Endovenous Laser Ablation–Induced Complications: Review of the Literature and New Cases

Unresolved questions on venous thromboembolic disease. Therapeutic management of superficial vein thrombosis (SVT). Consensus statement of the French Society for Vascular Medicine (SFMV)

Superficial vein thrombosis (SVT), a manifestation of venous thromboembolism (VTE), is a common condition, yet of all the types of VTE, it has been the least well studied. Recent studies have challenged the conception that SVT is a benign disease, showing that its risk factors overlap with those of deep-vein thrombosis (DVT) and that it is frequently associated with DVT or pulmonary embolism (PE). In 2010, the CALISTO trial demonstrated the benefit of treatment with fondaparinux at the dose of 2.5mg (one injection per day) for 45days for lower limb SVT. Prior to CALISTO, the treatment of SVT was based on venous compression therapy, nonsteroidal anti-inflammatory drugs (NSAID) and anticoagulation using various therapeutic regimens. Surgery could also be envisaged in certain cases. In CALISTO, the inclusion criteria designed to obtain a homogeneous population meant that numerous questions remained unanswered with respect to SVT occurring in other locations and under other circumstances, notably in pregnant women, patients with renal insufficiency, and patients with recurrent SVT or superficial vein thrombosis less than 5cm long. The aim of this section is to review the current state of knowledge of SVT and to propose or recommend therapeutic strategies for the management of SVT according to the clinical context, the location of the thrombosis, and the presence of particular risk factors.

Endovenous thermal ablation mid-term outcomes for the treatment of large diameter incompetent great saphenous veins

INTRODUCTION

The aim of this study was to assess the efficacy and safety of endovenous thermal ablation (EVTA) in treating large diameter, ≥12 mm, incompetent great saphenous vein (GSV) in comparison to smaller ones.

METHODS

A retrospective comparative study was undertaken including 196 patients (205 limbs) undergoing EVTA. According to maximum GSV diameter patients were divided into two groups (group A <12 mm, group B ≥12 mm). Primary outcome was anatomic success defined as absence of reflux of GSV. Secondary outcomes were complications, postoperative pain using the 10-cm Visual Analog Scale (VAS) and improvement of Venous Clinical Severity Score (VCSS) and Chronic Venous Insufficiency Quality-of-Life Questionnaire (CΙVIQ-20) scores assessed at 7- days, 1 month, 12 months and 24 months postoperatively.

RESULTS

118 patients with GSV diameter <12 mm (group A) and 87 with GSV diameter ≥12 mm (group B) were included. Patients' demographics, CEAP classification and length of ablated vein did not differ between the groups. Preoperative VCSS and VAS pain score were significant greater in group B (6.03 vs 6.94, p = .04 and 5.21 vs 5.77, p = .032, respectively). No differences in adverse events were observed post-operatively among groups. GSV occlusion rate at 1 month was 98.3% (SE 1.3%) in group A and 96.5 % (2.2%) in group B (p = .3), at 12 months 95.7% (SE 2%) and 94.2% (SE 2.8%) (p = .5), and at 24 months 94% (SE 2.4%) and 93.1% (SE 3%) (p = .4) respectively. Both groups experienced significant and similar improvement in their VCSSs and CIVIQ scores postoperatively. In a subgroup analysis among different EVTA and GSV >12 mm, 1470 nm endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) showed comparable results in terms of occlusion rates, complications, VCSS and CIVIQ scores.

CONCLUSIONS

Endovenous thermal ablation techniques are efective and safe in the treatment of GSV incompetence regardless the diameter of the GSV. Both 1470 nm EVLA and RFA techniques performed similar outcomes.

Treatment of varicose great saphenous vein with endovenous laser alone or combined with eco-guided foam sclerotherapy: A randomized controlled trial

Objectives: This study compares Endovenous Laser Ablation (EVLA) alone versus combined with ultrasound-guided foam sclerotherapy (UGFS) for Great Saphenous Vein (GSV) insufficiency. Methods: Sixty patients were randomly allocated to EVLA or EVLA-UGFS groups which focused on GSV occlusion rates, complications, additional treatments, and quality of life (QoL) changes. Results: Among 55 participants, the EVLA group had higher 12-month occlusion rates (92.3% vs. 75.8%, p = 0.11). Nervous injury (NI) was rarer in EVLA-UGFS (3.4% vs. 23.1%, p = 0.04). No significant difference in other complication rates (p > 0.05). QoL improved in both groups (p < 0.001). EVLA-UGFS required more subsequent procedures (24.1% vs. 7.7%, p = 0.03). Conclusions: EVLA and EVLA-UGFS effectively treat GSV insufficiency, enhancing QoL. The combined method reduces NI risk but may require more follow-up procedures.

