Randomized clinical trial comparing multiple stab incision phlebectomy and transilluminated powered phlebectomy for varicose veins

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review

PURPOSE OF REVIEW

Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease.

RECENT FINDINGS

Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.

Varicose Vein Treatment by Suction-assisted Shaving Phlebectomy without the Use of Transillumination/Irrigation: A Simple, Quick and Effective Method

Traditional management of saphenous vein incompetency is using high ligation and stripping with multiple stab incision phlebectomies for the varicose tributaries. A number of minimally invasive options have been described, each with their own advantages and disadvantages. We describe a new technique using suction-assisted shaving phlebectomy without transillumination and irrigation in the management of varicose veins.

Pain is a Limiting Factor in Patients Suitable for Transilluminated Powered Phlebectomy

OBJECTIVES

To analyze, perioperatively and in follow-up, transilluminated powered phlebectomy (TIPP), a surgical technique for the treatment of varicose veins.

METHOD

Retrospective study in one medical institution of patients undergoing TIPP between July 2015 and December 2017. Data analyzed included demographic data, surgery, and results. Postoperatively, pain was evaluated by a 10-point visual analogue scale. The Venous Clinical Severity Score (VCSS) was assessed 5-8 weeks following surgery.

RESULTS

Sixty-six patients with extensive varicosities who underwent TIPP were included. Postoperative pain scores were higher in patients undergoing bilateral compared to unilateral TIPP (visual analogue score 7 versus 5; P=0.031). Following surgery, the VCSS improved in 81.8% (54/66) of the patients. However, 39.7% (25/63; data missing in 3 patients) reported that they would not be willing to undergo a similar procedure in the future. Pain was the most common reason for dissatisfaction.

CONCLUSIONS

Transilluminated powered phlebectomy was associated with considerable pain and discomfort in many patients included in this study. For this reason, it should be reserved for a select group of patients in whom other treatment options are limited; TIPP could be considered in the following cases: patients with a large number of varicosities, reoperations, after extensive thrombophlebitis, obesity, or following bariatric surgery.

Transilluminated Powered Phlebectomy in the Treatment of Varicose Veins

Recent trends toward less invasive technologies for treating varicose veins have led to expanding interest in transilluminated powered phlebectomy. Although initial experience with transilluminated powered phlebectomy was variable, with the newer-generation system and modification of technique that allow for slower oscillation speed, higher suction, and extensive tumescence irrigation and drainage, these previous problems have been mostly eliminated. The following report reviews current instrumentation, operative technique, and reported outcomes for transilluminated powered phlebectomy.

Treatment Outcomes and Lessons Learned From Transilluminated Powered Phlebectomy for Varicose Veins in 1034 Patients

INTRODUCTION

Transilluminated powered phlebectomy (TIPP) is a minimally invasive technique of varicose vein removal, which combines irrigated illumination with tumescent anesthesia for ablation of superficial varicosities and endoscopic-powered venous resection. The objective of this study was to analyze treatment outcomes of this treatment modality.

METHODS

A retrospective evaluation of prospectively collected data from all patients undergoing TIPP procedure for symptomatic varicose veins during a recent 12-year period was performed. Pertinent patient demographics, disease classification, perioperative complications, quality of life, and treatment outcomes were collected and analyzed.

RESULTS

A total of 1167 limbs in 1034 patients (mean age, 52.4 years) were treated during the study period. The mean procedure time was 18.4 ± 8.9 minutes (range, 6.0-82.0 minutes). The mean number of incisions for TIPP procedure was 6.3 ± 3.6. All TIPP procedures were technically successful, and no patient required conversion to hook stab phlebectomy. Fifteen (1.5%) patients developed residual or recurrent varicosities, which were treated with sclerotherapy during the follow-up period. Postoperative complications included hematoma at 2 weeks (5.8%), ecchymosis at 2 weeks (32.9%), saphenous neuropathy (0.3%), cellulitis (1.0%), and skin pigmentation (1.9%). There was no postoperative deep vein thrombosis or mortality.

CONCLUSIONS

Transilluminated powered phlebectomy is an effective method for varicose vein removal and is associated with high clinical success and excellent cosmetic results. Meticulous technical steps are critical in achieving successful outcomes while minimizing complications. Technical considerations and lessons learned from our experiences are discussed in this report.

