Laser Treatment of Varicose Veins: Order Out of Chaos

Deep vein thrombosis after sclerotherapy and endovenous laser ablation of varicose veins - an observational study

Background: The risk of developing deep vein thrombosis (DVT) after endovenous ablation of varicose veins varies in the literature. Little is known about the characteristics of this complication and associated factors. This study aimed: 1) to study the occurrence of DVT after ultrasound-guided foam sclerotherapy (UGFS) alone or combined with endovenous laser ablation (EVLA) for lower-limb varicose veins; 2) to identify factors associated with DVT. Patients and methods: The study included all outpatients aged 18 years or older who underwent UGFS and EVLA or UGFS alone at the University Hospital of Zurich between 2011 and 2015. Data were extracted from the hospital electronic medical record. Patients were surveyed about their level of pain after the procedure and their level of satisfaction with the procedure. Duplex ultrasound was used to assess the deep venous system 7-10 days and 6-8 months after the procedure. Regression analysis was used to examine the association of patient and procedure characteristics with the development of DVT. Results: A total of 334 patients (561 procedures performed in 393 different sessions) were included: 73% of the patients underwent combined UGFS and EVLA and 27% underwent UGFS alone. DVT occurred in 24 (7.2%) patients, of whom 88% underwent combined procedures and 17% underwent interventions involving both the great and small saphenous veins on the same session. DVT occurred in 8.2% of patients receiving thromboprophylaxis and in 9.5% of patients not receiving thromboprophylaxis. DVT occurred in 5.2% of women and 11.9% of men. No factors associated with a diagnosis of DVT after intervention were identified. Pain and satisfaction levels did not differ between patients with and without DVT. Conclusions: This study adds to the knowledge of the risk of DVT following UGFS alone or combined with EVLA. Further studies are needed to revise thromboprophylaxis.

The effect of wavelength on endothermal heat-induced thrombosis incidence after endovenous laser ablation

OBJECTIVE

We hypothesized that the incidence of endothermal heat-induced thrombosis (EHIT) depends on the laser wavelength used in endovenous laser ablation (EVLA) of the saphenous veins.

METHODS

We identified patients undergoing EVLA in our office from 2005 to 2014 with an 810-nm (hemoglobin-specific) or 1470-nm (water-specific) laser. We reviewed the records for age, sex, body mass index, Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) class, vein diameter, vein(s) treated, adjunctive phlebectomy, energy delivered, laser pullback times, and EHIT (closure level ≥3) development. The Fisher exact test and Pearson χ(2) test were used to evaluate the association between EHIT and the categoric variables. Logistic regression was used to evaluate the relationship between EHIT and the continuous variables.

RESULTS

There were 1439 veins ablated in 1109 patients (769 female, 340 male). The great saphenous vein (GSV) was treated in 1332, the small saphenous vein (SSV) in 78, and both in 29 (22 procedures on accessory veins were excluded). The CEAP C class for these patients was 1 in 0, 2 in 616, 3 in 522, 4 in 150, 5 in 51, and 6 in 98, and was not recorded in 2. EHIT occurred in 76 cases (5.28%), in 73 after GSV ablation and in three after SSV ablation. The 810-nm laser was used in 1144 procedures, and EHIT developed in 69 patients (6.0%). The 1470-nm laser was used in 295 procedures, with EHIT developing in seven patients (2.4%; P = .0122 by Fisher exact test). The average energy delivered to the EHIT group (3517 ± 1998.1 J) was higher than for the non-EHIT group (2825.1 ± 1491.2 J; P = .0002). The average vein diameter was larger in the EHIT group (9.3 ± 3.8 mm) than in the non-EHIT group (7.2 ± 3.3 mm; P = .0001). EHIT occurred in 59 of 837 cases (6.6%) undergoing simultaneous stab phlebectomy compared with 17 of 525 cases (3.1%) undergoing only EVLA (P = .0049). Statistical analysis confirmed the association between EHIT and CEAP class was significant (P = .0001). No differences were seen for age, body mass index, sex, combined bilateral, and multiple or simultaneous GSV and SSV ablations between the two groups. A multivariate analysis confirmed that CEAP class, vein diameter, adjunctive phlebectomy, and laser wavelength were indeed risk factors for post-EVLA EHIT and that energy delivered and pullback time were not.

CONCLUSIONS

Water-specific laser fiber wavelength (1470 nm) reduces the risk of EHIT compared with a hemoglobin-specific wavelength (810 nm). CEAP class, simultaneous phlebectomy, and vein diameter >7.5 mm are associated with increased risk of EHIT after EVLA.

