Predictive factors of success following radio-frequency stylet (RFS) ablation of incompetent perforating veins (IPV)

Erste Erfahrungen mit einem neuen Radiofrequenzsystem zur endovenösen Perforanstherapie

Einführung Die Behandlung der Perforantenvarikose (PV) gehört zu den großen Herausforderungen in der Phlebologie – nicht nur aufgrund der Vergesellschaftung mit chronischen Ulzera crurium und der Rezidivrate. Endovenöse Verfahren der Perforantenablation (EPA) unterliegen technischen Schwierigkeiten. Wir berichten von einer ersten Serie der EPA mit einem neuartigen Radiowellensystem.

Material, Patienten und Methoden Ausschließlich isolierte PV wurden in die Studie aufgenommen. Zur Diagnosestellung wurden dopplersonografische Untersuchungen (DU) durchgeführt. Die ultraschallgeführte EPA erfolgt unter sterilen Kautelen in der ambulanten Operationsabteilung. Postinterventionelle DU wurden nach einem Tag und 14 Tagen, 5 Wochen sowie 3, 6 und 12 Monaten terminiert. Im Falle einer Rekanalisierung wurde eine Schaumsklerosierung angestrebt.

Ergebnisse Neun PV wurden behandelt. Der durchschnittliche Energieeintrag betrug 969J. Nach einem medianen Nachuntersuchungszeitraum von 257 Tagen betrug die primäre Verschlussrate 75%, die sekundäre nach Schaumsklerosierung 89%. Die minimale Komplikationsrate trug zu einer hohen Patientenakzeptanz bei.

Schlussfolgerung Die EPA zur Behandlung der PV mit dem neuen Radiowellensystem hat sich als wirksam und verträglich bewährt. Weiteren Untersuchungen wird es vorbehalten sein, die endgültige Rolle der EPA in der Behandlung von PV zu definieren.

The need for perforator treatment after VenaSeal and ClosureFast endovenous saphenous vein closure in CEAP 6 patients

OBJECTIVE

The authors have previously demonstrated that VenaSeal (Medtronic, Inc, Minneapolis, Minn) adhesive, compared with radiofrequency ablation (RFA, ClosureFast; Medtronic, Inc), in treatment of refluxing saphenous veins in CEAP 6 limbs, results in shorter healing times of venous ulcers. The authors hypothesize that the longer treated length possible with VenaSeal's nonthermal modality may affect the number of critical refluxing perforators contributing to the nonhealing wound. This follow-up study compares the need for follow-up treatment of perforator veins after saphenous vein treatment with either radiofrequency ablation (ClosureFast RFA) or adhesive closure (VenaSeal).

METHODS

A multi-institutional retrospective review of CEAP 6 patients who had closure of their saphenous veins from 2015 to 2020 was conducted. Patients who underwent follow-up treatment of perforator veins were grouped according to their method of initial management of their saphenous veins. The primary end point was incidence of a perforator procedure after ClosureFast or VenaSeal ablation. Secondary end points included sclerotherapy to facilitate wound healing. Bivariate analysis used the χ² test, Fisher exact test, t-test, and Wilcoxon rank sum test. A P value of <.05 defined statistical significance.

RESULTS

There were 119 CEAP 6 patients with saphenous closure: 51 limbs treated with VenaSeal and 68 with RFA. Median follow-up was 105 days (interquartile range: 44, 208). All limbs achieved wound healing during the study period. Mean time to wound healing post index procedure was shorter for VenaSeal than RFA (72 vs 293.8 days, P > .0009), as was median time (43 vs 104 days, P = .001). More limbs treated with RFA had previous known deep vein thrombosis (29% vs 10%, P = .009), deep venous insufficiency (82% vs 51%, P = .0003), and perforator reflux (57% vs 29%, P = .002). Limbs with identified follow-up perforator reflux treated with RFA had a higher prevalence of initially treated saphenous veins with RFA compared with those treated with VenaSeal (49% vs 27%, P = .003). There was no difference between the methods of vein closure and use of concurrent sclerotherapy.

