Recommended Reporting Standards for Endovenous Ablation for the Treatment of Venous Insufficiency: Joint Statement of the American Venous Forum and the Society of Interventional Radiology

Efficacy and safety of polidocanol in the treatment of varicose veins of lower extremities: A protocol for systematic review and meta-analysis

BACKGROUND

The varicose veins of the lower extremities showed earthworm-like dilatation and venous protrusion of the lower extremities. Polidocanol foam sclerotherapy, as a minimally invasive treatment with rapid recovery, less trauma and not easy to relapse, has achieved good results in clinical, but it is lack of evidence-based medicine. The purpose of this study is to evaluate the efficacy and safety of polidocanol in the treatment of varicose veins of the lower extremities by meta-analysis.

METHOD

Chinese National Knowledge Infrastructure, Wanfang Database, Chinese Scientifific Journals Database, China Biology Medicine disc, PubMed, EMBASE database, Web of Science, and Cochrane Library will be used as search sources to conduct for randomized controlled trials of polidocanol in the treatment of varicose veins of lower extremities. The search time is set from the establishment of the database in December 2020 in this study. Two researchers independently extract, delete files, extract data and evaluate the quality. Revman software version 5.3 will be used for statistical analysis of data.

RESULT

In this study, the efficacy and safety of polidocanol in the treatment of varicose veins of the lower extremities will be evaluated in terms of total effective rate, incidence of complications and recurrence rate.

CONCLUSION

This study will provide reliable evidence-based evidence for the clinical application of polidocanol in the treatment of varicose veins of lower extremities.

ETHICS AND DISSEMINATION

Private information from individuals will not be published. This systematic review also does not involve endangering participant rights. Ethical approval will not be required. The results may be published in a peer-reviewed journal or disseminated at relevant conferences.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/AUR4X.

Endovascular management of inferior vena cava filter thrombotic occlusion

Objective Inferior vena cava occlusion is a potentially life-threatening complication related to caval filters. We present our experience with filter-induced inferior vena cava occlusion in order to assess the feasibility, safety, and effectiveness of endovascular management. Methods A retrospective review of all patients undergoing inferior vena cava filter placement over a 60-month study period was performed. From this cohort, a total of 10 cases of inferior vena cava occlusion after filter placement were identified. Demographics, clinical data, procedures, and outcomes were extracted. Patients were followed to the last clinic visit or until they died. Results One-hundred eighty filters were placed by our group practice during the study period. Of those, a total of 10 patients were identified. Overall, there were 7 males; the mean age was 57.1 years (25-78 years). The median time between inferior vena cava filter placement and filter occlusion was 105 days (range 5-4745 days). All patients were clinically symptomatic at the time of their presentation. Nine out of 10 patients were successfully managed endovascularly. Trellis™-8 thrombectomy was the most common endovascular strategy performed ( n = 9). Four patients had balloon angioplasty, two of those with stent placement for chronically occluded inferior vena cava/iliac veins. No thromboembolic complications developed during a median follow-up period of 233 days (range 4-1083 days). Conclusions Endovascular management of inferior vena cava occlusion is feasible, safe, and effective in decreasing thrombus burden in the presence of an inferior vena cava filter. Further studies evaluating long-term inferior vena cava patency and optimal surveillance regimen after endovascular management of filter-related inferior vena cava occlusion are warranted.

Venous disease patient registries available in the United States

Patient registries are beneficial in that they allow the collection of prospective data focused on a specific medical issue. These registries give providers a "real-world" view of patient outcomes. Many medical disciplines have a long history of developing and using patient registries; the first patient registry for chronic venous disease in the United States was launched in 2011, fairly recently in comparison. Registries included in this review were identified by surveying members of major academic societies that focus on the care of chronic venous disease and by searching MEDLINE and Embase databases using Ovid interface. Medical directors of four of the five databases available in the United States completed a standard questionnaire, and the answers served as the basis for this review. This review is not a comparison of registries; it does, however, describe the common and unique features of four venous registries currently available in the United States with the purpose of increasing awareness of and fostering participation in these registries.

[Health related quality of life in chronic venous disease: Systematic literature review]

OBJECTIVE

Excepting life-threatening situations, improvement of health-related quality-of-life is the main therapeutic goal in chronic disease. The purpose of this review was to study the different ways of assessing Quality-of-Life (QoL) in patients with chronic venous disease (CVD) (CEAP classes C3 to C6).

