Prospective Randomized Study of Ultrasound-Guided Foam Sclerotherapy Combined with Great Saphenous Vein High Ligation in the Treatment of Severe Lower Extremity Varicosis

Interventions for great saphenous vein insufficiency: A systematic review and network meta-analysis

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.

Effectiveness of Sclerotherapy to Cure Lower Limb Chronic Venous Insufficiency Grades 1-6: A Systematic Review and Meta-Analysis

Chronic venous insufficiency is a medical condition that impacts the venous system in the lower limbs. The primary characteristic of this condition is the continual elevation of pressure within the leg veins due to walking, which leads to a range of associated issues, such as discomfort, swelling, alterations in the skin, and the development of ulcers. Sclerotherapy has emerged as a potentially effective treatment for chronic venous insufficiency, involving the injection of a sclerosing agent into the affected veins. This study aimed to evaluate the effectiveness of sclerotherapy in treating chronic venous insufficiency grades 1-6 in the lower limb through a systematic review and meta-analysis. The method for conducting this research is by searching articles with relevant keywords carried out through electronic databases, such as Cochrane Library, Pubmed, and Google Scholar. The researchers conducted a comprehensive search and included randomized controlled trials and clinical trials that assessed outcomes, such as patient satisfaction, clinical resolution, quality of life (QoL), and closure rates. Statistical methods were used to analyze the data. The results of the meta-analysis from 9.670 total samples showed that sclerotherapy is the most effective therapy for reducing clinical severity in lower limb venous insufficiency patients (pooled MD = -0.85, 95% CI (-1.41, -0.29), p < 0.00001, I2 = 99%). Sclerotherapy is the most effective therapy for increasing QoL if we use Venous Insufficiency Epidemiology and Economic Study-Quality of Life (VEINES-QOL) as a tool for measuring the QoL (VEINES-QOL scale types; pooled MD = 10.34, 95% CI (8.78, 11.90), p < 0.00001, I2 = 0%). Additionally, sclerotherapy is a more effective therapy for increasing QoL compared to placebo (pooled MD = -1.64, 95% CI (-2.60, -0.67), p = 0.002, I2 = 90%), deferred ablation (pooled MD = -0.22, 95% CI (-0.40, -0.03), p = 0.02), and ligation therapy (pooled MD = -1.29, 95% CI (-1.62, -0.97), p = 0.00001). It is also the most effective therapy for increasing the closure rate for 12-month duration outcome measures (pooled RR = 0.72, 95% CI (0.55, 0.94), p = 0.001, I2 = 91%). However, high heterogeneity was observed in the meta-analysis results, indicating the need for further research to address this variability. This study contributes to the existing body of knowledge on the treatment options for chronic venous insufficiency and highlights the potential of sclerotherapy as an effective treatment modality.

Is catheter-based foam sclerotherapy more effective than direct foam sclerotherapy when combined with high ligation for the treatment of primary great saphenous vein incompetence?

BACKGROUND

To retrospectively analyze the short-term outcomes of catheter-based versus direct foam sclerotherapy when combined with high ligation (HL) for the treatment of great saphenous vein (GSV) incompetence.

METHODS

From July 2018 to October 2019, a total of 82 lower limbs of 70 patients with GSV incompetence received HL combined with catheter-based foam sclerotherapy (CFS group) or direct foam sclerotherapy (DFS group) for GSV proximal trunk. Among them, 40 limbs of 36 patients were treated with CFS, and 42 limbs of 34 patients were treated with DFS. The occlusion of GSV proximal trunk was evaluated with venous duplex ultrasound examinations; Venous Clinical Severity Scores (VCSS) was used to assess clinical improvement; Aberdeen Varicose Veins Questionnaire (AVVQ) was used to assess quality-of-life scores; and Complications was used for the safety evaluation.

