Role of endovenous laser treatment in the management of chronic venous insufficiency

Endovenous ablation for venous leg ulcers

BACKGROUND

Venous leg ulcers (VLUs) are a serious manifestation of chronic venous disease affecting up to 3% of the adult population. This typically recalcitrant and recurring condition significantly impairs quality of life, and its treatment places a heavy financial burden upon healthcare systems. The longstanding mainstay treatment for VLUs is compression therapy. Surgical removal of incompetent veins reduces the risk of ulcer recurrence. However, open surgery is an unpopular option amongst people with VLU, and many people are unsuitable for it. The efficacy of the newer, minimally-invasive endovenous techniques has been established in uncomplicated superficial venous disease, and these techniques can also be used in the management of VLU. When used with compression, endovenous ablation aims to further reduce pressure in the veins of the leg, which may impact ulcer healing.

OBJECTIVES

To determine the effects of superficial endovenous ablation on the healing and recurrence of venous leg ulcers and the quality of life of people with venous ulcer disease.

SEARCH METHODS

In April 2022 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scrutinised reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions on the language of publication, but there was a restriction on publication year from 1998 to April 2022 as superficial endovenous ablation is a comparatively new technology.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing endovenous ablative techniques with compression versus compression therapy alone for the treatment of VLU were eligible for inclusion. Studies needed to have assessed at least one of the following primary review outcomes related to objective measures of ulcer healing such as: proportion of ulcers healed at a given time point; time to complete healing; change in ulcer size; proportion of ulcers recurring over a given time period or at a specific point; or ulcer-free days. Secondary outcomes of interest were patient-reported quality of life, economic data and adverse events.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for eligibility, extracted data, carried out risk of bias assessment using the Cochrane RoB 1 tool, and assessed GRADE certainty of evidence.

MAIN RESULTS

The previous version of this review found no RCTs meeting the inclusion criteria. In this update, we identified two eligible RCTs and included them in a meta-analysis. There was a total of 506 participants with an active VLU, with mean durations of 3.1 months ± 1.1 months in the EVRA trial and 60.5 months ± 96.4 months in the VUERT trial. Both trials randomised participants to endovenous treatment and compression or compression alone, however the compression alone group in the EVRA trial received deferred endovenous treatment (after ulcer healing or from six months). There is high-certainty evidence that combined endovenous ablation and compression compared with compression therapy alone, or compression with deferred endovenous treatment, improves time to complete ulcer healing (pooled hazard ratio (HR) 1.41, 95% CI 1.36 to 1.47; I2 = 0%; 2 studies, 466 participants). There is moderate-certainty evidence that the proportion of ulcers healed at 90 days is probably higher with combined endovenous ablation and compression compared with compression therapy alone or compression with deferred endovenous treatment (risk ratio (RR) 1.14, 95% CI 1.00 to 1.30; I2 = 0%; 2 studies, 466 participants). There is low-certainty evidence showing an unclear effect on ulcer recurrence at one year in people with healed ulcers with combined endovenous treatment and compression when compared with compression alone or compression with deferred endovenous treatment (RR 0.29, 95% CI 0.03 to 2.48; I2 = 78%; 2 studies, 460 participants). There is also low-certainty evidence that the median number of ulcer-free days at one year may not differ (306 (interquartile range (IQR) 240 to 328) days versus 278 (IQR 175 to 324) days) following combined endovenous treatment and compression when compared with compression and deferred endovenous treatment; (1 study, 450 participants). There is low-certainty evidence of an unclear effect in rates of thromboembolism between groups (RR 2.02, 95% CI 0.51 to 7.97; I2 = 78%, 2 studies, 506 participants). The addition of endovenous ablation to compression is probably cost-effective at one year (99% probability at GBP 20,000/QALY; 1 study; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Endovenous ablation of superficial venous incompetence in combination with compression improves leg ulcer healing when compared with compression alone. This conclusion is based on high-certainty evidence. There is moderate-certainty evidence to suggest that it is probably cost-effective at one year and low certainty evidence of unclear effects on recurrence and complications. Further research is needed to explore the additional benefit of endovenous ablation in ulcers of greater than six months duration and the optimal modality of endovenous ablation.

Effect of Endovenous Laser Ablation Along With Compression Therapy on Chronic Venous Ulcer Healing

Introduction Chronic venous insufficiency is a major cause of morbidity, and there is a paucity of data regarding its epidemiology due to the lack of a central wound registry. In this study, we aimed to study the time for healing of the ulcer and compliance with compression therapy (CT) following endovenous laser ablation (EVLA) ± ultrasound-guided foam sclerotherapy (UGFS) along with CT in patients with chronic venous ulcers. Methods This prospective observational study was conducted from January 2020 to June 2021 after obtaining institutional ethical committee clearance. Patients with chronic venous ulcers (>six weeks to 4 cm in 10% of patients. A total of 38% of patients underwent only EVLA, and EVLA+UGFS were done in 62% of participants. The healing rate at six months follow-up was 92%, with the average time taken being 2.55±1.38 months. Those who remained with an unhealed ulcer at six months follow-up had an ulcer size of >5 cm and an age of >50 years. Ninety-six percent of the patients were compliant with CT after an endovenous intervention. The recurrence rate at two years post-ablation was 6%. VCSS was 19.66±3.23 at presentation and 5.5±2.82 at six months of follow-up. Conclusion Endovenous ablation of superficial venous reflux along with CT is associated with a shorter healing time of venous ulcerations and reduced chances of recurrence. There is an improvement in VCSS score over the period of six months follow-up.

