Objective To study the incidence and the possibility of preventing thrombotic complications during major sclerotherapy for venous insufficiency of lower limbs. Methods A total of 2489 sclerotherapy sessions were performed on 2010 patients. 1087 sessions (43.7%) were carried out without heparin prophylaxis while in 1402 sessions (56.3%) a prophylaxis with low molecular weight (LMWH) was used. Thrombotic complications were divided into a) post sclerotherapy transient extension (POSTE) if they consisted of a simple extension of sclerotherapy, and b) deep venous thrombosis (DVT) when the complication occurred in a location separate from that of sclerosis. Results The overall incidence of a thrombotic complication was 0.52%. Out of 2489 sessions, 8 cases of POSTE (0.32%) and 5 thromboses of a gastrocnemius vein (0.2%) were diagnosed The most significant figures were reached in the great saphenous vein (GSV) subgroup, where the incidence of complications was 1.91% without prophylaxis and 0.31% (p = 0.009) with prophylactic heparin. Conclusions In this study prophylaxis with LMWH significantly reduced the incidence of thrombotic complications when sclerotherapy of the great saphenous vein was performed.

Objectives Aminaphtone, a naphtohydrochinone used in the treatment of capillary disorders, may affect oedema in chronic venous insufficiency. Aim of study is to investigate the effect of aminaphtone on vascular endothelial permeability in vitro and its effects on three-dimensional capillary-like structures formed by human umbilical vein endothelial cells. Method Human umbilical vein endothelial cells were treated with 50 ng/ml VEGF for 2 h and aminaphtone for 6 h. Permeability assay, VE-cadherin expression and Matrigel assay were performed. Results VEGF-induced permeability was significantly decreased by aminaphtone in a range concentration of 1–20 µg/ml. Aminaphtone restored VE-cadherin expression. Finally, 6 h pre-treatment with aminaphtone significantly preserved capillary-like structures formed by human umbilical vein endothelial cells on Matrigel up to 48 h compared to untreated cells. Conclusions Aminaphtone significantly protects endothelium permeability and stabilises endothelial cells organised in capillary-like structures, modulating VE-cadherin expression. These data might explain the clinical benefit of aminaphtone on chronic venous insufficiency.

In the literature cases of stroke and transient neurological symptoms have been described after sclerotherapy for chronic venous disease The initial interpretation of these phenomena was that of a micro air embolism in association with a patent foramen ovale. This explanation did not always manage to justify all neurological manifestations. Recent theories have demonstrated that in the area of sclerosis, a significant amount of endothelin 1. We carried out a retrospective assessment of sclerotherapy case studies on 540 patients at ten phlebological centres to search for a relationship between the use of aminaftone (a venotropic drug with demonstrated anti-endothelin action) and the occurrence of side effects after sclerotherapy was performed. Significant reduction of side effects was observed in sclerotherapy for teleangectasias and in patients with migraine history.

What is phlebology? Who are the phlebologists? These could seem obvious questions but the answer may not be so simple. The peculiarity of phlebology is that this deals with a very common disease that crosses the expertise of many disciplines: vascular surgery, angiology, dermatology, general surgery, interventional radiology and many more. Also in different geographical areas phlebology is generally practiced by very different professionals: in Central Europe or in the USA it has always been practiced mostly by dermatologists as in many other countries is mainly practiced by surgeons. A peculiarity of phlebology is that with relatively little equipment you can make a high level phlebology that is highly profitable for those who practice it. Furthermore, most of the phlebological activities may be performed in an office setting, with a possible widespread diffusion. The gray aspect of phlebology is, at the opposite, that every physician making a sclerotherapy or a bandage may consider himself as an expert without a true and extended knowledge. This explains the stagecoach that we have seen to what until a few decades ago it was considered the Cinderella of vascular diseases. In this situation it is needed to respond appropriately to the questions with which I began this editorial. In US it was established in 2007 the American Board of Venous and Lymphatic Medicine (ABVLM; http://www.abvlm.org) that certifies the phlebologist after a training course and an examination and in some countries such as Argentina phlebology is the subject of university education (in Buenos Aires, for example, there is a Chair of Phlebology; http://medi.usal.edu.ar/medi/flebologia-cursouniversitario-flebologia-eco-doppler-color). The Australasian College of Phlebology has three specific programs of training and certification, the Basic phlebology Training which lead to the title of certified sclerotherapist, a two years course diploma and the Advanced Phlebology Training with which the status of fellowship is achieved (http://www.phlebology. com.au). The training program is both theoretical and clinical with a minimum of procedures that must be performed by the trainee. In 2010 the International Union of Phlebology (UIP) has proposed its curriculum of phlebology1 but in Europe there is not currently a precise answer to the request for qualification in phlebology. The European College of Phlebology (ECoP) has been recently established in order to write common phlebological guidelines and to standardize education and training. For this reason the ECoP has supported the creation of a multidisciplinary commission at the European Union for Medical Specialists (UEMS).2 In Italy the Italian College of Phlebology (CIF) is proposing the evaluation of the practitioner made by an anonymous commission, which should determine the skill of the phlebologist;3 the Italian Society of Clinical and Experimental Phlebology (SIFCS) is advocating a school of excellence and a certificate of phlebology (http://www.phlebologycourses.org). Courses organized by scientific societies or universities or even private organizations (http://www.valet.it) are available but there is not a real shared path in the various European countries leading to the definition of a professional phlebologist. In order to overcome this situation the European Registry of phlebologists has been recently established with the initial participation of Italy, Germany, Portugal, Hungary, Poland, Greece Romania and Czech Republic. Those countries have or are organizing corresponding national registries and the project is open to all European countries. In Italy the Registro Italiano dei Flebologi is jointly sponsored by Italian Phlebological Association (AFI) and Italian Society of Phlebology (SIF). The register is to certify the training of the physician and to verify the possible lack of training in the various aspects of the phlebological practice (http://www.registroitalianoflebologi.it). By the inclusion in the registry he or she will be able to acquire the title of professional phlebologist which will be guaranteed by the inclusion of this category in the ESCO catalog (European classification of skills/competences, qualifications and occupations). All these similar but inhomogeneous attempts to achieve the target of the phlebologist qualification although demonstrating the great difficulty in finding a common pathway among European countries, however testify a strong desire of giving to phlebology the independence it deserves. I think that a specific (and shared among European countries) training program on the model of the Australasian College of Phlebology will be the best way to form the European phlebologist and I really hope that in the boundaries of the ECoP this will be achieved in the future, but for now the Registry of Phlebologist remains, at least in my opinion, the best way to define the European phlebologist.

