Systematic Review of Endovenous Laser Therapy Versus Surgery for the Treatment of Saphenous Varicose Veins

Challenging conventions: Reconsidering the indication for endovenous ablation in CEAP 2 patients

INTRODUCTION

Endovenous ablation may not always be necessary for every patient with chronic venous insufficiency who has an indication for endovenous ablation. This study investigates whether compression stockings and Daflon® can be as effective for some patients with CEAP two in chronic venous insufficiency.

METHODS

In this study, 137 patients who had endovenous ablation indication received plethysmographical hemodynamic tests and were divided into two groups. Group 1 had normal venous hemodynamics and received compression stockings and Daflon®. Group 2 had abnormal function and received laser ablation. All patients were reevaluated after 6 months.

RESULTS

The study showed that there was no statistically significant difference between Groups 1 and 2 in the 6th month measurements after the treatments.

CONCLUSION

As a result, we do not find it appropriate and do not recommend that every patient with complaints of chronic venous insufficiency and an indication for endovenous ablation undergo ablation without evaluating lower extremity venous hemodynamics.

Combined effect of yoga and naturopathy in uncomplicated varicose vein disease - a prospective randomized controlled trial

BACKGROUND

Though the treatment of uncomplicated varicose vein (UVV) might prevent late complications such as skin change or ulceration, but, there are limited studies available to justify this concept. Yoga and Naturopathy being a proficient tool in managing non communicable diseases including many cardiovascular diseases; no attempt was made to study its potential effect in Varicose Vein diseases.

OBJECTIVE

The present study aims to study the combination of Yoga and Naturopathy in uncomplicated varicose vein patients.

MATERIALS AND METHODS

50 UVV participants were prospectively recruited and randomly divided into two groups, Experimental and Active control groups. Both the groups practiced their respective interventions, and follow up was done after 1 and 3 months of active intervention. Finally study was completed with 46 participants (2 dropouts in each groups). The sample size was calculated based on the previous study, considering power as 0.8 and 'α' as 0.05, using 'G' power software. The variables such as Body weight, BMI, Systolic blood pressure (SBP), Diastolic blood pressure (DBP), Heart rate (HR), high-sensitivity C-reactive protein (hs-CRP), homocysteine (HCy) were recorded before and after the intervention, but Aberdeen Varicose Vein Questionnaire (AVVQ) and Visual analogue heaviness scale (VAHS) were recorded on 60 and 120 days of the follow up in addition to active intervention period.

RESULTS

There was a significant decrease in hs-CRP (p < 0.05) in the experimental group as compared to the control group. Body weight, BMI, SBP, HR, hs-CRP, HCy (p < 0.001) and DBP (p < 0.05) significantly decreases following the Combined Yoga and Naturopathy (CYN) intervention for a month in the experimental group. Also, the AVVQ (p < 0.01) and VAHS (p < 0.05) decreases following active intervention and two consecutive follow up. No adverse event was noted during or after the trial.

CONCLUSION

The combined effect of Yoga and Naturopathy reduced blood pressure and inflammatory markers suggestive of potential of recovery in inflammation in the endothelial tissue of the microvascular system in UVV patients.

TRIAL REGISTRY NUMBER

CTRI/2018/10/015895; Clinical Trials Registry- India; www.ctri.nic.in.

Outcomes of a Single-center Experience In Eliminating Routine Postoperative Duplex Ultrasound Following Endovenous Ablation

OBJECTIVES

The current guidelines recommend routine postoperative screening duplex ultrasound (DUS) after endovenous ablation (EVA). This is a grade 2C recommendation and several contemporary reports have called for revision of this recommendation as there is insufficient evidence to support universal screening DUS after EVA. There are currently no studies that evaluate outcomes among EVA patients who did not have screening DUS. The aim of our study is to present outcomes from our single-center experience among patients who did not have DUS routinely performed after EVA.

METHODS

We performed a single-center, prospective cohort study that included consecutive patients undergoing EVA of the great saphenous vein at our institution between September 30, 2021 and March 15, 2022. At 30 days post procedure, electronic medical records were queried to identify patients who may have presented for evaluation of VTE symptoms.

