Endovenous thermal ablation of the saphenous vein

Percutaneous Radiofrequency Ablation to Occlude the Thoracic Duct: Preclinical Studies in Swine for a Potential Alternative to Embolization

PURPOSE

To investigate the feasibility of percutaneous radiofrequency ablation (RFA) to occlude the thoracic duct (TD) in a swine model with imaging and histologic correlation.

MATERIALS AND METHODS

Six swine underwent TD RFA. Two terminal (4 hours; 1 open, 1 percutaneous) and four survival (30 days; all percutaneous) studies were performed. Two 20-gauge needles were placed adjacent to the TD under direct visualization after right thoracotomy or under fluoroscopic guidance using a percutaneous transabdominal approach after intranodal lymphangiography. Radiofrequency electrodes were advanced through the needles and ablation was performed at 90 degrees Celsius for 90 seconds. Lymphangiography was performed and the TD and adjacent structures were resected and examined microscopically at the end of each study period.

RESULTS

Four of six subjects survived the planned study period and underwent follow up lymphangiography. Two subjects in the survival group were euthanized early; 1 after developing an acute chylothorax and 1 due to gastric volvulus 14 days after ablation. Occlusion of the targeted TD segment was noted on lymphangiography in 3 of 4 remaining subjects (2 acute, 1 survival). Histology 4 hours after RFA demonstrated necrosis of the TD wall and hemorrhage within the lumen. Histology at 14 and 30 days revealed fibrosis with hemosiderin laden macrophages replacing the ablated TD. Collagen degeneration within the aortic wall involving a maximum of 60% thickness was noted in 5/6 subjects.

CONCLUSION

Percutaneous RFA can achieve short-segment TD occlusion. Further study is needed to improve safety and demonstrate clinical efficacy in treating TD leaks.

Challenges of treating mixed arterial-venous disease of lower extremities

INTRODUCTION

Mixed arterial-venous lower extremity disease (AVLED) poses a unique challenge for clinicians. This review will outline the impact mixed AVLED has on patients and the healthcare system, by reviewing its epidemiology, diagnosis, current treatment, and the challenges encountered implementing therapies.

EVIDENCE ACQUISITION

An extensive search of current literature from online sources, journals and book chapters identified the current challenges facing the treatment of mixed arterial venous ulcers of the lower extremities and potential solutions to these challenges.

EVIDENCE SYNTHESIS

The challenges that are identified in the search are the time to heal AVLED, patient education and motivation, early detection of AVLED, wound care center development, treatment consensus from multidisciplinary team members, and cost of treatment.

CONCLUSIONS

AVLED ulcers are a challenging problem, but over time we have continued and will continue to improve patient care and tackle these difficult challenges as we have throughout the last century. A diagnostic algorithm to address how we approach these patients in terms of conservative care with wound care and compression and treat arterial and venous insufficiency is crucial. In looking to the future, continued standardization of wound care centers will overcome the social and financial challenges faced by patients and continued clinical research will improve targeted therapies and treatment challenges faced by physicians.

Evaluating patient preferences for thermal ablation versus nonthermal, nontumescent varicose vein treatments

OBJECTIVE

To measure patient preferences for attributes associated with thermal ablation and nonthermal, nontumescent varicose vein treatments.

METHODS

Data were collected from an electronic patient preference survey taken by 70 adult participants (aged 20 years or older) at three Center for Vein Restoration clinics in New Jersey from July 19, 2019, through August 13, 2019. Survey participation was voluntary and anonymous (participation rate of 80.5% [70/87]). Patients were shown 10 consecutive screens that displayed three hypothetical treatment scenarios with different combinations of six attributes of interest and a none option. Choice-based conjoint analysis estimated the relative importance of different aspects of care, trade-offs between these aspects, and total satisfaction that respondents derived from different healthcare procedures. Market simulation analysis compared clusters of attributes mimicking thermal ablation and nonthermal, nontumescent treatments.

RESULTS

Of the six attributes studied, out-of-pocket (OOP) expenditures were the most important to patients (37.2%), followed by postoperative discomfort (17.1%), risk of adverse events (16.3%), time to return to normal activity (11.0%), number of injections (10.0%), and number of visits (8.4%). Patients were willing to pay the most to avoid postoperative discomfort ($68.9) and risk of adverse events ($65.8). The market simulation analysis found that, regardless of the level of OOP spending, 60% to 80% of respondents favored attribute combinations corresponding with nonthermal, nontumescent procedures over thermal ablation, and that less than 1% of participants would forgo either treatment under no cost sharing.

CONCLUSIONS

Patients are highly sensitive to OOP costs for minimally invasive varicose vein treatments. Market simulation analysis favored nonthermal, nontumescent procedures over thermal ablation.

Recent developments on foaming mechanical and electronic techniques for the management of varicose veins

Introduction: Varicose veins are a common disease, causing significant impairment of quality of life to afflicted individuals. Conventional surgery has represented the traditional treatment for years, with significant post-operative complications. By the end of the 20^th century, novel approaches had been developed to induce biochemical sclerosis into the treated vein in order to exclude it from blood circulation.Areas covered: Foaming techniques for treatment of varicose veins, both clinically-approved methods and those under experimental studies. A brief description of cavitation, which is the basis of microbubbles formation, and an overview of foam properties have been also provided, including a discussion on clinical efficacy and safety profile.Expert commentary: Foam sclerotherapy has rapidly gained popularity since it represents the most minimally invasive and cost-effective procedure in the short term. Several different methods of foam preparation have been described in literature. In general, the foam generation method may affect characteristics such as stability and bubble size distribution, which in turn affect the therapeutic action of foam itself. Therefore, the selection of a suitable foaming technique is of importance for treatment success. Future developments on foaming techniques are expected to make sclerotherapy, already an effective treatment, even safer and more versatile therapeutic procedure.