RESULTS

At day 7 post-operatively, complete occlusion of proximal trunk of the GSV was achieved in 92.5% legs of the CFS group and 71.4% of the DFS group (p = 0.014). Additionally, anterograde flow was found in 7.5% legs of the CFS group and 26.2% of the DFS group (p = 0.025). No significant differences in the occurrence of complications were observed between the two groups. The median follow-up was 285.5 days in the DFS group and 318 days in the CFS group (p = 0.140). VCSS and AVVQ reduction were significant in both CFS group and DFS group (5.3 ± 2.5, 5.5 ± 2.4, p < 0.001 for VCSS; 15.9 ± 8.0, 16.3 ± 8.6, p < 0.001 for AVVQ), but no significant difference were observed between two groups (p = 0.655 for VCSS, p = 0.934 for AVVQ).

CONCLUSIONS

Although the occlusion of great saphenous vein proximal trunk were different, two modalities result in similar clinical and quality-of-life improvements. DFS is a feasible alternative to CFS when combined with HL.

Application of femoral nerve block combined with modified swelling anesthesia in high ligation and stripping of great saphenous vein

Background

To analyze and explore the clinical efficacy of ultrasound guided femoral nerve block combined with modified swelling anesthetic solution in high ligation and stripping of the great saphenous vein.

Methods

90 patients with varicose great saphenous vein of lower limbs undergoing high ligation and stripping of great saphenous vein were randomly divided into group A (femoral nerve block combined with modified swelling anesthesia), group B (simple swelling anesthesia) and group C (epidural anesthesia), with 30 patients in each group. The serum CRP level, operation duration, intraoperative blood loss, postoperative hospitalization time, total hospitalization cost, postoperative VAS score, preoperative and postoperative VCSS score, intraoperative mean arterial pressure and heart rate, postoperative related complications, and patients, satisfaction with diagnosis and treatment were compared among the three groups.

Results

There was no significant difference in operation duration, intraoperative blood loss, postoperative complications, and preoperative and postoperative VCSS scores among the three groups (P > 0.05). The postoperative hospitalization time, postoperative VAS score and total hospitalization cost of patients in group A and B were lower than those in group C, and the postoperative hospitalization time and postoperative VAS score in group A were more significant (P < 0.05). Compared with group B, the fluctuation range of intraoperative mean arterial pressure and heart rate, and postoperative serum CRP level in group A and C were lower, especially in group A (P < 0.05). The three groups of patients were followed up regularly after surgery. The results showed that the number of postoperative complications in group A was lower than that in the other two groups (P < 0.05), and the postoperative complications of the three groups were effectively relieved after symptomatic treatment (dressing change, anti-infection, taking drugs to improve circulation, etc.). The satisfaction of patients in group A was significantly higher than that in groups B and C (P < 0.05).

Conclusions

Ultrasound guided femoral nerve block combined with modified swelling anesthetic solution applied in high ligation and stripping of the great saphenous vein can significantly improve postoperative inflammatory stress reaction of patients, effectively ensure the safety and reliability of surgical progress, help to improve analgesia effect and accelerate physical rehabilitation, and has short hospitalization time, low medical cost, and high satisfaction of patients' diagnosis and treatment, which is worthy of widespread clinical promotion and reference.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

SUMMARY BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy and safety of Buyang Huanwu decoction in the treatment of varicose veins of the lower extremities: A protocol of randomized controlled trial

BACKGROUND

Varicose veins of the lower extremities are common chronic venous diseases in the clinic. Although Western medicine has various surgical methods to treat varicose veins in the lower extremities, there are still a variety of complications. Some studies have shown that Buyang Huanwu decoction treatment of varicose veins of the lower extremities has a certain effect, and can reduce the occurrence of postoperative complications, but there is no evidence of evidence-based medicine. The research carried out in this scheme is to systematically evaluate the efficacy and safety of Buyang Huanwu decoction in the treatment of varicose veins in the lower extremities, and to provide reliable evidence for guiding clinical practice.

METHODS

This is a randomized, double-blind, placebo-controlled, parallel-group clinical trial, which studies the effectiveness and safety of Buyang Huanwu decoction in the treatment of varicose veins of the lower extremities. The patients are randomly and evenly divided into treatment group and control group, the former one is given Buyang Huanwu decoction and the latter one is given placebo. The study will last 49 days, including a 7-day washout period, 14-day intervention and 28-day follow-up, focusing on its efficacy and safety indicators. Observation indicators include: TCM syndrome score, Venous Clinical Severity Score (VCSS), Venous Disability Scote (VDS), Aberdeen Varicose Vein Questionnaire (AVVQ), Hemorheology Indicators, Adverse Reactions, etc. Data analysis is performed using SPSS 25.0 software.