RESULTS

Over the study period, a total of 80 lower extremity EVA procedures (71 EVLT, 9 RFA) were performed among 76 patients. Postoperative DUS was performed on 24 patients of which none were identified as having EHIT. Of the 54 patients who did not have DUS, a 30-day post procedure chart review revealed that none of these patients were seen for symptoms of venous thromboembolism (VTE). We estimate total cost savings of $14,289 by eliminating routine DUS without impact to clinical outcomes following EVA.

CONCLUSION

Postoperative DUS assessment after EVA comes with associated healthcare cost and has low yield given the incidence of clinically significant EHIT (3 and 4) is rare. In our experience, eliminating routine DUS had no impact on clinical outcomes, improved vascular lab access, and had a positive financial impact in our organization. Limiting DUS screening to EVA patients who exhibit symptoms of VTE can be a cost-effective approach that limits unnecessary imaging, time, and resources with no potential change in clinical outcomes based on our data. Further research is required and a randomized controlled trial would be ideal to answer this question.

Feasibility of incompetent perforator vein excision using stab avulsion

Objectives

Whether incompetent perforator veins (IPVs) require treatment remains controversial. We retrospectively evaluated the feasibility of IPV excision performed using the stab avulsion technique without ligation and sutures in patients undergoing endovenous ablation (EA).

Methods

This was a single-center, retrospective, observational cohort study. EA was performed in 1503 consecutive patients, including 33 patients with ulcers, between December 2014 and May 2021. Varicectomy was performed using the stab avulsion technique; IPV cases were included.

Results

Stab avulsion was performed at a mean number of 11.4 ± 7.8 sites. No deep vein thromboses or pulmonary emboli were noted. The incidence of nerve injury was 0.3%. All 33 (100%) patients with ulcers achieved healing by 1 year (median: 55.5 days; range: 13–365 days).

Conclusions

IPV excision via stab avulsion may be a viable option for treating varicose veins and ulcers. This technique offers multiple advantages, including simplicity, safety, and reduced healthcare costs.

Strategy to prevent nerve injury and deep vein thrombosis in radiofrequency segmental thermal ablation of the saphenous veins using a new objective pain scale

Objective

We evaluated the benefit of local anesthesia including tumescent anesthesia and active walking soon after surgery in preventing nerve injury and deep vein thrombosis caused during endovenous ablation.

Methods

Endovenous ablation was performed in 1334 consecutive patients. Varicectomy was performed using the stab avulsion technique. After surgery, patients were encouraged to walk 100–200 m inside the ward for 3–5 times/h. The pain was evaluated objectively using the Okamura pain scale and subjectively using the numerical rating scale.

Results

Stab avulsion was performed at 11.8 ± 8.0 sites and the mean operative time was 33.9 ± 15.2 min. The mean Okamura pain scale and numerical rating scale scores were 1.6 ± 1.3 and 3.0 ± 2.0, respectively. Deep vein thrombosis and pulmonary embolism were absent. The incidence of nerve injury was 0.3%.

Conclusions

Endovenous ablation should be performed with the patients under local anesthesia to prevent nerve injury and deep vein thrombosis.

Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery

The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.

Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery This Practice Guidelines document has been co-published in Phlebology [DOI: 10.1177/0268355520953759] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.06.008]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal's style. The contribution has been published under a Attribution-Non Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0), (https://creativecommons.org/licenses/by-nc-nd/4.0/)

The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT.

One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed.

Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.

Effect of endovenous ablation assessment stratified by great saphenous vein size, gender, clinical severity, and patient-reported outcomes

OBJECTIVE

The policies of insurance carriers have used the truncal vein size as a criterion for coverage. The objective of the present study was to compare the effect of great saphenous vein (GSV) size ≥5 mm vs <5 mm on patient presentation and clinical outcomes.

METHODS

Patients in a national cohort were prospectively captured in the Vascular Quality Initiative Varicose Vein Registry. From January 2015 to October 2017, the Vascular Quality Initiative Varicose Vein Registry database was queried for all patients who had undergone varicose vein procedures. The CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, Venous Clinical Severity Score, and patient-reported outcomes were compared by GSV size (<5 mm, group 1; ≥5 mm, group 2) before and after the procedures. A 2-sample Wilcoxon test was performed to assess the differences between the 2 groups stratified by GSV size. To assess for postoperative improvement, a matched-pairs Wilcoxon signed rank test was performed for each group separately.

