Radiofrequency ablation (VNUS closure®) does not cause neo-vascularisation at the groin at one year: Results of a case controlled study

PREVAIT after modern open surgery and endothermal ablation: a systematic review

INTRODUCTION

Presence of varices after operative treatment (PREVAIT) is a common finding after varicose vein surgery, and has been shown to significantly reduce the quality of life of those it affects. As such, long-term results after varicose vein interventions have to be taken into account when choosing a technique. This study aims to systematically review current evidence on the recurrence of varicose veins after three different techniques: conventional surgery (HLS), endovenous laser ablation (EVLA) and radiofrequency ablation (RFA).

EVIDENCE ACQUISITION

A literature search was performed on the PubMed and Web of Science databases, which returned 546 studies. Fourteen studies were included. Data were extracted using predefined forms.

EVIDENCE SYNTHESIS

A total of 2795 patients were included, for a total of 3056 legs treated. 503 legs (16.5%) were treated by HLS, 1791 (58.6%) by EVLA and 762 (25.0%) by RFA. PREVAIT was reported in 34.4% for patients treated by HLS, for a mean follow-up comprised between 18 months and 5 years; 16.6% by EVLA, for a mean follow-up between 112 days and 5 years and 6.7% of those treated by RFA, for a mean follow-up between 106 days and 5 years. Regarding patterns of recurrence, the development of new varicose veins was the most commonly reported mechanism of recurrence after HLS (range: 29.8-91%) and EVLA (range: 40-81.6%), but not RFA, where recanalization of the occluded saphenous trunk accounted for up to 67.0% of the cases. Only one study reported quality of life related recurrence, and included patients treated by HLS and EVLA, but not RFA. Aberdeen Varicose Vein Questionnaire (AVVQ) score, physical functioning domains of the SF-36 score and patient satisfaction were significantly worse in patients with clinical recurrence. Re-intervention rates after recurrence were reported in 5 studies, ranging between 7.7% and 37.7% for HLS and 0-57.0% for EVLA. Only one study reported data on re-intervention for RFA patients, which was 6.67%.

CONCLUSIONS

Recurrence is a reliable indicator of long-term efficacy of a varicose vein treatment and appears to occur more frequently after HLS. Although there are several mechanisms of recurrence, the development of new varicose veins was the most commonly observed. There is clear heterogeneity among definitions of recurrence and follow-up periods in literature.

Ten-year follow-up of a randomized controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia

OBJECTIVE

The long-term results of saphenofemoral ligation and stripping (SFL/S) were compared with 980-nm bare fiber endovenous laser ablation (EVLA) for the treatment of great saphenous vein (GSV) incompetence.

METHODS

This was a single-center, randomized, controlled trial with a follow-up time of 10 years. Patients with GSV incompetence were randomized to undergo SFL/S or EVLA under tumescent anesthesia. The primary outcome was recurrence of groin-related varicose veins seen on duplex ultrasound imaging and clinical examination. The secondary outcomes were (changes or improvement in) CEAP clinical class, venous symptoms, cosmetic results, quality of life, reinterventions, and complications.

RESULTS

Between June 2007 and December 2008, 122 patients (130 limbs) were included; of these, 68 limbs were treated with SFL/S and 62 limbs with EVLA. The 10-year estimated freedom from groin recurrence as seen on duplex ultrasound imaging was higher in the SFL/S group (73% vs 44% in the EVLA group; P = .002), and the same trend was seen for clinically evident recurrence (77% vs 58%, respectively; P = .034). Nine reinterventions (17%) were deemed necessary in the SFL/S group vs 18 (36%) in the EVLA group (P = .059). All reinterventions in the SFL/S group consisted of foam sclerotherapy. Reinterventions in the EVLA group included foam sclerotherapy (n = 5), crossectomy (n = 2), and endovenous procedures (n = 11). There was no significant differences in quality of life and relief of venous symptoms. Cosmetic appearance improved, with a better cosmetic rating in the SFL/S group compared with the EVLA group (P = .026). One patient in the SFL/S group had a persisting neurosensory deficit remaining at 10 years.