METHODS

A literature search was conducted with three databases: MEDLINE, WEB OF SCIENCE and COCHRANE LIBRARY in order to identify articles with the PRISMA reporting guidelines. Then we compared psychometric performance of general and specific QoL questionnaires for a French population with CVD.

RESULTS

A total of 481 articles were identified, from which 25 were selected and analyzed. CIVIQ 20, CIVIQ 14 and VEINES Qol/sym are the specific health related QoL scales validated for a French population with CVD. VEINES Qol/sym was specifically validated in patients with leg ulcer or post-thrombotic syndrome (PTS). CIVIQ 14 is a CIVIQ 20 optimized to be used more widely in international studies and validated in milder forms of the CVD spectrum (C0 à C4). The general health related QoL scales are SF-36, SF-12 and EQ-5D. EQ-5D is simple and provides health state utility values.

CONCLUSION

CIVIQ 14 is a simple specific health-related QoL scale for less severe CVD. VEINES Qol/sym was developed for severe CVD and PTS but clinically relevant point scales remain to be assessed. EQ-5D is a generic scale to be preferred to assess economic impact based on a cost-utility analysis.

The endovenous ASVAL method: principles and preliminary results

PURPOSE

We aimed to investigate the feasibility and safety of the endovenous ambulatory selective varicose vein ablation under local anesthesia (eASVAL) method in a selected group of pa-tients with varicose disease and present the short-term results of one-year ultrasonographic follow-up.

METHODS

Three hundred and ninety-five consecutive patients with varicose veins who had been treated with endovenous laser ablation (EVLA) were retrospectively reviewed over a period of two years. From this group, 41 patients who were treated using the eASVAL technique and had the great saphenous vein (GSV) preserved were included in the study. These patients had only limited segmental GSV reflux accompanied by a competent terminal valve. The eASVAL technique can be defined as EVLA of the proximal straight segments of the major tributaries connecting the symptomatic varicose veins with the GSV, followed by ultrasound-guided foam sclerotherapy of the superficial varicose veins themselves. The patients were assessed before and after the treatment by duplex scan findings and clinical assessment scores.

RESULTS

The GSVs were successfully preserved in all 41 cases, and all patients showed significant clinical improvement using the eASVAL approach (P < 0.001). Segmental reflux was no longer present in 75.3% of patients. The mean diameters of the GSVs were significantly reduced at one-year follow-up (8.5 mm vs. 7.5 mm, P < 0.001).

CONCLUSION

eASVAL is a feasible and safe procedure in selected patients, with promising results at one-year ultrasonographic follow-up. However, prospective studies are required, comparing this approach with the standard techniques.

The fate of calf perforator veins after saphenous vein laser ablation

PURPOSE

We aimed to assess hemodynamic changes in calf perforator veins (PVs) after endovenous laser ablation (EVLA) of saphenous veins.

METHODS

The series comprised 60 limbs of 41 patients (27 female, 14 male; median age, 43 years [range, 22-78 years]) who underwent EVLA for varicose veins. All patients were prospectively evaluated by means of color Doppler ultrasonography before and after the procedure.

RESULTS

EVLA did not change the rate of incompetent PVs (preoperatively, 154/483 [32%] vs. postoperatively, 167/501 [33%]; P = 0.173), but significantly increased the total number of all PVs (n=483 vs. n=501, P = 0.036). Following EVLA, 28% of the limbs had thrombosis of PVs, 34% had new US-detectable PVs, 42% showed new competency, and 52% showed new incompetency. New competent PVs were found more commonly in the medial leg (ablation site) than the lateral leg (nonablation site) (28.3% vs. 11.7%, P = 0.016), while new incompetent PVs were found more commonly in nonablation site than ablation site (31.7% vs. 18.3%, P = 0.086). Additionally, new competent PVs in the posterior leg were found more often in patients who had small saphenous vein ablation than patients who did not (30% vs. 0%, P = 0.002).

CONCLUSION

EVLA induces numerous changes in calf PVs. These changes seem to result from flow offloading in ablation site and onloading in nonablation site in the early postablation period.

The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness

BACKGROUND

Pelvic congestion syndrome (PCS) is described as chronic pelvic pain (CPP) arising from dilated and refluxing pelvic veins, although the causal relationship between pelvic vein incompetence (PVI) and CPP is not established. Non-invasive screening methods such as Doppler ultrasound and magnetic resonance venography are used before confirmation by venography. Percutaneous embolisation has become the principal treatment for PCS, with high success rates often cited.

