Systematic review and meta-analysis of endovenous cyanoacrylate adhesive ablation for incompetent saphenous veins

Endovenous Microwave Ablation Versus Laser Ablation for Small Saphenous Vein Varicosis

INTRODUCTION

Laser and radiofrequency ablation are two thermal ablation methods currently widely used to treat lower limb venous insufficiency. However, very few studies have been conducted on the use of microwaves, a form of thermal ablation, for the treatment of small saphenous vein (SSV) insufficiency. This study aimed to examine the efficacy and safety of endovenous microwave ablation (EMA) for the treatment of SSV insufficiency.

METHODS

The clinical data of 126 patients (126 lower limbs) with SSV insufficiency (SSV trunk reflux time ≥ 500 ms on lower limb color Doppler ultrasound) treated at the Surgery Department of The Sixth People's Hospital of Zhuji from January 2020 to June 2022 were analyzed retrospectively; 64 patients underwent EMA and 62 underwent endovenous laser ablation (EVLA). The perioperative marker data [duration of surgery, duration of hospitalization, length of thermal ablation, duration of thermal ablation, number of incisions, and numerical pain rating scale (NPRS)], complication data [skin ecchymosis, skin burns, surgical site infection, paresthesia, deep vein thrombosis (DVT), and heat-induced thrombosis (EHIT)], venous clinical severity score (VCSS), chronic venous disease quality of life questionnaire (CIVIQ-20) before and 1, 3, 12 months after surgery, and SSV trunk occlusion rate at 12 months after surgery were compared between the two groups.

RESULTS

No significant differences in the surgery or hospitalization durations were observed between the two groups. There were no significant differences in the length of the SSV that required thermal ablation between the two groups; however, the thermal ablation time was shorter in the EMA group than that in the EVLA group (6.14 ± 1.47 min vs 7.05 ± 1.16 min, P < 0.001). There were no statistical differences in the number of incisions, volume of tumescent solution used, or quantity of sclerosing foam used. The NPRS scores of the EMA group at 24 h and 72 h after surgery were significantly greater than those of the EVLA group (4.03 ± 0.98 vs 3.52 ± 1.28, P = 0.013; 3.78 ± 1.06 vs 3.15 ± 1.03, P = 0.001). Moreover, the two groups showed no significant difference in the NPRS score at 1 month (1.14 ± 0.84 vs 1.07 ± 0.75, P = 0.623). The EMA and EVLA group patients experienced similar postoperative complications. The VCSS and CIVIQ-20 score significantly improved at 1, 3, and 12 months after surgery. The VCSS and CIVIQ-20 scores were compared between the two groups at 12 months after surgery, and there were no significant differences (1.44 ± 0.63 vs 1.56 ± 0.56, P = 0.261; 24.24 ± 4.96 vs 25.19 ± 5.36, P = 0.304). There was no significant difference in the incidence of SSV trunk occlusion at 12 months after surgery between the two groups (95.31% vs 96.77%, OR 1.475; 95% CI 0.238-9.146, P = 1.000).

CONCLUSION

EMA and EVLA are equally effective treatment methods for SSV insufficiency. EMA is associated with higher NPRS scores in the early postoperative period.

[Varicosis-Current treatment concepts]

Varicosis is a chronic progressive disease characterized by varicose veins of the lower extremities. Pain, swelling and heaviness of the legs are typical symptoms. These symptoms are caused by a pathological venous reflux, arising from a weakness of the vein wall and progressive venous insufficiency. The indications for invasive surgery are the symptomatic clinical, etiological, anatomical, pathophysiological (CEAP) stages C2s-C6. Compression therapy and venoactive drugs can be recommended for conservative therapy. When it comes to surgical treatment conventional open vein surgery is associated with the best long-term results. Endovenous thermal ablation is associated with few postoperative complications and favors earlier mobilization of the patient. Sclerotherapy has become established with good clinical results for the ablation of reticular and telangiectatic veins, for recurrences and complicated vein anatomy.

Complications of cyanoacrylate adhesive closure therapy in chronic venous insufficiency: A single center, single-surgeon study

OBJECTIVES

In this study, we present the complication data of patients we treated for chronic venous insufficiency (CVI) with cyanoacrylate adhesive closure (CAC) therapy for 2 years.

