Extension of saphenous thrombus into the femoral vein: A potential complication of new endovenous ablation techniques

Great saphenous vein radiofrequency ablation versus standard stripping in the management of primary varicose veins-a randomized clinical trial

INTRODUCTION

Chronic venous insufficiency is the most common vascular disease in the adult population. However, randomized clinical trials (RCTs) comparing therapeutic options are limited.

PATIENTS AND METHODS

A total of 180 patients with saphenofemoral junction and great saphenous reflux detected on duplex were randomized to either ultrasound-guided radiofrequency ablation (RFA) or standard surgical treatment. The study participants blindly chose an assignment card that placed them in either group A (ultrasound-guided RFA of the great saphenous vein [GSV]; n = 90); or group B (surgical management n = 90). Patients were followed up for 24 months.

RESULTS

The primary occlusion rate in group A was 94.5% versus 100% in group B. Radiofrequency ablation had a lower overall complication rate (P = .02) and shorter post-intervention hospital stay (P = .001). Kaplan-Meier analysis showed no significant differences in recurrence rates at 24 months follow-up (P = .45). Radiofrequency ablation was significantly more expensive (P = .003).

CONCLUSION

Great saphenous vein occlusion was achieved efficiently in 94% of our group using RFA with minimal complications and obvious advantages as compared to standard surgery.

Comparison of Endovenous Laser Treatment for Varicose Veins with High Ligation Using Pulse Mode and without High Ligation Using Continuous Mode and Lower Energy

PURPOSE

To compare two methods of endovenous laser treatment (EVLT) for primary varicose veins of lower extremities: first-EVLT combined with high ligation of great saphenous vein using pulse mode ablation and 12 W laser ; second-EVLT without high ligation and using lower energy (10 W) and continuous mode.

MATERIALS AND METHODS

Ninety-three limbs of 75 patients were treated by 980 nm diode laser into the great saphenous veins from June, 2003. In the first group of 45 patients, (HL group), we performed a division of the sapheno-femoral junction after high ligation and EVLT was done with a 12 W laser in a pulse mode. In the second group of 30 patients (NL group) EVLT was performed without high ligation with a 10 W laser in a continuous mode using a laser fiber drawing device.

RESULTS

Operation time was significantly shorter in the NL group compared to the HL group (p < 0.05), and the early occlusion rates were 100% (HL group) and 97% (NL group). Subcutaneous bleeding occurred in 9 limbs (16%) in the HL group and 2 limbs (6%) in the NL group. In the NL group there was one case complicated with thrombus which extended into the femoral vein.

CONCLUSION

High ligation at sapheno-femoral junction is not necessary for EVLT and a lower energy continuous mode laser induces a lower rate of complications compared with a pulse mode ablation at a higher energy level. However, close follow-up with duplex scanning is necessary in early postoperative period.

Polidocanol for endovenous microfoam sclerosant therapy

BACKGROUND

Polidocanol is a liquid surfactant having endothelial cell lytic properties. In the form of a controlled, dispensed microfoam it is administered endovenously as a sclerosing agent in the treatment of varicose veins.

OBJECTIVE

This review summarizes efficacy of polidocanol endovenous microfoam sclerotherapy using a proprietary dispensing system to control foam characteristics and gas content for treating varicose veins.

METHODS

We reviewed in vitro, Phase I, Phase II and limited Phase III data for polidocanol microfoam with a focus on controlled foam formulation in therapy.

RESULTS/CONCLUSIONS

Clinical trials of controlled dispensing of polidocanol microfoam provide evidence of effective treatment of chronic venous insufficiency with low toxicity, minimal risk and few complications.

Side-effects and complications of foam sclerotherapy of the great and small saphenous veins: a controlled multicentre prospective study including 1,025 patients

OBJECTIVES

Increasing interest in foam sclerotherapy (FS) for saphenous insufficiency has highlighted the need to study the side-effects and complications of this treatment. The aim of this study is to better assess their nature and incidence.

METHODS

A multicentre, prospective and controlled study was carried out in which patients treated with FS for great (GSV) and small saphenous veins (SSV) trunk incompetence were included. Immediate untoward events were reported. Duplex ultrasound (DUS) examination was carried out to assess all patients between the eighth and 30th day. In addition, 20% of patients were called by an external auditor.

RESULTS

In total, 818 GSV and 207 SSV were treated in 1025 patients in 20 phlebology clinics. Ninety-nine percent of patients were controlled with DUS and non-duplex-checked patients were all called. The saphenous trunk was occluded in 90.3% of patients. Twenty-seven (2.6%) side-effects were reported: migraine (n = 8, 4 with visual disturbance); visual disturbance alone (n = 7); chest pressure alone (n = 7); and chest pressure associated with visual disturbance (n = 5). Eleven thrombo-embolic events occurred: 10 deep vein thrombosis (DVT) but only five in symptomatic patients, and one pulmonary embolism that occurred 19 days following the FS without DVT identified by DUS. One transient ischaemic stroke, with complete clinical recovery in 30 minutes, and one septicaemia with satisfactory outcome were reported as well.