In vitro impact of laser irradiation on platelet aggregation

The review of blood optical and rheological parameters plays an important role in many medical routine diagnosis and therapeutic applications and is the best way to understand the mechanism of action of low-level laser irradiation on biological tissues. The aim of this study was to investigate the in vitro effect of laser radiation on platelet count and aggregation. Blood samples were obtained from 30 healthy volunteers; each sample was divided into four aliquots, one of them was considered as a control while the other three were exposed to three different laser doses. A wavelength of 532 nm and a low power of 100 mW were used for irradiation with a 4-mm-diameter beam spot. The irradiation times were 1.8, 3.7, and 6.2 s giving doses of irradiation 1.5, 3, and 5 J/cm², respectively. Microsoft Excel was used for statistical analysis. Low laser irradiation induced significant changes in platelet aggregation in the presence of weak agonists such as adenosine diphosphate (ADP) (P ≤ 0.05) and epinephrine (P ≤ 0.01). Low-level laser therapy has no influence on platelet count; however, it promotes platelet aggregation in response to weak agonists, specifically ADP and epinephrine.

Ozone Gas Bath Combined with Endovenous Laser Therapy for Lower Limb Venous Ulcers: A Randomized Clinical Trial

BACKGROUND

Endovenous laser therapy (EVLT) is safe and effective for lower limb venous ulcers. However, severe necrosis and infection in the ulcer area are contraindications of puncture and EVLT. Local bath with ozone gas has been shown to improve the condition of ulcer areas. The aim of this study was to evaluate the clinical efficacy of ozone gas bath combined with EVLT in comparison with EVLT alone for the treatment for lower limb venous ulcers.

PATIENTS AND METHODS

Ninety-two patients with venous ulcers were randomized to receive ozone gas bath combined with EVLT (OEVLT group) or EVLT alone (EVLT group). In the OEVLT group, the venous ulcers were preconditioned with ozone gas bath prior to EVLT. The minimum follow-up time was 12 months. The two groups were compared in terms of complete occlusion of the treated veins, ulcer healing ratio, ratio of ulcer recurrence, patient satisfaction, complications, and side effects.

RESULTS

There was no significant difference in venous occlusion between the two groups. The ratio of ulcer healing in the OEVLT group was significantly higher than the EVLT group at 12 months follow-up. Patients in the OEVLT group showed better satisfaction and a lower recurrence ratio than the OEVLT group. No severe complications or side effects occurred in either groups.

CONCLUSIONS

Ozone gas bath combined with EVLT showed improved efficacy for the treatment of lower limb venous ulcers and lower recurrence ratio comparison with EVLT alone. This procedure is a safe and technically feasible.

Endovenous thermal ablation for healing venous ulcers and preventing recurrence

BACKGROUND

Venous leg ulcers represent the worst extreme within the spectrum of chronic venous disease. Affecting up to 3% of the adult population, this typically chronic, recurring condition significantly impairs quality of life, and its treatment places a heavy financial burden upon healthcare systems. The current mainstay of treatment for venous leg ulcers is compression therapy, which has been shown to enhance ulcer healing rates. Open surgery on the veins in the leg has been shown to reduce ulcer recurrence rates, but it is an unpopular option and many patients are unsuitable. The efficacy of the newer, minimally-invasive endovenous thermal techniques has been established in uncomplicated superficial venous disease, and these techniques are now beginning to be used in the management of venous ulceration, though the evidence for this treatment is currently unclear. It is hypothesised that, when used with compression, ablation may further reduce pressures in the leg veins, resulting in improved rates of healing. Furthermore, since long-term patient concordance with compression is relatively poor, it may prove more popular, effective and cost-effective to provide a single intervention to reduce recurrence, rather than life-long treatment with compression.

OBJECTIVES

To determine the effects of superficial endovenous thermal ablation on the healing, recurrence and quality of life of people with active or healed venous ulcers.

SEARCH METHODS

In August 2013 we searched Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions on the language of publication but there was a date restriction based on the fact that superficial endovenous thermal ablation is a comparatively new medical technology.

