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Zhang A, Xiong X, Yan J, Ma J, Wu H, Huang L. Study on the efficacy of endoscopic transection of communicating branch in the treatment of varicose ulcer of great saphenous vein. Minerva Surg 2022; 77:492-495. [PMID: 34342413 DOI: 10.23736/s2724-5691.21.09049-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Aijun Zhang
- Department of General Surgery, Wuhan Wuchang Hospital, Wuchang Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Xiong Xiong
- Department of General Surgery, Wuhan Wuchang Hospital, Wuchang Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Jiaohua Yan
- Department of Nursing, Wuhan Wuchang Hospital, Wuchang Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Jun Ma
- Department of Anesthesiology, Wuhan Wuchang Hospital, Wuchang Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Hui Wu
- Department of General Surgery, Wuhan Wuchang Hospital, Wuchang Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Le Huang
- Department of Hepatopancreatobiliary, Wuhan Fourth Hospital, Wuhan, China - .,Tongji Medical College, Puai Hospital, Huazhong University of Science and Technology, Wuhan, China
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Ho VT, Adkar SS, Harris EJ. Systematic review and meta-analysis of the management of incompetent perforators in patients with chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord 2022; 10:955-964.e5. [PMID: 35217217 DOI: 10.1016/j.jvsv.2021.12.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/05/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Incompetent perforator veins (IPVs) contribute to venous pathology and are surgically treated based on hemodynamic measurement, size, and Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) classification. The objective of this study was to systematically review and synthesize current literature regarding surgical management of IPVs, including open ligation, subfascial endoscopic perforator surgery (SEPS), endovascular laser ablation (EVLA), ultrasound guided sclerotherapy (USGS), and radiofrequency ablation (RFA). METHODS English-language literature published prior to November 2021 was reviewed from the PubMed, EMBASE, and MEDLINE databases for primary literature reporting safety and efficacy outcomes in the surgical treatment of incompetent perforating veins. Study quality and risk of bias was assessed using the Cochrane risk-of-bias tool for comparative studies and a modified version of the Newcastle-Ottawa Scale for non-comparative studies. A random effects model was used to pool effect sizes for efficacy outcomes of wound healing and freedom from wound recurrence. RESULTS A total of 81 studies were included for qualitative synthesis representing 7010 patients with a mean age of 54.7 years. Overall evidence quality was low to intermediate, with moderate to high risk of bias in comparative studies. There was an 11.3% complication rate across interventions, with no reported incidences of stroke or air embolism. With regards to efficacy, pooled estimates for short-term (up to 1-year) wound healing were 99.9% for USGS (95% CI 0.81 - 1), 72.2% for ligation (95% CI 0.04, 0.94) and 96.0% for SEPS (95% CI 0.79 -0.99). For short-term freedom from wound recurrence, the pooled estimate for SEPS is 91.0% (95% CI 0.3 - 0.99). CONCLUSION Current evidence regarding treatment of incompetent perforator veins is limited due to low adherence to reporting standards in observational studies and lack of randomization, blinding, and allocation concealment in comparative studies. Additional comparative studies are needed to guide clinical decision-making regarding invasive treatment options for incompetent perforator veins.
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Affiliation(s)
- Vy T Ho
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA
| | - Shaunak S Adkar
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA
| | - Edmund J Harris
- Division of Vascular Surgery, Department of Surgery, Stanford University, Palo Alto, CA
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Wang CM, Zhao SL, Feng QC, Gai S, Li X. One-year outcomes of radiofrequency ablation of incompetent perforator veins using the radiofrequency stylet device: Cohort study from East Asia. Phlebology 2020; 36:268-274. [PMID: 33201775 DOI: 10.1177/0268355520973488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The present study was designed to assess outcomes of patients undergone radiofrequency ablation (RFA) for their incompetent perforator veins (IPVs) with ClosureFast stylets. METHODS Data of 165 IPVs in 138 limbs of 117 consecutive patients between July 2017 to Nov. 2019 were retrospectively reviewed. Primary endpoints (technical success rate, complications) and secondary endpoints (VCSS) were analyzed. RESULTS The immediate technical success rate was 100%. There were no major complications. The rate of ecchymosis and induration was 5.8%. 129/165 IPVs in 79.5% (93/117) patients had achieved sonographic evaluation at 1 year followed-up, in which 3 perforators were recanalized. VCSS scores at pre-operation and 1-year follow-up were 5.77 ± 1.88 and 2.70 ± 1.39, respectively (t= 29.644, P= .000). CONCLUSIONS In conclusion, RFA is safe and effective for the treatment of IPVs. At the 1-year follow-up, the RFA of IPVs showed a low recanalization rate and had a satisfactory improvement on VCSS.
