Hrev_master Veins and Lymphatics 2014; volume 3:2268 [Veins and Lymphatics 2014; 3:2268] [page 5] Phlebology in 21st century Stefano Ricci, Editor-in-Chief Nowadays, it is difficult to have a clear idea of which evolution in our field – Phlebology – will be considered as a true advancement or will be disregarded by the selection of experi- ence. However that may be, we have the feel- ing that a sudden rush of ideas and methods is going on at the beginning of this century. Phlebology is an old branch of Medicine; its roots are in common with the origin of circula- tory physiology, where the venous function represented a mysterious subject solved by Harvey’s demonstration (Figure 1).1 The diffu- sion of veins pathology is witnessed by the description of ulcer treatment in the ancient Egyptian Ebers papyrus.2 Although many (and substantial) contributions during the cen- turies may be recalled, modern phlebology started at the beginning of 20th century by the introduction of an efficient surgical method of eliminating the incompetent great saphenous vein (GSV)3 after the suggestion of Trendelemburgh,4 derived by Rima hypothesis5 of GSV high interruption when involved in varices. In these same years, Keller3 and Mayo3 published two alternatives methods of GSV avulsion that resulted less successful in the following years but still demonstrated the par- ticular interest on the subject at that time.3 Babcock’s method (stripping of the GSV stem), made popular worldwide by T. Myers of the Mayo Clinic,3 dominated the century and till now it is probably the most employed method around the world. Throughout these nearly 100 years, GSV ablation remained near- ly unchanged, with few variations for less aggressive purposes: short stripping,6 vein invagination,7 isolated junction high ligation.8 Sclerotherapy proceeded simultaneously/ alternatively, most of the active solutions being suggested in the first fifty years of the 20th cen- tury.9 Five milestones occurring in the second half of the century, which will have a great influ- ence in the future, have to be underlined: i) the Muller’s ambulatory phlebectomy10 (with con- sequent shifting of surgery toward office set- ting), ii) the diffusion of ultrasound facilities11 (finally starting to understand what happens to veins circulation), iii) the Franceschi’s Conservator ambulatory conservative hemody- namic management of varicose veins (CHIVA) theory12 (consequence of the former, the begin- ning of conservative treatments), iv) the inven- tion of foam,13 especially when a simple method of production has been found,14 v) the endovas- cular GSV treatments by radio frequency15 and laser16 as an alternative to surgery. These advancements have been the basis of the new century phlebology evolution, but the true nature of change, as it probably happens in all history changes, has been the challeng- ing of the (phlebological) leading dogma:17 all treatments must go through the radical inter- ruption of the saphenofemoral junction (SFJ) and its tributaries. Several factors concurred and are presented below. First, outcome studies by ultrasound: a con- sensus document by Perrin and colleagues18 and a paper by Fischer and colleagues19 in 2001 showed a very high recurrence rate of groin dissection and high ligation in the mid (long) term. Second, the vein ablation by radio frequency and laser that have been spread worldwide in the last 10 years to become the preferred alter- native to surgery for many operators. These treatments achieve the closure of the GSV stem, leaving the terminal part of the SFJ open, allowing the drainage of one or more tributaries (epigastric, pudendal), with good results in the midterm.20 Third, the diffusion of foam sclerotherapy, achieving similar (although less favorable) results as radiofrequency (RF) and laser with lower costs and simpler settings.21 Here, the ter- minal part of the SFJ usually remains open as well, being washed out by junction tributaries. Fourth, some Authors reported good out- comes of saphenectomy without junction dis- connection.22,23 Fifth, an ultrasound (US) study of the SFJ showed that not all the terminal valves are incompetent in the presence of a GSV reflux.24,25 More refined preoperatory US inves- tigation of the junction is mandatory for evalu- ation of whatever surgical techniques. Currently, no study reports preoperative data on the terminal valve, making the interpreta- tion of surgical results doubtful. Sixth, CHIVA operators achieved stable results by high ligation of the junction, pre- serving the junction tributaries and the GSV stem, the blood being redirected through GSV perforators.26 Seventh, isolated phlebectomy of varicosi- ties may reduce the GSV caliber and eliminate reflux.27-29 As a consequence, although insufficient groin dissection due to poor surgical skill was considered as the cause of groin (and limb) recurrence for many years and in a plethora of papers, at present time exactly the opposite seems to be true: an excessive dissection may favor neo vascularisation of the groin area. Challenging the dogmas stimulated new ideas: GSV occlusion by steam as heating mechanism;30 vein endothelial damage by a rotating device before sclero-injection;31 GSV occlusion by special glue.32 Furthermore, vari- cose disease was submitted to outstanding changes. Limbs venous disease stimulated the research of cerebral venous flow as a cause of neurological diseases opening a never ending debate.33 Moreover, new oral anticoagulation agents are promising a better quality of life to thrombotic patients.34 Radiologists became able to produce three dimensional images35 and venous stenting began to be more dif- fused.36 We, as the Veins and Lymphatics journal’s group, are willing to spread these novelties together with all the other scientific media involved. We are minor and back in the list of phlebology issues, but we have the feeling of being in the right place at the right moment, using the best diffusion tool, freely accessible by those who have something to say and those who want something to learn. For the future we expect the following: a varicose veins cause explanation; an evolution of GSV incompetence treatment patient-orient- ed and effective from a phamaco-economic point of view, possibly simple and office-based; compression devices that patients are happy to put on; new treatments of lymphatic disorders; an open mentality avoiding dogmas; new tech- nologies possibly less expensive than those going to be replaced. As always, time and evidence will decide what will be a cornerstone in our practice, what will be forgotten (and probably reinvent- ed at other times), what will be juts helpful somehow. Anyway, what is sure is that Veins Correspondence: Stefano Ricci, E-mail: editor-in-chief@veinsandlymphatics.org Received for publication: 15 January 2014. Accepted for publication: 15 January 2014. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright S. Ricci, 2014 Licensee PAGEPress, Italy Veins and Lymphatics 2014; 3:2268 doi:10.4081/vl.2014.2268 Figure 1. Harvey’s demonstration of venous valves. No n- co mm er cia l u se on ly Editorial [page 6] [Veins and Lymphatics 2014; 3:2268] and Lymphatics will keep open its eyes to wit- ness these events. References 1. Harvey W. Exercitatio anatomica de motu cordis et sanguini in animai bus. Frankfurt: The Warnock Library; 1628. Available from: http://www. rarebookro- om.org/Control/hvyexc/index.html 2. Bryan PW. The Papyrus Ebers. London: Geoffrey Bles; 1930. 3. Rose SS. Historical development of varico- se veins surgery. In: Bergan JJ, Goldman MP, eds. Varicose veins and telangectasias. Diagnosis and treatment. St. Louis, MO: Quality Medical Publ.; 1993. 4. Trendelenburg F. Uber die Unterbindung der Vena saphena magna bei Unterschenkelvarizen. Beitr Klin Chir 1890;7:195. 5. Ricci S. Who discovered saphenous vein incontinence. In: Ricci S, Georgiev M, Goldman MP, eds. 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