Endovenous Laser Ablation and Concomitant Foam Sclerotherapy: Experience in 504 Patients

Treatment of varicose great saphenous vein with endovenous laser alone or combined with eco-guided foam sclerotherapy: A randomized controlled trial

Objectives: This study compares Endovenous Laser Ablation (EVLA) alone versus combined with ultrasound-guided foam sclerotherapy (UGFS) for Great Saphenous Vein (GSV) insufficiency. Methods: Sixty patients were randomly allocated to EVLA or EVLA-UGFS groups which focused on GSV occlusion rates, complications, additional treatments, and quality of life (QoL) changes. Results: Among 55 participants, the EVLA group had higher 12-month occlusion rates (92.3% vs. 75.8%, p = 0.11). Nervous injury (NI) was rarer in EVLA-UGFS (3.4% vs. 23.1%, p = 0.04). No significant difference in other complication rates (p > 0.05). QoL improved in both groups (p < 0.001). EVLA-UGFS required more subsequent procedures (24.1% vs. 7.7%, p = 0.03). Conclusions: EVLA and EVLA-UGFS effectively treat GSV insufficiency, enhancing QoL. The combined method reduces NI risk but may require more follow-up procedures.

Safety and Efficacy of Combining Saphenous Endovenous Laser Ablation and Varicose Veins Foam Sclerotherapy: An Analysis on 5500 Procedures in Patients With Advance Chronic Venous Disease (C3-C6)

BACKGROUND

endovenous laser ablation (EVLA) represents the gold standard in treating both great and small saphenous veins (GSV and SSV) incompetence. To achieve a "no-scalpel" procedure in patients with chronic venous insufficiency (CVI, CEAP C3-C6), concomitant phlebectomies could be replaced by ultrasound-guided foam sclerotherapy (UGFS) into varicose tributaries. The aim of this study is to present a single-centre experience on EVLA + UGFS for patients with CVI secondary to varicose veins and saphenous trunk incompetence, analysing ling-term outcomes.

METHODS

all consecutive patients with CVI and treated by EVLA + UGFS from 2010 to 2022 were included in the analysis. EVLA was performed using a 1470-nm diode laser (LASEmaR® 1500, Eufoton, Trieste, Italy), adapting the linear endovenous energy density (LEED) depending on saphenous trunk diameter. Tessari method was used for UGFS. Patients were evaluated clinically and by duplex scanning at 1, 3 and 6 months, and annually up to 4 years, to assess treatment efficacy and adverse reactions.

RESULTS

5500 procedures in 4895 patients (3818 women, 1077 men) with a mean age of 51.4 years were analysed during the study period. A total of 3950 GSVs and 1550 SSVs were treated with EVLA + UGFS (C3 59%, C4 23%, C5 17% and C6 1%). Neither deep vein thrombosis nor pulmonary embolism were detected during follow-up, as well as superficial burns. Ecchymoses (7%), transitory paraesthesia (2%), palpable vein induration/superficial vein thrombosis (15%) and transient dyschromia (1%) were registered. Saphenous and tributaries closure rate at 30 days, 1 and 4 years were 99.1%, 98.3% and 97.9%, respectively.

CONCLUSIONS

EVLA + UGFS for an extremely minimally invasive procedure appears to be a safe technique, with only minor effects and acceptable long-term outcomes, in patients with CVI. Further prospective randomized studies are needed to confirm the role of this combined therapy in such patients.

Combined microfoam sclerotherapy and miniphlebectomy as an optimal method of treating varicose vein tributaries after endovenous laser ablation

Introduction. The development of phlebology and mainstreaming of ultrasonic techniques has led to the emergence of microfoam sclerotherapy, which proved itself as a more effective technique. In the world literature, there are isolated publications that say about the effectiveness and safety of the microfoam sclerotherapy combined with mini-phlebectomy, but no specific studies comparing the combination treatment for the elimination of varicose syndrome with separate use of each of the techniques are described.

Aim. To increase the effectiveness of invasive treatment and to reduce the rate of complications in patients with varicose veins using a combination of microfoam sclerotherapy and mini-phlebectomy of tributaries after endovenous laser ablation.