CONCLUSION

This study demonstrates in a large sample of patients a low rate of adverse reactions after FS of great and small saphenous trunks. However, but the eventuality of exceptional but more serious complications has to be taken into account in the management of patients. A multicentre study like this one takes into account different practices and reports all possible complications, thus demonstrating the need for a common validated protocol.

Endovenous Laser Ablation (EVLA) in Patients With Varicose Great Saphenous Vein (GSV) and Incompetent Saphenofemoral Junction (SFJ): An Ambulatory Single Center Experience

Objectives: To evaluate treatment results for varicose great saphenous vein (GSV) using endovenous laser ablation (EVLA) in an ambulatory single center.

Material and methods: We prospectively studied 77 limbs with varicose GSV in 74 patients who were treated using 980-nm EVL with a 600-mm laser fiber and the power settings of 10-25 Watts. The patients were followed using color Doppler ultrasound.

Results: Continued closure of treated GSV was found in 98.3% of the legs evaluated at 3-week follow-up (n = 60). At 3- and 6-month intervals, 94.1% and 97% successful occlusion was achieved, respectively. The main complications of the procedure included prolonged leg pain (2 cases), hyperestheasia (one case) and lidocaine sensitivity (one case).

Conclusion: EVLA treatment of the GSV is a safe and highly effective method accompanied with few complications in midterm follow-up. It is feasible in ambulatory settings and the patients return to their daily activities early after intervention.

First results with a new 1470-nm diode laser for endovenous ablation of incompetent saphenous veins

Introduction

Most of the published EVLA data concern 810, 940, 980 nm diode lasers and 1064 or 1320 nm Nd:Yag laser systems. Major side effects are postoperative pain and bruising. The aim of this study was to show the outcome one year after EVLA of incompetent saphenous veins with a 1470 nm Diode laser (Ceralas E, biolitec).

Patients and method

Between December 2006 and February 2007, 134 saphenous veins (108 GSV, 26 SSV) in 117 legs of 100 consecutive patients where treated by EVLA for GSV and SSV incompetence. All patients were examined clinically and with duplex by an experienced phlebologist prior to intervention, and at the follow-up visits for complications, occlusion, flow and reflux in the treated vein segment. The clinical evaluation included clinical CEAP and the presence of recurrent varicose veins. Patient satisfaction was assessed by a 0 to 4 scale.

Results

After a mean follow-up period of 184 days (SD 27) 127 treated veins (102 GSV, 25 SSV) of 111 limbs in 94 patients and after 329 days (SD 14) 105 treated veins (94 GSV, 21 SSV) of 105 limbs in 83 patients were reinvestigated. Six patients were lost to follow up after six months and an additional 11 patients after one year. Up to one year follow-up all treated veins remained occluded. At six months, one new insufficient anterior accessory saphenous vein (AASV) and after 12 months, three new insufficient AASV occurred. After one year 45 patients were very satisfied with the method, 34 were satisfied, three were fairly and one was not satisfied. The mean of all answers was 0.5 (SD 0.5). In three cases phlebitic reactions after 10 days, but no severe complications such as deep vein thrombosis occured. After six months in 9.5% of the legs paresthesia was present in the treated area which reduced to 7.6% after one year. Intake of painkillers was mean 6.7 tablets (SD 3.5). When we compared GSV legs treated with LEED below or above 100 J/cm, the paresthesia rate was significantly lower in the first group with 2.3% compared to 15.5 % in the higher LEED group. The differences for number of days with analgesic intake and for the paraesthetic area were significant.

Discussion

In this prospective follow-up study with 100 consecutive patients and 134 treated saphenous veins a high occlusion rate of 100% could be demonstrated one year after treatment. However, with LEED > 100 J/cm in this study, the incidence of paresthesia rose significantly. Therefore it seems adequate to stay below 100 J/cm in the future as the occlusion rate was the same below and above 100 J/cm.

Conclusion

EVLA of GSV and SSV with a 1470 nm diode laser is a minimally invasive, safe and efficient therapy option with a high success rate.

Minimally invasive vein therapy and treatment options for endovenous heat-induced thrombus

Radiofrequency ablation and endovenous laser therapy are types of minimally invasive techniques that have been used in the treatment of chronic venous insufficiency. In both procedures, high-intensity heat via thermal energy is produced and delivered via an endovenous catheter placed in the saphenous vein. This results in changes that therapeutically induce closure of the vein by denaturing the vessel wall with subsequent thrombus formation. Patients undergo ultrasound 48 to 72 hours postprocedure to confirm vessel occlusion and assess for possible extension of thrombus into the deep venous system. Thrombus is frequently visualized with the procedure in the tributaries, the venous dilations, and at times the saphenofemoral junction. In any other setting, thrombus at the saphenofemoral junction would warrant anticoagulation. However, the characteristics, composition, and behavior of endovenous heat-induced thrombus are different than de novo thrombosis. This postprocedure endovenous heat-induced thrombus is considered a normal consequence of the procedure and does not require traditional anticoagulation in most cases, depending on the location.

