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Juhani AA, Abdullah A, Alyaseen EM, Dobel AA, Albashri JS, Alalmaei OM, Salem Alanazi YM, Almutairi DR, Alqahtani LN, Alanazi SA. Interventions for great saphenous vein insufficiency: A systematic review and network meta-analysis. Vascular 2024:17085381241273098. [PMID: 39148483 DOI: 10.1177/17085381241273098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
BACKGROUND Great saphenous vein insufficiency (GSVI) adversely affects the quality of life of affected individuals. Minimally invasive endo-venous ablation techniques have emerged as effective and safe treatments, despite the longstanding use of surgical interventions. We aim in our study to evaluate all the available interventions in the literature, either endo-venous or conventional approaches for the treatment of GSVI. METHODS A thorough search was performed across four electronic databases to identify relevant studies. A frequentist network meta-analysis (NWM) was executed on the combined data to derive network estimates pertaining to the outcomes of concern. Risk ratios (RRs) were employed as the effect size metric for binary outcomes, while mean differences (MDs) were utilized for continuous outcomes, each reported with a 95% confidence interval. The qualitative review was conducted employing the Cochrane risk of bias assessment tool 1. RESULTS Our NWM included 75 studies encompassing 12,196 patients. Regarding technical success rate within the first 5 years after treatment, Endo-venous Laser Ablation (EVLA) with High Ligation and Stripping (HL/S), EVLA alone, Cyanoacrylate Adhesive Injection, cryostripping, HL/S and Radiofrequency Ablation (RFA) were significantly better than Ultrasound-Guided Foam Sclerotherapy and F-care. Also, invagination stripping was inferior to all interventions. Conservative Hemodynamic Cure for Venous Insufficiency and Varicose Veins (CHIVA) demonstrated a significantly lower recurrence rate with a RR of 0.35 [0.15; 0.79] compared to RFA, but RFA was more effective in recurrence prevention than HL/S and Mechanochemical Ablation (MOCA), with a RR of 0.63 [0.41; 0.97] and 0.18 [0.03; 0.95], respectively. Endo-venous Steam Ablation (EVSA) emerged as the most effective in reducing post-intervention pain, showing a MD of -2.73 [-3.72; -1.74] compared to HL/S. In Aberdeen Varicose Vein Questionnaire outcome, our analysis favored MOCA over most studied interventions, with an MD of -6.88 [-12.43; -1.32] compared to HL/S. Safety outcomes did not significantly differ among interventions. CONCLUSION Our findings revealed significant variations in the technical success rates, recurrence rates, and post-intervention pain levels among different interventions. CHIVA exhibited enhanced performance in terms of lower recurrence rates, while EVSA emerged as a promising choice for mitigating post-intervention pain. Additionally, our analysis underscored the significance of patient-reported outcomes, with MOCA consistently yielding favorable results in terms of enhancing quality of life and expediting the return to regular activities.
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Affiliation(s)
- Abdulkreem Aa Juhani
- Faculty of medicine and surgery,.King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Abdullah Abdullah
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Amnah A Dobel
- College of Medicine, Taif University, Taif, Saudi Arabia
| | | | - Osama M Alalmaei
- College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
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Liu J, Guo Q. Early versus deferred endovenous sclerotherapy of superficial venous reflux in patients with venous ulceration. Int Wound J 2024; 21:e14445. [PMID: 37845810 PMCID: PMC10895194 DOI: 10.1111/iwj.14445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023] Open
Abstract
This study aimed to compare early endovenous sclerotherapy with superficial venous reflux combined with compression therapy and deferred intervention in patients with venous leg ulcers (VLUs). A total of 80 patients with 80 VLUs treated at the Department of General Surgery, Shangjin Nanfu Hospital, Chengdu, China, between February 2022 and January 2023 were included in the study. The primary outcome was the time to ulcer healing from the date of compression therapy or endovenous sclerotherapy. Secondary outcome measures were the rate of ulcer healing at 6 months, the rate of ulcer recurrence at 6 months, and patient-reported health-related quality of life. A total of 54 patients received early intervention and 26 received deferred intervention. The patient and clinical characteristics at baseline were similar between the two treatment groups. The median time to ulcer healing was 1.5 months (95% confidence interval [CI], 1.3-1.7 months) in the early-intervention group and 3.5 months (95% CI, 2.9-4.1 months) in the deferred-intervention group. The time to ulcer healing was shorter in the early-intervention group than in the deferred-intervention group (p < 0.001). The rate of ulcer healing at 6 months was 94% in the early-intervention group and 92% in the deferred-intervention group. The rate of ulcer recurrence before the end of the 6-month follow-up period was 2% in the early-intervention group and 4% in the deferred-intervention group. In conclusion, early endovenous sclerotherapy for superficial venous reflux resulted in faster healing of VLUs than deferred endovenous sclerotherapy.
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Affiliation(s)
- Jiabin Liu
- Department of General SurgeryShangjin Nanfu HospitalChengduSichuanChina
- Division of Thyroid Surgery, Department of General SurgeryWest China Hospital, Sichuan UniversityChengduSichuanChina
| | - Qiang Guo
- Department of General SurgeryShangjin Nanfu HospitalChengduSichuanChina
- Division of Vascular Surgery, Department of General SurgeryWest China Hospital, Sichuan UniversityChengduSichuanChina
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Sanches‐Pinto DC, Eriksson E, Gomez DS, Nunes MPT, Gemperli R, Soriano FG. Minced skin grafts for chronic wounds compared to conventional mesh grafts. Health Sci Rep 2023; 6:e1353. [PMID: 37359407 PMCID: PMC10285033 DOI: 10.1002/hsr2.1353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023] Open
Abstract
Background and Aims Skin grafting is the single most effective method to close a chronic wound. The current standard of care is to use meshed split thickness skin grafts. This entails the use of surgical instruments that need to be autoclaved and to have a power source, which usually requires an OR facility. The minced skin technique uses single use, presterilized instruments and the procedure can be done under local anesthesia, by a wound care practitioner, in a wound clinic, a physician's office or even at the bedside. The current study was designed to determine if the results from micrografting were non inferior to conventional mesh grafting. Methods In a prospective non inferiority study, 26 chronic ulcers were treated with micrografting (MSG) and 24 with conventional mesh grafts 1:3 (control group-CG) in a total of 21 patients, 10 male and 11 female. The donor site areas in the MSG group were predetermined to 2.5 × 5 cm and the mesh grafts expansion was set at 1:3. Results In the first weeks postoperatively, micrograft healing initially lagged behind the conventional mesh grafts but at 60 days after grafting, all MSG wounds were healed. The MSG wounds had better pigmentation, less itching, and less scarring. The micrografting procedure was easy to learn and expeditious to perform. The MSG mean expansion was 9.1 compared to three times (CG). Conclusion The MSG procedure is not inferior to conventional mesh grafting, requires smaller donor sites, and can be done with single use instruments, under local anesthesia, with early discharge.
