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Viljamaa J, Firoozi K, Venermo M, Pokela M, Pihlaja T, Halmesmäki K, Hakovirta H. A study protocol for comparing the treatment of varicose tributaries either concomitantly with or separately from endovenous laser ablation of the incompetent saphenous trunk (the FinnTrunk Study). A multicenter parallel-group randomized controlled study. PLoS One 2023; 18:e0285823. [PMID: 37220130 DOI: 10.1371/journal.pone.0285823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/01/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Opinions on the treatment of varicose tributaries in relation to saphenous ablation in varicose disease vary. Moreover, the possible role of the tributaries regarding the recurrence of varicose disease remains unclear. The aim of the FinnTrunk study is to compare two different treatment strategies for varicose disease in a randomized setting. In group one, the initial treatment will entail endovenous laser ablation (EVLA) of the incompetent saphenous trunk without tributary treatment. In group two, the varicose tributaries will be treated with ultrasound-guided foam sclerotherapy (UGFS) concomitantly with truncal ablation. The primary outcome measure is the need for additional procedures during the follow-up. The secondary outcome measures are the cost of treatment and recurrence of varicose disease. METHODS Consecutive patients with symptomatic varicose disease (CEAP clinical class C2-C3) will be screened for the study. Patients who fulfil the study criteria and give their informed consent will be scheduled for the procedure and randomized to either study group. Patients will be followed-up at 3 months, 1 year, 3 years, and 5 years. The post-procedure pain score based on a numeric rating scale (NRS) and also the use of analgesics, as well as possible procedure-related complications will be recorded at 3 months. Patient-reported outcome measures (PROMs) will be recorded at 1 year. Data pertaining to the additional treatment of varicose tributaries, the Aberdeen Varicose Vein Questionnaire (AVVQ), the Venous Clinical Severity Score (VCSS), and the health-related quality of life (EQ-5D-5L) will be collected at each follow-up visit. A duplex ultrasound (DUS) examination will be performed at each visit, and data on varicose tributaries and the need for additional treatment will be recorded. TRIAL REGISTRATION Registered on ClinicalTrials.gov, ID NCT04774939.
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Affiliation(s)
- Jaakko Viljamaa
- University of Turku, Turku, Finland
- Department of Vascular Surgery, Turku University Hospital, Turku, Finland
| | - Khalil Firoozi
- University of Turku, Turku, Finland
- Department of Vascular Surgery, Turku University Hospital, Turku, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Matti Pokela
- Department of Vascular Surgery, Oulu University Hospital, Oulu, Finland
- University of Oulu, Oulu, Finland
| | - Toni Pihlaja
- Department of Vascular Surgery, Oulu University Hospital, Oulu, Finland
- University of Oulu, Oulu, Finland
| | - Karoliina Halmesmäki
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harri Hakovirta
- University of Turku, Turku, Finland
- Department of Vascular Surgery, Turku University Hospital, Turku, Finland
- Satasairaala, Pori, Finland
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Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, Bush RL, Di Iorio M, Fish J, Fukaya E, Gloviczki ML, Hingorani A, Jayaraj A, Kolluri R, Murad MH, Obi AT, Ozsvath KJ, Singh MJ, Vayuvegula S, Welch HJ. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2023; 11:231-261.e6. [PMID: 36326210 DOI: 10.1016/j.jvsv.2022.09.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022]
Abstract
The Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society collaborated to update the 2011 Society for Vascular Surgery/American Venous Forum clinical practice guidelines and provide new evidence-based recommendations on critical issues affecting the care of patients with varicose veins. Each recommendation is based on a recent, independent systematic review and meta-analysis of the diagnostic tests and treatments options for patients with lower extremity varicose veins. Part I of the guidelines includes evidence-based recommendations for the evaluation of patients with CEAP (Clinical Class, Etiology, Anatomy, Pathology) class 2 varicose vein using duplex ultrasound scanning and other diagnostic tests, open surgical treatment (ligation and stripping) vs endovenous ablation techniques, thermal vs nonthermal ablation of the superficial truncal veins, and management of incompetent perforating veins in CEAP class 2 disease. We have also made recommendations on the concomitant vs staged treatment of varicose tributaries using phlebectomy or liquid or foam sclerotherapy (with physician-compounded foam or commercially prepared polidocanol endovenous microfoam) for patients undergoing ablation of incompetent superficial truncal veins.
