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x Contributing Authors
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Arnost Fronek, 9500 Gilman Dr., UCSD, La Jolla, CA,
USA
Steven S. Gale, Jobst Vascular Center, The Toledo Hospi-
tal, Toledo, OH, USA
María Antonia García-Olmedo Vascular Malformation
Area, Granada, Spain
Peter Gloviczki, Department of Vascular Surgery, Mayo
Clinic, Rochester, MN, USA
Mitchel P. Goldman, 7630 Fay Ave., Dermatology/
Cosmetic Laser Associates of La Jolla, Inc., La Jolla, CA,
USA
Linda M. Graham, Cleveland Clinic Foundation, Depart-
ment of Vascular Surgery, Cleveland, OH, USA
Jean-Jérôme Guex, 32 Bd. Dubouchage, Phlebology Clinic,
Nice, France
John A. Heit, 200 First Street SW, Mayo Clinic, Hematol-
ogy Research, Rochester, MN, USA
Russell D. Hull, Foothills Hospital, University of Calgary,
Calgary, Alberta, Canada
Colleen M. Johnson, Division of Vascular Surgery, Depart-
ment of Surgery, Southern Illinois University School of
Medicine, Springfi eld, IL, USA
Lowell Kabnick, 95 Madison Ave., Vein Institute of New
Jersey, Morristown, NJ, USA
Manju Kalra, Department of Vascular Surgery, Mayo
Clinic, Rochester, MN, USA
Robert M. Kaplan, 9500 Gilman Dr., UCSD, La Jolla, CA,
USA
Robert L. Kistner, 848 S. Beretania St. #307, Kistner Vein
Clinic, Honolulu, HI, USA
Brajesh K. Lal, 185 S. Orange Ave., UMDNJ–New Jersey
Medical School, Newark, NJ, USA
Rober D. Langer, 9500 Gilman Dr., UCSD, La Jolla, CA,
USA
Timothy K. Liem, Vascular Surgery, OP-11, Oregon Health
& Science University, Portland, OR
Peter H. Lin, Division of Vascular Surgery, Baylor College
of Medicine, Houston, TX, USA
Christopher Longo, Department of Vascular Surgery,
University of Michigan, Ann Arbor, MI, USA
Alan B. Lumsden, Division of Vascular Surgery, Baylor
College of Medicine, Houston, TX, USA
Fedor Lurie, 848 S. Beretania St. #307, Kistner Vein Clinic,
Honolulu, HI, USA
William Marston, Division of Vascular Surgery, Univer-
sity of North Carolina, Chapel Hill, NC
Elna Masuda, 888 S. King Street, Straub Clinic & Hospital,
Honolulu, HI, USA
Robert B. McLafferty, Division of Vascular Surgery,
Department of Surgery, Southern Illinois University
School of Medicine, Springfi eld, IL, USA
Lisa Mekenas, Vascular Lab, Sharp Memorial Hospital,
Department of Radiology
Nick Morrison, 9755 North 90th Street, Vein & Laser
Center of Arizona, Scottsdale, AZ, USA
Geza Mozes, Department of Vascular Surgery, Mayo Clinic,
Rochester, MN, USA
Kenneth Myers, Level 5, Suite 1, Epworth Hospital
Vascular Unit, Richmond, VIC, Australia
Peter Neglén, 1020 River Oaks Dr., River Oaks Hospital,
Flowood, MS, USA
Francisco J. Osse, Rua Prof. Artur Ramos 96—cj. 41,
Venaclinic, Sao Paulo, Brazil
Frank T. Padberg, Jr., 185 S. Orange Ave., UMDNJ–New
Jersey Medical School, Newark, NJ, USA
Peter J. Pappas, 185 S. Orange Ave., UMDNJ–New Jersey
Medical School, Newark, NJ, USA
Hugo Partsch, Baumeistergasse 85, Professor of Derma-
tology, Vienna, Austria
Luigi Pascarella, 9850 Genesee Ave., The Vein Institute of
La Jolla, La Jolla, CA, USA
Eric K. Peden, Division of Vascular Surgery, Baylor
College of Medicine, Houston, TX, USA
Michel Perrin, 26 Chemlin de Decines, Clinique du Grande
Large Chassieu, France
Graham F. Pineo, 601 South Tower—Foothills Hospital,
Calgary, AB, Canada
Thomas M. Proebstle, Department of Dermatology, Uni-
versity of Heidelberg, Heidelberg, Germany
Alessandra Puggioni, Department of Vascular Surgery,
Mayo Clinic, Rochester, MN, USA
Joseph D. Raffetto, 1400 VFW Parkway, Surgery 112 Vas-
cular, VA Boston Healthcare System, Boston, MA, USA
Jeffrey K. Raines, 1501 South Miami Avenue, Miami Vein
Center, Miami, FL, USA
Seshadri Raju, 1020 River Oaks Dr., University of Missis-
sippi Medical Center, Flowood, MS, USA
Contributing Authors xi
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Pritham P. Reddy, Division of Vascular Surgery, Depart-
ment of Surgery, Southern Illinois University School of
Medicine, Springfi eld, IL, USA
