Ultrasound findings after radiofrequency ablation of the great saphenous vein: Descriptive analysis

Early arteriovenous fistula after radiofrequency ablation of long saphenous vein

A 75-year-old woman developed an arteriovenous fistula (AVF) between the common femoral artery and common femoral vein following radiofrequency ablation (RFA) of left long saphenous vein. Failed coil embolization of the AVF was followed by successful surgical ligation. Awareness of the aetiology of this uncommon complication of RFA and its treatment options is important with the increasing use of RFA for varicose vein treatment.

Arteriovenous fistula after endovenous ablation for varicose veins

Endovenous ablation, using radiofrequency or laser, is becoming the mainstay of treatment for symptomatic varicose veins in the setting of saphenous vein incompetency. Both procedures have been shown to produce high rates of truncal vein occlusion with few complications. This article presents three patients who developed arteriovenous fistula (AVF) following great saphenous vein treatment: two following radiofrequency ablation (RFA) and one following laser ablation. This is the first published report of AVF following RFA for which operative details are known. We review the literature and discuss possible causes and management of this rare complication.

Surgical management of varicose veins: meta-analysis

Open surgery remains the gold standard by which endovascular treatment of superficial chronic venous insufficiency is measured. This meta-analysis of randomized controlled trials reviews the current evidence base, comparing open and endovascular treatment of varicose veins. Systematic review of studies reporting duplex scan follow-up after open surgical, laser (endovenous laser therapy [EVLT]), or radiofrequency (VNUS Closure device, VNUS Medical Technologies, San Jose, CA) treatment of refluxing great saphenous veins was completed. Primary outcome measures were occlusion and complication rates and time taken to resume work. No significant difference in recurrence rates at 3 months between open surgery and EVLT (RR 2.19, 95% CI 0.99-4.85, p = .05) or VNUS device (RR 7.57; 95% CI 0.42-136.02) were found. Return to work is significantly faster following VNUS (by 8.24 days; 95% CI 10.50-5.97) or EVLT (by 5.02 days; 95% CI 6.52-3.52). Endovascular treatment of varicose veins is safe and effective and offers the significant advantage of rapid recovery.

Does the number of pregnancies affect patterns of great saphenous vein reflux in women with varicose veins?

Objectives

Impact of pregnancies on great saphenous vein (GSV) reflux patterns deserves clarification. Which GSV segment is most affected? Is the saphenofemoral junction (SFJ) involved?

Methods

Colour-flow duplex ultrasonography was performed in 583 women extremities with primary varicose veins (clinical, aetiological, anatomical and pathological elements [CEAP C2]), without oedema, skin changes or ulcer. Women with previous thrombosis or varicose surgery were excluded. GSV reflux sources and drainage points were located at SFJ, thigh, knee and calf. Prevalence of most proximal reflux source was noted as a function of 0, 1, 2, 3 and 4 or more pregnancies. χ2 statistics was employed.

Results

Prevalence of GSV reflux was not dependent on 0, 1, 2, 3 or ≥4 pregnancies: 75%, 69%, 79%, 70% and 76% for right leg ( P = 0.79) and 78%, 81%, 82%, 79% and 73% for left leg ( P = 0.87), respectively. Prevalence of SFJ reflux and GSV reflux, starting at the thigh, knee or calf, was similar and showed no tendencies to increase with number of pregnancies.

Conclusions

Number of pregnancies did not influence GSV reflux patterns in women with primary varicose veins.

Cosmetic treatments: an emerging field of interest for interventional radiologists

The current trend in medical care in the 21st century is evolving into a minimally invasive specialty. The interest of Interventional Radiology (IR) in cosmetic is increasing particularly for outsetting patients, in the treatment of soft tissue vascular malformations, us-guided injections of Botox and varicous veins management. Advantages of cosmetic IR treatments are many: treatments takes less than an hour and provides immediate relief of symptoms; no scaring, because the procedure does not require a surgical incision; an immediate return to normal activity with little or no pain; and high success rate and low recurrence rate compared to surgery.