RESULTS

During the study period, 5757 vein ablation procedures had been performed for GSV: 770 for GSV size <5 mm and 4987 for GSV size ≥5 mm. Patients in group 1 were more likely to be women (81.7% vs 68.4%; P = .001) and older (56.8 vs 55.6 years; P = .012). The CEAP clinical class was more advanced in group 2 than in group 1 (P = .001). The maximal GSV diameter in group 2 was significantly greater than in group 1 (8.32 vs 3.86 mm; P = .001); 64% of group 2 and 59.2% of group 1 had undergone radiofrequency thermal ablation (P = .001). No mortalities occurred in either group. Group 2 had more complications postoperatively (0.6% vs 0%; P = .027), required postoperative anticoagulation (8.8% vs 5%, P = .001), developed partial recanalization (0.8% vs 0.3%; P = .001), and missed more work days (2.32 vs 1.6 days) compared with group 1. A similar rate of hematoma developed in both groups, but group 1 had a higher rate of paresthesia. Both groups had improvement in the Venous Clinical Severity Score and HASTI (heaviness, achiness, swelling, throbbing, itching) score. The degree of symptomatic improvement between the 2 groups was similar.

CONCLUSIONS

All patients demonstrated improvement in both clinical outcomes and patient-reported outcomes after endovenous ablation, regardless of GSV size. Patients with a preoperative GSV size ≥5 mm experienced similar improvement in symptoms but an increased complication rate. Patients with a smaller vein size should not be denied intervention or coverage by vein size.

Outcome of ClosureFAST radiofrequency ablation for large-diameter incompetent great saphenous vein

Purpose

There is limited data on the outcomes of radiofrequency ablation (RFA) for large diameter saphenous veins. This study aimed to determine whether the large-diameter great saphenous vein (GSV) affected closure rate, complications, and clinical and quality of life (QoL) improvement.

Methods

From January 2012 to September 2016, a total of 722 limbs were treated with ClosureFAST RFA in a single center. Patients were divided into 2 groups according to the vein diameter measured 3 cm below the saphenofemoral junction (group A ≤ 12 mm, group B > 12 mm). Vein closure was evaluated with duplex scan at 3–5 days, 1, 3, 6, and 12 months postoperatively. The incidence of complications, improvements in symptoms (measured by the Venous Clinical Severity Score [VCSS]) and QoL (measured by the Aberdeen Varicose Vein Symptom Severity Score [AVSS]) were evaluated.

Results

Groups consisted of 663 GSVs in group A (mean diameter, 6.00 ± 1.74 mm) and 59 in group B (mean diameter, 13.17 ± 1.28 mm). Vein closure rates at 12 months were 98.9% in group A and 100% in group B (P = 0.428). There was no significant difference in the incidence of complications. Both groups showed marked improvements in the VCSS and the AVSS with no significant differences.

Conclusion

For large-diameter veins, RFA showed comparable outcomes in terms of closure rate, complications, clinical and QoL improvements.

Non-Ionizing Radiation in Swedish Health Care-Exposure and Safety Aspects

The main aim of the study was to identify and describe methods using non-ionizing radiation (NIR) such as electromagnetic fields (EMF) and optical radiation in Swedish health care. By examining anticipated exposure levels and by identifying possible health hazards we also aimed to recognize knowledge gaps in the field. NIR is mainly used in health care for diagnosis and therapy. Three applications were identified where acute effects cannot be ruled out: magnetic resonance imaging (MRI), transcranial magnetic stimulation (TMS) and electrosurgery. When using optical radiation, such as class 3 and 4 lasers for therapy or surgical procedures and ultra-violet light for therapy, acute effects such as unintentional burns, photo reactions, erythema and effects on the eyes need to be avoided. There is a need for more knowledge regarding long-term effects of MRI as well as on the combination of different NIR exposures. Based on literature and after consulting staff we conclude that the health care professionals' knowledge about the risks and safety measures should be improved and that there is a need for clear, evidence-based information from reliable sources, and it should be obvious to the user which source to address.

Evidence for varicose vein treatment: an overview of systematic reviews

BACKGROUND

Varicose veins affect nearly 30% of the world's population. This condition is a social problem and needs interventions to improve quality of life and reduce risks. Recently, new and less invasive methods for varicose vein treatment have emerged. There is a need to define the best treatment options and to reduce the risks and costs. Since there are cosmetic implications, treatments for which effectiveness remains unproven present risks to consumers and higher costs for stakeholders. These risks and costs justify conducting an overview of systematic reviews to summarize the evidence.