METHODS

Complications of 382 CAC procedures performed by the same surgeon were reviewed retrospectively.

RESULTS

Independent of patients, depending on the payment system of the state; two hundred twenty-three (58.4%) of 382 procedures were performed using the Venex system, and the Variclose system was used in 159 (41.6%) patients. A phlebitis-like reaction occurred in 46 (12%) patients, induration in 18 (4.7%) patients, hyperpigmentation in five (1.3%) patients, abscesses in four (1%) patients, cellulitis in three (0.8%) patients, and granuloma in one (0.3%) patient. In addition, as serious complications, deep vein thrombosis (DVT) developed in three patients and pulmonary embolism in one of these patients. Interestingly, temporary blindness was also observed in one patient.

CONCLUSIONS

Although CAC therapy is a reliable method, its complications should not be ignored. Its use by experienced surgeons reduces the risk of complications.

Natural history and role of anticoagulation in the management of endovenous glue-induced thrombus

OBJECTIVE

The natural history of endovenous glue-induced thrombus (EGIT) resolution and the role of anticoagulation (AC) and/or anti-platelet (AP) agents in their management is currently ill-defined. The goal of this investigation is to determine the clinical behavior of EGITs and whether or not AC or AP affects treatment outcomes.

METHODS

We performed a retrospective review of all endovenous ablations utilizing cyanoacrylate glue (CAG) from January 2020 to December 2021 at the Center for Vein Restoration. Patients were divided into two groups: (1) patients who developed an EGIT (EGIT/CAG) and (2) patients treated with CAG and no EGIT development (CAG). Demographics, medical/surgical histories, revised Venous Clinical Severity Score (rVCSS), Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ), CEAP, EGIT category, type of anticoagulation, resolution time, location of any deep vein thrombosis (DVT) were analyzed, catheter tip distance, treatment length and proximal thigh diameters were all analyzed. EGITs were categorized as follows: EGIT 1: thrombus extension into the deep vein covering less than 25% of the luminal area; EGIT 2: thrombus between 25% and 49%; EGIT 3: thrombus between 50% and 74%; and EGIT 4: total occlusion. Our protocol is to perform post-procedure duplex scans within 3 to 7 days after endovenous ablations to assess for post-intervention DVTs.

RESULTS

During the study period, 2374 patients received 4321 CAG procedures. EGITs were observed in 133 patients (3.1%): EGIT 1 (n = 57); EGIT 2 (n = 35); EGIT 3 (n = 19); and EGIT 4 (n = 22). All EGITs were identified by surveillance scanning. No patient presented with limb or pulmonary symptoms suggestive of VTE. The average age, rVCSS, and CIVIQ 20 of the entire cohort was 65.3 ± 14.2 years, 8.2 ± 2.8, and 48 ± 18.3, respectively with 89 females and 44 males. For EGIT 1, 56 of 57 (98%) resolved at 4.2 ± 5.1 weeks, with one patient lost to follow-up. AC/AP regimen included two aspirin (ASA), one Eliquis, 5 Xarelto, and nothing in 49 patients (86%). For EGIT 2, 27 of 35 (77%) resolved at 4.4 ± 3.4 weeks, one was unresolved, six regressed to EGIT 1, and one remained an EGIT 2 at the last follow-up examination. AC/AP regimens included seven ASA, three Eliquis, three Xarelto, one Coumadin, and nothing in 21 patients (60%). For EGIT 3, 12 were in the common femoral vein (CFV), three in the popliteal vein (POPV), one in the external iliac vein, and three in the gastrocnemius veins. Nine of nineteen (47%) resolved at 6 ± 5.9 weeks, four regressed, one migrated to the proximal CFV, three became chronic, and two were lost to follow-up. AC/AP regimens included three ASA, three Eliquis, seven Xarelto, and nothing in six patients (32%). AC/AP compared with no AC/AP had no effect on clot resolution (P = .3). Of the 22 EGIT 4, one was in the CFV, two were in the POPV, and 18 (82%) were remote calf vein DVTs (15 gastrocnemius, one peroneal [PV], and three posterior tibial veins [PTVs]). The CFV EGIT became chronic, one POPV resolved, and one was lost to follow-up. For the gastrocnemius clots, five became chronic, eight resolved, and two were lost to follow-up. For the PTV clots, one resolved, one became chronic, and one was lost to follow-up. The PV clot became chronic. AC/AP regimen included four ASA, five Eliquis, six Xarelto, and nothing in seven patients. AC/AP compared with no AC/AP had no effect on clot resolution (P = .9). The average proximal thigh diameter (millimeters, mm), vein length treated (mm), and catheter distance (mm) from the junction were the following: EGIT 1 (5.9 ± 2.4, 37.5 ± 17.6, and 5.2 ± 1), EGIT 2 (5.9 ± 1.7, 38 ± 16.9, 4.79 ± 0.71), EGIT 3 (5.1 ± 2.6, 27.9 ± 16.6, and 5.26 ± 1.4), and EGIT 4 (5 ± 1.7, 29.9 ± 15.8, and 5.39 ± 2.18), respectively. Treatment length alone was significantly shorter in EGIT 3 and 4, compared with EGIT 1 and 2 (P ≤ .05). Catheter distance from the junction was longer in EGIT 1, 3, and 4 patients compared with CAG patients (P ≤ .02).