OBJECTIVES

Our proposal aimed to systematically and critically review the definitions and diagnostic criteria of PCS, the association between PVI and CPP, the accuracy of various non-invasive imaging techniques and the effectiveness of embolisation for PVI; and to identify factors associated with successful outcome. We also wished to survey clinicians and patients to assess awareness and management of PCS and gauge the enthusiasm for further research.

DATA SOURCES

A comprehensive search strategy encompassing various terms for pelvic congestion, pain, imaging techniques and embolisation was deployed in 17 bibliographic databases, including MEDLINE, EMBASE and Web of Science. There was no restriction on study design.

METHODS

Methodological quality was assessed using appropriate tools. Online surveys were sent to clinicians and patients. The quality and heterogeneity generally precluded meta-analysis and so results were tabulated and described narratively.

RESULTS

We identified six association studies, 10 studies involving ultrasound, two studies involving magnetic resonance venography, 21 case series and one poor-quality randomised trial of embolisation. There were no consistent diagnostic criteria for PCS. We found that the associations between CPP and PVI were generally fairly similar, with three of five studies with sufficient data showing statistically significant associations (odds ratios of between 31 and 117). The prevalence of PVI ranged widely, although the majority of women with PVI had CPP. Transvaginal ultrasound with Doppler and magnetic resonance venography are both useful screening methods, although the data on accuracy are limited. Early substantial relief from pain symptoms was observed in approximately 75% of women undergoing embolisation, a figure which generally increased over time and was sustained. Reintervention rates were generally low. Transient pain was a common occurrence following foam embolisation, while there was a < 2% risk of coil migration. Confidence in the embolisation technique is reasonably high, although there is a desire to strengthen the evidence base. Even among women with CPP, fewer than half had any knowledge about PCS.

CONCLUSIONS

The data supporting the diagnosis and treatment of PCS are limited and of variable methodological quality. There is some evidence to tentatively support a causative association, but it cannot be categorically stated that PVI is the cause of CPP in women with no other pathology, as the six most pertinent drew on clinically disparate populations and defined PVI inconsistently. Embolisation appears to provide symptomatic relief in the majority of women and is safe. However, the majority of included studies of embolism were relatively small case series and only the randomised controlled trial was considered at risk of potential biases. There is scope and demand for considerable further research. The question of the association of PVI and CPP requires a well-designed and well-powered case-control study, which will also provide data to derive a diagnostic standard. An adequately powered randomised trial is essential to provide evidence on the effectiveness of embolisation, but this faces methodological challenges.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012002237 and CRD42012002238.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of LAser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial

BACKGROUND

Foam sclerotherapy (foam) and endovenous laser ablation (EVLA) have emerged as alternative treatments to surgery for patients with varicose veins, but uncertainty exists regarding their effectiveness in the medium to longer term.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of foam, EVLA and surgery for the treatment of varicose veins.

DESIGN

A parallel-group randomised controlled trial (RCT) without blinding, and economic modelling evaluation.

SETTING

Eleven UK specialist vascular centres.

PARTICIPANTS

Seven hundred and ninety-eight patients with primary varicose veins (foam, n = 292; surgery, n = 294; EVLA, n = 212).

INTERVENTIONS

Patients were randomised between all three treatment options (eight centres) or between foam and surgery (three centres).

PRIMARY OUTCOME MEASURES

Disease-specific [Aberdeen Varicose Vein Questionnaire (AVVQ)] and generic [European Quality of Life-5 Dimensions (EQ-5D), Short Form questionnaire-36 items (SF-36) physical and mental component scores] quality of life (QoL) at 6 months. Cost-effectiveness as cost per quality-adjusted life-year (QALY) gained.

SECONDARY OUTCOME MEASURES

Quality of life at 6 weeks; residual varicose veins; Venous Clinical Severity Score (VCSS); complication rates; return to normal activity; truncal vein ablation rates; and costs.