DESIGN AND SETTING

Overview of systematic reviews within the Discipline of Evidence-Based Health, at Universidade Federal de São Paulo (UNIFESP).

METHODS

Systematic reviews on clinical or surgical treatments for varicose veins were included, with no restrictions on language or publication date.

RESULTS

51 reviews fulfilled the inclusion criteria. Outcomes and comparators were described, and a narrative review was conducted. Overall, there was no evidence that compression stockings should be recommended for patients as the initial treatment or after surgical interventions. There was low to moderate evidence that minimally invasive therapies (endovenous laser therapy, radiofrequency ablation or foam sclerotherapy) are as safe and effective as conventional surgery (ligation and stripping). Among these systematic reviews, only 18 were judged to present high quality.

CONCLUSIONS

There was evidence of low to moderate quality that minimally invasive treatments, including foam sclerotherapy, laser and radiofrequency therapy are comparable to conventional surgery, regarding effectiveness and safety for treatment of varicose veins.

Evaluation of pain during endovenous laser ablation of the great saphenous vein with ultrasound-guided femoral nerve block

Background

Endoluminal laser ablation is now considered the method of choice for treating greater saphenous vein insufficiency. General anesthesia and peripheral nerve blocks with sedation have the risk of post-procedural delay in discharge and prolonged immobilization with the risk of deep vein thrombosis. The main pain experienced by patients during the procedure is during the laser ablation and the multiple needle punctures given along and around the great saphenous vein. The aim of our study was to evaluate the safety and efficacy of blocking the femoral nerve only under ultrasound-guidance without sedation, to reduce or prevent pain during injectable tumescent anesthesia in endovenous laser ablation of the greater saphenous vein.

Methods

Sixty patients in two groups underwent endovenous laser ablation for the greater saphenous vein insufficiency at an outpatient clinic. All patients received tumescent anesthesia. However, one group received a femoral nerve block (FNB) under ultrasound guidance before the procedure. All patients were asked to record the pain or discomfort, using the visual analog score, from the start of the procedure until the end of the great saphenous vein laser ablation. The length of the great saphenous vein and duration of the procedure were also recorded. The results were analyzed using statistical methods.

Results

No complications from FNB were observed. The pain associated with application of tumescent anesthesia and laser ablation was more intense in the group without an FNB (P < 0.001). There was no significant difference between the two groups in the length of the great saphenous vein or procedure duration.

Conclusion

Ultrasound-guided FNB (without other peripheral nerve blocks) is a safe, adequate, and effective option to decrease and/or eliminate the intraoperative discomfort associated with tumescent anesthesia injections and laser ablation during endoluminal laser ablation of the greater saphenous vein.

Endovenous ablation therapy (laser or radiofrequency) or foam sclerotherapy versus conventional surgical repair for short saphenous varicose veins

BACKGROUND

Short (or small) saphenous vein (SSV) varices occur as a result of an incompetent sapheno-popliteal junction, where the SSV joins the popliteal vein, resulting in reflux in the SSV; they account for about 15% of varicose veins. Untreated varicose veins may sometimes lead to ulceration of the leg, which is difficult to manage. Traditionally, treatment was restricted to surgery or conservative management. Since the 1990s, however, a number of minimally invasive techniques have been developed; these do not normally require a general anaesthetic, are day-case procedures with a quicker return to normal activities and avoid the risk of wound infection which may occur following surgery. Nerve injury remains a risk with thermal ablation, but in cases where it does occur, the injury tends to be transient.

OBJECTIVES

To compare the effectiveness of endovenous laser ablation (EVLA), radiofrequency ablation (RFA) and ultrasound-guided foam sclerotherapy (UGFS) versus conventional surgery in the treatment of SSV varices.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Specialised Register (last searched 17 March 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2). We searched clinical trials databases for details of ongoing or unpublished studies.

SELECTION CRITERIA

We considered all randomised controlled trials (RCTs) comparing EVLA, endovenous RFA or UGFS with conventional surgery in the treatment of SSV varices for inclusion.