Combined endovenous laser treatment and ambulatory phlebectomy for the treatment of saphenous vein incompetence

Objectives

The aim of this retrospective study is to assess the safety and effectiveness of endovenous laser treatment (EVLT) combined with ambulatory phlebectomy (AP) as a single procedure for treating saphenous vein incompetence.

Methods

The study enrolled 148 patients with saphenofemoral or saphenopopliteal junction reflux associated with saphenous vein incompetence and enlarged branch veins. Patients were treated with EVLT (135 great saphenous veins, 41 small saphenous veins) concomitantly with AP as a single procedure. All patients were followed up by clinical assessment and duplex ultrasound at one week and 12 weeks after the procedure.

Results

No postprocedural deep vein thrombosis and pulmonary embolism occurred. Saphenous vein recanalization rate at three months was 5.7%. Residual varicosities were found in 11.4% of the patients at three months after procedure, but only 2.3% of those required subsequent interventions.

Conclusion

Combined EVLT and AP could be a safe and effective treatment modality for the saphenous vein incompetence.

Varicose veins

Varicose veins are common and often asymptomatic. A variety of treatment methods are available for those who develop symptoms or complications. The traditional open surgical treatment still forms the mainstay of treatment. Endovenous treatment methods offer a new alternative but have their own limitations. Foam sclerotherapy holds much promise as it can be done in an outpatient setting under local anesthesia, but it needs to be tested over a longer time period.

Endovenous Laser Treatment of Saphenous Vein Reflux: How Much Energy Do We Need to Prevent Recanalizations?

The aim of this study was to report the results of high-energy endovenous laser treatment to measure the relationship between the fluence and the outcome in terms of recanalization. In 97 patients, 129 great saphenous veins were treated with endovenous laser treatment, using a 980-nm diode laser. Follow-up visits were done at 3 days, 1 month, and 6 months. The best results were noted 1 month postoperative, but at 6 months, control late recanalizations occured decreasing occlusion rate to 90.6%. Patients were divided into 2 groups according to the outcome (occlusion or recanalization) at 6 months, and statistical analysis was done. The authors found 52 J/cm2 mean fluence in the occlusion group and 43.7 J/cm2 in the nonocclusion group. This was a statistical significant difference ( P < .01). The occlusion rate on long term is fluence dependent. But recanalizations might occur even in these higher fluence treatment groups. A fluence of 52J/cm2 is advised.

Natural History of the Great Saphenous Vein Stump Following Endovenous Laser Therapy

Background: Little is known about the ideal residual length of the great saphenous vein (GSV) stump and its potential role in complications such as acute deep venous thrombosis (DVT) and recanalization. This study was designed to learn about the natural history of the residual GSV stump length following endovenous laser treatment. Methods: Prospective data were collected from 50 limbs of 50 patients over an 11-month period. Clinical assessment and duplex ultrasound were performed preoperatively, at 24 hours and at 3 months after the procedure. Results: The residual GSV stump decreased in length from a mean of 15 mm at 24 hours to 13 mm at 3 months after the procedure. None of the patients developed acute DVT or proximal recanalization when the laser tip was positioned 28 mm distal to the saphenofemoral junction. Conclusion: Endovenous laser therapy of the GSV for symptomatic reflux is safe and effective. The residual GSV stump decreased in length over a 3-month period.

Technical review of endovenous laser therapy for varicose veins

BACKGROUND

In the last decade, several new treatments of truncal varicose veins have been introduced. Of these new therapies, endovenous laser therapy (EVLT) is one of the most widely accepted and used treatment options for incompetent greater and lesser saphenous veins.

OBJECTIVE

The objective of this report is to inform clinicians about the EVLT procedure and to review its efficacy and safety in treatment of truncal varicose veins. Also, we discuss some of the underlying theoretical principles and laser parameters that affect EVLT.

METHODS

We carried out a literature review of EVLT;s efficacy and safety. We included reports that included 100 or more limbs with a follow-up of at least 3 months. The principals and procedure of EVLT are described. Of the laser parameters, mode of administration, wavelength, fluence, wattage and pullback speed are discussed.

CONCLUSION

EVLT appears to be a very effective and safe option in the treatment of varicose veins but large randomized comparative studies are needed.

Randomized trial comparing endovenous laser ablation of the great saphenous vein with high ligation and stripping in patients with varicose veins: Short-term results

BACKGROUND

Endovenous laser (EVL) ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity and reduce work loss compared with high ligation and stripping (HL/S). However, the procedures have not previously been compared in a randomized trial with parallel groups where both treatments were performed in tumescent anesthesia on an out-patient basis.

