A Systematic Review and Meta-analysis of Thrombotic Events Following Endovenous Thermal Ablation of the Great Saphenous Vein

Safety and efficacy of endovenous ablation in patients with a history of deep vein thrombosis

OBJECTIVE

Endovenous ablation is the standard of care for patients with symptomatic superficial venous insufficiency. For patients with a history of deep vein thrombosis (DVT), concern exists for an increased risk of postprocedural complications, particularly venous thromboembolism. The objective of this study was to evaluate the safety and efficacy of endovenous thermal ablation in patients with a history of DVT.

METHODS

The national Vascular Quality Initiative Varicose Vein Registry was queried for superficial venous procedures performed from January 2014 to July 2021. Limbs treated with radiofrequency or laser ablation were compared between patients with and without a DVT history. The primary safety end point was incident DVT or endothermal heat-induced thrombosis (EHIT) II-IV in the treated limb at <3 months of follow-up. The secondary safety end points included any proximal thrombus extension (ie, EHIT I-IV), major bleeding, hematoma, pulmonary embolism, and death due to the procedure. The primary efficacy end point was technical failure (ie, recanalization at <1 week of follow-up). Secondary efficacy end points included the risk of recanalization over time and the postprocedural change in quality-of-life measures. Outcomes stratified by preoperative use of anticoagulation (AC) were also compared among those with prior DVT.

RESULTS

Among 33,892 endovenous thermal ablations performed on 23,572 individual patients aged 13 to 90 years, 1698 patients (7.2%) had a history of DVT. Patients with prior DVT were older (P < .001), had a higher body mass index (P < .001), were more likely to be male at birth (P < .001) and Black/African American (P < .001), and had greater CEAP classifications (P < .001). A history of DVT conferred a higher risk of new DVT (1.4% vs 0.8%; P = .03), proximal thrombus extension (2.3% vs 1.6%; P = .045), and bleeding (0.2% vs 0.04%; P = .03). EHIT II-IV, pulmonary embolism, and hematoma risk did not differ by DVT history (P = NS). No deaths from treatment occurred in either group. Continuing preoperative AC in patients with prior DVT did not change the risk of any complications after endovenous ablation (P = NS) but did confer an increased hematoma risk among all endovenous thermal ablations and surgeries (P = .001). Technical failure was similar between groups (2.0% vs 1.2%; P = .07), although a history of DVT conferred an increased recanalization risk over time (hazard ratio, 1.90; 95% confidence interval, 1.46, 2.46; P < .001). The groups had comparable improvements in postprocedural venous clinical severity scores and Heaviness, Aching, Swelling, Throbbing, and Itching scores (P = NS).

CONCLUSIONS

Endovenous thermal ablation for patients with a history of DVT was effective. However, appropriate patient counseling regarding a heightened DVT risk, albeit still low, is critical. The decision to continue or withhold AC preoperatively should be tailored on a case-by-case basis.

Endovenous thermal ablation mid-term outcomes for the treatment of large diameter incompetent great saphenous veins

INTRODUCTION

The aim of this study was to assess the efficacy and safety of endovenous thermal ablation (EVTA) in treating large diameter, ≥12 mm, incompetent great saphenous vein (GSV) in comparison to smaller ones.

METHODS

A retrospective comparative study was undertaken including 196 patients (205 limbs) undergoing EVTA. According to maximum GSV diameter patients were divided into two groups (group A <12 mm, group B ≥12 mm). Primary outcome was anatomic success defined as absence of reflux of GSV. Secondary outcomes were complications, postoperative pain using the 10-cm Visual Analog Scale (VAS) and improvement of Venous Clinical Severity Score (VCSS) and Chronic Venous Insufficiency Quality-of-Life Questionnaire (CΙVIQ-20) scores assessed at 7- days, 1 month, 12 months and 24 months postoperatively.

RESULTS

118 patients with GSV diameter <12 mm (group A) and 87 with GSV diameter ≥12 mm (group B) were included. Patients' demographics, CEAP classification and length of ablated vein did not differ between the groups. Preoperative VCSS and VAS pain score were significant greater in group B (6.03 vs 6.94, p = .04 and 5.21 vs 5.77, p = .032, respectively). No differences in adverse events were observed post-operatively among groups. GSV occlusion rate at 1 month was 98.3% (SE 1.3%) in group A and 96.5 % (2.2%) in group B (p = .3), at 12 months 95.7% (SE 2%) and 94.2% (SE 2.8%) (p = .5), and at 24 months 94% (SE 2.4%) and 93.1% (SE 3%) (p = .4) respectively. Both groups experienced significant and similar improvement in their VCSSs and CIVIQ scores postoperatively. In a subgroup analysis among different EVTA and GSV >12 mm, 1470 nm endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) showed comparable results in terms of occlusion rates, complications, VCSS and CIVIQ scores.

CONCLUSIONS

Endovenous thermal ablation techniques are efective and safe in the treatment of GSV incompetence regardless the diameter of the GSV. Both 1470 nm EVLA and RFA techniques performed similar outcomes.

Pharmacological Thromboprophylaxis for VTE Post-Endovenous Ablation of Varicose Veins: Network Meta-Analysis

OBJECTIVE

Endovenous ablation has revolutionized treatment of varicose vein surgery but is associated with a risk of venous thromboembolism. There is no consensus regarding anticoagulation protocols for these patients. This network meta-analysis (NMA) aims to identify which anticoagulant is optimal in this cohort for clot prevention with minimal risk of adverse bleeding events.

METHODS

Library databases were searched for studies where patients were treated with one or more anticoagulants following endovenous ablation for varicose veins. The methodological quality of included studies was quantified using the Risk of Bias (ROB) assessment tools. Findings were reported using the meta-analysis of observational studies in epidemiology (MOOSE) checklist. Statistical analysis was carried out using metainsight (rpackage).

RESULTS

Observational data on just under 1500 patients prescribed post ablation anticoagulation (Rivaroxaban, Enoxaparin, Fondaparinux) were analyzed. Patient characteristics were comparable across the cohorts. 81 thrombotic and 40 minor bleeding events occurred in total. Overall rivaroxaban is found to be superior to the other agents.

CONCLUSIONS

This NMA indicates that prophylactic rivaroxaban is the highest ranked anticoagulant for thromboprophylaxis in patients post endovenous ablation for varicose veins, with a low risk of adverse bleeding. The choice whether to anticoagulate these patients is likely to remain at the discretion of the treating clinician.

Deep vein thrombosis after sclerotherapy and endovenous laser ablation of varicose veins - an observational study

Background: The risk of developing deep vein thrombosis (DVT) after endovenous ablation of varicose veins varies in the literature. Little is known about the characteristics of this complication and associated factors. This study aimed: 1) to study the occurrence of DVT after ultrasound-guided foam sclerotherapy (UGFS) alone or combined with endovenous laser ablation (EVLA) for lower-limb varicose veins; 2) to identify factors associated with DVT. Patients and methods: The study included all outpatients aged 18 years or older who underwent UGFS and EVLA or UGFS alone at the University Hospital of Zurich between 2011 and 2015. Data were extracted from the hospital electronic medical record. Patients were surveyed about their level of pain after the procedure and their level of satisfaction with the procedure. Duplex ultrasound was used to assess the deep venous system 7-10 days and 6-8 months after the procedure. Regression analysis was used to examine the association of patient and procedure characteristics with the development of DVT. Results: A total of 334 patients (561 procedures performed in 393 different sessions) were included: 73% of the patients underwent combined UGFS and EVLA and 27% underwent UGFS alone. DVT occurred in 24 (7.2%) patients, of whom 88% underwent combined procedures and 17% underwent interventions involving both the great and small saphenous veins on the same session. DVT occurred in 8.2% of patients receiving thromboprophylaxis and in 9.5% of patients not receiving thromboprophylaxis. DVT occurred in 5.2% of women and 11.9% of men. No factors associated with a diagnosis of DVT after intervention were identified. Pain and satisfaction levels did not differ between patients with and without DVT. Conclusions: This study adds to the knowledge of the risk of DVT following UGFS alone or combined with EVLA. Further studies are needed to revise thromboprophylaxis.

Comparison of two ablation procedures combined with high ligation and foam sclerotherapy and compression therapy for patients with venous leg ulcers

AIM

To compare the ablation techniques' efficacy of endovenous microwave ablation (EMA) combined with high ligation (HL), foam sclerotherapy (FS) and compression therapy (CT) and endovenous laser ablation (EVLA) combined with HL-FS-CT in the treatment of VLUs.

METHOD

301 consecutive patients with VLUs from 2013 to 2022 in a 3200-bed hospital were intervened by EMA combined with HL-FS-CT and EVLA combined with HL-FS-CT were retrospectively compared.

RESULTS

One hundred thirty-four patients underwent EMA+HL-FS-CT and 167 patients underwent EVLA+HL-FS-CT. The primary outcome of the ulcer healing time was 1.45(0.75-1.5) months and 1.86(0.5-2.5) months, respectively, in the two groups (HR for ulcer healing was 1.26, 95% CI [0.96-1.66], p = 0.097). Secondary outcomes included that no significant difference was found in ulcer recurrence and GSV recanalization and complications between the two groups, and the postoperative VCSS and AVVQ were significantly lower than the baseline values in the respective groups (p = 0.0001).

CONCLUSION

EMA+HL-FS-CT and EVLA+HL-FS-CT are both effective at treating VLUs. Both of the two comprehensive treatments were beneficial to the healing of ulcers, but no evidence showed which one was superior in the ulcer healing time.

Appropriateness of care in superficial venous disease

Chronic superficial venous disease, including superficial venous insufficiency, superficial venous thrombosis, and aneurysms, are prevalent conditions that affect millions of individuals worldwide. With chronic venous insufficiency specifically, the advent of office-based minimally invasive procedures in recent decades has significantly expanded access to outpatient treatment. However, as venous insufficiency is rarely life- or limb-threatening, the clinical diagnosis, diagnostic evaluation, and treatment indications should be considered carefully when recommending elective intervention. Appropriateness of care guidelines intend to aid providers and patients in the decision-making process, based on the available evidence in the scientific literature, to select the best care for the patient when treating their superficial venous disease.

