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Juhani AA, Abdullah A, Alyaseen EM, Dobel AA, Albashri JS, Alalmaei OM, Salem Alanazi YM, Almutairi DR, Alqahtani LN, Alanazi SA. Interventions for great saphenous vein insufficiency: A systematic review and network meta-analysis. Vascular 2024:17085381241273098. [PMID: 39148483 DOI: 10.1177/17085381241273098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
BACKGROUND Great saphenous vein insufficiency (GSVI) adversely affects the quality of life of affected individuals. Minimally invasive endo-venous ablation techniques have emerged as effective and safe treatments, despite the longstanding use of surgical interventions. We aim in our study to evaluate all the available interventions in the literature, either endo-venous or conventional approaches for the treatment of GSVI. METHODS A thorough search was performed across four electronic databases to identify relevant studies. A frequentist network meta-analysis (NWM) was executed on the combined data to derive network estimates pertaining to the outcomes of concern. Risk ratios (RRs) were employed as the effect size metric for binary outcomes, while mean differences (MDs) were utilized for continuous outcomes, each reported with a 95% confidence interval. The qualitative review was conducted employing the Cochrane risk of bias assessment tool 1. RESULTS Our NWM included 75 studies encompassing 12,196 patients. Regarding technical success rate within the first 5 years after treatment, Endo-venous Laser Ablation (EVLA) with High Ligation and Stripping (HL/S), EVLA alone, Cyanoacrylate Adhesive Injection, cryostripping, HL/S and Radiofrequency Ablation (RFA) were significantly better than Ultrasound-Guided Foam Sclerotherapy and F-care. Also, invagination stripping was inferior to all interventions. Conservative Hemodynamic Cure for Venous Insufficiency and Varicose Veins (CHIVA) demonstrated a significantly lower recurrence rate with a RR of 0.35 [0.15; 0.79] compared to RFA, but RFA was more effective in recurrence prevention than HL/S and Mechanochemical Ablation (MOCA), with a RR of 0.63 [0.41; 0.97] and 0.18 [0.03; 0.95], respectively. Endo-venous Steam Ablation (EVSA) emerged as the most effective in reducing post-intervention pain, showing a MD of -2.73 [-3.72; -1.74] compared to HL/S. In Aberdeen Varicose Vein Questionnaire outcome, our analysis favored MOCA over most studied interventions, with an MD of -6.88 [-12.43; -1.32] compared to HL/S. Safety outcomes did not significantly differ among interventions. CONCLUSION Our findings revealed significant variations in the technical success rates, recurrence rates, and post-intervention pain levels among different interventions. CHIVA exhibited enhanced performance in terms of lower recurrence rates, while EVSA emerged as a promising choice for mitigating post-intervention pain. Additionally, our analysis underscored the significance of patient-reported outcomes, with MOCA consistently yielding favorable results in terms of enhancing quality of life and expediting the return to regular activities.
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Affiliation(s)
- Abdulkreem Aa Juhani
- Faculty of medicine and surgery,.King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Abdullah Abdullah
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Amnah A Dobel
- College of Medicine, Taif University, Taif, Saudi Arabia
| | | | - Osama M Alalmaei
- College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
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Chan SM, Tabari A, Rudié E, D'Amore B, Cox M, Mugahid A, Iqbal S, Daye D. Disparities in access to endovenous treatment options in chronic lower extremity superficial venous insufficiency: A national 7-year analysis. J Vasc Surg Venous Lymphat Disord 2024; 12:101867. [PMID: 38452897 DOI: 10.1016/j.jvsv.2024.101867] [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] [Received: 06/21/2023] [Revised: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVE The goal of this study was to analyze trends in treatment access for chronic superficial venous disease and to identify disparities in care. METHODS This retrospective study was exempt from institutional review board approval. The American College of Surgeon National Surgical Quality Improvement Program database was used to identify patients who underwent vein stripping (VS) and endovenous procedures for treatment of chronic superficial venous disease. Endovenous options included radiofrequency ablation (RFA) and laser ablation. Data was available from 2011 to 2018 and demographic information was extracted for each patient identified by Current Procedural Terminology codes. For all racial and ethnic groups, trend lines were plotted, and the relative rate of change was determined within each specified demographic. RESULTS There were 21,025 patients included in the analysis. The overall mean age was 54.2 years, and the majority of patients were female (64.8%). In total, 27.9%, 55.2%, and 16.9% patients underwent VS, RFA, and laser ablation, respectively. Patients who received laser ablation were older (P < .001). Hispanic ethnicity was associated with significantly lower odds of receiving endovascular thermal ablation (EVTA) over VS (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.64-0.78; P < .001). American Indian/Alaska Native patients were more likely to receive EVTA over VS (OR, 4.02; 95% CI, 2.48-6.86); similarly, Native Hawaiian/Pacific Islander patients were more likely to receive EVTA over VS, although this difference was not statistically significant (OR, 1.44; 95% CI, 0.93-2.27). On multinomial regression, Hispanic patients were less likely to receive RFA over VS, whereas American Indian/Alaskan Native patients were more likely to receive RFA over VS. In all racial and ethnic groups, the percentage of endovenous procedures increased, whereas vein stripping decreased. CONCLUSIONS Based on a hospital-based dataset, demographic indicators, including age, sex, race, and ethnicity, are associated with differences in endovenous treatments for chronic superficial venous insufficiency suggesting disparities in obtaining minimally invasive treatment options among certain patient groups.
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Affiliation(s)
- Shin Mei Chan
- UCSF Department of Radiology & Biomedical Imaging, University of California, San Francisco, CA
| | - Azadeh Tabari
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Emma Rudié
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brian D'Amore
- Drexel University College of Medicine, Philadelphia, PA
| | - Meredith Cox
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Duke University School of Medicine, Durham, NC
| | - Ayah Mugahid
- UCSF Department of Radiology & Biomedical Imaging, University of California, San Francisco, CA
| | - Shams Iqbal
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Dania Daye
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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3
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Bootun R, Burrows M, Chowdhury MM, Stather PW, Al-Jundi W. The risk of harm whilst waiting for varicose veins procedure. Phlebology 2023; 38:22-27. [PMID: 36441941 PMCID: PMC9713534 DOI: 10.1177/02683555221141824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Varicose veins (VV) negatively impact quality of life (QoL) and have risks of major complications including bleeding, ulceration and phlebitis. During the COVID-19 pandemic, the VSGBI (Vascular Society of Great Britain and Ireland) and GIRFT (Get It Right First Time) classified VVs as lowest priority for intervention. OBJECTIVE This study aims to determine harm caused and the impact on the QoL on patients waiting for their VVs procedures for more than 1 year. METHODS This was a prospective study conducted at the Norfolk and Norwich University Hospital (NNUH). Patients with VVs awaiting intervention for >1 year were included in the study. Patients with CEAP C6 disease were considered to be too high risk to be invited for treatment during the Covid-19 pandemic. Patients were sent QoL questionnaires and underwent a telephone consultation to assess harm. Both generic (EQ-VAS and EQ-5D) and disease-specific (AVVQ and CIVIQ-14) instruments were utilised. There were no control groups available for comparison. RESULTS 275 patients were identified (37.1% male) with median time on waiting list of 60 weeks (IQR 56-65). 19 patients (6.9%) came to major harm, including phlebitis (3.6%), bleeding (1.8%) and ulceration (1.8%). Fifty-two patients (18.9%) had minor harm, including worsening pain (12.7%) and swelling (6.2%). 6.9% reported psychological harm. Rising CEAP stage was also associated with worsening level of harm in patients with C5-6 disease (p < 0.0001). Only 8.7% stated they would decline surgery during the pandemic. 104 QoL questionnaires were returned. Median EQ-VAS and EQ-5D was 75 (IQR: 60-85) and 0.685 (0.566-0.761), respectively. Median AVVQ score was 23.2 (14.9-31.0) and CIVIQ-14 score was 33 (21-44).ConclusionsThis study highlights the impact of delaying VVs surgery during a pandemic. A significant rate of both major and minor as well as psychological harm was reported. In addition, VVs had a significant detriment to quality of life.
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Affiliation(s)
- Roshan Bootun
- Vascular Trainee, East of England Deanery, United Kingdom, and Honorary Research Fellow, Section of Vascular Surgery, Imperial College London, UK,Department of Vascular Surgery, Norfolk and Norwich University Hospital, UK,Roshan Bootun, Department of Vascular Surgery, Norfolk and Norwich University Hospital, Norwich, NR4 7UY, UK.
| | - Mandy Burrows
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, UK
| | - Mohammed M Chowdhury
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, UK,NIHR Clinical Lecturer in Vascular Surgery, Department of Vascular Surgery, Cambridge University Hospitals, University of Cambridge, UK
| | - Philip W Stather
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, UK,Clinical Associate Professor, Norwich Medical School, University of East Anglia, UK
| | - Wissam Al-Jundi
- Department of Vascular Surgery, Norfolk and Norwich University Hospital, UK,Honorary Senior Lecturer, Norwich Medical School, University of East Anglia, UK
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Bottini O, Rodriguez Santos F, Boroda A, Arias F, Calcina D, Agüero Wagner C, Grillo L, Morales Bazurto M, Santiago F, Nigro J, Morales M, Ferreyra M, Perea Ansinelli A, Diaz M, Segura J, Mazzurco M, Diez G, Halusch E, Ovelar J, Parrotta L, Fernandez J, Avramovic M, Ríos J, Esposito A, Alfonso H, Desjardins E, Arias L, Joviliano E, Toledo DE Aguiar E, Barreto Dos Santos J, Orrego A, Bombín J, Pizarro I, Cabezas J, Manosalvas R, Villota V, Rodriguez L, Martínez Granados A, Mérida J, García Bernard D, Serralde J, Vega Rasgado F, Teixeira E, Filizzola R, Corbeta R, Benito R, Chunga Prieto J, Rivera T, Volpi M, Sarutte S, Ortiz P, Prego A, Navas H, Alberti T, Guglielmone D, Mejía R, Simkin C, Intriago E, Bercovich J. The First Latin American Consensus on Superficial and Perforating Venous Mapping. INT ANGIOL 2023; 42:45-58. [PMID: 36892521 DOI: 10.23736/s0392-9590.23.04991-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
With the aim of obtaining a map which is useful as a diagnostic tool and therapeutical orientation, complementing the written report of duplex ultrasound venous study, Latin-American Scientific Societies of Phlebology, Vascular Surgery and Vascular Imaging were invited to participate, through their regional representatives, to the First Consensus of Superficial and Perforating Venous Mapping. A consensus process using a modified Delphi method was carried out. An International Working Group was formed, which developed a Prototype of the Venous Mapping that worked as a starting point for consensus, and was presented in a first virtual meeting of 54 experts (societies' representatives) when the methodology was explained. For the consensus process, two rounds of self-administrated questionnaires with feedback were used. In the first questionnaire a 100% consensus was obtained in the 15 statements (an agreement range of 85.2% to 100%) In the analysis of qualitative data, three categories according to the actions to implement were identified - actions which involved no action, minor changes and major changes. This analysis was used to build the second questionnaire, which reached a consensus in its six statements (agreement range of 87.1% to 98.1%). A final consensus on every field proposed was established with the approval of all the experts consulted and it was presented at a third online meeting. The document of the superficial and perforating venous mapping reached by consensus is presented hereafter.