CONCLUSIONS

Regardless of EGIT class or severity, the majority of EGITs are not associated with clot extension or migration and tend to resolve or regress. For EGIT class 1 and 2 patients, AC or AP therapy is not necessary, as 86% and 60%, respectively, resolved with observation alone by 4 weeks. For EGIT 3, 68% resolved or regressed regardless of AC or AP use. The majority of EGIT 4 were remote calf vein DVTs. EGIT 3 and 4 associated with the saphenofemoral/popliteal junction are rare. When compared with CAG patients, proximal thigh diameters and treatment lengths were larger and longer in EGIT 1 and 2 patients. Catheter proximity to the junction was not associated with a higher incidence of EGIT formation.

Incidence and Clinical Impact of Endovenous Glue-Induced Hypersensitivity Among Patients Who Underwent Endovenous Cyanoacrylate Ablation Procedures: A Registry-Based Cohort Study

BACKGROUND

The characteristics of endovenous glue-induced hypersensitivity (EGIH) remain unclear.

OBJECTIVE

To assess the clinical impacts on patients with EGIH after endovenous cyanoacrylate-glue ablation (CA).

MATERIALS AND METHODS

A prospectively designed endovenous CA-specific registry was created, and a total of 335 limbs from 173 patients who underwent endovenous CA were enrolled for a cohort study.

RESULTS

Symptomatic EGIH was observed in 55 (31.8%) patients. Beyond the target vein area, systemic side effects were noted in 5.8% of the treated patients after CA. The median onset time was 13 postoperative days (range: 1-35 days). The median duration was 7 days, but about 10.9% of the affected patients experienced symptoms lasting longer than 4 weeks. In the EGIH and non-EGIH groups, significant improvements in venous clinical severity score and Chronic Venous Insufficiency Quality of Life Questionnaire-14 scores were observed 3 months postoperatively. The development of EGIH did not affect the postoperative patient-reported satisfaction scores ( p = .524).

CONCLUSION

EGIH is observed in a substantial proportion of patients. The side effects do not affect the clinical outcomes and patient-reported outcome measures. Further studies are required on the detailed pathogenesis and definition of EGIH.

A network meta-analysis on the efficacy and safety of thermal and nonthermal endovenous ablation treatments

OBJECTIVE

We assessed the mid-term efficacy and safety of thermal and nonthermal endovenous ablation for the treatment of lower limb superficial venous insufficiency.

METHODS

We performed a systematic review in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement and a Bayesian network meta-analysis. The primary end points were great saphenous vein (GSV) closure and venous clinical severity score (VCSS) improvement. A meta-regression using GSV diameter as a covariate was undertaken for the two primary end points.

