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

Strategies to reduce rates of severe endothermal heat-induced thrombosis following radiofrequency ablation

OBJECTIVE

Endothermal heat-induced thrombosis (EHIT) is a potential complication of radiofrequency ablation (RFA). Data on effective prophylaxis of EHIT are limited. In 2018, a high-volume, single institution implemented strategies to decrease the incidence of EHIT, including a single periprocedural prophylactic dose of low-molecular-weight heparin to patients with a great saphenous vein (GSV) diameter of ≥8 mm or saphenofemoral junction (SFJ) diameter of ≥10 mm and limiting treatment to one vein per procedure. The size threshold was derived from existing literature. The study objective was to evaluate the effects of these institutional changes on thrombotic complication rates after RFA.

METHODS

A retrospective cohort control study was conducted using the Vascular Quality Initiative database. Data were collected for patients who underwent RFA with a GSV diameter of ≥8 mm or SFJ diameter of ≥10 mm from January 2015 to July 2022. The clinical end points were thrombotic complications (ie, thrombophlebitis, EHIT, deep vein thrombosis) and bleeding complications. Patient demographic and procedural variables were included in the analysis, and significant variables after univariable logistic regression were included in a multivariable logistic regression.

RESULTS

After the policy change, the overall vein center EHIT rate decreased from 2.6% to 1.5%, with a trend toward significance (P = .096). The inclusion criterion of a GSV diameter of ≥8 mm or an SFJ diameter of ≥10 mm yielded 845 patients, of whom 298 were treated before the policy change and 547 after. There was a significant reduction in the rate of EHIT classified as class ≥III (2.34 vs 0.366; P = .020) after the institutional changes. Treatment of two or more veins and an increased vein diameter were associated with an increased risk of EHIT (P = .049 and P < .001, respectively). No significant association was found between periprocedural anticoagulation and all-cause thrombotic complications or EHIT (P = .563 and P = .885, respectively).

CONCLUSIONS

The institutional policy changes have led to lower rates of EHIT, with a reduction in severe EHIT rates in patients with an ≥8-mm diameter GSV or a ≥10-mm diameter SFJ treated with RFA. Of the changes implemented, restricting treatment to one vein was associated with a reduction in severe EHIT. No association was found with periprocedural low-molecular-weight heparin, although a type 2 error might have occurred. Alternative strategies to prevent thrombotic complications should be explored, such as increasing the dosage and duration of periprocedural anticoagulation, antiplatelet use, and nonpharmacologic strategies.

Demographic and clinical characteristics of patients with varicose veins in Albania: a retrospective, single-centre analysis

Introduction

Chronic venous disease (CVD) constitutes a frequently underdiagnosed pathological condition that progressively diminishes patients' quality of life and imposes an escalating strain on healthcare resources. This study aims to comprehensively investigate the epidemiological landscape of varicose vein disease, examining age group distributions, gender patterns, residence influences, marital status correlations, weight considerations, educational impacts, and various aspects related to varicose veins.

Material and methods

This was a single-centre retrospective analysis, in Albania from May 2018 to September 2023. Data were collected retrospectively through hospital records. Data collection involved administering a structured questionnaire to study participants, categorically organised into three sections. The first section focused on collecting demographic information, the second section involved self-perception of identifying risk factors associated with varicose veins, and the final section included inquiries about the history of variceal surgery.

Results

The CEAP classification distribution in our cohort revealed a predominant presence of C2 (varicose veins) in 53.3% of patients, followed by C3 (oedema) at 29.2%, and C4 (changes in skin and subcutaneous tissue secondary to CVD) at 10.5%, whereas C5 (healed venous ulcer) and C6 (active venous ulcer) were less frequent. Based on the body mass index (BMI) scale, data from patients indicated that 9.7% were in the category of underweight, 54.8% had a normal BMI, and 35.5% were categorised as overweight.

Conclusions

The study's thorough exploration of patient perspectives, risk factors, and treatment choices contributes to a holistic understanding of varicose vein management, emphasising the importance of personalised approaches that account for demographic variations and individual beliefs.

Chronic venous insufficiency: a comprehensive review of management

Chronic venous insufficiency is an extensive progressive disease in need of public health attention. This insidious disease is a growing burden on patient quality of life and the health economy. Chronic venous insufficiency has become more pronounced in global populations, especially in regions exhibiting a higher rate of risk factors. It is critical for healthcare providers to recognise and intervene early to prevent ongoing and debilitating complications. This article provides a comprehensive review of chronic venous insufficiency outlining the anatomy, pathophysiology, clinical presentation, assessment and management options.

Interventions for great saphenous vein incompetence

BACKGROUND

Great saphenous vein (GSV) incompetence, causing varicose veins and venous insufficiency, makes up the majority of lower-limb superficial venous diseases. Treatment options for GSV incompetence include surgery (also known as high ligation and stripping), laser and radiofrequency ablation, and ultrasound-guided foam sclerotherapy. Newer treatments include cyanoacrylate glue, mechanochemical ablation, and endovenous steam ablation. These techniques avoid the need for a general anaesthetic, and may result in fewer complications and improved quality of life (QoL). These treatments should be compared to inform decisions on treatment for varicosities in the GSV. This is an update of a Cochrane Review first published in 2011.

OBJECTIVES

To assess the effects of endovenous laser ablation (EVLA), radiofrequency ablation (RFA), endovenous steam ablation (EVSA), ultrasound-guided foam sclerotherapy (UGFS), cyanoacrylate glue, mechanochemical ablation (MOCA) and high ligation and stripping (HL/S) for the treatment of varicosities of the great saphenous vein (GSV).

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 2 November 2020. We undertook reference checking to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) treating participants for varicosities of the GSV using EVLA, RFA, EVSA, UGFS, cyanoacrylate glue, MOCA or HL/S. Key outcomes of interest are technical success, recurrence, complications and QoL.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, applied Cochrane's risk of bias tool, and extracted data. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) and assessed the certainty of evidence using GRADE.