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Affiliation(s)
- Oscar Bottini
- Hospital Alemán, Universidad del Salvador, Buenos Aires, Argentina - .,Centro Medico Bottini, Buenos Aires, Argentina - .,Forum Venoso Latinoamericano, Buenos Aires, Argentina - .,Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina -
| | | | - Alejandro Boroda
- Hospital Alemán, Universidad del Salvador, Buenos Aires, Argentina.,Centro Medico Bottini, Buenos Aires, Argentina
| | | | - Daniela Calcina
- Hospital Alemán, Universidad del Salvador, Buenos Aires, Argentina.,Centro Medico Bottini, Buenos Aires, Argentina
| | - Chantal Agüero Wagner
- Clínica Vanguardia, Asunción, Paraguay.,Sociedad Paraguaya de Flebología y Linfología (SPFL), Asunción, Paraguay
| | - Lorena Grillo
- Hospital San Rafael de Ajuela, Universidad de Ciencias Medicas, Ajuela, Costa Rica.,Asociación de Cirujanos Vasculares Periféricos de Costa Rica, Ajuela, Costa Rica
| | | | - Fabricio Santiago
- Hospital Geral de Goiânia, Universidade Federal de Goiás, Goiânia, Brazil.,Sociedad Brasileña de Angiología y Cirugía Vascular, Goiânia, Brazil
| | - Juan Nigro
- Asociación Argentina de Angiología y Cirugía Cardiovascular (AAAyCCV), Buenos Aires, Argentina
| | - Marcelo Morales
- Asociación Cordobesa de Flebología y Linfología, Córdoba, Argentina
| | - Martín Ferreyra
- Asociación Cuyana de Flebología, Linfología y Arteriopatías, Cuyo, Argentina
| | | | - Monserrat Diaz
- Asociación de Flebología y Linfología de la Patagonia, Neuquen, Argentina
| | - Jorge Segura
- Asociación de Flebología y Linfología de la Provincia de Buenos Aires (AFLIPBA), Buenos Aires, Argentina
| | - Martín Mazzurco
- Asociación de Flebología y Linfología de Rosario, Rosario, Argentina
| | - Guillermo Diez
- Asociación de Flebología y Linfología de Rosario, Rosario, Argentina
| | - Eduardo Halusch
- Asociación de Flebología y Linfología de Salta, Salta, Argentina
| | - José Ovelar
- Colegio Argentino de Cirugía Venosa y Linfática (CACVYL), Buenos Aires, Argentina
| | - Luis Parrotta
- Colegio Argentino de Cirugía Venosa y Linfática (CACVYL), Buenos Aires, Argentina
| | - Jorge Fernandez
- Sociedad Argentina de Flebología y Linfología (SAFYL), Buenos Aires, Argentina
| | - Miguel Avramovic
- Sociedad Argentina de Flebología y Linfología (SAFYL), Buenos Aires, Argentina
| | - Jorge Ríos
- Sociedad de Enfermedades Vasculares de Río Cuarto, Río Cuarto, Argentina
| | - Alexis Esposito
- Sociedad de Flebología y Linfología Bonaerense (SFLB), Buenos Aires, Argentina
| | - Hector Alfonso
- Sociedad de Flebología y Linfología del Nordeste (SFYLNE), Sarmiento, Argentina
| | - Emilio Desjardins
- Sociedad Tucumana de Flebología y Linfología, San Miguel de Tucumán, Argentina
| | - Luis Arias
- Comunidad Científica Boliviana de Flebología y Linfología (COBOFLIN), La Paz, Bolivia
| | - Edwaldo Joviliano
- Sociedad Brasileña de Angiología y Cirugía Vascular, Goiânia, Brazil
| | | | | | - Alvaro Orrego
- Fundación Chilena de Flebología y Linfología, Santiago del Chile, Chile
| | - Juan Bombín
- Sociedad Chilena de Flebología y Linfología (SOCHIFYL), Santiago del Chile, Chile
| | - Ismael Pizarro
- Sociedad Chilena de Flebología y Linfología (SOCHIFYL), Santiago del Chile, Chile
| | - Javier Cabezas
- Asociación de Cirujanos Vasculares Periféricos de Costa Rica, Ajuela, Costa Rica
| | - Rafael Manosalvas
- Sociedad Ecuatoriana de Flebolinfología y Microcirculación (SEFMi), Quito, Ecuador
| | - Victor Villota
- Sociedad Ecuatoriana de Flebolinfología y Microcirculación (SEFMi), Quito, Ecuador
| | - Luis Rodriguez
- Asociación Flebologica y Terapia Endovascular de El Salvador (AFLEBOVASAL), San Salvador, El Salvador
| | - Alberto Martínez Granados
- Asociación Flebologica y Terapia Endovascular de El Salvador (AFLEBOVASAL), San Salvador, El Salvador
| | - José Mérida
- Asociación Guatemalteca de Flebología (ASOFLEGUA), Ciudad de Guatemala, Guatemala
| | | | - Javier Serralde
- Academia Mexicana de Flebología y Linfología (AMFYL), Ciudad de México, Mexico
| | | | - Eloy Teixeira
- Sociedad Paraguaya de Cirugía Vascular y Angiología, Asunción, Paraguay
| | - Roberto Filizzola
- Sociedad Paraguaya de Cirugía Vascular y Angiología, Asunción, Paraguay
| | - Roberto Corbeta
- Sociedad Paraguaya de Flebología y Linfología (SPFL), Asunción, Paraguay
| | - Roy Benito
- Sociedad Peruana de Flebología y Linfología, Lima, Perú
| | | | - Tomás Rivera
- Sociedad Dominicana de Cirugía Vascular y Endovascular, Santo Domigo, República Dominicana
| | - Mauricio Volpi
- Sociedad Uruguaya de Cirugía Vascular y Endovascular (SUCIVE), Montevideo, Uruguay
| | - Sebastián Sarutte
- Sociedad Uruguaya de Cirugía Vascular y Endovascular (SUCIVE), Montevideo, Uruguay
| | - Paola Ortiz
- Sociedad Uruguaya de Flebología y Linfología (SUFYL), Montevideo, Uruguay
| | - Alfredo Prego
- Sociedad Uruguaya de Flebología y Linfología (SUFYL), Montevideo, Uruguay
| | - Hugo Navas
- Sociedad Venezolana de Flebología y Linfología, Caracas, Venezuela
| | - Tomás Alberti
- Asociación Internacional de Diagnóstico Vascular no Invasivo (ADIVANI), Bogota, Colombia
| | - Daniel Guglielmone
- Asociación Internacional de Diagnóstico Vascular no Invasivo (ADIVANI), Bogota, Colombia
| | - Raúl Mejía
- Asociación Internacional de Diagnóstico Vascular no Invasivo (ADIVANI), Bogota, Colombia
| | - Carlos Simkin
- Forum Venoso Latinoamericano, Buenos Aires, Argentina
| | - Ernesto Intriago
- Sociedad Panamericana de Flebología y Linfología, Guayaquil, Ecuador
| | - Juan Bercovich
- Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina
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Pannier F, Noppeney T, Alm J, Breu FX, Bruning G, Flessenkämper I, Gerlach H, Hartmann K, Kahle B, Kluess H, Mendoza E, Mühlberger D, Mumme A, Nüllen H, Rass K, Reich-Schupke S, Stenger D, Stücker M, Schmedt CG, Schwarz T, Tesmann J, Teßarek J, Werth S, Valesky E. S2k guidelines: diagnosis and treatment of varicose veins. DER HAUTARZT 2022; 73:1-44. [PMID: 35438355 PMCID: PMC9358954 DOI: 10.1007/s00105-022-04977-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Affiliation(s)
- F Pannier
- Praxis für Dermatologie und Phlebologie, Helmholtzstr. 4-6, 53123, Bonn, Germany.
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Belramman A, Bootun R, Tang TY, Lane TRA, Davies AH. Pain Outcomes Following Mechanochemical Ablation vs Cyanoacrylate Adhesive for the Treatment of Primary Truncal Saphenous Vein Incompetence: The MOCCA Randomized Clinical Trial. JAMA Surg 2022; 157:395-404. [PMID: 35385061 PMCID: PMC8988024 DOI: 10.1001/jamasurg.2022.0298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Endovenous thermal ablations (ETAs) are recommended as first-line treatment for truncal vein reflux, have a short recovery time, and are cost-effective. However, ETAs are associated with discomfort during tumescent anesthesia infiltration. To minimize discomfort, nonthermal, nontumescent ablation techniques had emerged in the form of mechanochemical ablation (MOCA) and cyanoacrylate adhesive injection (CAE). Objective To assess pain scores immediately after truncal ablation using a 100-mm visual analog scale and 10-point number scale to compare pain-related outcomes following mechanochemical ablation vs cyanoacrylate adhesive treatment. Design, Setting, and Participants The Multicenter Randomized II Clinical Trial Comparing Mechanochemical Ablation vs Cyanoacrylate Adhesive for the Treatment of Primary Truncal Saphenous Veins Incompetence study was a prospective multicenter randomized clinical trial conducted at 3 sites between November 2017 and January 2020. Inclusion criteria were primary great or small saphenous varicose veins; exclusion criteria included recurrent varicose veins, current deep venous thrombosis, or serious arterial disease. There were 392 participants screened, 225 were excluded, and 167 participants underwent randomization. Four participants did not receive allocated intervention and were included in the intention-to-treat analysis. Follow-up took place at 2 weeks, and 3, 6, and 12 months. Interventions Patients with primary truncal vein incompetence were randomized to receive either MOCA or CAE. Main Outcomes and Measures The primary outcome measure was pain score immediately after completing truncal ablation using a 100-mm visual analog scale (VAS) and a 10-point number scale. Secondary outcome measures included degree of ecchymosis, occlusion rates, clinical severity, and generic and disease-specific quality of life (QoL) scores. Results Of 167 study participants, 99 (59.3%) were women, and the mean (SD) age was 56 (15.8) years. Overall, 155 truncal veins treated (92.8%) were great saphenous veins. Demographic data and baseline status were comparable between treatment groups. A total of 73 patients (47%) underwent adjunctive treatment of varicosities. Overall median (IQR) maximum pain score after truncal treatment was 23 mm (10-44) on the VAS and 3 (2-5) on the number scale, showing no significant difference in median (IQR) pain measured by VAS (MOCA, 24 [11.5-44.7] mm vs CAE, 20 [9.0-42.0] mm; P = .23) or by number scale (MOCA, 4 [2-5] vs CAE, 3 [2-4]; P = .18). Both groups demonstrated significant and comparable improvement in clinical severity, generic and disease-specific QoL scores, and complete occlusion rates. Four patients treated with CAE developed minor complications (superficial thrombophlebitis and thrombus extensions). Conclusions and Relevance To our knowledge, this was the first randomized clinical trial directly comparing nontumescent ablation techniques. The study demonstrated that the MOCA and CAE techniques have a similar periprocedural pain score. Trial Registration ClinicalTrials.gov Identifier: NCT03392753.
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Affiliation(s)
- Amjad Belramman
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Roshan Bootun
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Tjun Yip Tang
- Singapore General Hospital and Sengkang General Hospital
| | - Tristan R A Lane
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom.,Cambridge Vascular Unit, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Alun H Davies
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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7
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Kibrik P, Chait J, Arustamyan M, Alsheekh A, Kenney K, Marks N, Hingorani A, Ascher E. Success rate and factors predictive of redo endothermal ablation of Small Saphenous veins. J Vasc Surg Venous Lymphat Disord 2021; 10:395-401. [PMID: 34715387 DOI: 10.1016/j.jvsv.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Endothermal ablation as endothermal laser ablation (EVLA) or Radiofrequency ablation (RFA) is being progressively more employed for small saphenous vein (SSV) insufficiency treatment. Prior studies have shown recurrence rates of 0% to 10% in incompetent small saphenous veins (ISSVs). The objective of this study is to determine the efficacy of redo venous ablations for symptomatic recanalized SSVs and to predict factors related with recanalization. METHODS A retrospective analysis of 2,566 procedures in 1,752 patients with CVI due to ISSVs from 2012 to 2018 was performed, using individual chart review for data extraction. All 2,566 procedures were performed using endothermal ablation in patients who failed initial conservative management. Postoperative duplex ultrasound scans were performed within 3 to 7 days. We defined a successful obliteration as a lack of color flow by postoperative duplex scan. We defined recanalization as the presence of reflux on duplex ultrasound in the target vessel at follow-up. We conducted follow-ups every 3 months in the first year, followed by every 6 months subsequently. RESULTS Among the 2,566 procedures, redo ablation was performed in 91 ISSVs (86 patients), including 58 women and 28 men. 54 procedures were performed on the left lower extremity, 37 were performed on the right lower extremity. The average Body Mass Index (BMI) was 32.2 ± 7.66. The mean age was 62.4 ± 15.10 years. Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classes of the patients were: C1, 0; C2, 0; C3, 29; C4, 43; C5, 1; and C6, 18. The mean maximum diameter of the targeted veins, for the redo procedures, was 4.51± 1.33 mm. Forty procedures were performed using EVLA, 51 were performed using RFA. Initial technical success was 98.9%. Redo procedures had an early closure of 96.7%. At follow up after a mean duration of 24.9 ± 14.9 months, closure was 96.5%. No correlation was found between successful obliteration in the redo procedure and age, gender, CEAP, laterality, EVLA vs. RFA, BMI, or vein diameter. CONCLUSIONS Rates of successful closure for ISSVs on initial and redo procedures are comparable. The data validate the potential usefulness of performing redo SSV ablations.