Outcomes associated with ablation compared to combined ablation and transilluminated powered phlebectomy in the treatment of venous varicosities

BACKGROUND

Patients with painful varicose veins and venous insufficiency can be treated by eliminating axial reflux only or by eliminating axial reflux plus phlebectomy with transilluminated powered phlebectomy. This study was undertaken with the aim of determining and improving signs and symptoms of venous disease (measured by venous clinical severity score) and complications (by routine surveillance ultrasound and long-term post-operative follow up) for each treatment strategy.

METHODS

We performed a retrospective evaluation of prospectively collected data from 979 limbs undergoing procedures for significant varicose veins and venous insufficiency from March 2008 until June 2014 performed at a single tertiary referral hospital. Patient demographics, Clinical Etiology Anatomy and Pathophysiology classification, venous clinical severity scores pre- and post-procedure, treatment chosen, and peri-operative complications were collected; descriptive statistics were calculated and unadjusted surgical outcomes for patients stratified by the procedure performed. Multivariable logistic regression was used to evaluate the relationship between procedure type and thrombotic complications after adjusting for patient characteristics, severity of disease, pre-operative anticoagulation, and post-operative compression.

RESULT

Venous clinical severity scores improved more with radiofrequency ablation + transilluminated powered phlebectomy as compared to radiofrequency ablation alone (3.8 ± 3.4 vs. 3.2 ± 3.1, p = 0.018). Regarding deep venous thrombosis, there was no significant difference between radiofrequency ablation + transilluminated powered phlebectomy vs. radiofrequency ablation alone. There was no statistical difference in asymptomatic endovenous heat-induced thrombosis or infection, although there were slightly more hematomas and cases of asymptomatic superficial thrombophlebitis with combined therapy. On multivariable analysis, only procedure type predicted thrombotic complications.

CONCLUSION

Ablation of axial reflux plus transilluminated powered phlebectomy produces improved outcomes as measured by venous clinical severity score, with slight increases in minor post-operative complications and should be strongly considered as initial therapy when patients present with significant symptomatic varicose veins and superficial venous insufficiency. Implementation of a standardized thromboprophylaxis protocol with individual risk assessment results in few significant thrombotic complications amongst high-risk patients, thus potentially obviating the need for routine post-operative duplex.

[Efficiency of minimally invasive methods in treatment of varicose veins]

It was analyzed the results of studies comparing an efficiency of minimally invasive methods in treatment of varicose veins of lower extremities. Based on presented data similar efficiency of minimally invasive methods and conventional surgical treatment was proved. The graph reflecting remote results was made.

Retrospective long-term evaluation of the quality of life and the results of a modified transilluminated powered phlebectomy (TPP) technique

Einleitung: Transilluminierte Powered Phlebektomie (TPP) mit der Trivex-Methode ist mittlerweile eine etablierte Methode zur Behandlung der Seitenastvaricosis. Untersuchungen mit Follow-up-Zeiten bis zu 2 Jahren zeigen, dass die TPP mit weniger Inzisionen auskommt und eine reduzierte Operations-zeit sowie verbesserte kosmetische Ergebnisse aufweist, als die herkömmliche Häkchenphlebektomie. Bisher lassen sich in der Literatur keine langfristigen Follow-up-Untersuchungen/Ergebnisse von mehr als 2 Jahren finden, zudem wurde bisher noch keine systematische Evaluation der gesundheitsbezogenen Lebensqualität nach TPP-Phlebektomie mittels SQOR-V Score durchgeführt.