CONCLUSIONS

This study showed no clear long-term advantage of EVLA with a 980-nm wavelength and bare-tip fiber over high ligation and stripping of the GSV under local tumescent anesthesia.

Venography and Selective Ablation for Recurrent Varices after Surgery Using Radiofrequency Ablation Catheter

Recurrent varices after surgery (REVAS) is a common problem with no established treatment. Ultrasonography is a hard method to identify the source of veins that cause REVAS, especially in obese patients with thick thighs. Here, we report the case of a 64-year-old obese patient who previously underwent endothermal venous ablation for her right great saphenous vein. The patient presented with right leg swelling and venous ulceration due to REVAS. Although the source of REVAS was unclear because the patient had thick thighs on ultrasonography assessment, venography revealed that the source of REVAS was the incompetent perforator vein (IPV). Selective ablation for the IPV with radiofrequency ablation catheter was performed. We could ablate the target veins selectively so as not to ablate within the deep vein. The patient remains asymptomatic for 2 years after the procedure, and there has been no recurrence of her varicose veins. Venography allows better visualization of the source of REVAS than ultrasonography. With selective ablation, it is especially effective procedure in obese patients, in whom it is difficult to identify and access the source of REVAS with ultrasonography.

Histopathologic differences in the endovenous laser ablation between jacketed and radial fibers, in an ex vivo dominant extrafascial tributary of the great saphenous vein in an in vitro model, using histology and immunohistochemistry

OBJECTIVE

The study aimed to investigate the biologic effects of the 1470-nm endovenous laser (EVL), with a jacketed fiber and a radial fiber, during EVL ablation of an ex vivo dominant extrafascial tributary of the great saphenous vein in our in vitro model by histology and immunohistochemistry.

METHODS

Ten segments of the dominant extrafascial tributary of the great saphenous vein were harvested by a consultant vascular surgeon from patients during routine varicose vein surgery. Six segments were treated using an ex vivo model of our design by a 1470-nm EVL with a jacketed fiber. The other four segments were also treated by a 1470-nm EVL but with a radial-firing fiber. Each segment was split into five sections and treated at five different linear endovenous energy densities (LEEDs) at 10 W: 0, 20, 40, 60, and 80 J/cm. The veins were incubated and subsections collected at 6 and 24 hours after treatment. Subsections were immersed in buffered formalin and taken for histologic and immunohistochemical analysis. Histopathologic analysis was then performed.

RESULTS

Treatment with the radial fiber led to a pattern of damage that was more homogeneous than with the jacketed fiber, with no carbonization of tissue present. Significant transmural damage and necrosis were observed at LEEDs of 60 and 80 J/cm in both treatment groups. At the same LEEDs, p53 and caspase 3 analysis showed that transmural cell wall vein death (necrosis or apoptosis) occurred by 6 hours after treatment with both fibers.

CONCLUSIONS

There was a significant difference in the effects of treatment with a jacketed fiber and a radial fiber in EVL ablation in vitro. Although both fibers caused transmural vein wall cell death at similar LEEDs, the pattern of damage with the radial fiber was more homogeneous. There was no overtreatment of tissue in terms of carbonization after treatment with the radial fiber. Treatment with the jacketed fiber showed carbonization of tissue at the same LEEDs.

Report of the Society for Vascular Surgery and the American Venous Forum on the July 20, 2016 meeting of the Medicare Evidence Development and Coverage Advisory Committee panel on lower extremity chronic venous disease

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel assessed the benefits and risks of currently used lower extremity chronic venous disease (CVD) treatments and their effects on health outcome of the American adult population. The main purpose of the meeting was to advise the Centers for Medicare & Medicaid Services on coverage determination for interventions used for treatment of CVD. A systematic review of the Agency for Healthcare Research and Quality was presented, followed by lectures of invited experts and a public hearing of representatives of professional societies and the industry. After discussing critical issues, the panel voted for key questions. This report summarizes the presented evidence to support recommendations of the Society for Vascular Surgery/American Venous Forum coalition and the presentations on selected discussion topics. These included important venous disease evidence gaps that have not been sufficiently addressed, venous disease treatment disparities and how they may affect the health outcomes of Medicare beneficiaries, and mechanisms that might be supported by the Centers for Medicare & Medicaid Services to improve the evidence base to optimize the care of patients with lower extremity CVD.

