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CHRONIC VENOUS INSUFFICIENCY:

MANAGEMENT AND TREATMENT


Summary of selected presentations from the
Chronic Venous Disease and Haemorrhoidal Disease:
Their Management and Treatment MASTERCLASS held
in Lisbon, Portugal, from 23rd–24th September 2016
Speakers
Kursat Bozkurt, Eberhard Rabe,2 Mohamed I. Sharkawy3
1

1. Professor of Cardiovascular Surgery, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey
2. Professor of Dermatology, Phlebological Department in the Department of Dermatology,
University of Bonn, Bonn, Germany
3. Professor of Vascular Surgery and Peripheral Endovascular Intervention,
Faculty of Medicine, Cairo University, Cairo, Egypt

Disclosure: The authors received an honorarium from OM/Vifor Pharma (Meyrin, Switzerland) as
international experts and presenters at the Chronic Venous Disease and Haemorrhoidal Disease: Their
Management and Treatment MASTERCLASS held in Lisbon, Portugal. Prof Rabe is a consultant for
Sigvaris and EUROCOM.
Acknowledgements: Writing assistance was provided by Dr Ewen Legg of Halcyon Medical Writing.
Support: The publication of this article was funded by OM/Vifor Pharma. The views and opinions expressed
are those of the authors and not necessarily those of OM/Vifor Pharma.
Citation: EMJ Dermatol. 2017;5[Suppl 2]:2-13.

MEETING SUMMARY
This expert masterclass, supported by an independent grant from OM/Vifor Pharma, brought together
physicians specialising in vascular surgery, gynaecology, and dermatology from Pakistan, Egypt, Turkey,
Lebanon, and Germany to discuss the current management of chronic venous disease (CVD) and
haemorrhoidal disease. The meeting included plenary lectures and interactive case study discussions,
allowing delegates and presenters to take part in high-level discussions of pressing issues in the field.

CHRONIC VENOUS DISEASE: with a similar, though more severe, symptom


EPIDEMIOLOGY, RISK FACTORS, profile beginning with feelings of heaviness and
progressing to pain, oedema, and skin changes.
PATHOPHYSIOLOGY, AND DIAGNOSIS
Data from the international screening and
Epidemiology awareness-raising Vein Consult Program show
that the early stages of CVD predominate.1
CVD is a very concerning condition which creates
Varicose veins and oedema affect around 15%
a significant burden on healthcare provision and
of the population worldwide (Table 1). Severe
wider society. Varicose veins are often the first
disease, characterised by active or healed
sign of CVD. However, progression often over venous ulcers, affects approximately 2% of the
several years to chronic venous insufficiency (CVI), world’s population (Table 1), with a significant
defined by the presence of oedema and a Clinical concomitant burden for healthcare systems and
Etiologic Anatomic Pathophysiological (CEAP) patients.2 More recent CEAP-class based studies,
clinical class of ≥C3, represents a more significant conducted in Europe and the USA, put severe
problem for healthcare providers and patients disease from C4−C6 at approximately 5% while
(Table 1). In addition, post-thrombotic syndrome C2−C3 prevalence is approximately 25%, making
also contributes to the burden of venous disease moderate-to-severe CVD a very frequent pathology.

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Table 1: Revised Clinical Etiologic Anatomic Pathophysiological classification and worldwide prevalence
of chronic venous disease.

Grade Description of signs Prevalence* (%)


C0 No visible or palpable signs of venous disease 20.0
C1 Telangiectasias or reticular veins 21.6
C2 Varicose veins; distinguished from reticular veins by a diameter of ≥3 mm 16.0
C3 Oedema 14.6
C4 Changes in skin and subcutaneous tissue secondary to chronic venous disorder, divided 7.1
into two subclasses to better define the differing severity of venous disease:
C4a: pigmentation or eczema
C4b: lipodermatosclerosis or white atrophy
C5 Skin changes as defined in C4 with healed venous ulcers 1.4
C6 Skin changes as defined in C4 with active venous ulcers 0.5

