Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins

Patient-reported outcomes 5–8 years after ultrasound-guided foam sclerotherapy for varicose veins

Background

The aim was to determine the long-term (5–8 years) outcomes of ultrasound-guided foam sclerotherapy (UGFS) for varicose veins using health-related quality of life (HRQL), patient-reported outcomes (PROMs), patient satisfaction and retreatment rates.

Methods

Consecutive patients undergoing UGFS between April 2004 and May 2007 were invited for review at least 5 years after treatment. Patients completed generic (Short Form 12) and disease-specific (Aberdeen Varicose Vein Symptom Severity Score, AVSS) HRQL instruments, and questionnaires enquiring about lower limb symptoms, lifestyle factors and satisfaction with treatment. Data on retreatments were recorded prospectively.

Results

A total of 391 limbs in 285 patients were included (81·2 per cent response rate) at a median of 71 (i.q.r. 67–78) months following first UGFS treatment. Originally 72·1 per cent had symptomatic, uncomplicated varicose veins, 21·9 per cent had undergone surgery previously, 87·2 per cent had treatment of great saphenous veins and 19·9 per cent treatment of short saphenous veins. Disease-specific HRQL scores improved significantly at long-term follow-up, with 88·5 per cent having an improved AVSS compared with baseline. Regarding lower limb symptoms and lifestyle improvement, 62·7–93·8 per cent of patients had their pretreatment expectations met or exceeded. Overall, 82·0 per cent were very satisfied with their treatment and only 3·3 per cent were dissatisfied; 91·0 per cent would recommend the treatment to others. Some 15·3 per cent of limbs required retreatment by 5 years (Kaplan–Meier analysis).

Conclusion

UGFS has durable results as reported by PROMs to at least 5 years. Only 15·3 per cent of limbs required retreatment for recurrence during follow-up.

Saphenous vein stripping surgical technique and frequency of saphenous nerve injury

Objectives

Saphenous nerve injury is the most common complication after surgical treatment of varicose veins. The aim of this study was to establish its frequency at great saphenous vein long stripping when four methods of surgery were applied.

Methods

Eighty patients were divided into four groups depending on different stripping methods. Sensory transmission in saphenous nerve and sensory perception of shank were examined before surgery and two weeks, three and six months afterwards with clinical neurophysiology methods.

Results

In 36% of patients, surgeries caused the injury of saphenous nerve mainly by proximal stripping without invagination (65%, group I). Transmission disturbances ceased completely after three months in patients undergoing distal stripping with invagination (group IV), while in group I they persisted for six months in 35%. Group IV patients were the least injured and group I the most.

Conclusion

Neurophysiological findings may suggest that distal stripping with vein invagination gives the best saphenous nerve sparing.

Compression therapy versus surgery in the treatment of patients with varicose veins: A RCT

OBJECTIVE

Superficial venous reflux and varicose veins are common. The aim of this randomized controlled trial was to assess effectiveness of compression therapy compared with surgery for superficial venous reflux.

METHODS

153 patients with CEAP class C2-C3 and superficial venous reflux were randomized to receive either conservative treatment (compression stockings) (n = 77) or surgery (n = 76). Clinical examination including duplex ultrasound (DUS) was performed at entry and 1 and 2 years after randomization (compression group) or surgery (surgery group). Venous Clinical Severity Score without compression stockings (VCSS-S), Venous Segmental Disease Score (VSDS), Venous Disability Score (VDS), and health-related quality of life (HRQoL) were assessed at entry and at the follow-ups. Data were analysed on an intention-to-treat basis and according to the actual treatment performed.

RESULTS

At 2 years, 70/76 patients in the surgery group and 11/77 patients in the compression group had been operated on. VCSS-S decreased from 4.6 to 3.5 in the compression group (p < .01) and from 4.8 to 0.6 in the surgery group (p < .001). VSDS decreased from 7.7 to 7.0 in the compression group and from 8.2 to 0.9 in the surgery group (p < .0001). HRQoL did not change in the compression group, but improved significantly in the surgery group.

CONCLUSION

The surgical elimination of non-complicated superficial venous reflux is an effective treatment when compared with providing compression stockings only.

Radiofrequency Ablation as First-line Treatment of Varicose Veins

Endovascular radiofrequency ablation is a minimally invasive method to safely treat symptomatic refluxing varicose veins. A retrospective chart review was used to determine patient demographics, disease severity, treatment algorithm, and outcome in patients who underwent radiofrequency ablation of symptomatic refluxing veins that had failed conservative management. Statistical analysis was done using GraphPad Demo Version (San Diego, CA). Two hundred forty-one limbs in 179 patients (average age, 53 years; 73% females, 27% males) were treated. Preprocedure Clinical Etiological Anatomic and Pathologic (CEAP) scores were C2s: 236, C3s: 4, and C5s:1. Procedures were performed in the office using tumescent anesthetic; all patients could ambulate immediately after the procedure. Postprocedure total occlusion (TO) rate was seen in 93 per cent of limbs (223 limbs) at 3 months and 91 per cent of limbs (220 limbs) at 12 months posttreatment. No relationship was found between patients who did not have total occlusion and age, sex, diameter of veins, CEAP scores, preoperative reflux time, and volume of tumescent anesthetic ( P > 0.05). The VNUS procedure is an in-office, minimally invasive procedure with a low complication rate and quick recovery. Total occlusion rates are high and there is improvement in disease severity after treatment.

