Randomized clinical trial of the effect of adding subfascial endoscopic perforator surgery to standard great saphenous vein stripping

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.

The 2022 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 I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology

The Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society collaborated to update the 2011 Society for Vascular Surgery/American Venous Forum clinical practice guidelines and provide new evidence-based recommendations on critical issues affecting the care of patients with varicose veins. Each recommendation is based on a recent, independent systematic review and meta-analysis of the diagnostic tests and treatments options for patients with lower extremity varicose veins. Part I of the guidelines includes evidence-based recommendations for the evaluation of patients with CEAP (Clinical Class, Etiology, Anatomy, Pathology) class 2 varicose vein using duplex ultrasound scanning and other diagnostic tests, open surgical treatment (ligation and stripping) vs endovenous ablation techniques, thermal vs nonthermal ablation of the superficial truncal veins, and management of incompetent perforating veins in CEAP class 2 disease. We have also made recommendations on the concomitant vs staged treatment of varicose tributaries using phlebectomy or liquid or foam sclerotherapy (with physician-compounded foam or commercially prepared polidocanol endovenous microfoam) for patients undergoing ablation of incompetent superficial truncal veins.

A systematic review and meta-analysis of concomitant truncal and perforator surgery

OBJECTIVE

Incompetent perforator veins are encountered frequently during ultrasound assessment of the venous system in chronic venous disease. Some studies have shown that concomitant treatment of truncal and perforator incompetence improves ulcer healing, yet a Cochrane review was unable to determine the potential benefits of perforator surgery in venous ulcer management due to poor quality evidence. This study aims to establish the exact role of concomitant treatment in patients with chronic venous disease.

METHODS

A search of online databases including MEDLINE, Embase, and Cochrane was performed in March 2022. All studies comparing the outcomes of concomitant superficial venous plus perforator surgery with standard therapy were included. Variables assessed included ulcer healing, time to healing, and ulcer recurrence. Disease severity and quality of life, vein occlusion rates, number of incompetent perforator veins on duplex ultrasound post treatment, and reintervention and complication rates were also analyzed. Data were pooled using a random effects model.

RESULTS

Seven studies (872 limbs) were included for analysis. Included studies were of reasonable methodological quality. Ulcer healing rates were similar in each group (relative risk [RR], 1.07; 95% confidence interval [CI] 0.96-1.19; P = .23). Two studies reported no difference in mean time (days) to ulcer healing between groups (mean difference, -14.60; 95% CI, -34.57 to 5.38; P = .15; I² = 0%; P = .56). Ulcer recurrence was significantly lower in the concomitant group (3.7% vs 44%) (RR, 0.21; 95% CI, 0.07- 0.65; P = .007; I² = 43%; P = .17). Overall, there was no difference in disease severity measured at 12-month follow-up, with a weighted mean difference between groups of -0.88 (95% CI, -2.05 to 0.29; P = .14; I² = 84%; P = .002). Quality of life was reported in only one study. The total number of perforator veins identified at follow-up duplex ultrasound was significantly lower in the concomitant group (22.4% vs 89%) compared with standard therapy (RR, 0.31; 95% CI, 0.19-0.53; P < .0001; I² = 88%; P = .0002). There was no difference between groups for occlusion rates of treated great saphenous vein or incompetent perforators (RR, 2.22; 95% CI, 0.10-49.74; P = .61). Reported minor (RR, 0.98; 95% CI, 0.63-1.52; P = .92) and thrombotic complications (RR, 2.04; 95% CI, 0.59-6.99; P = .26) were similar between groups.

CONCLUSION

Concomitant truncal and perforator surgery is comparable to standard therapy in terms of ulcer healing, safety, and efficacy. Meta-analysis suggests that concomitant treatment could significantly reduce ulcer recurrence rates, but included studies were subject to some biases and short follow-up. Concomitant treatment may be considered to prevent recurrence rather than improve ulcer healing.

Current Best Practice in the Management of Varicose Veins

This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.

Systematic review and meta-analysis of the management of incompetent perforators in patients with chronic venous insufficiency

OBJECTIVE

Incompetent perforator veins (IPVs) contribute to venous pathology and are surgically treated based on hemodynamic measurement, size, and Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) classification. The objective of this study was to systematically review and synthesize current literature regarding surgical management of IPVs, including open ligation, subfascial endoscopic perforator surgery (SEPS), endovascular laser ablation (EVLA), ultrasound guided sclerotherapy (USGS), and radiofrequency ablation (RFA).