G.D. Richardson, 1 MacIntosh Place, Rural Clnical School,
UNSW, Wagga Wagga, NSW, Australia
Robert B. Rutherford, 14337 Dorsal St., The University of
Colorado Medical Center/School, Corpus Christi, TX,
USA
Neil Sadick, Weill Cornell Medical College of Cornell Uni-
versity, New York, NY, USA
Richard J. Sanders, 4545 East Ninth Ave. #420, Denver,
CO, USA
Geert W. Schmid-Schönbein, Department of Bioengineer-
ing, UCSD, La Jolla, CA, USA
Jocelyn A. Segall, Vascular Surgery, OP-11, Oregon Health
& Science University, Portland, OR
Mobeen A. Sheikh, Intervention Cardiology, Beth Deacon-
ess Medical Center, Boston, MA, USA
Philip Coleridge Smith, Thomas Valley Nuffi eld Hospital,
UCL Medical School, Wexham, UK
Lian Sorhaindo, Weill Cornell Medical College of Cornell
University, New York, NY
Paul Thibault, 41 Belford St., Central Vein & Cosmetic
Medical Centre, Broadmeadow, NSW, Australia
Patricia E. Thorpe, Department of Surgery, 200 Hawkins
Dr., University of Iowa Health Care, Iowa City, IA,
USA
Thomas W. Wakefi eld, Department of Vascular Surgery,
University of Michigan, Ann Arbor, MI, USA
Theodore E. Warkentin, 237 Barton St. E, Hamilton
Regional Laboratory Medicine Program, Hamilton,
Ontario, Canada
Margaret A. Weiss, 54 Scott Adam Rd., Johns Hopkins
School of Medicine, Baltimore, MD, USA
Robert A. Weiss, 54 Scott Adam Rd., Johns Hopkins School
of Medicine, Baltimore, MD, USA
Wei Zhou, Michael E. DeBakey Department of Sur-
gery, Baylor College of Medicine, Houston, TX,
USA
Robert W. Zickler, 185 S. Orange Ave., UMDNJ–New
Jersey Medical School, Newark, NJ, USA
Steven E. Zimmet, 1801 North Lamar Blvd., Zimmet Vein
and Dermatology Clinic, Austin, TX, USA
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Preface
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Over the last decade, the art and science of surgery have
changed dramatically. At this time, we in surgery are moving
from open surgery to minimally invasive interventions. We
have moved in some instances from operative procedures to
catheter-based or endoscopic manipulations. Where data are
available, we have moved from experience-driven dogma,
through retrospective analysis of experience, to evidencebased medicine from prospective randomized trials. Almost
all these changes can and should be viewed as good omens
for our patients and for our ability and security in practicing
surgery.
Some areas of surgery have been more resistant to change
and have proven to be diffi cult to change. Such is the story
of venous disorders. Up until quite recently, it seemed that
the only solution that we could provide in evaluating venous
disorders of the lower extremities was the dogma handed
down by our teachers. Now, there has been extensive scientifi c activity working on solutions to these stubborn problems. The current volume, edited and shepherded by the
eminently qualifi ed Dr. John Bergan, both catalogues the
signifi cant advances in this arena and offers practitioners an
up-to-date guide for treating patients. It is a most welcome
effort, a superb product, and it places a scientifi c stake in
the ground for the modern diagnosis and treatment of venous
disorders. You will enjoy this volume, and you will refer to
it frequently when treating the unfortunate individuals disabled by venous diseases.
Mark A. Talamini, M.D.
Professor and Chairman, Department of Surgery
University of California, San Diego
San Diego, California
USA
xiii
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Prologue
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Although it generally is acknowledged that venous disorders
have an enormous socio-economic impact, diagnosis and
treatment of such conditions have suffered from a lack of
interest and support, especially in academic centers. All
specialities have considered phlebology as a kind of unimportant appendix to their main discipline. So this subspecialty has gained the reputation of a Cinderella in clinical
medicine.