Adapted from Eklöf et al., 2004.3 *Data from Rabe et al. 2012.1

These figures appear to remain relatively constant USA. This represents more of a budgetary impact
on a country by country basis, including across than arterial disease. Venous ulcers contribute to
the Middle East and South Asia. 2 million lost work days annually in the USA; CVD in
general results in 4 million lost work days annually
The prevalence of CVI increases dramatically with in France. The annual cost for loss of work
age, with venous ulcers affecting 20.7% of those days varies from €270 million in Germany, to
>80 years of age compared with 0.3% of €320 million in France, and $3 billion per year in
41−50-year-olds.4 CVD is often considered to be the USA.11,12
more common in women, however both sexes
are substantially affected. While the incidence Risk Factors
of varicose veins is higher in females than males
The risk factors for varicose veins are non-
(13.9–46.3% of females and 11.4–29.3% of males
modifiable and include age, genetics, and female
based on 50,974 persons from Europe and the
sex/pregnancy. However, CVI has both modifiable
USA),5-10 the prevalence is similar in men, and
and non-modifiable risk factors, which include
in women who have never been pregnant.
age, obesity, hypertension, and prolonged sitting
The influence of sex on less severe forms of venous
or standing. Older age is the most important risk
disease is unclear. Furthermore, in the Edinburgh
factor for both varicose veins and CVI. In the large
Vein study, varicose veins were more common
cross-sectional San Diego Population Study, the
among male subjects in the general population.
odds ratio (OR) for older age was 2.42 for varicose
Data from the Bonn Vein Study indicate that
veins and 4.85 for CVI.5,10 In the large prospective
women with CVD are more likely to report having
Bonn Vein Study, the OR for varicose veins in
experienced symptoms occurring over the previous
70–79 year olds was 15.9.9,10,13 Obesity is the most
4 weeks than men with CVD. These differences
significant modifiable CVI risk factor, affecting
can be up to 2-fold for symptoms such as
between three-quarters and two-thirds of patients.
heaviness (23.8% versus 11.1%, in women and men,
Late stage CVI, characterised by ulceration,
respectively) and pain associated with standing
is extremely rare in non-obese patients. The
(24.2% versus 14.4% in women and men,
presence of modifiable risk factors in CVI offers
respectively). This may be one of the reasons why
the possibility to institute prophylactic strategies.
men with varicose veins seldom seek treatment and
present at later stages of CVI. Pathophysiology
CVD is a major socioeconomic burden worldwide. The major characteristics of CVD pathophysiology
In Western Europe, 2% (€900 million) of the annual are reflux, caused principally by valvular
healthcare budget is spent on chronic venous incompetence and obstruction. Obstruction and
conditions, the equivalent of $2.5 billion in the reflux may exist alone or in combination and

DERMATOLOGY SUPPLEMENT • February 2017 EMJ EUROPEAN MEDICAL JOURNAL 3


are exacerbated by muscle-pump dysfunction pain which increases throughout the day, in warm
or inactivity. These factors result in elevated temperatures, and predominantly with standing
ambulatory venous pressure leading to ambulatory rather than walking are indicative of a venous
venous hypertension. Increased venous pressure pathology. Diagnostic techniques can be separated
and reduced blood flow caused by the above into three levels: 1) history and examination;
mechanisms are the major drivers of the 2) non-invasive imaging; and 3) complex or invasive
downstream pathological features of CVD. imaging. The European Society of Vascular Surgery
(ESVS) recommends history-taking and physical
Up until the turn of the century, the primary theory
examination with an evidence level of 1C.10
of varicose veins pathophysiology was based on a
descending phenotype of disease progression. The The CEAP system (Table 1) is generally accepted as
‘descending theory’ postulates initiation of disease the best of the available diagnostic documentation
cranially, at the level of the saphenofemoral or systems (1B). A number of supplementary clinical
saphenopopliteal junctions, followed by extension scoring systems also exist. The Venous Clinical
to the main trunks and the superficial tributaries.11 Severity Score appears to be underutilised in
However, over the past 10–15 years the ‘ascending some clinical settings, despite its positive impact
theory’, suggesting a multifocal origin beginning on assessment of disease severity and patient
with the tributaries and moving to the trunks and wellbeing (2aB).10 The Venous Segmental Disease
then junctions, has gained traction.10,14
Score (VSDS) and Venous Disability Score (VDS)
Inflammation has a key role in valve failure and also represent useful diagnostic tools (2aB).10
vein wall remodelling, both of which contribute Routine use of these additional tests is becoming
to reflux and hypertension. Increased venous more frequent and should be encouraged.
hydrostatic pressure and low blood flow activate
Assessment of patient quality of life (QoL) should
inflammatory gene expression in the vascular
be incorporated into clinical examination.
endothelium. This leads to leukocyte rolling,
QoL correlates strongly with disease severity
adhesion, and migration. The above effects
and treatment-induced improvements, and is
contribute to inflammation and free-radical
increasingly viewed as the most important
formation which in turn induce apoptosis and
tissue necrosis. Thus, the venous wall and valve outcome measure when assessing novel therapies.10
damage found in primary venous disease becomes A number of QoL measures, both general and
self-reinforcing.15-17 venous-disease specific, are available and are
recommended by the ESVS (2aB). Both physical
Similarly, at the level of the microvasculature, and mental components of the generic SF-30
reduced blood flow and increased blood pressure questionnaire can detect the impact of CVD on
leads to activation of cell-cell interactions, inducing QoL. Data indicate that Stage C3 has a similar
white-cell trapping, which in turn leads to the impact to diabetes or cancer while Stage C5–C6
release of inflammatory mediators. Inflammation has a similar impact to heart failure.18 The Aberdeen
leads to the opening of the endothelial barrier Varicose Vein Quality of Life (AVVQ) questionnaire,
and venular endothelial-cell leakage. When fluid alongside the Chronic Venous Insufficiency
leaving the capillary (capillary filtration) exceeds Questionnaire (CIVIQ), or Venous Insufficiency
lymphatic flow the result is interstitial oedema. Epidemiological and Economic study questionnaire,
The fluid and immunologically active cells entering represent good-quality disease-specific measures
the surrounding tissue lead to further release of for assessing response to treatment (2aB).10
inflammatory mediators exacerbating oedema and
causing pain and discomfort. Since the pathological In terms of non-invasive diagnostic imaging,
mechanisms directly resulting in oedema occur duplex ultrasonography (DUS) is now the gold
within the microcirculation, this is the major target standard across the world (1A).11 DUS is sufficient
for pharmacological interventions against CVI. to investigate the deep venous system in the
majority of cases and should be used before
Diagnosis
considering phlebography, computed tomography
The presence of feelings of heaviness, tiredness, venography (CTV), or magnetic resonance
and swelling is a diagnostic feature of CVD and venography (MRV) for difficult to visualise pelvic or
can distinguish CVD from other sources of leg pain abdominal veins (1C).11 With the adoption of DUS,
such as arterial occlusive disease. In addition, handheld Doppler is now considered obsolete.10