CONCLUSIONS

ClosureFast and VenaSeal are both effective and safe modalities of saphenous ablation, but VenaSeal treatment was associated with less perforator RFA intervention.

Shortened protocol for radiofrequency ablation of perforator veins

BACKGROUND

Routine radiofrequency ablation (RFA) of an incompetent perforator vein (IPV) using the standard treatment protocol at 85°C has a treatment time of 6 minutes. To make treatment time more efficient, we sought to determine the effect of a shortened protocol for radiofrequency stylet (RFS) ablation by comparing the early success using three different temperatures: 85°C, 90°C, and 95°C.

METHODS

A retrospective study examined 642 procedures of IPV closures in 255 patients with varying degrees of venous insufficiency treated with RFA from 2009 to 2015. The Covidien (Mansfield, Mass) RFA system allows the operator to regulate temperature and allows increments in temperature of the RFS to 85°C, 90°C, and 95°C. The RFS probe was angled at four 90-degree angles at the mentioned temperatures with a shorter treatment time at 6, 4, and 3 minutes, respectively. The three different treatment protocols were compared. All patients had comparative preoperative and postoperative duplex ultrasound scans. Postoperative duplex ultrasound scans were performed 3 to 7 days after the procedure. Successful obliteration was defined as lack of color flow on postoperative duplex ultrasound scanning. Clinical correlation with age, gender, laterality, presenting symptoms (Clinical, Etiology, Anatomy, and Pathophysiology [CEAP] classification), location, and vein diameter was also performed.

RESULTS

Of the 255 patients who underwent RFS ablation, 138 were female, with a mean age of 65 years (standard deviation, ±14.6 years). These patients had CEAP presentations from C1 to C6 (0 C1, 1 C2, 57 C3, 118 C4, 4 C5, 75 C6). The location of the 642 IPVs was distributed as 472 in the calf and 170 in the ankle; 322 of these procedures were performed on the right leg. Use of a shortened protocol had no significant effect on the early obliteration rates with the 85°C, 90°C, and 95°C protocols, which were 66.1%, 61.8%, and 67.1%, respectively. Significant correlation was seen between location of targeted vein and successful obliteration (P < .001). There was a borderline inverse linear association between higher stylet temperature and successful obliteration in the proximal calf at 85°C. After accounting for within-patient correlation, the middle and distal calf continued to show higher nonobliteration compared with the ankle. No clinical correlation with age, gender, laterality, presenting symptoms of CEAP, or vein diameter was observed.

CONCLUSIONS

The study showed that shortening the protocol time for RFA of the perforator did not make a significant difference in the early success rate, regardless of the temperature. The overall early success rate is still low (65.1%). RFA of perforator veins has a higher successful closure rate in proximal calf and ankle areas compared with the middle and distal calf.

Perforator Vein Access for Venous Pharmacomechanical Thrombolysis

A 28-year-old Hispanic female with a history of deep vein thrombosis (DVT) presented to the emergency room with left lower extremity swelling and pain. On duplex venous examination, an extensive left lower extremity DVT extending to her left common iliac vein was identified. A perforator vein measuring 2.6 mm located in the midcalf area was used to access and perform mechanical and chemical thrombolysis. Complete resolution of symptoms was observed.

Treatment of incompetent perforators in recurrent venous insufficiency with adhesive embolization and sclerotherapy

Recurrent lower limb venous insufficiency is often a challenge in clinical practice and is most commonly due to incompetent perforators. Many of these patients do not have adequate symptom relief with compression and require some form of treatment for incompetent perforator interruption. Various treatment methods have been tried with different efficiencies.

Objective

To evaluate the feasibility, efficiency and safety of an outpatient combined cyanoacrylate adhesion–sodium tetradecyl sulphate sclerotherapy for treatment of patients with symptoms of persistent or recurrent lower limb venous insufficiency secondary to incompetent perforators.