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Affiliation(s)
- Chang-Ming Wang
- Department of Vascular Surgery and Interventional Radiology, 66482Peking University Third Hospital, Beijing, China
| | - Shi-Lu Zhao
- Department of Vascular Surgery and Interventional Radiology, 66482Peking University Third Hospital, Beijing, China
| | - Qi-Chen Feng
- Department of Vascular Surgery and Interventional Radiology, 66482Peking University Third Hospital, Beijing, China
| | - Shuo Gai
- Department of Vascular Surgery and Interventional Radiology, 66482Peking University Third Hospital, Beijing, China
| | - Xuan Li
- Department of Vascular Surgery and Interventional Radiology, 66482Peking University Third Hospital, Beijing, China
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Tolu I, Durmaz MS. Frequency and Significance of Perforating Venous Insufficiency in Patients with Chronic Venous Insufficiency of Lower Extremity. Eurasian J Med 2018; 50:99-104. [PMID: 30002576 PMCID: PMC6039150 DOI: 10.5152/eurasianjmed.2018.18338] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/11/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of this study was to reveal the frequency and impact of perforating venous insufficiency (PVI) in chronic venous insufficiency (CVI) of lower extremity (LE). MATERIALS AND METHODS Between 2012 and 2017, a total of 1154 patients [781 females (67.68%) and 373 males (32.32%), 228 (19.76%) unilateral and 926 (80.24%) bilateral LE] were examined using Doppler ultrasound (US). A total of 2080 venous systems of LEs [31.4% male (n=653) and 68.6% female (n=1427); 1056 left LEs (50.77%) and 1024 right LEs (49.23%)] were examined. All patients had symptoms of venous insufficiency (VI). RESULTS PVI was revealed in 27.5% (n=571) of LEs. Varicose veins (VVs) related with perforating vein (PV) were revealed in 44.7% of LEs (n=929). PVI was observed in 50.91% of patients with chronic deep venous thrombosis (DVT), 64.41% with deep venous insufficiency (DVI), 59.81% with great saphenous vein (GSV) insufficiency, 68.49% with small saphenous vein (SSV) insufficiency, 58.65% with accessory GSV insufficiency, and 58.77% with PV associated with VVs. There was a statistically significant relationship between PVI and chronic DVT, DVI, GSV, SSV, and accessory GSV insufficiency (p<0.001). A significant relationship was observed between the increase in PV diameter and the presence of PVI (p<0.001). CONCLUSION PVI is quite common in combined VI, and PV evaluation should be a part of LE venous system examination.
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Affiliation(s)
- Ismet Tolu
- Department of Radiology, Health Sciences University Training and Research Hospital, Konya, Turkey
| | - Mehmet Sedat Durmaz
- Department of Radiology, Health Sciences University Training and Research Hospital, Konya, Turkey
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Kusagawa H, Haruta N, Shinhara R, Hoshino Y, Tabuchi A, Sugawara H, Shinozaki K, Matsuzaki K, Nagata H, Niihara H, Kohno K, Takeda R. Surgical methods and clinical results of subfascial endoscopic perforator surgery in Japan. Phlebology 2018; 33:678-686. [DOI: 10.1177/0268355517750523] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objectives To clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan. Methods This study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively. Results Preoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 ( P < .0001) postoperatively. The primary ulcer healing rate was 96.2% (332/345 C6 limbs) at an average follow-up of 47.7 months, and the ulcer recurrence rate was 12.0% (49/393 C5, C6 limbs) at the average follow-up of 46.0 months after the ulcer healed. Conclusion These results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome.