MAIN RESULTS

We identified 11 new RCTs for this update. Therefore, we included 24 RCTs with 5135 participants. Duration of follow-up ranged from five weeks to eight years. Five comparisons included single trials. For comparisons with more than one trial, we could only pool data for 'technical success' and 'recurrence' due to heterogeneity in outcome definitions and time points reported. All trials had some risk of bias concerns. Here we report the clinically most relevant comparisons. EVLA versus RFA Technical success was comparable up to five years (OR 0.98, 95% CI 0.41 to 2.38; 5 studies, 780 participants; moderate-certainty evidence); over five years, there was no evidence of a difference (OR 0.85, 95% CI 0.30 to 2.41; 1 study, 291 participants; low-certainty evidence). One study reported recurrence, showing no clear difference at three years (OR 1.53, 95% CI 0.78 to 2.99; 291 participants; low-certainty evidence), but a benefit for RFA may be seen at five years (OR 2.77, 95% CI 1.52 to 5.06; 291 participants; low-certainty evidence). EVLA versus UGFS Technical success may be better in EVLA participants up to five years (OR 6.13, 95% CI 0.98 to 38.27; 3 studies, 588 participants; low-certainty evidence), and over five years (OR 6.47, 95% CI 2.60 to 16.10; 3 studies, 534 participants; low-certainty evidence). There was no clear difference in recurrence up to three years and at five years (OR 0.68, 95% CI 0.20 to 2.36; 2 studies, 443 participants; and OR 1.08, 95% CI 0.40 to 2.87; 2 studies, 418 participants; very low-certainty evidence, respectively). EVLA versus HL/S Technical success may be better in EVLA participants up to five years (OR 2.31, 95% CI 1.27 to 4.23; 6 studies, 1051 participants; low-certainty evidence). No clear difference in technical success was seen at five years and beyond (OR 0.93, 95% CI 0.57 to 1.50; 5 studies, 874 participants; low-certainty evidence). Recurrence was comparable within three years and at 5 years (OR 0.78, 95% CI 0.47 to 1.29; 7 studies, 1459 participants; and OR 1.09, 95% CI 0.68 to 1.76; 7 studies, 1267 participants; moderate-certainty evidence, respectively). RFA versus MOCA There was no clear difference in technical success (OR 1.76, 95% CI 0.06 to 54.15; 3 studies, 435 participants; low-certainty evidence), or recurrence (OR 1.00, 95% CI 0.21 to 4.81; 3 studies, 389 participants; low-certainty evidence). Long-term data are not available. RFA versus HL/S No clear difference in technical success was detected up to five years (OR 5.71, 95% CI 0.64 to 50.81; 2 studies, 318 participants; low-certainty evidence); over five years, there was no evidence of a difference (OR 0.88, 95% CI 0.29 to 2.69; 1 study, 289 participants; low-certainty evidence). No clear difference in recurrence was detected up to three years (OR 0.93, 95% CI 0.58 to 1.51; 4 studies, 546 participants; moderate-certainty evidence); but a possible long-term benefit for RFA was seen (OR 0.41, 95% CI 0.22 to 0.75; 1 study, 289 participants; low-certainty evidence). UGFS versus HL/S Meta-analysis showed a possible benefit for HL/S compared with UGFS in technical success up to five years (OR 0.32, 95% CI 0.11 to 0.94; 4 studies, 954 participants; low-certainty evidence), and over five years (OR 0.09, 95% CI 0.03 to 0.30; 3 studies, 525 participants; moderate-certainty evidence). No clear difference was detected in recurrence up to three years (OR 1.81, 95% CI 0.87 to 3.77; 3 studies, 822 participants; low-certainty evidence), and after five years (OR 1.24, 95% CI 0.57 to 2.71; 3 studies, 639 participants; low-certainty evidence). Complications were generally low for all interventions, but due to different definitions and time points, we were unable to draw conclusions (very-low certainty evidence). Similarly, most studies evaluated QoL but used different questionnaires at variable time points. Rates of QoL improvement were comparable between interventions at follow-up (moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Our conclusions are limited due to the relatively small number of studies for each comparison and differences in outcome definitions and time points reported. Technical success was comparable between most modalities. EVLA may offer improved technical success compared to UGFS or HL/S. HL/S may have improved technical success compared to UGFS. No evidence of a difference was detected in recurrence, except for a possible long-term benefit for RFA compared to EVLA or HL/S. Studies which provide more evidence on the breadth of treatments are needed. Future trials should seek to standardise clinical terminology of outcome measures and the time points at which they are measured.

Interventions for great saphenous vein reflux: network meta-analysis of randomized clinical trials

BACKGROUND

A variety of endovascular and open surgical interventions exist to treat great saphenous vein reflux. However, comparisons of treatment outcomes have been inconsistent.

METHODS

A systematic review and network meta-analysis of RCTs was performed to compare rates of incomplete stripping or non-occlusion of the great saphenous vein with or without reflux (anatomical failure) at early, mid- and long-term follow-up; and secondary outcomes (reintervention and clinical recurrence) among intervention groups. The surface under the cumulative ranking curve (SUCRA) method was used to estimate the probability of the intervention with the lowest anatomical failure rates.

RESULTS

Some 72 RCTs were included. Comparisons of endothermal techniques with open surgery were mostly not significantly different, except for endovenous laser ablation (EVLA), which had higher long-term anatomical failure rates (pooled risk ratio (RR) 1.87, 95 per cent c.i. 1.14 to 3.07). Mechanochemical ablation had higher anatomical failure rates than radiofrequency ablation (RFA) (pooled RR 2.77, 1.38 to 5.53), and cyanoacrylate closure (CAC) had a RR 0.56 (0.34 to 0.93) times lower than either RFA or EVLA at the early term. Ultrasound-guided foam sclerotherapy had a higher risk of anatomical failure and reintervention than open surgery, with the lowest SUCRA value, and CAC was ranked first, third and first for best intervention for anatomical failure at early, mid and long term respectively. However, clinical recurrence rates were not significantly different between all comparisons.

CONCLUSION

Mechanochemical ablation and ultrasound-guided foam sclerotherapy performed poorly, with higher anatomical failure rates in the long term. The other treatment modalities had similar rates of anatomical failure in the short and mid term.

Outcomes of Saphenous Vein Intervention in the Management of Superficial Venous Incompetence: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To determine the most effective modality of intervention to treat saphenous vein insufficiency.

SUMMARY BACKGROUND DATA

Endovenous therapies have instigated a paradigm shift in the management of superficial venous incompetence (SVI). When compared with open surgery, endovenous interventions (foam sclerotherapy (FS), radiofrequency ablation (RFA), endovenous laser ablation (EVLA), mechanochemical ablation (MOCA), and cyanoacrylate glue (CAE) closure) potentially offer reduced morbidity with similar procedural efficacy.

METHODS

A systematic review and series of network meta-analyses of randomized controlled trials (RCTs) were performed assessing risks of procedural failure (within 6-weeks) and recurrence (6-weeks to 5-years), defined by ultrasound, between the different SVI modalities. Treatment comparisons addressing risks of common adverse events, Venous Clinical Severity Score (VCSS) and pain were also performed.

RESULTS

A systematic search identified 51 articles, describing 36 RCTs, incorporating 7,576 limbs. Outcome data on ten modalities of intervention were analyzed up to five-year follow-up. CAE resulted in the lowest risk of procedural failure within six-weeks. Foam sclerotherapy had the highest risk of recurrence while high ligation with stripping (HLS) and CHIVA were ranked best to reduce long-term recurrence. No intervention increased risks of venous thromboembolism and there was minimal difference in morbidity between treatments. All interventions improved VCSS (Range -1.02 to -4.95), however RFA demonstrated the greatest improvement, followed by EVLA and HLS between two to five-years. EVLA was associated with the highest risk of pain, while MOCA offered the least.

CONCLUSION

While CAE offered the lowest risk of initial procedural failure, HLS resulted in lower rates of long-term recurrence without considerably increasing morbidity when compared with other endovenous options.

Prospective comparative study of different endovenous thermal ablation systems for treatment of great saphenous vein reflux

OBJECTIVE

The aim of our study was to compare three different endovenous thermal ablation (EVTA) modalities in the treatment of great saphenous vein (GSV) incompetence.

METHODS

We performed a single-center, prospective, comparative cohort study that included consecutive patients undergoing EVTA of the GSV. Patients were treated with either segmental radiofrequency ablation (sRFA) or endovenous laser ablation (EVLA) with a 1470-nm dual radial fiber or with a 1470-nm jacket-tip fiber. The clinical classification CEAP (clinical, etiologic, anatomic, pathophysiologic), 10-cm visual analog scale scores for pain, Venous Clinical Severity Scores (VCSSs), and chronic venous insufficiency quality-of-life questionnaire (CIVIQ-20) scores were recorded. The primary outcome was clinical success, which was defined as the absence of reflux or recanalization of the GSV and procedure-related complications, assessed at 7 and 30 days and 1 year postoperatively. The secondary outcomes were the assessment of postoperative pain using the VAS and improvement in the VCSSs and CIVIQ-20 scores.