A rare case of acute compartment syndrome after saphenectomy

Saphenectomy is one of the most validated criteria to treat varicose veins of the lower legs. Although many complications were well described, little is known about compartment syndrome due to muscle ischemia caused by constrictive bandages applied after stripping of varicose veins. We presented a case of successful conservative treatment of compartment syndrome after saphenectomy. Rehabilitation was found effective in improving fatigue, stiffness and tenderness showing the effectiveness of the combined conservative-rehabilitative treatment. However conservative treatment could not be considered the treatment of choice in daily practice. A severity score assessment of compartment syndrome should be useful to assess to which patients is allowed to not perform fasciotomy.

Valuing benefits to inform a clinical trial in pharmacy : do differences in utility measures at baseline affect the effectiveness of the intervention?

BACKGROUND

The generic health-related quality-of-life (HR-QOL) utility measures the EQ-5D and SF-6D are both commonly used to inform healthcare policy developments. However, their application to pharmacy practice is limited and the optimal method to inform policy developments is unknown.

OBJECTIVES

Our objective was to test the sensitivity of the EQ-5D and SF-6D within pharmacy when measuring whether changes in health status or other co-variates at baseline affect the effectiveness of the intervention at follow-up. A further objective was to consider the implications of the findings for pharmacy research and policy.

METHODS

The EQ-5D and SF-6D utility measures were employed within a randomized controlled trial (RCT) of community pharmacy-led medicines management for patients with coronary heart disease. The intervention covered a baseline visit with the potential for follow-up. Simultaneous quantile regression assessed the impact of the intervention on both EQ-5D and SF-6D measures at follow-up, controlling for baseline health, appropriateness of treatment, personal characteristics and self-reported satisfaction.

RESULTS

No statistically significant difference in HR-QOL across the intervention and control groups at follow-up was reported for either measure. Increased health gain was however associated with the baseline utility score (with the EQ-5D more sensitive for those in worse health) and the appropriateness of treatment, but not patient characteristics or self-reported satisfaction.

CONCLUSION

Neither generic measure detected a gain in HR-QOL as a result of the introduction of an innovative pharmacy-based service. This finding supports other work in the area of pharmacy, where health gains have not changed following interventions. Disease-specific utility measures should be investigated as an alternative to generic approaches such as the EQ-5D and SF-6D. Given that the RCT found an increase in self-reported satisfaction, broader measures of benefit that value patient experiences, such as contingent valuation and discrete-choice experiments, should also be considered in pharmacy.

The evaluation of a novel technique to treat saphenous vein incompetence: preclinical animal study to examine safety and efficacy of a new vein occlusion device

Objectives

We tested a novel technique to treat great saphenous vein (GSV) incompetence in an animal model.

Methods

V-block (VVT Medical Ltd, Kfar Saba, Israel), an occlusion device composed of a nitinol frame and anchoring hooks, was percutaneously deployed at the saphenofemoral junction in 12 sheep. Four of the 12 sheep were treated with adjunctive liquid sclerotherapy. Animals underwent duplex ultrasound, venography and histopathological evaluation immediately postimplantation at 30, 60 and 90 days.

Results

V-block was successfully deployed in all animals without adverse events. There was no device migration at follow-up. Histopathological analysis demonstrated V-block to be lodged within the GSV and surrounded by fibrous tissue in all samples. Obliteration of the GSV lumen, widespread intimal loss and multifocal medial smooth muscle loss was noted.

Conclusions

In this animal study V-block was deployed without complications, remained in stable position and led to GSV occlusion. This device has promise for future use in humans.

Generic health-related quality of life is significantly worse in varicose vein patients with lower limb symptoms independent of CEAP clinical grade

OBJECTIVES

To determine the relationship between lower limb symptoms and generic health-related quality of life (HRQL) in patients with varicose veins (VV).

METHODS

284 patients on the waiting list for VV treatment completed the Short Form-12 (SF12) and a questionnaire asking about the presence of lower limb symptoms commonly attributed to venous disease (pain or ache, itching, tingling, cramp, restless legs, a feeling of swelling, and heaviness).

RESULTS

Median age was 57 years (interquartile range 45-67); 100 (35%) were male, and 182 (64%) had CEAP clinical grade 2 or 3 disease. Jonckheere-Terpstra test for trend revealed that both physical (P < .0005) and mental (P = .001) HRQL worsened as the reported number of symptoms increased. Patients reporting tingling (P = .016, Mann-Whitney U test), cramp (P = .001), restless legs (P < .0005), swelling (P < .0005), and heaviness (P < .0005) had a significantly worse physical HRQL than those who did not. Mental HRQL was also significantly worse in patients with tingling (P = .010), cramp (P = .008), restless legs (P = .040), swelling (P = .001), and heaviness (P = .035). These significant relationships remained, and pain was also correlated with worse physical HRQL (P = .011), when linear regression was performed to control for CEAP clinical grade, age and sex.

CONCLUSIONS

Physical and mental HRQL is significantly worse in VV patients with lower limb symptoms irrespective of the clinical stage of disease. This observation confirms that VV are not primarily a cosmetic problem and that NHS rationing of treatment to those with CEAP C4-6 disease excludes many patients who would benefit from intervention in terms of HRQL. Generic HRQL instruments also allow comparison with interventions for other chronic conditions.