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Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Suman M Wasan
- Department of Medicine, University of North Carolina, Chapel Hill, and Rex Vascular Specialists, UNC Health, Raleigh, NC
| | | | - Jose Almeida
- Miller School of Medicine, University of Miami, Miami, FL
| | | | - Ruth L Bush
- Central Texas Veterans Affairs Healthcare System and Texas A&M University College of Medicine, Temple, TX
| | | | - John Fish
- Department of Medicine, Jobst Vascular Institute, University of Toledo, Toledo, OH
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University, Stanford, CA
| | | | | | - Arjun Jayaraj
- RANE Center for Venous and Lymphatic Diseases, Jackson, MS
| | - Raghu Kolluri
- Heart and Vascular Service, OhioHealth Riverside Methodist Hospital, Columbus, OH
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Whiteley MS. Current Best Practice in the Management of Varicose Veins. Clin Cosmet Investig Dermatol 2022; 15:567-583. [PMID: 35418769 PMCID: PMC8995160 DOI: 10.2147/ccid.s294990] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/27/2022] [Indexed: 12/01/2022]
Abstract
This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.
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Kuserli Y, Kavala AA, Turkyilmaz S. Comparison of high saphenous ligation and stripping, radiofrequency ablation, and subfascial endoscopic perforator surgery for the treatment of active venous ulcers: Retrospective cohort with five-year follow-up. Vascular 2021; 30:375-383. [PMID: 33896291 DOI: 10.1177/17085381211011356] [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: 11/15/2022]
Abstract
OBJECTIVE To compare the use of high saphenous ligation and stripping, radiofrequency ablation, and subfascial endoscopic perforator surgery for the treatment of active venous ulcers. METHODS One hundred ninety-five (n = 195) subjects who were treated for venous leg ulcers were enrolled between 2009 and 2014. Three groups were formed (Group A: high saphenous ligation and total stripping, Group B: radiofrequency ablation of the great saphenous vein + perforators, and Group C: radiofrequency ablation of the great saphenous vein + subfascial endoscopic perforator surgery) (n = 65 for each group). The venous clinical severity score for baseline, 1st, 6th, and 12th months, great saphenous vein occlusion at the 1st, 6th, and 12th months, and ulcer rates for the 1st, 2nd, 3rd, 4th, and 5th years were recorded. RESULTS For venous clinical severity score, only the first month decrease was significant for the subfascial endoscopic perforator surgery group (p = 0.001). Great saphenous vein occlusion was higher at the 6th and 12th months for the high saphenous ligation and stripping and subfascial endoscopic perforator surgery groups than for the radiofrequency ablation group (p = 0.036 and p = 0.037). The rate of ulcers for the subfascial endoscopic perforator surgery group was lower at the second, third, fourth, and fifth years (p = 0.011). No significant difference was found between groups for the five-year recovery rates (p > 0.05). CONCLUSION Subfascial endoscopic perforator surgery technique in conjunction with radiofrequency ablation of axial vein was superior to both high saphenous ligation and stripping and radiofrequency ablation of axial and perforators for ulcer healing.
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Affiliation(s)
- Yusuf Kuserli
- Department of Cardiovascular Surgery, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Ali Aycan Kavala
- Department of Cardiovascular Surgery, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Saygin Turkyilmaz
- Department of Cardiovascular Surgery, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Obermayer A, Aubry JF, Barnat N. Extracorporeal Treatment with High Intensity Focused Ultrasound of an Incompetent Perforating Vein in a Patient with Active Venous Ulcers. EJVES Vasc Forum 2020; 50:1-5. [PMID: 33377135 PMCID: PMC7758513 DOI: 10.1016/j.ejvsvf.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/18/2020] [Accepted: 11/26/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Endovenous techniques such as ultrasound guided foam sclerotherapy, thermal methods, or glues are generally recommended to occlude incompetent veins. However, these methods can be technically challenging and risky for patients with severe atrophic skin disorders like lipodermatosclerosis or atrophie blanche. High intensity focused ultrasound (HIFU), which has been shown to coagulate and occlude veins successfully, may offer an alternative method. This case report details ultrasound guided HIFU to occlude non-invasively a refluxing perforator vein causing active ulcers. Report A 95 year old man presented to the Institute for Functional Phlebology (Melk, Austria) with painful recurrent ulcers in his left medial calf. His limb was scored C2,3,4a, b,6, Ep, Ap, Pr,18 according to the Clinical, Etiology, Anatomic, Pathophysiology (CEAP) classification. Lower limb ultrasound revealed a refluxing posterior tibial perforating vein, measuring 2.7 mm in diameter at the level of the fascia. Extracorporeal HIFU pulses were delivered to this vein with the Sonovein device (Theraclion, Malakoff, France). Sonication was applied for eight seconds at a mean acoustic power of 80 W. The patient was followed up for three months post-treatment and occlusion was evaluated by duplex ultrasound. There were no complications during treatment or follow up. Three months after the treatment, reflux was abolished and the two initially active ulcers had healed. Discussion Although this is an early report, this study shows that HIFU can be successful in ablation of incompetent perforator veins in the treatment of venous leg ulcers. Endovenous methods are not suited to all patients with severe skin disorders. High intensity focused ultrasound can treat venous leg disorders non-invasively. Treatments have been performed on a refluxing perforator vein causing active ulcers. Short-term results showed that this technique is as good as other thermal therapies.