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Affiliation(s)
- Débora C. Sanches‐Pinto
- Divisão de Cirurgia Plástica e Queimaduras. Clinicas Hospital ‐ School of MedicineUniversity of São PauloSão PauloBrazil
| | | | - David S. Gomez
- Divisão de Cirurgia Plástica e Queimaduras. Clinicas Hospital ‐ School of MedicineUniversity of São PauloSão PauloBrazil
| | - Maria P. T. Nunes
- Department of Internal Medicine, School of MedicineUniversity of São PauloSão PauloBrazil
| | - Rolf Gemperli
- Divisão de Cirurgia Plástica e Queimaduras. Clinicas Hospital ‐ School of MedicineUniversity of São PauloSão PauloBrazil
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Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, Bush RL, Di Iorio M, Fish J, Fukaya E, Gloviczki ML, Hingorani A, Jayaraj A, Kolluri R, Murad MH, Obi AT, Ozsvath KJ, Singh MJ, Vayuvegula S, Welch HJ. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2023; 11:231-261.e6. [PMID: 36326210 DOI: 10.1016/j.jvsv.2022.09.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022]
Abstract
The Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society collaborated to update the 2011 Society for Vascular Surgery/American Venous Forum clinical practice guidelines and provide new evidence-based recommendations on critical issues affecting the care of patients with varicose veins. Each recommendation is based on a recent, independent systematic review and meta-analysis of the diagnostic tests and treatments options for patients with lower extremity varicose veins. Part I of the guidelines includes evidence-based recommendations for the evaluation of patients with CEAP (Clinical Class, Etiology, Anatomy, Pathology) class 2 varicose vein using duplex ultrasound scanning and other diagnostic tests, open surgical treatment (ligation and stripping) vs endovenous ablation techniques, thermal vs nonthermal ablation of the superficial truncal veins, and management of incompetent perforating veins in CEAP class 2 disease. We have also made recommendations on the concomitant vs staged treatment of varicose tributaries using phlebectomy or liquid or foam sclerotherapy (with physician-compounded foam or commercially prepared polidocanol endovenous microfoam) for patients undergoing ablation of incompetent superficial truncal veins.
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Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Suman M Wasan
- Department of Medicine, University of North Carolina, Chapel Hill, and Rex Vascular Specialists, UNC Health, Raleigh, NC
| | | | - Jose Almeida
- Miller School of Medicine, University of Miami, Miami, FL
| | | | - Ruth L Bush
- Central Texas Veterans Affairs Healthcare System and Texas A&M University College of Medicine, Temple, TX
| | | | - John Fish
- Department of Medicine, Jobst Vascular Institute, University of Toledo, Toledo, OH
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University, Stanford, CA
| | | | | | - Arjun Jayaraj
- RANE Center for Venous and Lymphatic Diseases, Jackson, MS
| | - Raghu Kolluri
- Heart and Vascular Service, OhioHealth Riverside Methodist Hospital, Columbus, OH
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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De Moraes Silva MA, Sordi LHSD, Grillo LCR, Garcia EDP, Silva LR, Grigório TS, Cardoso RS. Association of great saphenous vein diameter and clinical severity score after treatment of severe chronic venous insufficiency with foam sclerotherapy. REVISTA CIÊNCIAS EM SAÚDE 2021. [DOI: 10.21876/rcshci.v11i4.1222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Objectives: to evaluate the association of the greater saphenous vein (GSV) diameter in the treatment of patients with severe chronic venous insufficiency (C6 CEAP classification) with ultrasound-guided polidocanol foam sclerotherapy (UGFS). Methods: A prospective, descriptive and analytical study of 28 patients (30 limbs) that underwent UGFS. Patients were divided into 2 subgroups by GSV diameter (< 8 mm and ≥ 8 mm). Variables analyzed were ulcer healing, clinical intercurrences, clinical CEAP classification, Venous Clinical Severity Score (VCSS), diameter of the treated vein and presence of occlusion or recanalization by Doppler ultrasound. Patients were analyzed at the 1st, 3rd, and 6th months post-treatment. Results: The average age was 68.7 ± 10.5 years, 23 (82,1%) were women, and the average body mass index was 29.2 kg/m2. Although an improvement in VCSS score was observed during follow-up, no significant intergroup difference was noted. Seventeen (56%) limbs presented occlusion of the treated vein at the 1st month, 11 (36%) at the 3rd month, and 9 (30%) at the 6th month of follow-up. The ulcer healing rate was 56,6%. The average ulcer healing time was 90 days. Three (10%) patients presented with ulcer recurrence at the 6th month. Survival analysis showed no significant difference in ulcer healing rate between subgroups after one year of follow-up (log-rank, p = 0,178). Conclusion: There was no difference between the subgroups of large and small VSM diameter in terms of symptom severity. However, significant reduction of VCSS and pain relief was observed after foam sclerotherapy.