Third generation of laser (>1900) for endovenous thermoablation (EVLA) of varicose veins: A systematic review and meta-analysis

OBJECTIVES

Third generation lasers with longer wavelengths (>1900 nm) have been introduced, in recent years, for the treatment of varicose veins. The possible advantage of the new generation lasers is that they allow complete damage to the vein wall using a lower Power in Watts (W: J/sec) and a lower linear energy density (LEED: J/cm). The aim of this work is to evaluate the results present in the literature regarding efficacy and safeness of the new generation lasers for the treatment of varicose veins.

METHODS

Published articles were searched on PubMed database and on Cochrane Library, entering the keywords "1940 nm or 1920 nm laser AND varicose veins laser thermoablation (EVLA)." The primary endpoint of the study was to value rate of occlusion and adverse events at the short term follow-up. The search yielded a total of 14 studies. In the end, only six studies were judge eligibility.

RESULTS

The studies were heterogenous in their documentation, EVLA, duplex ultrasound protocol and result reporting. A total of 540 limbs of 377 patients were treated with endovenous laser ablation (EVLA) with laser 1920-1940 nm. The treated veins had a mean diameter of 0.74 ± 0.17 cm and a mean length of 27.87 ± 20.63 cm. The pooled estimates of immediate occlusion rate was of 99.8% (95% CI: 97.9% to 100.0) with high heterogeneity (I2 = 60%; 95% PI: 89.7% to 100%), while at short-term follow-up was of 98.2% (95% CI: 94.0% to 100.0%) with higher heterogeneity (I2:79%; 95% PI: 77.1% to 100.0%). EHIT occurred in 7 cases (pooled estimate: 0.7%). The other adverse events rate reported were 1% of hyperpigmentation, 2.8% of neurological complications, 0.6% thrombophlebitis and 1.9% of bruising/hematoma. The pooled mean estimates of LEED was equal to 38.2 J/cm (95% CI: 26.3 to 50.1 J/cm) although with a very large heterogeneity (I2 = 100%).

CONCLUSIONS

The overall success rate of EVLA was high. The analysis of these studies suggests that using lower parameters (Power and linear administered energy) may have no effect on the treatment success rate. Short-term results demonstrate comparable occlusion rates respect the second-generation lasers. Instead, data suggest a low complication rates. Short-term results demonstrate comparable complications rates respect the second-generation lasers (1300-1470 nm). Randomized studies with longer follow-up are required to evaluate the EVLA 1900 nm procedure further.

EndoVenous-assisted invaginated stripping of the great saphenous vein: A pilot and feasibility study

Objective: By incorporating an endovascular component into Great Saphenous Vein stripping, EndoVenous-assisted Invaginated Stripping (EVIS) aims to make the procedure minimally invasive. A study was conducted to investigate the surgical intervention. Methods: Sketches and videos were used to illustrate the technical aspects of EVIS. A prospective cohort study included 20 patients with chronic venous insufficiency (CVI). Results: EVIS is performed as a day-surgery. Technical success was 100%, and no complications were recorded. The mean operative time was 45 minutes, intraoperative pain score was 4.8, post-operative pain was 2.5, 1.8, 1.2, 0.5 at 48 hours, 1, 4, and 12 weeks, respectively. The mean blood loss was 15 mL, and the mean length of the GSV strapped was 19 cm. The follow-up duplex showed a reduction in the diameter of the residual GSV stump. Conclusions: EVIS is a combination of standard techniques that may prove valuable in managing CVI.

Safety of synchronous prophylactic ablation of the anterior saphenous vein in patients undergoing great saphenous vein thermal ablation- 6 months follow-up data of the SYNCHRONOUS study

BACKGROUND

The SYNCHRONOUS-study investigates simultaneous ASV-ablation with great saphenous vein (GSV) treatment in endovenous laser ablation (EVLA) for preventing varicose vein recurrence. This sub-study examines complication rates associated with prophylactic ASV-ablation.

METHODS

Among 1173 patients with refluxing GSV, 604 underwent GSV-ablation only, and 569 received additional ASV-ablation. Complication rates were compared over 6 months.

RESULTS

Approximately 80% of patients were complication-free with minor bruising and dysesthesia being most common complications. After 6 months, additional prophylactic ASV-ablation did not increase the rate of complications compared to GSV-only treatment.

CONCLUSION

The 6-months follow-up data suggests that prophylactic ASV-closure, alongside GSV-treatment, is safe, with similar complication rates to GSV-only EVLA.

Factors associated with ablation-related thrombus extension following microfoam versus radiofrequency saphenous vein closure

OBJECTIVE

Polidocanol endovenous microfoam ablation (MFA) is approved by the US Food and Drug Administration for great saphenous vein (GSV) closure, yet there are few published data on the subsequent risk of ablation-related thrombus extension (ARTE). Recent societal practice guidelines recommend against routine postprocedure duplex ultrasound (DU) examination after thermal ablation of the GSV in asymptomatic patients. At present, limited data do not allow this recommendation to extend to MFA. Our aim is to identify characteristics and outcomes associated with ARTE following MFA vs radiofrequency ablation (RFA).

METHODS

A retrospective review of a prospectively maintained database was conducted of patients who underwent MFA and RFA closure of incompetent above-knee GSVs. Patients treated for isolated tributary vein treatment or did not have a postprocedure DU examination within 48 to 72 hours were not included. Patients were classified into two groups: ARTE and no ARTE. Demographic data, Clinical, Etiologic, Anatomic and Pathophysiologic class, Venous Clinical Severity Score, operative details, postprocedure (48-72 hours) DU findings, and adverse events were analyzed. Variables that were significant on univariate analysis were evaluated using multivariate logistic regression with the primary outcome being development of ARTE.

RESULTS

Between June 2018 and February 2023, 800 limbs were treated with either MFA (n = 224) or RFA (n = 576). Ninety-six GSVs treated with MFA met the study criteria. One hundred fifty successive GSVs treated with RFA during the same period were included as a comparison group. There was no statistically significant difference in baseline demographics between the two groups. Six patients (2.4%) demonstrated ARTE on postoperative DU examination at 48 to 72 hours (MFA, n = 5 [5.2%]; RFA, n = 1 [0.7%]; P = .02). Saphenous vein ablation with MFA (P = .045) and a vein diameter of >10 mm (P = .017) were associated with ARTE on both univariable and multivariable analysis. All patients who developed ARTE were treated with oral anticoagulants (mean, 15.6 days). Body mass index, Clinical, Etiologic, Anatomic and Pathophysiologic class, Venous Clinical Severity Score, microfoam volume, operative time, and prior deep venous thrombosis were not predictive of ARTE.

CONCLUSIONS

ARTE after above-knee GSV closure occurred more frequently after MFA. Our results suggest that a saphenous vein diameter of >10 mm may be associated with ARTE. Despite this finding, all patients with ARTE were treated with short-term anticoagulation with no related complications. Until larger studies with high-risk subgroups have been studied after MFA, DU examination should be performed routinely after this procedure and patients with ARTE anticoagulated until the thrombus retracts caudal to the saphenofemoral junction or is no longer present on DU examination. Current societal guidelines recommending against routine post-thermal ablation DU examination should not be applied to similar patients after saphenous nonthermal MFA ablation.

Comparative effectiveness of non-compounded polidocanol 1% endovenous microfoam (Varithena) ablation versus endovenous thermal ablation utilizing a systematic review and network meta-analysis

OBJECTIVE

We compared the effectiveness and safety of polidocanol 1% endovenous microfoam ablation vs endovenous thermal ablation with radiofrequency or laser energy for treatment of venous insufficiency caused by lower extremity truncal vein incompetence via network meta-analysis of published comparative evidence.

METHODS

We conducted a systematic literature review following best practices, including a prospective protocol. We screened studies published in English from 2000 to 2023 for randomized and nonrandomized studies reporting direct or indirect comparisons between polidocanol 1% endovenous microfoam and endovenous thermal ablation. Thirteen studies met our eligibility criteria for the network meta-analysis. The co-primary effectiveness outcomes were the closure rate ≥3 months after procedure and the average change in the Venous Clinical Severity Score. For the subgroup of venous ulcer patients, the ulcer healing rate was the primary effectiveness outcome. The secondary outcomes included safety and patient-reported outcomes. Network meta-analyses were conducted on outcomes having sufficient data. Categorical outcomes were summarized using odds ratios (ORs) with 95% confidence intervals (CIs). Sensitivity tests and estimates of network inconsistency were used to investigate the robustness of our meta-analysis.

RESULTS

We found that polidocanol 1% endovenous microfoam was not significantly different statistically from endovenous thermal ablation for venous closure (OR, 0.65; 95% CI, 0.36-1.18; P = .16). Although not the primary aim of the study, the network meta-analysis also provided evidence to confirm our supposition that polidocanol 1% endovenous microfoam was significantly differentiated statistically from physician-compounded foam, with higher odds for vein closure (OR, 2.91; 95% CI, 1.58-5.37; P < .01). A sensitivity analysis using the longest available time point for closure in each study, with a minimum of 12 months of follow-up (median, 48 months; range, 12-72 months), showed results similar to those of the main analysis. No association was found between the risk of deep vein thrombosis and the treatment received. The available data were insufficient for a network meta-analysis of Venous Clinical Severity Score improvement and ulcer healing rates.