BACKGROUND:The foam sclerotherapy technique has become one of the most commonly used treatments for superficial venous insufficiency. Despite excellent results, few visual/neurologic disturbances have been recently reported; their pathogenesis is still debated but a correlation with endothelin-1 (ET-1) release from the treated vein has been proposed.OBJECTIVE:The purpose of this work was to evaluate the ET-1 release after sclerotherapy and to investigate the effects of the anti-endothelin drug aminaphtone.METHODS AND MATERIALS:As in vitro sclerotherapy model, an endothelial cell culture, mimicking vascular endothelium, was pretreated with aminaphtone and exposed to detergents. Cell survival and ET-1 release were measured. In in vivo experiments, 45 rats, fed with different aminaphtone-rich diets, were subjected to sclerotherapy, and the systemic ET-1 was measured.RESULTS:Aminaphtone cell exposure caused a statistically significant reduction in ET-1 release, both before and after in vitro sclerotherapy. Rats fed with aminaphtone showed a trend toward reduced mortality and a significant decrease of ET-1 release after sclerotherapy.CONCLUSION:This is the first study in which an anti-endothelin agent was able to cause a significant reduction of ET-1 release during sclerotherapy. Although clinical studies are required, these findings might advocate the use of anti-endothelin agents in prophylaxis of neurologic or visual disturbances after sclerotherapy.

In order to enhance the treatment of insufficient saphenous vein with sclerosing foam, we used a new technique called LAFOS (Laser Assisted FOam Sclerotherapy) in which a new specifically designed Ho: YAG 2100 nm laser has been used to shrink the vein immediately before sclerosing foam injection. This laser pretreatment is capable to significantly reduce vein diameter thus less foam volume is necessary to ablate the vein with lower chance of complications. The procedure is performed in ambulatory setting as anesthesia is not required. We are presenting the short time results of the first 50 cases treated by LAFOS.

To evaluate the chemical reaction of the venous wall to different sclerosing agents, the Authors studied the level of blood histamine concentration before and 8-10 min after sclerotherapy injection into large 3-6 mm subcutaneous varices. A total of 45 sessions were studied: a solution of iodine 2% was used in 15 (group A), liquid 2% polidocanol in 15 (group B), polidocanol 0.5% foam in 15 (group C). Histamine basal level was 4.49, 4.48 and 4.52 µg/100 mL, respectively, while after injection an increase was found of 4.50 (102%), 4.42 (99%) and 4.46 (100%) µg/100 mL, respectively. No significant relationship was found between agents and reactions. In C group, 2 cases had visual symptoms, both showing an 150% increase in histamine. Migraine with aura seems to be associated with high hematic levels of histamine. High histamine levels caused by sclerotherapy may explain the visual symptoms frequently reported after treatments. In fact, histamine is a vessel vasoconstrictor (venous spasm) but also a small artery vasodilator (hypotension). It could, therefore, mediate these minor sclerotherapy complications. For this reason, an antihistaminic pre-medication could be justified. The recently suggested endotheline hypothesis could support this.