SELECTION CRITERIA

Randomised clinical trials comparing endovenous thermal ablative techniques with compression therapy alone for venous leg ulcers were eligible for inclusion. Trials had to report on at least one objective measure of ulcer healing (primary outcome) such as proportion of ulcers healed at a given time point, time to complete healing, change in ulcer size, proportion of ulcers recurring over a given time period, or at a specific point, and ulcer-free days. Secondary outcomes sought included patient-reported quality of life, economic data and adverse events.

DATA COLLECTION AND ANALYSIS

Details of potentially eligible studies were extracted and summarised using a data extraction table. Data extraction and validity assessment were performed independently by two review authors, and any disagreements resolved by consensus or by arbitration of a third review author.

MAIN RESULTS

No eligible randomised controlled trials were identified. There is an absence of evidence regarding the effects of superficial endovenous thermal ablation on ulcer healing, recurrence or quality of life of people with venous leg ulcer disease.

AUTHORS' CONCLUSIONS

The review identified no randomised controlled trials on the effects on ulcer healing, recurrence or quality of life, of superficial endovenous thermal ablation in people with active or healed venous leg ulcers. Adequately-powered, high quality randomised controlled trials comparing endovenous thermal ablative interventions with compression therapy are urgently required to explore this new treatment strategy. These should measure and report outcomes that include time to ulcer healing, ulcer recurrence, quality of life and cost-effectiveness.

Wound Healing Society (WHS) venous ulcer treatment guidelines: what's new in five years?

Since the establishment of the guidelines for the treatment of venous ulcers by the Wound Healing Society in 2006, there has been an abundance of new literature, both in accord and discord with the guidelines. The goal of this update is to highlight new findings since the publication of these guidelines to assist practitioner and patient in appropriate health care decisions, as well as to drive future research endeavors.

Retrospective comparison of clinical outcomes between endovenous laser and saphenous vein-sparing surgery for treatment of varicose veins

BACKGROUND

The purpose of the present study was to compare management of varicose veins by endovenous laser ablation (EVL) and a vein-sparing procedure (CHIVA: Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire) for management of varicose veins.

METHODS

Data from 82 consecutive patients with great saphenous vein (GSV) reflux and primary varicose veins presenting to the vascular clinic at the Far Eastern Memorial Hospital between June and December 2005 were reviewed. Of these, 74 who met the inclusion criteria were included in this study. CHIVA was performed by a double division of the refluxing saphenous vein (i.e., proximal and distal ligation), and EVL was performed using 10-14 W beginning approximately 4 cm below the saphenofemoral junction to the level of the knee. Phlebectomy for significant branch varicose veins on the leg was routinely performed in all patients. Outcome measures included postoperative thrombophlebitis, bruising, pain, assessment of ultrasonographic and clinical symptoms (measured by the Venous Clinical Severity Score [VCSS]) and comparison of quality of life survey scores obtained preoperatively and postoperatively (measured by the Aberdeen Varicose Veins Score [AVVQ] and RAND-36). Patients were examined one week post-procedurally and again at 1, 3, 6, and 12 months.

RESULTS

Endovenous laser ablation and CHIVA were performed on 54 and 20 patients, respectively. The EVL patients had significantly higher pain scores and bruising than the CHIVA group (p<0.001). The VCSS of varicose, edema, pigmentation, and inflammation were significantly reduced after both EVL and CHIVA; however, patients treated by EVL had significantly more pain postoperatively than those treated by CHIVA (p=0.003). Twenty-two of 54 (40.7%) and 3 of 17 (17.6%) patients in the EVL and CHIVA groups, respectively, required sclerotherapy for residual varicosities (p=0.026). Both groups benefited significantly from surgery in disease-specific perceptions.

CONCLUSIONS

The CHIVA patients had less pain postoperatively and a significantly higher sclerotherapy-free period compared to patients in the EVL group. Further follow-up studies to compare long-term results of various approaches to surgically managing varicose veins are needed.

Results of endovenous ClosureFast treatment for varicose veins in an outpatient setting

Objective

Endovenous methods are increasingly used to treat varicose veins. We evaluated the outcome of patients treated with the new radiofrequency ablation (RFA)-ClosureFast catheter in an outpatient setting.

Method

Retrospective analysis of postinterventional duplex ultrasound (DUS), complication rate and quality of life of patients treated for incompetent saphenous veins.

Results

Between 2007 and 2009, 155 patients had been treated with ClosureFast. DUS was available from 73 (47%) patients (102 great [GSV] and 16 small [SSV] saphenous veins). After a mean follow-up of 12.2 months (range 1–29 months), DUS showed six (5.9%) open GSV and an occlusion of all treated SSV. One pulmonary embolism had occurred. Mean patient's satisfaction was 8.7 (10 = very satisfied), pain after one week 2.0 (no pain = 0, maximal = 10) and absence of work was 0.9 day (range 0–14 days).

Conclusion

RFA for incompetent saphenous veins can safely be performed in an outpatient setting with a low complication rate, minimal pain and fast recovery.

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

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

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

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

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