METHODS

English-language literature published prior to November 2021 was reviewed from the PubMed, EMBASE, and MEDLINE databases for primary literature reporting safety and efficacy outcomes in the surgical treatment of incompetent perforating veins. Study quality and risk of bias was assessed using the Cochrane risk-of-bias tool for comparative studies and a modified version of the Newcastle-Ottawa Scale for non-comparative studies. A random effects model was used to pool effect sizes for efficacy outcomes of wound healing and freedom from wound recurrence.

RESULTS

A total of 81 studies were included for qualitative synthesis representing 7010 patients with a mean age of 54.7 years. Overall evidence quality was low to intermediate, with moderate to high risk of bias in comparative studies. There was an 11.3% complication rate across interventions, with no reported incidences of stroke or air embolism. With regards to efficacy, pooled estimates for short-term (up to 1-year) wound healing were 99.9% for USGS (95% CI 0.81 - 1), 72.2% for ligation (95% CI 0.04, 0.94) and 96.0% for SEPS (95% CI 0.79 -0.99). For short-term freedom from wound recurrence, the pooled estimate for SEPS is 91.0% (95% CI 0.3 - 0.99).

CONCLUSION

Current evidence regarding treatment of incompetent perforator veins is limited due to low adherence to reporting standards in observational studies and lack of randomization, blinding, and allocation concealment in comparative studies. Additional comparative studies are needed to guide clinical decision-making regarding invasive treatment options for incompetent perforator veins.

Treatment of chronic venous disorder: A comprehensive review

Chronic venous disorder (CVD) is highly prevalent vascular disorder affecting up to 45% of the general population, with clinical manifestations ranging from teleangiectasias to venous leg ulcers (VLUs). We examined the currently available data in order to provide an updated, comprehensive review on treatment options of CVD. We searched MEDLINE, Cochrane, Scopus, EMBASE, ClinicalTrials, and OpenGrey databases for relevant articles in English published until November 2020. Compression treatment is the mainstay of conservative treatment. Pharmacological treatment can provide significant symptomatic relief and hence it should be considered as part of conservative treatment. Transcutaneous Lacer treatment (TCL) is a safe and effective alternative option to sclerotherapy for treatment of C1 stage. High ligation and stripping (HL/S), ultrasound-guided foam sclerotherapy (UGFS), endovenous thermal ablation (EVTA) systems and non thermal non tumescent ablation (NTNT) systems are safe and efficacious first-line options for treatment of saphenous insufficiency. Interventional treatment of co-existing incompetent perforator veins (IPVs) is not supported by contemporary evidence. Regarding deep venous insufficiency (DVI), treatment of symptomatic femoroiliocaval occlusive venous disease refractory to conservative treatment with percutaneous transluminal venoplasty stenting has produced encouraging results.

A systematic review supporting the Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society guidelines on the management of varicose veins

BACKGROUND

Several diagnostic tests and treatment options for patients with lower extremity varicose veins have existed for decades. The purpose of this systematic review was to summarize the latest evidence to support the forthcoming updates of the clinical practice guidelines on the management of varicose veins for the Society for Vascular Surgery (SVS), the American Venous Forum (AVF) and the American Vein and Lymphatic Society.

METHODS

We searched multiple databases for studies that addressed four clinical questions identified by the AVF and the SVS guideline committee about evaluating and treating patients with varicose veins. Studies were selected and appraised by pairs of independent reviewers. A meta-analysis was conducted when feasible.

RESULTS

We included 73 original studies (45 were randomized controlled trials) and 1 systematic review from 12,915 candidate references. Moderate certainty of evidence supported the usefulness of duplex ultrasound (DUS) examination as the gold standard test for diagnosing saphenous vein incompetence in patients with varicose veins and chronic venous insufficiency (clinical, etiological, anatomic, pathophysiological classification [CEAP] class C2-C6). High ligation and stripping (HL/S) was associated with higher anatomic closure rates at 30 days and 5 years when compared with radiofrequency ablation and ultrasound-guided foam sclerotherapy (UGFS) (moderate certainty), while no significant difference was seen when compared with endovenous laser ablation (EVLA) at 5 years. UGFS was associated with an increased risk of recurrence compared with HL/S. EVLA was associated with lower anatomic closure rates at 30 days than cyanoacrylate closure (CAC) and higher rates at one and 5 years when compared with UGFS. Thermal interventions were associated with lower generic quality of life scores and an increased risk of adverse events when compared with CAC or n-butyl cyanoacrylate (low certainty). Thermal interventions were associated with a lower risk of recurrent incompetence when compared with UGFS and an increased risk of recurrent incompetence than CAC. The evidence for great saphenous vein ablation alone to manage perforator disease was inconclusive.