CONCLUSIONS

Polidocanol 1% endovenous microfoam was not significantly different statistically from endovenous thermal ablation for venous closure and deep vein thrombosis risk for chronic venous insufficiency treatment, based on a network meta-analysis of published evidence. Polidocanol 1% endovenous microfoam was significantly differentiated statistically from physician-compounded foam, with higher odds of vein closure. A sensitivity analysis found venous closure findings were robust at follow-up intervals of 12 months or greater and for up to 6 years. New evidence meeting the inclusion criteria for this review will be incorporated at regular intervals into a living network meta-analysis.

The trends in venous thromboembolism occurrence and prevention after minimally invasive varicose vein surgery

OBJECTIVES

To assess the trends of VTE occurrence and prevention in varicose vein surgery.

METHOD

The registry-based CAPSIVS trial (NCT03041805) analysis includes results in 1878 lower limbs. The primary outcome is a 28-day symptomatic or asymptomatic DVT revealed with duplex ultrasound.

RESULTS

Any DVT, including EHIT, was observed in 3.4%, while symptomatic in 0.5%. Prophylactic anticoagulation was administrated in 20.4% with LMWH (13.2%) or DOAC (7.1%) for patients with higher VTE risk but did not reduce the events rate. With propensity score matching DOACs were superior to LMWHs (1.5% vs 9.8%). Duration of anticoagulation was essential: the lowest incidence (4.2%) was associated with prophylaxis for up to 7 days, while a single LMWH injection resulted in a DVT rate of 8.8%. With individual VTE history, any anticoagulation duration appeared insufficient.

CONCLUSIONS

Prophylactic anticoagulation after varicose vein surgery should be based on the individual VTE risk and provided for ≥7-30 days.

Increased body mass index and vein diameter are associated with incomplete target vein closure following microfoam ablation of incompetent saphenous veins

OBJECTIVE

Patient characteristics and risk factors for incomplete or non-closure following thermal saphenous vein ablation have been reported. However, similar findings have not been clearly described following commercially manufactured polidocanol microfoam ablation (MFA). The objective of our study is to identify predictive factors and outcomes associated with non-closure following MFA of symptomatic, refluxing saphenous veins.

METHODS

A retrospective review of a prospectively maintained patient database was performed from procedures in our Ambulatory Procedure Unit. All consecutive patients who underwent MFA with commercially manufactured 1% polidocanol microfoam for symptomatic superficial vein reflux between June 2018 and September 2022 were identified. Patients treated for tributary veins only, without truncal vein ablation, were excluded. Patients were then stratified into groups: complete closure (Group I) and non-closure (Group II). Preoperative demographics, procedural details, and postoperative outcomes were analyzed. Preoperative variables that were significant on univariate analysis (prior deep venous thrombosis [DVT], body mass index [BMI] ≥30 kg/m2, and vein diameter) were entered into a multivariate logistic regression model with the primary outcome being vein non-closure.

RESULTS

Between June 2018 and September 2022, a total of 224 limbs underwent MFA in our ambulatory venous center. Of these, 127 limbs in 103 patients met study inclusion criteria. Truncal veins treated included the above-knee great saphenous vein (Group I: n = 89, 77% vs Group II: n = 7, 58%; P = .14), below-knee great saphenous vein (Group I: n = 7, 6% vs Group II: n = 0; P = .38), anterior accessory saphenous vein (Group I: n = 17, 15% vs Group II: n = 4, 33%; P = .12, and small saphenous vein (Group I: n = 4, 4% vs Group II: n = 1, 8%; P = .41). Complete closure (Group I) occurred in 115 limbs, and 12 limbs did not close (Group II) based on postoperative duplex ultrasound screening. The mean BMI in Group II (36.1 ± 6.4 kg/m2) was significantly greater than Group I (28.6 ± 6.1 kg/m2) (P < .001). Vein diameter of ≥10.2 mm was independently associated with truncal vein non-closure with an odds ratio of 4.8. The overall mean foam volume was 6.2 ± 2.7 ml and not different between the two cohorts (Group I: 6.2 ± 2.6 ml vs Group II: 6.3 + 3.5 ml; P = .89). Post MFA improvement in symptoms was higher in Group I (96.9%) compared with Group II (66.7%) (P = .001). The mean postoperative Venous Clinical Severity Score was also lower in Group I (8.0 ± 3.0) compared with Group II (9.9 ± 4.2) (P = .048). The overall incidences of ablation-related thrombus extension and DVT were 4.7% (n = 6) and 1.6% (n = 2), and all occurred in Group I. All were asymptomatic and resolved with anticoagulation.

CONCLUSIONS

Microfoam ablation of symptomatic, refluxing truncal veins results in excellent overall closure rates and symptomatic relief. BMI ≥30 kg/m2 and increased vein diameter are associated with an increased risk of saphenous vein non-closure following MFA. Non-closure is associated with less symptomatic improvement and a lower post-procedure reduction in Venous Clinical Severity Score. Despite the incidence of ablation-related thrombus extension and DVT in this study being higher than reported rates following thermal ablation, MFA is safe for patients with early postoperative duplex ultrasound surveillance and selective short-term anticoagulation.

Venous thrombosis following endovenous laser ablation with and without thromboprophylaxis

OBJECTIVE

Venous thromboembolism (VTE) occurs infrequently after endovenous laser ablation (EVLA). The purpose of this study was to assess the incidence of VTE after EVLA with and without pharmacologic prophylaxis.

METHODS

From October 2019 to March 2020, a series of consecutive patients from the prospectively maintained VEINOVA (vein occlusion with various techniques) registry was retrospectively analyzed. All the patients underwent EVLA with and without postoperative thromboprophylaxis. A 1470-nm laser wavelength with a radial fiber was used for EVLA. Concomitant phlebectomy or sclerotherapy of insufficient tributaries was allowed. Perivenous tumescence was applied with 1% Rapidocaine (lidocaine hydrochloride monohydrate; Sintetica SA). Ablation of varicose veins was performed by continuously drawing back the laser fiber at a power of 10 W, aiming for a linear endovenous energy delivery of 60 to 90 J/cm. Compression stockings were applied postoperatively, and the patients were advised to wear them for 1 week. Duplex ultrasound was performed at the 1- and 4-week follow-up visits to determine the occlusion rate and the occurrence of EHIT and VTE.

RESULTS

Overall, 249 patients were identified from the registry. Of the 249 patients, 26 were omitted because of treatment of recurrent varicose veins. Finally, 223 consecutive patients with 223 legs and 227 saphenous veins (159 great saphenous veins, 49 small saphenous veins, and 19 anterior accessory saphenous veins) were included in the final analysis. Their mean age was 58.1 ± 13.8 years, and 167 patients (73.1%) were women. The clinical CEAP (clinical, etiology, anatomy, pathophysiology) classification was C2 for 11 legs (4.9%), C3 for 123 legs (55.2%), C4a or C4b for 86 legs (38.6%), and C5 to C6 for 3 legs (1.4%). Thromboprophylaxis was given to 132 patients (59.2%) for 3 days (rivaroxaban 10 mg once daily to 130 patients [98.5%] and low-molecular-weight heparin to 2 patients [1.5%]). No thromboprophylaxis was administered to 91 patients (40.8%) after EVLA. The average treatment length was 34.2 ± 19.3 cm and the average diameter was 5.0 ± 1.3 mm. At 1 week of follow-up, no thrombotic event had occurred in either group. At 4 weeks of follow-up, one case of EHIT class 2 (1.1%) and one case of pulmonary embolism (1.1%) had occurred in the group without thromboprophylaxis. In the thromboprophylaxis group, one deep vein thrombosis (0.8%) event had occurred (adjusted P = .135). At 1 and 4 weeks of follow-up, the treated varicose veins remained occluded in both groups.

CONCLUSIONS

Endovenous ablation of truncal varicose veins appears to be safe with a low thrombotic event rate with or without pharmacologic thromboprophylaxis. However, more data are needed before a final recommendation regarding the best thromboprophylaxis treatment option can be given.

The 2023 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 II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

Endovenous laser treatment vs conventional surgery for great saphenous vein varicosities: A propensity score matching analysis

BACKGROUND

Varicosis is a common venous condition, which is typically treated surgically. However, selection of the optimal surgical approach can be challenging. Previous studies comparing endovenous laser treatment (EVLT) and conventional surgery were retrospective and observational in nature and the results may therefore have been influenced by selection bias and the presence of other confounding factors. In this study, we used propensity score matching to reduce selection bias when comparing EVLT and conventional surgery for the treatment of varicose great saphenous veins.

AIM

To compare the perioperative and postoperative outcomes of EVLT and conventional surgery in patients with great saphenous vein varicosis.

METHODS

We retrospectively reviewed the records of 1063 patients treated for primary varicosis of the great saphenous vein at the Second Affiliated Hospital of Xuzhou Medical University between January 2009 and December 2019. Among them, 56 patients were excluded owing to additional small saphenous varicose vein involvement, 81 owing to recurring varicose veins, 83 owing to complicated varicose veins (CEAP clinical classification C5-C6), and 6 owing to perioperative phlebitis. Finally, 772 patients were enrolled in this study. Standard demographic and clinicopathological data were collected from the medical records of the patients. For propensity score matching, 522 patients (261 who underwent EVLT and 261 who underwent conventional surgery) were randomly matched 1:1 by age, sex, onset time, smoking status, presence of diabetes, family history, stress therapy, C class, and the affected leg.

RESULTS

Of the 772 patients included in the study, 467 underwent EVLT and 305 underwent conventional surgery. There were significant differences in age, onset time, smoking and diabetes status, and family history between the two groups. Following propensity score matching, no significant differences in patients' characteristics remained between the two groups. ELVT was associated with a shorter operation time and hospital stay than conventional surgery, both before and after propensity score matching. There were no differences in complications between the two groups after propensity score matching. Patients who underwent EVLT had a higher recurrence rate during the two-year follow-up period than those who underwent conventional surgery (33.33% vs 21.46%, χ2 = 11.506, P = 0.001), and a greater percentage of patients who underwent EVLT experienced pain one week after the procedure (39.85% vs 19.54%, P = 0.000).