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Affiliation(s)
- Hitoshi Kusagawa
- Department of Thoracic and Cardiovascular Surgery, Matsusaka Chuo General Hospital, Matsusaka, Japan (Presently, Matsusaka Ohta Clinic, Matsusaka, Japan)
| | - Naoki Haruta
- Department of Vascular Surgery, Takanobashi Central Hospital, Hiroshima, Japan
| | - Ryo Shinhara
- Department of Vascular Surgery, Mitsubishi Mihara Hospital, Mihara, Japan
| | - Yuji Hoshino
- Department of Vascular Surgery, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Atsushi Tabuchi
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Hiromitsu Sugawara
- Department of Surgery, Sendai Hospital of East Japan Railway Company, Sendai, Japan
| | - Koji Shinozaki
- Department of Surgery, Kobe Ekisai-kai Hospital, Kobe, Japan
| | - Kenji Matsuzaki
- Department of Cardiovascular Surgery, NTT Sapporo Hospital, Sapporo, Japan
| | - Hidetoshi Nagata
- Department of Surgery, Fujita Health University Banbuntane-hotokukai Hospital, Nagoya, Japan
| | - Hiroyuki Niihara
- Department of Dermatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Kunie Kohno
- Center for Community-Based Health Research and Education (COHRE), Organization for the Promotion of Project Research, Shimane University, Izumo, Japan
| | - Ryoji Takeda
- Department of Vascular Surgery, Rakuwakai Otowa Hospital, Kyoto, Japan
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Ozkan U. The fate of calf perforator veins after saphenous vein laser ablation. Diagn Interv Radiol 2016; 21:410-4. [PMID: 26268299 DOI: 10.5152/dir.2015.14059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Ugur Ozkan
- Department of Radiology, Private Ortadoğu Hospital, Adana, Turkey.
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Kuyumcu G, Salazar GM, Prabhakar AM, Ganguli S. Minimally invasive treatments for perforator vein insufficiency. Cardiovasc Diagn Ther 2016; 6:593-598. [PMID: 28123979 DOI: 10.21037/cdt.2016.11.12] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Incompetent superficial veins are the most common cause of lower extremity superficial venous reflux and varicose veins; however, incompetent or insufficient perforator veins are the most common cause of recurrent varicose veins after treatment, often unrecognized. Perforator vein insufficiency can result in pain, skin changes, and skin ulcers, and often merit intervention. Minimally invasive treatments have replaced traditional surgical treatments for incompetent perforator veins. Current minimally invasive treatment options include ultrasound guided sclerotherapy (USGS) and endovascular thermal ablation (EVTA) with either laser or radiofrequency energy sources. Advantages and disadvantages of each modality and knowledge on these treatments are required to adequately address perforator venous disease.
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Affiliation(s)
- Gokhan Kuyumcu
- Cleveland Clinic Imaging Institute, Cleveland, OH 44195, USA
| | - Gloria Maria Salazar
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anand M Prabhakar
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Suvranu Ganguli
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Böhler K. [Surgery of varicose vein insufficiency]. Wien Med Wochenschr 2016; 166:293-6. [PMID: 27405862 DOI: 10.1007/s10354-016-0486-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 06/09/2016] [Indexed: 12/01/2022]
Abstract
The basis of surgery of great saphenous vein insufficiency is the concept of "privat circulation" coined by Trendelenburg in 1891. It was only logical that the dissection of the insuffcient vein or it's partial or complete resection could bring about healing. Over the years varicose vein stripping was modified to finally result in the highly effectiv concept of crossectomy and stripping. For decades this was the Goldstandard in surgery of varicose vein insufficiency. All the other minimally invasive therapeutic techniques which have been developed in the last decades had to compete with crossectomy and stripping. Thanks to progress in technical development the classic stripping procedure has been replaced by highly effectiv, minimally invasiv procedures, at least in the western industrialisied countries. For a minority of patients with specific anatomical pathologies as well as countries with limited health resources vein stripping remains a surgical standard procedure.
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Affiliation(s)
- Kornelia Böhler
- Universitätsklinik für Dermatologie, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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Elias S, Peden E. Ultrasound-Guided Percutaneous Ablation for the Treatment of Perforating Vein Incompetence. Vascular 2016; 15:281-9. [DOI: 10.2310/6670.2007.00068] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recent advances in catheter-based endovenous interventions have broadened our understanding in the pathophysiology and therapeutic strategies of chronic venous insufficiency, a condition that can be caused by abnormality of various lower extremity venous structures, including superficial or deep vein reflux or incompetent perforating veins. This article reviews the history and therapeutic principles of percutaneous ablation of perforators (PAPs). Discussions related to treatment strategies and procedural techniques of PAPs using radiofrequency ablation, laser energy, and sclerosant injection are provided. Current clinical results of PAPs with radiofrequency and laser energy ablation as a treatment modality of chronic venous insufficiency are also discussed.