CONCLUSIONS

The current systematic review summarizes the evidence to develop and support forthcoming updated SVS/AVF/American Vein and Lymphatic Society clinical practice guideline recommendations. The evidence supports duplex scanning for evaluating patients with varicose veins and confirms that HL/S resulted in similar long-term saphenous vein closure rates as EVLA and in better rates than radiofrequency ablation and UGFS. Thermal interventions were associated with inferior generic quality of life scores than nonthermal interventions, but had a lower risk of recurrent incompetence than UGFS. The recommendations in the guidelines should consider this information as well as other factors such as patients' values and preferences, anatomic considerations of individual patients, and surgical expertise.

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.

Transilluminated powered phlebectomy in the treatment of large area venous leg ulcers: A case-control study with 3 years follow-up

OBJECTIVE

To evaluate the efficacy, safety and long-term outcome of TIPP for the adjunct therapy of superficial venous reflux-related VLUs.

METHODS

A total of 93 consecutive patients (104 legs) with superficial venous insufficiency-related VLUs who underwent TIPP (53 legs) or conventional phlebectomy (51 legs) between January 2010 and December 2013 were retrospectively studied.

RESULTS

Compared to patients in the conventional phlebectomy group, TIPP patients had larger ulcer areas before surgery (P < 0.005). However, TIPP group required a significantly shorter operation time (P < 0.005), fewer incisions (P < 0.005) but less ulcer healing time (1.25 month vs 2.5 months, P < 0.05). No significant difference in in-hospital and follow-up complications was found between the two groups. For long-term outcome, TIPP group leaded a lower ulcer recurrence rate at 36 months (13.2% vs 29.4%, P < 0.05).

CONCLUSION

TIPP may be an adjunct surgical method contributes to healing of VLUs, especially for large ulcer areas.

Great uncertainty regarding treatment of varicose vein recurrence

Introduction: Although varicose vein recurrence is common and 10–30 % of all varicose vein surgery is done for recurrence of some sort, there are very few studies that can guide us to the best re-treatment option. With the introduction of minimal invasive endovenous treatments there is a variety of possible options besides traditional open surgical techniques.

Method: The Scandinavian Venous Forum held a symposium at the GSP meeting in Lü-beck 2012 and this review article is based on data from the presentations at that symposium. Further data has been added regarding new knowledge that was not available a year ago, from PubMed search and article references.

Results: The most common reasons for recurrence are discussed and also the discrepancy between neovascularization (NV) and recurrence due to technical failures. It is likely that NV is the most commonly duplex detected type of recurrence following open groin surgery, less common early after endovascular techniques. However, technical or tactical failures are the most common reasons for redo surgery because of symptomatic recurrence. NV seldom leads to symptomatic recurrences and thus a need for re- treatment. There is a risk that the stumps left following endovenous treatments will become a source for symptomatic recurrence after 5–10 years and indications of that have been reported in the few available 5 year RCT-reports following laser treatments. Treatment of recurrence due to stumps in the groin can be done safely within a reasonable operating time through a medial approach and the stump itself can generally not be treated with any of the endovenous alternative methods. Foam treatment can be used for most other recurrent veins but the durability is unknown. Endovascular thermal ablation can only be used for reopened or remaining saphenous veins and accessory saphenous veins while tributaries have to be treated by stab excisions or foam.

Conclusion: Long term reports of results of redo surgery are limited but suggest reasonably good results from open surgical intervention and are non-existent for the endovenous techniques. So far groin recurrence seems best treated surgically by an indirect approach, preferably medial. More studies are needed to find the best treatment regime for varicose vein recurrence in general and hybrid procedures might be the way forward by combinations of different techniques.

Surgical methods and clinical results of subfascial endoscopic perforator surgery in Japan

Objectives

To clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan.

Methods

This study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively.

Results

Preoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 ( P < .0001) postoperatively. The primary ulcer healing rate was 96.2% (332/345 C6 limbs) at an average follow-up of 47.7 months, and the ulcer recurrence rate was 12.0% (49/393 C5, C6 limbs) at the average follow-up of 46.0 months after the ulcer healed.