RESULTS

We included 14 studies and 4177 patients, with a mean follow-up of 25.7 months. Radiofrequency ablation (RFA; odds ratio [OR], 3.99; 95% confidence interval [CI], 1.82-10.53), cyanoacrylate ablation (CAC; OR, 3.09; 95% CI, 1.35-8.37), and endovenous laser ablation (EVLA; OR, 2.72; 95% CI, 1.23-7.38) displayed increased odds for GSV closure compared with mechanochemical ablation (MOCA). MOCA inferiority compared with RFA (mean difference [MD], 0.96; 95% CI, 0.71-1.20), EVLA (MD, 0.94; 95% CI, 0.61-1.24), and CAC (MD, 0.89; 95% CI, 0.65-1.15) was also depicted regarding VCSS improvement. EVLA resulted in an increased risk of postoperative paresthesia compared with MOCA (risk ratio [RR], 9.61; 95% CI, 2.32-62.29), CAC (RR, 7.90; 95% CI, 2.44-38.16), and RFA (RR, 6.96; 95% CI, 2.31-28.04). Although the overall analysis identified nonstatistically significant differences for Aberdeen varicose vein questionnaire score improvement, thrombophlebitis, ecchymosis, and pain, further investigation revealed an increase pain profile for EVLA at 1470 nm compared with RFA (MD, 3.22; 95% CI, 0.93-5.47) and CAC (MD, 3.04; 95% CI, 1.05-4.97). A sensitivity analysis displayed a persistent underperformance of MOCA compared with RFA (OR, 4.33; 95% CI, 1.15-55.54) for GSV closure and both RFA (MD, 0.99; 95% CI, 0.22-1.77) and CAC (MD, 0.84; 95% CI, 0.08-1.65) regarding VCCS improvement. Although no regression model reached statistical significance, the GSV closure regression model revealed a trend for considerably decreased efficacy for both CAC and MOCA with larger GSV diameters compared with RFA and EVLA.

CONCLUSIONS

Although our analysis has produced skepticism regarding the efficacy of MOCA in the mid-term period for VCSS improvement and GSV closure rates, CAC showed equivalent results compared with both RFA and EVLA. Additionally, CAC displayed a decreased risk of postprocedural paresthesia and pigmentation and induration compared with EVLA. Also, both RFA and CAC had an improved pain profile compared with EVLA 1470 nm. The potential underperformance of nonthermal, nontumescent ablation modalities in ablating large GSVs necessitates further research.

Early results of cyanoacrylate adhesive ablation versus laser ablation for the treatment of great saphenous vein insufficiency in the Chinese mainland population

OBJECTIVE

In this study, we present our early outcomes of cyanoacrylate ablation (CA) versus endovenous laser ablation (EVLA) for the treatment of great saphenous vein (GSV) insufficiency in the Chinese mainland population.

METHODS

We retrospectively analyzed 108 patients (53 patients in the CA group and 55 patients in the EVLA group) with GSV insufficiency who were treated with CA and EVLA between May 2020 and May 2021. The Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire were used to assess clinical symptoms and quality of life, respectively. Total closure rates and procedure-related adverse events were also recorded in both groups.

RESULTS

There was no significant difference between patients treated with CA or EVLA in terms of demographic and clinical characteristics. The average procedure time was 17 min in the CA group and 35 min in the EVLA group (p < 0.001). The CA group had lower pain scores during the procedure and 3 days afterward than the EVLA group (p < 0.001). At month 12, the CA group had a 90.4% closure rate, while the EVLA group had an 83.0% closure rate, with no significant difference between the two groups (p > 0.05). There was no significant difference in the Venous Clinical Severity Score or Aberdeen Varicose Vein Questionnaire score between the groups (p > 0.05). During follow-up, neither group experienced any significant adverse events, such as pulmonary embolism or deep venous thrombosis. The incidence of ecchymosis and paresthesia was significantly lower in the CA group than in the EVLA group (p < 0.05).

CONCLUSIONS

Cyanoacrylate ablation has a high feasibility profile and is an effective approach to accomplish complete GSV target vein closure at early follow-up in the Chinese patients. Compared to EVLA, the improvement in quality-of-life outcomes is also sustained and similar, with less pain and fewer complications due to the absence of tumescence anesthesia and postprocedural compression stockings.