Guidelines for the management of varicose veins

Recently published evidence-based guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) include recommendations for evaluation, classification, outcome assessment and therapy of patients with varicose veins and more advanced chronic venous insufficiency (CVI). The need for such guidelines has been evident since imaging techniques and minimally invasive technologies have progressed by leaps and bounds and radiofrequency ablation, laser and sclerotherapy have largely replaced classical open surgery of saphenous stripping. This report reviews the most important guidelines recommended by the SVS/AVF Venous Guideline Committee. It is obvious, however, that some of the technology that is recommended in North America is either not available or not affordable in some parts of the world for patients with varicose veins and CVI. The readers are urged therefore to also consult the guidelines of their national societies, recent publications of the National Institute for Clinical Excellence and the Venous Forum of the Royal Society of Medicine. Venous specialists should also keep in mind that scientific evidence should always be combined with the physician's clinical experience and the patient's preference when the best treatment is selected for an individual patient.

Retrospective comparison of clinical outcomes between endovenous laser and saphenous vein-sparing surgery for treatment of varicose veins

BACKGROUND

The purpose of the present study was to compare management of varicose veins by endovenous laser ablation (EVL) and a vein-sparing procedure (CHIVA: Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire) for management of varicose veins.

METHODS

Data from 82 consecutive patients with great saphenous vein (GSV) reflux and primary varicose veins presenting to the vascular clinic at the Far Eastern Memorial Hospital between June and December 2005 were reviewed. Of these, 74 who met the inclusion criteria were included in this study. CHIVA was performed by a double division of the refluxing saphenous vein (i.e., proximal and distal ligation), and EVL was performed using 10-14 W beginning approximately 4 cm below the saphenofemoral junction to the level of the knee. Phlebectomy for significant branch varicose veins on the leg was routinely performed in all patients. Outcome measures included postoperative thrombophlebitis, bruising, pain, assessment of ultrasonographic and clinical symptoms (measured by the Venous Clinical Severity Score [VCSS]) and comparison of quality of life survey scores obtained preoperatively and postoperatively (measured by the Aberdeen Varicose Veins Score [AVVQ] and RAND-36). Patients were examined one week post-procedurally and again at 1, 3, 6, and 12 months.

RESULTS

Endovenous laser ablation and CHIVA were performed on 54 and 20 patients, respectively. The EVL patients had significantly higher pain scores and bruising than the CHIVA group (p<0.001). The VCSS of varicose, edema, pigmentation, and inflammation were significantly reduced after both EVL and CHIVA; however, patients treated by EVL had significantly more pain postoperatively than those treated by CHIVA (p=0.003). Twenty-two of 54 (40.7%) and 3 of 17 (17.6%) patients in the EVL and CHIVA groups, respectively, required sclerotherapy for residual varicosities (p=0.026). Both groups benefited significantly from surgery in disease-specific perceptions.

CONCLUSIONS

The CHIVA patients had less pain postoperatively and a significantly higher sclerotherapy-free period compared to patients in the EVL group. Further follow-up studies to compare long-term results of various approaches to surgically managing varicose veins are needed.

[New advances in the treatment of varicose veins: endovenous radiofrequency VNUS Closure®]

Lower limb varicose veins are often secondary to greater saphenous vein (GSV) insufficiency. Technological development has led to the appearance of new minimally invasive treatments, such as endovenous radiofrequency ablation (ERFA). This almost completely eliminates the disadvantages associated with conventional surgery (haematomas, scars, inguinal neovascularisation, and a prolonged time off work). Furthermore, it gives a better quality of life, less pain and inflammation than the endolaser. We review ERFA and present our results as a pioneering group in Spain. Between January 2006 and 2011 we have treated 153 limbs with a mean GSV diameter of 6.8 mm (range 4.5-19). Tumescent anaesthesia was exclusively used in 71% of the procedures, and 98.5% without an inguinal surgical approach. Clinical and ultrasound follow-up with a prospective register was performed at 1 week, 3, 6, 12 months, and then annually.

RESULTS

The occlusion rate of the treated vein was 97%, and there was a reflux rate of 6.6%. Inguinal neovascularisation was present on 0.7%. There was no neuritis, skin burns or deep vein thrombosis.

Five-year results of a randomized clinical trial comparing endovenous laser ablation with cryostripping for great saphenous varicose veins

BACKGROUND

This was the long-term follow-up of a previously reported randomized clinical trial comparing endovenous laser ablation (EVLA) with cryostripping for great saphenous varicose veins.

METHODS

A total of 120 patients with great saphenous varicose veins were randomized 1:1 to EVLA or cryostripping. Principal outcome measures were freedom from incompetence or neovascularization on duplex imaging, and improvement in Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Severity Score (AVVSS) 5 years after treatment.

RESULTS

Life-table analysis showed freedom from duplex-derived incompetence and neovascularization at 5 years in 62 (95 per cent confidence interval 50 to 76) per cent after EVLA and in 51 (39 to 66) per cent after cryostripping (P = 0.246). Neovascularization was more common after cryostripping, but incompetent tributaries were more common after EVLA. VCSS and AVVSS values improved significantly after treatment in both groups, and were maintained for 5 years, but with no significant difference between the groups.

CONCLUSION

In this study, no significant difference was demonstrated in late outcome after EVLA or cryostripping in patients with great saphenous varicose veins.

Using the knee-specific Hughston Clinic Questionnaire, EQ-5D and SF-6D following arthroscopic partial meniscectomy surgery: a comparison of psychometric properties

PURPOSE

To compare the psychometric properties of the Hughston Clinic Questionnaire (HCQ), EQ-5D and SF-6D in patients following arthroscopic partial meniscectomy surgery.