Material und Methode: Zwischen 2001–02 und 2009–05 wurden 627 Patienten mit Varizen mittels TPP, unter Verwendung einer modifizierten Operationstechnik, in der Praxisklinik Zollikerberg operiert. Insgesamt 141 Patienten dieser Patienten hatten bereits zuvor Krampfadernoperation mit verschiedenen nicht-TPP-Operationsmethoden erlebt. Diese 141 Patienten wurden im Rahmen einer retrospektiven Evaluation angeschrieben. SQOR-V und ein zusätzlicher neuer hausintern entwickelter TPP-Fragebogen wurden verwendet. 69 Patienten erklärten sich mit der Datenerhebung einverstanden (Informed Consent), beantworteten die Fragebögen und wurden in die Analyse inkludiert. Ergebnisse von TPP-Operation und nicht-TPP-Operationen wurden explorativ verglichen. Der postoperative Verlauf (6 Wochen) wurde analysiert, einschließ-lich Prä- und Post-OP-Foto-Dokumentation. Die Patienten wurden für eine Follow-up-Fotodokumentation und klinische Beurteilung in die Klinik eingeladen. 18 Patienten folgten dieser Einladung.

Ergebnisse: Der Follow-Up-Zeitraum betrug maximal 8 Jahre und 2 Monate, minimal 2 Monate (Durchschnitt: 4,58 Jahre, Median: 4,25 Jahre). Der ästhetische Eindruck hatte sich bei 70 % der Patienten nach der TPP-OP mäßig bis sehr verbessert. 87 % der Patienten hatten keine oder lediglich eine minimale Reduktion der Aktivitäten nach der TPP-OP. Keine oder minimale Ödeme wurden von 60 % der Patienten nach der TPP-OP berichtet. Zwei Patienten mit peripherer Thrombose wurden nach TPP-OP beobachtet, aber keine tiefen Venenthrombose. Hingegen erlitten 6 Patienten bei der nicht-TPP-OP tiefe Beinvenenthrombosen. Nach der eigenen Erfahrung mit beiden Arten von Krampfader-Operationen berichteten die Patienten über signifikant weniger Schmerzen nach der TPP-OP (p=0,001). Sie waren statistisch signifikant häufiger mit den Ergebnissen des TPP-OP (82 %) als mit der nicht-TPP-OP (7 %) (p<0,001) zufrieden. Nach nicht-TPP-OPs hatten mehr Patienten Rezidiv-Varizen und venöse Ulzera als nach der TPP-OP (Rezidiv: nicht-TPP 100 % vs. TPP 42 % bzw., Ulcus: nicht-TPP 3 % vs. TPP 1,4 %). Hämatome waren nach der TPP-OP stärker ausgeprägt (starke 35,3 %, moderate 38,2 %) und dauerte länger an (>4 Wochen 39,4 %), als nach der nicht-TP-OP (23,9 %, 43,3 %, >4 Wochen 32,4 %). Pigmentierungen wurden häufiger nach der TPP-OP (31 %) als nach nicht-TPP-OP (18 %) beobachtet.

Diskussion: Die Zufriedenheit mit den ästhetischen Ergebnissen der TPP-OP und die geringeren Schmerzen nach der TPP-OP waren statistisch signifikant besser als bei nichtTPP-OP. Klinisch wichtig ist die reduzierte Anzahl der Rezidiv-Varizen und die kleinere Zahl von Komplikationen nach der TPP-OP. Nachteilig sind die Hämatome und die Pigmentierungen, die jedoch überraschend gut toleriert wurden. Um diese vielversprechenden Ergebnisse zu bestätigen, sollten randomisierte klinische Studien durchgeführt werden.

Treatment of varicose veins by transilluminated powered phlebectomy surgery: a 9-year experience

Transilluminated powered phlebectomy (TIPP) is a minimally invasive technique for varicose vein removal that addresses some limitations of traditional procedures. The study objective was to analyze perioperative and follow-up outcomes after TIPP and present modifications gleaned over 9 years of performing the technique. Four hundred and thirty-one patients who underwent TIPP performed between June 2002 and April 2011 were included in this retrospective review. Descriptive statistics were used to describe demographic, treatment, and outcome data. The mean procedure time was 20.2 minutes. The majority (50.5%) of cases involved 10 to 20 incisions. No significant varicosities were reported at a follow-up of 12 weeks. Postoperative complications included 2 (0.5%) deep vein thromboses, 8 (1.9%) cellulitis episodes, 16 (3.7%) hemosiderin staining cases, 2 (0.5%) abscesses, and 2 (0.5%) cases of excessive or hypertrophic scarring. All but one patient reported good outcomes and were satisfied with the procedure. With proper training and experience, TIPP with a lower oscillation frequency and secondary tumescence results in good outcome and high patient satisfaction.