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In cases of deep abdominal or pelvic veins which pathology. Compression improves haemodynamics
cannot be visualised with DUS, CTV and MRV are through promotion of the venous pump
frequently used in well-resourced centres and and reduced venous reflux. While oedema
can now achieve three-dimensional images (1C).10 formation is ameliorated through improvements
Reliable diagnosis of abdominal pathologies in microcirculation and promotion of lymphatic
including Nutcracker syndrome, May–Thurner drainage. Oedema reduction results in improvement
syndrome, and pelvic varicocele can now of symptoms with the added advantage that these
be achieved with these techniques.10 Invasive effects are immediate.
techniques such as phlebography are recommended
where other tools are inconclusive (2bB).10 Compression treatment takes on a number
of forms including bandages, stockings, and
MANAGEMENT OF CHRONIC intermittent pneumatic compression, which is
emerging as a potentially exciting new method
VENOUS DISEASE
of thromboprophylaxis. In CVD, indications for
Treatment of CVI aims to both improve venous compression stockings vary according to their
function and improve the signs and symptoms pressure. Low-pressure (10–20 mmHg) stockings
of CVI. Addressing signs as symptoms is the are indicated for treatment of CEAP classification
most important goal of treatment from the C0–C1 with the aim of preventing swelling, heavy
patient perspective, however, this is not always legs, tenderness, and pain. Symptom prevention,
concomitant with improved venous function. For at the C2 stage, and oedema reduction, at the
example, the frequent recurrence of venous ulcers C3 stage, requires higher pressure stockings of
following invasive treatment is driven by continued 20–30 mmHg. Stockings with a pressure of
microcirculatory pathology, which is not affected 30–40 mmHg are indicated for ulcer prevention
by addressing venous reflux. (C4) and ulcer-recurrence prevention (C5). While
ulcer healing and pain relief for patients with C6
Management should also address the progressive CVI requires the use of compression-stocking kits
nature of CVI and act as a prophylactic against with pressures of ~40 mmHg.
aggravation and progression.19 Treatment comprises
both conservative and invasive therapeutic The consensus document from 2008, which will
options. Conservative treatments include physical be updated shortly, reveals a number of gaps
treatment, such as engaging in increased in the evidence base for compression therapy.23
movement or sports, compression treatment, and Currently, there are few recommendations with the
pharmacological therapy. Invasive treatments highest 1A evidence level. Prevention of venous
include surgery of superficial and deep veins, thromboembolism using low-pressure compression
including percutaneous phlebectomy using hooks and the prevention of C6 ulcers using compression
and stripping techniques. New less invasive bandages are level 1A recommendations; however,
treatment options include foam sclerotherapy, the use of high-pressure compression stockings
endovenous thermal ablation, and radiofrequency for the prevention of post-thrombotic syndrome,
ablation techniques.20-22 These techniques offer currently 1A, is likely to be downgraded on the
good mid-term results and have comparable strength of data from the SOX trial.24 A significant
efficacy to stripping, though vein diameter should increase in data available indicating that
be considered when making treatment decisions post-surgical compression for pain relief is only
as larger varicose veins may not be as amenable to efficacious during the first week post-surgery is
these less invasive techniques. also likely to affect recommendations in the new
consensus document.
Compression Therapy
Venoactive Drugs
Compression therapy is the foundation of
therapeutic management of CVI. As well as gross The actions of venoactive drugs are very similar
physical effects on oedema, compression reduces to those of compression therapy. Venoactive
inflammation by tightening the gaps between drugs reduce inflammation of the venous wall,
vascular endothelial cells and by reducing cell-cell reduce oedema formation and the development
interactions. Intermittent venous hypertension is of skin changes, and protect endothelial
also reduced and capillary and venular-flow velocity cells from contraction. Venoactive drugs are a
enhanced, addressing primary drivers of CVI heterogeneous group, many of which are derived