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Affiliation(s)
- Pavel Kibrik
- Vascular Institute of New York, Pavel Kibrik D.O, 960 50th street, Brooklyn, NY 11219
| | - Jesse Chait
- Vascular Institute of New York, Pavel Kibrik D.O, 960 50th street, Brooklyn, NY 11219
| | - Michael Arustamyan
- Vascular Institute of New York, Pavel Kibrik D.O, 960 50th street, Brooklyn, NY 11219
| | - Ahmad Alsheekh
- Vascular Institute of New York, Pavel Kibrik D.O, 960 50th street, Brooklyn, NY 11219
| | - Kevin Kenney
- Vascular Institute of New York, Pavel Kibrik D.O, 960 50th street, Brooklyn, NY 11219
| | - Natalie Marks
- Vascular Institute of New York, Pavel Kibrik D.O, 960 50th street, Brooklyn, NY 11219
| | - Anil Hingorani
- Vascular Institute of New York, Pavel Kibrik D.O, 960 50th street, Brooklyn, NY 11219
| | - Enrico Ascher
- Vascular Institute of New York, Pavel Kibrik D.O, 960 50th street, Brooklyn, NY 11219
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8
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Sharmila DN. Surgery for Varicose Veins. Indian J Surg 2021. [DOI: 10.1007/s12262-021-03044-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Sussman MS, Ryon EL, Bahga A, Almeida S, Almeida JI. A systematic review of the treatment of residual below the knee venous reflux after endovenous thermal ablation of the great saphenous vein. J Vasc Surg Venous Lymphat Disord 2021; 10:233-240. [PMID: 34425265 DOI: 10.1016/j.jvsv.2021.03.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/28/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Great saphenous vein (GSV) antireflux procedures have evolved during the past few decades to reduce elevated venous pressure. Untreated reflux in the below knee (BK) GSV (BK-GSV) can lead to persistent venous hypertension and deterioration of the venous circulation. The purpose of the present systematic review was to study the influence of BK-GSV intervention on venous disease progression. METHODS A search was conducted, adhering to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The PubMed and Embase databases were searched and cross-referenced. Studies were included if they had met the inclusion criterion of BK-GSV disease as a primary or secondary outcome. Two of the authors independently determined the eligibility and extracted the relevant data. RevMan, version 5.3 (Cochrane Training, London, UK), and SPSS (IBM Corp, Armonk, NY) were used for statistical computation. RESULTS Fifteen studies that had assessed BK-GSV reflux recurrence after ablative intervention were included in our analysis. Of the 15 studies, 6 had assessed patients after above knee (AK) high ligation and stripping (HLS), 7 after AK endovenous laser ablation (AK-EVLA), and 2 after AK- and BK-EVLA (AK+BK EVLA). In total, 525 limbs had undergone HLS, 696 AK-EVLA, and 147 AK+BK EVLA. AK+BK EVLA was associated with significantly lower odds of BK-GSV reflux recurrence compared with AK-EVLA only (odds ratio [OR], 0.1857; 95% confidence interval [CI], 0.076-0.4734; P < .0001). Although the odds of recurrent BK-GSV reflux appeared to be greater for patients who had undergone AK-HLS compared with AK+BK HLS, the difference was not statistically significant (OR, 0.62; CI, 0.27-1.43; P = .69). Finally, no statistically significant difference was observed in BK-GSV reflux recurrence between patients receiving AK-EVLA and those receiving AK-HLS (OR, 0.85; 95% CI, 0.52-1.39; P = .31). CONCLUSIONS Axial hydrostatic reflux from the groin to ankle is best controlled with AK+BK-GSV ablation. However, GSV ablation can result in saphenous nerve injury. For C4 to C6 disease, more aggressive treatment of the AK+BK-GSV is justified if the duplex ultrasound findings demonstrate groin to ankle reflux. Thermal ablation of the BK-GSV has a lower incidence of saphenous nerve injury than does BK saphenous stripping. More randomized controlled trials are needed to answer questions involving disease recurrence and the best techniques to mitigate these recurrences.
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Affiliation(s)
- Matthew S Sussman
- Division of Vascular Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla.
| | - Emily L Ryon
- Division of Vascular Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | - Amritpal Bahga
- Division of Vascular Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | - Stephanie Almeida
- Division of Vascular Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | - Jose I Almeida
- Division of Vascular Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
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Poschinger-Figueiredo D, Virgini-Magalhães CE, Porto LC, Amorim CS, de Araujo Gomes CF, Riguetti-Pinto CR, Mayall MR, de Castro LS, Fagundes FB. Radiofrequency Ablation for Axial Reflux Associated with Foam Sclerotherapy for Varicosities in One-Step Approach: A Prospective Cohort Study Comprising Large Diameters Saphenous Veins. Vasc Health Risk Manag 2021; 17:379-387. [PMID: 34239304 PMCID: PMC8259833 DOI: 10.2147/vhrm.s313282] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/02/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE This study assessed the outcomes and impact on the quality of life following one-step outpatient radiofrequency ablation (RFA) and ultrasound guided foam sclerotherapy (USGFS) for large reflux with varicosities in the great saphenous vein (GSV). DESIGN Prospective, single-centre, analytical cohort. MATERIALS AND METHODS Thirty symptomatic patients having reflux in the GSV and varicosities (CEAP C3 to C6) were treated with RFA and USGFS simultaneously, in a single-step procedure, from March 2016 to December 2016. They were followed up at 1 week, 6 months, 1 and 3 years. Clinical outcomes, changes in the Quality of Life (QOL) questionnaires SF-36™, VCSS and AVVQ, evolutive vein occlusion rates were assessed by duplex ultrasound, and ulcer closure was checked. RESULTS The sample was divided into two groups: (Group 1) GSV diameter ≥13.0 mm (median 19.0 [14-24]), 17 subjects, and (Group 2) GSV diameter ≤12.9 mm (median 10.3 [10-12]), 16 subjects. No major adverse event was observed, and the postoperative minor adverse event rates were similar between the two groups. A significant improvement was observed in VCSS and AVVQ from the preoperative levels to the sixth month and the third-year follow-up. Twelve of 13 ulcers had healed at 1 year and remained closed until 3 years. The entire sample had a significant increase in all short form 36 domains, except for mental health in the Group 2 (GSV ≥ 13.0 mm). Overall first week occlusion rate for the whole sample was 90.9% and 69.7% at the 3-year follow-up. No difference in occlusion rate was observed between the two groups at any time. CONCLUSION Exclusively outpatient combined techniques were safe and feasible in this study with no major adverse events, despite the large diameters of the GSV or ulcer presence. Within 3 years, both diameter groups showed equivalent improvement in all QOL parameters, satisfactory axial occlusion, and maintained ulcer closure.
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Affiliation(s)
- Douglas Poschinger-Figueiredo
- Teaching and Health Care Unit of Vascular and Endovascular Surgery’s Medical Staff, Pedro Ernesto University Hospital (HUPE), Rio de Janeiro State University (UERJ), Rio De Janeiro, Brazil
| | - Carlos Eduardo Virgini-Magalhães
- Teaching and Health Care Unit of Vascular and Endovascular Surgery’s Medical Staff, Pedro Ernesto University Hospital (HUPE), Rio de Janeiro State University (UERJ), Rio De Janeiro, Brazil
- Medical Sciences College (FCM), Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Luís Cristóvão Porto
- Histocompatibility and Cryopreservation Laboratory (HLA), Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
- Roberto Alcantara Gomes Biology Institute (IBRAG), Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Claudia Salvador Amorim
- Teaching and Health Care Unit of Vascular and Endovascular Surgery’s Medical Staff, Pedro Ernesto University Hospital (HUPE), Rio de Janeiro State University (UERJ), Rio De Janeiro, Brazil
| | - Cristiane Ferreira de Araujo Gomes
- Teaching and Health Care Unit of Vascular and Endovascular Surgery’s Medical Staff, Pedro Ernesto University Hospital (HUPE), Rio de Janeiro State University (UERJ), Rio De Janeiro, Brazil
| | - Cristina Ribeiro Riguetti-Pinto
- Teaching and Health Care Unit of Vascular and Endovascular Surgery’s Medical Staff, Pedro Ernesto University Hospital (HUPE), Rio de Janeiro State University (UERJ), Rio De Janeiro, Brazil
- Medical Sciences College (FCM), Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Monica Rochedo Mayall
- Teaching and Health Care Unit of Vascular and Endovascular Surgery’s Medical Staff, Pedro Ernesto University Hospital (HUPE), Rio de Janeiro State University (UERJ), Rio De Janeiro, Brazil
| | - Leonardo Silveira de Castro
- Teaching and Health Care Unit of Vascular and Endovascular Surgery’s Medical Staff, Pedro Ernesto University Hospital (HUPE), Rio de Janeiro State University (UERJ), Rio De Janeiro, Brazil
| | - Felipe Borges Fagundes
- Teaching and Health Care Unit of Vascular and Endovascular Surgery’s Medical Staff, Pedro Ernesto University Hospital (HUPE), Rio de Janeiro State University (UERJ), Rio De Janeiro, Brazil
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11
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Randomized Controlled Trial of Compression After Endovenous Thermal Ablation of Varicose Veins (COMETA Trial). Ann Surg 2021; 273:232-239. [PMID: 31850976 DOI: 10.1097/sla.0000000000003626] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The 21st century has witnessed a rise in the use of endovenous thermal ablation. Being highly clinically and cost-effective and improving the quality of life of patients, they are now considered to be the "gold-standard" treatment for varicose veins. Post-intervention management, especially in terms of postoperative compression, however, remains unclear. As a result, a randomized study was undertaken to investigate the effects of wearing compression stockings after varicose vein treatment. METHOD Patients with saphenous vein reflux undergoing treatment with endothermal ablation (with or without concurrent phlebectomies) were randomized to receive either 7 days of compression stockings or no stockings. The primary outcome measure for this study was the pain score over the first 10 postoperative days. The pain scores, clinical score, time to return to normal activities, and ecchymosis were assessed. Patients were followed-up at 2 weeks and 6 months post-ablation. RESULTS In total, 206 patients were randomized, 49% of them to the compression group. The mean age was 49.7 (±16) years and approximately 51% of the population was male. The median pain score in the compression group using a visual analog scale was significantly lower on days 2-5, compared to the no compression group. Those having concurrent phlebectomies and compression stockings also had significantly better pain scores on days 1-3, day 5, and day 7. Improvement in the median venous clinical severity score was noted at 6-month follow-up, but this was not significant. No difference in the generic- or disease-specific quality of life was observed and the time to return to activities was similar. There were no differences in the degree of ecchymosis between the 2 groups and both groups had similar occlusion rates. CONCLUSIONS These results indicate that wearing compression stockings after endothermal ablation is advantageous in the first few days after treatment and is especially beneficial for those having concurrent phlebectomies.