CONCLUSION

EVLT may not always be the best option for the treatment of great saphenous vein varicosis.

The correlation between Caprini score and the risk of venous thromboembolism after varicose vein surgery

BACKGROUND

The study aims to identify the incidence of symptomatic and asymptomatic venous thromboembolism (VTE) after minimally invasive varicose vein surgery and to assess the predictability of the Caprini risk score (CRS).

METHODS

CAPrini Score In Venous Surgery (NCT03041805) is a registry-based prospective study that enrolls patients undergoing minimally invasive open (high ligation, stripping, miniphlebectomy) and endovascular (thermal and non-thermal ablation) surgery on varicose veins. The main inclusion criteria are CRS assessment before intervention and a duplex ultrasound scan performance within 2-4 weeks after surgery. The primary outcome is a combination of asymptomatic or symptomatic DVT, including EHIT of class 2-4 and PE.

RESULTS

Totally 1878 records with defined outcomes were analyzed. The mean age of patients was 46.9±13.3 years; 66% were female. Endovenous laser ablation was performed in 88%. Varicose tributaries were treated in 40%, perforating veins in 3.9% of cases. CRS ranged from 1 to 12 (mean of 4.0±1.5). Prophylactic anticoagulation was prescribed in 20%. The primary outcome was reported in 63 cases (3.4%; 95% CI, 2.7-4.3%), comprising asymptomatic (N.=29, 1.5%) or symptomatic (N.=10, 0.5%) DVT or EHIT (n=28, 1.6%). No PE was reported. A significant correlation was found between CRS and VTE incidence (P=0.001). Under logistic regression CRS (OR, 1.3; 95% CI, 1.1-1.6) along with treatment of tributaries (OR, 6.3; 95% CI, 3.0-13.0) and perforating veins (OR, 10.7; 95% CI, 3.8-30.2) were associated with VTE in the absence of prophylactic anticoagulation.

CONCLUSIONS

The incidence of VTE after ablation of superficial veins is 3.4%, predominantly due to asymptomatic EHIT and DVT, and significantly correlates with CRS.

The application of infrared thermography technology in flap: A perspective from bibliometric and visual analysis

The application of infrared thermography technology (IRT) in flap has become a major focus of research, as it provides a non-invasive, real-time, and quantitative approach for monitoring flap perfusion. In this regard, we conducted a comprehensive visualization and scientometric analysis to systematically summarize and discuss the current state of research in this field. We systematically reviewed publications on the application of IRT in flap procedures from 1999 to 2022, using the Web of Science Core Collection (WoSCC). Through scientometric analysis, we examined annual trends, affiliations, countries, journals, authors, and their relationships, providing insights into current hotspots and future developments in this area. We analysed 522 English studies and found a steady increase in annual publications. The United States and Germany had the highest publication rates, with Beth Israel Deaconess Medical Center and Shanghai Jiaotong University being leading institutions. Notably, Lee BT and Alex Keller emerged as influential authors in this field. Compared to existing techniques, infrared-based technology offers significant advantages for non-invasive monitoring of flap perfusion, including simplicity of operation and objective results. Future trends should focus on interdisciplinary collaborations to develop new infrared devices and achieve intelligent image processing, enabling broader application in various clinical scenarios. This bibliometric study summarizes the progress and landscape of research on 'the Application of infrared thermography technology in flap' over the past two decades, providing valuable insights and serving as a reliable reference to drive further advancements and spark researchers' interest in this field.

ACR Appropriateness Criteria® Lower Extremity Chronic Venous Disease

Lower extremity venous insufficiency is a chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis or extrinsic venous obstruction. Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million males and 22 million females 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly. Various diagnostic and treatment strategies are in place for lower extremity chronic venous disease and are discussed in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Systematic Review and Meta-analysis of the Additional Benefit of Pharmacological Thromboprophylaxis for Endovenous Varicose Vein Interventions

OBJECTIVE

The primary objective of this systematic review and meta-analysis was to elucidate the rate of venous thromboembolism (VTE) after endovenous interventions for varicose veins in the presence of pharmacological and mechanical thromboprophylaxis versus mechanical thromboprophylaxis alone.

BACKGROUND

The VTE rate after endovenous procedures for varicose veins is higher than other day-case procedures and could be reduced with pharmacological thromboprophylaxis.

METHODS

The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines with a registered protocol (PROSPERO: CRD42021274963). Studies of endovenous intervention for superficial venous incompetence reporting the predefined outcomes with at least 30 patients were eligible. Data were pooled with a fixed effects model.

RESULTS

There were 221 trials included in the review (47 randomized trial arms, 105 prospective cohort studies, and 69 retrospective studies). In randomized trial arms, the rate of deep venous thrombosis with additional pharmacological thromboprophylaxis was 0.52% (95% CI, 0.23%-1.19%) (9 studies, 1095 patients, 2 events) versus 2.26% (95% CI, 1.81%-2.82%) (38 studies, 6951 patients, 69 events) with mechanical thromboprophylaxis alone. The rate of pulmonary embolism in randomized trial arms with additional pharmacological thromboprophylaxis was 0.45% (95% CI, 0.09-2.35) (5 studies, 460 participants, 1 event) versus 0.23% (95% CI, 0.1%-0.52%) (28 studies, 4834 participants, 3 events) for mechanical measures alone. The rate of EHIT grade III to IV was 0.35% (95% CI, 0.09-1.40) versus 0.88% (95% CI, 0.28%-2.70%). There was 1 VTE-related mortality and 1 instance of major bleeding, with low rates of minor bleeding.

CONCLUSIONS

There is a significant reduction in the rate of DVT with additional pharmacological thromboprophylaxis and routine prescription of anticoagulation after endovenous varicose vein intervention should be considered. VTE risk for individual study participants is heterogeneous and risk stratification in future randomized interventional studies is critical to establish the clinical effectiveness and safety of additional pharmacological thromboprophylaxis.

Endovenous ablation for venous leg ulcers

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Expanded Polytetrafluoroethylene Membranes for Vascular Stent Coating: Manufacturing, Biomedical and Surgical Applications, Innovations and Case Reports

Coated stents are defined as innovative stents surrounded by a thin polymer membrane based on polytetrafluoroethylene (PTFE)useful in the treatment of numerous vascular pathologies. Endovascular methodology involves the use of such devices to restore blood flow in small-, medium- and large-calibre arteries, both centrally and peripherally. These membranes cross the stent struts and act as a physical barrier to block the growth of intimal tissue in the lumen, preventing so-called intimal hyperplasia and late stent thrombosis. PTFE for vascular applications is known as expanded polytetrafluoroethylene (e-PTFE) and it can be rolled up to form a thin multilayer membrane expandable by 4 to 5 times its original diameter. This membrane plays an important role in initiating the restenotic process because wrapped graft stent could be used as the treatment option for trauma devices during emergency situations and to treat a number of pathological vascular disease. In this review, we will investigate the multidisciplinary techniques used for the production of e-PTFE membranes, the advantages and disadvantages of their use, the innovations and the results in biomedical and surgery field when used to cover graft stents.

A Report of Penile Mondor's Disease After Mechanochemical Ablation and Adjunct Foam Sclerotherapy of Bilateral Lower Extremity Truncal Incompetence

INTRODUCTION

Mondor's disease of the penis, or superficial thrombophlebitis affecting penile veins, is a rare condition. Common causes include prothombotic states, venous stasis or excessive manipulation. The literature includes one case report of Mondor's Disease after endovenous laser ablation and foam sclerotherapy and a case series after open saphenofemoral junction ligation. However, there have been no noted cases of this rare complication after mechanochemical ablation of the GSV.

CASE DETAILS

A 50-year-old man with bilateral great saphenous venous incompetence had truncal mechanochemical ablation of both above-knee GSV segments with the Clarivein^TM device with adjunctive 1% Fibrovein foam to varicose tributaries. Day three post-operatively he began experiencing suprapubic pain and noted tender "cord-like" veins along the penile shaft. Duplex investigation of the penis demonstrated occlusive thrombus in the superficial veins draining into the dorsal vein of the penis. The patient was treated with 75 mg oral Clopidogrel for four weeks and his symptoms resolved without functional impairment.

CONCLUSIONS

Vascular surgeons should be aware that this rare albeit self-limiting thrombotic complication can occur after endovenous mechanochemical ablation of the great saphenous vein with adjunct foam sclerotherapy, particularly as this procedure is performed very frequently. Interestingly, the majority of reported cases have occurred after bilateral interventions. The patients can be reassured that their symptoms will likely settle and the use of anti-thrombotic therapy is largely at the surgeon's discretion.

Outcome Measures of In-Office Endovenous Radiofrequency Treatment of Varicose Vein Feasibility

RFA is a relatively new treatment, approved by the FDA in 1999 and is a minimally invasive intervention that has become one of the most common alternatives due to its many advantages, including decreased pain, less morbidity, shorter hospital stay and faster return to work. We retrospectively analyzed a total of 503 limbs submitted for surgical interventions for VVs using the RFA, combined or not with surgical phlebectomies and sclerotherapy, in our institution between April 2012 and December 2020. The technical success was 99.8%, as in one case the RFA catheter arrested at the first third of the thigh due to the tortuosity of the vessel. On the first post-operative day, the mean VAS scale was 0.32 ± 0.56 (0-2). Perioperative complications occurred in 77 cases (15.3%): intraoperative pain in 24 cases, in nine cases associated with vagal syndrome, superficial hematoma in 30 cases, EHIT in seven cases, phlebitis in 14 cases and paresthesia in two cases. RFA procedures had been shown to be cost-effective therapeutic options in adult patients requiring treatment due to the incompetence of the GSV. In our study, we highlighted that this technique is feasible as an ambulatory procedure; it improves quality of life and symptoms in the majority of patients with varicose veins, with a rapid return to normal life and work activities.