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Affiliation(s)
- Steve Elias
- *Division of Vascular Surgery, Mount Sinai School of Medicine, New York, NY, and Center for Vein Disease, Englewood Hospital and Medical Center, Englewood, NJ; †Division of Vascular Surgery, The Methodist Physician Organization, Houston, TX
| | - Eric Peden
- *Division of Vascular Surgery, Mount Sinai School of Medicine, New York, NY, and Center for Vein Disease, Englewood Hospital and Medical Center, Englewood, NJ; †Division of Vascular Surgery, The Methodist Physician Organization, Houston, TX
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Current state of the treatment of perforating veins. J Vasc Surg Venous Lymphat Disord 2015; 4:131-5. [PMID: 26946910 DOI: 10.1016/j.jvsv.2015.03.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 03/15/2015] [Indexed: 11/24/2022]
Abstract
Perforating veins may play a role in the development of chronic venous insufficiency and ulceration. There is renewed interest in minimally invasive treatments vs historic surgical options. Current indications for treatment, technical success, and evidence for clinical efficacy are summarized. Existing recommendations include perforator closure in Clinical, Etiology, Anatomy, and Pathophysiology class 5 or class 6 disease through percutaneous thermal ablation, subfascial endoscopic perforator surgery, open surgery, or sclerotherapy. Closure rates for percutaneous thermal ablation are reported as 60% to 80% initially. More recanalization and de novo perforator formation have been reported than after thermal saphenous closure. Ultrasound-guided foam sclerotherapy has shown promise in perforator closure and wound healing, but with variable success rates. Regardless of method used, successful closure of perforators appears predictive of wound healing with minimal morbidity. However, the power and design of all studies supporting this are far from robust, and more work is needed.
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Whiteley MS, O'Donnell TF. Debate: whether venous perforator surgery reduces recurrences. J Vasc Surg 2014; 60:796-803. [PMID: 25154966 DOI: 10.1016/j.jvs.2014.06.102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Superficial venous surgery and perforator vein surgery, specifically, have a long and varied history in the evolution of vascular surgery, especially because venous disease continues to be extremely common. As with other areas of our specialty, perforator vein procedures have progressed from being purely open operations to becoming less invasive procedures. Despite this, there remains much discussion (as well as overt disagreement) about whether perforator vein surgery is actually appropriate and beneficial in the first place. Surgeons have no level I evidence from randomized controlled studies to determine whether perforator vein surgery does or does not reduce the chances of recurrence of superficial venous varicosities, so we must rely on the evidence as it currently is. Perhaps not surprisingly, our two experts have assembled divergent opinions on the role of perforator venous surgery in contemporary practice.
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Affiliation(s)
- Mark S Whiteley
- The Whiteley Clinic, Guildford and London; and Faculty of Health and Biomedical Sciences, University of Surrey, Guildford, United Kingdom.
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Whiteley AM, Taylor DC, Dos Santos SJ, Whiteley MS. Pelvic venous reflux is a major contributory cause of recurrent varicose veins in more than a quarter of women. J Vasc Surg Venous Lymphat Disord 2014; 2:411-5. [DOI: 10.1016/j.jvsv.2014.05.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 05/05/2014] [Indexed: 10/25/2022]
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Whiteley M. Part One: For the Motion. Venous Perforator Surgery is Proven and Does Reduce Recurrences. Eur J Vasc Endovasc Surg 2014; 48:239-42. [DOI: 10.1016/j.ejvs.2014.06.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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O'Donnell TF. Part Two: Against the Motion. Venous Perforator Surgery is Unproven and Does not Reduce Recurrences. Eur J Vasc Endovasc Surg 2014; 48:242-6. [DOI: 10.1016/j.ejvs.2014.06.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Vashist MG, Malik V, Singhal N. Role of Subfascial Endoscopic Perforator Surgery (SEPS) in Management of Perforator Incompetence in Varicose Veins : A Prospective Randomised Study. Indian J Surg 2014; 76:117-23. [PMID: 24891775 DOI: 10.1007/s12262-012-0675-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Accepted: 06/22/2012] [Indexed: 11/28/2022] Open
Abstract
The study was carried out to compare the efficacy of subfascial endoscopic perforator surgery (SEPS) and open subfascial ligation of perforators in varicose veins. This study was conducted on 100 patients of varicose veins from January 2006 to December 2010. Clinical scoring and color Doppler were performed in all the patients before surgery. Patients were divided into two groups: Group A and Group B alternately. Management of the perforators was done by subfascial endoscopic perforator surgery (SEPS) in Group A and by open subfascial ligation of perforators in Group B. Fifty patients were treated in each group. All the patients underwent ligation of incompetent saphenofemoral junction with stripping of long saphenous veins wherever the junction was incompetent with multiple ligation of superficial prominent veins. SEPS was done by two-port method without any tourniquet or balloon dissector. Total numbers of perforators ligated were 178 in Group A and 136 in Group B. Patients in both the groups got symptomatic relief of symptoms, but ulcer healing in 33 % patients in Group A was faster as compared to Group B. However, at 3 months of follow-up the ulcers healed in all the patients in both groups. Incidence of wound infection was higher in group B (16 %) as compared to group A (0 %). There were residual perforators in 8 % of patients on color Doppler at 3 months of follow-up in Group B while there was no residual incompetent perforator in Group A. Subfascial endoscopic perforator vein surgery is a safe and effective method for treating incompetent perforating veins. The number of perforators ligated in SEPS was more as compared to the open subfascial ligation group. Possibly some perforators may be missed on Doppler localization and missed ligation, which may be a cause of future recurrence in varicose veins. Early relief of symptoms in terms of ulcer healing was better in the SEPS group with less wound complication rate; however, all the ulcers healed in both the groups at 3 months of follow-up. Cosmetic results were equal in both the groups. Major advantage of SEPS was less incidence of wound complications and less incidence of residual incompetent perforators. Hence, SEPS should be added for the management of perforators along with conventional surgery in varicose veins.