RESULTS

A total of 153 patients (160 limbs) had undergone sRFA (sRFA group; n = 53 limbs), 1470-nm radial fiber EVLA (EVLA-R group; n = 55 limbs), or 1470-nm jacket-tip fiber EVLA (EVLA-J group; n = 52 limbs). The patient demographics, CEAP clinical class, and intraoperative details were comparable among the three groups. The GSV occlusion rate at 1 year was 93% in the sRFA group, 93% in the EVLA-R group, and 95% in the EVLA-J group. No major complications were observed postoperatively. Endothermal heat-induced thrombosis was observed in 2 (4.4%), 1 (2.2%), and 2 (4.4%) patients in the sRFA, EVLA-R, and EVLA-J groups, respectively (P > .5). The VCSS showed greater improvement in the EVLA-R group at 1 week compared with that in the sRFA (P = .05) and EVLA-J (P = .002) groups. Changes in the CIVIQ-20 score were in favor of the EVLA-R group at 7 days (-14.3 ± 10.3 vs -7.9 ± 5.9; adjusted difference, 6.06; 95% confidence interval [CI], 1.57-10.55; P = .01) and 30 days (-12 ± 8 vs -11.2 ± 7; adjusted difference, 5.5; 95% CI, 1.21-9.81; P = .02) postoperatively compared with the sRFA group and at 7 days compared with the EVLA-J group (-14.3 ± 10.3 vs -9.6 ± 7.9; adjusted difference, -4.4; 95% CI, -9.06 to 0.22; P = .05). Analyzing the different components of the CIVIQ-20, pain, and physical scores showed a greater reduction in the EVLA-R group in the early postoperative period compared with that in the sRFA and EVLA-J groups.

CONCLUSIONS

All three EVTA modalities showed equal effectiveness and safety for the treatment of GSV reflux. EVLA with the 1470-nm radial fiber showed better outcomes in terms of early postoperative VCSSs and pain and physical CIVIQ scores. The clinical and quality of life benefits were similar for all modalities at 1 year postoperatively.

Secondary Ablation of Recanalized Saphenous Vein after Endovenous Thermal Ablation

BACKGROUND

To describe the occlusion rate and clinical response of a redo ablative procedure in symptomatic patients with recanalization of saphenous vein after endovascular thermal ablation.

METHODS

A retrospective cohort study was performed in a prospectively collected data of symptomatic patients with recanalization of the great saphenous vein (GSV) or small saphenous vein (SSV) after endovascular thermal ablation who underwent a secondary ablation (SA) from June 2015 to May 2018.

RESULTS

Ten patients (15 limbs) with recanalization of the GSV or SSV were treated with SA. The median age was 67 years and 60% were men. The median time from the first ablation was 7.3 years (interquartile range [IQR] 6.5-9.6). For SA, radiofrequency ablation was performed in 12 limbs (80%) and ultrasound-guided foam sclerotherapy in 3 cases (20%). The GSV was the treated vessel in 14 cases (93.3%). No complications were reported. Median follow-up was 13 months. Preoperative and 1-year follow-up Venous Clinical Severity Score was 9 (IQR 5-10) and 4 (IQR 2-8), respectively. Duplex ultrasound evaluation after 1 year showed an occlusion rate of 93.3% evidencing a partially recanalized vein in 1 treated limb.

CONCLUSIONS

In this study, the occlusion rate was 93.3% at 1 year after SA; clinical improvement and no complications were reported. SA appears to be a valid option for the treatment of symptomatic patients with recanalized GSV or SSV.

Commonly Used Endovenous Laser Ablation (EVLA) Parameters Do Not Influence Efficacy: Results of a Systematic Review and Meta-Analysis

OBJECTIVES

The objective of this systematic review and meta-analysis was to summarise available randomised controlled trials (RCTs) of EVLA efficacy, and to define the differences in success rate of variations in wavelength, administered energy, outcome definition, and follow up period.

METHODS

A literature search was conducted in Embase, Medline (Ovid-SP), Cochrane Central Database, and Web of Science from inception to November 2017. RCTs with follow up of more than three months were included. The studied outcome was the proportion of patients with EVLA treatment success, defined as absence of reflux or occlusion of the great saphenous vein (GSV). Pooled proportions of anatomical success were compared. Subgroup and meta-regression analysis included wavelengths (short [810, 940, and 980 nm], long [1470, 1500, and 1920 nm]), amount of energy (≤50 J/cm, > 50 J/cm), follow up (≤1 year, > 1 year), outcome definition (occlusion, no reflux), and quality of the studies (low risk of bias, unclear/high risk of bias).

RESULTS

Twenty-eight RCTs, with a total of 2829 GSVs were included. The overall success rate of EVLA was 92% (95% CI 90-94%, I² = 68%). In subgroup analysis, no statistically significant differences were found for long or short wavelengths (95% [95% CI 91-97%] vs. 92% [95% CI 89-94%], p = .15), high or low administered energy (93% [95% CI 89-95%] vs. 92% [95% CI 90-94%], p = .99), long or short follow up (89% [95% CI 84-93%] vs. 93% [95% CI 91-95%], p = .13) and outcome definition (occlusion group 94% [95% CI 91-96%] vs. absence of reflux group 91% [95% CI 87-94%], p = .26). Studies with low risk of bias reported a significantly higher success rate than high or unclear risk of bias (93% [95% CI 90-95%] vs. 89% [95% CI 83-93%], p = .04).

CONCLUSIONS

The overall success rate of EVLA is high (92%), even with increasing follow up. Commonly used parameters of EVLA (wavelength, administered energy, and outcome definition) have no influence on the treatment success rate.

Different management options for primary varicose veins in females: A prospective study

Background

The aim of this study was to evaluate the long-term follow-up results of different management modalities in treating primary uncomplicated lower limb female varicosities.

Methods

A prospective study took place within a 3-year period from June 2010 until May 2012. Patients were divided into 3 groups: group I (n = 35) included those who underwent open surgical treatment. Group II (n = 25) included those who subjected to ultrasound-guided foam sclerotherapy (USGFS). While group III (n = 20) included those who treated with endovenous laser therapy (EVLT). The patients were followed up for 6 years.

Results

All selected patients were female aged from 35-62 years with a mean of 47 ± 7.6 years. Thirty-five patients (43.75%) were treated surgically by saphenofemoral junction disconnection (SFJD), and great saphenous vein (GSV) stripping; 25 patients (31.25%) with ultrasound-guided foam sclerotherapy and the remaining 20 patients (25%) were treated with endovenous laser therapy. A significant success rate of GSV ablation was obtained for the endovenous laser therapy treated group over the ultrasound-guided foam sclerotherapy treated patients (P = .023). There was no significant difference between the surgically treated group and those group treated with endovenous laser therapy (P = .85). Recurrence was observed following long-term follow-up after 6 years in 8.5% in group I, 36% in group II, and 10% in group III, respectively. Venous clinical severity score (VCSS) and health-related quality of life score (HRQOLS) improved significantly in all treated groups.

Conclusions

Long-term follow-up of patients with primary superficial varicosities among females is mandatory to elucidate the postoperative recurrence, especially those who underwent ultrasound-guided foam sclerotherapy. In addition to the observation of the development of newly formed varicosities in susceptible individuals which might develop later following long-term follow-up.

Five-year follow-up of a randomized clinical trial comparing open surgery, foam sclerotherapy and endovenous laser ablation for great saphenous varicose veins

BACKGROUND

New treatment methods have challenged open surgery as a treatment for great saphenous vein (GSV) insufficiency, the most common being ultrasound-guided foam sclerotherapy (UGFS) and endovenous laser ablation (EVLA). This study evaluated the long-term results of surgery, EVLA and UGFS in the treatment of GSV reflux.

METHODS

Patients with symptomatic GSV reflux were randomized to undergo either open surgery, EVLA or UGFS. The main outcome measure was the occlusion rate of the GSV at 5 years after operation.

RESULTS

The study included 196 patients treated during 2008-2010; of these, 166 (84·7 per cent) participated in the 5-year follow-up. At 5 years, the GSV occlusion rate was 96 (95 per cent c.i. 91 to 100) per cent in the open surgery group, 89 (82 to 98) per cent after EVLA and 51 (38 to 64) per cent after UGFS (P < 0·001). For patients who had received no additional treatment during follow-up, the occlusion rates were 96 per cent (46 of 48), 89 per cent (51 of 57) and 41 per cent (16 of 39) respectively. UGFS without further GSV treatment was successful in only 16 of 59 patients (27 per cent) at 5 years.