METHODS

A total of 84 participants (86% men; mean age 40) were recruited. The questionnaires were completed on average 5 days, 6 weeks and 6 months after surgery and compared for internal consistency, convergent validity, sensitivity to change and floor and ceiling effects.

RESULTS

Internally, the HCQ was the most consistent instrument (α = 0.923) followed by the SF-6D and EQ-5D. The EQ-5D and SF-6D were moderately correlated with the HCQ (ρ = 0.499 and 0.394, respectively). Six weeks after surgery, the most sensitive measures were the HCQ and EQ-5D (effect size: 2.04 and 0.99, respectively), at 6 months, with a smaller cohort (n = 42), again it was the HCQ and EQ-5D (effect size: 2.03 and 1.04, respectively). The SF-6D demonstrated no ceiling or floor effect during the study; the HCQ demonstrated a ceiling affect for 5% of respondents at 6 months after surgery compared to 26% of respondents for the EQ-5D.

CONCLUSION

For this patient population, our findings indicated that the EQ-5D was more consistently responsive to change over time, as a utility index was better at distinguishing differences between groups and reflected the results of the joint-specific HCQ for knee recovery better than the SF-6D. It is therefore recommended that for similar populations, the EQ-5D is preferable to the SF-6D for utilisation alongside the HCQ.

Invagination stripping with ultrasound-guided perivenous tumescence: an original method of great saphenous vein stripping

BACKGROUND

Although minimally invasive treatment of the great saphenous vein (GSV) is now preferred over stripping, in some cases, stripping is still necessary. However, stripping, as an invasive method of treatment, promotes significant bleeding and trauma to the saphenous vein track.

OBJECTIVE

To describe an original method of GSV stripping, reducing bleeding during procedure.

METHODS AND MATERIALS

Seventeen patients underwent stripping of 29 GSVs using tumescent infusion in the saphenous compartment guided by ultrasound, similar to the tumescent anesthesia used in laser ablation during treatment of saphenous vein insufficiency.

RESULTS

Less bleeding and shorter recovery time was observed than in conventional GSV stripping.

CONCLUSION

GSV stripping using tumescent ultrasound-guided technique promotes less bleeding than conventional stripping and should be always performed when GSV stripping is considered. The authors have indicated no significant interest with commercial supporters.

Surgical management of varicose veins: meta-analysis

Open surgery remains the gold standard by which endovascular treatment of superficial chronic venous insufficiency is measured. This meta-analysis of randomized controlled trials reviews the current evidence base, comparing open and endovascular treatment of varicose veins. Systematic review of studies reporting duplex scan follow-up after open surgical, laser (endovenous laser therapy [EVLT]), or radiofrequency (VNUS Closure device, VNUS Medical Technologies, San Jose, CA) treatment of refluxing great saphenous veins was completed. Primary outcome measures were occlusion and complication rates and time taken to resume work. No significant difference in recurrence rates at 3 months between open surgery and EVLT (RR 2.19, 95% CI 0.99-4.85, p = .05) or VNUS device (RR 7.57; 95% CI 0.42-136.02) were found. Return to work is significantly faster following VNUS (by 8.24 days; 95% CI 10.50-5.97) or EVLT (by 5.02 days; 95% CI 6.52-3.52). Endovascular treatment of varicose veins is safe and effective and offers the significant advantage of rapid recovery.

Varicose vein surgery: stripping versus the CHIVA method: a randomized controlled trial

OBJECTIVE

The objective of this randomized study was to compare the efficacy of the CHIVA method for the treatment of varicose veins with respect to the standard treatment of stripping.

CONTEXT

Varicose veins are a sign of chronic venous disorder. For over a century, varicose veins have been treated with surgical ablative techniques, with stripping being the standard treatment. Currently, postsurgical varicose veins recurrence (20%-80%) is a common, complex, and costly problem. Ambulatory Conservative Hemodynamic Management of Varicose Veins (CHIVA) is a new option for treating chronic venous disorder.

METHODS

In this open-label, randomized controlled trial, 501 adult patients with primary varicose veins were treated in a single center. They were assigned to an experimental group, the CHIVA method (n = 167) and 2 control groups: stripping with clinic marking (n = 167) and stripping with duplex marking (n = 167). The outcome measure was clinical recurrence within 5 years, assessed clinically by previously trained independent observers. Duplex ultrasonography was also used to assess recurrences and causes.

RESULTS

In an intention-to-treat analysis, clinical outcomes in the CHIVA group were better (44.3% cure, 24.6% improvement, 31.1% failure) than in both the stripping with clinic marking (21.0% cure, 26.3% improvement, 52.7% failure) and stripping with duplex marking (29.3% cure, 22.8% improvement, 47.9% failure) groups. The ordinal odds ratio between the stripping with clinic marking and CHIVA groups, of recurrence at 5 years of follow-up, was 2.64, (95% confidence interval [CI]: 1.76-3.97, P < 0.001). The ordinal odds ratio of recurrence at 5-years of follow-up, between the stripping with duplex marking and CHIVA group, was 2.01 (95% CI: 1.34-3.00, P < 0.001). This trial is registered at ISRCTN and carries the following ID number: ISRCTN52861672, available at: http://isrctn.org.

CONCLUSIONS

The present results indicate that, thanks to specific venous hemodynamic evaluation, the CHIVA method is more effective than stripping with clinical marking or stripping with duplex marking to treat varicose veins. When carrying out a stripping intervention, Duplex marking does not improve the clinical results of this ablative technique.