Material and methods. Simple single- center, non-randomized, retrospective study was conducted at the A.K. Eramishantsev Moscow State Hospital. It included 52 patients with varicose veins (a total of 77  lower  limbs, 22 patients had bilateral disease), who had no previous invasive treatment for this disease. They underwent endovenous laser ablation of truncal vein combined with microfoam sclerotherapy and mini-phlebectomy of tributaries. Microfoam sclerotherapy was performed with 0.5–2.0% of polidocanol foam, and mini-phlebectomy per Varady technique. The patients had a postprocedural follow-up clinical examination and duplex ultrasound the day after the intervention, then at 1, 6, and 12 months.

Results. Endovenous laser ablation of truncal veins was acutely successful in all cases. No cases of great saphenous vein recanalization were detected in follow-up period. In the early postprocedural period, the combined microfoam sclerotherapy and miniphlebectomy also showed 100% success rate, however redo sclerotherapy was required in 4 (5.2%) cases for new varicose tributaries developed in late postprocedural period.

Conclusion. Combined microfoam sclerotherapy and mini-phlebectomy, as a method of treatment for various veins syndrome, can provide additional benefit such as reducing the volume of mini-phlebectomy and the resultant tissue damage, the varicosity recurrence rate, the number of subcutaneous hematomas and ecchymoses, the discomfort of the tumescent anesthesia, the risk of postprocedural varicose veins thrombosis and pigmentation rate.

Update of the SFMV (French society of vascular medicine) guidelines on the conditions and safety measures necessary for thermal ablation of the saphenous veins and proposals for unresolved issues

Venous insufficiency is a very common disease affecting about 25% of the French population (if we combine all stages of its progression). It is a complex disease and its aetiology has not yet been fully elucidated. Some of its causes are well known, such as valvular dysfunction, vein wall defect, and the suctioning effect common to all varicose veins. These factors are generally associated and together lead to dysfunction of one or more of the saphenous veins. Saphenous vein dysfunction is revealed by ultrasound scan, a reflux lasting more than 0.5 seconds indicating venous incompetence. The potential consequences of saphenous vein dysfunction over time include: symptoms (heaviness, swellings, restlessness, cramps, itching of the lower limbs), acute complications (superficial venous thrombosis, varicose bleeding), chronic complications (changes in skin texture and colour, stasis dermatitis, eczema, vein atresia, leg ulcer), and appearance of unaesthetic varicose veins. It is not possible to repair an incompetent saphenous vein. The only therapeutic options at present are ultrasound-guided foam sclerotherapy, physical removal of the vein (saphenous stripping), or its thermal ablation (by laser or radiofrequency treatment), the latter strategy having now become the gold standard as recommended by international guidelines. Recommendations concerning thermal ablation of saphenous veins were published in 2014 by the Société française de médecine vasculaire. Our society has now decided to update these recommendations, taking this opportunity to discuss unresolved issues and issues not addressed in the original guidelines. Thermal ablation of an incompetent saphenous vein consists in destroying this by means of a heating element introduced via ultrasound-guided venous puncture. The heating element comprises either a laser fibre or a radiofrequency catheter. The practitioner must provide the patient with full information about the procedure and obtain his/her consent prior to its implementation. The checklist concerning the interventional procedure issued by the HAS should be validated for each patient (see the appended document).

A retrospective cohort study comparing two treatments for active venous leg ulcers

Endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS) have largely replaced traditional surgery for treatment of varicose veins (VVs) with active venous leg ulcers (VLUs), and multiple combined modes have emerged. A retrospective cohort study was performed to compare the effect of traditional surgery (high ligation and stripping followed with compression [compression plus HL-S]) to high ligation-endovenous laser ablation-foam sclerotherapy followed with compression (compression plus HL-EVLA-FS) on the treatment of active VLUs.Data of active VLUs treated in our center from 2008 to 2017 and followed up for 1 year were analyzed. The intervention measures in the first 5 years were compression plus HL-S, and in the following 5 years were compression plus HL-EVLA-FS. The primary outcome was ulcer healing time. The secondary outcomes were the VVs occlusion and clinical success as assessed by a change in venous clinical severity score (VCSS) and complications.The study included 120 patients and 200 patients treated with HL-S and HL-EVLA-FS, respectively, during 2008 to 2017. The average ulcer healing time were 2.3 ± 2.4 and 1.7 ± 1.7 months, respectively. Significant difference was found in the cumulative ulcers healing rate between the two groups (Hazard ratio [HR] and 95% confidence interval [CI] was respectively 1.458 and 1.140-1.865, P = .0002), but no difference was found in the VVs occlusion (HR and 95% CI was respectively 1.005 and 0.774-1.3071, P = .967). Significant difference occurred in 6 months and 12 months post-operatively in the VCSS change and in the procedure data and some complications between the 2 groups.In conclusion, the treatment of HL-EVLA-FS can accelerate the healing of VLUs, improve the VCSS and present superior procedure data. However, no advantage could be found in the VVs occlusion compared with control group.