A systematic review of routine post operative screening duplex ultrasound after thermal and non-thermal endovenous ablation

OBJECTIVE

The Society of Vascular Surgery and the American Venous Forum recommend duplex ultrasound (DUS) following endovenous ablation. However, this screening may not be cost-effective or clinically indicated. The most common abnormal finding, endovenous heat-induced thrombosis (EHIT level 1-2), represents extension of thrombus from the saphenous <50% across the femoral or popliteal vein, which is thought to have a benign course regardless of intervention. The likelihood of venous thromboembolism (VTE) after thermal and non-thermal ablations was explored to determine the utility of routine postoperative DUS.

METHODS

This is an updated and expanded systematic review including data from randomized trials and large observational studies (≥150 patients) of thermal and non-thermal ablations, examining the incidence of VTE. Using PubMed and EMBASE, 4584 publications were screened from 2000 through 2020. After applying inclusion and exclusion criteria, 72 studies were included. Random effects DerSimonian-Laird method was conducted to obtain the pooled incidence. We calculated the number of tests needed to detect one VTE, and the cost was derived from Center for Medicare Services tables.

RESULTS

A total of 31,663 patients were included. The pooled incidence of EHIT II-IV, deep venous thrombosis (DVT), and pulmonary embolism (PE) was 1.32% (95% confidence interval [CI], 0.75%-2.02%); DVT (excluding EHIT), 0.20% (95% CI, 0.0%-0.2%); EHIT (I-IV), 2.51% (95% CI, 1.54%-3.68%); and EHIT (II-IV), 1.00% (95% CI, 0.51%-1.61%). There was no mortality. There was a lower DVT rate in thermal vs non-thermal ablations (0.23% vs 0.43%; P = .02); however, for all VTE (EHIT I-IV + DVT + PE), thermal techniques had more thrombosis (2.5% vs 0.5%; P <.001). When clinical significance is defined as DVT + EHIT (II-IV), 175 studies are needed to identify one VTE, costing $21,813 per "significant VTE." Patients receiving pharmacological prophylaxis had less EHIT I-IV compared with those who did not (3.04% vs 1.63%; P < .001); those who received DUS during the first post-op week had three times higher EHIT incidence compared with those whose first DUS was >7 days postoperative (6.6% vs 2.4%; P < .001).

CONCLUSIONS

For thermal and non-thermal endovenous ablations, the incidence of VTE diagnosed with routine DUS is small and without clear clinical significance but caries a high cost. The Society of Vascular Surgery and the American Venous Forum recommendation to perform DUS within 72 hours is not justified by these data. We recommend a more targeted post-ablation scanning protocol including symptomatic patients and those at high risk.

Prospective randomized trial of antithrombotic strategies following great saphenous vein ablation using injectable polidocanol endovenous microfoam (Varithena)

OBJECTIVE

Postablation deep vein thrombosis (DVT) represents a potentially serious complication after Varithena polidocanol endovenous microfoam (PEM) ablation. The following primary outcomes were assessed: whether (1) adjunctive apixaban anticoagulation or (2) mechanical deep venous system (DVS) saline flushing could decrease saphenofemoral junction (SFJ) thrombus extension (postablation superficial thrombus extension [PASTE]) and/or DVT compared with compression alone, after great saphenous vein (GSV) PEM ablation.

METHODS

Varithena 1% PEM ablation patients were randomized to (1) SFJ compression, (2) compression and DVS saline flushing, or (3) compression, DVS saline flushing, and 5 days of postprocedural 5 mg oral apixaban anticoagulation twice daily. Duplex imaging was obtained 7 to 10 days after PEM ablation and PASTE/DVT incidence (primary end point) was compared between groups at this time point.

RESULTS

We treated 304 limbs in 257 patients with PEM. Overall, 103 limbs received SFJ compression (group C, 33.8%), 101 received compression and deep venous flushing (group D, 32.9%), and 100 received compression, deep flush, and anticoagulation (group A, 33.2%). Mean ultrasound follow-up time was 9.7 days (all patients) with a primary GSV closure rate of 92.4%. SFJ PASTE (II-IV) occurred in 0.9%, 1.0%, and 0% (groups C, D, and A, respectively). DVT occurred in 16.7%, 14.7%, and 1.98% (groups C, D, and A; χ², P = .002). Patients in group A receiving apixaban anticoagulation had a significant reduction in DVT compared with patients in group C (1.98% vs 16.7%, χ²; P < .001); likewise, patients in group A had a significantly decreased DVT occurrence compared with group D (14.7% vs 1.98%; χ², P = .00162), whereas patients in groups C and D were not statistically different (16.7% vs 14.7%; χ², P = .60).

CONCLUSIONS

(1) Neither adjunctive DVS flushing nor anticoagulation decreased clinically relevant SFJ PASTE (II-IV) incidence, which remained similarly low across all groups and ranged between 0% and 1%, regardless of adjunctive DVS flushing or anticoagulation. This rate was significantly lower than prior reports (2.3%-4.1%). (2) DVS flushing had no influence on the rate of DVT. Observed PEM-induced DVT incidence using SFJ compression alone or compression with DVS flushing (16.7% and 14.7%, respectively) was significantly higher than prior reports (2.5%-9.6%). This finding may relate to the greater extent of AK/BK GSV territory treated in the present study. (3) Five days of postprocedural oral apixaban anticoagulation, 5 mg given twice daily, significantly decreased DVT occurrence to 1.98%, compared with nonanticoagulated patients (16.7%). This finding is comparable with the DVT rates reported after endovenous thermal ablation (0.7-1.7%). (4) Postprocedural apixaban anticoagulation may have a significant preventive role in decreasing DVT occurrence after PEM ablation.

Factors Affecting Residual Stump Length Following Endovenous Laser Ablation

Background

Current instruction for endovenous laser ablation (EVLA) recommends that the laser fibre tip should be at least 2 cm caudal to the saphenofemoral or saphenopopliteal junction. This is to reduce risk of deep vein thrombosis (DVT) whilst ensuring that the Great Saphenous Vein (GSV)/Short saphenous vein (SSV) occlusion (residual stump) is close to the SFJ/SPJ to reduce recurrence rates. Our aim was to primarily assess the effects of pre-operative junction distance of the laser fibre on stump length but also look at other factors affecting this.

Patient and Methods

This was a retrospective analysis of an electronic collected database performing EVLA of the GSV and SSV under local anaesthesia. Patients with previous venous thromboembolic events and incomplete data were excluded. Patients were reviewed at 6 weeks with venous Duplex scan to assess for the residual stump distance and DVT. Multivariable logistic regression was used to account for confounders.

Results

Between 2012 and 2018, 2341 patients underwent EVLA and complete data were available on 825 (35.2%) patients. All patients were scanned 6 weeks after procedure. Sixty-nine patients (8.4%) had flush occlusion, 3 patients (.4%) had extension into femoral or popliteal vein but not considered to be a DVT and 1 patient had a DVT. High BMI and increasing length of the pre-operative junction was associated with lower incidence of flush occlusion; higher rates of flush occlusions were noted in patients undergoing short saphenous vein (SSV) EVLT (OR 4.11, 95% CI 2.34-7.20; P < .001).

Conclusions

Consideration should be given to increase the intra-procedure laser tip junction to more than 2 cm particularly in patients undergoing SSV treatment to ensure that residual stump is sufficiently distal to SPJ and SFJ reducing risks of thrombus into the femoral or popliteal veins. Lower BMI may be associated with higher risk of this though the reasons for this are unclear.

Current state of the problem of risk assessment and prevention of venous thromboembolic complications after thermal obliteration of superficial veins

Venous thromboembolic complications (VTEO) after modern minimally invasive superficial vein interventions are an infrequent but very dramatic event. This article presents a review of the literature, covering the issues of prevalence, prognosis and pharmacological prevention of VTEO. The performed studies demonstrate that the incidence of symptomatic thrombotic complications after endovenous thermal obliteration does not exceed 0,5%, but taking into account asymptomatic thermally induced thromboses and subclinical occlusions of the muscular veins of the lower leg, this figure can exceed 10%. There is a high heterogeneity of the data, possibly due to differences in the individual risk of VTEO. The most validated tool for assessing the latter is the Caprini Scale, which has not been sufficiently studied in the surgical treatment of varicose veins. The administration of prophylactic doses of anticoagulants after thermal obliteration of saphenous veins is widely used in routine clinical practice, despite the lack of convincing evidence for the appropriateness of this approach. In recent years, the use of direct oral anticoagulants against the official instruction (off-label) has gained great popularity as an alternative to heparin. The largest evidence base has accumulated for the use of rivaroxaban 10 mg, which is associated with high efficacy and safety. Based on completed clinical trials, it is not possible to formulate unequivocal recommendations for prophylactic anticoagulant doses after thermal obliteration of superficial veins at this time. Additional studies are required to identify patients with an individually increased risk of thrombosis in whom prophylactic doses of anticoagulants may be of maximum benefit.

Thrombotic complications after radiofrequency and cyanoacrylate endovenous ablation: Outcomes of a multicenter real-world experience

OBJECTIVE

Chronic venous insufficiency (CVI) affects >40% of the U.S. population; thus, intervention for symptomatic venous disease comprises a large portion of many vascular practices. The treatment of superficial CVI has evolved from open surgical treatment to minimally invasive endovenous closure, including both thermal and nonthermal techniques. Thrombotic complications of thermal ablation have been well reported, with an overall complication rate of <2%. However, a paucity of high-powered, real-world data is available on the thrombotic outcomes of nonthermal techniques. In the present study, we compared the incidence of endovenous heat-induced thrombosis (EHIT) and endovenous glue-induced thrombosis (EGIT) in a large cohort of patients with CVI.