Methods

Eighty-three limbs of 69 patients with symptoms of persistent or recurrent lower limb venous insufficiency secondary to incompetent perforators were treated with cyanoacrylate embolization of incompetent perforators and sclerotherapy of dilated collateral veins (surface branch varicose veins). Technical success, procedural pain, perforator occlusion, venous occlusion, clinical improvement and ulcer healing were assessed. Follow-up was done three- and six-month post-procedure.

Results

Procedure could be successfully performed in all patients. One hundred and ninety-one perforators were treated in total. Perforator and varicose veins occlusion rate was 100%. Deep venous extension of cyanoacrylate occurred in four (4.8%) patients, with no adverse clinical outcome. Venous clinical severity score improved from a baseline of 8.18 ± 3.60 to 4.30 ± 2.48 on three-month follow-up and 2.42 ± 1.52 on six-month follow-up (p < 0.0001). All ulcers showed complete healing within three months. Significant prolonged thrombophlebitis occurred in 38.5% of limbs.

Conclusion

Combined cyanoacrylate adhesion and setrol sclerotherapy is technically easy, has a lot of advantages including being an outpatient procedure and highly efficacious but with a guarded safety profile.

Minimally invasive treatments for perforator vein insufficiency

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.

Endovenous laser ablation of insufficient perforating veins: Energy is key to success

Objective

To evaluate the feasibility and anatomical success of endovenous laser ablation (EVLA) of incompetent perforating veins (IPV).

Methods

All 135 consecutive patients with IPV treated with ELVA (intention-to-treat) from January 2008 to December 2013 were included. Up to the end of 2011, an 810-nm laserset (14 W) was used, and afterwards, a 1470-nm laserset (6 W) was introduced. Duplex ultrasound was performed at 6 weeks’ follow-up to assess anatomical success.

Results

Overall anatomical success at 6 weeks’ follow-up was 56%. Anatomical success was 63% after treatment with 810 nm and 45% with 1470 nm ( p = 0.035). This difference in the success rate seems associated with the significantly higher amount of energy delivered in the 810 nm cohort (560 J) versus 1470 nm (186 J). Regardless of the type of laser, anatomical success was significantly higher after treatment with more than 400 J (66%) compared with 0–200 J (40%, p = 0.009) and 200–400 J (43%, p = 0.029). Complications were limited to two cases of transient paresthesia.

Conclusions

EVLA of IPVs is safe and feasible. The amount of energy is highly important in achieving anatomical success.

Current state of the treatment of perforating veins

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.

Debate: whether venous perforator surgery reduces recurrences

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.

Cyanoacrylate adhesive perforator embolization (CAPE) of incompetent perforating veins of the leg, a feasibility study

Consideration of treating incompetent perforating veins remains a conundrum based on scientific evidence available till date. While subfascial endoscopic perforator surgery (SEPS) proved to be a worthy alternative for open surgery, other even less invasive techniques were being introduced by the late nineties of the last century. Percutaneous thermo-ablation techniques are still being used today and seem more effective than non-thermal techniques. However, thermal techniques require anaesthesia and potentially may cause inadvertent damage to surrounding tissues such as nerves. Cyanoacrylate adhesive has a proven record, but not for the treatment of chronic venous disease of the leg. Innovation has led to the development of the VenaSeal® Sapheon Closure System which has been designed to use a modified cyanoacrylate glue as a new therapy for truncal vein incompetence. This paper explores the feasibility of ultrasound guided cyanoacrylate adhesive perforator embolization (CAPE). Results show a 76% occlusion rate of incompetent perforating veins without serious complications leading to the conclusion that further investigation with a dedicated delivery device in a larger patient population is warranted.