CONCLUSION

UGFS has significantly inferior occlusion rates compared with open surgery or EVLA, and results in additional treatments.

Cost-effectiveness analysis of five procedures for great saphenous vein reflux in a Norwegian healthcare setting or societal setting

Objective

The aim of this work was to estimate cost-effectiveness of five common procedures for varicose vein surgery (high ligation and stripping, radiofrequency ablation, endovenous laser ablation, steam vein sclerosis and cyanoacrylate glue) in a Norwegian setting from both a societal and a healthcare payer perspective.

Design

Cost-effectiveness analysis using decision tree modelling.

Methods

A structured literature search was conducted to estimate the clinical effectiveness and the rate of complications in the five methods. Data on costs and health-related quality of life associated with varicose vein disease were also collected. With the aid of an expert panel, a structured decision tree was developed. A 1-year perspective was modelled, and a variety of common complications were included. Monte Carlo simulation was used for probabilistic sensitivity analyses.

Results

The laser ablation strategy was the most cost-effective option from a societal perspective, with an incremental cost-effectiveness ratio of €8448 compared to a no-treatment alternative, and had a 42% probability of being cost-effective using the Norwegian willingness-to-pay threshold of €59,880. From a healthcare payer perspective, however, the steam vein sclerosis strategy was the most cost-effective with an incremental cost-effectiveness ratio of €4072 compared to a no-treatment alternative, and this strategy had a 50% probability of being cost-effective.

Conclusion

Results from this study did depend upon the perspective chosen for analyses. Although recent endovenous surgical procedures (including laser ablation and steam vein sclerosis) provide clinically effective treatment for advanced, symptomatic varicose vein disease, availability of high-level data is currently limiting the cost-effectiveness analyses.

Fate of the tributaries of sapheno femoral junction following endovenous thermal ablation of incompetent axial vein – A review article

Sapheno femoral junctional tributaries are usually left untreated at the time of endovenous ablation of axial vein. The long-term clinical significance of these untreated tributaries remains elusive and there is very little research done into this area. This article reviews the fate of untreated tributaries at sapheno femoral junction following ablation of incompetent axial vein. A literature search and analysis of evidence reveal that the junctional tributaries are one of the commonest (ranges between 8% and 31%) cause for recurrence following endovenous ablation of the axial veins. Follow up of this subset of patients after their axial vein treatment should be considered to identify neoreflux in side branches at sapheno femoral junction and plan treatment.

CHIVA with endoluminal procedu res: Laser versus VNUS

Introduction: Since it’s description the CHIVA strategy was performed with surgical techniques. After the introduction of endoluminal heat techniques these might be applied also in the CHIVA context.

Method: 104 patients were investigated before and 3–6 months after the treatment of the great saphenous vein (GSV) with CHIVA strategy using enoluminal heat techniques to close the groin segment (VNUS Closure-Fast™ or LASER [1470 nm, Intros radial]). General data (age, sex, BMI) and phlebological data (QoL as reflected in VCSS, clinics as C[CEAP], refilling time after muscle pump measured with light reflection rheography, diameters of GSV at the groin and proximal thigh, as well as diameters of the common femoral vein) were measured and compared.

Results: Significant reduction of diameters of GSV at proximal thigh from 6.5 ± 1.6 to 3.7 ± 1.1 and VFC from 15.2 ± 2.3 to 14.8 ± 2.2 were recorded, as well as reduction of clinical scores (VCSS from 5.6 ± 3.1 to 2.2 ± 2 and C[CEAP] from 3.2 ± 1 to 2.1 ± 1.1). Refilling time improved from 20.3 ± 11 to 28.8 ± 10.2. Results are comparable to those achieved after surgical crossectomy and published in other series.

Conclusion: The disconnection of the insufficiency point at the saphenofemoral junction seems to be possible in the context of CHIVA Strategy applying endoluminal heat technique. No difference could be found between both techniques, Laser or VNUS Closure-Fast™.

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.

Endovenous Laser Application

Introduction: Endoluminal vein treatment is a promising minimal invasive treatment option for peoples suffering from varicose veins. The basic mechanism underlying this procedure is to selectively induce heat in the vessel wall with the result of denaturation of proteins and shrinkage of collagen fibers due to energy application. So far energy could be applied either as RF-current, laser light or water steam. The different approaches to deliver such forms of energies are described.

Methods: Investigations on heat dependent vein tissue effects were performed. The degree of shrinkage and wall thickening due to heat induction was calculated. Tensile test on vein tissue were performed. Investigation using the radial emitting laser fibre in the ox-foot-model under reproducible condition were done and wavelengths dependent tissue reaction were explored.

Results: The experiments clearly demonstrate the degree of the shrinkage of length and diameter, the thickening of the vein wall, as well as the decrease of the elasticity of the tissue. The optical irradiation pattern of the radial emitting laser fiber serves for safe and reproducible energy application directly to the vein wall. Using a laser wavelength with high absorption by the tissue water needs reduced irradiation and irradiance compared to wavelengths with less water absorption. Conclusion: An experimental approach to improve laser application for endovenous varicose treatment is described. Laser parameters and treatment parameters were found which are now under clinical testing. The demonstrated tissue effects may help to find further arguments for clinical findings and sensations described by the patients during follow-up.

Systematic review and meta-analysis of randomized controlled trials evaluating long-term outcomes of endovenous management of lower extremity varicose veins

BACKGROUND

Early studies have demonstrated that endovenous therapy for varicose veins is associated with a faster recovery and lower complication rates compared with conventional therapy. More than one million procedures have been performed worldwide. The objective of this study was to determine long-term efficacy of currently available endovenous therapy methods for varicose veins compared with conventional surgery (saphenofemoral ligation and stripping of great saphenous vein [GSV] with or without multiple avulsions) in management of GSV-related varicose veins.

METHODS

In July 2017, we searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, Scopus, Cochrane Library, and Web of Science without date or language restriction for relevant randomized controlled trials (RCTs). Bibliographies of included studies were also searched for additional studies. RCTs comparing conventional surgery and endovenous therapy for treating lower extremity varicose veins with 5 years or more of follow-up were selected. Data extraction and quality assessment were performed independently by two review authors, and any disagreements were resolved by consensus or by arbitration of a third author. Cochrane RevMan 5 was used for analysis.

RESULTS

At time of data extraction, long-term follow-up was available for endovenous laser therapy (EVLT), radiofrequency ablation (RFA), and ultrasound-guided foam sclerotherapy. Included in the review were nine RCTs. The RCTs included 2185 legs; however, only 1352 legs were followed up for 5 years (61.9%). There was no statically significant difference in recurrence rate in comparing EVLT with conventional surgery in treating GSV incompetence (36.6% vs 33.3%, respectively; pooled risk ratio, 1.35; 95% confidence interval, 0.76-2.37; P = .3). Also, no significant difference was determined for recurrence rate in comparing RFA with surgery or EVLT.

CONCLUSIONS

Although the analysis showed that EVLT and RFA are as effective as conventional surgery in treating saphenous venous insufficiency, the number of patients available for analysis was too small for definitive conclusions to be drawn.

Current clinical evidence on endovenous laser ablation (EVLA) from randomised trials

Background Endovenous laser ablation (EVLA) is globally counted among the most frequently administered methods to treat saphenous vein incompetence. Technical development proceeded in three particular steps: EVLA #1 – Diode lasers linearly emitting wavelengths from 810 to 980 nm through optical bare fibres; EVLA #2 – Diode or Nd:YAG lasers emitting wavelengths from 1064 to 1500 nm; EVLA #3 – Modified optical fibres warranting an optimised emission geometry by centralisation of the fibre tip (Tulip-fibre, Jacket-tip) or radial emission of the laser beam. Due to the number of different EVLA techniques their value compared with standard surgery (high ligation and stripping, HLS) and other endovascular approaches has to be questioned.