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from plant extracts (Table 2). Their evidence base is between 1 and 2B depending on the substance
similarly heterogeneous with a significant number used). Whether pharmacological therapy can
of therapies having little or no peer-reviewed heal CVD remains unclear, though evidence
evidence available. suggests a possible effect on leg-ulcer healing.
Similarly, prophylactic use of venoactive drugs
Relief of symptoms is the main objective of has yet to be sufficiently investigated, though
pharmacological treatment, and strong evidence CVD pathophysiology and the anti-inflammatory
exists for an objective effect on oedema and venous mechanisms of venoactive drugs would suggest
symptoms (evidence level in most of the cases that retardation of progression is possible.

Table 2: Summary of venoactive drugs.25,26

Group Substance Origin Evidence Trials and


Grade*† meta-analyses*†
Benzopyrones
Alpha- Coumarin Melilot (Melilotus officinalis L.) Grade C‡ 2‡
benzopyrones Woodruff (Asperula odorata L.)
Gamma-benzopyrones (flavonoids)
Flavones Diosmin Citrus spp. Grade C 1
Sophora japonica L.
MPFF (micronised purified Rutaceae aurantiae Grade A 1
flavonoid fraction)
Rutin and rutosides, Sophora japonica L. Grade A 4
O-(β-hydroxyethyl)-rutosides Eucalyptus spp.
(troxerutin, HR) Fagopyrum esculentum Moench
Flavonols Quercetin glucoside, Red-vine-leaf extract - -
kaempferol, glucoside, (Vitis vinifera)
quercetin glucuronide
Flavanes and Hesperetin, hesperidin, Various plants - -
flavanones catechin, etc.
Anthocyanosides Blueberry extracts - -
(Vaccinium myrtillys L.),
red-vine-leaf extract (Vitis vinifera)
Proanthocyanidines Grape pips (Vitis vinifera) Grade C 1
(oligomers)
Saponins
Escin Horse chestnut seed Grade B 3
(Aesculus hippocastanum L.)
Ruscus extract Butcher’s broom (Ruscus aculeatus L.) Grade B 1
Other plant extracts
Centella asiatica extracts Centella asiatica - -
Ginkgo biloba extracts Ginkgo biloba L. Grade C -
Synthetic products
Calcium dobesilate Synthesis Grade A 2
Benzarone Synthesis - -
Naftazone Synthesis Grade C 1
Animal-derived extracts
Mesoglycan Polysaccharides from - -
different animal tissues

†Only trials assessing symptoms were considered when assessing evidence grade. ‡Evidence from
combined coumarin-troxerutin therapy.
MPFF: micronised purified flavonoid fraction.
Adapted from Ramelet et al., 2005.25 *Based on data from Nicholaides et al., 2008.26