Clinical outcomes of nonthermal ablation, thermal ablation, and surgical stripping for varicose veins

OBJECTIVE

The purpose of this study was to compare the clinical outcomes of radiofrequency ablation (RFA), cyanoacrylate closure (CAC), mechanochemical ablation (MOCA), and surgical stripping (SS) for incompetent saphenous veins and to determine a suitable treatment modality for a specific clinical situation.

METHODS

We retrospectively reviewed the data of patients with varicose veins who underwent RFA, CAC, MOCA, or SS from January 2012 to June 2023. The clinical outcomes, including postoperative complications and the Aberdeen Varicose Vein Questionnaire score, were assessed.

RESULTS

During the study period, 2866 patients with varicose veins were treated. Among them, 1670 patients (57.9%) were women. The mean age was 55.3 ± 12.9 years. RFA, CAC, MOCA, and SS were performed in 1984 (68.7%), 732 (25.4%), 78 (2.7%), and 88 (3.0%) patients, respectively. The complete target vein closure rate after RFA, CAC, and MOCA was 94.5%, 98%, and 98%, respectively. The absence of a target vein after SS was 98%. Deep vein thrombosis developed in four patients: one in the RFA group and three in CAC group. Surgical or endovenous procedure-induced thrombosis occurred in 2.3%, 4.8%, 6.4%, and 2.3% of the patients after RFA, CAC, MOCA, and SS, respectively. Phlebitis along the target vein occurred in 0.2% and 3.8% of patients after RFA and MOCA, respectively. A hypersensitivity reaction occurred in 3.7% of patients after CAC. Readmission was required for two patients who had undergone SS. Transient nerve symptoms developed in five (0.3%), zero, one (1.3%), and two (2.3%) patients after RFA, CAC, MOCA, and SS, respectively. After treatment, the Aberdeen Varicose Vein Questionnaire score improved significantly in all groups.

CONCLUSIONS

The clinical outcomes with improvement in quality of life were comparable among the different treatment modalities. The proximity of the nerve or skin to the target vein is the most important factor in selecting a suitable treatment modality.

Venous thrombosis following endovenous laser ablation with and without thromboprophylaxis

OBJECTIVE

Venous thromboembolism (VTE) occurs infrequently after endovenous laser ablation (EVLA). The purpose of this study was to assess the incidence of VTE after EVLA with and without pharmacologic prophylaxis.

METHODS

From October 2019 to March 2020, a series of consecutive patients from the prospectively maintained VEINOVA (vein occlusion with various techniques) registry was retrospectively analyzed. All the patients underwent EVLA with and without postoperative thromboprophylaxis. A 1470-nm laser wavelength with a radial fiber was used for EVLA. Concomitant phlebectomy or sclerotherapy of insufficient tributaries was allowed. Perivenous tumescence was applied with 1% Rapidocaine (lidocaine hydrochloride monohydrate; Sintetica SA). Ablation of varicose veins was performed by continuously drawing back the laser fiber at a power of 10 W, aiming for a linear endovenous energy delivery of 60 to 90 J/cm. Compression stockings were applied postoperatively, and the patients were advised to wear them for 1 week. Duplex ultrasound was performed at the 1- and 4-week follow-up visits to determine the occlusion rate and the occurrence of EHIT and VTE.

