Update of endovenous treatment modalities for insufficient saphenous veins—A review of literature

Outcomes of fluoroscopy-guided percutaneous high ligation of the great saphenous vein combined with foam sclerotherapy for symptomatic great saphenous veins

PURPOSE

To evaluate the effectiveness and safety of fluoroscopy-guided percutaneous high ligation (FPHL) combined with fluoroscopy-guided foam sclerotherapy (FGFS) to treat varicose veins of the greater saphenous veins (GSV).

MATERIALS AND METHODS

This was a retrospective study of 113 patients (mean age, 62.1 ± 10.8 years; 60 men) with varicose veins of the GSV (133 limbs) which were treated with FPHL combined with FGFS between April 1, 2019 and October 31, 2019. Demographic and clinical data were collected from these patients before the FPHL procedure, after which FGFS was performed. The preterminal GSV was percutaneously ligated by a percutaneously positioned polypropylene ligature under fluoroscopic guidance. The outcome of ligation was confirmed by venography. Then, foam sclerotherapy was performed under fluoroscopy. At 1-year follow-up, GSV occlusion was evaluated by ultrasound. The venous clinical severity scores (VCSSs) were compared between the preoperative and 1-year follow-up periods.

RESULTS

The technical success rate was 100% (133 limbs). Complete 12-month follow-up was available for 112 limbs (84.2%), and 103 of these limbs (92.0%) remained occluded during this period. The VCSS improved from 4.71 ± 2.15 to 0.74 ± 0.60 (V = 6328, P < .001). During follow-up, there were 16 limbs with thrombophlebitis and 38 limbs with saphenous junction pain; these events were alleviated within 2 weeks of the procedure. There was no deep venous thrombosis or other severe adverse events.

CONCLUSIONS

FPHL combined with FGFS to treat varicose veins in the GSV achieved an occlusion rate of 92% and improved the clinical symptoms within one year; this minimally invasive procedure was safe and effective.

Mechanochemical ablation as an alternative to venous ulcer healing compared with thermal ablation

OBJECTIVE

We aimed to compare mechanochemical ablation (MOCA) and thermal ablation (radiofrequency ablation and endovenous laser therapy) for venous ulcer healing in patients with clinical class 6 chronic venous insufficiency.

METHODS

Electronic medical records were reviewed of patients with venous ulcers who underwent truncal or perforator ablation between February 2012 and November 2015. These records contained history of venous disease and ulcer history, procedures, complications, follow-up, method of wound care, and current status of the ulcer. The patients were grouped according to the method of ablation for comparison.

RESULTS

In 66 patients, 82 venous segments were treated, 29 with thermal methods and 53 with MOCA; 16% of patients had prior venous intervention. Before ablation, three patients in the thermal group had a history of deep venous thrombosis compared with seven in the MOCA group. On average, patients treated with MOCA were older (thermal ablation, 57.2 years; MOCA, 67.9 years; P = .0003). Ulcer duration before intervention ranged from 9.2 months for thermal ablation to 11.2 months for MOCA (P = NS). In total, 74% of patients treated with MOCA healed their ulcers compared with 35% of those treated with thermal ablation (P = .01). A healed ulcer was defined as elimination of ulcer depth and superficial skin coverage. The mean time to heal was 4.4 months in the thermal ablation group compared with 2.3 months with MOCA (P = .01). The mean length of follow-up was 12.8 months after thermal ablation and 7.9 months after MOCA (P = .02). Both age (P = .03) and treatment modality (P = .03) independently had an impact on ulcer healing on multiple logistic regression analysis. All but two patients were treated with an Unna boot after venous ablation. Complications included readmission of two patients with nonaccess-related infections, one nonocclusive deep venous thrombosis, and one late death unrelated to the procedure second to pneumonia in the setting of advanced colon cancer. There were three recurrent ulcers at 1 week, 2 months, and 7 months after MOCA that rehealed with Unna boot therapy and continued compression.

CONCLUSIONS

MOCA is safe and effective in treating chronic venous ulcers and appears to provide comparable results to methods that rely on thermal ablation. Younger age and use of MOCA favored wound healing. MOCA was an independent predictor of ulcer healing. Randomized studies are necessary to further support our findings.

Single-center retrospective review of early outcomes of radiofrequency ablation versus cyanoacrylate ablation of isolated great saphenous vein insufficiency

OBJECTIVE

Data comparing radiofrequency ablation (RFA) with cyanoacrylate closure (CAC) treatment of isolated great saphenous vein (GSV) insufficiency are limited. In this study, we present our early outcomes of RFA vs CAC for the treatment of GSV insufficiency.