Review of Intravascular Approaches to the Treatment of Varicose Veins

This is an in-depth review article for intravascular approaches to the treatment of varicose veins. The review discusses thermocoagulation of abnormal veins performed by an endoluminal radiofrequency device or laser. The article sites specific findings and is based on our clinical experience and extensive literature search. It was found that the two techniques were less invasive, less expensive, and faster alternative to treat varicose saphenous trunks compared to ligation and stripping. Minor adjustments to the technique prevented or minimized side effects to patients. Ambulatory phlebectomy in conjunction with treatment produced optimal long-term results.

Patterns of Saphenous Venous Reflux in Women Presenting with Lower Extremity Telangiectasias

BACKGROUND

Telangiectasias have been treated with sclerotherapy without concomitant assessment or treatment of saphenous veins.

OBJECTIVE

To clarify if ultrasound (US) mapping of saphenous veins is justifiable, this investigation determined prevalence of specific patterns of saphenous vein reflux in women with telangiectasias.

METHODS

US mapping of the great and small saphenous veins (GSV, SSV) was performed in 1,740 extremities of 910 consecutive patients, mostly women (86%). A subgroup of 269 limbs of women with telangiectasias (CEAP C1 class) was included in this study. Patterns of GSV and SSV reflux were classified as perijunctional, proximal, distal, segmental, multisegmental, and diffuse.

RESULTS

Reflux was detected in 125 extremities (46%): 5% had reflux in both the GSV and the SSV, 39% had GSV reflux, and 2% had SSV reflux. The most common pattern of GSV reflux was segmental (73%, 87/119). Prevalence of reflux was significantly greater in GSV versus SSV (p < .001). GSV segmental plus distal reflux (40%, 108/269) was significantly more prevalent than saphenofemoral junction or near junction reflux (4%, 11/269; p < .001).

CONCLUSIONS

US mapping of the GSV in women with telangiectasias is justifiable, even in asymptomatic extremities. Further research will determine if segmental reflux should be treated to avoid evolution to severe valvular insufficiency.

Neovascularization After Great Saphenous Vein Ablation

OBJECTIVE

To determine the prevalence, distribution, and flow characteristics of intraluminal neovascularization in patients undergoing great saphenous vein (GSV) endovenous laser (EVLT) or radiofrequency ablation (RFA).

METHODS

Duplex ultrasound (DU) was performed in patients undergoing EVLT or RFA before, during, and after their procedures. Follow-up included assessment for deep venous thrombosis and obliteration. When new vessels were identified, the source, extent, direction, and location of flow were noted. Flow channel diameters were measured and the resistivity index (RI) was used to characterize the flow patterns.

RESULTS

A total of 102 venous ablations were performed of which 46 were RFA, and 56 EVLT. Arterio-venous fistulae (AVF) were found in five patients that were not identified by DU prior to intervention. Involved segments had variable length and multiple channels (mean diameter 2.2mm). No patient had local or systemic symptoms related to the AVF. The mean RI was 0.42, consistent with an AVF. The perivenous arteries feeding the AVF had enhanced flow but a significantly higher RI (0.63, p<0.001).

CONCLUSION

Multiple small vessels were found directly adjacent to the involved vein segments forming small AVF within the obliterated vein. The prevalence of AVF in the ablated GSV was 5%. This process may be responsible for recanalization or recurrence after endovenous ablation procedures.

Patient characteristics and physician-determined variables affecting saphenofemoral reflux recurrence after ligation and stripping of the great saphenous vein

OBJECTIVE

To identify patient and physician-controlled treatment variables that might predict the persistence or redevelopment of saphenofemoral junction (SFJ) reflux.