DATA COLLECTION AND ANALYSIS

We independently reviewed, assessed and selected trials that met the inclusion criteria; any disagreements were resolved by discussion. We extracted data and used the Cochrane's tool for assessing risk of bias. When the data permitted, we performed either fixed-effect meta-analyses with odds ratios (ORs) and 95% confidence intervals (CIs) or random-effects meta-analyses where there was moderate to significant heterogeneity.

MAIN RESULTS

We identified three RCTs, all of which compared EVLA with surgery; one also compared UGFS with surgery. There were no trials comparing RFA with surgery. The EVLA versus surgery comparison included 311 participants: 185 received EVLA and 126 received surgery. In the UGFS comparison, each treatment group contained 21 people. For several outcomes in the EVLA comparison, only a single study provided relevant data; as a result, the current review is limited in its ability to demonstrate meaningful results for some planned outcomes. The quality of evidence according to GRADE was moderate to low for the outcome measures in the EVLA versus surgery comparison, but low for the UGFS versus surgery comparison. Reasons for downgrading in the EVLA versus surgery comparison were risk of bias (for some outcomes, the outcome assessors were not blinded; and in one study the EVLA-surgery allocation of 2:1 did not appear to be prespecified); imprecision (data were only available from a single small study and the CIs were relatively wide); indirectness (one trial reported results at six months rather than one year and was inadequately powered for SSV varices-only analysis). Reasons for downgrading in the UGFS versus surgery comparison were imprecision (only one trial offered UGFS and several participants were missing from the analysis) and a limitation in design (the study was inadequately powered for SSV participants alone).For the EVLA versus surgery comparison, recanalisation or persistence of reflux at six weeks occurred less frequently in the EVLA group than in the surgery group (OR 0.07, 95% CI 0.02 to 0.22; I² = 51%; 289 participants, 3 studies, moderate-quality evidence). Recurrence of reflux at one year was also less frequent in the EVLA group than in the surgery group (OR 0.24, 95% CI 0.07 to 0.77; I² = 0%; 119 participants, 2 studies, low-quality evidence). For the outcome clinical evidence of recurrence (i.e. presence of new visible varicose veins) at one year, there was no difference between the two treatment groups (OR 0.54, 95% CI 0.17 to 1.75; 99 participants, 1 study, low-quality evidence). Four participants each in the EVLA and surgery groups required reintervention due to technical failure (99 participants, 1 study, moderate-quality evidence). There was no difference between the two treatment groups for disease-specific quality of life (QoL) (Aberdeen Varicose Veins Questionnaire) either at six weeks (mean difference (MD) 0.15, 95% CI -1.65 to 1.95; I² = 0%; 265 participants, 2 studies, moderate-quality evidence), or at one year (MD -1.08, 95% CI -3.39 to 1.23; 99 participants, 1 study, low-quality evidence). Main complications reported at six weeks were sural nerve injury, wound infection and deep venous thrombosis (DVT) (one DVT case in each treatment group; EVLA: 1/161, 0.6%; surgery 1/104, 1%; 265 participants, 2 studies, moderate-quality evidence).For the UGFS versus surgery comparison, there were insufficient data to detect clear differences between the two treatment groups for the two outcomes recanalisation or persistence of reflux at six weeks (OR 0.34, 95% CI 0.06 to 2.10; 33 participants, 1 study, low-quality evidence), and recurrence of reflux at one year (OR 1.19, 95% CI 0.29 to 4.92; 31 participants, 1 study, low-quality evidence). No other outcomes could be reported for this comparison because the study data were not stratified according to saphenous vein.

AUTHORS' CONCLUSIONS

Moderate- to low-quality evidence exists to suggest that recanalisation or persistence of reflux at six weeks and recurrence of reflux at one year are less frequent when EVLA is performed, compared with conventional surgery. For the UGFS versus conventional surgery comparison, the quality of evidence is assessed to be low; consequently, the effectiveness of UGFS compared with conventional surgery in the treatment of SSV varices is uncertain. Further RCTs for all comparisons are required with longer follow-up (at least five years). In addition, measurement of outcomes such as recurrence of reflux, time taken to return to work, duration of procedure, pain, etc., and choice of time points during follow-up should be standardised such that future trials evaluating newer technologies can be compared efficiently.

The Efficacy of Femoral Block and Unilateral Spinal Anaesthesia on Analgesia, Haemodynamics and Mobilization in Patients undergoing Endovenous Ablation in the Lower Extremity

OBJECTIVE

This study aimed to investigate the efficacy of femoral block and unilateral spinal anaesthesia on analgesia, haemodynamics and mobilization during endovenous ablation in patients with lower extremity venous insufficiency.