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Affiliation(s)
- M G Vashist
- Department of Surgery Pt. B.D.Sharma Post Graduate Institute of Medical Sciences Rohtak, 33/9 J Medical Campus, PGIMS, Rohtak, 124001 Haryana India
| | - Vijay Malik
- Department of Surgery Pt. B.D.Sharma Post Graduate Institute of Medical Sciences Rohtak, 33/9 J Medical Campus, PGIMS, Rohtak, 124001 Haryana India
| | - Nitin Singhal
- Department of Surgery Pt. B.D.Sharma Post Graduate Institute of Medical Sciences Rohtak, 33/9 J Medical Campus, PGIMS, Rohtak, 124001 Haryana India
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Varicose Vein Recurrence and Patient Satisfaction 10–14 Years Following Combined Superficial and Perforator Vein Surgery: A Prospective Case Study. Eur J Vasc Endovasc Surg 2013; 46:372-7. [DOI: 10.1016/j.ejvs.2013.05.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 05/28/2013] [Indexed: 11/17/2022]
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Kusagawa H, Shomura S, Komada T, Katayama Y, Haruta N. Subfascial endoscopic perforator surgery using screw-type ports is a very useful component of a comprehensive treatment program for chronic venous insufficiency. Ann Vasc Dis 2012; 5:357-63. [PMID: 23555537 DOI: 10.3400/avd.oa.12.00031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 06/22/2012] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Subfascial endoscopic perforator surgery (SEPS) with a two-port system utilizing screw-type ports, CO2 insufflation and an ultrasonic coagulation system, is a useful procedure that does not require burdensome apparatus and techniques. SEPS was accepted as a national advanced medical system by the Japanese Ministry of Health, Labor and Welfare in May 2009. PATIENTS AND METHODS Forty-one limbs of 35 patients with 10 active ulcers (C6) and 2 healed ulcers (C5) were treated by SEPS between February 2010 and December 2011. Thirty-three limbs had concomitant superficial vein surgery. SEPS alone was performed on 8 limbs, in 6 of which the superficial veins had already been ablated. In 2 limbs, incompetent perforating veins (IPVs) existed under the affected skin, around the scars of past surgery. RESULTS All stasis ulcers of the 10 C6 limbs healed between 1 week and 14 months after SEPS (mean 2.9 months), with no ulcer recurrence during the follow-up period (2 to 24 months). IPVs under the scars were easily and safely interrupted by SEPS. CONCLUSION SEPS is a very useful component of a comprehensive treatment program for chronic venous insufficiency, especially in patients with venous stasis ulcers and IPVs under the scars of past surgery.
