRAPHIC ASSESSMENT OF VASCULAR MALFORMATIONS ARE BASED ON THE TWO FOLLOWING REQUIREMENTS: Technical know-how: mastering the use of ultrasound devices and the method of examination. Medical know-how: ability to adapt the methods and scope of the examination to its clinical indication and purpose, and to rationally analyze and interpret its results. AIMS OF THE QUALITY STANDARDS: To describe an optimal method of examination in relation to the clinical question and hypothesis. To achieve consistent practice, methods, glossary, and reporting. To provide good practice reference points, and promote a high-quality process. ITEMS OF THE QUALITY STANDARDS: The three levels of examination; their clinical indications and goals. The reference standard examination (level 2), its variants according to clinical needs. The minimal content of the examination report; the letter to the referring physician (synthesis, conclusion and proposal for further investigation and/or therapeutic management). Commented glossary (anatomy, hemodynamics, semiology). Technical bases. Settings and use of ultrasound devices. Here, we discuss the methods of using ultrasonography for the assessment of peripheral vascular malformations and tumors.

[Quantitative evaluation and qualitative results of surgical lymphovenous anastomosis in lower limb lymphedema]. / Evaluations quantitative et qualitative des résultats de l'anastomose lymphoveineuse chirurgicale dans les lymphoedèmes des membres inférieurs.

PURPOSE: Treatment of lymphedema (LE) includes complex decongestive physiotherapy (manual lymphatic drainage, bandaging, exercises, skin care, elastic stockings). Surgical therapy is rarely useful. However, lymphovenous anastomosis (LVA) is the most used surgery in LE. We have assessed LVA in lower limb LE. METHODS: Thirteen patients (5 women, 8 men) with primary (n=10) or secondary LE (n=3) were included. Primary LE started at a mean âge (+/- SD) of 28.9 +/- 14.5 years. LE was located in left lower limb (n=7), right (n=4) or both (n=2). LVA was performed 7.1 +/- 4.9 years after the onset of LE by the same surgeon. Two to five lymphatic vessels were used for LVA. Assessment of LVA was based upon objective criteria (volumetry, erysipelas) and subjective criteria (global discomfort, heaviness, cutaneous tenderness, difficulties for doing significant effort or walking more than 1 km). Global assessement of LVA was collected for each patient. RESULTS: Before LVA, excess of volume (+/- SD) of LE was 1906 +/- 1277 ml or 28.5 +/- 18% in comparison with the controlateral limb. After LVA, excess of volume (+/- SD) remained stable with 1863 +/- 1468 ml or 24.4 +/- 18.9%. Volumetry was appreciated with a mean (+/- SD) follow-up of 52 +/- 3 months. Frequency of erysipelas was unchanged for the 6 patients with recurrent episodes. Only heaviness and cutaneous tenderness were significantly reduced after LVA. But global discomfort (+/- SD) decreased from 6.7 +/- 2.7 to 5 +/- 3.2 on visual analogic scale (NS). No differences were observed for significant effort or walking more than 1 km. Global assessment of LVA by the patient was very good (n=3), good (n=2), intermediate (n=5) and bad (n=3). CONCLUSION: LVA failed to improve the volume of lower limb LE and reduce the frequency of erysipelas. LVA improves few subjectives criteria but not global discomfort. Further studies are needed to evaluate LVA and to select patients to obtain best results.

[Sclerotherapy with ultrasonography in various risk zones (summary of a video film)]. / Sclérose sous échographie dans certaines zones a risques (résumé d'un film vidéo).

The sclerosing injection of varicose veins remains a technique which is often essential in the management of a patient with superficial venous insufficiency. The sclerosing injection of high reflux sites, in particular the junctions of the great and small saphenous veins with the deep venous system, is technically difficult. Even great skill and long experience cannot necessarily protect the most hardened phlebologist from a complication which may often be catastrophic. An alternative is therefore suggested: the sclerosing injection of junction sites under ultrasonographic control. This method enables endovenous injection under visual control. It would nonetheless be wrong to think that this method finally eliminates all possible risk: clinical, phlebological and ultrasonographic training are the sole guarantees of optimum and constant results from the technique. More than 2,500 injections have be performed in this way since 1987, without any complications. Although the follow-up remains short, results suggest that the use of the method will become more widespread. It is an extremely valuable aid in the training of future phlebologists, but under no circumstances should be used by untrained practitioners.

[Principles and results of physiotherapeutic therapy in mechanical lymphatic insufficiency of secondary or primary nature]. / Principes et résultats des traitements physiothérapiques dans les insuffisances lymphatiques mécaniques de nature secondaire ou primitive.

The modern treatment of edemas in mechanical lymphatic insufficiency or lymphedema, combines the restarting of the remaining lymphatic system by manual lymphatic drainage, volumetric reduction by wrapping with bandages and exercise and maintaining the result by wearing a retention device. Intensive courses are necessary, followed by intercurrent course & sometimes a maintenance treatment. In view of the anatomico-functional deficit, all available armamentarium should be used in addition to the measures previously mentioned: hygiene measures, prescription of coumarin (Lysedem). Psychological care is of importance to motivate patients for long-term treatments, if good quality results are to be obtained. However, primary lymphedema seems to respond less favorably than secondary lymphedema.