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Rabe E, Breu FX, Flessenkämper I, Gerlach H, Guggenbichler S, Kahle B, Murena R, Reich-Schupke S, Schwarz T, Stücker M, Valesky E, Werth S, Pannier F. Sclerotherapy in the treatment of varicose veins : S2k guideline of the Deutsche Gesellschaft für Phlebologie (DGP) in cooperation with the following societies: DDG, DGA, DGG, BVP. DER HAUTARZT 2021; 72:23-36. [PMID: 33252705 PMCID: PMC8692296 DOI: 10.1007/s00105-020-04705-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- E Rabe
- Emeritus Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn (AöR), Venusberg-Campus 1, 53127, Bonn, Germany.
| | | | | | | | | | - B Kahle
- Klinik für Dermatologie, Allergologie und Venerologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - R Murena
- Phlebologische Praxis, Köln, Germany
| | - S Reich-Schupke
- Privatpraxis für Haut- und Gefäßmedizin, Wundtherapie, Recklinghausen, Germany
| | - T Schwarz
- Praxis für Gefäßmedizin, Freiburg, Germany
| | - M Stücker
- Klinik für Dermatologie, Venerologie und Allergologie, Ruhr-Universität Bochum, St. Josef Hospital, Bochum, Germany
| | - E Valesky
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinik Frankfurt, Frankfurt, Germany
| | - S Werth
- Universitäts-Gefäßzentrum, Innere Medizin III, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - F Pannier
- Praxis Dermatologie & Phlebologie Bonn und Dermatologische Universitätsklinik Köln, Bonn, Germany
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Ultrasound-guided foam sclerotherapy as a therapeutic modality in venous ulceration. Surgeon 2021; 20:e206-e213. [PMID: 34629303 DOI: 10.1016/j.surge.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 08/09/2021] [Accepted: 08/19/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The objective of this systematic review and meta-analysis was to evaluate rates of ulcer healing following ultrasound-guided foam sclerotherapy (UGFS). METHODS The MEDLINE, CENTRAL and Embase databases were used to search for relevant studies using the terms ' (sclerotherapy AND ulcer) OR (vein AND ulcer) OR (sclerotherapy AND vein)'. Heterogeneity between studies was quantified using the I2 statistic. A random effects model was used to calculate risk ratios where substantial heterogeneity was found. RESULTS The initial search yielded 8266 articles. 8 studies were included in the qualitative synthesis and 3 in the meta-analysis. Superior complete ulcer healing rates were noted in patients treated with foam sclerotherapy versus compression therapy alone (pooled OR 6.41, 95% CI = 0.3-148.2, p = 0.246, random effects method). A marked degree of heterogeneity was observed between studies (I2 = 81%). CONCLUSION A prospective, trial is warranted in order to determine the true merits of UGFS in the setting of venous ulceration.
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Farah MH, Nayfeh T, Urtecho M, Hasan B, Amin M, Sen I, Wang Z, Prokop LJ, Lawrence PF, Gloviczki P, Murad MH. A systematic review supporting the Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society guidelines on the management of varicose veins. J Vasc Surg Venous Lymphat Disord 2021; 10:1155-1171. [PMID: 34450355 DOI: 10.1016/j.jvsv.2021.08.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/13/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Several diagnostic tests and treatment options for patients with lower extremity varicose veins have existed for decades. The purpose of this systematic review was to summarize the latest evidence to support the forthcoming updates of the clinical practice guidelines on the management of varicose veins for the Society for Vascular Surgery (SVS), the American Venous Forum (AVF) and the American Vein and Lymphatic Society. METHODS We searched multiple databases for studies that addressed four clinical questions identified by the AVF and the SVS guideline committee about evaluating and treating patients with varicose veins. Studies were selected and appraised by pairs of independent reviewers. A meta-analysis was conducted when feasible. RESULTS We included 73 original studies (45 were randomized controlled trials) and 1 systematic review from 12,915 candidate references. Moderate certainty of evidence supported the usefulness of duplex ultrasound (DUS) examination as the gold standard test for diagnosing saphenous vein incompetence in patients with varicose veins and chronic venous insufficiency (clinical, etiological, anatomic, pathophysiological classification [CEAP] class C2-C6). High ligation and stripping (HL/S) was associated with higher anatomic closure rates at 30 days and 5 years when compared with radiofrequency ablation and ultrasound-guided foam sclerotherapy (UGFS) (moderate certainty), while no significant difference was seen when compared with endovenous laser ablation (EVLA) at 5 years. UGFS was associated with an increased risk of recurrence compared with HL/S. EVLA was associated with lower anatomic closure rates at 30 days than cyanoacrylate closure (CAC) and higher rates at one and 5 years when compared with UGFS. Thermal interventions were associated with lower generic quality of life scores and an increased risk of adverse events when compared with CAC or n-butyl cyanoacrylate (low certainty). Thermal interventions were associated with a lower risk of recurrent incompetence when compared with UGFS and an increased risk of recurrent incompetence than CAC. The evidence for great saphenous vein ablation alone to manage perforator disease was inconclusive. CONCLUSIONS The current systematic review summarizes the evidence to develop and support forthcoming updated SVS/AVF/American Vein and Lymphatic Society clinical practice guideline recommendations. The evidence supports duplex scanning for evaluating patients with varicose veins and confirms that HL/S resulted in similar long-term saphenous vein closure rates as EVLA and in better rates than radiofrequency ablation and UGFS. Thermal interventions were associated with inferior generic quality of life scores than nonthermal interventions, but had a lower risk of recurrent incompetence than UGFS. The recommendations in the guidelines should consider this information as well as other factors such as patients' values and preferences, anatomic considerations of individual patients, and surgical expertise.
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Affiliation(s)
- Magdoleen H Farah
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Tarek Nayfeh
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Meritxell Urtecho
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Bashar Hasan
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Mustapha Amin
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Zhen Wang
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | | | - Peter F Lawrence
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Calif
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn.
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Abstract
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.