METHODS

A retrospective review was conducted at two tertiary-level institutions of patients who had undergone superficial endovenous ablation from 2018 to 2021. The patient demographics, comorbidities, and periprocedural outcomes were collected through medical record review. A Caprini risk assessment model score was assigned using the information available from the electronic medical records. The patients were categorized by procedure type (ClosureFast [Medtronic Inc, Minneapolis, MN] radiofrequency ablation [RFA] vs VenaSeal [Medtronic Inc] cyanoacrylate glue closure [CAG]). The primary end point was the incidence of EHIT or EGIT. The secondary end point was the incidence of deep vein thrombosis and/or pulmonary embolism.

RESULTS

A total of 803 patients had undergone 1096 procedures during the study period. Their mean age was 62 ± 15 years, and 67% were women. Of the 1096 procedures, 700 were RFA and 396 were CAG procedures, with a combined closure rate of 98% by postprocedure duplex ultrasound at 7 days. The average Caprini score was 5.2 ± 1.8 (RFA, 5.0; vs CAG, 5.4; P < .001). The incidence of EHIT and EGIT was 1.9% and 1.3%, respectively (P = .57). The deep vein thrombosis rate was 0.1% in the RFA cohort and 0.3% in the CAG cohort (P = .81). A comparative analysis of thermal vs nonthermal techniques was performed. A univariate analysis of the risk factors for EHIT and EGIT revealed no significant factors predisposing to thrombotic events.

CONCLUSIONS

The results from the present study have demonstrated the safety of RFA and CAG closure techniques for CVI, with lower thrombotic rates than previously reported. Further work might help to identify how these results can be achieved across all venous ablative techniques for CVI, even for patient populations with advanced venous disease and possibly a greater than average risk of thrombotic events.

Non-randomized comparative study of three methods for great saphenous vein ablation associated with mini-phlebectomy; 48 months clinical and sonographic outcome

Background

Varicose veins are one of the earliest clinical features of superficial venous insufficiency (SVI) of the lower limbs that affects around 20–40% of the population with a lot of burden on patients’ quality of life (QoL) and health systems if left untreated. They are defined as subcutaneous veins in the lower extremities which are dilated to ≥3 mm in diameter in the upright position and retrograde flow of >0.5 s in duration. (VVs) could occur in the great saphenous vein (GSV) or small saphenous vein (SSV) and/or in any of their tributaries.

Methods

A prospective non-randomized comparative study for three methods of treatment of varicose veins was conducted. All symptomatic varicose veins with Clinical, Etiological, Anatomical, Pathophysiological (CEAP) Clinical classes of 2 or greater and demonstrated venous reflux with a duration of 0.5 s or greater on duplex ultrasound imaging GSV larger than 10 mm in diameter by duplex ultrasound were included.

Results

A total of 150 patients with 183 legs in all three groups are treated. The mean age of the patients in all groups was comparable (37.32) years, and a total of 87% were women. Demographic and preoperative clinical features, presentations, and anatomic characteristics were comparable in all groups. Disfigurement was the main presenting complaint in all. All postoperative complications were significantly higher in the group of surgery over 48 months of follow up the degree of satisfaction measured by VCSS score was highest among the RFA group followed by the EVLA group.

Conclusion

The results of our study suggest that the long-term results of endovenous thermal ablation methods (EVLA, RFA) are superior to open surgery for the management of varicose veins, with the RFA group showing better results in terms of improvement in QoL based on VCSS compared to the EVLA group.

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Varicose veins are a very common disorder in all communities.

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A very wide variety of treatment options are available.

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The ideal method of treatment is still debatable.

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Our research paper tries to answer the question of what is the most suitable method of treatment for varicose veins.

Endovenous laser ablation using laser systems emitting at wavelengths > 1900 nm: a systematic review

The aim of this systematic review was to summarize the currently available literature reporting clinical application of endovenous laser ablation (EVLA) by means of laser systems emitting at wavelengths > 1900 nm, pertaining dosimetry, intraoperative parameters, postoperative outcomes, and efficacy based on occlusion rates, recanalization, and postoperative complications. A literature search was conducted in PubMed, Cochrane Library, Embase, OVID, and Web of Science for publications since the year 2000 until December 2021. Case series, prospective trials, retrospective studies, and randomized controlled trials describing the application of a 1920/1940-nm wavelength laser for EVLA in humans with a minimum of one postoperative follow-up visit were included in the study. Four case series and one randomized controlled trial with a total of 509 EVLA procedures (396 great saphenous veins and 113 small saphenous veins) were identified, meeting the inclusion criteria. The studies were heterogenous in their documentation, EVLA, and duplex ultrasound protocol and result reporting. Overall, the applied average cumulative LEED values ranged from 17.8 to 53 J/cm. Complications observed were pigmentation (0-9.75%), paresthesia (2.5-7.3%), thrombophlebitis (0-5%), EHIT Class 2 (2.26-2.4%), and EHIT Class 1 (1.2-2.4%). Four cases of recanalizations were observed in one study cohort within the first month after treatment. Follow-up at 12 months was available for 3 studies (procedures n = 218) with recanalizations in 8 limbs. Follow-up at 24-36 months was available for 2 studies (procedures n = 126) showing recanalizations in 5 limbs. Recanalizations were asymptomatic and incidental findings on follow-up duplex ultrasound. Pooled occlusion rates were 99.2% at 1 M, 96.3% at 12 M, and 96% at 24 M. Overall, patients undergoing EVLA with long wavelength laser systems > 1900 nm show high occlusion rates, significant improvement in VCSS, low postoperative complication rate, low pain levels, low analgesic requirement, and early convalescence. Apart from persistent paresthesia, all the complications regressed spontaneously within 6 months. EVLA by means of 1920/1940 nm shows promising clinical results with high efficacy and low complication rates. Heterogeneity still exists regarding ideal protocol for duplex ultrasound examination and documentation of anatomical parameters (e.g., vein diameter, ideal stump length and status of accessory veins) and light dosimetry for EVLA.

Efficacy and safety of endovenous microwave ablation versus laser ablation for great saphenous vein varicosis: study protocol for a multicentre, randomised controlled non-inferiority trial

INTRODUCTION

Endovenous microwave ablation (EMA) is a relatively novel thermal ablation treatment for great saphenous vein (GSV) varicosis, and its efficacy and safety are rarely reported. This study aims to explore whether EMA can be comparable to endovenous laser ablation (EVLA), which is a widely used thermal ablation treatment in clinical practice.

METHODS AND ANALYSIS

This is a multicentre, randomised controlled non-inferiority trial to compare the efficacy and safety of EMA and EVLA in patients with GSV varicosis. We will recruit 180 patients in 6 centres and randomly assign them into treatment group (EMA group) and control group (EVLA group) in a 1:1 ratio. The patients will return to the hospitals at 7 days, 3 months, 6 months and 12 months, and will be called at 1 month after the treatment for follow-up visits. The primary outcome is the occlusion rate of GSV immediately, at 6 months, and at 12 months after the treatment. The secondary outcomes are Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) Score, operation time and instrument performance evaluation.

ETHICS AND DISSEMINATION

This protocol has been approved by the Clinical Trial Ethics Committee of Beijing Hospital (2020BJYYEC-126-02), Peking Union Medical College Hospital (KS2020393), Beijing Tsinghua Changgung Hospital (No.20279-2-02), Beijing Luhe Hospital.Capital Medical University (2020-LHYW-030-01), the First Hospital of Hebei Medical University (No.2020249), and the First Affiliated Hospital of Xi'an Jiaotong University (XJTU1AF2021LSY-12). The trial results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04726124.

Chemothromboprophylaxis in varicose vein surgery. A systematic review

INTRODUCTION

Venous Thromboembolism (VTE) is a possible complication after varicose vein surgery, reported after both open and endovascular interventions. Nonetheless, there are no internationally accepted recommendations regarding postoperative VTE prevention strategies, with some authors advocating for its use, while others recommend against it. This study aims to systematically review current evidence on the efficacy and safety of chemothromboprophylactic strategies after varicose vein surgery.

EVIDENCE ACQUISITION

A literature search was performed on the MEDLINE, Scopus, SciELO and Web of Science databases, which returned 532 studies. Ten studies were included. Data were extracted using piloted forms.

EVIDENCE SYNTHESIS

A total of 6929 patients were included for analysis, out of which 70.4% were treated by open surgery (n=4878) and 29.6% by endovenous procedures (n=2051; 79.1% EVLA; 20.9% RFA). VTE chemothromboprophylaxis was performed in 76.3% of the patients (n=5284), from which 62.5% were treated by open surgery (n=3301) and 37.5% by endovenous interventions (n=1983). Among those treated by open surgery, reported deep venous thrombosis (DVT) rates ranged between 0-6.25%, while pulmonary embolism (PE) was reported in 0-0.07% of the cases. Regarding endovenous interventions, EHIT and DVT rates ranged between 0-2.5% and 0-0.9%, respectively, with no cases of PE described. The remaining 23.7% of the patients did not underwent VTE chemothromboprophylaxis (n=1645), with DVT and PE rates after open surgery ranging between 0-5.17% and 0-1.48%, respectively. Only one study reported thrombotic complications after endovenous interventions in this subgroup of patients, with post-operative EHIT rates of 7.3%, and no information regarding PE or DVT. Bleeding complications were higher in patients undergoing chemothromboprophylaxis (0-10.2%) when compared to those who did not (0-0.18%), and were more frequent after endovenous interventions (0-10.2% versus 0-0.75% after open surgery).

CONCLUSIONS

VTE is a possible complication after both open and endovascular varicose vein procedures, although overall VTE complications occur less frequently after endovascular interventions. There's a clear heterogeneity regarding peri and postoperative chemoprophylaxis regimens used. Further studies are required to stratify risk factors and indications for chemothromboprophylaxis after varicose vein surgery.