Third-generation treatment of varicose veins: cyanoacrylate adhesive closure and mechanochemical ablation

Background: The mainstream of incompetent saphenous veins treatment has dramatically changed from the first-generation conventional high ligation and stripping surgery to the second-generation endovenous thermal ablation as a minimally invasive technique using laser or radiofrequency. The third-generation treatment of nonthermal non-tumescent techniques is already available, including cyanoacrylate adhesive closure (CAC) and mechanochemical ablation (MOCA).Current Concepts: The non-thermal non-tumescent techniques are developed to overcome the complications of thermal ablation, including nerve injury and vein perforation. The technique also reduces the need for painful tumescent anesthesia and postoperative compression. MOCA employs a dual injury using a single-catheter-based delivery system consisting of a mechanical abrasion with a rotating wire and chemical ablation with a sclerosant. CAC is executed by injecting a glue that produces a polymer with the blood and obliterates the lumen. CAC does not need tumescent anesthesia and postoperative compression. Therefore, patient recovery is fast and satisfaction is excellent. However, the new devices are expensive and not included in the medical insurance in Korea, and long-term effects of the new treatments are unproven; therefore, the cost-effectiveness is unconfirmed.Discussion and Conclusion: MOCA and CAC are newly developed minimal invasive treatments for varicose veins. They are reported to be safe and effective techniques. However, further studies are needed to evaluate the long-term outcomes and cost-effectiveness.

Cyanoacrylate Embolization versus Endovenous Laser Ablation in Treating Saphenous Vein Insufficiency: A Systematic Review and Meta-Analysis

INTRODUCTION

Cyanoacrylate embolization (CAE) is a novel non-thermal non-tumescent venous ablation technique that has shown promising results in treating saphenous vein insufficiency. We aimed to assess the efficacy and safety profile of CAE in comparison to endovenous laser ablation (EVLA) in treating saphenous vein insufficiency.

MATERIAL AND METHODS

We conducted a systematic review and meta-analysis in accordance with the PRISMA Statement. A systematic search was performed through online databases including PubMed, ScienceDirect, and Cochrane to find relevant studies. Manual searching was also performed from the references of the selected studies. Specific keywords that we used were "(cyanoacrylate) AND (laser OR laser ablation OR laser therapy) AND (vein OR venous OR saphenous vein OR venous insufficiency OR varicose vein)". Outcomes of interest were efficacy, safety, and intervention time. Efficacy was determined by venous closure rate one year post-intervention and Venous Clinical Severity Score (VCSS) one year post-intervention. Safety was determined by rates of periprocedural pain, skin pigmentation, nerve damage, phlebitis, deep vein thrombosis (DVT) and ecchymosis. Data extraction and quality assessment of included studies were performed by two reviewers, and statistical analysis was conducted using RevMan 5.4.0 software.

RESULTS

Five relevant articles (2 randomized-controlled trials and 3 cohort studies) were selected for this study, consisting a total of 1432 venous ablation procedures (710 CAE and 722 EVLA). From the efficacy point of view, venous closure rates and VCSS did not differ significantly between CAE group and EVLA group. From the safety point of view, pooled data showed that CAE group was associated with less periprocedural pain score (P < 0.001), lower skin pigmentation rates (0.60% vs 4.46%; P = 0.008), and lower nerve damage rates (0% vs 3.94%; P = 0.007). Rates of phlebitis, deep vein thrombosis, and ecchymosis did not differ significantly between the two groups. In addition, intervention time was significantly faster in CAE group compared to EVLA group (P < 0.001).

CONCLUSION

Cyanoacrylate embolization yields similar efficacy compared to EVLA. However, CAE is associated with less periprocedural pain, lower occurrence rates of skin pigmentation and nerve damage, and faster intervention time.

Changes of stump length depending on starting position of glue injection related to venous diameter during cyanoacrylate closure for incompetent saphenous veins

OBJECTIVES

A common pattern of recurrence after cyanoacrylate treatment of incompetent saphenous veins has been associated with reflux from the residual stump. The purpose of this study was to analyze the starting point of cyanoacrylate glue injection from the junction to decrease stump length.

METHODS

A retrospective review was performed using prospectively collected data of patients with cyanoacrylate closure (CAC). Preoperatively, the diameter of the saphenous vein was measured. CAC was performed according to the manufacturer's instructions. After the procedure, clinical outcomes including pain, venous clinical severity score (VCSS), and quality of life (QoL) using the Aberdeen Varicose Vein Questionnaire (AVVQ) were evaluated. Postoperative duplex scanning was performed to evaluate the occlusion rate of the target vein, stump length, and presence of endovenous glue-induced thrombosis (EGIT). The stump length was analyzed according to the preoperative venous diameter to determine the proper point of glue injection to decrease the stump length.