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12
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Joyce DP, Walsh SR, Yap CJQ, Chong TT, Tang TY. Compression therapy following ClariVein® ablation therapy: a randomised controlled trial of COMpression Therapy Following MechanO-Chemical Ablation (COMMOCA). Trials 2019; 20:678. [PMID: 31806052 PMCID: PMC6894465 DOI: 10.1186/s13063-019-3787-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endovenous treatment of varicose veins has increased in popularity over the last decade. There remains, however, a degree of uncertainty regarding the role of compression bandaging or hosiery following this intervention. The National Institute for Clinical Excellence Guideline Development Group has advocated further research to evaluate the clinical and cost-effectiveness of this post-procedure intervention. In addition to this, the duration of compression bandaging also warrants clarification. METHODS Ethical approval for the study was obtained from the Singhealth Centralised Institutional Review Board (CIRB Ref: 2017/2710). Consent to enter the study will be sought from each participant only after a full explanation has been given, an information leaflet offered and time allowed for consideration. Signed participant consent will be obtained. Patients will be randomised to either compression (group A) or no compression (group B). The primary aim of the study is to assess the patient's pain scores for the first 10 days post procedure using a visual analogue scale. Secondary aims include an assessment of patient compliance with compression, quality of life scores, clinical effectiveness, rates of bruising and phlebitis, time taken to return to normal activities, patient satisfaction and occlusion rate at 6 months. DISCUSSION The purpose of this study is to examine the effect of compression therapy in patients having mechano-chemical ablation (MOCA) therapy for truncal incompetence of their varicose veins using the ClariVein® device. This study may provide clarification on the role of compression therapy in patients undergoing MOCA. TRIAL REGISTRATION ClinicalTrials.gov, NCT03685838. Registered on 26 September 2018.
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Affiliation(s)
- Doireann P Joyce
- Department of Vascular Surgery, Galway University Hospital, Galway, Ireland
| | - Stewart R Walsh
- Department of Vascular Surgery, Galway University Hospital, Galway, Ireland
| | - Charyl J Q Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Tze T Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Tjun Y Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore.
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13
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Belramman A, Bootun R, Lane TRA, Davies AH. Foam sclerotherapy versus ambulatory phlebectomy for the treatment of varicose vein tributaries: study protocol for a randomised controlled trial. Trials 2019; 20:392. [PMID: 31269978 PMCID: PMC6610823 DOI: 10.1186/s13063-019-3398-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 05/06/2019] [Indexed: 11/19/2022] Open
Abstract
Background Ambulatory phlebectomies and foam sclerotherapy are two of the most common treatments for varicose vein tributaries. Many studies have been published on these treatments, but few comparative studies have attempted to determine their relative effectiveness. Methods/design This is a prospective single-centre randomised clinical trial. Patients with primary truncal vein incompetence and varicose vein tributaries requiring treatment will be assigned randomly to either ambulatory phlebectomies or foam sclerotherapy. The primary outcome measure is the re-intervention rate for the varicose vein tributaries during the study period. The secondary outcomes include the degree of pain during the first two post-operative weeks and the time to return to usual activities or work. Improvements in clinical scores, quality of life scores, occlusion rates and cost-effectiveness for each intervention are other secondary outcomes. The re-intervention rate will be considered from the third month. Discussion This study compares ambulatory phlebectomies and foam sclerotherapy in the treatment of varicose vein tributaries. The re-intervention rates, safety, patient experience and the cost-effectiveness of each intervention will be assessed. This study aims to recruit 160 patients and is expected to be completed by the end of 2019. Trial registration ClinicalTrials.gov, NCT03416413. Registered on 31 January 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3398-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amjad Belramman
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Roshan Bootun
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK.,Specialty Training Registrar in Vascular Surgery, East of England Deanery, UK
| | - Tristan R A Lane
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK. .,Specialty Training Registrar in Vascular Surgery, London Deanery, UK. .,Imperial College Healthcare NHS Trust, London, UK.
| | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
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14
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Ding J, Mu X, Yuan Y, Tang L, Wei K, Zhao X, Qing L, Liu C. Therapies of varicose veins: Protocol for the reporting and methodological quality of pairwise meta-analyses. Medicine (Baltimore) 2019; 98:e16042. [PMID: 31232937 PMCID: PMC6636969 DOI: 10.1097/md.0000000000016042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Many pairwise meta-analyses (MAs) related to therapies of varicose veins have been published, but their reporting and methodological quality remain unclear. The present study was designed to assess the overall quality of pairwise MAs related to therapies of varicose veins. METHODS We will systematically search 4 electronic databases, including PubMed, EMBASE, Cochrane Library, Chinese Biomedical Database, to identify pairwise MAs related to therapies of varicose veins. The search time-span was set from inception to March 2019. The pairwise MAs related to therapies of varicose veins will be included in our overview. The reporting and methodological quality of included MAs will be assessed using preferred reporting items for systematic review and meta-analysis and a measurement tool to assess systematic reviews 2, respectively. Meanwhile, we will extract some general characteristics of included MAs, including first author; published year, journal, sample size, number of studies, number of randomized controlled trials and intervention details, and so on. All literatures screening, quality assessment, and data extraction will be independently completed by 2 of all reviewers, and any disagreement will be resolved by discussion. Besides, an increasingly popular method - evidence mapping, will be used to present the whole evidence landscape related to therapies of varicose veins. The assessment results will be presented as percentage and event/total. The Excel 2016 will be used to manage and analyze data. RESULTS The results of the overview will be submitted to a peer-reviewed journal for publication. CONCLUSION This overview will summarize the overall reporting and methodological quality related to therapies of varicose veins. PROSPERO REGISTRATION NUMBER CRD42019126722.
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Affiliation(s)
- Jie Ding
- Chinese Medicine Hospital, Occupation University of Wuwei
| | | | - Yuan Yuan
- Chinese Medicine Hospital, Occupation University of Wuwei
- Gansu University of Traditional Chinese Medicine
- The 94th Hospital of the Joint Logistic Support Force of the Chinese People's Liberation Army
| | - LiYao Tang
- Gansu University of Traditional Chinese Medicine
| | - KongXi Wei
- Gansu University of Traditional Chinese Medicine
| | - XiYun Zhao
- Affiliated Hospital of Gansu University of Traditional Chinese Medicine
| | - LiNa Qing
- The First Hospital of Lanzhou University
| | - Cai Liu
- The Third People's Hospital of Gansu Province, Lanzhou, China
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15
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Novak CJ, Khimani N, Kaye AD, Jason Yong R, Urman RD. Current Therapeutic Interventions in Lower Extremity Venous Insufficiency: a Comprehensive Review. Curr Pain Headache Rep 2019; 23:16. [PMID: 30830460 DOI: 10.1007/s11916-019-0759-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Chronic venous disease (CVD), although affecting up to 40% of the US population, is often underdiagnosed by healthcare professionals due to an incomplete understanding of the presenting symptoms. CVD is a common cause of lower extremity pain and discomfort, including aching, cramping, tingling, burning, swelling, heaviness, restlessness, and fatigue, and may lead to significant morbidity if left untreated. The negative impact of CVD on quality of life is well established and the optimization of management strategies is an important area of evolving research. RECENT FINDINGS Management of CVD has rapidly evolved over the last two decades with the development of minimally invasive endovenous ablative techniques, now the mainstay of treatment. We discuss the data supporting various methods of CVD treatment with an emphasis on the impact on patient comfort and quality of life. Both radiofrequency ablation (RFA) and endovenous laser therapy (EVLA) are excellent options for treatment of lower extremity venous disease, but RFA is associated with less post-procedure discomfort. Ultrasound-guided foam therapy is best reserved for the adjuvant setting or for patients ineligible for RFA or EVLA.
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Affiliation(s)
| | - Namrata Khimani
- Vein Institute and Pain Centers of America, New York, NY, USA.
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - R Jason Yong
- Vein Institute and Pain Centers of America, New York, NY, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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16
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Gornati VC, Utsunomia K, Labropoulos N. Challenges in advancing the laser fiber through the great saphenous vein during endovenous ablation and strategies to overcome them. Phlebology 2019; 34:530-535. [PMID: 30624132 DOI: 10.1177/0268355518822201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives To determine the incidence of possible obstacles and patients’ characteristics when performing endovenous laser treatment (EVLT) and suggestions to improve the ability to overcome them. Method A prospective study with 215 limbs treated with EVLT. A sequence of maneuvers was performed to move the fiber forward when difficulty was found and if unsuccessful another entry site was punctured. Results In 29 of 215 (13.48%) limbs, resistance was encountered while navigating the fiber; 16 (55.17%) solved with lower limb extension; 13 (44.82%) needed ultrasound guided maneuvers; five (17.24%) needed a saline flush and in three patients (10.34%) another entry site was necessary. In 214 of 215 cases (99.53%), ablation was accomplished and no complications were observed. Conclusions Both obstruction and higher patients' BMI are the main obstacles during endovenous laser ablation and usually needs additional maneuvers to accomplish the procedure in our study and the use of tricks to overcome these issues is feasible.
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Affiliation(s)
| | | | - Nicos Labropoulos
- 2 Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
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17
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Ahmed M, Lutze S, Tembulatow M, Daeschlein G, Jünger M, Arnold A. Long-term outcome of open surgery in CVI patients concerning postoperative complications, perioperative hemodynamics and clinical efficacy, Part II1. Clin Hemorheol Microcirc 2018; 71:117-127. [PMID: 30584123 DOI: 10.3233/ch-189401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic venous disease (CVD) is extremely common worldwide with prevalence increasing with age. It is associated with a reduced quality of life, particularly in relation to pain, physical function and mobility. Symptomatic chronic venous insufficiency (CVI) with venous ulcer at its' endpoint, indicates interventional surgery to cure venous reflux therewith promoting wound healing and preventing recurrence. In this retrospective, single-centre, consecutive case-control study in a single patient population of a university clinic in northern Germany a holistic evaluation of varicose vein surgeries has been undertaken. Part I covered postoperative complications in relation to co-morbidities, co-medication and clinical presentation. Part II of this article presents now the hemodynamic results in relation to the perioperative evolution of CVI specific symptoms. METHODS Records of n = 429 (467 extremities) patients from 2009-2013 treated with open surgery were analysed with regards to perioperative hemodynamics. Evolution of CVI symptomology was accessed postoperatively with the help of a questionnaire and patient records in the case of complication development. Venous hemodynamics was analysed in the whole patient population and with regards to complication subgroups: no events (NE), neglectable adverse events (NAE) and non-neglectable adverse events (NNAE). RESULTS Postoperatively, patients' CVI-symptoms like pain (p < 0.001), swelling (p < 0.001) and itching (p = 0.003) significantly improved. The venous refill time and venous pump capacity improved significantly after open vein surgery (p < 0.05). Regardless of the development of postoperative complications there was a significant improvement of venous function at 6 weeks- and one-year postoperative in follow-up (p < 0.05). Symptom regression was strongly correlated with hemodynamic improvement. CONCLUSION A significant improvement of patients' symptoms was achieved by means of open-surgery, regardless of postoperative complication development. This was in accordance with the improvement of venous hemodynamics. A strong correlation between symptom regression and improvement in venous hemodynamics could be proven.
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Affiliation(s)
- M Ahmed
- Dermatological Clinic of the University of Greifswald, Germany
| | - S Lutze
- Dermatological Clinic of the University of Greifswald, Germany
| | - M Tembulatow
- Dermatological Clinic of the University of Greifswald, Germany
| | - G Daeschlein
- Dermatological Clinic of the University of Greifswald, Germany
| | - M Jünger
- Dermatological Clinic of the University of Greifswald, Germany
| | - A Arnold
- Dermatological Clinic of the University of Greifswald, Germany
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Belramman A, Bootun R, Tang TY, Lane TRA, Davies AH. Mechanochemical ablation versus cyanoacrylate adhesive for the treatment of varicose veins: study protocol for a randomised controlled trial. Trials 2018; 19:428. [PMID: 30086774 PMCID: PMC6081848 DOI: 10.1186/s13063-018-2807-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thermal ablation techniques have become the first-line treatment of truncal veins in the management of chronic venous disease (CVD). Despite excellent outcomes, these methods are often associated with pain; generally due to their use of heat and the necessity of fluid infiltration around the vein. More recently, novel non-thermal techniques, such as mechanochemical ablation (MOCA) and cyanoacrylate adhesive (CAE) have been developed to overcome these unwelcome effects. So far, the novel techniques have been found to have similar efficacy to thermal methods, yet no direct comparisons between the non-thermal treatment techniques have been conducted to date, giving rise to this study. METHODS/DESIGN This is a prospective, multicentre, randomised clinical trial, recruiting patients with truncal saphenous incompetence. Patients will be randomised to undergo either MOCA or CAE truncal ablation, followed by treatment of any varicosities. All patients will be required to wear compression stockings for 4 days post intervention. The primary outcome measure is the pain score immediately following completion of truncal ablation, measured by a 100-mm Visual Analogue Scale (VAS). The secondary outcomes are entire treatment pain scores, clinical scores, quality of life scores, occlusion rates, time to return to usual activities/work at 2 weeks, 3, 6 and 12 months. Re-intervention rate will be considered from the third month. Cost-effectiveness will be assessed for each intervention at 12 months. The study is powered to detect a mean 10-mm difference in maximum pain score. Allowing for loss to follow-up, the total target recruitment is 180 patients. DISCUSSION The study will be the first study to compare MOCA against CAE and is designed to determine which method causes less pain. Completion of this study is expected to be the end of 2019. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT03392753 . Registered on 17 November 2017.
