Endovenous Laser Treatment of Incompetent Below-Knee Great Saphenous Veins

Treatment of varicose great saphenous vein with endovenous laser alone or combined with eco-guided foam sclerotherapy: A randomized controlled trial

Objectives: This study compares Endovenous Laser Ablation (EVLA) alone versus combined with ultrasound-guided foam sclerotherapy (UGFS) for Great Saphenous Vein (GSV) insufficiency. Methods: Sixty patients were randomly allocated to EVLA or EVLA-UGFS groups which focused on GSV occlusion rates, complications, additional treatments, and quality of life (QoL) changes. Results: Among 55 participants, the EVLA group had higher 12-month occlusion rates (92.3% vs. 75.8%, p = 0.11). Nervous injury (NI) was rarer in EVLA-UGFS (3.4% vs. 23.1%, p = 0.04). No significant difference in other complication rates (p > 0.05). QoL improved in both groups (p < 0.001). EVLA-UGFS required more subsequent procedures (24.1% vs. 7.7%, p = 0.03). Conclusions: EVLA and EVLA-UGFS effectively treat GSV insufficiency, enhancing QoL. The combined method reduces NI risk but may require more follow-up procedures.

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.

A systematic review of the treatment of residual below the knee venous reflux after endovenous thermal ablation of the great saphenous vein

BACKGROUND

Great saphenous vein (GSV) antireflux procedures have evolved during the past few decades to reduce elevated venous pressure. Untreated reflux in the below knee (BK) GSV (BK-GSV) can lead to persistent venous hypertension and deterioration of the venous circulation. The purpose of the present systematic review was to study the influence of BK-GSV intervention on venous disease progression.

METHODS

A search was conducted, adhering to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The PubMed and Embase databases were searched and cross-referenced. Studies were included if they had met the inclusion criterion of BK-GSV disease as a primary or secondary outcome. Two of the authors independently determined the eligibility and extracted the relevant data. RevMan, version 5.3 (Cochrane Training, London, UK), and SPSS (IBM Corp, Armonk, NY) were used for statistical computation.

RESULTS

Fifteen studies that had assessed BK-GSV reflux recurrence after ablative intervention were included in our analysis. Of the 15 studies, 6 had assessed patients after above knee (AK) high ligation and stripping (HLS), 7 after AK endovenous laser ablation (AK-EVLA), and 2 after AK- and BK-EVLA (AK+BK EVLA). In total, 525 limbs had undergone HLS, 696 AK-EVLA, and 147 AK+BK EVLA. AK+BK EVLA was associated with significantly lower odds of BK-GSV reflux recurrence compared with AK-EVLA only (odds ratio [OR], 0.1857; 95% confidence interval [CI], 0.076-0.4734; P < .0001). Although the odds of recurrent BK-GSV reflux appeared to be greater for patients who had undergone AK-HLS compared with AK+BK HLS, the difference was not statistically significant (OR, 0.62; CI, 0.27-1.43; P = .69). Finally, no statistically significant difference was observed in BK-GSV reflux recurrence between patients receiving AK-EVLA and those receiving AK-HLS (OR, 0.85; 95% CI, 0.52-1.39; P = .31).

CONCLUSIONS

Axial hydrostatic reflux from the groin to ankle is best controlled with AK+BK-GSV ablation. However, GSV ablation can result in saphenous nerve injury. For C4 to C6 disease, more aggressive treatment of the AK+BK-GSV is justified if the duplex ultrasound findings demonstrate groin to ankle reflux. Thermal ablation of the BK-GSV has a lower incidence of saphenous nerve injury than does BK saphenous stripping. More randomized controlled trials are needed to answer questions involving disease recurrence and the best techniques to mitigate these recurrences.

Persistent below-knee great saphenous vein reflux after above-knee endovenous laser ablation with 1470-nm laser: a prospective study

Background

In endovenous laser ablation (EVLA), the great saphenous vein (GSV) is usually ablated from the knee to the groin, with no treatment of the below-knee segment regardless of its reflux status. However, persistent below-knee GSV reflux appears to be responsible for residual varicosities and symptoms of venous disease.

Objectives

To evaluate clinical and duplex ultrasound (DUS) outcomes of the below-knee segment of the GSV after above-knee EVLA associated with conventional surgical treatment of varicosities and incompetent perforating veins.