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Affiliation(s)
- Alfred Obermayer
- Institute for Functional Phlebosurgery, Karl Landsteiner Society, Melk, Austria
| | - Jean-François Aubry
- Physics for Medicine Paris, INSERM, ESPCI Paris, CNRS, PSL Research University, Paris, France
| | - Nesrine Barnat
- Physics for Medicine Paris, INSERM, ESPCI Paris, CNRS, PSL Research University, Paris, France.,Theraclion, Malakoff, France
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Cavezzi A. Medicine and Phlebolymphology: Time to Change? J Clin Med 2020; 9:E4091. [PMID: 33353052 PMCID: PMC7766771 DOI: 10.3390/jcm9124091] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023] Open
Abstract
Biomedical science is undergoing a reappraisal of its scientific advancement process and of the related healthcare management. Progress in medicine should combine improvements of knowledge, efficacy, and safety of diagnostic/therapeutic procedures, with adequate cost-effectiveness profiles. This narrative review is aimed at assessing in medicine, more specifically in phlebology and lymphology: (a) scientific literature possible biases, (b) the level of evidence, comprehensiveness, and cost-effectiveness of the main therapeutic options, and (c) the possible contribution of integrative and translational medicine. Current medical research may have cognitive biases, or industry-tied influences, which impacts clinical practice. Some reductionism, with an increasing use of drugs and technology, often neglecting the understanding and care of the root causative pathways of the diseases, is affecting biomedical science as well. Aging brings a relevant burden of chronic degenerative diseases and disabilities, with relevant socio-economic repercussions; thus, a major attention to cost-effectiveness and appropriateness of healthcare is warranted. In this scenario, costly and innovative but relatively validated therapies may tend to be adopted in venous and lymphatic diseases, such as varicose veins, leg venous ulcer, post-thrombotic syndrome, pelvic congestion syndrome, and lymphedema. Conversely, a more comprehensive approach to the basic pathophysiology of chronic venous and lymphatic insufficiency and the inclusion of pharmacoeconomics analyses would benefit overall patients' management. Erroneous lifestyle and nutrition, together with chronic stress-induced syndromes, significantly influence chronic degenerative phlebo-lymphatic diseases. The main active epigenetic socio-biologic factors are obesity, dysfunctions of musculo-respiratory-vascular pumps, pro-inflammatory nutrition, hyperactivation of stress axis, and sedentarism. An overall critical view of the scientific evidence and innovations in phebolymphology could be of help to improve efficacy, safety, and sustainability of current practice. Translational and integrative medicine may contribute to a patient-centered approach. Conversely, reductionism, eminence/reimbursement-based decisional processes, patients' lack of education, industry-influenced science, and physician's improvable awareness, may compromise efficacy, safety, appropriateness, and cost-effectiveness of future diagnostic and therapeutic patterns of phlebology and lymphology.
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Woodburn KR. Endothermal ablation for the treatment of clinically significant incompetent lower limb perforating veins: factors influencing the early outcomes. Phlebology 2020; 36:127-134. [PMID: 32903159 DOI: 10.1177/0268355520955085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To review the clinical experience and early outcomes of endothermal perforator ablation. METHOD Retrospective review of an endovenous practice from 2007-2019. Clinically significant incompetent perforators were treated by Endovenous Laser Ablation (EVLA), or segmental radiofrequency ablation (RFA). RESULT Complete data were available for 110 of the 116 symptomatic incompetent perforating veins treated. Radiofrequency ablation of 20 perforators produced a 55% perforator closure rate, while 90 EVLA perforator ablations resulted in a closure rate of 80%. Closure rates with EVLA varied by location and perforator length. Closure rates for truncal ablation were 95.5% for RFA and 97.2% for EVLA. CONCLUSION Early closure rates following endothermal ablation of incompetent lower limb perforating veins are lower than those obtained for truncal ablation. EVLA perforator closure appears to be more effective than segmental RFA in most situations but short treatment lengths and location at the ankle are associated with the poorest outcomes.