Symptomatic recurrent varicose veins due to primary avalvular varicose anomalies (PAVA): A previously unreported cause of recurrence

A 56-year-old woman presented in 2006 with symptomatic primary varicose veins in her right leg. Venous duplex ultrasonography at that time showed what appeared to be "neovascular tissue" around the saphenofemoral junction. However, there had been no previous trauma or surgery in this area. This appearance has subsequently been described as primary avalvular varicose anomalies. She underwent endovenous treatment at that time. In 2018, she presented with symptomatic recurrent varicose veins of the same leg. Venous duplex ultrasonography showed successful ablation of the great saphenous and anterior accessory saphenous veins. All of the recurrent venous reflux was arising from the primary avalvular varicose anomalies. This report shows that primary avalvular varicose anomalies is a previously unreported cause of recurrent varicose veins and leads us to suggest that if found, treatment of the primary avalvular varicose anomalies should be considered at the primary procedure.

One-year results of the use of endovenous radiofrequency ablation utilising an optimised radiofrequency-induced thermotherapy protocol for the treatment of truncal superficial venous reflux

Background

In previous in vitro and ex vivo studies, we have shown increased thermal spread can be achieved with radiofrequency-induced thermotherapy when using a low power and slower, discontinuous pullback. We aimed to determine the clinical success rate of radiofrequency-induced thermotherapy using this optimised protocol for the treatment of superficial venous reflux in truncal veins.

Methods

Sixty-three patients were treated with radiofrequency-induced thermotherapy using the optimised protocol and were followed up after one year (mean 16.3 months). Thirty-five patients returned for audit, giving a response rate of 56%. Duplex ultrasonography was employed to check for truncal reflux and compared to initial scans.

Results

In the 35 patients studied, there were 48 legs, with 64 truncal veins treated by radiofrequency-induced thermotherapy (34 great saphenous, 15 small saphenous and 15 anterior accessory saphenous veins). One year post-treatment, complete closure of all previously refluxing truncal veins was demonstrated on ultrasound, giving a success rate of 100%.

Conclusions

Using a previously reported optimised, low power/slow pullback radiofrequency-induced thermotherapy protocol, we have shown it is possible to achieve a 100% ablation at one year. This compares favourably with results reported at one year post-procedure using the high power/fast pullback protocols that are currently recommended for this device.

Assessment of the efficacy and safety of steam vein sclerosis as compared to classic surgery in lower extremity varicose vein management

Introduction

For the last 10 years, endovenous thermal ablation methods have gradually predominated over the classic Babcock procedure in varicose vein treatment. Steam vein sclerosis is the newest thermal ablation technique.

Aim

To assess the efficacy and safety of steam vein sclerosis as compared to the Babcock procedure in lower extremity varicose vein treatment.

Material and methods

One hundred and two adult subjects with varicose veins of clinical grade C2 to C6 according to the CEAP classification, treated with varicose vein surgery between 2010 and 2012, were enrolled in the study. These were subdivided into two groups: the study group of 52 patients treated with endovenous steam vein sclerosis and the control group of 50 patients treated with the Babcock procedure. A single lower extremity with isolated great or small saphenous vein insufficiency was operated on in each subject. The groups were compared for demography, disease severity, involved veins, potential perioperative and postoperative complications, as well as treatment efficacy based on the VCSS score reduction.

Results

There were no statistically significant differences between the groups in terms of demography, disease severity, involved veins, or perioperative and postoperative complications. The treatment efficacy of both methods, assessed based on the recurrence rate and the quantitative VCSS score reduction, was similar. Clinically significant recanalisation was observed in 1 (1.9%) patient in the study group.

Conclusions

The efficacy and safety analysis shows that steam vein sclerosis is a safe, simple method which can be recommended as effective varicose vein treatment.