Methods Selective literature analysis based on a systematic PubMed search focussed on randomised controlled trials (RCT) comparing EVLA with HLS and other thermal or nonthermal ablation techniques – radiofrequency ablation (RFA), ultrasound guided foam sclerotherapy (UGFS), endothermal steam ablation (EStA).

Results The search terms “endovenous”, “laser”, “varicose vein” resulted in 509 publications, hereof 57 RCTs, hereof 24 randomised studies comparing EVLA with other treatment approaches: 15 studies comprise comparisons with standard surgery and further 9 studies with other endovenous techniques. 6 RCTs contain long-term followup data on EVLA #1 vs. HLS suggesting superiority of HLS in terms of same site clinical and duplex detected recurrence from the groin. 15 RCTs are reporting short-term results clearly demonstrating inferiority of EVLA #1 against EVLA #2, EVLA #3, and RFA with respect to postoperative complaints and patients’ quality of life.

Conclusions The first generation endovenous laser systems are disadvantageous or even harmful as compared with more advanced EVLA techniques and RFA in terms of patients’ complaints and side effects. Furthermore, evidence is rising that EVLA #1 is inferior to standard surgery regarding long-term treatment efficacy. Therefore, the application of EVLA #1 in the treatment of saphenous vein incompetence cannot be recommended any longer. In view of the more recently published RCTs reporting long-term superiority of standard surgery, HLS should still be implemented as control group in studies investigating endovenous treatment approaches.

Editor's Choice - Five Year Results of Great Saphenous Vein Treatment: A Meta-analysis

OBJECTIVES

The most frequently used treatment options for great saphenous vein incompetence are high ligation with stripping (HL+S), endovenous thermal ablation (EVTA), mainly consisting of endovenous laser ablation (EVLA) or radiofrequency ablation, and ultrasound guided foam sclerotherapy (UGFS). The objective of this systematic review and meta-analysis was to compare the long-term efficacy of these different treatment modalities.

METHODS

A systematic literature search was performed. Randomised controlled trials (RCTs) with follow-up ≥ 5 years were included. Pooled proportions of anatomical success, which was the primary outcome, rate of recurrent reflux at the saphenofemoral junction (SFJ), and mean difference in venous clinical severity score (VCSS) were compared using a z test or Student t test. Quality of life data were assessed and described.

RESULTS

Three RCTs and 10 follow-up studies of RCTs were included of which 12 were pooled in the meta-analysis. In total, 611 legs were treated with EVLA, 549 with HL+S, 121 with UGFS, and 114 with HL+EVLA. UGFS had significantly lower pooled anatomical success rates than HL+S, EVLA, and EVLA with high ligation: 34% (95% CI 26-44) versus 83% (95% CI 72-90), 88% (95% CI 82-92), and 88% (95% CI 17-100) respectively; p ≤ .001. The pooled recurrent reflux rate at the SFJ was significantly lower for HL+S than UGFS (12%, 95% CI 7-20, vs. 29%, 95% CI 21-38; p ≤ .001) and EVLA (12%, 95% CI 7-20, vs. 22%, 95% CI 14-32; p = .038). VCSS scores were pooled for EVLA and HL+S, which showed similar improvements.

CONCLUSION

EVLA and HL+S show higher success rates than UGFS 5 years after GSV treatment. Recurrent reflux rates at the SFJ were significantly lower in HL+S than UGFS and EVLA. VCSS scores were similar between EVLA and HL+S.

Which endovenous ablation method does offer a better long-term technical success in the treatment of the incompetent great saphenous vein? Review

Objective

The aim of this review article was to evaluate the long-term technical success rates of the known endovenous ablation procedures in the treatment of the incompetence of the great saphenous vein.

Methods

A literature search was conducted in the PubMed-database until the 5 January 2016. All publications with four to five years follow-up were eligible. Meta-analysis was performed by the IVhet-model.

Results

Eight hundred and sixty-two unique publications were found; 17 of them were appropriate for meta-analysis. Overall, 1420 limbs were included in the trial, 939 for endovenous laser ablation, 353 for radiofrequency ablation and 128 for ultrasound guided foam sclerotherapy. Overall, technical success rates were 84.8% for endovenous laser ablation, 88.7% for radiofrequency ablation and 32.8% for ultrasound guided foam sclerotherapy. There were no significant differences between endovenous laser ablation, radiofrequency ablation and ultrasound guided foam sclerotherapy regarding the great saphenous vein reopening ( p = 0.66; OR: 0.22; 95% of CI: 0.08–0.62 for radiofrequency ablation vs. endovenous laser ablation; p = 0.96; OR: 0.11; 95% of CI: 0.06–0.20 for endovenous laser ablation vs. ultrasound guided foam sclerotherapy; p = 0.93; OR: 3.20; 95% of CI: 0.54–18.90 for ultrasound guided foam sclerotherapy vs. radiofrequency ablation).

Conclusion

Both endovenous laser ablation and radiofrequency ablation are efficient in great saphenous vein occlusion on the long term. Lacking long-conducted large trials, the efficacy and reliability of ultrasound guided foam sclerotherapy to treat great saphenous vein-reflux is not affirmed.

Relationships between duplex findings and quality of life in long-term follow-up of patients treated for chronic venous disease

OBJECTIVE

Relationships between duplex findings and data on health-related quality of life (QoL) to assess long-term results of treatment of varicose veins and chronic venous insufficiency (CVI) are not well known. The goal of this review was to correlate duplex findings and QoL assessments in clinical studies with long-term follow-up.

METHODS

A review of the English language literature on PUBMED revealed 17 clinical studies, including 9 randomized controlled trials (RCTs), 6 prospective, and 2 retrospective studies that included patients with at least 5-year follow-up after endovenous laser ablation (EVLA), radiofrequency ablation (RFA), ultrasound-guided foam sclerotherapy (UGFS), and traditional superficial venous surgery.

RESULTS

At 5 years, great saphenous vein (GSV) occlusion rate on duplex ultrasound ranged from 66% to 82% for EVLA, from 62% to 92% for RFA, from 41% to 58% for UGFS and from 54% to 85% for surgery. Freedom from GSV reflux rates were 82% and 84%, respectively for EVLA and surgery, and ranged between 84% and 95% for RFA. Significant improvements were observed in several domains of generic QoL and in most domains of venous disease-specific QoL, irrespective of the treatment. In at least one RCT, CIVIQ scores correlated well with abnormal duplex findings in patients who underwent treatment with UGFS. In another RCT, long-term AVVQ was significantly better after surgery as compared with UGFS similar to results of duplex findings.

CONCLUSIONS

Analysis of the available literature confirmed that all four techniques were effective in the abolishment of reflux or obliteration of the GSV. Moreover, well-designed RCTs with large sample size are needed to produce robust long-term data on clinical outcome after treatment of varicose veins and CVI and to better understand the relationships between duplex-derived data and QoL assessments.

Comparative Study of Cryostripping and Endovenous Laser Therapy for Varicose Veins: Mid-Term Results

Background

Conventional stripping is considered to be the standard procedure for great saphenous vein (GSV) varicosities, but many other alternative treatments such as cryostripping, endovenous laser therapy (EVLT), radio-frequency ablation, and ultrasound-guided foam sclerotherapy have been developed. Among them, both cryostripping and laser therapy have been reported to be less traumatic, with lower rates of complications and recurrences when compared to conventional stripping. To compare the efficacy of these treatments, we have analyzed and compared the mid-term clinical outcomes of cryostripping and EVLT.