METHODS

Forty patients of ASA physical status I and II, with ages ranging between 30 and 45 years, and who were scheduled for endovenous laser ablation for varicose veins were prospectively enrolled in this study. Patients were randomized into a unilateral spinal anaesthesia group (group HS, n=20) or a femoral block group (group F, n=20). Group HS received 7.5-10 mg of heavy bupivacaine for unilateral spinal anaesthesia, while group F received 100 mg prilocaine for femoral block with ultrasound guidance. The level of motor blockage (Bromage score), visual pain score, mean heart rate and mean arterial pressures were recorded at postoperative 0, 1, 2, 3d and 6 h, respectively.

RESULTS

Perioperative visual pain score values in both groups were <4. None of the groups required an additional analgesic agent. Bromage scores were significantly lower in group F than in group HS during the postoperative period (p<0.01). Motor function returned to normal in all patients at 3 h in group F and at 6 h in group HS. Postoperative mean heart rate and arterial pressure did not differ between the groups (p>0.05).

CONCLUSION

In patients with lower extremity venous insufficiency who were undergoing endovenous laser ablation, an ultrasound-guided femoral block provided similar analgesia with that of unilateral spinal anaesthesia. In group F, the duration of anaesthesia and mobilization time was shorter.

Real time echo-guided endolaser for thermal ablation without perivenous tumescence

Abstract Background There is no consensus in the medical literature on the ideal procedure for endovenous laser application. Objective To assess the safety and efficacy of real time echo-guided endovenous laser for thermal ablation of great saphenous vein (GSV) incompetence, without perivenous tumescence. Methods Thirty-four limbs of patients with CEAP clinical scores of 2 to 6 and bilateral incompetence of the saphenofemoral junction (SFJ) and GSV, confirmed by Echo-Doppler, underwent endovenous laser therapy and were followed for 1 year. Laser ablation was performed using a 600 µ bare optical fiber introduced endovenously close to the malleolus along the full extent of the GSV in an anterograde direction, using a standardized echo-Doppler-guided AND? 15 watt continuous mode 980 nm diode laser with real-time monitoring of thermal ablation of the whole target vein. Adverse effects and complications were recorded. Results Hyperesthesia, cellulitis, and fibrous cord, all transitory, developed in 2.9% of the 34 limbs treated; 8.8% developed hypoesthesia in the perimalleolar region, which was transitory and had no clinical consequences; there were no cases of deep venous thrombosis. Immediate occlusion was achieved in 100% of the 34 saphenous veins that underwent photocoagulation, although one exhibited recanalization without reflux at 1-month follow-up. After 6 months and 1 year, occlusion was 100% according to echo-Doppler findings. Conclusions Real-time echo-guided 980 nm endovenous laser ablation without perivenous tumescence provided controlled thermal ablation with safe, effective, immediate and medium-term GSV occlusion and can therefore be recommended as a method for the treatment of chronic venous disease.

Retrieval of a Dislodged Catheter Using Combined Fluoroscopy and Intracardiac Echocardiography

This report details a method of percutaneous, transluminal retrieval of an intracardiac foreign body using fluoroscopy in combination with intracardiac echocardiography. During retrieval, intracardiac echocardiography (ICE) provided real-time anatomic localization of a constantly moving, almost radiolucent micropuncture coaxial dilator fragment with respect to the tricuspid and pulmonary valves. This method may serve as a crucial aid in retrieval of intracardiac foreign bodies that are difficult to see with fluoroscopy and which may be adjacent to cardiac valves.

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.

Noninterruption of Warfarin Therapy is Safe and Does not Compromise Outcome in Patients Undergoing Endovenous Laser Therapy (EVLT)

Objective: To assess the need for cessation of oral anticoagulation with warfarin for patients undergoing endovenous laser therapy (EVLT). Methods: Between September 2004 and July 2010, 518 patients underwent 770 EVLT procedures on the lower extremity, at our institution. Of these patients, 5 underwent a total of 12 separate lower extremity EVLT procedures for the treatment of symptomatic reflux without interruption of warfarin therapy. Results: No bleeding complications were observed during the procedure or in early follow-up. None of the patients developed a deep venous thrombosis. Complete ablation of the target vessel was observed in all patients on follow-up Duplex ultrasounds at 1 and 8 weeks postintervention. Conclusion: Endovenous laser therapy can be safely performed and does not compromise target vessel ablation in patients receiving oral anticoagulation warfarin therapy. Warfarin therapy should not be routinely interrupted in patients undergoing this procedure.