METHODS

Patients with varicose veins due to GSV insufficiency were randomized to either EVL (980 nm) or HL/S in tumescent anesthesia. Miniphlebectomies were also performed. Patients were examined preoperatively and at 12 days, and 1, 3, and 6 months postoperatively. Sick leave, time to normal physical activity, pain score, use of analgesics, Aberdeen score, Medical Outcomes Study Short Form-36 quality-of-life score, Venous Clinical Severity Score (VCSS), and complication rates were investigated. The total cost of the procedures, including lost wages and equipment, was calculated. Cost calculations were based on the standard fee for HL/S with the addition of laser equipment and the standard salary and productivity level in Denmark.

RESULTS

A follow-up of 6 months was achieved in 121 patients (137 legs). The groups were well matched for patient and GSV characteristics. Two HL/S procedures failed, and three GSVs recanalized in the EVL group. The groups experienced similar improvement in quality-of-life scores and VCSS score at 3 months. Only one patient in the HL/S group had a major complication, a wound infection that was treated successfully with antibiotics. The HL/S and EVL groups did not differ in mean time to resume normal physical activity (7.7 vs 6.9 calendar days) and work (7.6 vs 7.0 calendar days). Postoperative pain and bruising was higher in the HL/S group, but no difference in the use of analgesics was recorded. The total cost of the procedures, including lost wages, was euro 3084 ($3948 US) in the HL/S and euro 3396 ($4347 US) in the EVL group.

CONCLUSIONS

This study suggests that the short-term efficacy and safety of EVL and HL/S are similar. Except for slightly increased postoperative pain and bruising in the HL/S group, no differences were found between the two treatment modalities. The treatments were equally safe and efficient in eliminating GSV reflux, alleviating symptoms and signs of GSV varicosities, and improving quality of life. Long-term outcomes, particularly with respect to recurrence rates, shall be investigated in future studies, including the continuation of the present.

Mathematical modeling of 980-nm and 1320-nm endovenous laser treatment

BACKGROUND AND OBJECTIVES

Endovenous laser treatment (ELT) has been proposed as an alternative in the treatment of reflux of the great saphenous vein (GSV) and small saphenous vein (SSV). Numerous studies have since demonstrated that this technique is both safe and efficacious. ELT was presented initially using diode lasers of 810 nm, 940 nm, and 980 nm. Recently, a 1,320-nm Nd:YAG laser was introduced for ELT. This study aims to provide mathematical modeling of ELT in order to compare 980 nm and 1,320 nm laser-induced damage of saphenous veins.

STUDY DESIGN/MATERIALS AND METHODS

The model is based on calculations describing light distribution using the diffusion approximation of the transport theory, the temperature rise using the bioheat equation, and the laser-induced injury using the Arrhenius damage model. The geometry to simulate ELT was based on a 2D model consisting of a cylindrically symmetric blood vessel including a vessel wall and surrounded by an infinite homogenous tissue. The mathematical model was implemented using the Macsyma-Pdease2D software (Macsyma, Inc., Arlington, MA). Calculations were performed so as to determine the damage induced in the intima tunica, the externa tunica and inside the peri-venous tissue for 3 mm and 5 mm vessels (considered after tumescent anesthesia) and different linear endovenous energy densities (LEED) usually reported in the literature.

RESULTS

Calculations were performed for two different vein diameters: 3 mm and 5 mm and with LEED typically reported in the literature. For 980 nm, LEED: 50 to 160 J/cm (CW mode, 2 mm/second pullback speed, power: 10 W to 32 W) and for 1,320 nm, LEED: 50 to 80 J/cm (pulsed mode, pulse duration 1.2 milliseconds, peak power: 135 W, repetition rate 30 Hz to 50 Hz).

DISCUSSION AND CONCLUSION

Numerical simulations are in agreement with LEED reported in clinical studies. Mathematical modeling shows clearly that 1,320 nm, with a better absorption by the vessel wall, requires less energy to achieve wall damage. In the 810-1,320-nm range, blood plays only a minor role. Consequently, the classification of these lasers into hemoglobin-specific laser wavelengths (810, 940, 980 nm) and water-specific laser wavelengths (1,320 nm) is inappropriate. In terms of closure rate, 980 nm and 1,320 nm can lead to similar results and, as reported by the literature, to similar side effects. This model should serve as a useful tool to simulate and better understand the mechanism of action of the ELT.

The treatment of varicose veins

INTRODUCTION

Over the past few years, there has been a move to less invasive endoluminal methods in the treatment of lower limb varicose veins combined with a renewed interest in sclerotherapy, with the recent addition of foam sclerotherapy. The development of these new techniques has led many to question some of the more conventional teaching on the treatment of varicose veins. This review examines these new treatments for lower limb varicose veins and the current evidence for their use.

MATERIALS AND METHODS

An extensive search of available electronic and paper-based databases was performed to identify studies relevant to the treatment of varicose veins with particular emphasis on those published within the last 10 years. These were analysed by both reviewers independently.

RESULTS

There is no single method of treatment appropriate for all cases. Conventional surgery is safe and effective and is still widely practised. Whilst the new treatments may be popular with both surgeons and patients, it is important that they are carefully evaluated not only for their clinical benefits and complications when compared to existing treatments but also for their cost prior to their wider acceptance into clinical practice.