Conclusion

These results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome.

One-year results of the use of endovenous radiofrequency ablation utilising an optimised radiofrequency-induced thermotherapy protocol for the treatment of truncal superficial venous reflux

Background

In previous in vitro and ex vivo studies, we have shown increased thermal spread can be achieved with radiofrequency-induced thermotherapy when using a low power and slower, discontinuous pullback. We aimed to determine the clinical success rate of radiofrequency-induced thermotherapy using this optimised protocol for the treatment of superficial venous reflux in truncal veins.

Methods

Sixty-three patients were treated with radiofrequency-induced thermotherapy using the optimised protocol and were followed up after one year (mean 16.3 months). Thirty-five patients returned for audit, giving a response rate of 56%. Duplex ultrasonography was employed to check for truncal reflux and compared to initial scans.

Results

In the 35 patients studied, there were 48 legs, with 64 truncal veins treated by radiofrequency-induced thermotherapy (34 great saphenous, 15 small saphenous and 15 anterior accessory saphenous veins). One year post-treatment, complete closure of all previously refluxing truncal veins was demonstrated on ultrasound, giving a success rate of 100%.

Conclusions

Using a previously reported optimised, low power/slow pullback radiofrequency-induced thermotherapy protocol, we have shown it is possible to achieve a 100% ablation at one year. This compares favourably with results reported at one year post-procedure using the high power/fast pullback protocols that are currently recommended for this device.

Five-year results of a randomized controlled trial comparing high ligation combined with endovenous laser ablation and stripping of the great saphenous vein

PURPOSE

To report 5-year follow-up data of a randomized study comparing high ligation and stripping (HL + S) with high ligation and endovenous laser ablation (HL + EVLA) of the great saphenous vein (GSV).

METHODS

One hundred patients were randomized. After 5 years, patient satisfaction with the overall result, CEAP-C class, VCSS, CIVIQ2 quality of life score, and recurrence rate were assessed (clinical examination and duplex ultrasound).

RESULTS

Five-year follow-up rates were 83% HL + S and 68% HL + EVLA. Patient satisfaction with the overall result was rated good or very good by 88% after HL + S and 87% after HL + EVLA. There were significant improvements for both groups in CEAP-C class (HL + S 2.28 vs. 1.19; HL + EVLA 2.3 vs. 1.17), VCSS (HL + S 4.79 vs. 1.81; HL + EVLA 4.13 vs. 1.87), and CIVIQ2 score (HL + S 82 vs. 94; HL + EVLA 75 vs. 93) (p < .001). There was no difference in recurrence rates on clinical examination and duplex ultrasound (HL + S 55% vs. HL + EVLA 40%; p = .217). A reopened or residual incompetent GSV-partial or complete-was found in 24% (HL + S) and 40% (HL + EVLA), respectively (p = .141).

CONCLUSION

Varicose vein surgery is followed by favorable clinical results and high patient satisfaction, with no difference between HL + S and HL + EVLA.

Debate: whether venous perforator surgery reduces recurrences

Superficial venous surgery and perforator vein surgery, specifically, have a long and varied history in the evolution of vascular surgery, especially because venous disease continues to be extremely common. As with other areas of our specialty, perforator vein procedures have progressed from being purely open operations to becoming less invasive procedures. Despite this, there remains much discussion (as well as overt disagreement) about whether perforator vein surgery is actually appropriate and beneficial in the first place. Surgeons have no level I evidence from randomized controlled studies to determine whether perforator vein surgery does or does not reduce the chances of recurrence of superficial venous varicosities, so we must rely on the evidence as it currently is. Perhaps not surprisingly, our two experts have assembled divergent opinions on the role of perforator venous surgery in contemporary practice.

Subfascial endoscopic perforator surgery for posterolateral perforators performed in the prone position

OBJECTIVES

Subfascial endoscopic perforator surgery (SEPS) is usually performed for posteromedial perforators in the supine position, but subfascial endoscopic perforator surgery for posterolateral perforators in the prone position has not been reported.

METHODS

A 51-year-old male suffered from a venous stasis ulcer around his lateral malleolus because of reflux in the small saphenous vein and incompetent perforating veins around the ulcer.