Catheter-directed foam sclerotherapy, an alternative to ultrasound-guided foam sclerotherapy for varicose vein treatment: A systematic review and meta-analysis

PURPOSE

Catheter-directed foam sclerotherapy is a new addition to the treatment modalities available for varicose veins. As a modification of ultrasound-guided foam sclerotherapy, catheter-directed foam sclerotherapy has been purported to offer higher complete ablation rates and an improved safety profile. The aim of this study is to appraise the current literature on the outcomes of catheter-directed foam sclerotherapy compared to ultrasound-guided foam sclerotherapy in chronic venous insufficiency.

METHODS

The review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data from studies that reported the outcomes of catheter-directed foam sclerotherapy and ultrasound-guided foam sclerotherapy were extracted, to determine the pooled proportion of complete ablation rates, using a random effect meta-analysis model.

RESULTS

A total of 62 studies, involving 3689 patients, were included in the systematic review. Higher rates of complete ablation were reported in catheter-directed foam sclerotherapy compared to ultrasound-guided foam sclerotherapy during the short- and medium-term follow-ups (Relative Risk = 1.06, Relative Risk = 1.15, Relative Risk = 1.19, p < 0.05). Fewer major and minor complications were also reported in patients who underwent catheter-directed foam sclerotherapy (Relative Risk = 0.23, Relative Risk= 0.43-0.76, p < 0.05).

CONCLUSION

Catheter-directed foam sclerotherapy has been demonstrated to have many advantages over ultrasound-guided foam sclerotherapy, offering superior complete ablation rates in the short-, medium- and long-term follow-ups. It also has a better safety profile, conferring a lower risk of major and minor complications. The conclusions should however be viewed in the context of significant limitations imposed by limited study data.

Comparison of combined compression and surgery with high ligation-endovenous laser ablation-foam sclerotherapy with compression alone for active venous leg ulcers

We aimed to assess the ulcer healing time and recurrence rates after treatment with compression therapy (CT) with or without high ligation-endovenous laser ablation-foam sclerotherapy (HL-EVLA-FS) in people with active venous leg ulcers (VLUs). A retrospective cohort study was conducted with 350 patients with active VLUs treated by compression with or without HL-EVLA-FS in our hospital from 2013 to 2017. The primary outcome was the ulcer healing time; secondary outcomes were the 12-month recurrence rates, the relationship between recurrence and venous reflux, and the complications of the two treatments. In total, 193 patients (200 limbs) underwent compression plus HL-EVLA-FS, and 157 patients (177 limbs) underwent CT alone. The ulcer healing time was shorter in the compression plus HL-EVLA-FS group than in the CT alone group (Hazard Ratio [HR] for ulcer healing, 1.845 [95% CI, 1.474–2.309], P = 0.0001). The 12-month ulcer recurrence rates were significantly reduced in the compression plus HL-EVLA-FS group (HR for ulcer recurrence, 0.418 [95% CI, 0.258–0.677], P = 0.0001). Calf perforator vein reflux (CPVR) and isolated superficial venous reflux (ISVR) were risk factors for ulcer recurrence. The combined operation with CT resulted in faster healing of VLUs, a lower ulcer recurrence rate and lower VCSS values after intervention than CT alone.

Ambulatory varicosity avulsion later or synchronized (AVULS): a randomized clinical trial

OBJECTIVE

A randomized clinical trial assessing the difference in quality of life and clinical outcomes between delayed and simultaneous phlebectomies in the context of endovenous truncal vein ablation.