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Affiliation(s)
- Amjad Belramman
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, 4N12A, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
| | - Roshan Bootun
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, 4N12A, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
- East of England Deanery, London, UK
| | - Tjun Yip Tang
- Singapore General Hospital, London, Singapore
- Sengkang General Hospital, Singapore, Republic of Singapore
| | - Tristan R. A. Lane
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, 4N12A, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
- London Deanery, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Alun H. Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, 4N12A, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
- Imperial College Healthcare NHS Trust, London, UK
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Bream E, Black N. What is the Relationship Between Patients’ And Clinicians’ Reports of the Outcomes of Elective Surgery? J Health Serv Res Policy 2017; 14:174-82. [DOI: 10.1258/jhsrp.2009.008115] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives To identify studies in which patients’ and clinicians’ reports of health status and complications of one of four elective operations - hip and knee replacement, varicose vein surgery and groin hernia repair - are reported, and to describe the associations that have been reported between clinicians’ and patients’ reports. Methods Systematic search of several bibliographic databases and review of citations of articles meeting inclusion criteria. A narrative summary of the findings was conducted. Results Most of the 62 studies of health status identified were for hip (23) or knee (33) disease. The literature on complications was even more limited with 12 studies of surgical site infection, one for urinary tract infection and none for lower respiratory tract infections. Procedure-specific complications were restricted to one for arthroplasties and three for hernia repair. Despite considerable variation in the findings of studies, some clear patterns emerge, albeit they are largely based on arthroplasty. Patients’ and clinicians’ views of health status generally correlate moderately (0.5-0.6) when both are reporting on the same dimension of health status. Inevitably this is confined to disability, though patients’ and clinicians’ reports of symptoms are also moderately correlated. In contrast, comparisons of different dimensions, such as patients’ reports of disability and clinicians’ reports of impairment, result in poor correlation (0.3). There is huge variation in the way postoperative complications are measured which limits the extent to which an overview can be undertaken. Despite that, moderate to strong correlations have been reported between patients’ and clinicians’ views of complications. Conclusions Patients’ views of their level of disability reflect clinicians’ views and can be relied upon to assess this dimension of health status. In addition, patients are the ‘gold standard’ judges of symptoms and quality of life. Given these findings, clinicians, provider managers, commissioners and politicians can be confident that patients’ reports provide an accurate indication of the outcome of elective surgery.
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Affiliation(s)
| | - Nick Black
- Health Services Research Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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20
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Quality of life after great saphenous vein ablation in Thai patients with great saphenous vein reflux. Asian J Surg 2017; 40:295-300. [DOI: 10.1016/j.asjsur.2015.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 09/21/2015] [Accepted: 10/01/2015] [Indexed: 11/18/2022] Open
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Comparison of Foam Sclerotherapy Alone or Combined With Stripping of the Great Saphenous Vein for Treating Varicose Veins. Dermatol Surg 2017; 43:541-547. [DOI: 10.1097/dss.0000000000001022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Marston WA, Owens LV, Davies S, Mendes RR, Farber MA, Keagy BA. Endovenous Saphenous Ablation Corrects the Hemodynamic Abnormality in Patients with CEAP Clinical Class 3–6 CVI Due to Superficial Reflux. Vasc Endovascular Surg 2016; 40:125-30. [PMID: 16598360 DOI: 10.1177/153857440604000206] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This investigation was designed to determine whether minimally invasive radiofrequency or laser ablation of the saphenous vein corrects the hemodynamic impact and clinical symptoms of chronic venous insufficiency (CVI) in CEAP clinical class 3–6 patients with superficial venous reflux. Patients with CEAP clinical class 3–6 CVI were evaluated with duplex ultrasound and air plethysmography (APG) to determine anatomic and hemodynamic venous abnormalities. Patients with an abnormal (>2 mL/second) venous filling index (VFI) and superficial venous reflux were included in this study. Saphenous ablation was performed utilizing radiofrequency (RF) or endovenous laser treatment (EVLT). Patients were reexamined within 3 months of ablation with duplex to determine anatomic success of the procedure, and with repeat APG to determine the degree of hemodynamic improvement. Venous clinical severity scores (VCSS) were determined before and after saphenous ablation. Eighty-nine limbs in 80 patients were treated with radiofrequency ablation (RFA) (n=58), or EVLT (n=31). The average age of patients was 55 years and 66% were women. There were no significant differences in preoperative characteristics between the groups treated with RFA or EVLT. Postoperatively, 86% of limbs demonstrated near total closure of the saphenous vein to within 5 cm of the saphenofemoral junction. Eight percent remained open for 5–10 cm from the junction, and 6% demonstrated minimal or no saphenous ablation. The VFI improved significantly after ablation in both the RF and EVLT groups. Postablation, 78% of the 89 limbs were normal, with a VFI <2 mL/second, and 17% were moderately abnormal, between 2 and 4 mL/second. VCSS scores (11.5 ±4.5 preablation) decreased significantly after ablation to 4.4 ±2.3. Minimally invasive saphenous ablation, using either RFA or EVLT, corrects or significantly improved the hemodynamic abnormality and clinical symptoms associated with superficial venous reflux in more than 90% of cases. These techniques are useful for treatment of patients with more severe clinical classes of superficial CVI.
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Affiliation(s)
- William A Marston
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7212, USA.
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Passman MA, Dattilo JB, Guzman RJ, Naslund TC. Combined Endovenous Ablation and Transilluminated Powered Phlebectomy: Is Less Invasive Better? Vasc Endovascular Surg 2016; 41:41-7. [PMID: 17277242 DOI: 10.1177/1538574406296207] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This study was undertaken to evaluate the evolution of operative vein approaches from combined “open” saphenous stripping-stab avulsion phlebectomy to combined “minimally invasive” endovenous ablation-transilluminated powered phlebectomy with a focus on comparing clinical outcomes. All patients undergoing a combined operative approach for concomitant saphenous vein insufficiency and associated varicose tributary veins between January 1, 1998 and December 31, 2005 were identified. Patients were stratified by operative approach into 3 groups: combined saphenous vein stripping-stab avulsion phlebectomy (STRIP-PHLEB); combined saphenous vein stripping-transilluminated phlebectomy (STRIP-TPP); and combined endovenous ablation-transilluminated phlebectomy (EVAB-TPP). Clinical volume, indications, technical details, and complications were retrospectively reviewed. Over the 8-year period, there were 72 limbs in 59 patients treated with STRIP-PHLEB, 92 limbs in 81 patients with STRIP-TPP, and 99 limbs in 76 patients with EVAB-TPP, with a time-dependent transition in operative techniques noted. There was no difference in distribution of CEAP clinical classification between groups, overall with most limbs in the C2-C4 categories (93.1%) and fewer in the C5-C6 categories (6.9%). There was no difference in overall complication rates between STRIP-PHLEB and EVAB-TPP, although the distribution of complications did shift with a trend toward more wound problems noted in procedures involving saphenous stripping (STRIP-PHLEB 5.6%, STRIP-TPP 6.5%, EVAB-TPP 2.0%; P = NS), and more hematomas in procedures involving transilluminated powered phlebectomy (STRIP-PHLEB 5.6%, STRIP-TPP 16.3%, EVAB-TPP 6.9%; P < .05; see Table 2). Complications associated with the endovenous ablation portion were low including technical inability to cannulate 1.6%, saphenous re-cannulation 2.4%, hematoma 2.4%, severe phlebitis 3.1%, venous thromboembolism 0.8%, and no wound or thermal injury problems. With the shift of combined operative vein approaches for concomitant saphenous vein insufficiency and varicose tributary veins towards “minimally invasive” techniques the overall complication rate has remained unchanged. While combined endovenous ablation-transilluminated phlebectomy offers some advantage of “less” invasiveness, this perceived benefit should be balanced against unchanged overall risk over traditional operative approaches.
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Affiliation(s)
- Marc A Passman
- Division of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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Kim SM, Jung IM, Chung JK. Improvements of deep vein reflux following radiofrequency ablation for saphenous vein incompetence. Phlebology 2016; 32:55-60. [DOI: 10.1177/0268355516629867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The aim of this study was to describe the changes of deep vein reflux after radiofrequency ablation for great saphenous vein incompetence. Method The data on 139 limbs which were treated with radiofrequency ablation for great saphenous vein incompetence were prospectively collected and reviewed. Results Deep vein reflux was present in 43 of 139 limbs (30.9%). There were no significant differences in the rate of successful closure, the incidence of procedure-related complications, and the improvements of symptoms and quality of life between the limbs with or without deep vein reflux. With a mean follow-up of 5.9 months, the peak reflux velocity and duration of reflux were improved in all limbs with deep vein reflux and it was completely corrected in 13 limbs (30.2%) after radiofrequency ablation. Conclusions The presence of deep vein reflux does not affect the treatment outcomes of radiofrequency ablation for great saphenous vein incompetence and is improved in all patients. Deep vein reflux is not a barrier to performing radiofrequency ablation.
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Affiliation(s)
- Suh Min Kim
- Department of Surgery, Dongguk University College of Medicine, Goyang, Korea
| | - In Mok Jung
- Departments of Surgery, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Jung Kee Chung
- Departments of Surgery, SMG-SNU Boramae Medical Center, Seoul, Korea
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Neglén P. Chronic Venous Obstruction: Diagnostic Considerations and Therapeutic Role of Percutaneous Iliac Stenting. Vascular 2016; 15:273-80. [DOI: 10.2310/6670.2007.00071] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Iliac venous outflow obstruction has an important role in the expression of symptomatic chronic venous insufficiency. This anatomic obstruction is frequently overlooked, owing in part to diagnostic difficulty. The combination of venous obstruction and reflux leads to more severe clinical disease. Current diagnostic modalities do not allow an definitive assessment of hemodynamically critical venous obstruction. No single invasive or noninvasive study can accurately detect borderline obstruction of potential hemodynamic significance. A high index of suspicion is critical in the initial recognition of chronic venous obstruction. The diagnosis relies on clinical signs and symptoms and radiologic assessment of morphologic venous outflow obstruction. Treatment strategy should be based on the results of morphologic investigations such as transfemoral phlebography or, preferably, intravascular ultrasonography. Percutaneous iliac venous stenting offers a safe and efficient method to correct pelvic venous obstruction. Percutaneous iliac stenting does not preclude subsequent venous bypass or corrective superficial and deep reflux surgery. This article reviews the etiologic factors and diagnostic modalities of iliac venous obstruction. The therapeutic role of percutaneous iliac stenting in the management of venous obstruction is also discussed.
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Bootun R, Davies AH. Long-term follow-up for different varicose vein therapies: is surgery still the best? Phlebology 2016; 31:125-9. [PMID: 26916779 DOI: 10.1177/0268355516632438] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Management of varicose vein disease has changed drastically over the past decades. Since its introduction in vein practice, surgery has gone through several stages of evolution until the method of ligation with stripping eventually became and remained the standard for a long time. It was found to be effective at treating the condition and, indications of its beneficial impact on patients' quality of life soon also became evident. However, being associated with significant morbidity, surgery gradually fell out of favour, especially, once the newer endovenous techniques were launched around the turn of the century. These endothermal methods allowed procedures to be carried out under local anaesthetic as day case interventions, often with a similar or even better effect on occlusion rates and quality of life. In addition, there is mounting evidence that these newer techniques might be more cost-effective. This review evaluates surgical treatment of varicose veins compared to endovenous methods and also assesses its place in current phlebological practice.