RESULTS

Overall, 249 patients were identified from the registry. Of the 249 patients, 26 were omitted because of treatment of recurrent varicose veins. Finally, 223 consecutive patients with 223 legs and 227 saphenous veins (159 great saphenous veins, 49 small saphenous veins, and 19 anterior accessory saphenous veins) were included in the final analysis. Their mean age was 58.1 ± 13.8 years, and 167 patients (73.1%) were women. The clinical CEAP (clinical, etiology, anatomy, pathophysiology) classification was C2 for 11 legs (4.9%), C3 for 123 legs (55.2%), C4a or C4b for 86 legs (38.6%), and C5 to C6 for 3 legs (1.4%). Thromboprophylaxis was given to 132 patients (59.2%) for 3 days (rivaroxaban 10 mg once daily to 130 patients [98.5%] and low-molecular-weight heparin to 2 patients [1.5%]). No thromboprophylaxis was administered to 91 patients (40.8%) after EVLA. The average treatment length was 34.2 ± 19.3 cm and the average diameter was 5.0 ± 1.3 mm. At 1 week of follow-up, no thrombotic event had occurred in either group. At 4 weeks of follow-up, one case of EHIT class 2 (1.1%) and one case of pulmonary embolism (1.1%) had occurred in the group without thromboprophylaxis. In the thromboprophylaxis group, one deep vein thrombosis (0.8%) event had occurred (adjusted P = .135). At 1 and 4 weeks of follow-up, the treated varicose veins remained occluded in both groups.

CONCLUSIONS

Endovenous ablation of truncal varicose veins appears to be safe with a low thrombotic event rate with or without pharmacologic thromboprophylaxis. However, more data are needed before a final recommendation regarding the best thromboprophylaxis treatment option can be given.

The first meta-analysis research on the effects of endovenous laser ablation combined with sapheno-femoral junction high ligation of the great saphenous vein

Endovenous laser ablation (EVLA) is a common minimally invasive technique used to treat varicose veins. The most commonly used laser wavelengths for EVLA/EVLT of varicose veins are 810 nm and 1470 nm. The laser pulse frequency is typically set to continuous wave (CW) mode, with a pulse duration of a few milliseconds (ms) delivered in a radial mode. The energy delivered per pulse is typically set between 40 and 120 Joules, with a power setting of 10 to 30 watts and an intensity setting of 40 to 120 J/cm2. The controversy exists regarding the benefits of performing saphenofemoral junction (SFJ) ligation prior to EVLA to decrease the recurrence rate of varicose veins. This meta-analysis aims to investigate the effectiveness of combining EVLA with high ligation versus using EVLA alone in treating lower extremity varicose veins. We conducted a systematic search of four databases from their inception until July 1, 2022, for randomized controlled trials and prospective controlled trials evaluating the advantages and disadvantages of EVLA with or without high ligation for the treatment of lower extremity varicose veins. In analyzing binary data, rate difference (RD) is used, while odds ratio (OR) is used for evaluating the confidence interval (CI) of binary data. A P value of less than 0.05 is deemed statistically significant. Heterogeneity is assessed using the chi-square test. If the I2 statistic, which reflects statistical heterogeneity, is greater than 50%, a random-effects model should be used. In the absence of significant statistical heterogeneity, a fixed-effects model should be used if I2 is less than 50%. We used the Cochrane risk-of-bias tool to assess the quality of the studies and Review Manager 5.4 for the primary and secondary outcome analysis. The meta-analysis was conducted in accordance with the Cochrane Handbook. There were no significant differences in the rate of major complications (RR = 1.63; 95% CI, 0.40-6.69; P = 0.50) or in the frequency of minor complications (RR = 1.07, 95% CI, 0.87-1.31; P = 0.52) between the EVLA with high ligation (EVLA/HL) group and the EVLA group. However, the rate of vein occlusion was significantly lower in the EVLA group than in the EVLA/HL group (RR = 1.06; 95% CI, 1.03-1.09; P = 0.0004). Our meta-analysis indicates that combining EVLA with high ligation provides stable long-term clinical efficacy in treating varicose veins of the lower extremities, although it increases the invasiveness of the surgery. The use of EVLA alone may be less effective in preventing vein occlusion.