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Data indicate that the use of venoactive drugs The effects of calcium dobesilate on the capillary
is both safe and economic, with digestive side and vein wall include: reduction of reactive oxygen
effects the main notable adverse outcomes.25,26 species, reduction in apoptotic factors, amelioration
of endothelial dysfunction, inhibition of leukocyte
Despite the strong evidence base for an objective
adhesion to the endothelium, and reduction
effect, some physicians question the clinical
of capillary-wall permeability via anti-vascular
significance of the oedema reduction achieved
endothelial growth factor activity and inhibition
by venoactive drugs. Data from a 2006 review
of alterations to cell-junction proteins.28-35 These
show that the majority of reductions range from
combined mechanisms act to improve capillary and
40–50 mL, which does not appear to be clinically
vein wall function and integrity, reducing blood and
relevant given the volume of the calf as a whole.27
fluid extravasation and, thus, oedema formation.
However, this comparison is based on a number of
erroneous assumptions. Firstly, water displacement Calcium dobesilate acts on blood components to
volumetry, the primary method used to assess reduce erythrocyte fragility and inhibit platelet
oedema, principally measures the foot and ankle aggregation, in addition to reducing plasma
area, representing around 2,500–3,000 mL. viscosity.36,37 These effects may in turn reduce
Though this is still a large volume in comparison to thrombosis in the microcirculation and the
reductions achieved with venoactive drugs, venous associated symptom, white atrophy.
oedema mainly occurs in the cutis and subcutis,
representing approximately 20% of this volume Finally, improved capture of fluid and
(600 mL). Furthermore, only around one-third macromolecules from the extracellular space
of this fatty tissue is made up of water, reducing and accelerated lymph flow acts to normalise
the volume of tissue exposed to oedema to lymph physiology and improve symptoms.38,39
approximately 200 mL. With these adjustments The understanding of the importance of this
made the effect achieved by venoactive drugs mechanism has increased over the past 10 years
in fact represents a reduction in volume of as the weight of evidence now suggests that ≥90%
approximately 25%. of the fluid contributing to oedema is reabsorbed
by the lymph system.40-42
Another controversy relates to the place of
venoactive drugs in therapy and whether they can Clinical Effects of Calcium Dobesilate
replace compression therapy, surgery, or both.
Clinical data indicate calcium dobesilate is
The majority of venoactive drugs require a
efficacious in reducing the symptoms and signs
3−4-week run-in phase before achieving oedema-
of CVI. A 2001 meta-analysis by Espinosa and
reducing efficacy, making them unsuitable to
Giannone43 synthesised the results of four
replace compression therapy in many situations
randomised, double-blind, placebo-controlled
where an immediate reduction in oedema is
clinical studies where patients received 1.5 g of
required. Similarly, unlike surgical interventions,
calcium dobesilate per day or placebo for at least
venoactive drugs cannot restore varicose veins
4 weeks (N=324). Calcium dobesilate achieved
or resolve obstruction. In fact, pharmacological
significant improvements in the most frequent
interventions represent an excellent synergistic
subjective symptoms compared with placebo.
therapy alongside both compression therapy
and surgical interventions, rather than a A 2004 randomised, double-blind, placebo-
potential replacement. controlled trial of calcium dobesilate (1.5 g/day
for 4 weeks) in outpatients (N=253) with CVI
CALCIUM DOBESILATE: CLINICAL (CEAP: C3−4) investigated effects on oedema
EFFICACY IN THE TREATMENT and leg volume. Despite the need for a 3−4-week
OF SYMPTOMATIC CHRONIC run-in period to begin reducing oedema, there
VENOUS DISEASE was a significant (p=0.0109) 48% decrease in leg
volume in moderate CVI after 4 weeks of calcium
Calcium dobesilate affects a number of dobesilate treatment (Figure 1a). Following
pathophysiological mechanisms to improve the withdrawal of treatment the reduction in oedema
symptoms of CVI. These mechanisms can be partially reversed, although subsequent trials
broadly categorised as capillary and vein-wall suggest a long-term effect can be achieved with
effects, blood-component effects, and lymphatic- calcium dobesilate. In patients with more severe
circulation effects.28,29 CVI (patients with previous treatment, CEAP

DERMATOLOGY SUPPLEMENT • February 2017 EMJ EUROPEAN MEDICAL JOURNAL 7


Stage C4, or CVI duration >12 years) a 77% displacement volumetry. The volume of the lower
reduction was achieved (Figure 1b).44 A more calf diminished in the calcium dobesilate group
recent meta-analysis by Ciapponi et al.45 on three at the end of the active treatment period by
calcium dobesilate trials (N=608) found similar 64.7 mL compared with 0.8 mL in the placebo
results including a greater improvement in pain, group (p=0.0002), independent of compression-
heaviness, and ankle swelling in patients with stocking use. Pain was reduced in both groups but
severe stages of the disease compared with those the reduction was significantly more pronounced
with mild CVI. in the calcium dobesilate group compared with
placebo (p=0.0071).46
In order to conform with updated guidelines, the
effect of calcium dobesilate on calf volume and Due to the preference of some regulatory
pain was investigated over 8 weeks in a double- authorities for data from water displacement
blind, placebo-controlled multicentre trial (N=256). volumetry, a similar study was carried out using
Patients had symptomatic CVI and pitting oedema this outcome measure to assess oedema. This
(C3–C5) and at least one symptom such as randomised, double-blind, placebo-controlled study
discomfort or pain. Calf volume was measured assessed calcium dobesilate at 1.5 g/day over 12
with the circumference method, rather than water weeks in patients with CVI at Stage C3–C4 (N=351).