Mechanochemical endovenous ablation of the saphenous vein: a look at contemporary outcomes

OBJECTIVES

Endovenous ablation techniques have replaced greater saphenous vein (GSV) ligation and stripping for treatment of venous insufficiency. Our objective was to investigate our initial procedural experience and clinical presentation of patients undergoing mechanochemical ablation (MOCA) at a single institution. We hypothesized that closure level and success rate improved over time and were comparable to other endovenous ablation techniques.

METHODS

We retrospectively reviewed all MOCA procedures performed at the West Los Angeles Veterans Affairs Hospital from 2015-2020. Variables included CEAP and VCSS scores, patient symptoms, post procedure duplex ultrasound, closure level, and need for anticoagulation. Success was defined as GSV thrombosis on initial post procedure duplex ultrasound. Procedure associated extension of thrombus into the deep veins was defined using the American Venous Forum (AVF) endothermal heat induced thrombosis classification.

RESULTS

104 venous ablation procedures were performed on 86 patients. Eleven (12.8%) patients received bilateral interventions, and six (7%) patients had asynchronous interventions on the same leg. The average age was 58.4 years (SD 12) and 93% were male. Pre-procedural symptoms included pain (102, 98.1%), varicose veins (87, 83.7%), edema (58, 55.8%), and active ulcers (19, 18.3%). A CEAP category of C2 was the most common indication (34.6%), followed by C3 (22.1%) and C6 (21.2%). Forty-five (43.2%) patients had deep system reflux, and 53% had concomitant phlebectomies. Average VCSS score was 7.5 (SD 3.5).We observed a GSV ablation rate of 92.7% (n=89) in the 96 procedures which had post-procedure follow up, with no temporal evidence of a learning curve. On post procedure duplex of the 89 technically successful ablations, 77 (86.5%) patients had AVF EHIT level 1 closure, three (3.4%) had level 2 closure, eight (8.9%) had level 3 closure, and one had a level 4 closure. Fourteen (15.7%) patients were newly started on anticoagulation for an average of 33.2 days (SD 34.1). Of the 19 legs treated for active venous ulcers, 13 (68.4%) had improvement or resolution of their venous ulcers. No pulmonary embolic complications were reported.

CONCLUSION

We observed a successful GSV thrombosis rate of 92.7% using MOCA without evidence of a learning curve and comparable to that reported in the literature. The rate of thrombus extension into the deep veins was 14.6%, with no adverse effects associated with anticoagulation or clinically significant sequelae of AVF EHIT level 2 or greater. Comparisons with MOCA associated thrombus extension into deep veins in the literature are limited as post procedure screening duplex are not standard of care. However, we demonstrated that MOCA ablation of the GSV is a safe procedure that may be performed with good technical success.

A systematic review and meta-analysis of mechanochemical endovenous ablation using Flebogrif for varicose veins: A summary of evidence

OBJECTIVE

In the present study, we reviewed and analyzed the currently available data on the Flebogrif device (Balton, Warsaw, Poland) to define its role in the global varicose vein treatment devices market.

METHODS

A systematic literature search was performed in MEDLINE, Embase, and the Cochrane Library. Studies were eligible if they had included patients treated using the Flebogrif for saphenous vein incompetence, had been reported in English, and had the full text available. The methodologic quality of the studies was assessed using the methodologic index for nonrandomized studies (MINORS) score. A random effects model was used to estimate the primary outcome of anatomic success, defined as the occlusion rate of the treated vein. The estimates are reported with the 95% confidence intervals (CIs). The secondary outcomes were clinical success, complication rate, pain during and after the procedure, and time to return to work.

RESULTS

A total of 392 patients are reported in the included studies. A total of 348 legs were treated with Flebogrif (in 6 patients both legs). A total of 50 patients/legs were treated with EVLA (Ammollo et al.). In conclusion, 348 Flebogrif procedures are performed in 392 patients. Four studies reported the 3-month anatomic success, and three studies reported the 12-month anatomic success. The pooled 3-month anatomic success rate was 95.6% (95% CI, 93.2%-98.0%). The 12-month anatomic success rate was 93.2% (95% CI, 90.3%-96.1%). The only major complication reported within 3 months was deep vein thrombosis, which developed in 0.3% of the patients. The minor complications of thrombophlebitis and hyperpigmentation had occurred in 13.3% to 14.5% and 3.3% to 10.0% of patients, respectively, within 3 months. The methodologic quality of the included studies was moderate.

CONCLUSIONS

Mechanochemical ablation using the Flebogrif device is a safe and well-tolerated procedure for the treatment of saphenous vein insufficiency. However, well-designed studies of sufficient sample size and follow-up are required to compare the effectiveness with other endovenous treatment modalities and define the definitive role of the Flebogrif device.

Rivaroxaban for the prevention of venous thromboembolism after radiofrequency ablation of saphenous veins concomitant with miniphlebectomy, sclerotherapy, or no treatment of varicose tributaries

OBJECTIVE

To assess the efficacy and safety of once-daily 10 mg rivaroxaban for venous thromboembolism prophylaxis after ClosureFast radiofrequency ablation (RFA) of saphenous veins.

METHOD

The medical records of patients, who had a Caprini score of ≥3, underwent RFA, received prophylactic rivaroxaban for five days, and completed follow up at one month were reviewed for efficacy (a combination of endovenous heat-induced thrombosis [EHIT] grade of 2-4, any symptomatic or asymptomatic deep vein thrombosis [DVT], and symptomatic pulmonary embolism [PE]) and safety (a combination of major and clinically relevant non-major [CRNM] bleeding) outcomes.

RESULTS

The results of RFA for 248 great saphenous and 24 small saphenous veins with the concomitant miniphlebectomy (63.8%) and sclerotherapy (16.5%) were analyzed. The primary efficacy outcome occurred in 5 of 218 (2.3%; 95%CI, 1.0-5.3%) patients: three EHITs and two symptomatic DVTs. The CRNM bleeding was reported in two patients (0.9%; 95% CI, 0.2-3.3%). No difference was observed in comparison with 79 similar patients who received 40 mg of subcutaneous enoxaparin during the same time period.

CONCLUSION

Once-daily 10 mg rivaroxaban is suitable for VTE prophylaxis after RFA of saphenous veins.

Current status of endothermal heat induced thrombosis

BACKGROUND

There remain many questions regarding the pathophysiology and risk factors for endothermal heat induced thrombosis formation. Moreover, there are a paucity of data on the timing of its occurrence, and there has been no consensus regarding for its treatment. The purpose of this review is to summarize the current knowledge on the pathophysiology, risk factors and treatment strategies for endothermal heat induced thrombosis.

METHODS

The PubMed database was searched from 2001 to present for endothermal heat induced thrombosis, EHIT, deep vein thrombosis, chronic venous insufficiency, varicose veins, endovenous laser and radiofrequency ablation (treatment). All relevant articles identified by the authors mentioning endothermal heat induced thrombosis were included in this review.

RESULTS

A multitude of risk factors, several pathophysiological hypotheses and different treatment strategies are described in the literature.

CONCLUSIONS

Endothermal heat induced thrombosis is marginally understood. There remains a theoretical risk for significant venous thromboembolic complications. With the new uniform classification of EHIT (American Venous Forum), healthcare providers should continue to investigate the nature of this event.

A narrative review on the epidemiology, prevention, and treatment of venous thromboembolic events in the context of chronic venous disease

OBJECTIVE

Chronic venous disease (CVD) describes a spectrum of conditions associated with venous hypertension. The association between various CVD etiologies and the subsequent risk of venous thromboembolism (VTE), such as deep vein thrombosis or pulmonary embolism, is a topic of considerable clinical interest. The aims of the present review were to characterize the risk of VTE according to the CVD etiology and to determine the optimal anticoagulation strategy for the treatment or prevention of VTE in patients with CVD.

METHODS

An extensive search of the available surgical and medical data was conducted in PubMed and Google Scholar. We searched for the following terms and other related terms to identify relevant studies: CVD, chronic venous insufficiency, varicose veins, post-thrombotic syndrome (PTS), anticoagulation, venous thromboembolism, and venous disease scoring systems (eg, CEAP [clinical, etiology, anatomic, pathophysiology], Villalta, Ginsberg, venous clinical severity score). The identified studies included randomized control trials, retrospective and prospective observational studies, narrative and systematic reviews, case reports, and case series that contributed to the proposed aims. The ClinicalTrials.gov database was also queried to identify any relevant ongoing clinical trials.

RESULTS

Congenital CVD carries a heightened risk of VTE, although few higher level studies are available to inform on this topic or on the appropriate anticoagulation strategies for these patients. Noncongenital CVD seems to carry a heightened risk of VTE, although few studies have adequately differentiated between primary and secondary etiologies. Varicose veins are a risk factor for primary VTE but might not be associated with an increased risk of recurrent VTE. In the hospital setting, patients with varicosities should be provided thromboprophylaxis. In the setting of varicose vein intervention, high-risk patients should be identified using risk assessment models and receive thromboprophylaxis. The risk of recurrent VTE in the setting of PTS is unclear but indefinite anticoagulation is not currently indicated. For patients with PTS, residual vein thrombosis might be an indicator of when anticoagulation can be safely stopped, although practical limitations to its application exist.

CONCLUSIONS

CVD is associated with an increased risk of VTE. Few studies have differentiated between classes of CVD using a standardized method and have assessed the efficacy of anticoagulation prophylaxis against or treatment of VTE. Additional studies are needed to determine the optimal therapy for preventing and treating VTE in patients with active concurrent CVD.

Thrombus Extension after Great Saphenous Vein Mechanochemical Ablation

BACKGROUND

The objective of this study is to examine factors associated with thrombus extension after early experience with mechanochemical ablation, which combines mechanical damage to the venous endothelium with infusion of a sclerosant.

METHODS

A retrospective review was performed of patients who underwent mechanochemical ablation to treat saphenous vein insufficiency in the thigh including the saphenofemoral junction. Data abstracted included patient demographics, procedural details, and postprocedural outcomes. Thrombus extension was determined by postprocedural duplex ultrasound and classified as flush closure with the femoral vein and any extension of thrombus into the femoral vein.