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A prospective safety and effectiveness study using endovenous laser ablation with a 400-μm optical fiber for the treatment of pathologic perforator veins in patients with advanced venous disease (SeCure trial). J Vasc Surg Venous Lymphat Disord 2020; 8:805-813. [DOI: 10.1016/j.jvsv.2020.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 01/17/2020] [Indexed: 11/21/2022]
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Abstract
OBJECTIVE To provide an evidence-based overview of endovenous laser ablation and describe its role as an effective and durable technique for the management of superficial venous insufficiency. METHODS The published literature on the treatment of varicose veins using endovenous laser ablation was reviewed. The literature search focused on the history of endovenous laser ablation, its safety and durability, known complications, and differences in outcomes based on the iterations of fiber type and laser wavelength. RESULTS Treatment safety and efficacy of endovenous laser ablation appear to be based on the amount of energy administered over a defined distance, or the linear endovenous energy density. The ideal linear endovenous energy density varies with the laser wavelength and fiber-type. Post-operative pain and bruising may be reduced by the use of higher wavelength fibers or the use of radial or jacket-tip fibers as compared to bare-tip fibers. The incidence of endothermal heat-induced thrombosis remains low and has declined with increasing experience. Reports have demonstrated a greater than 90% technical success rate with saphenous endovenous laser ablation, long-term durability of ablation, and commensurate improvement in quality of life. CONCLUSIONS Endovenous laser ablation is a safe and durable treatment option for the management of incompetent superficial and perforator veins of the lower extremities. As an endothermal technology, it remains a key component of the standard of care for the treatment of chronic venous insufficiency.
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Affiliation(s)
| | - Lowell S Kabnick
- Atlantic Health, Morristown Medical Center, Kabnick Vein Center, Morristown, NJ, USA
| | - Mikel Sadek
- Department of Surgery, NYU Langone Health, New York City, NY, USA
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Reitz KM, Salem K, Mohapatra A, Liang NL, Avgerinos ED, Singh MJ, Hager E. Complete Venous Ulceration Healing after Perforator Ablation Does Not Depend on Treatment Modality. Ann Vasc Surg 2020; 70:109-115. [PMID: 32603845 DOI: 10.1016/j.avsg.2020.06.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/06/2020] [Accepted: 06/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Venous leg ulceration (VLU) represents the most advanced form of chronic venous insufficiency (CVI). Persistent VLU that fails to respond to noninvasive treatment requires a minimally invasive endovascular treatment, which may include chemical (ultrasound-guided foam sclerotherapy [UGFS]) and thermal ablation (endovenous laser therapy [EVLT] or radiofrequency ablation [RFA]) targeting incompetent veins. Current guidelines suggest ablation of incompetent perforating veins (IPVs) juxtaposed to active or healed VLU; however, the ideal treatment modality is unknown. We hypothesize that similar to incompetent superficial vein treatment options therapies, VLU healing will be equivalent across minimally invasive IPV treatment options. METHODS Using the Vascular Low Frequency Disease Consortium, adults with VLU across 11 medical centers were retrospectively reviewed (2013-2017). We included those who underwent IPV therapies. The primary outcome was complete ulcer healing over time compared with cumulative hazard curves, log-rank testing, and multivariable Cox proportional hazard regression. Secondary outcomes included number of subsequent procedures, which were compared using negative binomial regression. RESULTS Of the 832 adults with VLU, 158 (19%) were exclusively treated conservatively, and 232 (28%) underwent index treatment for IPV and constitute the full and final cohort. The mean age was 60 ± 14 years, 57% were men, and the mean ulcer area was 3.0 cm2 (interquartile range, 1-6 cm2). Ninety-one (39%) were treated with EVLT, 127 (55%) RFA, and 14 (6%) UGFS. Patients treated with RFA were older (RFA 62 ± 14 years; EVLT 59 ± 14 years; UGFS 52 ± 9 years; P = 0.01), more likely to be men (RFA 68%, n = 86; EVLT 41%, n = 37; UGFS 64%, n = 9; P < 0.001), with a higher frequency of anticoagulation (RFA 36%, n = 46; EVLT 18%, n = 16; UGFS 14%, n = 2; P = 0.005). VLU did not significantly differ in size between groups (RFA 6.2 ± 8; EVLT 4.2 ± 5.4; UGFS 6.1 ± 8; P < 0.001). There were no differences in 1-year ulcer healing rates between groups (P = 0.18). The number of subsequent procedures did not differ by treatment modality (P = 0.47). CONCLUSIONS This multi-institutional retrospective study does not demonstrate any association of IPV treatment modality with differing rates of VLU healing or number of subsequent procedures.