Changes in health-related quality of life after ultrasound-guided foam sclerotherapy for great and small saphenous varicose veins

BACKGROUND

Health-related quality of life (HRQOL) improves after superficial venous surgery for varicose veins, but the effect of ultrasound-guided foam sclerotherapy on HRQOL is unknown. The aim of this study was to determine changes in HRQOL after ultrasound-guided foam sclerotherapy for varicose veins.

METHODS

Consecutive patients undergoing ultrasound-guided foam sclerotherapy for varicose veins were sent the Short Form 12 (SF-12) questionnaire, a generic measure of HRQOL, and the Aberdeen Varicose Vein Symptom Score (AVSS) questionnaire, a disease-specific measure of HRQOL, 1 week before treatment and 1, 6, and 12 months after treatment.

RESULTS

The study enrolled 296 patients (34% male; 395 treated legs) with a median age of 57 years (range, 22-89 years). Of these, 24% had had previous superficial venous surgery, and 66% were CEAP C(2-3) (uncomplicated varicose veins). Questionnaire completion rates were 82%, 73%, and 69% at 1, 6, and 12 months after treatment. The median Physical Component Summary score of the SF-12 (higher score indicates better HRQOL) improved from 47.6 pretreatment to 49.4 at 1 month (P < .008, Wilcoxon signed rank test), to 51.9 at 6 months (P < .0005), and to 52.9 at 12 months (P < .0005). The median AVSS (lower score indicates better HRQOL) improved from 19.0 pretreatment to 16.5 at 1 month (P < .0005), to 8.7 at 6 months (P < .0005), and to 8.6 at 12 months (P < .0005).

CONCLUSIONS

Ultrasound-guided foam sclerotherapy for great and small saphenous varicose veins leads to significant improvements in generic and disease-specific HRQOL for at least 12 months after treatment.

Recovery after ultrasound-guided foam sclerotherapy compared with conventional surgery for varicose veins

Background

The advantages of minimally invasive alternatives such as ultrasound-guided foam sclerotherapy (UGFS) over conventional surgery for the treatment of varicose veins include lower morbidity and faster recovery times. The aim was to compare morbidity, analgesia use, and time to return to driving and work following UGFS with those reported after conventional surgery for varicose veins.

Methods

Patients who had UGFS or surgery for varicose veins were sent a questionnaire 4 weeks after treatment.

Results

A total of 332 (84·9 per cent) of 391 patients who had UGFS and 53 (56 per cent) of 94 who had surgery returned a questionnaire. The groups were similar in terms of age, sex, and the proportion who had treatment of bilateral or recurrent veins. Patients who had surgery were more likely to have significant bruising (44 versus 7·2 per cent; P &lt; 0·001) and pain (17 versus 5·5 per cent; P = 0·001). After UGFS, 43·2 per cent of patients returned to work within 24 h compared with none who had surgery (P &lt; 0·001). Patients who had UGFS were more likely to return to driving within 4 days (P = 0·014).

Conclusion

UGFS was associated with less pain and analgesia requirement, time off work and quicker return to driving.

The classification systems of the EQ-5D, the HUI II and the SF-6D: what do they have in common?

PURPOSE

EQ-5D, HUI II and SF-6D often produce very different valuations for the same health state. This paper aims at clarifying to what extent this might be caused by differences between the multi-attribute classification systems belonging to these instruments.

METHODS

Subjects were 264 patients of rehabilitation clinics in Mecklenburg-Western Pomerania (44.3% female; mean age 49.1) who completed the EQ-5D, the HUI II and the SF-36 (the basis of the SF-6D). After scaling with principal component analyses for categorical data, each attribute of each classification system was regressed on the classification systems of the other two instruments, and all attributes together were subjected to ordinary principal component analysis with varimax rotation.

RESULTS

Adjusted multiple R(2) for regression analyses ranged from 0.01 to 0.57. The HUI II attribute 'sensation' and the SF-6D attribute 'role limitation' are virtually unrelated to the remainder. All other attributes of all three instruments can be predicted by each other. EQ-5D and HUI II focus distinctly more on physical functioning than SF-6D.

CONCLUSION

Although all three classification systems have a lot in common, they differ so much that EQ-5D, HUI II and SF-6D would produce different valuations even if these valuations were determined according to the same principle.

Predicting the short form-6D preference-based index using the eight mean short form-36 health dimension scores: estimating preference-based health-related utilities when patient level data are not available

OBJECTIVE

The objective is to derive an algorithm to predict a cohort preference-based short form-6D (short form-6D) score using the eight mean health dimension scores from the short form-36 (SF-36) when patient level data are not available.

METHODS

Health-related quality of life data (N = 6890) covering a wide range of health conditions was used to explore the relationship between the SF-6D and the eight health dimension scores. Models obtained using ordinary least square regressions were compared for goodness of fit and predictive abilities on both within-sample subgroups and out-of-sample published data sets.

RESULTS

The models explained more than 83% of the variance in the individual SF-6D scores with a mean absolute error of 0.040. When using mean health dimension scores from within-sample subgroups and out-of-sample published data sets, the majority of predicted scores were well within the minimal important difference (0.041) for the SF-6D.

CONCLUSIONS

This article presents a mechanism to estimate a mean cohort preference-based SF-6D score using the eight mean health dimension scores of the SF-36. Using published summary statistics, the out-of-sample validation demonstrates that the algorithms can be used to inform both clinical and economic research. Further research is required in different health conditions.

Uncomplicated varicose vein surgery in the UK--a postcode lottery?