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Affiliation(s)
- Roshan Bootun
- Imperial College London, Charing Cross Hospital, London, UK
| | - Alun H Davies
- Imperial College London, Charing Cross Hospital, London, UK
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28
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Raju A, Mallick R, Campbell C, Carlton R, O’Donnell T, Eaddy M. Real-World Assessment of Interventional Treatment Timing and Outcomes for Varicose Veins: A Retrospective Claims Analysis. J Vasc Interv Radiol 2016; 27:58-67. [DOI: 10.1016/j.jvir.2015.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 10/01/2015] [Accepted: 10/01/2015] [Indexed: 11/17/2022] Open
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COST-EFFECTIVENESS OF RADIOFREQUENCY ABLATION VERSUS LASER FOR VARICOSE VEINS. Int J Technol Assess Health Care 2015; 31:289-96. [PMID: 26715372 DOI: 10.1017/s0266462315000537] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Although the clinical benefits of endovenous thermal ablation are widely recognized, few studies have evaluated the health economic implications of different treatments. This study compares 6-month clinical outcomes and cost-effectiveness of endovenous laser ablation (EVLA) compared with radiofrequency ablation (RFA) in the setting of a randomized clinical trial. METHODS Patients with symptomatic primary varicose veins were randomized to EVLA or RFA and followed up for 6 months to evaluate clinical improvements, health related quality of life (HRQOL) and cost-effectiveness. RESULTS A total of 131 patients were randomized, of which 110 attended 6-month follow-up (EVLA n = 54; RFA n = 56). Improvements in quality of life (AVVQ and SF-12v2) and Venous Clinical Severity Scores (VCSS) achieved at 6 weeks were maintained at 6 months, with no significant difference detected between treatment groups. There were no differences in treatment failure rates. There were small differences in favor of EVLA in terms of costs and 6-month HRQOL but these were not statistically significant. However, RFA is associated with less pain at up to 10 days. CONCLUSIONS EVLA and RFA result in comparable and significant gains in quality of life and clinical improvements at 6 months, compared with baseline values. EVLA is more likely to be cost-effective than RFA but absolute differences in costs and HRQOL are small.
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30
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Brittenden J, Cotton SC, Elders A, Tassie E, Scotland G, Ramsay CR, Norrie J, Burr J, Francis J, Wileman S, Campbell B, Bachoo P, Chetter I, Gough M, Earnshaw J, Lees T, Scott J, Baker SA, MacLennan G, Prior M, Bolsover D, Campbell MK. Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of LAser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial. Health Technol Assess 2015; 19:1-342. [PMID: 25858333 DOI: 10.3310/hta19270] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Foam sclerotherapy (foam) and endovenous laser ablation (EVLA) have emerged as alternative treatments to surgery for patients with varicose veins, but uncertainty exists regarding their effectiveness in the medium to longer term. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of foam, EVLA and surgery for the treatment of varicose veins. DESIGN A parallel-group randomised controlled trial (RCT) without blinding, and economic modelling evaluation. SETTING Eleven UK specialist vascular centres. PARTICIPANTS Seven hundred and ninety-eight patients with primary varicose veins (foam, n = 292; surgery, n = 294; EVLA, n = 212). INTERVENTIONS Patients were randomised between all three treatment options (eight centres) or between foam and surgery (three centres). PRIMARY OUTCOME MEASURES Disease-specific [Aberdeen Varicose Vein Questionnaire (AVVQ)] and generic [European Quality of Life-5 Dimensions (EQ-5D), Short Form questionnaire-36 items (SF-36) physical and mental component scores] quality of life (QoL) at 6 months. Cost-effectiveness as cost per quality-adjusted life-year (QALY) gained. SECONDARY OUTCOME MEASURES Quality of life at 6 weeks; residual varicose veins; Venous Clinical Severity Score (VCSS); complication rates; return to normal activity; truncal vein ablation rates; and costs. RESULTS The results appear generalisable in that participants' baseline characteristics (apart from a lower-than-expected proportion of females) and post-treatment improvement in outcomes were comparable with those in other RCTs. The health gain achieved in the AVVQ with foam was significantly lower than with surgery at 6 months [effect size -1.74, 95% confidence interval (CI) -2.97 to -0.50; p = 0.006], but was similar to that achieved with EVLA. The health gain in SF-36 mental component score for foam was worse than that for EVLA (effect size 1.54, 95% CI 0.01 to 3.06; p = 0.048) but similar to that for surgery. There were no differences in EQ-5D or SF-36 component scores in the surgery versus foam or surgery versus EVLA comparisons at 6 months. The trial-based cost-effectiveness analysis showed that, at 6 months, foam had the highest probability of being considered cost-effective at a ceiling willingness-to-pay ratio of £20,000 per QALY. EVLA was found to cost £26,107 per QALY gained versus foam, and was less costly and generated slightly more QALYs than surgery. Markov modelling using trial costs and the limited recurrence data available suggested that, at 5 years, EVLA had the highest probability (≈ 79%) of being cost-effective at conventional thresholds, followed by foam (≈ 17%) and surgery (≈ 5%). With regard to secondary outcomes, health gains at 6 weeks (p < 0.005) were greater for EVLA than for foam (EQ-5D, p = 0.004). There were fewer procedural complications in the EVLA group (1%) than after foam (7%) and surgery (8%) (p < 0.001). Participants returned to a wide range of behaviours more quickly following foam or EVLA than following surgery (p < 0.05). There were no differences in VCSS between the three treatments. Truncal ablation rates were higher for surgery (p < 0.001) and EVLA (p < 0.001) than for foam, and were similar for surgery and EVLA. CONCLUSIONS Considerations of both the 6-month clinical outcomes and the estimated 5-year cost-effectiveness suggest that EVLA should be considered as the treatment of choice for suitable patients. FUTURE WORK Five-year trial results are currently being evaluated to compare the cost-effectiveness of foam, surgery and EVLA, and to determine the recurrence rates following each treatment. This trial has highlighted the need for long-term outcome data from RCTs on QoL, recurrence rates and costs for foam sclerotherapy and other endovenous techniques compared against each other and against surgery. TRIAL REGISTRATION Current Controlled Trials ISRCTN51995477. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 27. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Julie Brittenden
- Division of Applied Medicine, University of Aberdeen, Aberdeen, UK
| | | | - Andrew Elders
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Emma Tassie
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jennifer Burr
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Jill Francis
- School of Health Sciences, City University London, London, UK
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Bruce Campbell
- Department of Vascular Surgery, Royal Devon and Exeter Hospital (Wonford), Exeter, UK
| | - Paul Bachoo
- Division of Applied Medicine, University of Aberdeen, Aberdeen, UK
| | - Ian Chetter
- Department of Vascular Surgery, Hull Royal Infirmary, Hull, UK
| | - Michael Gough
- Vascular Surgery, St James University Hospital, Leeds, UK
| | | | - Tim Lees
- Vascular Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Julian Scott
- Vascular Surgery, St James University Hospital, Leeds, UK
| | - Sara A Baker
- Vascular Surgical Unit, Royal Bournemouth Hospital, Bournemouth, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Maria Prior
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Denise Bolsover
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Luebke T, Brunkwall J. Cost-effectiveness of endovenous laser ablation of the great saphenous vein in patients with uncomplicated primary varicosis. BMC Cardiovasc Disord 2015; 15:138. [PMID: 26510413 PMCID: PMC4625802 DOI: 10.1186/s12872-015-0130-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 10/20/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although widely applied, the cost-effectiveness of endovenous laser ablation (EVLT) for varicose veins has not been established. METHODS Cost-effectiveness analysis was performed on the evaluation of EVLT for the treatment of uncomplicated varicose veins by using published data from randomizd clinical trials regarding the costs and the quality of life. Incremental cost per quality-adjusted life year (QALY) gained at 6 months following treatment was calculated. Sensitivity analysis was carried out to investigate the uncertainty associated with the results of our analysis. RESULTS Over the time horizon of 1-6 months, it was found that the incremental cost of EVLT compared with conventional surgery was €466.66 and the incremental effect was -0.007 QALY at 1 month, -0.0075 QALY at 3 months and 0.0 QALY at 6 months. This shows that the strategy "EVLT" was dominated by the strategy "HL/S" at any time point for the base cases analyses. The results of various alternative economic evaluations indicated that EVLT may be a potentially cost effective (i.e. incremental cost effectiveness ratio of between €12158.67 and €514721.67 per QALY, respectively) treatment option compared to conventional surgical treatment for varicose veins with a certainty between 54.9 and 98.8 %. CONCLUSION For patients with uncomplicated varicose veins and evidence of saphenofemoral reflux, surgical treatment for varicose veins offers a robust health benefit for relatively less costs compared to EVLT.
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Affiliation(s)
- Thomas Luebke
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay.
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay
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van der Velden SK, Biemans AAM, De Maeseneer MGR, Kockaert MA, Cuypers PW, Hollestein LM, Neumann HAM, Nijsten T, van den Bos RR. Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins. Br J Surg 2015; 102:1184-94. [PMID: 26132315 DOI: 10.1002/bjs.9867] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 02/26/2015] [Accepted: 05/07/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND A variety of techniques exist for the treatment of patients with great saphenous vein (GSV) varicosities. Few data exist on the long-term outcomes of these interventions. METHODS Patients undergoing conventional surgery, endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS) for GSV varicose veins were followed up for 5 years. Primary outcome was obliteration or absence of the treated GSV segment; secondary outcomes were absence of GSV reflux, and change in Chronic Venous Insufficiency quality-of-life Questionnaire (CIVIQ) and EuroQol - 5D (EQ-5D™) scores. RESULTS A total of 224 legs were included (69 conventional surgery, 78 EVLA, 77 UGFS), 193 (86.2 per cent) of which were evaluated at final follow-up. At 5 years, Kaplan-Meier estimates of obliteration or absence of the GSV were 85 (95 per cent c.i. 75 to 92), 77 (66 to 86) and 23 (14 to 33) per cent in the conventional surgery, EVLA and UGFS groups respectively. Absence of above-knee GSV reflux was found in 85 (73 to 92), 82 (72 to 90) and 41 (30 to 53) per cent respectively. CIVIQ scores deteriorated over time in patients in the UGFS group (0.98 increase per year, 95 per cent c.i. 0.16 to 1.79), and were significantly worse than those in the EVLA group (-0.44 decrease per year, 95 per cent c.i. -1.22 to 0.35) (P = 0.013). CIVIQ scores for the conventional surgery group did not differ from those in the EVLA and UGFS groups (0.44 increase per year, 95 per cent c.i. -0.41 to 1.29). EQ-5D™ scores improved equally in all groups. CONCLUSION EVLA and conventional surgery were more effective than UGFS in obliterating the GSV 5 years after intervention. UGFS was associated with substantial rates of GSV reflux and inferior CIVIQ scores compared with EVLA and conventional surgery. REGISTRATION NUMBER NCT00529672 (http://www.clinicaltrials.gov).
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Affiliation(s)
- S K van der Velden
- Departments of Dermatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - A A M Biemans
- Elisabeth-Twee Steden Hospital, Tilburg, The Netherlands
| | - M G R De Maeseneer
- Departments of Dermatology, Erasmus University Medical Centre, Rotterdam, The Netherlands.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - M A Kockaert
- Departments of Dermatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - P W Cuypers
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - L M Hollestein
- Departments of Dermatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - H A M Neumann
- Departments of Dermatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - T Nijsten
- Departments of Dermatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - R R van den Bos
- Departments of Dermatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Galego GDN, Lima GBB, Franklin RN, Bortoluzzi CT, Silveira PG. Outcome of 1470nm laser diode ablation for superficial venous insufficiency. J Vasc Bras 2015. [DOI: 10.1590/1677-5449.0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND: Endovenous laser ablation is a minimally invasive procedure that can be used to treat superficial venous insufficiency. We believe that using a longer wavelength will reduce the frequency of the most common adverse effects associated with the use of shorter wavelengths.OBJECTIVES: To report the results of an initial series of patients with chronic superficial venous insufficiency treated using a 1470 nanometer diode laser and to compare results using linear and radial laser fibers.METHODS: We conducted an observational cohort study. Seventy-four patients, for whom at least two postoperative Doppler ultrasonography scans were available, were recruited with a total of 121 saphenous veins treated (92 great and 29 small saphenous veins). There were 57 patients in Group A (treated with the linear fiber) and 17 in Group B (radial fiber). Follow-up ideally comprised clinical consultation and Doppler ultrasonography at 1 month, 6 months and 12 months after the procedure. Success was defined as total occlusion of the venous segment that had been treated.RESULTS: Success rates at mean follow-up of 13.4 months (range 7 - 27) were 83% for great saphenous veins and 89% for small saphenous veins. Patients treated with the radial fiber required less energy to achieve occlusion of the small saphenous vein and exhibited fewer adverse reactions, with statistical significance.CONCLUSIONS: Treatment of great and small saphenous vein insufficiency using the 1470 nm diode laser is safe and effective. The radial fiber was associated with fewer intercurrent conditions than the linear fiber, although success rates were similar.