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Affiliation(s)
- Hitoshi Kusagawa
- Department of Thoracic and Cardiovascular Surgery, Matsusaka Chuo General Hospital, Matsusaka, Mie, Japan
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Lantis JC, Boone D, Lee L, Mendes D, Benvenisty A, Todd G. The effect of percutaneous intervention on wound healing in patients with mixed arterial venous disease. Ann Vasc Surg 2011; 25:79-86. [PMID: 21172582 DOI: 10.1016/j.avsg.2010.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Revised: 09/06/2010] [Accepted: 09/10/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Open venous ulcers in patients with combined arterial and venous insufficiency are notoriously hard to treat. Patients with an ankle-brachial index (ABI) of 0.5-0.8 have been shown to heal poorly. Because adequate compression therapy is contraindicated in patients with an ABI of <0.7, we decided to undertake an aggressive approach of percutaneous revascularization for these patients. METHODS A total of 27 patients with clinical and duplex scan evidence of chronic venous insufficiency, active leg ulcers, and impaired arterial perfusion (ABI: <0.7) were treated using a protocol that required performing percutaneous revascularization before ambulatory compression therapy. The patients were followed at 2-week intervals (average) before and after revascularization. Wound measurements and time to complete closure were also recorded. RESULTS The results of the patients were compared with their own previous wound healing trajectories. Additionally, their healing rate was compared with previously published rates of impaired arterial perfusion venous wound closure; 25% closure at 10 weeks, 50% at 19 weeks. At enrollment, the average ABI and wound sizes were 0.56 and 12 cm(2), respectively. On average, the wounds had remained open for 17 weeks. After the intervention, the average ABI was 0.97, average time taken to complete closure was 10 weeks, closure rate at 10 weeks was 75%, and absolute closure rate was 100%. CONCLUSION Although previous studies have shown that closure of mixed arterial venous ulcers occur without arterial intervention, attaining a near normal ABI allows for timelier wound closure. Therefore, we advocate an aggressive approach of percutaneous revascularization in this population.
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Affiliation(s)
- John C Lantis
- St. Luke's-Roosevelt Hospital, Columbia University, New York, NY 10025, USA.
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Nelzén O, Fransson I. Early results from a randomized trial of saphenous surgery with or without subfascial endoscopic perforator surgery in patients with a venous ulcer. Br J Surg 2010; 98:495-500. [DOI: 10.1002/bjs.7370] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2010] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The aim was to clarify the role of incompetent perforators (IPs) in venous leg ulcers. This short-term report focused on safety, patient satisfaction and the fate of IPs after subfascial endoscopic perforator surgery (SEPS), or saphenous surgery alone.
Methods
Patients aged 30–78 years with an open or recently healed venous ulcer, and with an incompetent saphenous vein and IPs, were allocated randomly to saphenous surgery alone, or in combination with SEPS. A control duplex scan was performed 6–9 months after surgery, and clinical follow-up was scheduled after 1 week, 3 and 12 months. A standard questionnaire was completed at each clinical visit.
Results
Seventy-five patients were enrolled; 37 had SEPS and 38 had saphenous surgery alone. SEPS prolonged the operation by a median of 15 min (P = 0·003). Duplex imaging revealed significantly more remaining IPs in the no-SEPS group (P < 0·001). Compared with the preoperative scan, significantly more legs were free from IPs in the SEPS group compared with the no-SEPS group (21 of 36 versus 7 of 37 respectively; P < 0·001). There were no other major outcome differences between the groups.
Conclusion
There was no short-term clinical benefit from adding SEPS to saphenous surgery in patients with varicose ulcers and IPs, although SEPS reduced the number of perforators remaining after 1 year.
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Affiliation(s)
| | - O Nelzén
- Vascular Surgery Unit, Skaraborg Hospital/Kärnsjukhuset, Skövde, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - I Fransson
- Skaraborg Leg Ulcer Centre and Department of Vascular Surgery, Skaraborg Hospital/Kärnsjukhuset, Skövde, Sweden
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Elias S. Minimally Invasive Vein Surgery: Latest Options for Vein Disease. ACTA ACUST UNITED AC 2010; 77:270-8. [DOI: 10.1002/msj.20186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Marsh P, Price BA, Holdstock JM, Whiteley MS. One-year outcomes of radiofrequency ablation of incompetent perforator veins using the radiofrequency stylet device. Phlebology 2010; 25:79-84. [DOI: 10.1258/phleb.2009.008084] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives Early success treating incompetent perforator veins (IPVs) with radiofrequency ablation (RFA) and the trend to move varicose vein surgery into a walk-in walk-out service led to the design of a specific device enabling RFA of IPVs using local anaesthesia (ClosureRFS™ stylet). Our aim was to assess one-year outcomes of a clinical series of patients undergoing treatment with this device. Truncal reflux, where present, was treated initially, and RFA of IPVs was performed as a secondary procedure. Method Duplex ultrasound examinations were performed and the presence of IPVs documented. Results were compared with preoperative scans. IPVs were classified as closed, not closed/reopened or de novo. Results Of the 75 patients invited for follow-up, 53 attended at a median time of 14 months (range 11–25). Sixty-seven limbs were analysed (M:F 1:2.1, median age 62, range 25–81). Of the 124 treated IPVs, 101 were closed (82%). Clinical, aetiological, anatomical and pathological clinical score was improved in 49.3% limbs. IPV closure was reduced in patients with recurrent varicose veins compared with primary varicose veins (72.3% versus 87%, P = 0.056). Conclusion These results demonstrate the radiofrequency stylet device to be an effective treatment for IPVs.