Primary avalvular varicose anomalies are a naturally occurring phenomenon that might be misdiagnosed as neovascular tissue in recurrent varicose veins

OBJECTIVE

The objective of this study was to report a phenomenon in patients with primary varicose veins that resembles neovascular tissue in postsurgical recurrences-primary avalvular varicose anomalies (PAVA).

METHODS

Between March 2012 and July 2013, 756 patients (122 men, 634 women) with primary varicose veins (mean age, 53 years; range, 18-89 years) underwent duplex ultrasonography with retrospective analysis of their reflux patterns. We diagnose PAVA as small, refluxing vessels in legs with primary varicose veins and no history of surgery, trauma, or infection in the area that show one or more of three patterns of distribution: lymph node pattern-PAVA arising directly from groin lymph nodes; peritruncal pattern-PAVA wrapping around the great, small, or anterior accessory saphenous veins; and atypical pattern. PAVA are predominantly found within the saphenous fascia, but components have been found to emerge into the superficial and deep venous compartments.

RESULTS

We analyzed results from 1398 legs (756 patients). Sixty-four legs (4.6%) in 58 patients exhibited PAVA, bilateral in six patients and unilateral in 52 patients. Lymph node involvement and peritruncal PAVA were seen in 23.4% and 70.3% of legs, respectively. The small saphenous vein was the most common truncal vein to be involved (48.9% of peritruncal cases). More than one pattern of PAVA could be observed in seven legs. Of the 48 women with PAVA, 42% had concurrent pelvic vein reflux.

CONCLUSIONS

Neovascularization has been identified as a major cause of clinically recurrent varicose veins. Neovascular tissue has been described after endovenous thermoablation. We suggest that this might represent PAVA undetected preoperatively in some cases. PAVA are thin-walled, serpiginous, incompetent vessels that resemble neovascular tissue. We conclude that neovascularization should be diagnosed as a source of recurrence after endovenous surgery only if PAVA had been actively looked for, and excluded, in the preoperative diagnostic duplex ultrasound examination.

New Concept: Different Types of Insufficiency of the Saphenofemoral Junction Identified by Duplex as a Chance for a More Differentiated Therapy of the Great Saphenous Vein

Even though the item ‘saphenofemoral junction’ (SFJ) is anatomically well defined, the incontinence of the SFJ is often incompetently described in clinical practice and studies. Especially with regard to the optimal therapy of the great saphenous vein, it might be of importance to have a more distinct regard to the SFJ as it is known that about 10–30% of the saphenous refluxes have no femoral origin. Considering the terminal and preterminal valve three types of incompetence of the SFJ may be differentiated: Type 1: Incompetent terminal, but competent preterminal valve; Type 2: Competent terminal, but incompetent preterminal valve; Type 3: Incompetent terminal and preterminal valve (complete incompetence). A review on prior studies and reports leads to the assumption that the differentiation of the distinct types of SFJ-incompetence allows a more individual and – perhaps – more effective therapy. Finally, studies are necessary to evaluate the here given new concept.

Endovenous radiofrequency ablation (venefit procedure): impact of different energy rates on great saphenous vein shrinkage

BACKGROUND

Despite adequate treatment of varicose veins, recurrences and primary failures still occur. This article hypothesizes that increasing the dose of radiofrequency ablation (RFA) could improve efficacy through inducing a greater shrinkage of the treated vein.

METHODS

A comparative clinical study of 67 extremities with varicose veins caused by great saphenous vein (GSV) reflux treated with RFA ClosureFAST was conducted. Group 1 (n = 22) received 1 treatment cycle (20 sec) and group 2 (n = 45) received 2 cycles (40 sec) along the GSV trunk. Clinical and duplex follow-up were performed at day 4, and at 1, 3, and 6 months. The main outcomes measured were GSV diameters, occlusion rate, and secondary effects. Statistical analysis was performed using the Student's t test, linear mixed model, Bland-Altman plot, Lin's concordance correlation coefficient, and intraclass correlation coefficient.

