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Caggiati A, Labropoulos N, Boyle EM, Drgastin R, Gasparis A, Doganci S, Meissner M. The Anterior Saphenous Vein. Part 2. Anatomic considerations in normal and refluxing patients. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum and the International Union of Phlebology. Phlebology 2024; 39:313-324. [PMID: 38526958 PMCID: PMC11129527 DOI: 10.1177/02683555231223055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
BACKGROUND The term Anterior Accessory of the Great Saphenous Vein suggest this is a branch tributary vein despite this vessel's anatomic features of a truncal vein. A multisocietal group suggested to designate this the Anterior Saphenous Vein (ASV). This study was aimed to evaluate its ultrasound anatomy in normal and varicose limbs. METHODS The clinical anatomy of the ASV was evaluated by narrative review of the literature. Additionally, the course of the ASV was evaluated in 62 limbs with no evidence of venous disease and 62 limbs with varicosities. RESULTS The ASV length, patterns of origin and termination are reported in both normal and patients with varicose veins. Discussion of the patterns is supported by the narrative review of the literature. CONCLUSIONS The ASV must be considered a truncal vein and its treatment modalities should be the same that for the great and small saphenous veins rather than a tributary vein.
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Affiliation(s)
| | | | - Edward M Boyle
- Inovia Vein Specialty Centers, St Charles Health System, Bend, OR, USA
| | - Rachel Drgastin
- Inovia Vein Specialty Centers, St Charles Health System, Bend, OR, USA
| | | | - Suat Doganci
- Department of Cardiovascular Surgery, Health Sciences University, Gulhane School of Medicine, Ankara, Turkey
| | - Mark Meissner
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
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Boyle EM, Drgastin R, Labropoulos N, Caggiati A, Gasparis A, Doganci S, Meissner M. The anterior saphenous vein. Part 4. Clinical and technical considerations in treatment. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology. Phlebology 2024; 39:333-341. [PMID: 38129968 PMCID: PMC11129528 DOI: 10.1177/02683555231223063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND The decision to treat a refluxing anterior saphenous vein (ASV) should be a clinical decision based on the assessment on the ASV's contribution to patient's signs and symptoms. Once the decision to treat has been made, there are anatomic, clinical, and technical considerations in treatment planning. METHODS Clinical scenarios were discussed by a panel of experts and common anatomic, clinical, and technical considerations were identified. RESULTS There are unique clinical considerations such as whether both the great saphenous vein (GSV) and ASV should be concomitantly treated, if a normal ASV should be treated when treating a refluxing GSV and when and how to treat the associated tributary varicose tributaries. Being aware of the anatomic, clinical, and technical considerations allows development of a treatment plan that optimizes long-term outcomes in patients with ASV reflux. CONCLUSION Ultimately the treatment plan should be tailored to address these types of variables in a patient-centered discussion.
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Affiliation(s)
| | | | - Nicos Labropoulos
- Division of Vascular Surgery, Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | | | - Antonios Gasparis
- Division of Vascular Surgery, Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Suat Doganci
- Department of Cardiovascular Surgery, Health Sciences University, Gulhane School of Medicine, Ankara, Turkey
| | - Mark Meissner
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
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Drgastin R, Boyle EM, Labropoulos N, Caggiati A, Gasparis A, Doganci S, Meissner M. The anterior saphenous vein. Part 3. Systematic review of the literature and payor coverage policies. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum and the International Union of Phlebology. Phlebology 2024; 39:325-332. [PMID: 38526968 PMCID: PMC11129522 DOI: 10.1177/02683555231223281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
OBJECTIVE The objective of this study is to systemically review the literature on Anterior Saphenous Vein (ASV) reflux treatment and insurance impediments to treatment coverage. METHODS A literature search was performed using a PRISMA framework. In addition, a cross-sectional analysis of insurance policies for ASV treatment was evaluated. RESULTS Published evidence and treatment considerations in the literature for ASV treatment are discussed. In 155 of 226 (68.6%) insurance policies reviewed coverage of ASV ablation was allowed while 62/226 (27.4%) did not specify coverage and 9/226 (4.0%) specified ASV treatment was not covered. Of the 155 that provide ASV coverage, 98 (62.2%) provide coverage with criteria such as requiring prior treatment of the great saphenous vein. CONCLUSIONS Vein treatment experts should continue to advocate to insurance carriers to update their varicose vein treatment policies to reflect the substantial clinical evidence so that patients with ASV reflux can be appropriately treated.