RESULTS

Stripping of the small saphenous vein and subfascial endoscopic perforator surgery utilizing screw-type ports was successfully conducted in the prone position.

CONCLUSIONS

The prone position enables interruption of the posterolateral perforators, because gravity-dependent flattening of the muscles enables creation of sufficient subfascial space.

Treatment of primary varicose veins has changed with the introduction of new techniques

New technologies have produced a revolution in primary varicose vein treatments. Duplex ultrasound is now used for preoperative diagnosis, postoperative surveillance, and during many procedures. Ultrasound has also altered our understanding of the pathophysiology of chronic venous disease. Laser and radiofrequency saphenous ablations are common. Classic techniques, such as sclerotherapy, high ligation, stripping, and phlebectomy, have been improved. Magnetic resonance venography, computed tomographic venography, and intravascular ultrasound have improved diagnostic capabilities. New strategies like ambulatory selective varices ablation under local anesthesia (ASVAL) and conservative hemodynamic treatment for chronic venous insufficiency (CHIVA) raise important questions about how to manage these patients.

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.

Subfascial endoscopic perforator surgery using screw-type ports is a very useful component of a comprehensive treatment program for chronic venous insufficiency

BACKGROUND

Subfascial endoscopic perforator surgery (SEPS) with a two-port system utilizing screw-type ports, CO2 insufflation and an ultrasonic coagulation system, is a useful procedure that does not require burdensome apparatus and techniques. SEPS was accepted as a national advanced medical system by the Japanese Ministry of Health, Labor and Welfare in May 2009.

PATIENTS AND METHODS

Forty-one limbs of 35 patients with 10 active ulcers (C6) and 2 healed ulcers (C5) were treated by SEPS between February 2010 and December 2011. Thirty-three limbs had concomitant superficial vein surgery. SEPS alone was performed on 8 limbs, in 6 of which the superficial veins had already been ablated. In 2 limbs, incompetent perforating veins (IPVs) existed under the affected skin, around the scars of past surgery.

RESULTS

All stasis ulcers of the 10 C6 limbs healed between 1 week and 14 months after SEPS (mean 2.9 months), with no ulcer recurrence during the follow-up period (2 to 24 months). IPVs under the scars were easily and safely interrupted by SEPS.

CONCLUSION

SEPS is a very useful component of a comprehensive treatment program for chronic venous insufficiency, especially in patients with venous stasis ulcers and IPVs under the scars of past surgery.

Early results from a randomized trial of saphenous surgery with or without subfascial endoscopic perforator surgery in patients with a venous ulcer

Background

The aim was to clarify the role of incompetent perforators (IPs) in venous leg ulcers. This short-term report focused on safety, patient satisfaction and the fate of IPs after subfascial endoscopic perforator surgery (SEPS), or saphenous surgery alone.

Methods

Patients aged 30–78 years with an open or recently healed venous ulcer, and with an incompetent saphenous vein and IPs, were allocated randomly to saphenous surgery alone, or in combination with SEPS. A control duplex scan was performed 6–9 months after surgery, and clinical follow-up was scheduled after 1 week, 3 and 12 months. A standard questionnaire was completed at each clinical visit.

Results

Seventy-five patients were enrolled; 37 had SEPS and 38 had saphenous surgery alone. SEPS prolonged the operation by a median of 15 min (P = 0·003). Duplex imaging revealed significantly more remaining IPs in the no-SEPS group (P &lt; 0·001). Compared with the preoperative scan, significantly more legs were free from IPs in the SEPS group compared with the no-SEPS group (21 of 36 versus 7 of 37 respectively; P &lt; 0·001). There were no other major outcome differences between the groups.

Conclusion

There was no short-term clinical benefit from adding SEPS to saphenous surgery in patients with varicose ulcers and IPs, although SEPS reduced the number of perforators remaining after 1 year.

One-year outcomes of radiofrequency ablation of incompetent perforator veins using the radiofrequency stylet device

Objectives

Early success treating incompetent perforator veins (IPVs) with radiofrequency ablation (RFA) and the trend to move varicose vein surgery into a walk-in walk-out service led to the design of a specific device enabling RFA of IPVs using local anaesthesia (ClosureRFS™ stylet). Our aim was to assess one-year outcomes of a clinical series of patients undergoing treatment with this device. Truncal reflux, where present, was treated initially, and RFA of IPVs was performed as a secondary procedure.