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Affiliation(s)
- Jade Whing
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Sandip Nandhra
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Craig Nesbitt
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Gerard Stansby
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
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Siribumrungwong B, Wilasrusmee C, Orrapin S, Srikuea K, Benyakorn T, McKay G, Attia J, Rerkasem K, Thakkinstian A. Interventions for great saphenous vein reflux: network meta-analysis of randomized clinical trials. Br J Surg 2021; 108:244-255. [PMID: 33793723 PMCID: PMC10364879 DOI: 10.1093/bjs/znaa101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/12/2020] [Accepted: 11/01/2020] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- B Siribumrungwong
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand.,Centre of Excellence in Applied Epidemiology, Thammasat University Hospital, Thammasat University, Pathum Thani, Thailand
| | - C Wilasrusmee
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - S Orrapin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - K Srikuea
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - T Benyakorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - G McKay
- Centre for Public Health, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - J Attia
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, and Hunter Medical Research Institute, NSW, Australia
| | - K Rerkasem
- Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine; Non-Communicable Disease Centre of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - A Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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11
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Cartee TV, Wirth P, Greene A, Straight C, Friedmann DP, Pittman C, Daugherty SF, Blebea J, Meissner M, Schul MW, Mishra V. Ultrasound-guided foam sclerotherapy is safe and effective in the management of superficial venous insufficiency of the lower extremity. J Vasc Surg Venous Lymphat Disord 2021; 9:1031-1040. [PMID: 34144767 DOI: 10.1016/j.jvsv.2021.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 03/31/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Superficial venous disease of the lower extremity has a significant impact on quality of life. Both truncal and tributary vein reflux contribute to this disease process. Endovenous foam sclerotherapy is a widely used technique throughout the world for the management of superficial venous reflux and ultrasound guidance improves its safety and efficacy. METHODS A PubMed search for ultrasound-guided foam sclerotherapy (UGFS) was conducted and all abstracts were reviewed to identify clinical trials and systematic reviews for a full-text analysis. Additional articles were also identified through searching the references of the selected studies. RESULTS The production of foam for sclerotherapy in a 1:3 or 1:4 ratio of air to sclerosant is optimal in a low silicone, low-volume syringe system. Physiologic gas may decrease any side effects, with the trade-off of decreased foam stability. Proper technique with appropriate sterility and cleansing protocols are paramount for safe and effective treatment. The technical success of UGFS for great saphenous vein disease is inferior to endothermal and surgical modalities and retreatment is more common. However, the clinical improvement in patient-reported quality of life is similar between these three modalities. When used for tributary veins in combination with endothermal approaches of the truncal veins, UGFS has high rates of success with excellent patient satisfaction. UGFS has demonstrated an excellent safety profile comparable with or superior to other modalities. CONCLUSIONS With proper technique, UGFS is safe and effective for the management of superficial venous disease.
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Affiliation(s)
- Todd V Cartee
- Department of Dermatology, Penn State Health, Hershey, Pa.
| | - Paul Wirth
- Department of Dermatology, Penn State Health, Hershey, Pa
| | - Amrit Greene
- Department of Dermatology, Penn State Health, Hershey, Pa
| | | | | | - Chris Pittman
- Department of Radiology, University of South Florida Morsani College of Medicine, Tampa, Fla; Vein911 Vein Treatment Centers, Tampa, Fla
| | | | - John Blebea
- Department of Surgical Disciplines, Central Michigan University College of Medicine, Mount Pleasant, Mich
| | - Mark Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Marlin W Schul
- Indiana University School of Medicine, West Lafayette campus, Lafayette, Ind; Indiana Vascular Associates, LLC, Lafayette, Ind
| | - Vineet Mishra
- Division of Mohs Surgery, Dermatology & Vascular Surgery, Scripps Clinic, San Diego, Calif
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12
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Orhurhu V, Chu R, Xie K, Kamanyi GN, Salisu B, Salisu-Orhurhu M, Urits I, Kaye RJ, Hasoon J, Viswanath O, Kaye AJ, Karri J, Marshall Z, Kaye AD, Anahita D. Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review. Cardiol Ther 2021; 10:111-140. [PMID: 33704678 PMCID: PMC8126535 DOI: 10.1007/s40119-021-00213-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Indexed: 02/08/2023] Open
Abstract
PURPOSE OF REVIEW Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease. RECENT FINDINGS Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.
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Affiliation(s)
- Vwaire Orhurhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Robert Chu
- Johns Hopkins School of Medicine, Baltimore, MA, USA
| | | | | | | | - Mariam Salisu-Orhurhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rachel J Kaye
- Medical University of South Carolina, Charleston, SC, USA
| | - Jamal Hasoon
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Shreveport Shreveport, Shreveport, LA, USA
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Valley Anesthesiology and Pain Consultants-Envision Physician Services, Phoenix, AZ, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Aaron J Kaye
- Medical University of South Carolina, Charleston, SC, USA
| | - Jay Karri
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Zwade Marshall
- Regenerative Spine and Pain Specialist, Fayetteville, GA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport Shreveport, Shreveport, LA, USA
| | - Dua Anahita
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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13
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[Guidelines for sclerotherapy of varicose veins : S2k guideline of the German Society of Phlebology (DGP) in cooperation with the following professional associations: DDG, DGA, DDG, BVP. German Version]. DER HAUTARZT 2021; 72:50-64. [PMID: 33151348 DOI: 10.1007/s00105-020-04707-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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14
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McNamara SA, Cahn BA, Sanders M, Lopez AJ. Venous Procedures to Treat Venous Leg Ulcers. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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de Aguiar ET, Dos Santos JB, Carvalho DD. Venous thromboembolism after ultrasound guided foam sclerotherapy. Phlebology 2020; 36:233-239. [PMID: 33019844 DOI: 10.1177/0268355520957202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To analyze prevalence of venous thromboembolism (VTE) after ultrasound guided foam sclerotherapy. METHOD Clinical retrospective study with patients treated from 2004 to 2014. Charts with incomplete data and follow-up less than 60 days were excluded. Polidocanol foam (Tessari method) was used. The primary outcome was the prevalence of VTE and the secondary were possible risk factors. Chi-square test and Marascuillo prodecure were applied at a significance level of 5%. RESULTS 2,616 patients were included with 4,712 lower limbs treated. The mean age was 50.7±0.86, in majority female, 83.7%. VTE occurred in 0.49% (pulmonary embolism 0,3%) in a mean time of 44.0±42.2 days. Male gender, personal or family history of phlebitis or DVT and high caliber varicose veins were significantly associated to VTE. CONCLUSION incidence of VTE is low, male gender, personal or family history of VTE and caliber of varicose veins greater than 7 mm increased the risk.