BACKGROUND

Endovenous ablation has replaced open surgery as the treatment of choice for truncal varicose veins. Timing of varicosity treatment is controversial with delayed and simultaneous pathways having studies advocating their benefits. A previous small randomized study has shown improved outcomes for simultaneous treatment.

METHODS

Patients undergoing local anesthetic endovenous thermal ablation were randomized to either simultaneous phlebectomy or delayed varicosity treatment. Patients were reviewed at 6 weeks, 6 months, and 1 year with clinical and quality of life scores completed, and were assessed at 6 weeks for need for further varicosity intervention, which was completed with either ultrasound-guided foam sclerotherapy or local anesthetic phlebectomy. Duplex ultrasound assessment of the treated trunk was completed at 6 months.

RESULTS

101 patients were successfully recruited and treated out of 221 suitable patients from a screened population of 393. Patients in the simultaneous group (n = 51) showed a significantly improved Venous Clinical Severity Score at all time points, 36% of the delayed group required further treatment compared with 2% of the simultaneous group (P < 0.001). There were no deep vein thromboses, with 1 superfificial venous thrombosis in each group.

CONCLUSIONS

Combined endovenous ablation and phlebectomy delivers improved clinical outcomes and a reduced need for further procedures, as well as early quality of life improvements.

A systematic review and meta-analysis on the role of varicosity treatment in the context of truncal vein ablation

Background

With the advent of endovenous truncal ablation under local anaesthetic for the treatment of varicose veins, the fate of varicosed tributaries has become controversial, with centres offering different timings of treatment, if offered at all. This study aims to review the literature assessing delayed and simultaneous varicosity treatment during truncal ablation.

Methods

Randomised trials and cohort studies concerning varicosity treatment timing were identified through a systematic literature search. Requirements for further treatment, quality of life and rate of venous thrombotic events were assessed for meta-analysis.

Results

Four studies were identified assessing need for further varicosity procedure, with no significant difference seen between simultaneous or delayed treatment ( p = 0.339). Two studies assessed quality of life, with simultaneous treatment providing significantly improved outcomes at six weeks ( p = 0.029) but not at 12 weeks ( p = 0.283). Studies examining venous thrombotic events showed no difference in venous thromboembolism rate between simultaneous or delayed treatment approaches ( p = 0.078).

Conclusion

The evidence base regarding timing of varicosity treatment is sparse; however, it does show that simultaneous treatment of varicosities leads to early gains in quality of life, with a non-significant trend for fewer further procedures but more venous thrombotic events.

US-guided femoral and sciatic nerve blocks for analgesia during endovenous laser ablation

PURPOSE

Endovenous laser ablation may be associated with significant pain when performed under standard local tumescent anesthesia. The purpose of this study was to investigate the efficacy of femoral and sciatic nerve blocks for analgesia during endovenous ablation in patients with lower extremity venous insufficiency.

METHODS

During a 28-month period, ultrasound-guided femoral or sciatic nerve blocks were performed to provide analgesia during endovenous laser ablation in 506 legs and 307 patients. The femoral block (n = 402) was performed at the level of the inguinal ligament, and the sciatic block at the posterior midthigh (n = 124), by injecting a diluted lidocaine solution under ultrasound guidance. After the blocks, endovenous laser ablations and other treatments (phlebectomy or foam sclerotherapy) were performed in the standard fashion. After the procedures, a visual analogue pain scale (1-10) was used for pain assessment.

RESULTS

After the blocks, pain scores were 0 or 1 (no pain) in 240 legs, 2 or 3 (uncomfortable) in 225 legs, and 4 or 5 (annoying) in 41 legs. Patients never experienced any pain higher than score 5. The statistical analysis revealed no significant difference between the pain scores of the right leg versus the left leg (p = 0.321) and between the pain scores after the femoral versus sciatic block (p = 0.7).

CONCLUSIONS

Ultrasound-guided femoral and sciatic nerve blocks may provide considerable reduction of pain during endovenous laser and other treatments, such as ambulatory phlebectomy and foam sclerotherapy. They may make these procedures more comfortable for the patient and easier for the operator.