RESULTS

Both groups were comparable for demographic and specific study variables with a very low intraobserver variability. The immediate occlusion rate was 100% for both groups. Group 2 showed a quicker and greater reduction in medium diameter along the period of the study (P = 0.0074). Beyond the 6-month period of study, 1 partial GSV recanalization in group 1 and 1 complete GSV recanalization in an obese patient in group 2 were detected. No skin burns, paresthesia, or deep vein thromboses appeared.

CONCLUSIONS

Two cycles of RFA treatment in all segments of the GSV achieves quicker and greater vein shrinkage of the medium diameter without an increase in side effects. Further studies are needed to evaluate the implications in terms of intermediate and long-term clinical efficacy.

Update on endovenous radio-frequency closure ablation of varicose veins

Until recent years, the gold standard for treatment of truncal varicose veins has been high ligation and stripping of the saphenous vein. In the course of the last decade, new minimally invasive techniques based on endothermal ablation are progressively supplanting conventional surgery in the treatment of varicose veins. The endovenous treatment of varicose veins has been developed to reduce complications associated with conventional surgery and to improve quality of life. Radio frequency ablation (RFA) available since 1999 is now established as a safe and efficacious treatment for the ablation of refluxing saphenous veins. Among the emerging therapies, RFA with VNUS ClosureFAST is promising because it has eliminated almost all disadvantages associated with conventional surgery by "stripping" (bruises, scars, ecchymosis, inguinal recurrence, neovascularization, and mainly, prolonged incapacity) with an immediate occlusion rate close to 100%. When it is compared with endovenous laser ablation, RFA technology is associated with less postprocedural pain, less ecchymosis and tenderness, and better quality of life (QOL) measures. The aim of this article is to summarize the available evidence in the RFA treatment of varicose veins.

Cost-effectiveness of traditional and endovenous treatments for varicose veins

Background

The aim of this study was to evaluate the cost-effectiveness of traditional and endovenous treatments for patients with primary great saphenous varicose veins.

Methods

A Markov model was constructed to compare costs and quality-adjusted life years (QALYs) for great saphenous vein (GSV) reflux. Eight popular treatment strategies were compared up to 5 years. Estimates for the effectiveness of treatments were obtained from published randomized studies and cost values were obtained from published National Health Service (NHS) healthcare resource group tariffs and device manufacturers. Parameter uncertainty was tested using sensitivity analysis and Monte Carlo simulation.

Results

Ultrasound-guided foam sclerotherapy (UGFS) had the lowest initial cost, but a higher requirement for further interventions. Day-case surgery (with concomitant treatment of varicosities), endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) performed in an outpatient or office setting (with staged treatment of varicosities) were likely to be cost-effective treatment strategies. The incremental cost-effectiveness ratio (ICER) for UGFS (versus conservative care), EVLA (versus UGFS) and RFA (versus EVLA) were £1366, £5799 and £17 350 per QALY respectively. The ICER for traditional surgery (performed on a day-case basis) was £19 012 compared with RFA. Other strategies were not cost-effective using the NHS threshold of £20 000 per QALY.

Conclusion

Day-case surgery or endovenous ablation using EVLA or RFA performed as an outpatient are likely to be cost-effective treatment strategies for patients with primary unilateral GSV reflux requiring treatment.

Pain Following 980-nm Endovenous Laser Ablation and Segmental Radiofrequency Ablation for Varicose Veins: A Prospective Observational Study

Objectives: The aim of this study was to evaluate postoperative pain following endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) and identify risk factors for increased pain. Methods: Patients undergoing either segmental RFA (VNUS Closure Fast TM, VNUS Medical Technologies, San Jose, California) or EVLA (980 nm) for varicose veins completed a preoperative disease-specific quality-of-life questionnaire (Aberdeen Varicose Vein Questionnaire [AVVQ]) and a diary card recording postoperative pain, return to normal activities, and return to work. Median 3- and 10-day pain scores were calculated. Results: In all, 81 patients returned diary cards (RFA = 45, EVLA = 36). Patients receiving RFA reported less postoperative pain than those receiving EVLA at 3 days (14.5 vs 25.8 mm, P = .053, Mann-Whitney U test) and 10 days (13 vs 23.3 mm, P = .014, Mann-Whitney U test) and returned to work earlier than those receiving EVLA (median 5 vs 9 days, P = .022). Conclusions: Patients treated with segmental RFA had less postoperative pain and returned to work quicker than those treated with EVLA.