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Affiliation(s)
- P Marsh
- The Whiteley Clinic, 1 Stirling House, Stirling Road, Guildford, GU2 7RF, UK
| | - B A Price
- The Whiteley Clinic, 1 Stirling House, Stirling Road, Guildford, GU2 7RF, UK
| | - J M Holdstock
- The Whiteley Clinic, 1 Stirling House, Stirling Road, Guildford, GU2 7RF, UK
| | - M S Whiteley
- The Whiteley Clinic, 1 Stirling House, Stirling Road, Guildford, GU2 7RF, UK
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Morales-Cuenca G, Moreno-Egea A, Aguayo-Albasini JL. Los cirujanos generales frente a la cirugía de las varices. Cir Esp 2009; 85:205-13. [DOI: 10.1016/j.ciresp.2008.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 10/13/2008] [Indexed: 10/21/2022]
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Bacon JL, Dinneen AJ, Marsh P, Holdstock JM, Price BA, Whiteley MS. Five-year results of incompetent perforator vein closure using TRans-Luminal Occlusion of Perforator. Phlebology 2009; 24:74-8. [DOI: 10.1258/phleb.2008.008016] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In 2000, we developed a percutaneous method of treating incompetent perforator veins (IPV) using ultrasound-guided radiofrequency ablation (RFA), which we termed TRansluminal Occlusion of Perforator (TRLOP). Objective To audit the five-year outcome of the TRLOP technique as indicated by the rate of IPV closure on duplex ultrasound (DUS). Methods Patients underwent DUS five years post-TRLOP. Experienced vascular technologists documented the presence of IPVs using a two co-ordinate system, blinded to previous results. Results were then compared with preoperative scans. IPVs were classified as: closed; not closed/reopened; or de novo. Closed IPVs were defined as the absence of any IPV at or within 5 cm of a previous IPV in the vertical and horizontal plane. Any IPVs found outside the delineated area were defined as de novo IPVs. Results Of 67 patients invited, 37 attended DUS (55% participation rate; men to women ratio of 14:23, age 40–84; mean 64). Preoperative clinical, aetiological, anatomical and pathological classification: C2, 36.2%; C3, 27.6%; C4, 34.5%; C6, 1.7%. From 125 IPVs analysed, 101 were closed (81%), 24 were not closed/reopened (19%) and 14 de novo IPVs were found. Discussion Despite these results representing our learning curve for the procedure, we found TRLOP to be an effective treatment for IPVs. The closure rates described are comparable with the published clinical series data for subfascial endoscopic perforator surgery.
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Affiliation(s)
- J L Bacon
- The Whiteley Clinic, Stirling Road, Guildford, UK
| | - A J Dinneen
- The Whiteley Clinic, Stirling Road, Guildford, UK
| | - P Marsh
- The Whiteley Clinic, Stirling Road, Guildford, UK
| | | | - B A Price
- The Whiteley Clinic, Stirling Road, Guildford, UK
| | - M S Whiteley
- The Whiteley Clinic, Stirling Road, Guildford, UK
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Luebke T, Brunkwall J. Meta-analysis of subfascial endoscopic perforator vein surgery (SEPS) for chronic venous insufficiency. Phlebology 2009; 24:8-16. [PMID: 19155335 DOI: 10.1258/phleb.2008.008005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives The degree of benefits and risks, and the role of subfascial endoscopic perforator vein surgery (SEPS) in the management for chronic venous insufficiency (CVI) remains uncertain. Methods A multiple health database search was performed including Medline, Embase, Ovid, Cochrane Database of Systematic Reviews, and Cochrane Database of Abstracts of Reviews of Effectiveness, on all studies published between 1985 and 2008 that reported on health outcomes in patients with CVI treated with SEPS and comparing this therapy with the conventional Linton procedure. Three studies, which compared SEPS with conventional surgery, were included in the present meta-analysis. Results Between SEPS and Linton groups, there was a significant lower rate of wound infections for SEPS (odds ratio [OR] 0.06 [95% confidence interval (CI) 0.02 to 0.25]) and a significantly reduced hospital stay for SEPS (OR –8.96 [95% CI –11.62 to –6.30]). In addition, SEPS was associated with a significant reduced rate of recurrent ulcers (mean follow-up 21 months) (OR 0.15 [95% CI 0.04–0.62]). There was no significant difference between the groups in the following dimensions: rate of hospital re-admission (OR 0.21 [95% CI 0.03 –1.31]), death at six months (OR 3.00 [95% CI 0.11–78.27]), ulcer healing rate at four months (OR 0.44 [95% CI 0.09–2.12]), and the rate of deep vein thrombosis (DVT) (OR 0.35 [95% CI 0.01–8.85]). Conclusion From the level of evidence available by now it seems that SEPS, used as a part of a treatment regimen for severe CVI, benefits most patients in the short term regarding ulcer healing and the prevention of ulcer recurrence. It can be safely performed with less early postoperative complications compared with the Linton procedure. However, further prospective randomized trials are required to define the long-term benefits of SEPS.
