Roger Greenhalgh (top left), Stephen Black (top right), Armando Mansilha (bottom left), Manj Gohel (bottom middle) and Lowell Kabnick (bottom right)

In a boost for vascular education, the CX 2020 LIVE sessions have been granted European Union (EU) and US reciprocal Continuing Medical Education (CME) points in recognition of its highly interactive nature. In awarding this, the European Accreditation Council on CME (EACCME) is taking into account that this is a livestream with speakers performing from a panel and receiving questions from a global audience. On Tuesday, 759 attendees from 79 different countries tuned in. Each audience member could submit their name, country, and a question or point to the speaker in real-time, enabling interaction, discussion, and polling. Roger Greenhalgh (London, UK) chaired the most recent session, with Stephen Black (London, UK) moderating, as participants from five continents learnt about the latest development in superficial venous disease. Panellists fielded questions from 29 different countries, including the USA, Brazil, Ukraine, Kenya, Mexico, Spain, Saudi Arabia, Egypt, Argentina, Moldova, and the Russian Federation. 

The first three talks of the session teased forthcoming, as-yet-unpublished guidelines from the European Venous Forum (EVF), the European Society for Vascular Surgery (ESVS), and the American Venous Forum (AVF)/Society for Vascular Surgery (SVS). These presentations were given by Armando Mansilha (Porto, Portugal), Manj Gohel (Cambridge, UK), and Lowell Kabnick (New York, USA), respectively. Additionally, a clinical assessment and work-up of patients with possible pelvic vein incompetence was presented by Aleksandra Jaworucka-Kaczorowska (Gorzów Wielkopolski, Poland), followed by a network meta-analysis on the use of cyanoacrylate glue, from Raghu Kolluri (Columbus, USA), audience polling, and, finally, an edited case from Kathleen Gibson (Bellevue, USA). 

Spontaneous superficial vein thrombosis “far from a benign pathology” 

Traditionally, superficial vein thrombosis (SVT) was treated with surgical management due to the perceived increased risk of deep vein thrombosis (DVT), which in turn could cause pulmonary embolism (PE), associated with a higher risk of death. Interestingly, it emerged in the CX 2020 LIVE discussion that surgical intervention is no longer mandatory. Instead, venous experts are searching for factors that explain a possible underlying hypercoagulable state that can lead to spontaneous thrombosis. One possible therapeutic option that is emerging for the treatment of SVT is the administration of anticoagulants. SVT is therefore no longer seen as requiring emergency surgery, but is indicative of an underlying condition that can be treated medically. 

Manj Gohel (Cambridge, UK) told the CX 2020 LIVE audience that SVT is “far from a benign pathology”, discussing how the latest set of recommendations from the ESVS are set to pave the way for new approaches to treating this specific type of blood clot. 

Though acknowledging that venous thrombosis is an “enormously varied topic”, Gohel said the writing committee felt strongly that superficial vein thrombosis should be included in the new guidelines, as it is “largely neglected” in other recommendations worldwide. “It is important to realise,” he added, “that it is significantly more common than deep vein thrombosis [DVT]; at least five times more common [as suggested] in most studies.”  

Gohel said: “Anticoagulation, rather than antibiotics, is going to be the mainstay of treatment for most patients”. While he stated that “there will be a role for ablation of superficial venous reflux”, he clarified that he thought that this will probably not play a part in the treatment of sudden spontaneous thrombosis in the superficial vein.  

A question posed to Gohel from a CX audience member from Iraq asked: “After treating superficial vein thrombosis, how long do you suggest waiting before treating the varicose vein in absence of any other contraindications?”  

In his reply, Gohel highlighted the importance of treating the underlying superficial reflux. “All too often these patients have been treated and seen in thrombosis clinics, they have been told there is no DVT, and almost forgotten about”.  

Multidisciplinary team important for managing pelvic vein incompetence 

Roger Greenhalgh (top left), Stephen Black (top right), Aleksandra Jaworucka-Kaczorowska (bottom left), Raghu Kolluri (bottom middle), Kathleen Gibson (bottom right)

In her talk, Jaworucka-Kaczorowska looked at the clinical assessment and work-up of patients with possible pelvic vein incompetence. She showcased some extreme examples that she has encountered in her work as a gynaecologist, all the while emphasising the importance of drawing upon multiple skillsets in the treatment of these patients.  

In particular, Jaworucka-Kaczorowska—noting she was a gynaecological surgeon—stated that she referred patients to a relevant centre with the appropriate radiological experience if they required percutaneous embolisation. Responding to this, Greenhalgh observed: “I think we have learned that when a physician can see a problem, the answer is that it is a multidisciplinary team that they require.” 

Cyanoacrylate: A “good technique”, but “not a panacea” 

The discussion next turned to the use of cyanoacrylate glue. Delivering his Podium 1st presentation, Kolluri said the VenaSeal closure system (Medtronic), a type of cyanoacrylate glue, is “a promising therapeutic option” with high rates of anatomic success, improved pain scores, and a low occurrence of adverse events compared with alternative treatment modalities. He made this conclusion based on the six-month results of a network meta-analysis published in the May issue of the Journal of Vascular Surgery: Venous and Lymphatic Disorders, comparing different interventions for chronic venous insufficiency (CVI) management. Following his talk, Gibson provided a step-by-step guide to cyanoacrylate closure using VenaSeal.  

The discussion following the two cyanoacrylate-focused talks highlighted that this new technique may be particularly useful in carefully selected patients, but was not suitable for all veins. 

When asked: “Are you a fan of cyanoacrylate glue”, 61% of CX 2020 LIVE respondents answered “no”. 

Gibson summarised her take-home message: “It is not going to replace endothermal ablation. I think it is an advance; I think there are some situations where it is extremely good. For example, in the elderly population, where they have a very low incidence of hypersensitivity.”  

Kolluri concurred, stating that his patients, who benefit from the use of cyanoacrylate glue, have quite severe disease, with multiple comorbidities, and are at high risk of bleeding.  

Turning to the other panellists, Greenhalgh invited each to provide their take on the technique. Gohel: “It is not a panacea; it is not going to replace everything”; Kabnick: “Thermal is still the gold standard”; Mansilha: “One more good technique. The strategy is the point”.  

Moderator Black concluded the session: “I think like all new techniques, you learn the good and the bad, and this will find a good place in the long term”. 

CME accreditation 

The 10 livestreams that comprise CX 2020 LIVE are together worth 10 CME points, with one point awarded for each session. Participants can only claim CME points for the sessions that they have watched live.