Niche preclinical and clinical applications of photoacoustic imaging with endogenous contrast

In the past decade, photoacoustic (PA) imaging has attracted a great deal of popularity as an emergent diagnostic technology owing to its successful demonstration in both preclinical and clinical arenas by various academic and industrial research groups. Such steady growth of PA imaging can mainly be attributed to its salient features, including being non-ionizing, cost-effective, easily deployable, and having sufficient axial, lateral, and temporal resolutions for resolving various tissue characteristics and assessing the therapeutic efficacy. In addition, PA imaging can easily be integrated with the ultrasound imaging systems, the combination of which confers the ability to co-register and cross-reference various features in the structural, functional, and molecular imaging regimes. PA imaging relies on either an endogenous source of contrast (e.g., hemoglobin) or those of an exogenous nature such as nano-sized tunable optical absorbers or dyes that may boost imaging contrast beyond that provided by the endogenous sources. In this review, we discuss the applications of PA imaging with endogenous contrast as they pertain to clinically relevant niches, including tissue characterization, cancer diagnostics/therapies (termed as theranostics), cardiovascular applications, and surgical applications. We believe that PA imaging's role as a facile indicator of several disease-relevant states will continue to expand and evolve as it is adopted by an increasing number of research laboratories and clinics worldwide.

Ablösung der Lasersondenspitze – eine seltene Komplikation der endoluminalen Therapie

Hintergrund In der Vergangenheit bestand die chirurgische Therapie der Stammvarikose in Crossektomie, Stripping und falls notwendig in minichirurgischer Phlebektomie. In den letzten 10 Jahren haben endoluminale Techniken und hier speziell Lasertechniken an Bedeutung gewonnen. Komplikationen nach endoluminalen Laserprozeduren sind selten beschrieben.

Methode Wir berichten erstmalig in einem Fallbericht über die intraoperative Ablösung der Lasersondenspitze bei endoluminaler Therapie einer Vena saphena magna Stammvarikose. Ein unmittelbarer sicherer Nachweis der abgelösten Sondenspitze mittels Duplexsonografie war aufgrund der infiltrierten TLA Lösung nicht möglich. Eine CT-Diagnostik blieb ergebnislos.

Ergebnisse Am Tag nach der Operation ließ sich die abgelöste Sondenspitze problemlos mittels Ultraschall nachweisen. Um eine Embolisation der abgesprengten Glaspartikel sicher zu vermeiden, entschlossen wir uns zu einem offenen chirurgischen Vorgehen mit Resektion der Sondenspitze und Durchführung einer korrekten Crossektomie.

Schlussfolgerung Mit zeitlicher Verzögerung (Stunden) ist eine Ortung der abgelösten Sondenspitze mittels Ultraschall sicher möglich. Chirurgische Intervention, aber auch passives Zuwarten, sind zu diskutieren.

Pilot single-arm study to investigate the efficacy and safety of endovenous Microwave ablations for treatment of varicose veins in Singapore – one year results of the MAESTRO registry

Objectives

Aim was to report a prospective two-centre Singaporean experience using Endovenous Microwave Ablation (EMA) to treat symptomatic primary great saphenous vein reflux. We evaluated 1-year safety, efficacy and patient satisfaction.

Methods

50 patients (63 limbs; 29 females; mean age 58.0 ± 12.1 years) were included. Patients were reviewed at 2-weeks, 3-, 6- and 12-months and underwent Duplex ultrasound assessment. Three quality of life (QoL) questionnaires were completed.

Results

The truncal closure rates at 2-weeks, 3-, 6- and 12-months were 63/63 (100%), 59/59 (100%), 58/58 (100%) and 59/60 (98.3%), respectively. There was 100% technical success and no serious adverse events. There were sustained improvement of QoL questionnaire scores from 2 weeks to 12 months.

Conclusion

EMA is a safe and efficacious venous ablative technology at 12 months and is associated with a high rate of target vein occlusion and sustained QoL improvement.

[Truncal mechanochemical versus thermal endovenous ablation for varicose vein disease: a systematic review and meta-analysis]

OBJECTIVE

To compare the outcomes of thermal and mechanochemical endovenous ablative techniques in patients with varicose veins.

MATERIAL AND METHODS

We searched the PubMed, EMBASE and Cochrane Library databases for studies devoted to mechanochemical and thermal endovenous ablative techniques from inception until July 2021. The primary outcome was anatomical success. Secondary endpoints were intraoperative pain syndrome, complications, modification of disease severity and quality of life.