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Darvall KAL, Bate GR, Bradbury AW. Patient-reported outcomes 5–8 years after ultrasound-guided foam sclerotherapy for varicose veins. Br J Surg 2014; 101:1098-104. [DOI: 10.1002/bjs.9581] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 01/10/2014] [Accepted: 05/02/2014] [Indexed: 11/11/2022]
Abstract
Abstract
Background
The aim was to determine the long-term (5–8 years) outcomes of ultrasound-guided foam sclerotherapy (UGFS) for varicose veins using health-related quality of life (HRQL), patient-reported outcomes (PROMs), patient satisfaction and retreatment rates.
Methods
Consecutive patients undergoing UGFS between April 2004 and May 2007 were invited for review at least 5 years after treatment. Patients completed generic (Short Form 12) and disease-specific (Aberdeen Varicose Vein Symptom Severity Score, AVSS) HRQL instruments, and questionnaires enquiring about lower limb symptoms, lifestyle factors and satisfaction with treatment. Data on retreatments were recorded prospectively.
Results
A total of 391 limbs in 285 patients were included (81·2 per cent response rate) at a median of 71 (i.q.r. 67–78) months following first UGFS treatment. Originally 72·1 per cent had symptomatic, uncomplicated varicose veins, 21·9 per cent had undergone surgery previously, 87·2 per cent had treatment of great saphenous veins and 19·9 per cent treatment of short saphenous veins. Disease-specific HRQL scores improved significantly at long-term follow-up, with 88·5 per cent having an improved AVSS compared with baseline. Regarding lower limb symptoms and lifestyle improvement, 62·7–93·8 per cent of patients had their pretreatment expectations met or exceeded. Overall, 82·0 per cent were very satisfied with their treatment and only 3·3 per cent were dissatisfied; 91·0 per cent would recommend the treatment to others. Some 15·3 per cent of limbs required retreatment by 5 years (Kaplan–Meier analysis).
Conclusion
UGFS has durable results as reported by PROMs to at least 5 years. Only 15·3 per cent of limbs required retreatment for recurrence during follow-up.
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Affiliation(s)
- K A L Darvall
- Birmingham University Department of Vascular Surgery, Flat 5 Netherwood House, Solihull Hospital, Lode Lane, Solihull B91 2JL, UK
| | - G R Bate
- Birmingham University Department of Vascular Surgery, Flat 5 Netherwood House, Solihull Hospital, Lode Lane, Solihull B91 2JL, UK
| | - A W Bradbury
- Birmingham University Department of Vascular Surgery, Flat 5 Netherwood House, Solihull Hospital, Lode Lane, Solihull B91 2JL, UK
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Rasmussen L, Lawaetz M, Serup J, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy, and surgical stripping for great saphenous varicose veins with 3-year follow-up. J Vasc Surg Venous Lymphat Disord 2013; 1:349-56. [PMID: 26992754 DOI: 10.1016/j.jvsv.2013.04.008] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 04/24/2013] [Accepted: 04/29/2013] [Indexed: 01/13/2023]
Abstract
INTRODUCTION This study compares the outcome 3 years after treatment of varicose veins by endovenous laser ablation (EVLA), radiofrequency ablation, ultrasound-guided foam sclerotherapy (UGFS), or surgery by assessing recurrence, Venous Clinical Severity Score (VCSS), and quality of life (QOL). METHODS A total of 500 patients (580 legs) were randomized to one of the three endovenous treatments or high ligation and stripping of the great saphenous vein (GSV). Follow-up included clinical and duplex ultrasound examinations and VCSS and QOL questionnaires. Kaplan-Meier (KM) life-table analysis was used. P values below .05 were considered statistically significant. RESULTS At 3 years, eight (KM estimate, 7%), eight (KM estimate, 6.8%), 31 (KM estimate, 26.4%), and eight (KM estimate, 6.5%) of GSVs recanalized or had a failed stripping procedure (more than 10 cm open refluxing part of the treated GSV; CLF, EVLA, UGFS, and stripping, respectively; P < .01). Seventeen (KM estimate, 14.9%), 24 (KM estimate, 20%), 20 (KM estimate, 19.1%), and 22 (KM estimate, 20.2%) legs developed recurrent varicose veins (P = NS). The patterns of reflux and location of recurrent varicose veins were not different between the groups. Within 3 years after treatment, 12 (KM estimate, 11.1%), 14 (KM estimate, 12.5%), 37 (KM estimate, 31.6%), and 18 (KM estimate, 15.5%) legs were retreated in the CLF, EVLA, UGFS, and stripping groups, respectively (P < .01). VCSS, SF-36, and Aberdeen QOL scores improved significantly in all the groups with no difference between the groups. CONCLUSIONS All treatment modalities were efficacious and resulted in a similar improvement in VCSS and QOL. However, more recanalization and reoperations were seen after UGFS.
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Affiliation(s)
- Lars Rasmussen
- Danish Vein Centers and Surgical Center Roskilde, Naestved, Denmark.
| | - Martin Lawaetz
- Danish Vein Centers and Surgical Center Roskilde, Naestved, Denmark
| | - Julie Serup
- Danish Vein Centers and Surgical Center Roskilde, Naestved, Denmark
| | - Lars Bjoern
- Danish Vein Centers and Surgical Center Roskilde, Naestved, Denmark
| | - Bo Vennits
- Danish Vein Centers and Surgical Center Roskilde, Naestved, Denmark
| | - Allan Blemings
- Danish Vein Centers and Surgical Center Roskilde, Naestved, Denmark
| | - Bo Eklof
- Danish Vein Centers and Surgical Center Roskilde, Naestved, Denmark
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Rasmussen L, Lawaetz M, Bjoern L, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years. J Vasc Surg 2013; 58:421-6. [DOI: 10.1016/j.jvs.2012.12.048] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 12/03/2012] [Accepted: 12/13/2012] [Indexed: 10/26/2022]
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Kuhlmann A, Prenzler A, Hacker J, Graf von der Schulenburg JM. Impact of radiofrequency ablation for patients with varicose veins on the budget of the German statutory health insurance system. HEALTH ECONOMICS REVIEW 2013; 3:9. [PMID: 23551943 PMCID: PMC3637434 DOI: 10.1186/2191-1991-3-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 03/19/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES In contrast to other countries, surgery still represents the common invasive treatment for varicose veins in Germany. However, radiofrequency ablation, e.g. ClosureFast, becomes more and more popular in other countries due to potential better results and reduced side effects. This treatment option may cause less follow-up costs and is a more convenient procedure for patients, which could justify an introduction in the statutory benefits catalogue. Therefore, we aim at calculating the budget impact of a general reimbursement of ClosureFast in Germany. METHODS To assess the budget impact of including ClosureFast in the German statutory benefits catalogue, we developed a multi-cohort Markov model and compared the costs of a "World with ClosureFast" with a "World without ClosureFast" over a time horizon of five years. To address the uncertainty of input parameters, we conducted three different types of sensitivity analysis (one-way, scenario, probabilistic). RESULTS In the Base Case scenario, the introduction of the ClosureFast system for the treatment of varicose veins saves costs of about 19.1 Mio. € over a time horizon of five years in Germany. However, the results scatter in the sensitivity analyses due to limited evidence of some key input parameters. CONCLUSIONS Results of the budget impact analysis indicate that a general reimbursement of ClosureFast has the potential to be cost-saving in the German Statutory Health Insurance.
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Affiliation(s)
- Alexander Kuhlmann
- Leibniz Universität Hannover, Center for Health Economics, Hannover, Germany
| | - Anne Prenzler
- Leibniz Universität Hannover, Center for Health Economics, Hannover, Germany
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Abstract
Objective: To report the patterns of reflux in the great saphenous vein as well as to investigate the correlations between patterns of reflux, the demographics and the clinical findings in the population studied. Methods: A total of 1882 limbs were assessed by duplex ultrasound examination in 1449 patients (348 men and 1101 women). Ages ranged from 21 to 94 years (mean 51.8). The presence of symptoms of venous disease (aching, heaviness, night cramps, swelling, itching, burning, tingling and throbbing) and clinical signs were recorded. Results: Varicose veins without saphenous reflux occurred at a younger age (43 versus 55.6 years P < 0.05). The presence of incompetence at the saphenofemoral junction occurred in older patients (58.5 versus 54.1 years P < 0.05). Venous reflux to the ankle also occurred in older patients (mean 64.0 years P < 0.05). Saphenous vein reflux without clinical varices was associated with more advanced signs (C4–C6: 20.3% P < 0.05). A younger age was associated with less advanced signs (C0–C2:49.4 versus C4–C6: 60.1 years P < 0.05). Presence of symptoms was associated with advancing patient age (51.1 versus 49.1 years P < 0.05). Conclusions: A significant correlation between the extent of great saphenous vein reflux and the patient age and the clinical stage of SVI has been observed in this study. The authors hypothesize that these findings support the concept of early treatment of venous insufficiency before symptomatic and physiological deterioration occurs.
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La insuficiencia venosa crónica en el Sistema Nacional de Salud. Diagnóstico, indicaciones quirúrgicas y priorización de listas de espera. Documento de la Sociedad Española de Angiología y Cirugía Vascular (SEACV) y del Capítulo de Flebología y Linfología de la SEACV. ANGIOLOGIA 2013. [DOI: 10.1016/j.angio.2012.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Darvall KAL, Bate GR, Adam DJ, Bradbury AW. Generic health-related quality of life is significantly worse in varicose vein patients with lower limb symptoms independent of CEAP clinical grade. Eur J Vasc Endovasc Surg 2012; 44:341-4. [PMID: 22831872 DOI: 10.1016/j.ejvs.2012.06.022] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 06/25/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To determine the relationship between lower limb symptoms and generic health-related quality of life (HRQL) in patients with varicose veins (VV). METHODS 284 patients on the waiting list for VV treatment completed the Short Form-12 (SF12) and a questionnaire asking about the presence of lower limb symptoms commonly attributed to venous disease (pain or ache, itching, tingling, cramp, restless legs, a feeling of swelling, and heaviness). RESULTS Median age was 57 years (interquartile range 45-67); 100 (35%) were male, and 182 (64%) had CEAP clinical grade 2 or 3 disease. Jonckheere-Terpstra test for trend revealed that both physical (P < .0005) and mental (P = .001) HRQL worsened as the reported number of symptoms increased. Patients reporting tingling (P = .016, Mann-Whitney U test), cramp (P = .001), restless legs (P < .0005), swelling (P < .0005), and heaviness (P < .0005) had a significantly worse physical HRQL than those who did not. Mental HRQL was also significantly worse in patients with tingling (P = .010), cramp (P = .008), restless legs (P = .040), swelling (P = .001), and heaviness (P = .035). These significant relationships remained, and pain was also correlated with worse physical HRQL (P = .011), when linear regression was performed to control for CEAP clinical grade, age and sex. CONCLUSIONS Physical and mental HRQL is significantly worse in VV patients with lower limb symptoms irrespective of the clinical stage of disease. This observation confirms that VV are not primarily a cosmetic problem and that NHS rationing of treatment to those with CEAP C4-6 disease excludes many patients who would benefit from intervention in terms of HRQL. Generic HRQL instruments also allow comparison with interventions for other chronic conditions.