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Affiliation(s)
- Eduardo T de Aguiar
- Spaço Vascular, São Paulo, Brazil.,ABFL - Brazilian Association of Phlebology and Lymphology, São Paulo, Brazil.,University of São Paulo, São Paulo, Brazil
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16
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Fan W, Yang X, Yang B, Fu C, Huang R, Xv F, Liu G. The safety and efficacy of Sclerosing foam on treating venous leg ulcers: Protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e21608. [PMID: 32769918 PMCID: PMC7593037 DOI: 10.1097/md.0000000000021608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/08/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Venous leg ulcers (VLUs) are common throughout the world, which seriously affects the patient's work and life. Relevant researches suggested that sclerosing foam (SF) has potential benefits for VLUs. However, there is no consistent conclusion. The purpose of our study is to assess whether SF is effective and safe for VLUs. METHODS Relevant clinical randomized controlled trials will be obtained from a search of 8 databases (with no language restrictions) from their inception to May 2020: PubMed, the Cochrane Library, EMBASE, Web of Science, China National Knowledge Infrastructure Database, Wanfang Database, China Science and Technology Journal Database, and Chinese Biological Medicine. Data will be analyzed using RevMan 5.3 after literature screening and data extraction according to predefined inclusion and exclusion criteria. Cochrane Collaboration Risk of bias Tool will be applied in evaluating the quality of enrolled articles. The primary outcome is Closure of venous leg ulcers, ulcer healing rate, adverse events related to SF. The secondary outcomes include ulcer healing time, ulcer recurrence rate, pain. Risk ratio will be used for categorical data; mean differences will be used for measurement data. Where possible and appropriate, meta-analysis will be performed for each outcome. RESULTS To clarify whether Sclerosing foam can be safe and efficient on treating venous leg ulcers. CONCLUSION Our review will provide useful information to judge whether Sclerosing Foam is an effective and safe intervention for patients with venous leg ulcers.
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Affiliation(s)
- Weijing Fan
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine
- Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Xiao Yang
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine
| | - Baozhong Yang
- Dongfang Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Changgeng Fu
- Dongfang Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Renyan Huang
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine
- Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Feng Xv
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine
- Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Guobin Liu
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine
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17
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Javier JJ, Ortiz P. Treatment of chronic venous insufficiency in Latin America. J Vasc Surg Venous Lymphat Disord 2020; 8:667-675. [PMID: 32234293 DOI: 10.1016/j.jvsv.2020.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 01/25/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Venous disease is common in Latin America, with an estimated 68.11% prevalence of chronic venous disease. The diverse social, political, and economic characteristics of the many nations that make up Latin America mean that different conditions affect how these diseases are diagnosed and treated, which may differ markedly from the way they are treated by the health care systems of the United States and Europe. Our goal was to review the current state of treatment of chronic venous insufficiency (CVI) in Latin America. METHODS This is a narrative review of the medical literature on the subject and synthesizes sometimes fragmentary information on CVI across a large and diverse region. RESULTS CVI represents an unmet medical need in Latin America. Conservative treatments, such as compression stockings, may be used at first, and there are nonpharmacologic and complementary and alternative medicine approaches in use. Endovenous approaches, such as endovenous thermal ablation, have largely replaced surgical interventions. In Europe and the United States, such procedures are mainly carried out in ambulatory facilities, whereas they are mainly performed in the hospital in Latin America. CONCLUSIONS Recent strong economic growth in Latin America and improvements in social security and health care suggest that innovative approaches to chronic venous disease and CVI will be implemented.
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Affiliation(s)
- Julian J Javier
- Division of Venous Disease, Naples Cardiac & Endovascular Center, Naples, Fla; Department of Venous Disease, Centro Cardiovascular Clinica Canela, La Romana, Dominican Republic.
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18
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de Abreu GCG, de Camargo O, de Abreu MFM, de Aquino JLB. Ultrasound-guided foam sclerotherapy for chronic venous disease with ulcer. A prospective multiple outcome cohort study. J Vasc Bras 2020; 19:e20180108. [PMID: 32499822 PMCID: PMC7244209 DOI: 10.1590/1677-5449.180108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Chronic Venous Disease (CVD) is the main cause of chronic leg ulcers. Varicose veins are the most frequent cause of venous leg ulcers (VLU). 50.9% of Brazilian women have varicose veins and ulcer prevalence is as high as 4%. Ultrasound-guided foam sclerotherapy (UGFS) is a low-cost treatment option for varicose veins. Objectives To analyze UGFS outcomes in patients with VLU. Methods Prospective consecutive single center cohort study. Patients with great saphenous vein (GSV) reflux and VLU were treated and followed-up for 180 days. The following were studied: quality of life (QoL), disease severity, healing, and elimination of GSV reflux. The Aberdeen questionnaire, a venous clinical severity score, and Duplex scanning (DS) results were analyzed. Results 22 patients aged 35 to 70 years were treated. There was improvement in quality of life, disease severity reduced, and ulcer diameter reduced (p < 0.001; ANOVA). 77.27% of VLU healed completely (95%CI: 59.76-94.78%). The dimensions of 20/22 VLU reduced (90.91%; 95%CI: 78.9-100%). GSV reflux was eliminated in 63.64% (95%CI: 43.54-83.74%). Men had greater QoL benefit and women had more complications. There were no severe complications. The VLU that had healed completely at the end of the study were smaller at baseline than those that did not completely heal. The GSV that were completely occluded at the end of the study were smaller at baseline than those that were not completely occluded (p < 0.05; Mann-Whitney). Conclusion The results suggest that most patients benefited from UGFS.