Office Based Endovenous Radiofrequency Ablation of Truncal Veins: A Case for Moving Varicose Vein Treatment out of Operating Theatres

OBJECTIVES

This study aims to assess the efficacy and outcomes at one year after office based endovenous radiofrequency ablation (OBEVRFA) as a standalone procedure for varicose veins under local anaesthesia.

METHODS

A retrospective study of prospectively collected data of all OBEVRFAs done in the vascular unit from April 2014 to June 2016 was performed. The demographics, clinical findings, initial venous duplex ultrasound (DUS) findings, the vein ablated, and immediate complications were recorded. Patients were reviewed at six weeks and again if necessary with or without a repeat DUS. The follow up period ranged from 12 to 38 months. Patients undergoing further procedures for symptomatic residual veins within the follow up period were recorded. Average cost and income were obtained from the hospital Patient Level Information and Costing Systems data.

RESULTS

A total of 523 limbs were listed for OBEVRFA during the study period. Ninety-four (18%) were cancelled on the day of surgery for various reasons. A total of 429 procedures in 394 patients were performed. There were 35 bilateral cases; each limb performed on separate occasions. The female to male ratio was 1.2:1. The median age was 54 years (range 17-88 years). The CEAP (Clinical, Etiologic, Anatomic and Pathophysiologic) classification was C2 to C3, 291 (68%); C4 to C5, 11 (26%), and C6, 26 (6%). Forty-seven (11%) recurrent varicose veins were treated. There were three recorded cases of endovenous heat induced thrombosis (EHIT). Sixty (14%) patients were lost to follow up. One hundred and five (29%) patients underwent repeat DUS for persistent symptoms. In the follow up period, only 86 patients (23%) needed further multiple avulsions.

CONCLUSIONS

OBEVRFAs of the truncal veins for the treatment of varicose veins is safe and effective and could be performed in all suitable patients to free up theatre capacity.

Mini-invasive high-tie by clip apposition versus crossectomy by ligature: Long-term outcomes and review of the available therapeutic options

Objective The aim of the present study is to compare a mini-invasive (smaller than 2-cm incision) sapheno-femoral high-tie by clip apposition (HT group) with a traditional high-ligation by ligature (HL group). Methods One hundred fifty chronic venous disease patients were included in group HT and compared with 150 cases constituting the group HL. The main outcome was the sonographic detection of saphenous trunk recurrences. Procedural pain, esthetic satisfaction, and disease specific quality of life were assessed. Results At 4.5 ± 2.4 years follow-up, 8 cases (5.3%) of Great Saphenous Vein reflux reappearance were reported in group HT vs. 19 cases (12.6%) (odds ratio: 2.6; 95% confidence interval: 1.1-6.1; P = 0.04) of group HL. Esthetic satisfaction was scored as high and very high in group HT and HL, respectively (P < .0001). Conclusions Proper high-ligation technique provides satisfying outcomes both in terms of recurrence rate and patient esthetic satisfaction. The different outcomes obtained by the two groups encourage further investigations regarding recurrence pathogenesis.

The impact of 2013 UK NICE guidelines on the management of varicose veins at the Heart of England NHS Foundation Trust, Birmingham, UK

OBJECTIVE

Although varicose veins are a common cause of morbidity, the UK National Health Service and private medical insurers have previously sought to ration their treatment in a non-evidence based manner in order to limit health-care expenditure and reimbursement. In July 2013, the UK National Institute for Health and Care Excellence published new national Clinical Guidelines (CG168) to promote evidence-based commissioning and management of varicose veins. The aim of this study was to evaluate the impact of CG168 on the referral and management of varicose veins at the Heart of England NHS Foundation Trust, Birmingham, UK.

METHODS

Interrogation of a prospectively gathered database, provided by the Heart of England NHS Foundation Trust Performance Unit, of patients undergoing interventions for varicose veins since 1 January 2012. Patients treated before (group 1) and after (group 2) publication of CG168 were compared.

RESULTS

There were 253 patients, 286 legs (48% male, mean (range) age 54 (20-91) years) treated in group 1, and 417 patients, 452 legs, (46% male, mean (range) age 54 (14-90) years) treated in group 2, an increase of 65%. CG168 was associated with a significant reduction in the use of surgery (131 patients (52%) group 1 vs. 127 patients (30%) group 2, p = 0.0003, χ(2)), no change in endothermal ablation (30 patients (12%) group 1 vs. 45 patients (11%) group 2), a significant increase in ultrasound-guided foam sclerotherapy (92 patients (36%) group 1 and 245 patients (59%) group 2, p = 0.0001, χ(2)) and an increase in treatment for C2/3 disease (53% group 1 and 65.2% group 2, p = 0.0022, χ(2)).

CONCLUSIONS

Publication of National Institute for Health and Care Excellence CG168 has been associated with a significant increase (65%) in the number of patients treated, referral at an earlier (CEAP C) stage and increased use of endovenous treatment. CG 168 has been highly effective in improving access to, and quality of care, for varicose veins at Heart of England NHS Foundation Trust.