Phenol as a novel sclerosing agent: A safety and efficacy study on experimental animals

BACKGROUND

Varicose and ectatic cutaneous vessels are common chronic conditions that might need surgical treatment. There are several treatment modalities, but all can cause complications and have significant recurrence rates. A new effective and safe treatment with low or no recurrence is needed. Phenol seems to be a potential therapeutic agent.

OBJECTIVE

To assess the efficacy and safety of phenol as a sclerosing agent in the treatment of varicose veins and other vascular ectatic conditions.

METHODS

The dorsal ear veins of white New Zealand rabbits were injected with 0.1 ml of a sclerosing agent. Four experimental groups were used to test the sclerosant efficacy of different concentrations of phenol (1%, 5%, 20% and 50%). Sodium tetradecyl sulphate (STS), a commonly used sclerosing agent, was used as a positive control, while normal saline was used as a negative control. The blood vessels of the treated ears were photographed before and 1 h, 2 days, 8 days and 45 days after treatment. Biopsies from the treated areas were obtained for histologic examinations.

RESULTS

A concentration of 1% phenol was too low to cause significant vascular changes, whereas a concentration of 5% phenol caused 90% lumen narrowing. Interestingly, 1% STS only caused 25% lumen narrowing. Concentrations of 20 and 50% phenol caused 100% lumen narrowing but caused haemorrhage and necrosis. Toxicity monitoring showed no apparent haematologic, cardiac, pulmonary, hepatic or renal toxicity associated with the concentrations of phenol used in this study.

CONCLUSION

A concentration of 5% phenol appears to be a potent and safe sclerosing agent for ectatic small vessels. This provides a significant new therapeutic option, which may eventually advance to the clinic and have an impact on the treatment of patients suffering from varicose veins and other vascular ectatic conditions.

Efeitos imediatos do eletrocautério endovascular em varizes de membros inferiores

OBJETIVOS: Determinar a importância das variáveis: Intensidade de Energia (I), Potência (P) e Tempo de Aplicação (T) nas alterações histológicas ocorridas em varizes de membros inferiores submetidas à eletrocauterização endovascular. MÉTODO: Estudo prospectivo experimental realizado em pacientes submetidos à eletrocauterização endovenosa de fragmento proximal da veia safena magna, de acordo com uma tabela de aleatorização - GI: I=0J, P=0W, T=15s; GII: I=300J, P=60W, T=5s; GIII: I=600J, P=60W, T=10s; GIV: I=900J, P=60W, T=15s; GV: I=450J, P=90W, T=5s; GVI: I=900J, P=90W, T=10s; GVII: I=1350J, P=90W, T=15s; GVIII: I=600J, P=120W, T=5s; GIX: I=1200J, P=120W, T=10s; GX: I=1800J, P=120W, T=15s. Os fragmentos foram submetidos a estudo anatomopatológico com o objetivo de analisar a profundidade das alterações tissulares, assim classificadas: Grupo A - endotélio e média, Grupo B - endotélio, média e adventícia. RESULTADOS: A intensidade das alterações histológicas - Grupo A e B - ocorridas nos fragmentos foram proporcionais à Intensidade de Energia de eletrocauterização (p=0,0001). Essa associação linear também pode ser verificada para as variáveis Potência (p=0,017) e Tempo de Aplicação (p=0,0001). O índice de correlação de Spearman foi maior para variável Tempo de Aplicação: 0,42269 (p=0,002) quando comparada com a variável Potência de Energia: 0,3542 (p=0,005). CONCLUSÃO: O Tempo de Aplicação de Energia é mais importante do que a Potência de Energia utilizada para uma mesma energia de eletrocauterização, na determinação da profundidade dos efeitos histológicos observados na parede das varizes de membros inferiores.

Minimally invasive treatment of varicose veins: Endovenous laser ablation (EVLA)

Varicose veins are a frequently encountered medical condition. In the era of minimally invasive surgery, several techniques, in the treatment of varicose veins, have been developed in the last few years. One of the most frequently used new techniques is endovenous laser ablation. Fibrotic sealing of the treated vein lumen is the final result. The vein ablation is obtained under local - tumescent anaesthesia and the patients can be treated in an office setting with immediate return to full activity. Safety and effectiveness seem to be the major characteristics and advantages of this technique.

Varicose vein: current management

The continued advancement of RFA and EVLS technology should provide for an increased safety profile and lasting efficacy for treating the major saphenous veins. The challenge lies in determining what type of patient comorbidities and anatomic variability result in higher recurrences after endothermal varicose vein treatment so that one can modify the choice of treatment appropriately. Further standardization of the FS technique may allow for its wider use in treating truncal varicosities. The powered phlebectomy system seems to be suited for isolated branch varicosities, but the sequelae of pain and ecchymosis may prevent it from becoming a mainstream treatment with stab phlebectomy and sclerotherapy as alternatives.