INTRODUCTION

Recent research confirms that uncomplicated varicose vein surgery provides significant benefits in terms of quality of life compared to conservative treatment at a relatively small cost. There appear to be major variations in indications for treating varicose veins across the UK and this seems to be based mainly on financial restraint imposed by local Primary Care Trusts (PCTs). This survey was aimed at quantifying this variation.

MATERIALS AND METHODS

An E-mail questionnaire was sent to 245 surgical members of the Vascular Society of Great Britain and Ireland across the UK. The main questions asked were aimed at finding out whether surgeons were having any restrictions imposed on them by their local PCTs with regard to treatment of varicose veins.

RESULTS

A total of 109 surgeons replied (44% response rate). Of these, 64% of surgeons had restrictions set upon them by their local PCTs; however, 62% of surgeons under restrictions still offered surgery for symptomatic uncomplicated varicose veins. Restrictions varied from 100% to 0% across different regions in the UK.

CONCLUSIONS

Many patients are denied surgical treatment for their symptomatic uncomplicated varicose veins according to where they live in the UK regardless of their symptoms.

Management of varicose veins: a survey of current practice by members of the Vascular Society of Great Britain and Ireland

INTRODUCTION

In 1999, a survey was published detailing the management of varicose veins by members of the then Vascular Surgical Society (VSS). Since then, newer methods for treating varicose veins have been developed and far more explicit rationing has been introduced in the NHS.

SUBJECTS AND METHODS

In order to examine whether there had been a significant change in established practice in the UK, a questionnaire was sent to all Vascular Society of Great Britain and Ireland (VSGBI) members in the 2004 yearbook by E-mail or post.

RESULTS

Of the 426 questionnaires distributed, a 69% response rate was achieved. Of respondents, 97% treated varicose veins in their NHS practice, whilst 88% did so in private practice. Some 73% used hand-held Doppler assessment in the clinic and 96% used duplex ultrasound assessment selectively. Despite UK National Institute for Health and Clinical Excellence (NICE) guidelines, only 68% said that their primary care trusts funded treatment of symptomatic varicose veins, while 93% did so for complications. In either NHS or private practice, respectively, 83% or 72% of responders offered surgery as preferred treatment for primary varicose veins, while 14% or 20% preferred endovascular treatments (endovascular laser treatment, radiofrequency ablation and foam sclerotherapy). Of responders, 17% did not follow-up patients after treatment.

CONCLUSIONS

This survey suggests that there is rationing of access to care for symptomatic varicose veins. Despite publicity for endovenous techniques, surgery remains the preferred treatment for varicose veins in the UK.

Randomized clinical trial comparing endovenous laser with cryostripping for great saphenous varicose veins

BACKGROUND

The aim of this randomized single-centre trial was to compare the 2-year results of endovenous laser ablation (EVLA) and cryostripping for varicose veins.

METHODS

A total of 120 patients with uncomplicated great saphenous varicose veins were randomized equally to one of the two treatments. Principal outcomes measures were: freedom from recurrent varicose veins on duplex imaging, and improvement in Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Severity Score (AVVSS) 6, 12 and 24 months after treatment.

RESULTS

Life-table analysis showed overall freedom from recurrent incompetence at 2 years in 77 (95 per cent confidence interval (c.i.) 72 to 78) per cent of patients after EVLA and in 66 (95 per cent c.i. 60 to 67) per cent after cryostripping (P = 0.253). VCSS and AVVSS values improved significantly after treatment, but the differences between the treatments were not significant. EVLA provided significantly more favourable results than cryostripping with respect to duration of operation, postprocedural pain, induration and resumption of normal activity.

CONCLUSION

EVLA and cryostripping were similarly effective in patients with varicose veins, but patients favoured EVLA because of less pain and postoperative morbidity, and quicker return to normal activity.

REGISTRATION NUMBER

ISRCTN33832691 (http://www.controlled-trials.com).

Treatment of varicose veins: the present and the future--a questionnaire survey

INTRODUCTION

The treatment options for varicose veins have increased over the last few years. Despite a lack of randomised trials comparing the various modalities, many surgeons are changing their practice. The aim of this study was to assess the current practice of surgeons in Great Britain and Ireland.

MATERIALS AND METHODS

A postal questionnaire survey was sent to surgical members of the Vascular Society of Great Britain and Ireland and the Venous Forum of The Royal Society of Medicine. Of 561 questionnaires sent, 349 were returned completed (62%).

RESULTS

The types of varicose vein treatments offered by each surgeon varied widely in both NHS and private practice. The vast majority (96%) offered conventional surgery (CS) on the NHS. Foam sclerotherapy (FS) endovenous laser (EVL) and radiofrequency ablation (RF) were more likely to be offered in private practice than in NHS practice. Overall, 38% of respondents for NHS practice and 45% of respondents for private practice offered two or more modalities. Of the respondents who were not yet performing FS, EVL, or RF, 19% were considering or had undertaken training in FS, 26% in EVL and 9% in RF. When asked to consider future practice, 70% surgeons felt that surgery would remain the most commonly used treatment. This was followed by FS (17%), EVL (11%) and RF (2%).

CONCLUSIONS

Over one-third of respondents are now offering more than one treatment modality for the treatment of varicose veins. Whilst there is movement towards endovascular treatments, the problem of cost has yet to be solved. At present, surgery remains the most popular modality in both the NHS and private practice; however, improved outcomes and patient preference may lead to a change in practice.

