Les déconvenues esthétiques en sclérothérapie peuvent être de divers types : – objectives dues à une non-amélioration de la lésion cible (disparition insuffisante, aggravation, récidive rapide) – objectives dues à l’apparition d’une lésion nouvelle (pigmentation, matting, cicatrice, etc.) – subjective, traduisant une différence d’appréciation du résultat entre médecin et patient. Les deux premiers types peuvent correspondre à trois catégories de causes : – erreurs stratégiques, comme, une absence de contrôle satisfaisant des reflux jonctionnels, tronculaires et perforants en raison d’une analyse hémodynamique et d’une cartographie écho-Doppler insuffisante. – erreurs tactiques, comme, le choix d’une méthode non appropriée aux lésions (sclérothérapie sur très gros troncs). – erreurs techniques : excès de dosage et de concentration des sclérosants (ou sous-dosage), mauvaise technique, manque de pratique. Le troisième type, subjectif peut découler d’une mauvaise estimation des possibilités thérapeutiques par le médecin, le patient ou les deux ou d’une dysmorphophobie du patient. La prévention des mauvais résultats demande des connaissances théoriques complètes et mises à jour régulièrement, ainsi qu’une technique sans reproche. La plupart des mauvais résultats sont dus à des erreurs. Il est toujours bon de confronter ses méthodes et ses résultats à ceux de ses collègues.

Les récidives au sens large se définissent (PREVAIT) comme la présence de varices après intervention. Nous avons pu observer au fil des années que les récidives avaient changé d’aspect et de mécanisme physiopathologique. À l’époque du « tout chirurgical sans écho-Doppler », il y a 20 ans et plus, l’essentiel des récidives était observé chez des patients re-consultant tardivement pour varices volumineuses. On observait en échographie un moignon de crosse de gros calibre ; le tronc était souvent en place sur une bonne partie de son trajet et l’on retrouvait les varices classiques de cuisse : tributaires médiales et saphène accessoire antérieure de cuisse (SAAC). Par la suite, la constatation des médiocres résultats de la chirurgie a amené à plus de précision dans la réalisation de la crossectomie : cette fois au ras de la fémorale, avec ligature élargie des collatérales de la crosse et stripping par invagination. La grande saphène était parfois distinguée de ses tributaires. Les récidives, observées quelques années plus tard, s’avéraient moins volumineuses. À ce moment, les progrès de l’échographie permettaient d’identifier la néovasculogenèse. De même, l’importance des veines de la lame lympho-ganglionnaire était relevée par certains. Il en découlait une série de propositions préventives comme l’enfouissement du moignon de saphène, etc. Ces méthodes comptent quelques résultats satisfaisants. Plus récemment la chirurgie a encore évolué : pas de stripping de la GVS, pas de crossectomie, avec quelques résultats favorables qui montrent à quel point le traitement des varices ne peut pas être le même pour tous les patients. Leur recul est faible également. Il est clair que la chirurgie à ciel ouvert telle qu’elle doit être pratiquée aujourd’hui (précédée d’un écho-marquage effectué sous AL) n’a plus rien à voir avec la CS des années héroïques. Depuis 10 à 15 ans, des traitements alternatifs sont apparus : méthodes endoveineuses chimiques (sclérothérapie écho-guidée à la mousse [SEM]) et thermiques radio-fréquence (RF) et laser (EVLT) essentiellement. Concernant la SEM, elle obéit aux règles de l’école française (R. Tournay) et s’attaque en priorité aux sources de reflux les plus hautes et les plus volumineuses. De même, les méthodes thermiques obéissent aux principes de Tournay. Si l’on lit entre les lignes et si l’on compare ce qui est comparable en privilégiant la qualité technique des interventions par rapport à la qualité des statistiques (medicine based evidence vs. evidence based medicine), force est de constater que les résultats de RF et EVLT, d’une part, et de CS d’autre part, sont très bons et assez comparables, tant au plan des récidives cliniques et QoL qu’anatomiques. Les méthodes endoveineuses présentent un peu plus de récidives sur le même site (définition REVAS) et les récidives post-CS un peu plus sur d’autres sites. La SEM présente des recanalisations plus nombreuses, mais prévisibles et aisément reprises, tout à fait acceptables à ce niveau de coût–efficacité. Et enfin, si l’incidence des récidives n’a finalement pas tellement changé depuis 25 ans, à savoir de l’ordre de 40 % à 5 ans, il faut quand même observer que ce ne sont pas les mêmes : elles n’ont pas la même gravité clinique ni anatomique. Médecins et patients sont devenus beaucoup plus difficiles, et les moyens d’exploration écho-Doppler mettent maintenant en évidence des veines refluantes de 2 mm dont la relevance clinique est fort douteuse, mais qui sont pourtant retenues comme des récidives vraies.