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Affiliation(s)
| | - Otacílio de Camargo
- Pontifícia Universidade Católica de Campinas - PUC-Campinas, Campinas, SP, Brasil
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19
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Lim SY, Tan JX, D'Cruz RT, Syn N, Chong TT, Tang TY. Catheter-directed foam sclerotherapy, an alternative to ultrasound-guided foam sclerotherapy for varicose vein treatment: A systematic review and meta-analysis. Phlebology 2020; 35:369-383. [PMID: 31918640 DOI: 10.1177/0268355519898309] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Sheng Y Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joshua Xd Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Reuban T D'Cruz
- Department of General Surgery, National University Hospital, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tze T Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Tjun Y Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
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20
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Zhu Y, Wu D, Sun D, Song K, Li J, Lin J. Ultrasound- and fluoroscopy-guided foam sclerotherapy for lower extremity venous ulcers. J Vasc Surg Venous Lymphat Disord 2020; 8:783-788. [PMID: 31917182 DOI: 10.1016/j.jvsv.2019.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/13/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE In foam sclerotherapy for varicose veins, ultrasound can track the spread of foam in only one direction. We hypothesized that using fluoroscopy in combination with ultrasound can reveal the spread of foam to deep veins through perforator veins and to other varicose veins in different directions. In this study, we examined the safety and effectiveness of ultrasound- and fluoroscopy-guided foam sclerotherapy for lower extremity venous ulcers. METHODS This retrospective study included all patients receiving ultrasound- and fluoroscopy-guided foam sclerotherapy for varicose ulcers (Clinical, Etiology, Anatomy, and Pathophysiology class 6) of the lower extremities at the Fourth Affiliated Hospital of Jiangsu University (Zhenjiang, China) between May 1, 2016, and April 30, 2018. Polidocanol foam sclerosant was injected through indwelling needles (placed every 20 cm for saphenous veins and every 5-10 cm for others) into the varicose veins. When the contrast medium in the target vessels was replaced by the hypointense foam sclerosant or on signs of foam entry into the perforator veins under fluoroscopy, the injection was stopped and the site was manually pressed. All patients received postprocedure compression with elastic bandages until ulcer healing and compression stockings (30-40 mm Hg) thereafter. RESULTS A total of 35 patients (42 limbs) were included. The maximal ulcer diameter was 3.6 ± 1.4 cm (range, 1.1-5.8 cm). The number of injection sites ranged from 3 to 10; total foam amount ranged from 4.5 to 35 mL. All 35 patients completed 12-month follow-up. Ulcer healing rate was 100%, and 1-year recurrence rate was 2.9%. The Venous Clinical Severity Score was 12.98 ± 3.91 before treatment, decreasing to 3.02 ± 2.39 at 12 months (P < .01). Superficial thrombophlebitis developed in 21 (50%) limbs. No deep venous thrombosis or pulmonary embolism was observed during follow-up. Among the 33 limbs (27 patients) with ultrasound examination at 12 months, 28 (84.8%) limbs had complete occlusion and the remaining 5 (15.2%) had recanalization. CONCLUSIONS Ultrasound- and fluoroscopy-guided foam sclerotherapy is safe and effective for the treatment of venous ulcers of the lower extremities.
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Affiliation(s)
- Yongqiang Zhu
- Department of Interventional Radiology, Fourth Affiliated Hospital, Jiangsu University, Jiangsu, China.
| | - Dingquan Wu
- Department of Interventional Radiology, Fourth Affiliated Hospital, Jiangsu University, Jiangsu, China
| | - Donghui Sun
- Department of Interventional Radiology, Fourth Affiliated Hospital, Jiangsu University, Jiangsu, China
| | - Kui Song
- Department of Interventional Radiology, Fourth Affiliated Hospital, Jiangsu University, Jiangsu, China
| | - Jie Li
- Department of Interventional Radiology, Fourth Affiliated Hospital, Jiangsu University, Jiangsu, China
| | - Jing Lin
- Department of Interventional Radiology, Fourth Affiliated Hospital, Jiangsu University, Jiangsu, China
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21
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Polimanti AC, Pereira LA, Carmine TM, Fürst RVDC, Bezerra AS, Corrêa JA. Influence of polidocanol ultrasound-guided foam sclerotherapy on quality of life in lower extremity chronic venous disease: initial results. J Vasc Bras 2019; 18:e20190049. [PMID: 31673252 PMCID: PMC6805124 DOI: 10.1590/1677-5449.190049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/05/2019] [Indexed: 11/21/2022] Open
Abstract
Chronic Venous Insufficiency (CVI) is not only detrimental to patients' Quality of Life (QoL) but also places a considerable burden on public health resources. Ultrasound guided foam sclerotherapy (USFS) is a good treatment option, but its effect on patients' QOL is still unclear. This article presents the results from the first 27 patients in a prospective, longitudinal, non-controlled study for evaluation of the clinical and QOL impact of USFS treatment for CEAP C4 to C6 grade CVI with contraindications for open surgery. Clinical symptoms were measured with the Venous Clinical Severity Score (VCSS) and QOL by the Assessment of Burden Chronic Disease - Venous questionnaire (ABC-V). We observed 22.2% reductions in VCSS (p<0.001) in the first week after the procedure, and a 37.8% reduction in ABC-V scores (p=0.03) over the first 3 months.
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Affiliation(s)
- Afonso César Polimanti
- Faculdade de Medicina do ABC – FMABC, Disciplina de Angiologia e Cirurgia Vascular, Santo André, SP, Brasil.
| | - Lucas Abdo Pereira
- Faculdade de Medicina do ABC – FMABC, Disciplina de Angiologia e Cirurgia Vascular, Santo André, SP, Brasil.
| | - Tainan Montecorado Carmine
- Faculdade de Medicina do ABC – FMABC, Disciplina de Angiologia e Cirurgia Vascular, Santo André, SP, Brasil.
| | | | - Alexandre Sacchetti Bezerra
- Faculdade de Medicina do ABC – FMABC, Disciplina de Angiologia e Cirurgia Vascular, Santo André, SP, Brasil.
| | - João Antônio Corrêa
- Faculdade de Medicina do ABC – FMABC, Disciplina de Angiologia e Cirurgia Vascular, Santo André, SP, Brasil.