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Affiliation(s)
- T Luebke
- Department of Vascular Surgery, University of Cologne, Cologne, Germany
| | - J Brunkwall
- Department of Vascular Surgery, University of Cologne, Cologne, Germany
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Poblete H, Elias S. Venous ulcers: new options in treatment: minimally invasive vein surgery. THE JOURNAL OF THE AMERICAN COLLEGE OF CERTIFIED WOUND SPECIALISTS 2009; 1:12-9. [PMID: 24527103 PMCID: PMC3478919 DOI: 10.1016/j.jcws.2008.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Venous disease has a spectrum of presentations. The most advanced state of chronic venous insufficiency (CVI) managed by wound care specialists being ulceration of the lower extremity. The goal of all treatments for advanced venous disease is to decrease ambulatory venous hypertension. Treatment can be divided into exogenous and endogenous methods. Exogenous methods include those applied externally such as compression, elevation, debridement and wound dressings. Endogenous methods treat the underlying venous pathology either due to venous valvular dysfunction or venous obstruction leading to venous hypertension. Recently, significant advances in endogenous methods have evolved. The development of a new concept, minimally invasive vein surgery (MIVS), has improved upon traditional, open, invasive treatments of venous disease. MIVS techniques are performed percutaneously, with minimal anesthesia, no incisions and rarely require hospital admission. This article summarizes the concept of MIVS, describes each method of MIVS and its complementary role in the management of venous leg ulcers patients.
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Affiliation(s)
- Honesto Poblete
- Center for Vein Disease, Mt. Sinai School of Medicine, New York, NY, USA
| | - Steven Elias
- Center for Vein Disease, Mt. Sinai School of Medicine, New York, NY, USA
- Center for Vein Disease, Englewood Hospital and Medical Center, Englewood, NJ, USA
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Blasco SB, Hernández González M, Sabench Pereferrer F, Diáz Lara C, Vilalta FB, Rivas AM, Del Castillo Déjardin DDC. Subfascial endoscopic perforator vein surgery (SEPS) modified technique: subaponeurotic approach without balloon. MINIM INVASIV THER 2008; 17:246-50. [PMID: 18686169 DOI: 10.1080/13645700802274497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Subfascial Endoscopic Perforator Vein Surgery (SEPS) is one of the best procedures and a minimally invasive option for treating chronic venous insufficiency. We explain our experience with SEPS, which has been turned into a subaponeurotic approach without balloon, and assess the possible advantages of this technique. The subaponeurotic space was entered using the Visiport Plus (Autusuture, Tyco Healthcare) video-assisted technique, which shows how the trocar enters through the subcutaneous tissue and superficial aponeurosis of the leg. A blunt retractor was inserted which, together with CO2 insufflation (20 mm Hg), enabled the veins to be dissected. Ligation was performed using tripolar sealing. In no case was a balloon used. There were no incidents such as haemorrhage or subcutaneous emphysema during the procedure. The patients (n = 206) remained in the hospital for less than 24 hours and suffered no post-surgical complications. Active ulcers were cured, with no relapses, in 100% of cases. This is a very effective method for treating advanced chronic insufficiency because it prevents local damage and the rate of post-surgical complications is low. Technically it has more advantages because the fact that it does not use a balloon means that it exerts less pressure on the tissues.
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