Methods

Thirty-six patients (59 GSVs) were distributed into 2 groups, a control group (26 GSVs with normal below-knee flow on DUS) and a test group (33 GSVs with below-knee reflux). Above-knee EVLA was performed with a 1470-nm bare-fiber diode laser and supplemented with phlebectomies of varicose tributaries and insufficient perforating-communicating veins through mini-incisions. Follow-up DUS, clinical evaluation using the venous clinical severity score (VCSS), and evaluation of complications were performed at 3-5 days after the procedure and at 1, 6, and 12 months.

Results

Mean patient age was 45 years, and 31 patients were women (86.12%). VCSS improved in both groups. Most patients in the test group exhibited normalization of reflux, with normal flow at the beginning of follow-up (88.33% of GSVs at 3-5 days and 70% at 1 month). However, in many of these patients reflux eventually returned (56.67% of GSVs at 6 months and 70% at 1 year).

Conclusions

These data suggest that reflux in the below-knee segment of the GSV was not influenced by the treatment performed.

Clinical and technical outcomes from a randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous varicose veins

Background

This report describes the clinical effectiveness and recurrence rates from a randomized trial of endovenous laser ablation (EVLA) and surgery for varicose veins.

Methods

Some 280 patients were randomized equally using sealed opaque envelopes to two parallel groups: surgery and EVLA. Inclusion criteria included symptomatic disease secondary to primary, unilateral, isolated saphenofemoral junction incompetence, leading to reflux into the great saphenous vein (GSV). Outcomes were: technical success, recurrent varicose veins on clinical examination, patterns of reflux on duplex ultrasound examination, and the effect of recurrence on quality of life, assessed by the Aberdeen Varicose Vein Questionnaire (AVVQ). Assessments were at 1, 6, 12 and 52 weeks after the procedure.

Results

Initial technical success was greater following EVLA: 99·3 versus 92·4 per cent (P = 0·005). Surgical failures related mainly to an inability to strip the above-knee GSV. The clinical recurrence rate at 1 year was lower after EVLA: 4·0 versus 20·4 per cent (P &lt; 0·001). The number of patients needed to treat with EVLA rather than surgery to avoid one recurrence at 1 year was 6·3 (95 per cent confidence interval 4·0 to 12·5). Twelve of 23 surgical recurrences were related to an incompetent below-knee GSV and ten to neovascularization. Of five recurrences after EVLA, two were related to neoreflux in the groin tributaries and one to recanalization. Clinical recurrence was associated with worse AVVQ scores (P &lt; 0·001).

Conclusion

EVLA treatment had lower rates of clinical recurrence than conventional surgery in the short term. Registration number: NCT00759434 (http://www.clinicaltrials.gov).

The clinical significance of below-knee great saphenous vein reflux following endovenous laser ablation of above-knee great saphenous vein

Aims

The standard technique for endovenous laser ablation (EVLA) for varicose veins due to great saphenous vein (GSV) reflux involves obliteration of the above-knee (AK) GSV. This study assesses the significance of persistent below-knee (BK) GSV reflux following such therapy.

Methods

Sixty-nine limbs (64 patients) with varicosities and GSV reflux underwent AK-EVLA. Post treatment, GSV reflux (ultrasound: six, 12 weeks) and Aberdeen varicose vein severity scores (AVVSS, 12 weeks) were assessed, and residual varicosities treated with foam sclerotherapy (six weeks).

Results

The untreated BK-GSV remained patent in all limbs. Ultrasound showed normal antegrade flow in 34/69 (49%, Group A), flash reflux <1 s in 7/69 (10%, Group B) and >1 s reflux in 28/69 (41%, Group C). Although AVVSS improved in all groups ( P < 0.001): A: 14.6 (8.4–19.3) versus 2.8 (0.5–4.4), B: 13.9 (7.5–20.1) versus 3.7 (2.1–6.8), C: 15.1 (8.9–22.5) versus 8.1 (5.3–12.6) the improvement was less in Group C ( P < 0.001 versus A and B) and was associated with a greater requirement (A: 4/34 [12%]; B: 1/7 [14%]; C: 25/28 [89%]) for sclerotherapy (persisting varicosities) ( P < 0.001).

Conclusion

Although AK-GSV EVLA improves symptoms regardless of persisting BK reflux, the latter appears responsible for residual symptoms and a greater need for sclerotherapy for residual varicosities.