As a matter of fact, venous disorders are much more
complex than, for instance, peripheral arterial occlusive diseases. At the beginning of this new millennium there are
encouraging signs that the period of stagnation has ended.
The Vein Book gives impressive testimony documenting
the rapid ascent of the subject of venous disorders into the
world of science. The transition from dogma of the nineteenth and twentieth century to evidence-based medicine
and medicine-based evidence exemplifi es this. Future developments can already be seen, and the way ahead looks very
promising.
Fascinating new insights in the fi elds of basic science will
certainly stimulate more clinical research. The new tools of
noninvasive diagnostic instrumentation, such as the duplex
Doppler, have opened our eyes to an improved anatomic and
functional understanding of venous pathology. Nowadays
this has become the basis for rational therapeutic decisions
and for assessing the outcome after treatment.
New therapeutic options for treating varicose veins have
been developed, which are less invasive and are at least as
effective as traditional surgical methods. Based on the
growing experience with such procedures and on the results
of comparative studies, the indications for surgery of varicose veins have changed and will certainly change in the
near future.
Abolishing superfi cial refl ux and also advanced reconstructive surgical procedures on the deep veins may soon
yield excellent results, especially in severe forms of chronic
venous insuffi ciency. These conditions, especially venous
ulcerations, have been considered until now to be chronic,
incurable lesions.
Venous disorders frequently start with acute thrombosis.
This is but one feature of a complex thromboembolic disease
process that provides appealing links with other fi elds of
medicine. An example is the fascinating area of coagulation
disorders. A major part of this volume, The Vein Book, is
written by some of the most internationally recognized
experts in thrombosis research who provide genuine insights
into this important subject.
The future of phlebology has already arrived, and The
Vein Book is destined to be a part of it.
Hugo Partsch, M.D.
Emeritus Head of the Dermatological Department
of the Wilhelminen Hospital,
Professor at the Medical University
and Honorary President of the IUP.
Vienna, November 2005
xv
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Introduction
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Venous disorders are important. They range in severity from
trivial telangiectasias to death-dealing pulmonary embolization. Their impact on disability is enormous. Their cost to
the economic system in Western countries is almost incalculable. This volume intends to bring under a single hardcover the major facets that have changed the face of diagnosis
and treatment of venous disorders during the last quarter
century.
Much of the activity in diagnosis and treatment of venous
disorders actually has been in investigations toward causation. These are well represented in this volume, where the
molecular basis of venous insuffi ciency is discussed as well
as in the inappropriate activity of leukocytes and how this
impacts on venous function. This is discussed further in the
chapters on physiologic testing of venous disorders. All of
this, of course, is based on the anatomical fi ndings and the
newly uncovered pathologic anatomy revealed by ultrasound testing.
Classifi cation of venous dysfunction has undergone some
revisions and has helped in making treatment of venous
insuffi ciency more of a science. The fundamental basis for
all treatment in venous disorders is compression therapy,
and this is thoroughly discussed in this volume by a preeminent authority in this fi eld.
After 1970, the vascular laboratory became dominant
in the study of patients with arterial diseases. After 1980,
use of the Doppler and its marriage to pulsed Doppler
systems made venous diagnosis more accurate. Since 1985,
duplex scanning has emerged as the main direct test for
diseases of the veins. The ultrasound applications are
seen throughout this volume. These are mentioned many
times in those chapters that deal with primary venous
insuffi ciency.
In treating venous insuffi ciency, compression is fundamental and this is well discussed, as is sclerotherapy, which
is described in a number of chapters encompassing the scle-
rosants themselves, their applications, and the all important
complications of sclerotherapy.
As treatment of varicose veins has changed from
traumatic surgery to minimal invasion, the new modalities
command attention. These include modifi cations of surgery,
radiofrequency closure of the saphenous vein, use of the
laser in obliteration of the saphenous vein, and the use of
foam as a substitute for all three modalities. No book of this
magnitude would be complete without a description of the
surgical stripping of the saphenous vein, even though many
phlebologists believe that to be obsolete. Part of the reasons
for the downturn in interest in surgery is the phenomenon
of neovascularization, which appears to be the consequence
of a clean groin dissection, and that is exceedingly well
described in a chapter on that subject.
Venous thromboembolic disease is an exceedingly important venous subject although it is quite separate in its thinking from the general subject of venous insuffi ciency. A
complete coverage of this subject extends from diagnosis
through various forms of treatment and must contain a thorough discussion of prevention as well as treatment.