Methods

Patients diagnosed with varicose veins of the GSV and treated with cryostripping or laser therapy between September 2008 and April 2013 were enrolled in this study. Duplex ultrasonography was used for the diagnosis and evaluation of varicosity and reflux, and the clinical-etiology-anatomy-pathophysiology classification was used to measure the clinical severity. The symptoms, Venous Clinical Severity Score (VCSS), recurrence rates, and complication rates of the cryostripping and laser therapy groups were analyzed and compared.

Results

A total of 68 patients were enrolled in this study. 32 patients were treated with cryostripping, and 36 patients were treated with laser therapy. The median follow-up period was 29.6 months. Recurrence was noted in three patients from the cryostripping group and in two patients from the EVLT group. There was no difference in the VCSS score, operative time, duration of hospital stay, and complication rate between the cryostripping group and the EVLT group.

Conclusion

The mid-term clinical outcomes of cryostripping were not inferior to those of EVLT. Further, considering its cost-effectiveness, cryostripping seems to be a safe and feasible method for the treatment of varicose veins.

Five-year follow-up of a randomized, controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia

OBJECTIVE

The objective of this study was to compare the long-term results (groin-related recurrence, great saphenous vein [GSV] occlusion rate, Clinical class, Etiology, Anatomy, and Pathophysiology [CEAP] staging, and quality of life [QoL]) after the treatment of a GSV incompetence by saphenofemoral ligation and stripping (SFL/S) with endovenous laser ablation bare fiber, 980 nm (EVLA).

METHODS

Patients with GSV insufficiency and varicose veins were randomized to either undergo SFL/S or EVLA, both of which were performed under tumescent anesthesia. The long-term results, which included the anatomic occlusion rate, varicose vein recurrence at the saphenofemoral junction (SFJ), relief of venous symptoms and QoL, were compared up to 5 years after treatment.

RESULTS

A total of 130 legs of 121 patients were treated with either SFL/S (n = 68) or EVLA (n = 62). In the first 12 months, three recanalizations of the GSV were observed after EVLA. Up to 5 years later, more recurrent varicose veins caused by neoreflux in incompetent tributaries of the SFJ were observed in after EVLA (31%; 19/61) compared with SFL/S (7%; 4/60; P < .01). Neovascularization in the groin with clinically visible recurrence identified at 3 and 5 years post-treatment follow-up was only observed in the SFL/S group (n = 6). After 5 years, clinically visible recurrences originating from the SFJ region after EVLA were observed 33% (20/61) compared with 17% of patients (10/60) after SFL/S (P < .04). In both treatment groups, venous symptoms improved significantly. Patients in both groups reported a continuing significant cosmetic improvement measured on a visual analog scale of 1 to 10 (mean, 7.49; P < .01). There was no difference in the CEAP staging and a standardized, non-disease-specific instrument for describing and valuing health states (EuroQol-5D), between the groups up to 5 years after follow-up.

CONCLUSIONS

At the 5-year follow-up, a significantly higher varicose vein recurrence rate originated at the SFJ region after EVLA compared with SFL/S. There were no differences in the relief of venous symptoms, CEAP staging, or general QoL between the groups.

Same Site Recurrence is More Frequent After Endovenous Laser Ablation Compared with High Ligation and Stripping of the Great Saphenous Vein: 5 year Results of a Randomized Clinical Trial (RELACS Study)

OBJECTIVE

To compare the long-term clinical efficacy of endovenous laser ablation (EVLA) with high ligation and stripping (HLS) as standard treatment for great saphenous vein (GSV) incompetence.

DESIGN

Investigator initiated two centre randomized controlled trial with 5 year follow up.

MATERIALS AND METHODS

Interventions were performed on ambulatory and hospitalized patients at two vein centres, a university dermatology department (EVLA) and a specialized vein clinic (HLS). Four hundred patients suffering from GSV incompetence were assigned to EVLA or HLS of the GSV. One hundred and eighty five and 161 patients (=limbs), respectively, were treated per protocol. Main outcome measures were clinically recurrent varicose veins after surgery (REVAS classification, primary study objective), Duplex detected saphenofemoral recurrence, clinical venous severity scoring (Homburg Varicose Vein Severity Score), quality of life (Chronic Venous Insufficiency Questionnaire 2), side effects, and patient satisfaction 5 years after treatment.

RESULTS

Two hundred and eighty one legs (81% of the study population) were evaluated with a median follow up of 60.4 (EVLA) and 60.7 months (HLS). Overall, REVAS was similarly observed in both groups: 45% (EVLA) and 54% (HLS), p = .152. Patients of the EVLA group showed significantly more clinical recurrences in the operated region (REVAS: same site): 18% vs. 5%, p = .002. In contrast, more different site recurrences were observed in the HLS group: 50% vs. 31%, p = .002. Duplex detected saphenofemoral refluxes occurred more frequently after EVLA: 28% vs. 5%, p < .001. Both treatments improved disease severity and quality of life without any difference.

CONCLUSIONS

EVLA and HLS are comparably effective concerning overall REVAS, improvement of disease severity, and quality of life. In terms of same site clinical recurrence and saphenofemoral refluxes, HLS is superior to EVLA 5 years after treatment.

CLINICAL TRIAL REGISTRATION

ISRCTN18322872.

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.

Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins

BACKGROUND

A variety of techniques exist for the treatment of patients with great saphenous vein (GSV) varicosities. Few data exist on the long-term outcomes of these interventions.

METHODS

Patients undergoing conventional surgery, endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS) for GSV varicose veins were followed up for 5 years. Primary outcome was obliteration or absence of the treated GSV segment; secondary outcomes were absence of GSV reflux, and change in Chronic Venous Insufficiency quality-of-life Questionnaire (CIVIQ) and EuroQol - 5D (EQ-5D™) scores.

RESULTS

A total of 224 legs were included (69 conventional surgery, 78 EVLA, 77 UGFS), 193 (86.2 per cent) of which were evaluated at final follow-up. At 5 years, Kaplan-Meier estimates of obliteration or absence of the GSV were 85 (95 per cent c.i. 75 to 92), 77 (66 to 86) and 23 (14 to 33) per cent in the conventional surgery, EVLA and UGFS groups respectively. Absence of above-knee GSV reflux was found in 85 (73 to 92), 82 (72 to 90) and 41 (30 to 53) per cent respectively. CIVIQ scores deteriorated over time in patients in the UGFS group (0.98 increase per year, 95 per cent c.i. 0.16 to 1.79), and were significantly worse than those in the EVLA group (-0.44 decrease per year, 95 per cent c.i. -1.22 to 0.35) (P = 0.013). CIVIQ scores for the conventional surgery group did not differ from those in the EVLA and UGFS groups (0.44 increase per year, 95 per cent c.i. -0.41 to 1.29). EQ-5D™ scores improved equally in all groups.

CONCLUSION

EVLA and conventional surgery were more effective than UGFS in obliterating the GSV 5 years after intervention. UGFS was associated with substantial rates of GSV reflux and inferior CIVIQ scores compared with EVLA and conventional surgery.

REGISTRATION NUMBER

NCT00529672 (http://www.clinicaltrials.gov).

Endovenous laser ablation with and without high ligation compared to high ligation and stripping for treatment of great saphenous varicose veins: Results of a multicentre randomised controlled trial with up to 6 years follow-up

Objectives

High ligation and stripping was compared to endovenous laser ablation for the therapy of great saphenous vein varicosity. Long-term efficacy was assessed in terms of avoidance of inguinal reflux and mechanisms of recurrence were investigated.

Design

Multicentre, randomised, three-arm, parallel trial.

Materials and methods

A total of 449 patients were randomised into three different treatment groups: high ligation and stripping group ( n = 159), endovenous laser ablation group ( n = 142; 980 nm, 30 W continuous mode, bare fibre) or a combination of laser ablation with high ligation (endovenous laser ablation group/ high ligation group, n = 148). Patients were examined clinically and by duplex ultrasound once a year. The primary end point of this study is inguinal reflux at the saphenofemoral junction after 2 years. This paper presents secondary data on sonographically determined inguinal reflux and clinical recurrences in the treated area after up to 6 years of follow-up.