RESULTS

The results appear generalisable in that participants' baseline characteristics (apart from a lower-than-expected proportion of females) and post-treatment improvement in outcomes were comparable with those in other RCTs. The health gain achieved in the AVVQ with foam was significantly lower than with surgery at 6 months [effect size -1.74, 95% confidence interval (CI) -2.97 to -0.50; p = 0.006], but was similar to that achieved with EVLA. The health gain in SF-36 mental component score for foam was worse than that for EVLA (effect size 1.54, 95% CI 0.01 to 3.06; p = 0.048) but similar to that for surgery. There were no differences in EQ-5D or SF-36 component scores in the surgery versus foam or surgery versus EVLA comparisons at 6 months. The trial-based cost-effectiveness analysis showed that, at 6 months, foam had the highest probability of being considered cost-effective at a ceiling willingness-to-pay ratio of £20,000 per QALY. EVLA was found to cost £26,107 per QALY gained versus foam, and was less costly and generated slightly more QALYs than surgery. Markov modelling using trial costs and the limited recurrence data available suggested that, at 5 years, EVLA had the highest probability (≈ 79%) of being cost-effective at conventional thresholds, followed by foam (≈ 17%) and surgery (≈ 5%). With regard to secondary outcomes, health gains at 6 weeks (p < 0.005) were greater for EVLA than for foam (EQ-5D, p = 0.004). There were fewer procedural complications in the EVLA group (1%) than after foam (7%) and surgery (8%) (p < 0.001). Participants returned to a wide range of behaviours more quickly following foam or EVLA than following surgery (p < 0.05). There were no differences in VCSS between the three treatments. Truncal ablation rates were higher for surgery (p < 0.001) and EVLA (p < 0.001) than for foam, and were similar for surgery and EVLA.

CONCLUSIONS

Considerations of both the 6-month clinical outcomes and the estimated 5-year cost-effectiveness suggest that EVLA should be considered as the treatment of choice for suitable patients.

FUTURE WORK

Five-year trial results are currently being evaluated to compare the cost-effectiveness of foam, surgery and EVLA, and to determine the recurrence rates following each treatment. This trial has highlighted the need for long-term outcome data from RCTs on QoL, recurrence rates and costs for foam sclerotherapy and other endovenous techniques compared against each other and against surgery.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN51995477.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 27. See the NIHR Journals Library website for further project information.

Pharmacomechanical Thrombolysis in the Management of Acute Inferior Vena Cava Filter Occlusion Using the Trellis-8 Device

Purpose: To evaluate the performance and safety of the Trellis-8 system, a pharmacomechanical thrombolysis infusion catheter, and adjunctive therapies in the treatment of symptomatic inferior vena cava (IVC) filter–related acute thrombotic occlusion. Methods: Eight consecutive patients (6 men; mean age 57.4 years, range 34–78 years) with acute thrombotic occlusion of the IVC in the presence of an IVC filter underwent percutaneous venous thrombectomy using the Trellis-8 thrombectomy system and adjunctive techniques between January 2009 and November 2013. Demographics, clinical data, procedures, and outcomes were retrospectively reviewed. All patients had clinical signs of lower extremity venous hypertension on presentation. The median time between IVC filter placement and occlusion was 25 months. Patients were followed for the development of thromboembolic complications to the last clinic visit or until they died. Results: The procedure was technically successful in 6 patients, whereas it could not be performed in 2 due to failure to cross the occlusion. The median follow-up period was 7.8 months, at which time all patients undergoing successful Trellis-8 thrombectomy had relief of symptoms without thromboembolic or bleeding complications. Conclusion: In this limited performance and safety evaluation, the Trellis-8 thrombectomy system combined with adjunctive therapies, such as mechanical thrombectomy and balloon angioplasty, was effective in 75% of patients with IVC filter–related acute caval occlusion.

Targeted endovenous treatment of Giacomini vein insufficiency-associated varicose disease: considering the reflux patterns

PURPOSE

We aimed to assess the technical feasibility of targeted endovenous treatment of Giacomini vein insufficiency (GVI)-associated varicose disease and report our early results.

METHODS

We retrospectively screened 335 patients with varicose disease who underwent endovenous laser ablation from September 2011 to January 2013, and determined 17 patients who underwent Giacomini vein ablation. Using a targeted endovenous treatment approach considering the reflux pattern, all healthy great saphenous veins (GSV) or vein segments were preserved while all insufficient veins (Giacomini vein, perforator veins, small saphenous vein, anterior accessory GSV, major tributary veins, or incompetent segments of the GSV) were ablated. Treatment success was analysed using Doppler findings and clinical assessment scores before and after treatment.