Finally, the post-thrombotic state of chronic venous
insuffi ciency occupies much time and effort because it is
essentially incurable. Aspects of its care run the full gamut
from simple compression through surgery, venous reconstruction, and foam sclerotherapy to the futuristic subject of
synthetic and artifi cial valves. There is much to be done in
improving the care of this condition.
All these subjects and more are the content of this volume.
The authors of each chapter and section join me in the hope
that you will enjoy application of the knowledge as much as
we have enjoyed bringing it to you.
John Bergan, M.D.
La Jolla, CA, USA
November 2005
xvii
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CHAPTER
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1
Historical Introduction
ALBERTO CAGGIATI and CLAUDIO ALLEGRA
Since the fi fth century bc, the heart has been regarded as the
center of the vascular system (Empedocles of Agrigentum;
500–430 bc). In the great Epic of India, “Mahabharata,” it
was stated that “all veins proceed from the heart, upwards,
downwards and sideways and convey the essences of food
to all parts of the body.” The Chinese Wang Shu So reported
in his Mei ching, that “the heart regulates all the blood in
the body . . . The blood current fl ows continuously in a circle
and never stops . . .” Herasistratus (310–250 bc) was so
close to the discovery of the circulation to guess the existence of capillaries: “. . . the blood passes from the veins into
arteries thorough ‘anastomoses,’ small inter-communicating
vessels . . .”
These correct theories were darkened by Hippocratic
dogma for centuries. Hippocrates of Cos, the “father of the
Medicine” (460–377 bc) affi rmed in “De Nutritione” that
the liver is the “root” of all veins and that the veins alone
contain blood destined for the body’s nourishment. Arteries
would contain an elastic ethereal fl uid, the “spirit of life.”
This wrong convincement, based upon the Pythagorean doctrine of the four humors (blood, phlegm, yellow bile, and
black bile), remained the basis for medical practice for more
than 2000 years!
As irrational as this theory seems to us today, more than
three centuries (1316–1661) passed until it was abolished.
Many authors confuted Hippocratic theories, allowing, and
sometimes anticipating, Harvey’s discovery. In 1316,
Mondino de Luzzi furnished a rudimental but exact description of the circulatory system that was omitted by all subsequent authors: “. . . Postea vero versus pulmonem est aliud
orifi cium venae arterialis, quae portat sanguinem ad pulmonem a corde; quia cum pulmo deserviat cordi secundum
modum dictum, ut ei recompenset, cor ei transmittit san-
guinem per hanc venam, quae vocatur vena arterialis; est
vena, quia portat sanguinem, et arterialis, quia habet duas
tunicas; et habet duas tunicas, primo quia vadit ad membrum
quod existit in continuo motu, et secundo quia portat sanguinem valde subtilem et cholericum . . .” The same occurred
to the Spanish Ludovicus Vassaeus and Miguel Servetus.
The anatomy of the cardiovascular system was so well
depicted by Vassaeus (De Anatomen Corporis Humani
tabulae quator, 1544) that Marie Jean Pierre Florens affi rmed
that he “. . . described the blood circulation a century before
William Harvey . . .” In 1546, the anti-Arabist theologician
and physician Servetus exactly described the pulmonary
circulation: “. . . the blood enters the lungs by the way of the
pulmonary artery in greater quantities than necessary for
their nutrition, mixes with the pneuma and returns by way
the pulmonary veins . . .” Servetus’ discovery did not diffuse
between contemporary physicians, probably because it was
reported in a theological book. Servetus’ theories were so
innovative that he was accused of heresy by Calvinists and
burned. Andrea Cesalpino, Professor of Medicine at Rome,
fi rst identifi ed the function of the valves (. . . certain membranes placed at the openings of the vessels prevent the blood
from returning . . .) and the centripetal direction of the fl ow
in the veins (1571). He also supposed the existence of “vasa
in capillamenta resoluta” (capillaries) and affi rmed that in
the lung, the blood “. . . is distributed into fi ne branches and
comes in contact with the air . . .” (1583). Finally, he coined
the term “circulation.” According to important historians like
Florens, Richet, and Castiglioni, Cesalpino’s groundwork
determined the Harvey’s revolution.
In 1628, William Harvey explained in his De Motu Cordis
the theory of the blood circulation (see Figure 1.1). However,
the discovery of the circulation cannot be considered
The Vein Book
1
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