Results

Median time to follow-up was 4.0 years; the mean time follow-up 3.6 years. Follow-up rates were: 2 years 74%, 3 years 47%, 4 years 39%, 5 years 36% and 6 years 31%. Most reflux into the great saphenous vein appeared in the endovenous laser ablation group (after 6 years: high ligation/stripping versus endovenous laser ablation p = 0.0102; high ligation/endovenous laser ablation vs. endovenous laser ablation p < 0.0002). Furthermore, more refluxive side branches were also observed in the endovenous laser ablation group (after 6 years high ligation/stripping vs. endovenous laser ablation p = 0.0569; high ligation/endovenous laser ablation vs. endovenous laser ablation p = 0.0111). In terms of clinical recurrence during the 6 years post therapy, no significant differences between the three treatment groups were observed ( p values from log-rank test: high ligation/stripping vs. endovenous laser ablation p = 0.5479; high ligation/stripping vs. high ligation/endovenous laser ablation p = 0.2324; high ligation/endovenous laser ablation vs. endovenous laser ablation p = 0.0848). The postoperative decline and later development in Class C (clinical etiological anatomical pathological) went parallel in all groups.

Conclusions

Clinical recurrence appears with the same frequency in all three treatment groups, but the responsible pathological mechanisms seem to differ. Most reflux into the great saphenous vein and side branches appears after endovenous laser ablation, whereas more saphenofemoral junction-independent recurrences are seen after high ligation/stripping.

Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices

BACKGROUND

Minimally invasive techniques to treat great saphenous varicose veins include ultrasound-guided foam sclerotherapy (UGFS), radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). Compared with flush saphenofemoral ligation with stripping, also referred to as open surgery or high ligation and stripping (HL/S), proposed benefits include fewer complications, quicker return to work, improved quality of life (QoL) scores, reduced need for general anaesthesia and equivalent recurrence rates. This is an update of a review first published in 2011.

OBJECTIVES

To determine whether endovenous ablation (radiofrequency and laser) and foam sclerotherapy have any advantages or disadvantages in comparison with open surgical saphenofemoral ligation and stripping of great saphenous vein varices.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2014) and CENTRAL (2013, Issue 12). Clinical trials databases were also searched for details of ongoing or unpublished studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of UGFS, EVLT, RFA and HL/S were considered for inclusion. Primary outcomes were recurrent varicosities, recanalisation, neovascularisation, technical procedure failure, patient QoL scores and associated complications.

DATA COLLECTION AND ANALYSIS

CN and RB independently reviewed, assessed and selected trials which met the inclusion criteria. CN and RB extracted data and used the Cochrane Collaboration's tool for assessing risk of bias. CN and RB contacted trial authors to clarify details as needed.

MAIN RESULTS

For this update, eight additional studies were included making a total of 13 included studies with a combined total of 3081 randomised patients. Three studies compared UGFS with surgery, eight compared EVLT with surgery and five compared RFA with surgery (two studies had two or more comparisons with surgery). Study quality, evaluated through the six domains of risk of bias, was generally moderate for all included studies, however no study blinded participants, researchers and clinicians or outcome assessors. Also, nearly all included studies had other sources of bias. The overall quality of the evidence was moderate due to the variations in the reporting of results, which limited meaningful meta-analyses for the majority of proposed outcome measures. For the comparison UGFS versus surgery, the findings may have indicated no difference in the rate of recurrences in the surgical group when measured by clinicians, and no difference between the groups for symptomatic recurrence (odds ratio (OR) 1.74, 95% confidence interval (CI) 0.97 to 3.12; P = 0.06 and OR 1.28, 95% CI 0.66 to 2.49, respectively). Recanalisation and neovascularisation were only evaluated in a single study. Recanalisation at < 4 months had an OR of 0.66 (95% CI 0.20 to 2.12), recanalisation > 4 months an OR of 5.05 (95% CI 1.67 to 15.28) and for neovascularisation an OR of 0.05 (95% CI 0.00 to 0.94). There was no difference in the rate of technical failure between the two groups (OR 0.44, 95% CI 0.12 to 1.57). For EVLT versus surgery, there were no differences between the treatment groups for either clinician noted or symptomatic recurrence (OR 0.72, 95% CI 0.43 to 1.22; P = 0.22 and OR 0.87, 95% CI 0.47 to 1.62; P = 0.67, respectively). Both early and late recanalisation were no different between the two treatment groups (OR 1.05, 95% CI 0.09 to 12.77; P = 0.97 and OR 4.14, 95% CI 0.76 to 22.65; P = 0.10). Neovascularisation and technical failure were both statistically reduced in the laser treatment group (OR 0.05, 95% CI 0.01 to 0.22; P < 0.0001 and OR 0.29, 95% CI 0.14 to 0.60; P = 0.0009, respectively). Long-term (five-year) outcomes were evaluated in one study so no association could be derived,but it appeared that EVLT and surgery maintained similar findings. Comparing RFA versus surgery, there were no differences in clinician noted recurrence (OR 0.82, 95% CI 0.49 to 1.39; P = 0.47); symptomatic noted recurrence was only evaluated in a single study. There were also no differences between the treatment groups for recanalisation (early or late) (OR 0.68, 95% CI 0.01 to 81.18; P = 0.87 and OR 1.09, 95% CI 0.39 to 3.04; P = 0.87, respectively), neovascularisation (OR 0.31, 95% CI 0.06 to 1.65; P = 0.17) or technical failure (OR 0.82, 95% CI 0.07 to 10.10; P = 0.88).QoL scores, operative complications and pain were not amenable to meta-analysis, however quality of life generally increased similarly in all treatment groups and complications were generally low, especially major complications. Pain reporting varied greatly between the studies but in general pain was similar between the treatment groups.

AUTHORS' CONCLUSIONS

Currently available clinical trial evidence suggests that UGFS, EVLT and RFA are at least as effective as surgery in the treatment of great saphenous varicose veins. Due to large incompatibilities between trials and different time point measurements for outcomes, the evidence is lacking in robustness. Further randomised trials are needed, which should aim to report and analyse results in a congruent manner to facilitate future meta-analysis.

Systematic review, network meta-analysis and exploratory cost-effectiveness model of randomized trials of minimally invasive techniques versus surgery for varicose veins

BACKGROUND

A Health Technology Assessment was conducted to evaluate the relative clinical effectiveness and cost-effectiveness of minimally invasive techniques (foam sclerotherapy (FS), endovenous laser ablation (EVLA) and radiofrequency ablation (RFA)) for managing varicose veins, in comparison with traditional surgery.

METHODS

A systematic review of randomized clinical trials (RCTs) was undertaken to assess the effectiveness of minimally invasive techniques compared with other treatments, principally surgical stripping, in terms of recurrence of varicose veins, Venous Clinical Severity Score (VCSS), pain and quality of life. Network meta-analysis and exploratory cost-effectiveness modelling were performed.

RESULTS

The literature search conducted in July 2011 identified 1453 unique citations: 31 RCTs (51 papers) satisfied the criteria for effectiveness review. Differences between treatments were negligible in terms of clinical outcomes, so the treatment with the lowest cost appears to be most cost-effective. Total FS costs were estimated to be lowest, and FS was marginally more effective than surgery. However, relative effectiveness was sensitive to the model time horizon. Threshold analysis indicated that EVLA and RFA might be considered cost-effective if their costs were similar to those for surgery. These findings are subject to various uncertainties, including the risk of bias present in the evidence base and variation in reported costs.

CONCLUSION

This assessment of currently available evidence suggests there is little to choose between surgery and the minimally invasive techniques in terms of efficacy or safety, so the relative cost of the treatments becomes one of the deciding factors. High-quality RCT evidence is needed to verify and further inform these findings.