Adjunctive Proximal Vein Ligation with Endovenous Obliteration of Great Saphenous Vein Reflux: Does It Have Clinical Value?

The risk of clot extension to the deep venous system or pulmonary embolism following endovenous great saphenous vein (GSV) obliteration is possibly related to the size of the proximal GSV. Some practitioners therefore exclude endovenous GSV obliteration for veins greater than an arbitrary size, starting as little as 15 mm. Others provide adjunctive proximal GSV ligation either routinely, or in selected patients with large veins. The clinical value of adjunctive proximal GSV ligation is unknown. A survey of either the American Venous Forum or the American College of Phlebology, selected for their pedagogic or long-time experience with endovenous GSV obliteration. Respondent characteristics included obliteration technique (laser, radiofrequency [RF], or foam sclerotherapy), academic status, surgical training, indication for and frequency of adjunctive proximal GSV ligation, and society membership. The incidence of pulmonary embolus (PE) and deep vein thrombus (DVT) was also tallied. Twenty-one thousand nine hundred sixty-five endovenous GSV obliteration cases were reported, 10,290 with a laser (46.8%), 6,275 (28.6%) with RF, and 5,400 (24.6%) with foam. Only two PEs were reported. Of the 34 patients with DVT, at least 11 had only asymptomatic ultrasound evidence of thrombus extension into the femoral vein, and at least five had only calf vein thrombosis. Comparing ligators (7) with non-ligators (15), the only characteristic significantly correlating with adjunctive proximal GSV ligation was whether the respondent had complete general or vascular surgical training; non-surgeons never ligated the saphenous vein (p < .001). There was no difference between outcomes of ligators and non-ligators. Endovenous obliteration of the GSV poses little risk of PE or DVT, no matter what size the proximal GSV. Although these adverse events may be reduced with adjunctive proximal GSV ligation, the results of this study suggest that adjunctive proximal GSV ligation is superfluous in most patients.

Comparação entre o laser endovenoso e a fleboextração total da veia safena interna: resultados em médio prazo

OBJETIVO: Comparar a fotocoagulação endovenosa com laser diodo e a fleboextração total da veia safena interna. MÉTODOS: Trata-se de um estudo prospectivo, controlado e cego de 20 pacientes com varizes sintomáticas e insuficiência bilateral da veia safena interna que foram operados entre março de 2002 e fevereiro de 2004. Para cada caso, foram realizadas aleatoriamente (sorteio) as duas técnicas, sendo uma em cada lado. A avaliação pós-operatória consistiu na aplicação de questionários, exame físico e fotografia digital em todos os pacientes desde o 7º dia de pós-operatório. Também foi realizado controle ultra-sonográfico no 30º dia de pós-operatório e pletismografia a ar no 60º dia após a cirurgia. Este projeto foi aprovado pela comissão de ética, e os pacientes foram incluídos ao assinarem o consentimento pós-informação. Os dados foram submetidos a análise estatística com os programas SPSS e SAS. RESULTADOS: A técnica que utilizou o laser endovenoso apresentou dor semelhante, mas menos edema e menos hematoma durante o pós-operatório. O índice de melhora estética e de satisfação com a cirurgia foi de 100% para as duas técnicas, mas a maioria dos pacientes respondeu que o membro operado com o laser foi o mais beneficiado. Houve melhora do tempo de enchimento venoso nos dois grupos, mas sem diferença significativa entre eles. Durante o seguimento (média de 26 meses), houve um caso de parestesia leve e transitória do lado convencional e somente uma recanalização do lado laser. CONCLUSÃO: A fotocoagulação endovenosa para o tratamento da veia safena interna em pacientes com varizes de membros inferiores é segura e apresenta resultados comparáveis aos da fleboextração convencional.

Incompetent Great Saphenous Veins Treated with Endovenous 1,320-nm Laser: Results for 71 Legs and Morphologic Evolvement Study

BACKGROUND

Endovenous lasers with various wavelengths have been utilized with good outcomes in treating leg varicose veins. The natural history and evolution of treated veins after endovenous procedures, however, have seldom been addressed.

OBJECTIVE

This study determines the efficacy vein ablation and serial venous morphologic evolution of incompetent great saphenous veins (GSVs) after endovenous 1,320-nm laser treatment.

METHODS

Fifty patients with symptomatic varicose veins secondary to GSV insufficiency treated with 1,320-nm endovenous laser ablation were enrolled. The treated varicose veins in each limb were mapped and sized before laser treatment. Vein wall diameters were measured with duplex ultrasound at follow-up visits.

RESULTS

Seventy-one limbs in 50 patients were enrolled. During the mean 13.1-month follow-up, closure of GSVs was observed in 94% of limbs (67/71). Vein diameters at 3 cm below saphenofemoral junction level were reduced to 81% at 2 days, 75% at 1 month, 48% at 3 months, and 39% at 5 months. Average mean duration for treated GSVs to narrow as fibrotic cords (internal diameter,<2.5 mm) was 5.8 months.