RESULTS

This meta-analysis enrolled 10 comparative studies and 1.252 participants after truncal ablations. The follow-up period ranged from 4 weeks to 36 months. With regard to overall anatomical success, 245 out of 267 (91.8%) patients after mechanochemical ablation and 249 out of 266 (93.6%) patients after thermal ablation had favorable results after a month (low-quality evidence; odds ratio [OR] 0.79; 95% CI 0.40-1.55). No statistical heterogeneity was identified (χ²=1.48; df=2; p=0.48; I²=0%). Further analysis identified different incidence of total occlusion after 12 months or later (OR 0.36; 95% CI 0.11-1.21; p=0.05; I²=68%). Mechanochemical ablation resulted less intraoperative pain. Mean difference was -1.3 (95% CI -2.53- -0.07; p=0.00001). MOCA was followed by fewer incidence of nerve injury, hematoma, deep vein thrombosis and phlebitis. There were more cases of skin pigmentation compared to thermal ablation (low-quality evidence, p>0.05). Subsequent assessment of disease severity identified significant between-group difference of means (-0.64 (95% CI -1.82-0.53; p=0.004) and -0.16 (95% CI -0.43-0.11; p=0.005) after 6 and 12 months, respectively). Further assessment of quality of life revealed no between-group differences. These data were characterized by moderate methodological quality.

CONCLUSION

Mechanochemical ablation is as effective as standard TA within the first postoperative month. However, this approach is associated with lesser anatomical success after 12 months. In most studies, pain syndrome was less severe in case of mechanochemical ablation. These data suggest that mechanochemical ablation is a safe alternative for varicose veins. However, further large-scale trials are required to define the role of MOCA.

How effective is cyanoacrylate closure in small saphenous vein insufficiency? A single center experience

OBJECTIVES

The present study was aimed to evaluate the efficacy and early outcomes of n-butyl cyanoacrylate (NBCA) ablation in small saphenous vein (SSV) insufficiency.

METHODS

In this single-center, retrospective, single-arm study, NBCA ablation was performed in 80 patients with SSV insufficiency between September 2018 and May 2020. Primary outcomes (anatomic success rate and occlusion rate) and secondary outcomes (VCSS and AVVQ scores) of the patients were analyzed.

RESULTS

No technical failure and device-related complications were encountered. Anatomic success rate was 100% after procedures. Each treated SSV was occluded on colored Doppler ultrasonography immediately after the procedure, and all veins remained occluded at 2 weeks after the procedure. Partial recanalization was observed in five patients at 12-month follow-up. Kaplan-Meier analysis revealed an occlusion rates at 6 months and 12 months follow-up were 97.5% and 93.75%, respectively. The mean pretreatment VCSS (4.72 ± 2.04) decreased to 1.61 ± 0.93, 0.87 ± 0.58, and 0.73 ± 0.52 at 2 weeks, 6 months, and 12 months after treatment, respectively (p < .001). The mean pretreatment AVVQ score (11.92 ± 2.23) decreased to 8.2 ± 1.89, 4.2 ± 1.16, and 3.32 ± 1.19 at 2 weeks, 6 months, and 12 months after treatment, respectively (p < .001). The Clinical, Etiologic, Anatomic, and Pathophysiology clinical classification at 12 months demonstrated a significant reduction in disease severity compared with preoperative values (p < .001). There was no mortality and major adverse events including anaphylaxis and pulmonary thromboembolism (PTE) related to procedure after follow-ups. Moreover, there were no symptoms or signs of any sural nerve injury and no cases of skin necrosis, infection, or hyperpigmentation. In addition, no hematoma, deep venous thrombosis, and hypersensitivity reactions were observed. Phlebitis-like abnormal reaction was observed in three patients (3.8%).

CONCLUSIONS

In conclusion, in patients with SSV insufficiency, NBCA ablation with VenaBlock® system appears to be an effective and reliable treatment method. At the 12-month follow-up, the NBCA of SSVs showed a low recanalization rate and had a satisfactory improvement on the VCSS and AVVQ scores.

Morphological changes of veins and perivenous tissues during endovenous laser coagulation using 2-μm laser radiation and various types of optical fibers

OBJECTIVE

To determine the morphological changes in veins and perivenous tissues after endovenous laser coagulation (EVLC) using laser radiation with a wavelength of 1910 nm and different types of fibers (bare tip and radial).

METHODS

The EVLC procedure was carried out on 22 surface veins of six sheep. The radiation source was a diode-pumped solid-state laser, which was based on a LiYF₄:Tm crystal and had an emission wavelength of 1910 nm and a maximum output power of 10 W. Two types of optical fibers were used: (1) bare tip and (2) radial or radial with two rings. Histological and morphometric methods were used, and the statistical digital data were analyzed.