Objective To evaluate the heredity factor of the chronic venous disorders and odds ratio linked to maternal or paternal heredity. Methods Cross-sectional epidemiological study conducted in daily practice of medical practitioners on all patients consulting them. The practitioners described the venous status of all patients consulting them and recorded the familial past history of venous disease. Results Among 21319 patients, 60.4% have a familial history of chronic venous disorder: unilateral paternal 7.5%, unilateral maternal 40.9% and bilateral: 12.0%. Chronic venous disorder prevalence is 58.8% in the global population, 38.2% in the absence of parental history, 67.0% for unilateral paternal, 71.3% for unilateral maternal and 79.2% for bilateral ( p < 0.0001). After adjustment on age and sex, results show significant ( p < 0.0001) odds ratio of 3.2 for unilateral paternal, of 3.4 for unilateral maternal and of 5.6 for a history in both parents. In the context of a history in both parents, the odds ratio increased to 5.6 for women and 8.4 for men. Conclusion This large cross-sectional study confirms the association between heredity and venous disease, but its results could call into question the maternal predominant character of the chronic venous disorder heredity.

OBJECTIVES:A variety of studies have suggested that flavonoids are effective for the treatment of CVD. However, many questions remain about their mechanism of action and when, how, and for what signs and symptoms they should be used.METHOD:A panel of experts in CVD met in Budapest, Hungary in December 2011 to discuss the current state of knowledge of CVD and the role of flavonoids in its treatment. The discussion was based on a literature search in the current databases. The goals of this paper are recommendations for further studies on the use of flavonoids in the treatment of CVD.RESULTS:There is good evidence to recommend the use of flavonoids in the treatment of CVD. However, because of the poor quality of some older clinical trials, inadequate reporting, and insufficient information, much work is still needed to firmly establish their clinical efficacy and to determine when and how they should be employed. In particular, long-term randomized, placebo-controlled, double-blind studies are needed to establish the efficacy and safety of flavonoids. Additional studies are also needed to establish their mechanism of action, pharmacokinetics, toxicity, and cost-effectiveness.CONCLUSIONS:Aside from good evidence for the use of flavonoids in CVD further studies are indicated to establish long term treatment in this indication.

Ultrasound-guided foam sclerotherapy (UGFS) has become a common treatment of sephenous veins incompetence. The use of homemade foam is world-wide widespread though it is off-label in many countries.

The Vein Consult program is the first worldwide venous diseases observatory; its french results are presented here. Thirty three thousand and ninety seven patients, mean age 51 year, and females for 70% of them, were included in the study. Nearly two-thirds (65.5%) of the patient base of general practitioners, had presented during seven years on average symptoms of venous disorders, dominated by heavy legs (48.9%), pain (40.9%) and bloating (37.4%). Forty eight per cent of patients who did not consult for this reason were however directly concerned by signs and/or symptoms of venous disorders. These results demonstrate that the disease is underestimated by physicians and patients themselves, despite the presence of typical clinical features signing their entry into the venous disease. In recent years, three important modifications, related to the publication of the latest international consensus on the management of vein disease, have occurred in the management of patients presenting with venous insufficiency: - the appearance of a care pathway and the role of the general practitioner (GP); - the discontinued reimbursement of phlebotropic drugs; - continued reimbursement of compression. The creation of a care pathway and the pivotal role of the general practitioner have led to a reduction in direct access to specialist consultations, which are now only reimbursed at 35%, if they were not prescribed by their GP. In addition, the discontinued reimbursement of phlebotropic drugs has not only disturbed patients, but has also left them to manage their disease themselves, which may give rise to hesitations. Today, treatment with phlebotropic drugs must comply with the consensus conference on the management of chronic vein disease [1]. In particular, the conference carried out an exhaustive review of the international literature on the action of phlebotropic drugs and classified them according to the level of proof of their efficacy using the methodology recommended by the Health Authorities. Three of these drugs were given a grade A recommendation by the international committee that presided these recommendations: calcium dobesilate, hydroxyethyl-rutoside and micronised purified flavonoid fraction. These structural changes have without doubt had a considerable impact on patients with vein disease who are seeking care and on the treatment they can benefit from. In order to verify this hypothesis, a study corresponding to the implementation in France of the "Veinoconsult" research programme validated by the scientific council of the International Union of Phlebology (IUP) was carried out. This study has already taken place in different countries whose national phlebology societies belong to this organization. The aim of the study was to determine: - the prevalence of vein disease in patients consulting GPs; - the proportion of patients whose vein disease was treated effectively or not; - reasons why certain patients were no longer treated; - the clinical status of those currently being treatment; - the quality of life and the diagnostic and therapeutic resources that patients benefit from today; - and the stage of vein disease at which patients are now referred to angio-phlebologists and vascular surgeons.