METHODS

Between March 2015 and February 2017, a total of 159 patients underwent CAC (n = 75) or RFA (n = 84) for treatment of GSV insufficiency by a single surgeon. Medical data of the patients were retrieved from the institutional database and retrospectively analyzed. All patients underwent lower extremity venous color duplex ultrasound examination. The Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire were used. Total closure rates of the GSV with RFA or CAC were recorded at 1 month, 6 months, and 12 months. Procedure-related adverse events and quality of life of the patients were also evaluated.

RESULTS

The mean age was 46.33 ± 14.40 years in the CAC group and 48.09 ± 13.25 years in the RFA group (P = .4). The mean treated saphenous vein diameter was 7 mm in the CAC group and 7.25 mm in the RFA group (P = .07). The length of treated venous segment was 30 cm in both the CAC and RFA groups (P = .66). The mean duration of operation was 25 minutes in the CAC group and 35 minutes in the RFA group (P < .001). The incidence of adverse events was higher in the RFA group (P < .05). At 1 month, 6 months, and 12 months of follow-up, there was no statistically significant difference in the total closure rates between the CAC and RFA groups. There was no significant difference in the Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire score between the groups (P > .05).

CONCLUSIONS

Our study results suggest that both RFA and CAC are effective in closure of the target GSV. Although the incidence of tumescent anesthesia-related and procedure-related complications is higher with the RFA technique, both techniques can be used safely with similar success rate and patient satisfaction.

Endovenous ablation and surgery in great saphenous vein reflux: a systematic review and network meta-analysis of randomised controlled trials protocol

INTRODUCTION

Endovenous ablations are the new standard procedures for treatment of great saphenous vein reflux including endovenous laser ablation (EVLA), radio frequency ablation (RFA), endovenous steam ablation (EVSA), mechanochemical ablation (MOCA), cyanoacrylate injection and ultrasound-guided foam sclerotherapy (UGFS). EVLA and RFA have demonstrated similar anatomical success for short-term outcome, but results are controversial for longer term (≥5 years). Additional evidences from randomised controlled trials have been published. This study is, therefore, conducted to, directly and indirectly, compare outcomes among all procedures stratifying by short-term and long-term follow-up.

METHODS AND ANALYSIS

Medline and Scopus will be searched from 2000 to September 2018 with predefined search strategy. Interventions of interest are open surgery (ie, saphenofemoral or high ligation (HL) with stripping) and endovenous ablations (ie, EVLA, RFA, EVSA, MOCA, cyanoacrylate injection and UGFS). The primary outcome is anatomical success. Two independent reviewers will select studies, extract data and assess risk of bias. Disagreement will be adjudicated by the third party. Outcomes will be directly pooled if there are at least three studies in that comparison. A fixed-effect model will be used unless heterogeneity is present, in which case a random-effect model will be applied. Sources of heterogeneity will be explored using meta-regression analysis, and sub-group analysis will be done accordingly. Publication bias will be assessed using Egger's test and funnel plot. A network meta-analysis will be applied to indirect compare all interventions including RFA, EVLA, EVLA with HL, UGFS, UGFS with HL and HL with stripping. Probability of being best intervention will be estimated and ranked. Inconsistency assumption will be checked using a design-by-treatment interaction model.

ETHICS AND DISSEMINATION

Ethical approval is not required for systematic review and network meta-analysis. The study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018096794.

Double prepuncture as a valuable adjunctive technique for complex endovenous ablation

OBJECTIVE

The objective of this study was to characterize the technique and to report the results of double prepuncture used during complex radiofrequency ablation (RFA) in cases of treating multiple incompetent veins or encountering focal obstruction to catheter advancement.

METHODS

A double prepuncture technique was applied in patients requiring endovascular ablation of multiple veins and patients with great saphenous vein cannulation failure. We treated 13 limbs in 12 patients during a 24-month period with RFA in which the double prepuncture technique was used. Clinical history, operative reports, outcomes, and follow-up were reviewed.