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de Moraes Silva MA, Flumignan RLG, Miranda F, Cardoso RS, Silva SGDJ, Guedes HJ, Nakano LCU. Protocol for a systematic review and meta-analysis of interventions for pathologic perforator veins in chronic venous disease. BMJ Open 2019; 9:e024088. [PMID: 31048426 PMCID: PMC6502043 DOI: 10.1136/bmjopen-2018-024088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 03/04/2019] [Accepted: 03/08/2019] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Perforator veins (PVs) play an important role in the development of chronic venous insufficiency and ulceration. Procedures to eliminate incompetence and reflux in PV may include open surgery, subfascial endoscopic surgery, intravenous ablation techniques and sclerotherapy. With the aim of filling the evidence gap, this is a protocol for a systematic review that will assess the effects of any form of intervention for the treatment of pathologic PVs of the lower limbs in patients with chronic venous disease. METHODS AND ANALYSIS Systematic searches will be carried out in MEDLINE, EMBASE, Cochrane CENTRAL, IBECS and LILACS databases at a minimum without date or language restrictions for relevant randomised controlled trials (RCTs) and quasi-RCTs (trials in which the method of allocation is not truly random). In addition, a search will also be carried out in the WHO International Clinical Trials Registry Platform, in the clinical trial registries of ClinicalTrials.gov and in the grey literature source OpenGrey.eu. The RCT and quasi-RCT comparison techniques isolated or in combination for treating PVs will be considered. Three review authors will independently perform data extraction and quality assessments of data from included studies, and any disagreements will be resolved by discussion. The primary outcomes will be wound healing and pain. Secondary outcomes will include oedema, adverse events, recurrence or recanalisation, quality of life and economic aspects. The Cochrane handbook will be used for guidance. If the results are not appropriate for a meta-analysis in RevManV.5 software (eg, if the data have considerable heterogeneity and are drawn from different comparisons), a descriptive analysis will be performed. ETHICS AND DISSEMINATION Ethics committee approval is not necessary. We intend to update the public registry used in this review, report any important protocol amendments and publish the results in a widely accessible journal. PROSPERO REGISTRATION NUMBER CRD42018092974.
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Affiliation(s)
- Melissa Andreia de Moraes Silva
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Division of Vascular and Endovascular Surgery, Hospital de Clínicas de Itajubá, Itajubá, MG, Brazil
| | - Ronald Luiz Gomes Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Fausto Miranda
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Rodolfo Souza Cardoso
- Division of Vascular and Endovascular Surgery, Hospital de Clínicas de Itajubá, Itajubá, MG, Brazil
| | | | - Henrique Jorge Guedes
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Luis Carlos Uta Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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de-Abreu GCG, Camargo OD, de-Abreu MFM, de-Aquino JLB. Ultrasound-guided foam sclerotherapy for severe chronic venous insufficiency. ACTA ACUST UNITED AC 2018; 44:511-520. [PMID: 29019582 DOI: 10.1590/0100-69912017005014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/22/2017] [Indexed: 11/21/2022]
Abstract
Chronic venous insufficiency is characterized by cutaneous alterations caused by venous hypertension; in severe forms, it progresses to lower limb ulcers. Lower limb varicose veins are the main cause of chronic venous insufficiency, and the classic treatment includes surgery and compressive therapy. Minimally invasive alternative treatments for varicose veins include new techniques such as venous thermal ablation using laser or radiofrequency. The use of different methods depends on clinical and anatomical factors. Ultrasound-guided foam sclerotherapy is the venous injection of sclerosing foam controlled by Doppler ultrasound. Sclerotherapy is very useful to treat varicose veins, and probably, is cheaper than other methods. However, until the present, it is the less studied method.
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Montminy ML, Jayaraj A, Raju S. A systematic review of the efficacy and limitations of venous intervention in stasis ulceration. J Vasc Surg Venous Lymphat Disord 2018; 6:376-398.e1. [DOI: 10.1016/j.jvsv.2017.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/20/2017] [Indexed: 11/27/2022]
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Vemulapalli S, Parikh K, Coeytaux R, Hasselblad V, McBroom A, Johnston A, Raitz G, Crowley MJ, Lallinger KR, Jones WS, Sanders GD. Systematic review and meta-analysis of endovascular and surgical revascularization for patients with chronic lower extremity venous insufficiency and varicose veins. Am Heart J 2018; 196:131-143. [PMID: 29421005 DOI: 10.1016/j.ahj.2017.09.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/26/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Chronic lower extremity venous disease (LECVD) is twice as prevalent as coronary heart disease, and invasive therapies to treat LECVD accounted for an estimated $290 million in Medicare expenditures in 2015. Despite increasing use of these invasive therapies, their comparative effectiveness is unknown. METHODS We conducted a systematic review and meta-analysis of treatments for patients (symptomatic and asymptomatic) with lower extremity varicosities and/or lower extremity chronic venous insufficiency/incompetence/reflux. We searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for relevant English-language studies published from January 2000 to July 2016. We included comparative randomized controlled trials (RCTs) with >20 patients and observational studies with >500 patients. Short-, intermediate-, and long-term outcomes of placebo, mechanical compression therapy, and invasive therapies (surgical and endovascular) were included. Quality ratings and evidence grading was performed. Random-effects models were used to compute summary estimates of effects. RESULTS We identified a total of 57 studies representing 105,878 enrolled patients, including 53 RCTs comprised of 10,034 patients. Among the RCTs, 16 were good quality, 28 were fair quality, and 9 were poor quality. Allocation concealment, double blinding, and reporting bias were inadequately addressed in 25 of 53 (47%), 46 of 53 (87%), and 15 of 53 (28.3%), respectively. Heterogeneity in therapies, populations, and/or outcomes prohibited meta-analysis of comparisons between different endovascular therapies and between endovascular intervention and placebo/compression. Meta-analysis evaluating venous stripping plus ligation (high ligation/stripping) compared with radiofrequency ablation revealed no difference in short-term bleeding (odds ratio [OR]=0.30, 95% CI -0.16 to 5.38, P=.43) or reflux recurrence at 1-2 years (OR=0.76, 95% CI 0.37-1.55, P=.44). Meta-analysis evaluating high ligation/stripping versus endovascular laser ablation revealed no difference in long-term symptom score (OR 0.02, 95% CI -0.19 to 0.23, P=.84) or quality of life at 2 years (OR 0.06, 95% CI -0.12 to 0.25, P=.50). CONCLUSIONS The paucity of high-quality comparative effectiveness and safety data in LECVD is concerning given the overall rise in endovascular procedures. More high-quality studies are needed to determine comparative effectiveness and guide policy and practice.