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

Background

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

Methods

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

Results

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

Conclusion

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

Clinical outcomes and quality of life 5 years after a randomized trial of concomitant or sequential phlebectomy following endovenous laser ablation for varicose veins

Background

Endovenous laser ablation (EVLA) is a popular treatment for superficial venous insufficiency. Debate continues regarding the optimal management of symptomatic varicose tributaries following ablation of the main saphenous trunk. This randomized trial compared the 5-year outcomes of endovenous laser therapy with ambulatory phlebectomy (EVLTAP) with concomitant ambulatory phlebectomy, and EVLA alone with sequential treatment if required following a delay of at least 6 weeks.

Methods

Patients undergoing EVLA for great saphenous vein insufficiency were randomized to receive EVLTAP or EVLA alone with sequential phlebectomy, if required. Outcomes included disease-specific quality of life (QoL) (Aberdeen Varicose Vein Questionnaire; AVVQ), requirement for secondary procedures, clinical severity (Venous Clinical Severity Score; VCSS), residual and recurrent varicose tributaries, and generic QoL. Patients were followed up for 5 years.

Results

Fifty patients were randomized equally into two parallel groups. The EVLTAP group had lower VCSS scores at 12 weeks (median 0 (i.q.r. 0–1) versus 2 (0–2); P &lt;0·001), and lower AVVQ scores at 6 weeks (median 7·9 (i.q.r. 4·1–10·7) versus 13·5 (10·9–18·1); P &lt; 0·001) and 12 weeks (2·0 (0·4–7·7) versus 9·6 (2·2–13·8); P = 0·015). VCSS and AVVQ scores were equivalent by 1 year, but only after 16 of 24 patients in the EVLA group, compared with one of 25 in the EVLTAP group (P &lt; 0·001), had received a secondary intervention. From 1 to 5 years both groups had equivalent outcomes.

Conclusion

EVLA with either concomitant or sequential management of tributaries is acceptable treatment for symptomatic varicose veins, with both treatments achieving excellent results at 5 years. Concomitant treatment of varicosities is associated with optimal improvement in both clinical disease severity and QoL.

Guidelines of the First International Consensus Conference on Endovenous Thermal Ablation for Varicose Vein Disease--ETAV Consensus Meeting 2012

AIM

Endovenous thermal ablation (ETA) procedures are catheter-directed, ultrasound (US)-guided thermal methods for treatment in varicose veins disease. Radiofrequency, laser or steam energy thermally denatures vein wall collagen, leading first to vein wall inflammation, then fibrosis and finally to occlusion. The aim of this guideline is to give evidence-based recommendations for ETA procedures.

METHODS

These guidelines were drafted during a consensus meeting of a group of experts in the field of ETA in June 2012 (Hvar, Croatia) under the auspices of the International Union of Phlebology (IUP). These guidelines review the present state of knowledge as reflected in peer-reviewed published medical literature. The recommendations of these guidelines are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

RESULTS

Recommendations on the use of ETA procedures were made based on the quality of evidence for efficacy, safety, tolerability, cosmetic outcome, patient satisfaction/preference and, where appropriate, on the experts' opinion. Health economics were not considered, since differences in national health systems and pricing make it difficult to form general conclusions that are relevant at an international level.

Primary care trust commissioning of varicose vein intervention--new guidance needed?

OBJECTIVES

In light of evidence of national variability in service commissioning of varicose vein intervention, our aim was to evaluate the current state of primary care trust commissioning for all forms of varicose vein intervention in England. We also sought to clarify the extent to which access to endovenous and surgical varicose vein services is being restricted.

METHODS

Under the Freedom of Information Act (2001), a structured email survey was sent to 108 primary care trusts in England. Trusts were asked how many elective endovenous laser therapy and open procedures were commissioned from 2008 to 2011 and they were asked to submit their commissioning policy for analysis. The 'qualifying criteria' expressed in each policy were analysed by theme and geographical region.

RESULTS

Of 108 surveys, 95 (88%) were completed and returned. Of these, 91 (96%) stated that varicose vein interventions were actively commissioned. Eighty-eight (97%) of primary care trusts that commissioned varicose vein interventions stated that access was restricted. Qualifying criteria varied considerably between regions.

CONCLUSIONS

Access to varicose vein intervention appears to be restricted, with national variation in commissioning across England. This might have an impact on patient care and surgical training. We propose that a national decision be made about which varicose vein patients should be offered funding for treatment on the National Health Service.

Comparison of endovenous laser ablation and high ligation and stripping for varicose vein treatment: a meta-analysis

Objectives:

To evaluate the efficiency and safety of endovenous laser ablation (EVLA) for primary lower extremity varicosities compared with high ligation and stripping (HLS).

Method:

Prospective non-randomized studies and randomized control trials on comparison of EVLA and HLS in treating varicose vein were included in this study. A meta-analysis on the data of suitable 13 clinical trials was performed using the Mantel–Haenszel method and the risk ratio was calculated. Thirteen studies including a total of 2245 limbs were eligible for inclusion. Among them, 1128 limbs were treated with endovenous laser ablation, whereas 1117 were treated with high ligation and stripping. Primary outcome measures were technical success rates and recurrence rates at different follow-up duration and complication rates.

Results:

No significant difference in initial technical success rates, Procedural failures were more common following EVLA compared with conventional surgery at one- and two-year follow-up. However, the duplex-detected and clinical recurrence rate was similar between conventional surgery and EVLA after one and two years. No statistical significance was found in postoperative phlebitis and bruise in EVLA and HLS (17.9% versus 21.5%). However, fewer complications were observed in EVLA compared with HLS, including bleeding and haematoma (1.28% versus 4.83%), wound infection (0.33% versus 1.91%) and paraesthesia (6.73% versus 11.27%).

Conclusions:

EVLA for varicose veins is safe and effective compared with HLS in a two-year range. More randomized controlled studies follow-up results are needed to clarify longterm recurrence (5 years).

Endovenous Laser Application

Introduction: Endovenous laser ablation is becoming a common procedure in clinical routine. Although technical improvements and certain laser parameters are available there is demand to improve the situation by developing feedback-systems, thus getting online information for the clinical outcome and preventing for under- and over-treatment.

Methods: By means of Monte Carlo simulation the potential of detecting signals due to heat induced shrinkage of the vessel was investigated. Remission spectra of native and coagulated vein tissue were compared to identify potential parameters for signalling the physiological change of the tissue due to the heating process. A miniaturized temperature sensor was developed for intraluminal measurements during laser energy application.

Results: Monte Carlo simulation shows that the detection of remitted light from the vessels wall is possible for small vessel calibres of less than 6 mm in diameter. Remission spectra of native compared to coagulated vein tissue differ. While native tissue relates more to the content of deoxy-hemoglobin, the spectra of coagulated tissue relates more to the oxy-hemoglobin state. Based on the principle of temperature dependent fluorescence emission a miniaturized sensor was developed which can be used in the light field of radial emitting fibres.

Conclusion: Several optical changes for online-monitoring of signals during endovenous laser ablation showed potential to serve as feedback mechanism. Up to now, only the measurement of the endoluminal temperature could be realized. Further investigations are needed to find suitable technical realization to prevent for under- or overheating during endovenous laser ablation.

[High ligation and vein stripping. The classic procedure]

The guidelines of the Society for Vascular Surgery and the American Venous Forum for management of patients with varicose veins recommend at level 1B endovenous thermal ablation for treatment of saphenous incompetence. High ligation and stripping is recommended only at level 2B. Consequently today most of the surgical procedures in the US are done endoluminally. The situation in Germany is different. The vast majority of the over 300,000 procedures done annually for varicose veins are surgical. In specialized centers in Germany, post-operative failures after high ligation are uncommon. Improper operative approaches seem likely in many of the randomized controlled trials (RCT). After proper high ligation, the results are very good.