Calcium
A 5 dobesilate
Placebo
0

-5
Leg Volume Change

-10
(mL/L)

Significant
decreases in
-15 leg volume (by
a further -48%)
-20 with calcium
dobesilate
-25 treatment after
p=0.0109
only 4 weeks
-30
-2 0 2 4 6
Time (weeks)
B 5 Calcium
dobesilate
0 Placebo

-5
Leg volume change

-10 Significant
(mL/L)

decrease in
leg volume with
-15
calcium dobesilate
starting from
-20 the second week
of treatment
and reaching
-25
-77% by Week 4
p=0.0359 p=0.0038
-30
-1 0 2 4 6
Time (weeks)

Figure 1: Changes in the leg volume during therapy with calcium dobesilate or placebo in patients with
A) moderate or B) more severe chronic venous insufficiency.44
Copyright © 2016 by European Medical Journal. Reprinted by Permission of SAGE Publications, Ltd.

8 DERMATOLOGY SUPPLEMENT • February 2017 EMJ EUROPEAN MEDICAL JOURNAL


The primary endpoint of relative volume change calcium dobesilate with both drugs having the
in the most pathological leg from baseline same level of clinical evidence (B).49 In a more
to Week 12 was not achieved in this study (-0.6% technical evaluation of the data from the 2014
versus -0.3%; p=0.09), likely due to a number of Austrian Health Technology Assessment report,
protocol violations related to inadequacies in the only calcium dobesilate had a moderate level of
accuracy of water displacement volumetry out evidence from placebo-controlled trials with the
with the laboratory setting. However, at a 24-week remaining therapies having only a low strength
follow-up, patients previously treated with calcium of evidence.
dobesilate showed a significant change in both
relative (-1.01% versus -0.08%; p=0.002) and The most rigorous and up-to-date evidence
absolute volume (-25.7 mL versus -1.1 mL; p=0.002) currently available for venoactive drugs comes
versus placebo. These data suggest a putative from the 2016 Cochrane review on phlebotonics
long-term effect of calcium dobesilate which for CVI. Sixty-six randomised controlled trials
warrants further investigation and may affect were assessed, and 53 trials (N=6,013) provided
future guidelines regarding the optimal time course quantifiable data. The majority of trials were on
of calcium dobesilate therapy.47 rutosides (28), followed by hidrosmine and diosmine
(10), and calcium dobesilate (9). Most studies were
The importance of QoL data in CVI has been flawed with only four presenting a low risk of bias.
previously highlighted. In the above study, the Of these high-quality studies, three assessed
CIVIQ QoL subscore assessing pain or discomfort calcium dobesilate and one assessed coumarin/
in ankles or legs during the past 4 weeks was troxerutin dual therapy. The authors concluded
significantly improved by Week 12 in the calcium that moderate-quality evidence showed that
dobesilate group (p=0.03) compared with phlebotonics have beneficial effects on oedema
baseline, though this difference was not significant and on some signs and symptoms related to
compared with placebo.47 Long-term QoL data, CVI when compared with placebo. There was an
from a 2008 study by Martínez-Zapata et al.,48 increased risk of gastrointestinal adverse events
showed a significant difference in favour of calcium compared with placebo. The meta-analysis found
dobesilate compared with placebo at 12 months no difference in terms of ulcer healing, though
(p=0.02). In this study, as in the 2016 study by very few studies looked into this. Concluding,
Rabe et al.,47 QoL improved in both the calcium the authors also emphasised the need for further
dobesilate and placebo group up to Month 3. high-quality randomised controlled trials to
However, over the longer-term QoL continued to improve the evidence base for phlebotonics in CVI.50
improve in the calcium dobesilate group, while in
the placebo group it deteriorated to a point below IMPACT OF CHRONIC VENOUS
baseline values.48
DISEASE ON DIABETIC LIMB SALVAGE
Consensus and Guideline Documents
Leg ulcers can be grouped with those of a mainly
The Siena Consensus document represents one venous origin (Group I: 75%), those of a mixed
of the earliest guidelines for CVI treatment. venous and arterial origin (Group II: 14%), and
Recommendations in this document were based on those contributed to by both CVI and diabetes
data pertaining to symptom improvement rather (Group III: 9%), which more often affect the
than clinical signs such as oedema.25 The Siena foot. Group II ulcers are often misdiagnosed
document graded the use of venoactive drugs for resulting in incomplete or erroneous therapeutic
CVI with evidence level A, and this was confirmed strategies. Those ulcers of a mixed diabetic and
in the International Guideline On Management venous origin (Group III) represent a significant
of CVD, published in 2008, which recommended treatment challenge, often failing to heal, leading
calcium dobesilate specifically with an evidence to limb amputation.
level of A based on two trials/meta-analyses
(Table 1).25,26 In terms of other venoactive drugs, Forty percent of diabetic foot lesions are
micronised purified flavonoid fraction (MPFF) associated with CVI. The combined features
also had a Grade A recommendation while the of diabetes and CVI create treatment-resistant
remaining pharmacological therapies were graded ulcers which increase the risk of limb loss. When
C or B, and were not recommended as first-line encountering a patient with a diabetic ulcer and
treatments.26 The 2014 update of this guideline CVI, general examination followed by regional and
recommended MPFF at Grade 1B versus 2B for finally local examination should be carried out.