RESULTS

The use of a linear endovenous energy density of 20 J/cm and optical bare fibers for veins with diameters of 3-4 mm resulted in a slit-shaped or wide venous wall perforation. A thermal effect was observed on the perivenous connective tissue (PVCT), which caused damage to its structures. Wide perforations were accompanied by complete destruction of the PVCT in the projection of the formed defect. The distance between the remaining vein wall fragment, located opposite to the perforation, and injured small vessels was 257.7 ± 23.6 μm. The radius of thermal damage increased to 2073.5 ± 8.0 μm near the vessel perforation. Using optical radial fibers for veins with diameters of 3.9 ± 0.5 mm did not lead to perforations. The destructive effect of the laser on small vessels of the PVCT extended to a distance of 425.7 ± 22.0 μm.

CONCLUSIONS

Analysis of thermal vessel damage in perivenous tissue after EVLC with bare-tip fiber shows that in the projection of a wide perforation, the damaged vessels of the PVCT are located at a large distance from the coagulated vein wall. On the opposite side of the perforation, the distance from the coagulated vein wall to the damaged vessels of the PVCT is significantly reduced because of the minimal output of laser radiation energy through the poorly damaged part of the wall. Using an optical radial fiber facilitates the application of a uniform distribution of thermal energy to the vein wall and damage to all its layers; at the same time, it minimizes the thermal energy that extends beyond the vein wall and damages the surrounding tissue.

CLINICAL RELEVANCE

The use of radiation with a wavelength of 1910 nm will make it possible to carry out endovenous laser coagulation of varicose veins at lower power values compared with radiation in the micron and one and a half micron regions of the spectrum. Understanding of morphological changes of veins and perivenous tissues after endovenous laser coagulation with 1910-nm laser radiation and different types of optical fibers (bare-tip, radial, radial 2ring) help predict possible complications and reduce their rate.

Current strategies for endovascular management of varicose veins: An updated review of superficial ablation technologies

Chronic venous insufficiency (CVI) which causes varicose veins and venous ulcers, is a major cause of morbidity and mortality in the general population. The last several years have witnessed many revolutionary developments in the realms of minimally invasive techniques (both thermal and non-thermal) to treat CVI. Moreover, multiple newer societal recommendations have been published over the past one year on the basis of the current evidence. In this article, we will briefly summarise the imaging for varicose veins and review the existing evidence in literature as well as the current guidelines and recommendations for the management of varicose veins, especially focusing on the various superficial ablation technologies.

Cyanoacrylate Closure of Small Saphenous Vein Insufficiency

BACKGROUND

As minimally invasive techniques were issued, endovenous thermal ablations have emerged. However, the thermal-associated complication has been reported in the treatment of small saphenous vein (SSV) insufficiency, such as sural nerve injury. Recently introduced cyanoacrylate closure (CAC) is a nonthermal modality, so this thermal-associated complication can be avoided.

OBJECTIVE

This retrospective study analyzed the feasibility, safety, and 2-year results of CAC for treating SSV insufficiency, particularly the incidence of sural nerve injury.

MATERIALS AND METHODS

One hundred sixty-three SSV insufficiencies in 128 patients were treated with CAC were reviewed. Pain, venous severity, and quality of life (QoL) scores were evaluated. Postoperative duplex scanning also evaluated anatomical and clinical success rates.

RESULTS

The mean patient age was 56.8 years. The initial technical success rate was 100%. The occlusion rate after 2 years was 96.3%. Pain, venous severity, and QoL scores were improved significantly from 2.4 to 0.0, 4.39 to 0.47, and 11.95 to 2.69, respectively, before and 2 years after CAC. No major complications were observed, such as sural nerve injury.

CONCLUSION

Cyanoacrylate closure for the ablation of SSV insufficiency could be a great alternative to endothermal ablation with an excellent success rate and shorter procedure time.

Use of 1,470 nm laser for treatment of superficial venous insufficiency

BACKGROUND

There are several ways to treat varicose veins of the lower limbs, among which use of 1470nm diode lasers stands out. This technique can be used to treat patients in outpatient settings, with early return to work, good esthetic results, and low rates of complications. However, variables such as the laser wavelength, the power administered in each area, the type of fiber, and the linear intravenous energy density (LEED) are still extensively discussed.