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Affiliation(s)
| | | | - Nicos Labropoulos
- Division of Vascular Surgery, Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | | | - Antonios Gasparis
- Division of Vascular Surgery, Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Suat Doganci
- Department of Cardiovascular Surgery, Gulhane School of Medicine, Health Sciences University, Ankara, Turkey
| | - Mark Meissner
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
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Caggiati A, Labropoulos N, Boyle EM, Drgastin R, Gasparis A, Doganci S, Meissner M. The anterior saphenous vein. Part 2. Anatomic considerations in normal and refluxing patients. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2024; 12:101855. [PMID: 38551527 DOI: 10.1016/j.jvsv.2024.101855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND The term Anterior Accessory of the Great Saphenous Vein suggests this is a branch tributary vein despite this vessel's anatomic features of a truncal vein. A multisocietal group suggested to designate this the anterior saphenous vein (ASV). This study was aimed to evaluate its ultrasound anatomy in normal and varicose limbs. METHODS The clinical anatomy of the ASV was evaluated by narrative review of the literature. Additionally, the course of the ASV was evaluated in 62 limbs with no evidence of venous disease and 62 limbs with varicosities. RESULTS The ASV length, patterns of origin and termination are reported in both normal and patients with varicose veins. Discussion of the patterns is supported by the narrative review of the literature. CONCLUSIONS The ASV must be considered a truncal vein and its treatment modalities should be the same that for the great and small saphenous veins rather than a tributary vein.
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Affiliation(s)
| | | | - Edward M Boyle
- Inovia Vein Specialty Centers, St Charles Health System, Bend, OR, USA.
| | - Rachel Drgastin
- Inovia Vein Specialty Centers, St Charles Health System, Bend, OR, USA
| | | | - Suat Doganci
- Department of Cardiovascular Surgery, Health Sciences University, Gulhane School of Medicine, Ankara, Turkey
| | - Mark Meissner
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
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Drgastin R, Boyle EM, Labropoulos N, Caggiati A, Gasparis A, Doganci S, Meissner M. The anterior saphenous vein. Part 3. Systematic review of the literature and payor coverage policies. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2024; 12:101856. [PMID: 38551528 DOI: 10.1016/j.jvsv.2024.101856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
OBJECTIVE The objective of this study is to systemically review the literature on Anterior Saphenous Vein (ASV) reflux treatment and insurance impediments to treatment coverage. METHODS A literature search was performed using a PRISMA framework. In addition, a cross-sectional analysis of insurance policies for ASV treatment was evaluated. RESULTS Published evidence and treatment considerations in the literature for ASV treatment are discussed. In 155 of 226 (68.6%) insurance policies reviewed coverage of ASV ablation was allowed while 62/226 (27.4%) did not specify coverage and 9/226 (4.0%) specified ASV treatment was not covered. Of the 155 that provide ASV coverage, 98 (62.2%) provide coverage with criteria such as requiring prior treatment of the great saphenous vein. CONCLUSIONS Vein treatment experts should continue to advocate to insurance carriers to update their varicose vein treatment policies to reflect the substantial clinical evidence so that patients with ASV reflux can be appropriately treated.
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Affiliation(s)
| | | | - Nicos Labropoulos
- Division of Vascular Surgery, Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | | | - Antonios Gasparis
- Division of Vascular Surgery, Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Suat Doganci
- Department of Cardiovascular Surgery, Gulhane School of Medicine, Health Sciences University, Ankara, Turkey
| | - Mark Meissner
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
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Boyle EM, Drgastin R, Labropoulos N, Caggiati A, Gasparis A, Doganci S, Meissner M. The anterior saphenous vein. Part 4. Clinical and technical considerations in treatment. Endorsed by the American Vein and Lymphatic Society, the American Venous Forum, and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2024; 12:101857. [PMID: 38551526 DOI: 10.1016/j.jvsv.2024.101857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND The decision to treat a refluxing anterior saphenous vein (ASV) should be a clinical decision based on the assessment on the ASV's contribution to patient's signs and symptoms. Once the decision to treat has been made, there are anatomic, clinical, and technical considerations in treatment planning. METHODS Clinical scenarios were discussed by a panel of experts and common anatomic, clinical, and technical considerations were identified. RESULTS There are unique clinical considerations such as whether both the great saphenous vein (GSV) and ASV should be concomitantly treated, if a normal ASV should be treated when treating a refluxing GSV and when and how to treat the associated tributary varicose tributaries. Being aware of the anatomic, clinical, and technical considerations allows development of a treatment plan that optimizes long-term outcomes in patients with ASV reflux. CONCLUSIONS Ultimately the treatment plan should be tailored to address these types of variables in a patient-centered discussion.