DERMATOLOGY SUPPLEMENT • February 2017 EMJ EUROPEAN MEDICAL JOURNAL 9


600

500 17%

Number of patients 85
400
19%
300
59
35% 16%
200 34 401
52% 72
251
100 69 173
35%
131
21 63
AFLS 38
0
Tissue loss Previous Bone Associated Blood Blood
Major local foot lesions diseases quantity quality
amputation surgery

Figure 2: Major amputation and amputation-free limb salvage following aetiological key-based
treatment in diabetic ulcer patients referred for major amputation.
The authors’ recommendation was to apply the diabetic foot protocol to identify, detect, and correct all
aetiological features as part of a strategic management plan. Use of a colour-coded key displaying the six
aetiological factors as the cover sheet of the patient’s file was also recommended. Finally, categorisation
of the patient by respective physician speciality was strongly discouraged because of the effects on
downstream discovery of aetiological features.
ALFS: amputation free limb salvage.

Underlying general aetiological features which of such teams is vanishingly small, even in highly
may be contributing to ulcer formation, such developed healthcare systems such as that of
as rheumatoid arthritis, systemic lupus, and the USA.
uncontrolled diabetes, must be taken into account.
A recently published paper aimed to develop a
Next, regional aetiological features such as
strategy to overcome these issues using data from
ischaemia and CVI which may retard the healing
an internal hospital-based analysis carried out in
process should be noted. Finally, local disease
Cairo University’s Hospitals. The analysis identified
features including arterial ischaemia, venous
six modifiable aetiological factors in patients with
hypertension, and lymph oedema should be
diabetic foot lesions, who were referred for major
accounted for.
amputation. The impact of targeted treatment
Experience from large centres which receive high aimed at these modifiable factors (blood quality
numbers of referrals for limb amputation due [haemoglobin <9 g/dL and/or serum albumin
to diabetic foot lesions suggests that a lack of <3 g/dL], blood quantity, bone lesions, associated
dedicated foot-care teams combined with narrow diseases, tissue loss, and previous local foot
speciality-focussed, rather than pathology-focussed surgery) was then analysed prospectively over
treatment strategies contributes to limb loss in 5 years in a population of 4,102 patients.51
diabetic patients. For example, a vascular surgeon
In this study, one of the six identified aetiological
may, upon finding no pulse in a foot affected
factors was present in all the referred cases,
by diabetic lesions, label this a vascular case.
and in the majority of cases there were two or
Investigation and correction of the source of this
more factors present (78%). The most common
issue, such as a superficial femoral occlusion, may
aetiological factor was blood quality (66%) while
not lead to healing of the diabetic lesion as issues
the least common was tissue loss (8%). The
such as poor blood quality have been missed in the
presence of associated disease, which included
narrow specialist-driven focus on vascular disease.
CVI, was a factor in 28% of cases.51
These problems could be overcome through
oversight by a multidisciplinary team; however, in Use of an aetiologically-driven treatment paradigm
the real-world clinical environment the availability resulted in limb salvage in the majority of