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Affiliation(s)
| | - Karim Salem
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Eric Hager
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
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Nicolaides A, Kakkos S, Baekgaard N, Comerota A, de Maeseneer M, Eklof B, Giannoukas A, Lugli M, Maleti O, Mansilha A, Myers KA, Nelzén O, Partsch H, Perrin M. Management of chronic venous disorders of the lower limbs. Guidelines According to Scientific Evidence. Part II. INT ANGIOL 2020; 39:175-240. [PMID: 32214074 DOI: 10.23736/s0392-9590.20.04388-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | | | | | | | | | - Bo Eklof
- American Venous Forum, Hoffman Eastates, IL, USA
| | | | | | | | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Department of Angiology and Vascular Surgery, S. João Hospital, Porto, Portugal
| | | | - Olle Nelzén
- Vascular Surgery Unit, Skaraborg Hospital, Kärnsjukhuset, Skövde, Sweden
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de Moraes Silva MA, Flumignan RLG, Miranda F, Cardoso RS, Silva SGDJ, Guedes HJ, Nakano LCU. Protocol for a systematic review and meta-analysis of interventions for pathologic perforator veins in chronic venous disease. BMJ Open 2019; 9:e024088. [PMID: 31048426 PMCID: PMC6502043 DOI: 10.1136/bmjopen-2018-024088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 03/04/2019] [Accepted: 03/08/2019] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Perforator veins (PVs) play an important role in the development of chronic venous insufficiency and ulceration. Procedures to eliminate incompetence and reflux in PV may include open surgery, subfascial endoscopic surgery, intravenous ablation techniques and sclerotherapy. With the aim of filling the evidence gap, this is a protocol for a systematic review that will assess the effects of any form of intervention for the treatment of pathologic PVs of the lower limbs in patients with chronic venous disease. METHODS AND ANALYSIS Systematic searches will be carried out in MEDLINE, EMBASE, Cochrane CENTRAL, IBECS and LILACS databases at a minimum without date or language restrictions for relevant randomised controlled trials (RCTs) and quasi-RCTs (trials in which the method of allocation is not truly random). In addition, a search will also be carried out in the WHO International Clinical Trials Registry Platform, in the clinical trial registries of ClinicalTrials.gov and in the grey literature source OpenGrey.eu. The RCT and quasi-RCT comparison techniques isolated or in combination for treating PVs will be considered. Three review authors will independently perform data extraction and quality assessments of data from included studies, and any disagreements will be resolved by discussion. The primary outcomes will be wound healing and pain. Secondary outcomes will include oedema, adverse events, recurrence or recanalisation, quality of life and economic aspects. The Cochrane handbook will be used for guidance. If the results are not appropriate for a meta-analysis in RevManV.5 software (eg, if the data have considerable heterogeneity and are drawn from different comparisons), a descriptive analysis will be performed. ETHICS AND DISSEMINATION Ethics committee approval is not necessary. We intend to update the public registry used in this review, report any important protocol amendments and publish the results in a widely accessible journal. PROSPERO REGISTRATION NUMBER CRD42018092974.