RESULTS

RFA was performed with the double puncture technique on, collectively, 10 great saphenous veins, 5 small saphenous veins, and 5 anterior accessory saphenous veins. Mean preoperative Clinical, Etiology, Anatomy, and Pathophysiology score was 4.38 ± 1.6. Three limbs required prepuncture because of difficulty in advancing the catheter cephalad through tortuosity and focal obstruction after failure with techniques such as a guidewire, a guide catheter, and manual compression with ultrasound guidance. Ten limbs received planned double prepuncture for multiple adjacent incompetent veins, for which venipuncture and cannulation of the second target vein would be difficult after tumescent application to the first vein. Postoperative ultrasound demonstrated successful closure of all target veins in which the double prepuncture technique was used. One patient had a deep venous thrombosis (7.7%) that resolved without complications.

CONCLUSIONS

Double prepuncture is a useful technical adjunct both for simultaneous endovenous ablation of multiple adjacent incompetent veins and when catheter passage is impeded. This technique aids in efficient and successful application of endovenous ablation to complex venous anatomy.

The effect of commercial insurance policies on outcomes of venous ablation

OBJECTIVE

The use of venous ablation (VA) for treatment of chronic venous insufficiency has exponentially increased. To limit cost and overuse, insurance companies have adopted aleatory policies. The goal of this study was to compare the policies of five major local insurance carriers and to determine whether treatment within the criteria of a certain policy is associated with improved patient outcomes.

METHODS

A retrospective single-center review of patients treated with VA was performed. Demographics, comorbidities, symptoms, and clinical class (Clinical, Etiology, Anatomy, and Pathophysiology classification) were recorded. Clinical success was defined on chart review by the patients' reporting of improvement or resolution of symptoms in the leg treated on follow-up, and technical success was defined by vein closure on ultrasound. Patients underwent a telephone survey inquiring about intensity of symptoms on a numeric rating scale of 0 to 10 before and after treatment of each leg as well as effects on quality of life (QOL). The policies of Aetna, Cigna, Anthem Blue Cross Blue Shield, UnitedHealthcare, and Connecticut Care were reviewed. The clinical and technical success rates were compared when veins were treated within the criteria of each policy. A subgroup analysis looking at patients who had clinical success only was performed to determine the potential rate of denial of coverage for each policy. A multivariable analysis was performed to determine independent predictors of clinical success.

RESULTS

There were 253 patients with 341 legs treated. The mean age was 58.5 ± 15.2 years (68% women). The most common symptom was pain (89.7%), with 47.8% of patients having C3 disease. The clinical success, technical success, and complication rates were 84.2%, 95.1%, and 5.6%, respectively. On survey, there was improvement of the numeric rating scale score in 84.3% of legs treated after the procedure, and 76.7% continued to experience improvement after a mean follow-up of 26.8 months. There was improvement of QOL in 76.5% of patients. There was no significant difference in procedural success, technical success, complication rate, or improvement in QOL when patients were treated within any of the five insurance policies. On multivariable analysis, there was no single policy significantly associated with clinical success. However, subgroup analysis of procedures with clinical success (n = 287) showed a significant difference between the five policies on analysis of the potential denial of coverage, ranging from 5.6% for Connecticut Care to 64.1% for UnitedHealthcare (P < .0001).

CONCLUSIONS

The different insurance policies have no correlation with outcomes of VA. Policies with more stringent criteria typically restrict treatment to larger veins and deny procedures to a significant number of patients with chronic venous insufficiency who can benefit from them.

Foam sclerotherapy of the great saphenous vein in association with pre-terminal saphenous junction ligation/division as an office-based procedure: 12-Month results

Objective Ultrasound-guided foam sclerotherapy (UGFS) - one of the most frequently recommended methods for treating great saphenous vein incompetence - is easy and inexpensive. However, it achieves a lower occlusion rate compared to endovenous thermal ablation. The application of UGFS to pre-terminal great saphenous vein interruption, eliminating the saphenous stem wash out effect, enhances the short-term occlusion rate. This study explores the results of this technique at 12 months. Method Thirty great saphenous veins (28 patients) with junction incompetence, with calibres >6 mm and >30 cm reflux stem length were submitted to echo-guided pre-terminal great saphenous vein interruption and foam great saphenous vein occlusion. Participants were subjected to a 12-month post-operative review by ultrasound assessment of great saphenous vein occlusion and terminal stump stability. Comparisons were made between pre-operative and 12-month Validation of Venous Clinical Severity Score (VCSS), photopletismography, Aberdeen questionnaire and complications. Results After 12 months, 28/30 great saphenous veins remained occluded (93%). One complete and one partial recanalization did not require retreatment. Four saphenous stumps showed a reflux during Valsalva (one due to recanalization, one limited to the stump, two with reflux in the anterior accessory saphenous vein). VCSS improved from 3.33 ± 1.64 to 0.67 ± 1.21 ( p < 0.05). Aberdeen questionnaire scores decreased from 9.44 ± 6.18 to 2.47 ± 3.77 ( p < 0.05). For photopletismographic examination, the mean venous refilling time (normal value: > 25 s) improved from 17.94 ± 11.97 to 31.4 ± 11.99 ( p < 0.05). Conclusion Applying pre-terminal great saphenous vein interruption to UGFS of the saphenous stem achieved an occlusion rate at one year similar to that of endovenous thermal ablation. The procedure is simple, effective, office based, and may be used as a 10-min prolongation to a phlebectomy.