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Affiliation(s)
| | | | - Nicos Labropoulos
- Division of Vascular Surgery, Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | | | - Antonios Gasparis
- Division of Vascular Surgery, Department of Surgery, Stony Brook Medicine, Stony Brook, NY, USA
| | - Suat Doganci
- Department of Cardiovascular Surgery, Health Sciences University, Gulhane School of Medicine, Ankara, Turkey
| | - Mark Meissner
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
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Kabnick LS, Jimenez JC, Coogan SM, Gache L, Frame D, Gunnarsson C, Ozsvath K. Comparative effectiveness of non-compounded polidocanol 1% endovenous microfoam (Varithena) ablation versus endovenous thermal ablation utilizing a systematic review and network meta-analysis. J Vasc Surg Venous Lymphat Disord 2024:101896. [PMID: 38679141 DOI: 10.1016/j.jvsv.2024.101896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/25/2024] [Accepted: 04/10/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE We compared the effectiveness and safety of polidocanol 1% endovenous microfoam ablation vs endovenous thermal ablation with radiofrequency or laser energy for treatment of venous insufficiency caused by lower extremity truncal vein incompetence via network meta-analysis of published comparative evidence. METHODS We conducted a systematic literature review following best practices, including a prospective protocol. We screened studies published in English from 2000 to 2023 for randomized and nonrandomized studies reporting direct or indirect comparisons between polidocanol 1% endovenous microfoam and endovenous thermal ablation. Thirteen studies met our eligibility criteria for the network meta-analysis. The co-primary effectiveness outcomes were the closure rate ≥3 months after procedure and the average change in the Venous Clinical Severity Score. For the subgroup of venous ulcer patients, the ulcer healing rate was the primary effectiveness outcome. The secondary outcomes included safety and patient-reported outcomes. Network meta-analyses were conducted on outcomes having sufficient data. Categorical outcomes were summarized using odds ratios (ORs) with 95% confidence intervals (CIs). Sensitivity tests and estimates of network inconsistency were used to investigate the robustness of our meta-analysis. RESULTS We found that polidocanol 1% endovenous microfoam was not significantly different statistically from endovenous thermal ablation for venous closure (OR, 0.65; 95% CI, 0.36-1.18; P = .16). Although not the primary aim of the study, the network meta-analysis also provided evidence to confirm our supposition that polidocanol 1% endovenous microfoam was significantly differentiated statistically from physician-compounded foam, with higher odds for vein closure (OR, 2.91; 95% CI, 1.58-5.37; P < .01). A sensitivity analysis using the longest available time point for closure in each study, with a minimum of 12 months of follow-up (median, 48 months; range, 12-72 months), showed results similar to those of the main analysis. No association was found between the risk of deep vein thrombosis and the treatment received. The available data were insufficient for a network meta-analysis of Venous Clinical Severity Score improvement and ulcer healing rates. CONCLUSIONS Polidocanol 1% endovenous microfoam was not significantly different statistically from endovenous thermal ablation for venous closure and deep vein thrombosis risk for chronic venous insufficiency treatment, based on a network meta-analysis of published evidence. Polidocanol 1% endovenous microfoam was significantly differentiated statistically from physician-compounded foam, with higher odds of vein closure. A sensitivity analysis found venous closure findings were robust at follow-up intervals of 12 months or greater and for up to 6 years. New evidence meeting the inclusion criteria for this review will be incorporated at regular intervals into a living network meta-analysis.
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Affiliation(s)
| | - Juan Carlos Jimenez
- Division of Vascular and Endovascular Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA
| | | | | | | | | | - Kathleen Ozsvath
- Samaritan Hospital, Troy, NY; St. Peter's Vascular Associates, St. Peter's Medical Associates, Albany, NY
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Lawrence PF. Journal of Vascular Surgery: Venous and Lymphatic Disorders – May 2022 Audiovisual Summary. J Vasc Surg Venous Lymphat Disord 2022. [DOI: 10.1016/j.jvsv.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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