CONCLUSION

The endovenous 1,320-nm laser ablation procedures have excellent efficacy in treating incompetent GSVs. This excellent shrinkage behavior may be the basis for nice long-term results of patients treated with 1,320-nm Cooltouch endovenous laser.

Tratamento de varizes com laser endovenoso: estudo prospectivo com seguimento de 39 meses

OBJETIVO: Avaliar os resultados da terapêutica endovenosa com laser no tratamento de varizes primárias. PACIENTES E MÉTODO: No período compreendido entre julho de 2001 e setembro de 2004 (39 meses), 253 pacientes (417 membros) foram tratados ambulatorialmente com laser de diodo de 810 e 980-nm, com energia liberada endovenosamente através de fibra óptica introduzida por punção guiada por eco-Doppler. Foi utilizada anestesia por infiltração intumescente perivasal com solução de lidocaína a 0,2% (50-150 ml). A potência e duração do pulso foram determinadas pelo diâmetro da veia. Os controles foram realizados com eco-Doppler aos 7 dias, 1 mês, 3 meses, 6 meses, 1 ano e, a seguir, anualmente, para avaliar a eficácia do tratamento e os efeitos adversos. RESULTADOS: A oclusão primária da veia safena magna foi obtida em 405 dos 417 membros (97,1%) tratados. Houve reintervenção em 12 casos (2,9%), com sucesso. O tempo médio de observação foi de 18 meses, e, nesse período, a taxa de recidiva global de varizes foi de 7,4%, sendo 6,3% (26 membros) veias colaterais tributárias da crossa e 1,2% (cinco membros) com recanalização da safena magna. Todas as recorrências ocorreram entre o terceiro e o 12º mês. Os efeitos indesejáveis mais freqüentes foram: equimoses (60,6%); dor suportável durante o procedimento (16,1%); hematomas (5,5%); flebite em colaterais não-tratadas (3,4%); hiperpigmentação (2,9%); e parestesia transitória (3,4%). Nenhum caso de tromboflebite da safena magna foi observado. Não houve nenhum caso de trombose venosa profunda ou embolia pulmonar. CONCLUSÃO: O tratamento endovenoso de varizes com laser, conforme descrito, foi eficaz para ocluir a safena magna e seus principais ramos, com efeitos adversos autolimitados e com recorrência inferior a 8% no período de seguimento.

Endovenous Laser Ablation of Saphenous Vein is an Effective Treatment Modality for Lower Extremity Varicose Veins

We present our first experiences with the use of a new minimally invasive treatment of lower extremity varicose veins. We studied the occlusion rates of the great saphenous vein (GSV) with laser ablation, its failure rates, and its complications. Sixty-six limbs in 62 consecutive patients were treated and followed-up for 1 year. All of the patients had incompetent GSV proven by means of duplex scanning. The GSV segment from 2 cm distal to the sapheno-femoral junction to just above the knee was ablated by using laser energy. In addition, all patients had stab avulsions of the varicose veins of the leg with Crochet hooks. All patients were followed post-operatively on the 3rd day, 1 month, 3 months, and 1 year after surgery. All patients were treated as day-case surgeries. Among 62 patients studied, 46 patients were women (74%) and 16 were men (26%). The median age of the patients was 53 years (range 28–69 years). Median operation time was 65 min (range 40–140 min). Successful treatment (total obliteration of the GSV on duplex) was accomplished in 64 of 66 limbs (97%). In two cases, recanalization of the lower one-third of the treated segment of the GSV was noted after 3 months. There were no instances of neuropathy or skin burn. Endovenous laser ablation of varicose veins is effective in inducing thrombotic vessel occlusion and is associated with only minor adverse effects. The procedure seems to be a promising alternative for surgical stripping of the GSV.

Diffuse phlegmonous phlebitis after endovenous laser treatment of the greater saphenous vein

Endovenous laser treatment (EVLT) has become a valuable and safe option in the treatment of varicose veins. Although long-term results are lacking, most patients seem to benefit in the short-term from EVLT. Reported postoperative complications are limited, consisting usually of pain, ecchymosis, induration, phlebitis, or spot skin burn injuries. The most feared complication is an extension of the saphenous thrombus into the femoral vein, with possible pulmonary embolism. Here we report a septic thrombophlebitis after EVLT resulting in a phlegmonous infection of the whole leg that was treated by surgical drainage. Aggressive local therapy and antibiotic treatment resulted in complete resolution of symptoms and eventual satisfactory healing.

Mathematical modeling of endovenous laser treatment (ELT)

Background and objectives

Endovenous laser treatment (ELT) has been recently proposed as an alternative in the treatment of reflux of the Great Saphenous Vein (GSV) and Small Saphenous Vein (SSV). Successful ELT depends on the selection of optimal parameters required to achieve an optimal vein damage while avoiding side effects. Mathematical modeling of ELT could provide a better understanding of the ELT process and could determine the optimal dosage as a function of vein diameter.