10 DERMATOLOGY SUPPLEMENT • February 2017 EMJ EUROPEAN MEDICAL JOURNAL


patients referred for amputation. Cases involving and the patient was allowed to recover for 2 days
associated diseases, such as CVI, were the most under observation which resulted in resolution of
successfully treated with only 16% proceeding to the issue with no recurrence for >17 years.
major amputation, while those associated with
tissue loss and previous foot surgery were the
Case Study 3
least successful with 35% and 52%, respectively, A 65-year-old man with no history of diabetes or
necessitating amputation (Figure 2). Cases with hypertension presented with a swollen left leg,
previous foot surgery were thought to be the which had been present for the past 10 months,
most problematic due to a history of progressive and a small swelling in his left groin. DUS revealed
local tissue loss caused by localised interventions an acute thrombosis in the femoral popliteal vein,
undertaken without adequate attempts to address a floating non-adherent common femoral vein
the underlying aetiological cause.51 thrombus, and a compressed narrowed left iliac
vein caused by a soft tissue mass. Magnetic
SUMMARY OF CASE STUDIES resonance imaging (MRI) showed an amalgamated
group of left external iliac lymph nodes cuffing
Case Study 1 the external and internal iliac vessels. The arteries
A 79-year-old female patient presented with a were enhancing while the veins were obliterated,
venous leg ulcer. The patient had a small the left external iliac vein by the mass of a
saphenous varicose vein on her right leg and lymphadenopathy and the left external iliac vein
complained of feelings of heaviness, pain, and by the amalgamated group of left external iliac
swelling. Ulcer healing was achieved following lymph nodes.
endovenous laser therapy and compression. Biopsy revealed non-Hodgkin lymphoma;
However, moderate pain, feelings of heaviness, the lymphoma was follicular in nature and
and slight oedema remained. Following 6 weeks characterised by macroscopic follicularly observed
of 1.5 g/day calcium dobesilate, pain, feelings of in cross sections of the lymph node. Treatment
heaviness, and oedema had all resolved. of this tumour type with rituximab is known to
Case Study 2 produce a high response rate with an extremely
favourable toxicity profile. Reductions in tumour
A 49-year-old male of average weight and height size of 90% can be expected in 5–9 months with
presented due to a history of recurrent left calf a remission-rate ranging from 75–90%.52
popliteal deep vein thrombosis (DVT), consisting
of 3 attacks over the previous 4 years. Route lab The attending physician was faced with three
results were normal, and the patient was negative possible management plans for the initiation
for protein C and S, and Factor V Leidin mutation. of treatment, address: the tumour, the floating
The patient was using routine oral anticoagulant thrombus, or the ilio-femoral DVT. Due to the
and had an international normalised ratio of possibility of rapid tumour shrinkage with
2.2–3.0. The patient’s acute presentation was a rituximab which could result in freeing of the
rapid progressive left-limb oedema and foot thrombus and a subsequent risk of pulmonary
cyanosis, without groin or scrotal oedema. The embolism, the physician inserted a retrievable
clinical presentation was that of phlegmasia dolens inferior vena cava filter to deliver iliofemoral
and DUS showed a left iliofemoral DVT. catheter directed thrombolytic therapy. Therapy
with rituximab was started following catheter
Thrombolytic therapy was indicated due to the placement and calcium dobesilate therapy
phlegmasia dolens and foot cyanosis. An inferior initiated to deal with the potential for venous
vena cava filter was inserted through the right hypertension. After 2 weeks, the groin swelling and
femoral vein. Then a perfusion catheter was inserted oedema was resolved.
by the popliteal route, ascending through the
popliteal vein to the left iliofemoral vein, allowing SUMMARY
tissue plasminogen activator therapy for 24 hours
which resulted in rapid resolution of the oedema. CVD creates a significant burden on healthcare
However, following treatment, venography revealed provision and wider society. CVD pathophysiology
the underlying aetiology to be left common iliac is driven by increased venous pressure, reflux, and/
vein compression syndrome by the right common or obstruction, resulting in venous hypertension
iliac artery. Following dilation, a stent was inserted and reduced blood flow. These factors induce

DERMATOLOGY SUPPLEMENT • February 2017 EMJ EUROPEAN MEDICAL JOURNAL 11


inflammation in the microcirculature and Calcium dobesilate has a unique multi-target mode
subsequent oedema. The primary common goal of action which both preserves microvascular
of all treatment methods is the improvement integrity and improves microvascular circulation.
of clinical signs, symptoms, and patient QoL. Calcium dobesilate has specific effects on capillary
Technical common goals, including ablation of permeability and oedema reduction; however, its
reflux and improvement of venous function, are effects are broader and include anti-inflammatory
secondary to symptom relief in the eyes of both mechanisms of action. Calcium dobesilate
patients and modern clinicians. Both invasive effectively improves CVI symptoms and is well
techniques and compression act to achieve tolerated with a low incidence of minor reversible
the combined goals of symptom reduction digestive disorders. Finally, and most importantly,
and resolution of pathological mechanisms. calcium dobesilate improves the QoL of patients.
Pharmacological interventions represent a
complimentary therapeutic option acting on both
symptoms and mechanisms.

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