Treatment of varicose veins by transilluminated powered phlebectomy surgery: a 9-year experience

Transilluminated powered phlebectomy (TIPP) is a minimally invasive technique for varicose vein removal that addresses some limitations of traditional procedures. The study objective was to analyze perioperative and follow-up outcomes after TIPP and present modifications gleaned over 9 years of performing the technique. Four hundred and thirty-one patients who underwent TIPP performed between June 2002 and April 2011 were included in this retrospective review. Descriptive statistics were used to describe demographic, treatment, and outcome data. The mean procedure time was 20.2 minutes. The majority (50.5%) of cases involved 10 to 20 incisions. No significant varicosities were reported at a follow-up of 12 weeks. Postoperative complications included 2 (0.5%) deep vein thromboses, 8 (1.9%) cellulitis episodes, 16 (3.7%) hemosiderin staining cases, 2 (0.5%) abscesses, and 2 (0.5%) cases of excessive or hypertrophic scarring. All but one patient reported good outcomes and were satisfied with the procedure. With proper training and experience, TIPP with a lower oscillation frequency and secondary tumescence results in good outcome and high patient satisfaction.

Outcome of transilluminated powered phlebectomy for varicose vein: review of 299 patients (447 limbs)

PURPOSE

Varicose vein incompetence in the legs is very prevalent in the Korean population. New technologies and improvements in established methods have changed the treatment of varicose veins. Transilluminated powered phlebectomy is an alternative surgical technique that combines endoscopic powered vein resection and ablation of superficial varicosities with tumescent anesthesia and irrigated illumination. The present study sought to determine the clinical efficacy and safety of transilluminated powered phlebectomy from clinical data.

METHOD

Four hundred and forty-seven limbs in 299 patients (157 male, 142 female; mean age 50.6 years) with varicose veins were treated with transilluminated powered phlebectomy over a 7-year period. The patients were followed for 1 year postoperatively. The analyzed data included sex, age, body mass index, operative time (from skin incision to the application of elastic bandages on the legs for compression purposes), and postoperative complications.

RESULTS

The mean operative time was 87.2 min for both limbs and 57.3 min for single limbs. The median number of incisions was five. Postoperative complications included an episode of cellulitis in 10 patients (2.2%), wound abscess in two patients (0.4%), hematoma in 15 patients (3.4%), residual veins in five patients (1.1%), cutaneous nerve damage in 10 patients (2.2%), and seroma in 13 patients (2.9%). No skin perforation and deep venous thrombosis were observed at the 1-year follow-up.

CONCLUSION

Transilluminated powered phlebectomy is an effective and safe method for the excision of varicosities.

Varicose vein: current management

The continued advancement of RFA and EVLS technology should provide for an increased safety profile and lasting efficacy for treating the major saphenous veins. The challenge lies in determining what type of patient comorbidities and anatomic variability result in higher recurrences after endothermal varicose vein treatment so that one can modify the choice of treatment appropriately. Further standardization of the FS technique may allow for its wider use in treating truncal varicosities. The powered phlebectomy system seems to be suited for isolated branch varicosities, but the sequelae of pain and ecchymosis may prevent it from becoming a mainstream treatment with stab phlebectomy and sclerotherapy as alternatives.

Randomized clinical trial of different bandage regimens after foam sclerotherapy for varicose veins

BACKGROUND

This trial compared outcomes after foam sclerotherapy in patients wearing compression bandaging for 24 h or 5 days after treatment.

METHODS

Consecutive patients with primary uncomplicated varicose veins were randomized after foam sclerotherapy treatment. The primary endpoint was 6-week Aberdeen Varicose Vein Severity Score (AVVSS) and Burford pain score.