Study design/materials and methods

The model is based on calculations describing the light distribution using the diffusion approximation of the transport theory, the temperature rise using the bioheat equation and the laser-induced injury using the Arrhenius damage model. The geometry to simulate ELT was based on a 2D model consisting of a cylindrically symmetric blood vessel including a vessel wall and surrounded by an infinite homogenous tissue. The mathematical model was implemented using the Macsyma-Pdease2D software (Macsyma Inc., Arlington, MA, USA). Damage to the vein wall for CW and single shot energy was calculated for 3 and 5 mm vein diameters. In pulsed mode, the pullback distance (3, 5 and 7 mm) was considered. For CW mode simulation, the pullback speed (1, 2, 3 mm/s) was the variable. The total dose was expressed as joules per centimeter in order to perform comparison to results already reported in clinical studies.

Results

In pulsed mode, for a 3 mm vein diameter, irrespective of the pullback distance (2, 5 or 7 mm), a minimum fluence of 15 J/cm is required to obtain a permanent damage of the intima. For a 5 mm vein diameter, 50 J/cm (15W-2s) is required. In continuous mode, for a 3 mm and 5 mm vein diameter, respectively 65 J/cm and 100 J/cm are required to obtain a permanent damage of the vessel wall. Finally, the use of different wavelengths (810 nm or 980 nm) played only a minor influence on these results.

Discussion and conclusion

The parameters determined by mathematical modeling are in agreement with those used in clinical practice. They confirm that thermal damage of the inner vein wall (tunica intima) is required to achieve the tissue alterations necessary in order to lead the vein to permanent occlusion. However, in order to obtain a high rate of success without adverse events, the knowledge of the vein diameter after tumescent anesthesia is recommended in order to use the optimal energy. As clearly demonstrated by our calculations, both pulsed and continuous mode operations of the laser can be efficient. An interesting observation in our model is that less amount of energy is required in pulsed mode than in continuous mode. Damaging the vein sequentially along its entire length may lead to permanent occlusion. However, the pulsed mode requires a very precise positioning of the fiber after each pullback and the duration of the treatment is much longer. For these reasons, continuous irradiation seems to be preferred by most clinicians. This model should serve as a useful tool to simulate and better understand the mechanism of action of the ELT

Endovenous Ablation of Incompetent Saphenous Veins:A Large Single-Center Experience

PURPOSE

To evaluate the effectiveness of endovenous treatment of symptomatic varicose veins using the endovenous laser (EVL) or radiofrequency (RF) energy over a >3-year follow-up.

METHODS

From February 2002 to August 2005, 981 consecutive patients (770 women; mean age 51 years, range 15-90) with symptomatic varicose veins in 1250 lower limbs underwent endovenous ablation of 1149 great saphenous veins (GSV) and 101 small saphenous veins (SSV) under tumescent anesthesia without intravenous sedation or regional anesthesia. There were 990 GSV and 101 SSV procedures using EVL; 159 GSVs were treated with RF energy. An ultrasound evaluation was performed within 2 weeks of the procedure to evaluate occlusion of the vein, wall thickness, and clot extension into the deep venous system. Follow-up from the first 200 procedures in the series included clinical evaluation and duplex ultrasound scanning at 6 and 12 months and annually thereafter.

RESULTS

Of the 1149 GSVs treated, 39 (3.4%) recanalizations were seen in 33 of the EVL and 6 of the RF procedures for inadequate treatment as judged by ultrasound. There were 9 (9.0%) failures among the 101 SSVs treated with EVL. Overall, both EVL and RF procedures were well tolerated, with only minor complications. One obese patient with ulcer developed pulmonary embolus on the fourth postoperative day. There were no differences between EVL and RF in efficacy or complications. Follow-up at a mean 3 years (range 30- 42 months) in 143 treated limbs showed no neovascularization in the groin.

CONCLUSION

Outcomes with EVL and RF were good, with low complication rates that may be related to the use of local tumescent anesthesia without intravenous sedation.

Comparison of endovenous treatment with an 810 nm laser versus conventional stripping of the great saphenous vein in patients with primary varicose veins

BACKGROUND

Patients with varicose veins seek medical assistance for many reasons, including esthetic ones. The development of suitable and more flexible instruments, along with less invasive techniques, enables the establishment of new therapeutic procedures.

OBJECTIVE

To compare endovenous great saphenous vein photocoagulation with an 810 nm diode laser and the conventional stripping operation in the same patient.

METHODS

Twenty patients selected for operative treatment of primary great saphenous vein insufficiency on duplex scanning were assigned to a bilateral random comparison. In all cases, both techniques were performed, one on each lower limb. Clinically, evaluation was assessed on the seventh, thirtieth, and sixtieth postoperative days. Patients underwent examination with duplex ultrasonography and air plethysmography during the follow-up.

RESULTS

Patients who received endovenous photocoagulation presented with the same pain but fewer swellings and less bruising than the stripping side. Most patients indicated that the limb operated on by laser received more benefits than the other. There was only one recanalization and no adverse effects. The venous filling time showed better hemodynamics in both techniques.