Saphenofemoral junction ligation and disconnection for varicose veins-a longitudinal study of cosmesis and function

BACKGROUND

Saphenofemoral junction ligation and disconnection (SFJLD) can be performed without exceeding the safe limits of local anesthetic if stripping of the long saphenous vein is not routine. We studied the early cosmetic and functional outcome of this procedure to identify the optimum time gap from SFJLD to multiple stab avulsions for varicose veins (VV).

METHODS

A series of patients with primary VV underwent SFJLD under local anesthetic as day case procedures. The volume of VV was quantified with a cartograph wheel, whereas the extent and severity of VV was assessed with four validated questionnaires: (a) Clinical Etiology Anatomy Pathology Score, (b) Venous Clinical Severity Score, (c) Aberdeen Varicose Vein Severity Score, and (d) Short Form 36. Patients were assessed preoperatively, and at 1, 3, and 6 months postoperatively. The analysis of variance for repeated measures test was used; a p value <0.05 was found to be significant.

RESULTS

There were 48 patients (15 men; mean age: 54 years; 95% CI: 29-79). In all, 91% (n = 44) of patients had cosmetic and symptomatic improvement. The volume of VV reduced significantly over the three postoperative time points when compared with preoperatively (112 [95% CI: 88-136] vs. 75 [95% CI: 55-97] vs. 65 [95% CI: 43-87] vs. 58 [95% CI: 31-86], p = 0.001). Using the Clinical Etiology Anatomy Pathology, Venous Clinical Severity Score, and Aberdeen Varicose Vein Severity Score questionnaires, severity of VV improved postoperatively when compared withpreoperatively (p = 0.001 respectively). Improvements in quality of life were also noted postoperatively with the Short Form 36 questionnaire (p = 0.032). At maximum follow-up of 3 years, 13% (n = 6) had recurrent VV.

CONCLUSION

SFJLD confers cosmetic and symptomatic improvement at 1 month. Improvement is sustained on early follow-up, thereby allowing multiple stab avulsions to be performed as a staged procedure within 6 months. The rates of recurrent VV are acceptable on short-term follow-up.

Great saphenous varicose vein surgery without saphenofemoral junction disconnection

Background

The aim of this case–control study was to determine whether preoperative duplex imaging could predict the outcome of varicose vein surgery without saphenofemoral junction (SFJ) disconnection. The duplex protocol included a reflux elimination test (RET) and assessment of the competence of the terminal valve of the femoral vein.

Methods

One hundred patients with chronic venous disease who had a positive RET result and an incompetent terminal valve were compared with 100 patients matched for age, sex, clinical class (Clinical Etiologic Anatomic Pathophysiologic (CEAP) class C2–C6) and disease duration, but who had a positive RET result and a competent terminal valve. All patients underwent ligation and proximal avulsion of the incompetent tributaries from the great saphenous vein trunk without SFJ disconnection. Clinical and duplex follow-up lasted for 3 years, and included Hobbs' clinical score.

Results

Of legs with a competent terminal valve, 100 per cent were rated as cured (Hobbs' class A or B) and 14·0 per cent developed recurrent varices. Patients with an incompetent terminal valve had significantly worse results: 29·0 per cent had Hobbs' class A or B and 82·0 per cent developed recurrence (P &lt; 0·001).

Conclusion

Preoperative duplex assessment of the terminal valve could be used to identify patients suitable for varicose vein surgery without the need for SFJ disconnection.

Endovenous therapy for the treatment of congenital venous malformations

The treatment of a congenital venous malformation using endovenous radiofrequency ablation in a patient is described. The patient initially underwent two treatments of foam sclerotherapy with moderate success. Later the main feeding vessel of the venous malformation became evident on examination with venous duplex and was identified as the great saphenous vein. At this point, endovenous radiofrequency ablation was used to ablate the feeding vessel and successfully treat the lesion. The procedure proceeded without complications, and the patient made a good recovery. It is recommended that patients presenting with such malformations be considered for endovenous therapy as early as possible.