Comparison of ultrasound-guided endovenous laser ablation and radiofrequency for the varicose veins treatment: An updated meta-analysis

PURPOSE

To investigate and compare the relative efficacy, recurrence and complications of endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) for the treatment of varicose veins patients.

METHODS

Searches were applied to the Cochrane Library as well as MEDLINE, EMBASE, BIOSIS databases. 12 articles published in English (10 randomized controlled trials and 2 cohort study) were identified from specialized trails. Fixed effect model and Random effect model were applied to compare the vein ablated length, pain scores (3days and 10days), quality of Life, occlusion, over all complication, thrombophlebitis, haematoma and recanalization between the EVLA and RFA group. The results were expressed as odds ratio (OR) or relative risk (RR) and 95% confidence intervals (CI) for categorical outcomes.

RESULTS

12 reported studies with a combined total of 1577 patients were included. vein ablated length (SMD:0.37, 95%CI: 0.04 to 0.77), 3days pain scores (SMD:11.25, 95%CI: 3.42 to 25.92) and 10days (SMD:0.79,95%CI: 0.48 to 2.05),1 month quality of Life (SMD: 0.09,95%CI: 0.28 to 0.10) and 1 year (SMD: 0.04,95%CI: 0.21 to 0.13), occlusion (OR:1.05,95%CI:0.41 to 2.73), thrombophlebitis (RR:1.03,95%CI:0.56 to 1.92), haematoma (OR:1.55, 95%CI:0.54 to 4.45) and recanalization (OR:0.68,95%CI:0.43 to 1.09) following RFA showed no difference when compared with EVLA. These results were not statistically significant. RFA was associated with the lower overall complication (OR: 3.49, 95%CI:1.36 to 8.96) in patients with varicose veins compared to the EVLA treatment.

CONCLUSION

EVLA and RFA seem to be the same safe and effective on clinical efficacy (vein ablated length, 3days and 10days pain scores, 1 month and 1 year quality of life, occlusion, thrombophlebitis, haematoma and recanalization). Data on RFA seems to having potential benefits from reducing risk of overall complication than EVLA, which is needed by large high-quality prospective randomized trials.

Mechanochemical ablation for symptomatic great saphenous vein reflux: A two-year follow-up

Background Several studies have shown comparable early efficacy of mechanochemical ablation to endothermal techniques. The goal of this report was to show if early efficacy is maintained at 24 months. Methods This was a two-year analysis on the efficacy of mechanochemical ablation in patients with symptomatic C2 or more advanced chronic venous disease. Patients with reflux in the great saphenous vein involving the sapheno-femoral junction and no previous venous interventions were included. Demographic information, clinical, and procedural data were collected. The occlusion rate of treated veins was assessed with duplex ultrasound. Patient clinical improvement was assessed by Clinical-Etiology-Anatomy-Pathophysiology (CEAP) class and venous clinical severity score. Results Of the initial 126 patients, there were 65 patients with 24 month follow-up. Of these 65 patients, 70% were female, with a mean age of 70 ± 14 years and an average body mass index (BMI) of BMI of 30.5 ± 6. The mean great saphenous vein diameter in the upper thigh was 7.6 mm and the mean treatment length was 39 cm. Adjunctive treatment of the varicosities was performed in 14% of patients during the procedure. Closure rates were 100% at one week, 98% at three months, 95% at 12 months, and 92% at 24 months. There was one patient with complete and four with partial recanalization ranging from 7 to 12 cm (mean length 9 cm). There was significant improvement in CEAP and venous clinical severity score (P < .001) for all time intervals. Conclusion Early high occlusion rate with mechanochemical ablation is associated with significant clinical improvement which is maintained at 24 months, making it a very good option for the treatment of great saphenous vein incompetence.