Saphenous pulsation on duplex may be a marker of severe chronic superficial venous insufficiency

BACKGROUND

Pulsatile flow in deep, perforating veins and varicose veins (VVs) has been described previously to support a hypothesis of arteriovenous (AV) fistulae in the pathogenesis of VVs. Its presence has also been suggested as a cause of failure of VV treatments. However, AV communications have never been adequately visualized and direct pressure tracings within leg veins have been inconclusive. The present study was observational aiming to investigate the prevalence and rate of spontaneous pulsation within the great saphenous vein (GSV) in volunteers and patients using color duplex and compare this to reflux and markers of disease severity.

METHODS

Twenty-seven consecutive patients (32 legs, median Venous Clinical Severity Score (VCSS) = 5 [0-11]) attending the VV clinic and 23 consecutive ambulatory normal volunteers (46 legs) had their GSV assessed at midthigh using color duplex. Subjects were examined standing with the hips resting against an adjustable couch, bearing weight on the contralateral leg, with the test leg touching the ground. The presence of flow and reflux were initially determined using manual calf compression. Saphenous pulsation (SP) was defined as a cyclical change in velocity. The GSV diameter and SP rate were then recorded after 2 minutes of dependency. The number of pulsations was counted from video recordings.

RESULTS

The resting SP, if present, was discrete, monophasic, of variable amplitude, antegrade, and irregular, irrespective of respiration. Pulsation was detected in 2/44 (4.5%) legs with C(0-1) (C part of CEAP), 9/17 (52.9%) legs with C(2-3), and 16/17 (94.1%) legs with C(4-6) (P < .05, z test of column proportions). Reflux occurred in 8/32 (25%) legs without SP (C(0) = 2, C(1) = 1, C(2) = 3, C(3) = 2). The median GSV diameter was significantly elevated in the presence of SP (no pulse: 3.5 [range, 1.5-8.1] mm; pulse: 7 [range, 4-9.4] mm; P < .0005). The median refluxing GSV diameter in GSV pulsators compared with nonpulsators was 7 (range, 4-9.4) mm; vs 5.1 (range, 2.7-8.1) mm, respectively (P = .003). The median SP rate in refluxing GSVs was 52 (range, 22-95) beats per minute.

CONCLUSIONS

The high prevalence of pulsatile antegrade saphenous flow is a novel observation in patients with severe superficial chronic venous insufficiency. It is detectable in 75% of patients with GSV reflux and significantly increases with clinical severity and saphenous diameter. It may be a marker of advanced venous disease and, as it is easy to record, it could supplement duplex evaluations of reflux. Further work is needed to establish the clinical relevance of the SP in terms of disease progression, recurrence after treatment, and as a hemodynamic marker of severity.

The role of perforators in chronic venous insufficiency

Thesis

Venous ulcers (VU) consume considerable resources in healthcare systems, up to 1% of healthcare budgets in industrialized countries. Best practice guidelines (GLs) incorporate evidence-based diagnostic and therapeutic recommendations in a cost-effective manner and have been associated with improved and less costly outcomes for many diseases.

Objectives

To determine whether there are common elements in GLs for VU and their evidentiary strength.

Methods

A systematic analysis of GLs for VU that were identified through clinicaltrials.gov, a government-sponsored website, and from experts outside the USA.

Results

Ten of 12 GLs on VU (7 North America and 5 Europe) were evidence-based, with the majority using the GRADE method. Only two had been developed or updated within the last three years. Venous duplex and ankle ABIs were recommended in all. Debridement was suggested in two, while simple non-adherent wound dressings were favoured in nine, and hydrocolloid in two. Only one GL discussed a range of dressing options, dependent on the condition of the VU. High pressure multi-layer compression bandages were favoured in 10. Only two focused on the importance of improving ankle joint mobility.

Conclusions

While there are numerous evidence-based GLs for VU, the majority may lag recent developments in the field. There is consensus on the elements for dressings and compression among the various GLs, which should facilitate the development of a common consensus GL, similar to that for DVT/PE. To improve patient care and reduce wasted resources, it is imperative for specialty societies to develop this consensus document.