Method

Duplex ultrasound examinations were performed and the presence of IPVs documented. Results were compared with preoperative scans. IPVs were classified as closed, not closed/reopened or de novo.

Results

Of the 75 patients invited for follow-up, 53 attended at a median time of 14 months (range 11–25). Sixty-seven limbs were analysed (M:F 1:2.1, median age 62, range 25–81). Of the 124 treated IPVs, 101 were closed (82%). Clinical, aetiological, anatomical and pathological clinical score was improved in 49.3% limbs. IPV closure was reduced in patients with recurrent varicose veins compared with primary varicose veins (72.3% versus 87%, P = 0.056).

Conclusion

These results demonstrate the radiofrequency stylet device to be an effective treatment for IPVs.

The role of perforators in chronic venous insufficiency

Thesis

Venous ulcers (VU) consume considerable resources in healthcare systems, up to 1% of healthcare budgets in industrialized countries. Best practice guidelines (GLs) incorporate evidence-based diagnostic and therapeutic recommendations in a cost-effective manner and have been associated with improved and less costly outcomes for many diseases.

Objectives

To determine whether there are common elements in GLs for VU and their evidentiary strength.

Methods

A systematic analysis of GLs for VU that were identified through clinicaltrials.gov, a government-sponsored website, and from experts outside the USA.

Results

Ten of 12 GLs on VU (7 North America and 5 Europe) were evidence-based, with the majority using the GRADE method. Only two had been developed or updated within the last three years. Venous duplex and ankle ABIs were recommended in all. Debridement was suggested in two, while simple non-adherent wound dressings were favoured in nine, and hydrocolloid in two. Only one GL discussed a range of dressing options, dependent on the condition of the VU. High pressure multi-layer compression bandages were favoured in 10. Only two focused on the importance of improving ankle joint mobility.

Conclusions

While there are numerous evidence-based GLs for VU, the majority may lag recent developments in the field. There is consensus on the elements for dressings and compression among the various GLs, which should facilitate the development of a common consensus GL, similar to that for DVT/PE. To improve patient care and reduce wasted resources, it is imperative for specialty societies to develop this consensus document.

Treatment of incompetent perforating veins using the radiofrequency ablation stylet: a pilot study

BACKGROUND

Although the role of incompetent perforating veins (IPV) in chronic venous insufficiency remains controversial, they are often treated by surgical or by minimal invasive techniques.

OBJECTIVES

To describe the procedure of radiofrequency ablation (RFA) of IPV and to evaluate its short-term effectiveness and safety.

METHODS

In a clinical pilot study, 14 IPV in 12 patients were treated with a radiofrequency stylet. After three months, ultrasound (US) examination was used to assess anatomical success rate and exclude deep venous thrombosis. Also, self-reported side-effects were investigated.

RESULTS

Of the 14 treated IPV, nine (64%) were obliterated on US examination and the others showed remaining reflux. Two patients reported localized paresthesia, but no deep venous thrombosis was recorded.

CONCLUSION

RFA of IPV may be a promising procedure, but patient and incompetent perforator vein selection is important and further standardization of the procedure is required. Comparative clinical trials between RFA and other therapies are warranted.

Five-year results of incompetent perforator vein closure using TRans-Luminal Occlusion of Perforator

Objective

To audit the five-year outcome of the TRLOP technique as indicated by the rate of IPV closure on duplex ultrasound (DUS).

Methods

Patients underwent DUS five years post-TRLOP. Experienced vascular technologists documented the presence of IPVs using a two co-ordinate system, blinded to previous results. Results were then compared with preoperative scans. IPVs were classified as: closed; not closed/reopened; or de novo. Closed IPVs were defined as the absence of any IPV at or within 5 cm of a previous IPV in the vertical and horizontal plane. Any IPVs found outside the delineated area were defined as de novo IPVs.

Results

Of 67 patients invited, 37 attended DUS (55% participation rate; men to women ratio of 14:23, age 40–84; mean 64). Preoperative clinical, aetiological, anatomical and pathological classification: C2, 36.2%; C3, 27.6%; C4, 34.5%; C6, 1.7%. From 125 IPVs analysed, 101 were closed (81%), 24 were not closed/reopened (19%) and 14 de novo IPVs were found.

Discussion

Despite these results representing our learning curve for the procedure, we found TRLOP to be an effective treatment for IPVs. The closure rates described are comparable with the published clinical series data for subfascial endoscopic perforator surgery.

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.