RESULTS

During the study period, CAC was performed in 408 patients. Mean age was 56.2±11.5 years (range, 19 to 84 years). A total of 279 patients (68.4%) were women. Occlusion of the target vein was achieved in all patients. After the procedure, pain, VCSS, and QoL were improved (P<.001). EGIT developed in 5.8% of patients. There was a 1.53-fold linear increase in the stump length by for every 1-mm increment of the preoperative venous diameter. In 20 patients with a venous diameter ≥5 mm, glue injection was performed safely 4 cm distal to the junction to decrease the stump length.

CONCLUSION

The stump length linearly increased with an increase in the saphenous vein diameter. If the diameter of the saphenous vein is more than 5 mm, cyanoacrylate glue may be injected 4 cm distal to the junction to decrease stump length.

Comparison Between Cyanoacrylate Embolization and Radiofrequency Ablation for Superficial Venous Incompetence: A Systematic Review and Meta-analysis

BACKGROUND

Chronic venous disease is a debilitating condition involving great saphenous vein (GSV) incompetence.

OBJECTIVE

To investigate the efficacy and effectiveness of cyanoacrylate embolization (CAE) versus radiofrequency ablation (RFA) in patients with incompetent GSVs.

MATERIALS AND METHODS

PubMed, Embase, and the Cochrane library were searched. The primary outcomes were the Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ), closure rate, and visual analog scale (VAS) for pain.

RESULTS

This meta-analysis included 378 and 590 patients who underwent CAE and RFA, respectively. Cyanoacrylate embolization was comparable with RFA in VCSS (weighted mean difference [WMD] = -0.03, 95% confidence interval [CI]: -0.18 to 0.12, p = .686), AVVQ (WMD = -0.08, 95% CI: -0.38 to 0.21, p = .570), closure rate (odds ratio [OR] = 0.61, 95% CI: 0.18-2.01, p = .414), and VAS (standardized mean difference [SMD] = 0.24, 95% CI: -0.59 to 1.06, p = .523). There were no significant differences between CAE and RFA regarding the occurrence of phlebitis (OR = 1.22, 95% CI: 0.70-2.13, p = .479) and pigmentation (OR = 0.48, 95% CI: 0.18-1.31, p = .153), but CAE had a lower risk of ecchymosis (OR = 0.45, 95% CI: 0.25-0.81, p = .007) and paresthesia (OR = 0.16, 95% CI: 0.03-0.99, p = .049).

CONCLUSION

Cyanoacrylate embolization and RFA demonstrated no significant differences in VCSS, AVVQ, closure rate, and pain score for patients with incompetent GSVs. Patients in the CAE group had a lower risk of ecchymosis and paresthesia compared with the RFA group.

Choosing the Best Treatment Approach for Axial Vein Reflux: Thermal versus Nonthermal Approaches

Chronic venous insufficiency is a common and treatable medical condition which has a high morbidity if left untreated, progressing to lower extremity edema, skin changes of lipodermatosclerosis, and venous ulceration. Treatment options have significantly expanded over the last several decades, shifting away from the traditional surgical approach to more minimally invasive procedures such as endoluminal venous laser ablation or radiofrequency ablation. Even more recently, several techniques using nonthermal methods to ablate varicose veins have been developed, which offer the advantage of not requiring labor-intensive and painful tumescent anesthesia to protect the surrounding tissues. These techniques include mechanochemical ablation, cyanoacrylate closure, or polidocanol microfoam injection and can be offered to a wider range of patients without the need for sedation while offering similar closure rates and improved postprocedure symptom profile. Furthermore, certain patient characteristics which might preclude or complicate the use of thermal ablation methods might not pose a problem with nonthermal nontumescent methods.

A systematic review and meta-analysis comparing the efficacy of cyanoacrylate ablation over endovenous thermal ablation for treating incompetent saphenous veins

OBJECTIVES

The aim of this study was to systemically review and analyze the efficacy of cyanoacrylate ablation (CA) in comparison with endovenous thermal ablation (ETA) for the treatment of incompetent saphenous veins.