RESULTS

Some 124 legs were randomized, 61 to 24 h and 63 to 5 days of bandaging. Target vein occlusion rates at 6-week duplex imaging were 90 and 89 per cent respectively (P = 0.842). There was no significant difference in phlebitis after 2 weeks (P = 0.445) or skin discoloration after 6 weeks (46 versus 40 per cent; P = 0.546). There was no significant difference in the change in AVVSS from baseline to 2 weeks (-0.29 versus -0.80; P = 0.717) or to 6 weeks (-5.89 versus -5.14; 95 per cent confidence interval (c.i.) for the difference -3.29 to 1.80; P = 0.563), or in change in Burford pain score from baseline to 2 weeks (-9.04 versus -2.80; P = 0.248) or to 6 weeks (-17.32 versus -8.46; 95 per cent c.i. for the difference -19.06 to 1.33; P = 0.088), or in change in Short Form 36 score from baseline to 6 weeks (2.02 versus 1.74; P = 0.903).

CONCLUSION

There was no advantage to compression bandaging for more than 24 h when thromboembolus deterrent stockings were worn for the remainder of 14 days.

REGISTRATION NUMBER

NCT00991497 (http://www.clinicaltrials.gov).

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.

Article Commentary: Chronic Venous Insufficiency: Current Management of Varicose Vein Disease

This review encompasses the basic pathophysiology, diagnosis, and current therapies for superficial venous insufficiency.

Interventions for uncomplicated varicose veins

Objective

To review the evidence regarding interventions (compression, sclerotherapy, surgery and endoluminal) for uncomplicated venous disease.

Method

A literature search of MEDLINE and EMBASE was performed. In addition, bibliographies of published data and the Cochrane Peripheral Vascular Review Group Specialist Register were examined. Publications describing an intervention for uncomplicated venous disease or trials comparing one intervention against another were considered.

Results

Uncomplicated but symptomatic varicose veins are associated with a significant reduction in quality of life (QoL). Evaluation must include a detailed history and examination supported by non-invasive imaging. Although HHD is useful, its utility is limited in the popliteal fossa. It can not provide morphological/anatomical detail when considering an endoluminal treatment option. Regardless of intervention, all treatments considered are associated with a significant improvement in QoL at acceptable cost.

Conclusion

Uncomplicated symptomatic varicose veins lead to a reduced QoL, which can be significantly improved by all interventions considered.

Standard varicose vein surgery

This article examines the practice of standard varicose vein surgery including sapheno-femoral and sapheno-popliteal ligation, perforator surgery and surgery for recurrent varicose veins. The technique of exposure of the sapheno-femoral junction and the sapheno-popliteal junction is outlined and advice given on avoidance of complications for both. The evidence regarding methods of closure over the ligated sapheno-femoral junction is examined as is the requirement for stripping and the use of different types of stripper. The requirement to strip the small saphenous vein and the extent of dissection necessary in the popliteal fossa is also examined. Complications of standard varicose vein surgery are outlined. The frequency of wound infection, nerve injury, vascular injury and venous thromboembolism are listed and strategies to avoid these complications are examined.

Transilluminated powered phlebectomy surgery for varicose veins: a review of 339 consecutive patients

Transilluminated powered phlebectomy (TIPP) is a promising alternative to traditional ambulatory phlebectomy procedures. This retrospective review of 339 patients represents the senior author's first consecutive series of 400 cases performed using TIPP for the treatment of varicose veins in a 6-year period. Patients were followed for 12 weeks postoperatively. Data analyzed included operative time, intraoperative complications, stab incision ranges, postoperative complications, and patient satisfaction. The mean operative time was 19.7 minutes, and 246 (61.5%) cases involved 10 to 20 incisions. Postoperative complications included an episode of symptomatic deep vein thrombosis in one (0.3%) patient, excessive or hypertrophic scarring in two (0.6%) patients, discoloration of the lower extremity skin due to hemosiderin staining in eight (2.3%) patients, and cellulitis in one (0.3%) patient. No recurrences were observed at a follow-up of 12 weeks. Three hundred thirty-eight (99.7%) patients reported good outcomes and were satisfied with the procedure. This review by an individual surgeon is beneficial in analyzing the outcomes and complications associated with TIPP, as a standard protocol was followed and an adequate volume was performed to advance past the learning curve associated with the technique. When concomitant saphenous vein incompetence is present, staged treatment of varicosities with TIPP after endovenous laser ablation is recommended. With proper training and experience, utilization of TIPP with a lower oscillation frequency and secondary tumescence results in good outcome and high patient satisfaction.