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Affiliation(s)
- K A L Darvall
- Birmingham University, Department of Vascular Surgery, Heart of England NHS Trust, Birmingham, UK.
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Whiddon LL. Advances in the treatment of superficial venous insufficiency of the lower extremities. Proc (Bayl Univ Med Cent) 2011; 20:136-9. [PMID: 17431447 PMCID: PMC1849874 DOI: 10.1080/08998280.2007.11928269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Minimally invasive techniques for ablation of incompetent saphenous veins using either radiofrequency or laser energy sources have gained acceptance and are being widely applied today. Tumescent local anesthesia provides protection to tissues surrounding the treated veins and allows the procedures to be done on conscious patients. Results thus far compare favorably with surgical stripping procedures. Efficacy rates and complication rates support these techniques, and patient satisfaction appears high. Microphlebectomy, also minimally invasive, has advantages over direct incisional excision of varicosities. Foam sclerosant injection therapy has been used extensively in Europe and is proving useful in treating refluxing pelvic veins and recurrent varicosities.
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Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg 2011; 98:1079-87. [PMID: 21725957 DOI: 10.1002/bjs.7555] [Citation(s) in RCA: 376] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This randomized trial compared four treatments for varicose great saphenous veins (GSVs). METHODS Five hundred consecutive patients (580 legs) with GSV reflux were randomized to endovenous laser ablation (980 and 1470 nm, bare fibre), radiofrequency ablation, ultrasound-guided foam sclerotherapy or surgical stripping using tumescent local anaesthesia with light sedation. Miniphlebectomies were also performed. The patients were examined with duplex imaging before surgery, and after 3 days, 1 month and 1 year. RESULTS At 1 year, seven (5.8 per cent), six (4.8 per cent), 20 (16.3 per cent) and four (4.8 per cent) of the GSVs were patent and refluxing in the laser, radiofrequency, foam and stripping groups respectively (P < 0.001). One patient developed a pulmonary embolus after foam sclerotherapy and one a deep vein thrombosis after surgical stripping. No other major complications were recorded. The mean(s.d.) postintervention pain scores (scale 0-10) were 2.58(2.41), 1.21(1.72), 1.60(2.04) and 2.25(2.23) respectively (P < 0.001). The median (range) time to return to normal function was 2 (0-25), 1 (0-30), 1 (0-30) and 4 (0-30) days respectively (P < 0.001). The time off work, corrected for weekends, was 3.6 (0-46), 2.9 (0-14), 2.9 (0-33) and 4.3 (0-42) days respectively (P < 0.001). Disease-specific quality-of-life and Short Form 36 (SF-36(®)) scores had improved in all groups by 1-year follow-up. In the SF-36(®) domains bodily pain and physical functioning, the radiofrequency and foam groups performed better in the short term than the others. CONCLUSION All treatments were efficacious. The technical failure rate was highest after foam sclerotherapy, but both radiofrequency ablation and foam were associated with a faster recovery and less postoperative pain than endovenous laser ablation and stripping.
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Abstract
Endovenous saphenous vein obliteration in the form of radiofrequency or laser therapies has quickly ascended to a position of prime importance in the treatment of reflux within the superficial venous system. The technical aspects of these procedures, as well as their decreased morbidity when compared with saphenous vein stripping, make them highly appealing to both practitioners and patients alike. Less bruising, less pain, and less postoperative recovery are associated with these endovenous techniques than with the historical "gold standard" of saphenous vein stripping. Efficacy exceeds that of sclerotherapy, the other nonsurgical option. These improvements have led to greater acceptance by patients and consequently greater patient demand for endovenous ablation procedures. Practitioners should therefore become well versed in the techniques of performing these procedures safely and effectively for patients.
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Darvall K, Bate G, Adam D, Silverman S, Bradbury A. Duplex Ultrasound Outcomes following Ultrasound-guided Foam Sclerotherapy of Symptomatic Recurrent Great Saphenous Varicose Veins. Eur J Vasc Endovasc Surg 2011; 42:107-14. [DOI: 10.1016/j.ejvs.2011.03.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 03/13/2011] [Indexed: 11/25/2022]
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Disselhoff BCVM, der Kinderen DJ, Kelder JC, Moll FL. Five-year results of a randomized clinical trial comparing endovenous laser ablation with cryostripping for great saphenous varicose veins. Br J Surg 2011; 98:1107-11. [PMID: 21633948 DOI: 10.1002/bjs.7542] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2011] [Indexed: 11/09/2022]
Abstract
BACKGROUND This was the long-term follow-up of a previously reported randomized clinical trial comparing endovenous laser ablation (EVLA) with cryostripping for great saphenous varicose veins. METHODS A total of 120 patients with great saphenous varicose veins were randomized 1:1 to EVLA or cryostripping. Principal outcome measures were freedom from incompetence or neovascularization on duplex imaging, and improvement in Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Severity Score (AVVSS) 5 years after treatment. RESULTS Life-table analysis showed freedom from duplex-derived incompetence and neovascularization at 5 years in 62 (95 per cent confidence interval 50 to 76) per cent after EVLA and in 51 (39 to 66) per cent after cryostripping (P = 0.246). Neovascularization was more common after cryostripping, but incompetent tributaries were more common after EVLA. VCSS and AVVSS values improved significantly after treatment in both groups, and were maintained for 5 years, but with no significant difference between the groups. CONCLUSION In this study, no significant difference was demonstrated in late outcome after EVLA or cryostripping in patients with great saphenous varicose veins.
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[Diagnosis and treatment of varicose veins: part 2: therapeutic procedures and results]. Chirurg 2011; 81:1125-37; quiz 1138. [PMID: 21052970 DOI: 10.1007/s00104-010-1980-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This is the second of two articles on the diagnosis and treatment of varicose veins. Primary varicosis is a congenital degenerative disease of the peripheral venous system of the lower extremities. Treatment is carried out according to an individualized concept which takes the incurability and progression of the disease into consideration. Conservative treatment with compression bandages is an option for all forms of varicosis and the accompanying complications. Veins can be specifically ablated by sclerotherapy of varices. In addition to high ligation and stripping mini-phlebectomy and subfascial endoscopic perforator surgery (SEPS) can also be performed. The indications in cases of SEPS should be extremely limited because of possible severe complications. Radiofrequency ablation (RFO) and endovenous laser therapy (ELT) are also available as endovenous therapy options. Information in the literature on recurrence rates of the various procedures is extremely variable and the reasons for recurrent varicosis are the subject of controversy. The data relating to the results of RFO and ELT are relatively good and both procedures show a significant improvement in quality of life and the venous clinical severity score (VCSS).
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Biemans AAM, van der Velden SK, Bruijninckx CMA, Buth J, Nijsten T. Validation of the chronic venous insufficiency quality of life questionnaire in Dutch patients treated for varicose veins. Eur J Vasc Endovasc Surg 2011; 42:246-53. [PMID: 21531589 DOI: 10.1016/j.ejvs.2011.04.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 04/03/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ) is a disease-specific instrument to measure the impact of chronic venous insufficiency (CVI) on patients' lives. The objective of this study is to test the psychometric properties of the CIVIQ, and to validate the use of the questionnaire translated into the Dutch language. METHODS A standardised questionnaire, including CIVIQ and Short Form (36) Health Survey (SF-36), was obtained before and 1 month after treatment to all new patients with varicose veins. The feasibility was tested by missing responses and response distribution. CIVIQ scores were compared to the SF-36 scores and between different levels of severity of varicose veins. The CIVIQ's reliability was assessed using Cronbach's alpha and test-retest reliability. The structure was studied using factor analysis. The scores before and after therapy were compared to assess responsiveness. RESULTS There was a response rate of 93.5%. None of 20 items missed < 10% of responses, but three showed ceiling effect. The CIVIQ correlated well with the physical and moderately with the mental MCS of the SF-36, suggesting a good construct validity of the CIVIQ. The median CIVIQ scores increased significantly with the severity of varicose veins. The CIVIQ showed an excellent internal consistency and an excellent test-retest reliability. The CIVIQ score decreased in 76% of patients after treatment. The results were in accordance with the Norman's rule and showed a median effect size. CONCLUSION This study confirms the feasibility, validity, reliability and responsiveness of the CIVIQ in patients with varicose veins. The psychometric properties of the Dutch CIVIQ were comparable to the original French version.
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Affiliation(s)
- A A M Biemans
- Department of Dermatology, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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Abstract
Varicose vein operations belong to the most commonly performed surgical procedures in Germany. Besides the classic operation employing modern technology, which shows manageable recurrence rates with good cosmetic results and must be considered as the established standard therapeutic procedure, endoluminal treatment methods (endovenous radiofrequency therapy, endoluminal laser therapy) have been increasingly used in recent years. The endoluminal treatment methods offer patients reduced post-operative pain and a shorter recovery time compared to traditional surgery. Unfortunately due to limitations caused by vessel diameter and the ability to probe the vessel, they are only available to a limited range of patients. It remains to be seen how these procedures compare to the classical techniques, in particular in regards to improving the long-term quality of life and recurrence rates. A further therapeutic option is chemical endoluminal therapy, catheter-assisted foam sclerotherapy. It can be used as a safe treatment option with good postoperative results in some cases. However, the primary closure rates are inferior to surgery and endoluminal procedures.
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Carradice D, Mekako AI, Mazari FAK, Samuel N, Hatfield J, Chetter IC. Randomized clinical trial of endovenous laser ablation compared with conventional surgery for great saphenous varicose veins. Br J Surg 2011; 98:501-10. [DOI: 10.1002/bjs.7394] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2010] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Endovenous laser ablation (EVLA) is a popular minimally invasive treatment for varicose veins. Surgical treatment, featuring junctional ligation and inversion stripping, has shown excellent clinical and cost effectiveness. The clinical effectiveness of both treatments was compared within a randomized trial.
Methods
Some 280 patients were randomized equally into groups receiving either surgery or EVLA. Participants had primary, symptomatic, unilateral venous insufficiency, with isolated saphenofemoral junction incompetence, leading to reflux into the great saphenous vein. Outcomes included: quality of life (QoL), Venous Clinical Severity Score (VCSS), pain scores and time taken to return to normal function. Owing to the nature of the procedures, blinding was not possible.
Results
Both groups had significant improvements in VCSS after treatment (P < 0·001), which resulted in improved disease-specific QoL (Aberdeen Varicose Vein Questionnaire, P < 0·001) and quality-adjusted life year (QALY) gain (P < 0·001). The pain and disability following surgery impaired normal function, with a significant decline in five of eight Short Form 36 (SF-36®) domains (P < 0·001 to P = 0·029). Periprocedural QoL was relatively preserved following EVLA, leading to a significant difference between the two treatments in pain scores (P < 0·001), six of eight SF-36® domains (P = 0·004 to P = 0·049) and QALYs (P = 0·003). As a result, surgical patients took longer to return to work and normal activity (14 versus 4 days; P < 0·001). Complications were rare.
Conclusion
EVLA was as effective as surgery for varicose veins, but had a less negative impact on early postintervention QoL. Registration number: NCT00759434 (http://www.clinicaltrials.gov).
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Affiliation(s)
- D Carradice
- Academic Vascular Surgical Unit, University of Hull, Hull, UK
| | - A I Mekako
- Academic Vascular Surgical Unit, University of Hull, Hull, UK
| | - F A K Mazari
- Academic Vascular Surgical Unit, University of Hull, Hull, UK
| | - N Samuel
- Academic Vascular Surgical Unit, University of Hull, Hull, UK
| | - J Hatfield
- Academic Vascular Surgical Unit, University of Hull, Hull, UK
| | - I C Chetter
- Academic Vascular Surgical Unit, University of Hull, Hull, UK
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Noppeney T, Kluess H, Breu F, Ehresmann U, Gerlach H, Hermanns HJ, Nüllen H, Pannier F, Salzmann G, Schimmelpfennig L, Schmedt CG, Steckmeier B, Stenger D. Leitlinie zur Diagnostik und Therapie der Krampfadererkrankung. GEFASSCHIRURGIE 2010. [DOI: 10.1007/s00772-010-0842-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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