DISCUSSION

This study will evaluate the effectiveness and safety of Buyang Huanwu decoction and provide clinical evidence for the treatment of varicose veins of the lower extremities.

TRIAL REGISTRATION

OSF Registration number: DOI 10.17605/OSF.IO/WGJXT.

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

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

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

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

Endovenous ablation and surgery in great saphenous vein reflux: a systematic review and network meta-analysis of randomised controlled trials protocol

INTRODUCTION

Endovenous ablations are the new standard procedures for treatment of great saphenous vein reflux including endovenous laser ablation (EVLA), radio frequency ablation (RFA), endovenous steam ablation (EVSA), mechanochemical ablation (MOCA), cyanoacrylate injection and ultrasound-guided foam sclerotherapy (UGFS). EVLA and RFA have demonstrated similar anatomical success for short-term outcome, but results are controversial for longer term (≥5 years). Additional evidences from randomised controlled trials have been published. This study is, therefore, conducted to, directly and indirectly, compare outcomes among all procedures stratifying by short-term and long-term follow-up.

METHODS AND ANALYSIS

Medline and Scopus will be searched from 2000 to September 2018 with predefined search strategy. Interventions of interest are open surgery (ie, saphenofemoral or high ligation (HL) with stripping) and endovenous ablations (ie, EVLA, RFA, EVSA, MOCA, cyanoacrylate injection and UGFS). The primary outcome is anatomical success. Two independent reviewers will select studies, extract data and assess risk of bias. Disagreement will be adjudicated by the third party. Outcomes will be directly pooled if there are at least three studies in that comparison. A fixed-effect model will be used unless heterogeneity is present, in which case a random-effect model will be applied. Sources of heterogeneity will be explored using meta-regression analysis, and sub-group analysis will be done accordingly. Publication bias will be assessed using Egger's test and funnel plot. A network meta-analysis will be applied to indirect compare all interventions including RFA, EVLA, EVLA with HL, UGFS, UGFS with HL and HL with stripping. Probability of being best intervention will be estimated and ranked. Inconsistency assumption will be checked using a design-by-treatment interaction model.

ETHICS AND DISSEMINATION

Ethical approval is not required for systematic review and network meta-analysis. The study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018096794.

The use of high venous ligation as an adjunct to endovenous therapy in the management of great saphenous vein incompetence: A systematic review and meta-analysis of randomized controlled trials

Background

In recent years, endovenous intervention has emerged as a minimally invasive alternative to open venous surgery. However, endovenous intervention does not formally disconnect the deep and superficial venous systems and it is hypothesized that recurrence may be greater in the absence of high venous ligation. This study aims to compare the efficacy of a hybrid endovenous approach with adjuvant high venous ligation and standard operative intervention in the management of great saphenous incompetence.

Methods

In March 2018, Medline and Embase were systematically searched for relevant randomized controlled trials. All randomized controlled trials comparing a hybrid approach with standard operative intervention were included. Studies were required to include at least one pre-defined outcome. Data were extracted and assessed by two independent reviewers. Pooled risk ratios were calculated using a random effects model. Additional subgroup analyses were performed.

Results

Eight randomized controlled trials including 1244 patients were analysed. Pooled standardized data revealed no difference in overall recurrence (pooled RR = 1.00 [95% CI = 0.57, 1.77]), major operative morbidity (RR = 0.43 [95% CI = 0.06, 2.89]), or re-interventions (RR = 0.94 [95% CI = 0.12, 7.24]) for the hybrid group compared with standard operative intervention alone. Subgroup analysis revealed comparable short-, medium- and long-term recurrence rates between both cohorts. Furthermore, no difference in recurrence was identified when the hybrid approach was compared to open surgery alone (RR = 1.01 [95% CI = 0.63, 1.61]) or endovenous monotherapy (RR = 0.67 [95% CI = 0.04, 12.24]).

Conclusion

The use of a hybrid approach in the management of great saphenous incompetence appears to offer no recurrence, re-intervention or morbidity benefit when compared to standard operative intervention.