AIM:The Vein Consult Program is an international, observational, prospective survey aiming to collect global epidemiological data on chronic venous disorders (CVD) based on the CEAP classification, and to identify CVD management worldwide. The survey was organized within the framework of ordinary consultations, with general practitioners (GPs) properly trained on the use of the CEAP classification.METHODS:Screening for CVD was to be performed by enrolling in the survey all consecutive outpatients >18 years whatever the reason for consultation, to record patient's data and classify them according to the CEAP, from the stage C0s to C6. The program enrolled 6232 GPs 91545 subjects were analysed. Their mean age was 50.6±16.9 years, younger patients being in the Middle East and older ones in Europe, and the proportion of women was higher than that of men.RESULTS:The worldwide prevalence of CVD was 83.6%: 63.9% of the subjects ranging C1 to C6, and 19.7% being C0s subjects. C0s patients were more frequently men whatever the age and the geographical zone. C1-C3 appeared to be more frequent among women whatever the country but the rate of severe stages (C4-C6) did not differ between men and women. GPs consider CVD subjects as patients eligible to specialist referral beginning from C2 but some geographical disparities were observed.CONCLUSION:The VCP survey provides reliable results on CVD global epidemiology and shows that CVD affects a significant part of the populations worldwide, underlining the importance of adequate screening for CVD and training of both GPs and specialist physicians.

Since the publications of Zamboni et al. in 2009, multiple sclerosis (MS) has known a new aetiology: the Chronic cerebro Spinal Venous Insufficiency: CCSVI. As this aetiology could be treated by angioplasty, with several amazing results, this (re) discovery has been the topic of much research and publications. As of today, one can say with robust arguments that anatomical and functional anomalies of the CCSVI do exist and that they are more frequent in patients with MS (up to 13 times more), and other neurological disorders. They may benefit from endovenous treatment. Compared to other suggested aetiologies of MS, CCSVI seems to be a step forward. More studies are still necessary to establish indications and demonstrate results but CCSVI must certainly be taken into account in the management of MS.

This prospective survey, realized by an independent institute at the end of the year 2011, has analyzed the prescription of compression garments in a sample of 180 French physicians. From the beginning of the survey on, 180 physicians (80 general practionners, 60 vascular physicians/phlebologists, and 40 gynecologists, distributed all over France) have I prospectively recorded the data on their next 10 patients seen in consultation for whom there had been : - initial prescription, - renewed prescription, - or consultation without renewal wearing medical stockings). (patients already Physicians participating in the study were all regular prescribers of medical compression (at least in 1015 patients per month). The study allowed to determine medical compression patients' demographic and medical characteristics, physician accounted indications, models and types of garments prescribed, and finally compliance and observance. This study, that reports new and original data, confirms the excellent level of knowledge of prescribers, their influence on the seriousness of medical compression wearing in France, as it does confirm the adequacy and relevance of the material offer of compression garment makers.

AIM:The present study assessed the effect of Ruscus aculeatus, hesperidin methyl-chalcone and ascorbic acid (HMC-AA), in the treatment of chronic venous disorders (CVD) in Latin American patients.METHODS:This study is an observational, single arm, multicentric and prospective trial. Patients suffering from CVD and belonging to C0s-C3 Clinical Etiological Anatomical and Physiopathological (CEAP) classes were included. Patient profiles, risk factors, clinical symptomatology and quality of life (QoL) assessed by SF-12 and CIVIQ questionnaires were evaluated at inclusion and after 12-week treatment.RESULTS:The main factors influencing the previous management of patients were age, gender, body mass index (BMI), familial history, physical activity, exposure to heat, heavy loads lifting, profession and clinical characteristics. All clinical symptoms significantly improved with treatment and, as BMI and CEAP classes increased. Ankle circumferences decreased over time, correlating with BMI and CEAP classes. The physical and psychological dimensions of the SF-12 score significantly increased over time and improved within each CEAP class. The CIVIQ score significantly improved over time, correlating with age and CEAP classes.CONCLUSION:A 12-week treatment with Ruscus aculeatus HMC-AA showed a significant decrease in the clinical symptoms and a significant improvement in the QoL of patients with CVD.

Background Visual disturbances (VDs) are reported with an average rate of 1.4% after foam sclerotherapy (FS). Some clinical clues indicate that they could correspond to migraine with aura (MA). Aims To validate the hypothesis that VDs occurring after FS correspond to MA and are not transient ischaemic cerebro-vascular events. Method A prospective multicentre study was carried out by the French Society of Phlebology in collaboration with the Neurology Department of the Marseille University Hospital (France). We included prospectively and consecutively all patients who experienced VDs after FS using air to make the foam. The patients were assessed (1) clinically with a specific form describing procedures of FS and recording neurological symptoms, later analysed by a neurologist specialized in migraine; and (2) by a brain diffusion-weighted magnetic resonance imaging (MRI) (T1, T2, T2*, diffusion) carried out within two weeks and analysed by a neuroradiologist. Results Twenty patients, 16 women and four men, were included in 11 phlebology clinics. All kinds of veins were treated. VDs occurred in average seven minutes after FS. Clinical assessment showed that VDs presented characteristics of MA in all patients, with headache in 10 and without in 10. Paresthesia was observed in five patients and dysphasic speech disturbance in one. Fifteen patients (75%) had a personal history of migraine. Fifteen MRIs were performed within two weeks (mean: 8 days) and three were late (26 days). All of them were normal. MRI was not performed in two patients. Conclusion These results show that VDs occurring after FS correspond to MA and are not transient ischaemic cerebro-vascular events. We suggest a pathophysiological hypothesis resting on the release of endothelin that would reach the cerebral cortex through a paten foramen ovale.