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Affiliation(s)
- Melissa Andreia de Moraes Silva
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Division of Vascular and Endovascular Surgery, Hospital de Clínicas de Itajubá, Itajubá, MG, Brazil
| | - Ronald Luiz Gomes Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Fausto Miranda
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Rodolfo Souza Cardoso
- Division of Vascular and Endovascular Surgery, Hospital de Clínicas de Itajubá, Itajubá, MG, Brazil
| | | | - Henrique Jorge Guedes
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Luis Carlos Uta Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Bitner J, Sachdev U, Hager ES, Dillavou ED. Standardized care protocol and modifications to electronic medical records to facilitate venous ulcer healing. J Vasc Surg Venous Lymphat Disord 2019; 7:570-576. [PMID: 30777673 DOI: 10.1016/j.jvsv.2018.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 11/12/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Venous ulcers are painful, recurrent, and difficult to heal. Electronic medical records (EMRs) are often not optimized to track wounds. Specialized wound care programs may not interface with office-based records, creating a need to standardize the process of venous ulcer measurement and dressing documentation within existing systems. This work describes the creation of an EMR protocol to track venous ulcer size, to standardize dressings, to address related health issues, and to improve education of the patient. We hypothesized that the institution of an EMR protocol to track clinical features of venous ulcer patients, including wound size and health status, would facilitate wound healing. METHODS We performed a retrospective review of a prospective database from September 2014 to May 2017. Modifications to the EMR included the formation of a venous ulcer patient list, a dressing tracker, calculation of total ulcer area, graphing of ulcer size over time, and images of the wound area. Patient education materials were created through the EMR and loaded into an automatic end-visit printout that emphasized smoking cessation, weight loss, and consultation with specialty services as necessary. Quarterly meetings with the supervising physician were established to review each patient's wound progress and to target areas of improvement. RESULTS During the study period, 204 patients with chronic C5 and C6 disease were observed. Before the start of the project, the healing rate was 53.3%. Wound healing rates improved from 59.5% (quarter 1) to 77.94% (quarter 8). In the quarter before the project started, there were no patients who had quit or cut down on smoking or smokeless tobacco, no patients who were referred for weight loss consultation, and nine who were already patients of bariatric surgery. During the study period, 29% of patients quit smoking, 19% decreased smoking, and 20% cut down smokeless tobacco use. There were 54 patients who underwent advanced arterial evaluation; 175 patients underwent sclerotherapy and 137 patients had endovenous thermal ablation to treat axial reflux in the affected limb. The EMR modification project took 13 months to craft and to implement, with approximately 8 hours of meeting time from the surgical team. CONCLUSIONS A comprehensive care model for venous ulcer patients through EMR modification improved overall patient care, increased communication between providers, and facilitated ulcer healing. EMR modification can be introduced with an acceptable time investment on the part of both the provider and the institutional information technology team.
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Affiliation(s)
- Julie Bitner
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ulka Sachdev
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Eric S Hager
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ellen D Dillavou
- Department of Surgery, Division of Vascular Surgery, Duke University Health System, Durham, NC.
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Barnat N, Grisey A, Lecuelle B, Anquez J, Gerold B, Yon S, Aubry JF. Noninvasive vascular occlusion with HIFU for venous insufficiency treatment: preclinical feasibility experience in rabbits. ACTA ACUST UNITED AC 2019; 64:025003. [DOI: 10.1088/1361-6560/aaf58d] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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16
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Aurshina A, Ascher E, Mount L, Hingorani A, Marks N, Hingorani A. Success rate and factors predictive of redo radiofrequency ablation of perforator veins. J Vasc Surg Venous Lymphat Disord 2018; 6:621-625. [DOI: 10.1016/j.jvsv.2018.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 01/22/2018] [Indexed: 10/17/2022]
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17
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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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18
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Prasad BP K, Joy B, Toms A, Sleeba T. Treatment of incompetent perforators in recurrent venous insufficiency with adhesive embolization and sclerotherapy. Phlebology 2017; 33:242-250. [DOI: 10.1177/0268355517696612] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
| | - Binu Joy
- Department of Radiology, Rajagiri Hospital, Aluva, Kerala
| | - Ajith Toms
- Department of Radiology, Rajagiri Hospital, Aluva, Kerala
| | - Teena Sleeba
- Department of Radiology, Rajagiri Hospital, Aluva, Kerala
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Ozsvath K, Hager E, Harlander-Locke M, Masuda E, Elias S, Dillavou ED. Current techniques to treat pathologic perforator veins. J Vasc Surg Venous Lymphat Disord 2017; 5:293-296. [DOI: 10.1016/j.jvsv.2016.10.085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 10/30/2016] [Indexed: 01/08/2023]
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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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Hager ES, Washington C, Steinmetz A, Wu T, Singh M, Dillavou E. Factors that influence perforator vein closure rates using radiofrequency ablation, laser ablation, or foam sclerotherapy. J Vasc Surg Venous Lymphat Disord 2016; 4:51-6. [DOI: 10.1016/j.jvsv.2015.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/25/2015] [Indexed: 10/22/2022]
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