METHODS

A systematic literature search was conducted using databases of Pubmed, Embase, and Cochrane Library from the times of their inception to April 2020. Studies were selected based on inclusion and exclusion criteria after assessing the risk of bias in comparative studies with Cochrane and rating quality of evidence with the GRADE methodology. The meta-analysis was carried out using the Review Manager 5.4 program to conduct homogeneity tests.

RESULTS

One cohort study and three randomized controlled trials (RCT), including a total of 1457 participants were included in the meta-analysis. ETA included endovenous laser ablation (ELVA) and radiofrequency ablation (RFA) in the selected studies. Comparison between CA and a combination of EVLA and RFA or RFA alone were carried out in two of RCTs, while comparison between CA with EVLA was conducted in one RCT and the cohort study. There was no statistical difference in closure rates between CA and ETA after pooled analysis. Similar symptom alleviation observed between different groups. However, the CA group showed a lower ecchymosis rate than RFA and a significantly lower incidence of adverse events, such as ecchymosis, phlebitis and paresthesia, than EVLA. Compared with ETA, the patients received CA treatment exhibited lower pain scores in a shorter procedure duration without needing compression stocking, returned to normal life sooner, and had significantly better quality of care. There was no significant difference in the number needed to treat for additional therapy after three months of follow-up between groups.

CONCLUSIONS

This meta-analysis indicates that CA has better overall outcomes than ETA and offers superior clinical benefits in the treatment of incompetent saphenous veins.

Private payers' varicose vein policies are inaccurate, disparate, and not evidence based, which mandates a proposal for a reasonable and responsible policy for the treatment of venous disease

Varicose veins afflict more than one in five Americans, and although varicose veins may be an asymptomatic cosmetic concern in some, many others experience symptoms of pain, aching, heaviness, itching, and swelling. More advanced venous disease can result from untreated venous insufficiency. The complications of chronic venous disease, including bleeding, thrombosis, and ulceration, are seen in up to 2 million Americans annually. Numerous reports have documented venous disease adversely affects quality of life and that treatment of venous disease can improve quality of life. It has previously been documented that private insurers, and Centers for Medicare & Medicaid Services subcontractors for that matter, have disparate policies that in many instances are self-serving, contain mistakes, use outdated evidence, and disregard evidence-based guidelines. The two leading venous medical societies, the American Venous Forum and the American Venous and Lymphatic Society, have come together to review the varicose vein coverage policies of seven major U.S. private medical insurance carriers whose policies cover more than 150 million Americans. The authors reviewed the policies for venous disease and, if significant gaps or inconsistencies are found, we hope to point them out, and, finally, to propose a thoughtful and reasonable policy based on the best available evidence.

Two-Year Follow-Up after Endovenous Closure with Short-Chain Cyanoacrylate versus Laser Ablation in Venous Insufficiency

Background: The current treatment of venous disease is focused on the minimally invasive exclusion of the affected vein. Besides widely used thermal ablation, chemical ablation with cyanoacrylate, reported as safe and highly effective, has been gaining increasing interest. Patients and methods: In the current report, we present data from a two-year observation in 89 patients (61 female/28 male, mean age 44.3 ± 13.5) suffering from venous insufficiency (C2–C4), treated either using short-chain cyanoacrylate, the VenaBlock system (n = 43) or laser thermoablation with ELVeS 1470 (n = 46). The assessment comprised the occurrence of venous disease-related symptoms and the ultrasound examination of the leg venous system. Results: The frequency of recanalization after 2 years from the VenaBlock procedure was significantly higher than after laser treatment (37.2 vs. 8.7%). Apart from recanalization, in some individuals from both groups, the symptoms of recurrence and/or disease progression, including the development of insufficiency in other veins of treated or contralateral legs (9.3 vs. 15.2% and 9.3 vs. 17.4%, respectively), were observed. Unexpectedly, the general prevalence of the disease progression did not differ significantly between the VenaBlock and ELVeS groups (44.2 vs. 34.8%, respectively). Conclusions: Despite the higher recanalization rate of VenaBlock compared to ELVeS, the overall effectiveness of cyanoacrylate and laser thermoablation after two years was similar. Therefore, both methods similarly failed to prevent recurrence and disease progression, which seem to be method-independent.