RESULTS

Seventy-three patients met inclusion criteria. The mean age of the population was 60, 17.8% were female, and the mean body mass index (BMI) was 30.7. Seven (9.6%) patients who underwent mechanochemical ablation experienced saphenous vein closure flush with the femoral vein. Eleven (15%) patients experience extension of thrombus to less than 50% of the diameter of the femoral vein and one patient experienced complete thrombosis of the femoral vein. There was no significant difference in age, sex, or comprehensive classification system for chronic venous disorders between the group with thrombus extension and the group without, with the exception of BMI. The mean BMI in the group with thrombus extension was 26.8 vs. 32 in the group without (P = 0.02). There was no significant difference between the 2 groups in sclerosant volume used, distance between catheter tip and SFJ, and mean diameter of GSV in the thigh.

CONCLUSIONS

In this cohort, the incidence of thrombus extension into the femoral vein with mechanochemical ablation was high relative to rates of thrombus extension associated with reported rates of thermal ablation. Further investigation with larger cohorts, and standardized reporting is required to characterize the true rate of thrombus extension after mechanochemical ablation and identify maneuvers which may prevent thrombus extension.

Treatment of Varicose Veins Affects the Incidences of Venous Thromboembolism and Peripheral Artery Disease

[Figure: see text].

Systematic review on the incidence and management of endovenous heat-induced thrombosis following endovenous thermal ablation of the great saphenous vein

OBJECTIVE

A systematic review and meta-analysis was performed to determine the incidence of endovenous heat-induced thrombosis (EHIT) and evaluate its management after endovenous thermal ablation of the great saphenous vein (GSV).

METHODS

MEDLINE and Embase were searched for studies with at least 100 patients who underwent great saphenous vein endovenous thermal ablation and had duplex ultrasound follow-up within 30 days. Data were gathered on the incidence of thrombotic complications and on the management of cases of EHIT. The primary outcome for the meta-analysis was EHIT types 2 to 4 and secondary outcomes were deep venous thrombotic events (which we defined as types 2-4 EHIT plus deep vein thrombosis [DVT]), DVT, and pulmonary embolism (PE). Pooled proportions were calculated using random effects modelling.

RESULTS

We included 75 studies (23,265 patients). EHIT types 2 to 4 occurred in 1.27% of cases (95% confidence interval [CI], 0.74%-1.93%). Deep venous thrombotic events occurred in 1.59% (95% CI, 0.95%-2.4%). DVT occurred in 0.28% (95% CI, 0.18%-0.4%). Pulmonary embolism occurred in 0.11% (95% CI, 0.06%-0.18%). Of the 75 studies, 24 gave a description of the management strategy and outcomes for EHIT and there was inconsistency regarding its management. Asymmetrical funnel plots of studies that reported incidence of EHIT 2 to 4 and DVT suggest publication bias.

CONCLUSIONS

The recently published guidelines on EHIT from the Society for Vascular Surgery/American Venous Forum provide a framework to direct clinical decision-making. EHIT and other thrombotic complications occur infrequently and have a benign course.

Randomized Controlled Trial of Compression After Endovenous Thermal Ablation of Varicose Veins (COMETA Trial)

BACKGROUND

The 21st century has witnessed a rise in the use of endovenous thermal ablation. Being highly clinically and cost-effective and improving the quality of life of patients, they are now considered to be the "gold-standard" treatment for varicose veins. Post-intervention management, especially in terms of postoperative compression, however, remains unclear. As a result, a randomized study was undertaken to investigate the effects of wearing compression stockings after varicose vein treatment.

METHOD

Patients with saphenous vein reflux undergoing treatment with endothermal ablation (with or without concurrent phlebectomies) were randomized to receive either 7 days of compression stockings or no stockings. The primary outcome measure for this study was the pain score over the first 10 postoperative days. The pain scores, clinical score, time to return to normal activities, and ecchymosis were assessed. Patients were followed-up at 2 weeks and 6 months post-ablation.

RESULTS

In total, 206 patients were randomized, 49% of them to the compression group. The mean age was 49.7 (±16) years and approximately 51% of the population was male. The median pain score in the compression group using a visual analog scale was significantly lower on days 2-5, compared to the no compression group. Those having concurrent phlebectomies and compression stockings also had significantly better pain scores on days 1-3, day 5, and day 7. Improvement in the median venous clinical severity score was noted at 6-month follow-up, but this was not significant. No difference in the generic- or disease-specific quality of life was observed and the time to return to activities was similar. There were no differences in the degree of ecchymosis between the 2 groups and both groups had similar occlusion rates.

CONCLUSIONS

These results indicate that wearing compression stockings after endothermal ablation is advantageous in the first few days after treatment and is especially beneficial for those having concurrent phlebectomies.

The Analysis of Selected Morphological and Hemodynamic Parameters of the Venous System and Their Presumable Impact on the Risk of Recurrence after Varicose Vein Treatment

INTRODUCTION

The current treatment of venous disease is focused on reflux elimination in main venous trunks, especially in the saphenous vein. However, a high recurrence rate, independent of the method of treatment, suggests that the reason of low effectiveness may be due to a strategy focused on symptoms, without considering their origin.

METHOD

The aim of study was the comparison of retrospective data from 535 women with venous disease, either after treatment (n = 183) or not treated before (n = 352). The analysis concerned clinical symptoms and the results of the extended diagnostics, including the examination of the lower limb, pelvic and abdominal veins either using duplex-doppler ultrasound as well as venography with computed tomography or magnetic resonance.

RESULTS

The comparison of selected venous system parameters revealed more advanced disease progression in previously treated patients, compared to non-treated individuals (e.g., ipsi- or bilateral incompetence of sapheno-phemoral junction-29.5% vs. 20.4%, at P < 0.05 and 13.6% vs. 7.7% at P < 0.05, respectively). This difference could be explained by post-treatment alterations in the venous system, an older age and the higher number of pregnancies in the recurrence group. However, both groups did not differ in regards to the symptoms of pelvic venous insufficiency or the frequency of relevant variants/abnormalities in venous system.

CONCLUSIONS

Based on the aforementioned findings, we postulate the revision of treatment strategy, which should consider abdominal and pelvic veins as the source of reflux in many female subjects.

Feasibility and potential significance of prophylactic ablation of the major ascending tributaries in endovenous laser ablation (EVLA) of the great saphenous vein: A case series

Background

Recurrent varicosities after endovascular laser ablation (EVLA) of the great saphenous vein (GSV) are frequently due to varicose transformed, initially unsealed major ascending tributaries of the saphenofemoral junction (SFJ). Preventive ablation of these veins, especially the anterior accessory saphenous vein, is discussed as an option, along with flush occlusion of the GSV. However, few related data exist to date.

Methods

A consecutive case series of 278 EVLA procedures of the GSV for primary varicosis in 213 patients between May and December 2019 was retrospectively reviewed. The ablations were performed with a 1470 nm dual-ring radial laser and always included flush occlusion of the GSV, and concomitant ablation of its highest ascending tributaries by additional cannulation and ablation when this seemed anatomically appropriate. The initial technical success, comprising occlusion of the GSV and its major tributaries, was set as the primary endpoint. Possible determinants were explored using downstream multiple logistic regression analysis.

Results

The early technical success was 92.8%, with the GSV occluded in 99.6% and the highest ascending SFJ tributary, if present, in 92.4%. Additional ablations of ascending tributaries were performed in 171 cases (61.5%), the latter being associated with success (OR 10.39; 95% CI [3.420–36.15]; p < 0.0001). Presence of anterior as opposed to posterior accessory saphenous vein was another positive predictor (OR 3.959; 95% CI [1.142–13,73]; p = 0.027), while a confluence of the tributary in the immediate proximity to the SFJ had a negative impact (OR 0.2253; 95% CI [0.05456–0.7681]; p = 0.0253). An endothermal heat-induced thrombosis (EHIT) ≥ grade 2 was observed in three cases (1.1%).

Conclusions

A co-treatment of the tributaries is feasible and could improve the technical success of EVLA if a prophylactic closure of these veins is desired, especially if their distance to the SFJ is short. Its effect on the recurrence rate needs further research.

Endovenous Thermal Ablation for a Varicose Vein Patient with Factor XII Deficiency: A Case Report

Factor XII (FXII) deficiency is a rare coagulation disorder, and its potential relationship with venous thrombosis was reported. Here we present a case of a 67-year-old woman with FXII deficiency who successfully underwent endovenous thermal ablation (ETA) for primary varicose vein due to the incompetent great saphenous vein (GSV). The FXII deficiency was revealed through preoperative examinations, and the patient underwent ETA as a day surgery. For prophylaxis of thrombosis, she received compression therapy alone. Her postoperative course was uneventful, without any kind of thrombosis. In the presence of FXII deficiency, ETA could be safely performed.

Iatrogenic Arteriovenous Fistula Formation after Endovenous Laser Treatment Resulting in High-output Cardiac Failure: A Case Report and Review of the Literature

Formation of a clinically significant iatrogenic arteriovenous fistula after endovenous laser treatment of the great saphenous vein is an extremely rare complication. Because of the infrequency of reported cases, there is no clear consensus on how to best manage this complication. We present a unique case of an iatrogenic high-output superficial femoral artery-common femoral vein fistula resulting in right heart failure and a distal deep vein thrombosis. Deployment of a covered arterial stent graft resulted in resolution of the arteriovenous fistula and high-output cardiac state. Clinically significant arteriovenous fistulas resulting from inadvertent vessel injury during endovenous laser treatment appear to be amenable to percutaneous endovascular interventions. During these challenging endovascular cases, intravascular ultrasonography can be used to help delineate the morphology of the fistula tract and obtain vessel measurements to ensure accurate endoprosthesis sizing and placement.