A prospective study of incidence of saphenous nerve injury after total great saphenous vein stripping

BACKGROUND AND OBJECTIVES

Total stripping of the great saphenous vein (GSV) is a validated surgical strategy of treating patients with primary varicose veins (PVV). An often cited, but not well documented and studied, complication of total stripping is postoperative damage of the saphenous nerve (SN).

OBJECTIVE

The objective was to evaluate the incidence of SN damage and to assess the therapeutic efficacy after total stripping of the GSV.

MATERIALS AND METHODS

Patients undergoing total stripping of the GSV because of PVV in the entire lower limb were enrolled. Pre- and postoperative neurologic examination was performed to identify potential sensory neurologic deficits.

RESULTS

Total stripping of the GSV in 69 limbs occurred because of pain (9%) or a tired feeling in the limbs (77%) or for cosmetic reasons (14%). The overall incidence of postoperative sensory neurologic deficits was 7 and 6%, respectively, after 6-week follow-up and both 3% after 3-month follow-up. In 99% of the patients, total stripping of the GSV resulted in reduction of the primary signs and symptoms.

CONCLUSION

The incidence of SN damage after total stripping of the GSV is low. Thus, total stripping of the GSV resulted in improvement of the primary complaint in almost all patients. Total stripping of the GSV is an effective surgical strategy in treating PVV.

A comparison of the performance of the EQ-5D and SF-6D for individuals aged >or= 45 years

We sought to compare the performance of the EQ-5D and SF-6D with regard to the criteria of practicality, convergent validity, and construct validity, the level of agreement between the two measures was also assessed. Responses from 1865 individuals aged >or= 45 years in one general practice were analysed. Of these, 93.1% completed the EQ-5D, compared with 86.4% for the SF-6D, where individuals who were older, female, of a lower occupational skill level, from an area of lower deprivation, or used prescribed medication were significantly less likely to complete the SF-6D. The performance of both measures was comparable with regard to both convergent and construct validities, as both the EQ-5D and SF-6D scores were closely related to scores on the EuroQol visual analogue scale (VAS) (p<0.001) and able to discriminate between people who did and did not take: (i) analgesics and (ii) other prescribed medication. Despite EQ-5D and SF-6D scores being highly correlated (p<0.001), individuals who were healthier (according to the VAS) had higher mean scores on the EQ-5D (p<0.001), whereas less healthy individuals had higher mean scores on the SF-6D (individuals with knee pain, osteoarthritis, back pain, rheumatoid arthritis, and hip pain had significantly lower mean scores on the EQ-5D, p<0.001).

Reduction in varicose vein services: impact on operative training

INTRODUCTION

This study examines the impact of rationing varicose vein operations on operative training on a general surgical unit with a vascular interest.

PATIENTS AND METHODS

Log-books of middle-grade surgeons were analysed for 3-month periods before and after a decision by the local Primary Care Trust to ration varicose vein referrals. Number, intermediate equivalents and type of operations were recorded, whether they were general or vascular cases and whether the trainee had carried out or assisted with the operation.

RESULTS

There was a slight fall in the total number of operations in which the middle-grade surgeons were involved (208 to 186). There was a significant increase in general surgical cases with the fall in number of varicose vein operations (P < 0.0001). The fall in case-load and work-load operative training in vascular surgery was compensated by an increase in general surgical cases (P = 0.0003). This was largely due to increased number of hernia repairs (P = 0.0035).

CONCLUSIONS

From the point of operative training, a vascular unit in a district general hospital would not be sustainable following withdrawal of varicose vein services. However, this can be off-set by increasing general surgical case-load to fill the gap created.

Role of endovenous laser treatment in the management of chronic venous insufficiency

Endovenous laser therapy (EVLT) is a recognized option in the treatment of uncomplicated varicose veins. This uncontrolled case series evaluates its effectiveness in the management of chronic venous insufficiency. Patients with a history of active or healed ulcers were selected for EVLT. The procedure was carried out in an outpatient setting over a period of 12 months. Assessment was carried out for evidence of ulcer healing and recurrence, long saphenous vein occlusion, and patient satisfaction at 3, 12, and 22 months. Results are expressed as means with range. EVLT was used to treat 23 limbs in 20 patients with a median age of 59 years (range 32-76) including 12 females and eight males. All patients had evidence of chronic venous insufficiency, graded at C5 or greater on the CEAP classification (C5 16, C6 7). Patients with long saphenous vein insufficiency were included, whereas those with either deep or combined deep and superficial venous incompetence were excluded. The cumulative 3-, 12-, and 22-month healing rates were 87% (20/23), 100% (23/23), and 95% (21/22), respectively. The only patient having a recurrence of ulcers at 22 months' follow-up (CEAP 6) had mid-calf perforator incompetence with recanalized long saphenous vein. Duplex scan demonstrated long saphenous vein occlusion in 100% (23/23), 96% (22/23), and 91% (20/22) at 3, 12, and 22 months, respectively. In all, 84% (16/19) of patients were satisfied with the results of treatment without any major procedure-related complication. These results demonstrate that EVLT, carried out in an outpatient setting, is effective in the treatment and prevention of chronic venous ulcers, with good patient satisfaction and no major complication.

The Symptoms of Varicose Veins: Difficult to Determine and Difficult to Study

OBJECTIVES

To investigate the activities which may exacerbate symptoms in patients with varicose veins.

METHODS

Questionnaires sent to patients before clinics and at least six months later.

