Global guidelines trends and controversies in lower limb venous and lymphatic disease

Abstract

Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.

Medicine and Phlebolymphology: Time to Change?

“…This well-referenced study significantly contributed to downgrade the evidence for compression stockings in PTS prevention, after an acute DVT episode. In agreement with several authors' reflection [44,100], we speculate here that the following biases may have influenced the final results of the SOX trial: (a) the non-immediate, but delayed (within 14 days) adoption of the compression stocking in the treatment arm, (b) the misleading use of a placebo stocking, which anyway has a proven psycho-physical effect on the limb, (c) the suboptimal assessment of the patient's compliance to the routine use of the stocking, which was delivered by mail, without any direct counselling from the caregivers, (d) the different anticoagulants used throughout the two groups, and (e) the required minimal duration of compression regime (3 days a week), which is not coherent with all the pertinent literature.…”

“…Experts have acknowledged that guidelines and recommendations in phlebology and lymphology may need frequent actualizations [44] as per the need to review past ascertained consensus statements and to introduce new potentially influencing evidences from the succeeding trials.…”

“…In fact, when assessing the level of evidence in the published guidelines for each of the varicose vein treatments, a significant difference emerges as to their indications and contraindications, or in peculiar situations such as small saphenous vein therapy [44].…”

“…Endovascular/open surgery interventions in deep vein diseases (DVT, PTS) still lack long-term validation studies, as multiple factors (leg/diaphragmatic pump dysfunction and obesity primarily) seem to interfere with the objective durable benefits. Similarly, the lack of a common validated hemodynamic criterion to assess iliac vein obstruction, together with the suboptimal imaging of the morphologic changes in abdomino-pelvic veins, represent further limitations prior to any decisional process in these patients [44]. Scientific data show that primary obstructive syndromes based on compression (e.g., May-Thurner) may suffer from an over-diagnosis and over-treatment issue.…”

Some features of compression therapy for early forms of chronic venous diseases of the lower limbs

“…большая доказательная база свидетельствует, что компрессионная терапия с использованием современного градуированного трикотажа служит эффективным методом улучшения венозного оттока из нижних конечностей у пациентов с различными формами и стадиями хронических заболеваний вен [10]. Вместе с тем четкие и объективные критерии, позволяющие сделать оптимальный выбор типа и класса компрессионного трикотажа, отсутствуют [11][12][13]. более того, эффективность компрессионной терапии начальных форм хронических заболеваний вен обычно оценивают лишь на основании субъективных ощущений пациента, которые могут быть ошибочны.…”