CONCLUSION

The endovenous great saphenous vein photocoagulation is safe and well tolerated and presents results comparable to those of conventional stripping.

Endovenous Ablation of Truncal Veins

The use of endovenous procedures to eliminate saphenous and primary branch reflux has been growing exponentially over the last few years. Although initially developed by dermatologic surgeons, the technique has been embraced by many other specialties including radiology, vascular surgery and anesthesiology. Radiofrequency energy was the first used in 1999 for endovenous ablation. More recently, laser technology targeting hemoglobin (810 nm, 940 nm & 980 nm) and water (1320 nm) have been developed to quickly and effectively treat saphenous reflux, with minimal side effects. The placement of peri-vascular anesthesia, using the tumescent technique, has further streamlined these procedures. The purpose of this article is to review our experience and outline advantages and disadvantages of the various techniques available.

Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications

BACKGROUND

Endovenous laser therapy (EVLT) and radiofrequency ablation (RFA) are new, minimally invasive percutaneous endovenous techniques for ablation of the incompetent great saphenous vein (GSV). We have performed both procedures at the Mayo Clinic during two different consecutive periods. At the time of this report, no single-institution report has compared RFA with EVLT in the management of saphenous reflux. To evaluate early results, we reviewed saphenous closure rates and complications of both procedures.

METHODS

Between June 1, 2001, and June 25, 2004, endovenous GSV ablation was performed on 130 limbs in 92 patients. RFA was the procedure of choice in 53 limbs over the first 24-month period of the study. This technique was subsequently replaced by EVLT, which was performed on the successive 77 limbs. The institutional review board approved the retrospective chart review of patients who underwent saphenous ablation. According to the CEAP classification, 124 limbs were C2-C4, and six were C5-C6. Concomitant procedures included avulsion phlebectomy in 126 limbs, subfascial endoscopic perforator surgery in 10, and small saphenous vein ablation in 4 (EVLT in 1, ligation in 1, stripping in 2). Routine postoperative duplex scanning was initiated at our institution only after recent publications reported thrombotic complications following RFA. This was obtained in 65 limbs (50%) (54/77 [70%] of the EVLT group and 11/53 [20.8%] of the RFA group) between 1 and 23 days (median, 7 days).

RESULTS

Occlusion of the GSV was confirmed in 93.9% of limbs studied (94.4% in the EVLT [51/54] and 90.9% in the RFA group [10/11]). The distance between the GSV thrombus and the common femoral vein (CFV) ranged from -20 mm (protrusion in the CFV) to +50 mm (median, 9.5 mm) and was similar between the two groups (median, 9.5 mm vs 10 mm). Thrombus protruded into the lumen of the CFV in three limbs (2.3%) after EVLT. All three patients were treated with anticoagulation. One received a temporary inferior vena cava filter because of a floating thrombus in the CFV. Duplex follow-up scans of these three patients performed at 12, 14, and 95 days, respectively, showed that the thrombus previously identified at duplex scan was no longer protruding into the CFV. No cases of pulmonary embolism occurred. The distance between GSV thrombus and the saphenofemoral junction after EVLT was shorter in older patients (P = .006, r(2) = 0.13). The overall complication rate was 15.4% (20.8% in the EVLT and 7.6% in the RFA group, P =.049) and included superficial thrombophlebitis in 4, excessive pain in 6 (3 in the RFA group), hematoma in 1, edema in 3 (1 in the RFA group), and cellulitis in 2. Except for two of the three patients with thrombus extension into the CFV, none of these adverse effects required hospitalization.

CONCLUSION

GSV occlusion was achieved in >90% of cases after both EVLT and RFA at 1 month. We observed three cases of thrombus protrusion into the CFV after EVLT and recommend early duplex scanning in all patients after endovenous saphenous ablations. DVT prophylaxis may be considered in patients >50 years old. Long-term follow-up and comparison with standard GSV stripping are required to confirm the durability of these endovenous procedures.

Superficial vein surgery and SEPS for chronic venous insufficiency

Venous insufficiency in its severe forms leads to skin changes which, in turn may be treated by surgical therapy. Interventions are directed towards correction of the underlying abnormal venous physiology. This involves removal of varicose veins and ablation of incompetent axial veins and relevant perforating veins. In performing ablation of saphenous vein reflux, techniques include high ligation with stripping, radiofrequency ablation, endovenous laser therapy, and foam sclerotherapy. Incompetent perforator interruption can be accomplished surgically by subfascial endoscopic perforator surgery (SEPS) or controlled sclerotherapy using ultrasound. A variety of techniques have emerged to manage the varicose veins themselves. Surgical treatment of chronic venous insufficiency with high ligation in the groin and inversion stripping of the great saphenous vein to the knee combined with stab avulsion of varicose veins continues to be the standard in treatment of varicose veins. There are few comparisons of sclerotherapy of perforating veins with SEPS, but SEPS has become the most popular of surgical options.