RESULTS

Both questionnaires were returned by 149 of 203 patients (74%) but only 124 contained adequate data for comparison--55 from patients who had surgical treatment and 69 who had no surgery. At initial presentation, worsening of discomfort attributed to varicose veins was common during (58%) or after (48%) standing and in hot weather (44%), but less when sitting with the feet down (31%), and after (31%) or when walking (19%). Surgery significantly reduced the total number of symptoms reported by patients at follow-up (p<0.02). However, none of the symptoms reported during specific activities was significantly lessened by surgery compared with no treatment--possibly because the attrition of patients during the study resulted in small numbers for analysis.

CONCLUSIONS

Symptoms are a common indication for treating varicose veins and it is therefore important to be sure that they are due to the veins, rather than other causes. This report highlights traditional and logical questions which may help to identify symptoms caused by varicose veins but illustrates the difficulty of validating them.

Conventional versus invaginated stripping of the great saphenous vein: a randomized, double-blind, controlled clinical trial

Background

An invaginated strip of the great saphenous vein (GSV) may be associated with diminished blood loss and less discomfort compared to conventional stripping in patients with unilateral primary GSV varicosis.

Methods

Ninety-two patients were randomized for conventional (CON) or invaginated (INVAG) stripping and were followed for 26 weeks postoperatively.

Results

Both groups (n = 46) were well balanced for age, gender distribution, and body mass index. The CON group lost twice as much blood compared to the INVAG group (CON: 28 ± 4 g, INVAG: 15 ± 2 g, p < 0.001). Infragenual incision length following a conventional strip was twice as long (CON: 16 ± 1 mm, INVAG: 8 ± 1 mm, p < 0.001). Pain as measured with a visual analog scale (minimal 0, max 10) decreased in both groups in a similar fashion from 3.2 ± 0.3 preoperatively to 0.6 ± 0.2 after 26 weeks (p < 0.001). Saphenous nerve damage after one month was observed in four CON patients compared to no patients following invagination. Return to work was not different (CON: 13 ± 2 days, INVAG: 11 ± 2 days).

Conclusion

Invagination of the GSV in uncomplicated primary varicosis may be associated with less surgical trauma compared to a conventional stripping technique.

Superficial Thrombophlebitis

Superficial thrombophlebitis (STP) is a common disease usually characterized by an auto-resolving vasculitis of medium-sized veins of the upper subcutis or deep dermis that clinically manifests as a tender or painful palpable cord-like structure. It usually occurs in the setting of varicous veins, or hypercoagulable states, and may be the alarm signal for an underlining silent cancer. STP mainly involves the legs, but special locations, including the anterior chest wall or the penis, characterize specific clinical forms (Mondor's disease). The clinical signs and symptoms usually allow an easy diagnosis, but complementary techniques and biopsy are sometimes required. The main histopathologic differential diagnosis of STP is cutaneous polyarteritis nodosa.

Treatment of chronic venous insufficiency

Chronic venous insufficiency (CVI) results from venous hypertension secondary to superficial or deep venous valvular reflux. Treatment modalities are aimed at reducing venous valvular reflux, thereby inhibiting the ensuing pathologic inflammatory process. Compression therapy using pumps, bandaging, and/or graded compression stockings is the mainstay of treatment for CVI. Compression therapy has been shown to be effective in reducing venous hypertension retarding the development of inflammation and pathologic skin changes. Pharmacologic agents such as diuretics and topical steroid creams reduce swelling and pain short term but offer no long-term treatment advantage. Herbal supplements may reduce the inflammatory response to venous hypertension, but are not licensed by the US Food and Drug Administration, and vary in their efficacy, quality, and safety. However, several randomized controlled trials using the herbal horse chestnut seed extract containing aescin have shown short-term improvement in signs and symptoms of CVI. Endovascular and surgical techniques aimed at treatment of primary and secondary venous valvular reflux have been shown to improve venous hemodynamics promoting healing of venous ulcers and improving quality of life. The newer endovascular treatments of varicose veins using laser, radiofrequency ablation, and chemical foam sclerotherapy show some promise.

Racial and ethnic differences in preference-based health status measure

OBJECTIVE

To document the racial and ethnic differences in individuals' perception of their general health status assessed by preference-based measures.

METHODS

Using the 2003 Medical Expenditure Panel Survey (MEPS), a nationally representative sample of 20 428 people with reported concurrent EuroQol (EQ-5D) US scores were included in the study. Given the upper-bound of preference-based scores at 1.0, a two-part model was derived to identify the relationship between race/ethnicity and the preference-based score after controlling for individual demographic covariates, comorbidity profile, and functional and activity limitations. In order to generalize the results to the whole US population, the complex survey sampling design of the MEPS was taken into account using the specified sample weight, variance estimation stratum, and primary sampling unit.

RESULTS

In the fully adjusted model, Asians were more likely to report being in full health (score of 1.0) than Whites by 4.2 percentage points (p < 0.05), whereas no differences were identified for Blacks and Hispanics compared to Whites. Beyond health and disease conditions, education and income explained the racial/ethnic difference for EQ-5D score for Blacks and Hispanics relative to Whites, but this was not the case between Asians and Whites. No clinically important differences were identified between racial/ethnic groups for individuals not reporting full health.

CONCLUSIONS

This study adds to the literature of health-related quality of life (HRQoL) by providing additional empirical evidence at the US national level to demonstrate racial/ethnic differences assessed by preference-based measures. Healthcare researchers and clinicians need to be aware that Asians are more likely to perceive a higher preference-based score than Whites, given the same health and disease conditions. Subgroup analysis may be considered regarding the optimal decision making and conclusions based on cost-effectiveness analysis.