METHODS

Thirteen European centers, with substantial lower extremity venous disease practices, examined their experience with SFJ ligation and GSV stripping for primary varicose veins in patients followed for > or =2 years, entering their data into a protocol-driven matrix that stipulated duplex Doppler imaging as an essential component of follow-up examinations and required a complete review of all peri-operative examinations, as well as all operative procedure and anesthesia notes. Matrix entries were centrally audited for consistency and credibility, and queried for correction or clarification before being accepted into the study database. Presence or absence of Doppler-detectable SFJ reflux was the dependent variable and principal outcome measure.

RESULTS

Among 1,638 limbs, 315 (19.2%) had SFJ reflux. After adjustment for follow-up length and inputting for missing values, multivariable analysis identified seven significant predictors. Ultrasonic groin mapping (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.20 to 0.40) and <3-cm groin incisions at or immediately below the groin crease (OR, 0.50; 95% CI, 0.32 to 0.78) were both uniquely associated with diminished probability of follow-up SFJ reflux. Prior parity (OR, 2.69; 95% CI, 1.45 to 4.97), body mass index >29 kg/m(2) (OR, 1.65; 95% CI, 1.12 to 2.43), <3-cm suprainguinal incisions (OR, 3.71; 95% CI, 1.70 to 5.88), stripping to the ankle (OR, 2.43; 95% CI, 1.71 to 3.46), and interim pregnancy during follow-up (OR, 4.74; 95% CI, 2.47 to 9.12), were each independent predictors of a greater probability of having SFJ reflux.

CONCLUSIONS

The findings suggest that ultrasound groin mapping, reticence for short suprainguinal or longer groin incisions and extended stripping, and counseling women about the effect of future pregnancy are prudent clinical choices, especially for obese or previously parous patients.

Changes in superficial and perforating vein reflux after varicose vein surgery

OBJECTIVES

This prospective duplex study was conducted to study the effect of current surgical treatment for primary varicose veins on the development of venous insufficiency < or = 2 years after varicose vein surgery.

METHODS

The patients were part of a randomized controlled study where surgery for primary varicose veins was planned from a clinical examination alone or with the addition of preoperative duplex scanning. Postoperative duplex scanning was done at 2 months and 2 years.

RESULTS

Operations were done on 293 patients (343 legs), 74% of whom were women. The mean age was 47 years. In 126 legs, duplex scanning was done preoperatively, at 2 months and 2 years, and at 2 months and 2 years in 251 legs. Preoperative perforating vein incompetence (PVI) was present in 64 of 126 legs. Perforator ligation was not done on 42 of these; at 2 months, 23 of these legs (55%) had no PVI, and at 2 years, 25 legs (60%) had no PVI. Sixty-one legs had no PVI preoperatively, 5 (8%) had PVI at 2 months, and 11 (18%) had PVI at 2 years. In the group of 251 legs, reversal of PVI between 2 months and 2 years was found in 28 (41%) of 68 and was more common than new PVI, which occurred in 41 (22%) of 183 (P = .003). After 2 years, the number of legs without venous incompetence in which perforator surgery was not performed was 11 (26%) of 42 legs with preoperative PVI and 18 (30%) of 61 legs without preoperative PVI, (P = .713). After 2 years, new vessel formation was more common in the surgically obliterated saphenopopliteal junction (SPJ), 4 (40%) of 10, than in the saphenofemoral junction (SFJ), 17 (11%) of 151(P = .027), and new incompetence in a previously normal junction was more common in the SFJ, 11 (18%) of 63, than in the SPJ, 3 (1%) of 226 (P < .001). Reflux in the great saphenous vein (GSV) below the knee was abolished after stripping above the knee in 17 (34%) of 50 legs at 2 months and in 22 legs (44%) after 2 years.

CONCLUSIONS

Varicose vein surgery induces changes in the remaining venous segments of the legs that continue for several months. In most patients, perforators and the GSV below the knee can be ignored at the primary surgery. A substantial number of recurrences in the SFJ and SPJ are unavoidable with present surgical knowledge because they stem from new vessel formation and progression of disease.