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Abstract
Sclerotherapy has wide applicability in treating venous disease at every stage of clinical disease. The various sclerosant drugs and formulations each have unique properties, utilities, and side effects. Treating physicians should be aware of the differences between agents, accounting for disease presentation, vein characteristics, and patient comorbidities when selecting the appropriate sclerosing agents. Successful outcomes rely on proper patient evaluation and assessment for contraindications to sclerotherapy. Thorough patient education regarding realistic expectations with sclerotherapy in terms of symptoms relief, recurrence, and improvement in appearance is of chief importance.
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Oliveira AFD, Oliveira Filho HD. Escleroterapia de safena associada a enxerto de pele no tratamento de úlceras venosas. J Vasc Bras 2017; 16:270-275. [PMID: 29930660 PMCID: PMC5944303 DOI: 10.1590/1677-5449.008217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Contexto Úlceras são a resultante final de varizes associadas a refluxo de veias safenas. Objetivo Demonstrar a possibilidade de associar dois procedimentos, a escleroterapia com espuma de veias safenas e o enxerto de pele parcial, para o tratamento de pacientes com úlceras venosas relacionadas a refluxo de veias safenas. Métodos Foram tratados 20 membros em 20 pacientes, todos com ulcerações relacionadas a refluxo de veias safenas. Realizamos o enxerto de pele expandida, seguido da escleroterapia ecoguiada com espuma de polidocanol nas veias associadas às úlceras, através de punção ou dissecção da veia. Resultados Em todos os casos, houve melhora dos sintomas relacionados à úlcera e cicatrização da lesão. Em 11 casos, obtivemos a viabilidade do enxerto de pele por completo; em quatro casos, houve cicatrização de cerca de 50% da lesão; e nos cinco casos restantes, houve cicatrização de aproximadamente 75% da lesão. A primeira ultrassonografia de controle revelou esclerose completa dos vasos tratados em 19 dos 20 casos e esclerose parcial sem refluxo detectável em um caso. Na segunda ultrassonografia, realizada após 45 dias, observamos esclerose completa de 15 casos; em cinco casos, houve esclerose parcial, dos quais três sem refluxo detectável e dois com refluxo em segmentos isolados associados a varizes. A complicação mais frequente foi a pigmentação nos trajetos venosos, observada em 13 pacientes. Um caso apresentou trombose assintomática de veias musculares da perna. Conclusão Essa associação de procedimentos consiste em uma opção válida com potencial para promover um tratamento mais breve e de menor custo.
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Li X, Fan L, Ren S, Li X. Outcomes of Foam Sclerotherapy plus Ligation versus Foam Sclerotherapy Alone for Venous Ulcers in Lower Extremities. Ann Vasc Surg 2017. [PMID: 28648655 DOI: 10.1016/j.avsg.2017.06.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Foam sclerotherapy (FS) is a safe and effective approach for managing patients with varicose veins and venous ulcers in lower extremities. But, recanalization of the ablated varicose veins and phlebitis are common postoperative complications that jeopardize its clinical effects. We hypothesize that ligation of the ablated varicose veins after FS will improve the outcomes of patients with varicose veins and venous ulcer. This study was aimed to evaluate the clinical efficacy of ligation after FS in comparison with FS alone for the management of patients with varicose veins and venous ulcers in lower extremities. METHODS Eighteen patients underwent FS plus ligation (FSL) and 15 patients received FS alone. Aberdeen varicose veins questionnaire (AVVQ) and the revised venous clinical severity score (rVCSS), venous disability scores (VDSs), duplex sonography, ulcer healing rate, and ulcer healing time were documented to compare the outcomes in both groups. RESULTS The ulcer healing time in patients treated with FSL was shorter than that in patients who received FS (P = 0.022; log-rank test). The average healing time was significantly shorter in FSL group than in FS group (35.67 ± 24.62 days vs. 62.86 ± 47.43, P = 0.042). The mean rVCSS, VDS, and AVVQ at 3 months after treatment in both groups decreased significantly in comparison with baseline, respectively. There were no severe complications or side effects in both groups. CONCLUSIONS Ligation of the treated varicose veins after FS can improve the outcomes of patients with venous ulcers in comparison with FS alone. FSL is a safe, effective, and technically feasible procedure and can be used as a day surgery.
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Affiliation(s)
- Xin Li
- Department of Neurology, First Affiliated Hospital of Jiamusi University, Heilongjiang, China
| | - Lin Fan
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Shiyan Ren
- Department of Vascular Surgery, Aviation General Hospital, China Medical University, Beijing, China.
| | - Xianlun Li
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China.
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Prospective Randomized Study of Ultrasound-Guided Foam Sclerotherapy Combined with Great Saphenous Vein High Ligation in the Treatment of Severe Lower Extremity Varicosis. Ann Vasc Surg 2017; 39:256-263. [DOI: 10.1016/j.avsg.2016.06.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 05/11/2016] [Accepted: 06/17/2016] [Indexed: 11/23/2022]
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Paravastu SCV, Horne M, Dodd PDF. Endovenous ablation therapy (laser or radiofrequency) or foam sclerotherapy versus conventional surgical repair for short saphenous varicose veins. Cochrane Database Syst Rev 2016; 11:CD010878. [PMID: 27898181 PMCID: PMC6464398 DOI: 10.1002/14651858.cd010878.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
| | - Margaret Horne
- The University of Edinburgh Medical SchoolCentre for Population Health SciencesTeviot PlaceEdinburghUK
| | - P Dominic F Dodd
- Northern General HospitalSheffield Vascular InstituteHerries RoadSheffieldUKS5 7AU
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Mosti G, Cavezzi A, Massimetti G, Partsch H. Recalcitrant Venous Leg Ulcers May Heal by Outpatient Treatment of Venous Disease Even in the Presence of Concomitant Arterial Occlusive Disease. Eur J Vasc Endovasc Surg 2016; 52:385-91. [DOI: 10.1016/j.ejvs.2016.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/04/2016] [Indexed: 01/09/2023]
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