RESULTS

Targeted endovenous treatment was technically successful in all cases. Seven GSVs were preserved totally and three GSVs were preserved partially (10/17, 58%), with no major complications. Clinical assessment scores and Doppler findings were improved in all cases.

CONCLUSION

Targeted endovenous treatment of GVI-associated varicose disease is safe and effective. In majority of GVI cases saphenous vein can be preserved using this approach.

Comparison of disease-specific quality of life tools in patients with chronic venous disease

Objectives

This work was presented as a poster in the American Venous Forum 25th Annual Meeting; 28 February 2013; Phoenix, Arizona, USA. Quality of life (QoL) is an important outcome measure in the treatment for chronic venous disease. The Aberdeen Varicose Vein Questionnaire (AVVQ) and the ChronIc Venous Insufficiency quality of life Questionnaire (CIVIQ-14) are two validated disease-specific QoL questionnaires in current use. The aim of this study is to evaluate the relationship between the AVVQ and the CIVIQ-14 to enable better comparison between studies and to compare these disease-specific QoL tools with generic QoL and clinician-driven tools.

Methods

Adults attending our institution for management of their varicose veins completed the AVVQ, CIVIQ-14 and EuroQol-5D (EQ-5D). Clinical data, CEAP classification and the Venous Clinical Severity Score (VCSS) were collected. The relationship between the AVVQ and CIVIQ-14 scores was analysed using Spearman’s correlation. The AVVQ and CIVIQ-14 scores were also analysed with a generic QoL tool (EQ-5D) and a clinician-driven tool, the VCSS.

Results

One hundred patients, mean age 57.5 (44 males; 56 females), participated in the study. The median AVVQ score was 21.9 (range 0–74) and the median CIVIQ-14 score was 30 (range 0–89). A strong correlation was demonstrated between the AVVQ and CIVIQ-14 scores ( r = 0.8; p < 0.0001). Strong correlation was maintained for patients with C1-3 disease ( r = 0.7; p < 0.0001) and C4-6 disease ( r = 0.8; p < 0.0001). The VCSS correlated strongly with the AVVQ and CIVIQ-14 scores ( r = 0.7; p < 0.0001 and r = 0.7; p < 0.0001, respectively). Both the AVVQ and CIVIQ-14 scores correlated well with the EQ-5D score ( r = −0.5; p < 0.0001 and r = −0.7; p < 0.0001, respectively).

Conclusions

This study demonstrates that there is good correlation between two widely used varicose vein specific QoL tools (AVVQ and CIVIQ-14) across the whole spectrum of disease severity. Strong correlation exists between these disease-specific QoL tools and generic and clinician-driven tools. Our findings confirm valid comparisons between studies using either disease-specific QoL tool.

Endovenous laser ablation and sclerotherapy for incompetent vein of Giacomini

PURPOSE

To retrospectively evaluate the feasibility and effectiveness of endovenous laser ablation or ultrasound-guided foam sclerotherapy for Giacomini vein insufficiency. This is the largest cohort of patients treated for Giacomini vein insufficiency with endovenous laser ablation or ultrasound-guided foam sclerotherapy.

MATERIAL AND METHODS

Over a three-year period, 23 females and nine males (age range, 19-67 years) treated for Giacomini vein insufficiency with or without saphenous vein insufficiency were retrospectively reviewed. Diagnosis of venous insufficiency was made by color Doppler ultrasonography. Symptomatic insufficiency of the Giacomini vein or the saphenous veins was treated with endovenous laser ablation. Ultrasound-guided foam sclerotherapy was used for tortuous incompetent Giacomini veins. The venous disease was categorized according to the clinical, etiological, anatomical, and pathological classification, and clinical severity was graded with the venous clinical severity score. Follow-up included clinical examination and color Doppler ultrasonography.

RESULTS

Thirty-nine limbs in 32 patients were treated (25 endovenous laser ablation and seven ultrasound-guided foam sclerotherapy). All procedures were technically successful. One patient in the ultrasound-guided foam sclerotherapy group had a recurrence with successful repeated treatment. Recurrence was not seen in the endovenous laser ablation group. No complications were observed. All patients had resolution and improvement in 100% of their symptoms at 12 months of follow-up.

CONCLUSION

Giacomini vein insufficiency is mostly seen with insufficiency of the great saphenous vein and can be effectively treated with endovenous laser ablation or ultrasound-guided foam sclerotherapy.