Radiofrequency ablation for uncomplicated varicose veins

In recent years, minimally invasive endovenous treatments have gained popularity in the treatment of superficial venous reflux. The perceived advantages of endovenous therapy include reduced pain, high vein occlusion rates, and early return to work and normal activities. Endovenous radiofrequency ablation (RFA) involves the delivery of thermal energy from a bipolar catheter to the venous segment to be treated. This technique has been available since 1998 and numerous devices and catheters are now produced. Numerous prospective and randomized studies have compared the effectiveness of RFA with traditional and endovenous procedures. In this article, the available evidence for clinical effectiveness, quality of life and cost gains following endovenous RFA is summarized. The scientific principles behind RFA and technical procedural considerations are discussed and standards of care for the delivery of endovenous RFA are proposed.

Randomized clinical trial comparing endovenous laser with cryostripping for great saphenous varicose veins

BACKGROUND

The aim of this randomized single-centre trial was to compare the 2-year results of endovenous laser ablation (EVLA) and cryostripping for varicose veins.

METHODS

A total of 120 patients with uncomplicated great saphenous varicose veins were randomized equally to one of the two treatments. Principal outcomes measures were: freedom from recurrent varicose veins on duplex imaging, and improvement in Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Severity Score (AVVSS) 6, 12 and 24 months after treatment.

RESULTS

Life-table analysis showed overall freedom from recurrent incompetence at 2 years in 77 (95 per cent confidence interval (c.i.) 72 to 78) per cent of patients after EVLA and in 66 (95 per cent c.i. 60 to 67) per cent after cryostripping (P = 0.253). VCSS and AVVSS values improved significantly after treatment, but the differences between the treatments were not significant. EVLA provided significantly more favourable results than cryostripping with respect to duration of operation, postprocedural pain, induration and resumption of normal activity.

CONCLUSION

EVLA and cryostripping were similarly effective in patients with varicose veins, but patients favoured EVLA because of less pain and postoperative morbidity, and quicker return to normal activity.

REGISTRATION NUMBER

ISRCTN33832691 (http://www.controlled-trials.com).

Closure of the Cribriform Fascia: An Efficient Anatomical Barrier Against Postoperative Neovascularisation at the Saphenofemoral Junction? A Prospective Study

BACKGROUND

Neovascularisation at the sapheno-femoral junction (SFJ) ligation site in the groin may occur within one year after great saphenous vein (GSV) surgery. Several anatomical and prosthetic barrier techniques have been proposed to prevent this evolution.

OBJECTIVE

A prospective study examined whether closing the cribriform fascia could reduce the incidence of postoperative neovascularisation in the groin.

PATIENTS AND METHODS

Patients with primary varicose veins and incompetence at the level of the SFJ were included. After SFJ ligation in 235 limbs of 193 patients an anatomical barrier was constructed by closing the cribriform fascia. Postoperative duplex scanning was performed after 2 and 12 months. Results were compared with historical control groups in which either a silicone patch saphenoplasty or no barrier technique had been performed.

RESULTS

After one year, 10 limbs had developed recurrent thigh varicose veins and duplex scan showed neovascularisation at the SFJ ligation site in 15 of 223 re-examined limbs (6.7%). This was comparable to the group of 191 limbs with silicone patch saphenoplasty (5.2%) (P=0.526) and superior to the group of 189 limbs without barrier (14.8%) (P<0.01).

CONCLUSION

Interposition of an anatomical barrier by closing the cribriform fascia after SFJ ligation reduced ultrasound detected neovascularisation at the SFJ after one year. In primary varicose vein operations application of an anatomical barrier technique (without prosthetic patch) is an alternative option to prevent postoperative neovascularisation.