OBJECTIVES

To analyze the results of superficial venous insufficiency treatment with a 1470nm diode laser.

METHODS

Retrospective study conducted at a private clinic in a private hospital in Florianopolis, based on a database collected prospectively. The sample comprised 287 patients who underwent surgery to treat superficial venous insufficiency with 1470nm diode laser, from January 2016 to December 2018, totaling 358 great saphenous veins (GSVs) and 84 small saphenous veins (SSVs) treated.

RESULTS

The total occlusion rates after 12 months of surgery were 94.4% in the GSVs, with an average LEED of 45.90 J/cm, and 96.4% in the SSVs, with an average LEED of 44.07 J/cm.

CONCLUSIONS

During the follow-up period, the 1470nm diode laser proved to be a safe treatment, with great efficacy and low rates of complications (pain, edema, bruising, deep vein thrombosis, and endothermal heat-induced thrombosis - EHIT).

One-year outcome using cyanoacrylate glue to ablate truncal vein incompetence: A Singapore VenaSeal™ real-world post-market evaluation study (ASVS)

OBJECTIVE

We present 12 months efficacy data from A Singapore VenaSeal™ real-world post-market evaluation Study (ASVS), a prospective single-arm Asian population registry aimed to evaluate cyanoacrylate glue (CAG) closure of refluxing truncal veins.

METHODS

Duplex ultrasound was used to assess truncal vein closure. The revised Venous Clinical Severity Score (rVCSS) and three quality of life (QoL) questionnaires were completed to assess improvement in venous disease symptoms.

RESULTS

90/100 (90%) patients (136 legs; 140 truncal veins) completed evaluation at 6- and 12 months. The truncal closure rates at 6 and 12 months were 139/140 (99.3%) and 137/140 (97.9%), respectively. rVCSS and QoL questionnaires scores were sustained from the 3 to 12 months visits, although there were no futher significant improvement. No serious adverse events were reported between 3 and 12 months.

CONCLUSIONS

CAG remains a safe and efficacious venous ablative technology at 12 months and is associated with a high rate of target vein occlusion and sustained QoL improvement.

Efficacy of High Temporal Frequency Photoacoustic Guidance of Laser Ablation Procedures

Inaccurate placement of the ablation catheter and the inability to monitor the real-time temperature within the tissue of interest such as veins curbs the treatment efficacy of laser ablation procedures during thermal therapies. Our previous studies have validated the efficacy of photoacoustic (PA) imaging during endovenous laser ablation (EVLA) procedures. However, the PA-guided therapies suffer from low temporal resolution, due to the low pulse repetition rates of pulsed lasers, which could cause a problem during fast catheter motion and rapid temperature changes. Herein, to enhance the accuracy and sensitivity for tracking the ablation catheter tip and temperature monitoring, we proposed to develop a high frame rate (500 Hz), combined ultrasound (US), and PA-guided ablation system. The proposed PA-guided ablation system was evaluated in a set of ex vivo tissue studies. The developed system provides a 2 ms temporal resolution for tracking and monitoring the ablation catheter tip's location and temperature, which is 50 times higher temporal resolution compared to the previously proposed 10 Hz system. The proposed system also provided more accurate feedback about the temperature variations during rapid temperature increments of 10°C per 250 ms. The co-registered US and PA images have an imaging resolution of about 200 μm and a field of view of 45 × 40 mm². Tracking the ablation catheter tip in an excised tissue layer shows higher accuracy during a relatively fast catheter motion (0.5-3 mm/s). The fast US/PA-guided ablation system will potentially enhance the outcome of ablation procedures by providing location and temperature feedback.

Iatrogenic Arteriovenous Fistula Formation after Endovenous Laser Treatment Resulting in High-output Cardiac Failure: A Case Report and Review of the Literature

Formation of a clinically significant iatrogenic arteriovenous fistula after endovenous laser treatment of the great saphenous vein is an extremely rare complication. Because of the infrequency of reported cases, there is no clear consensus on how to best manage this complication. We present a unique case of an iatrogenic high-output superficial femoral artery-common femoral vein fistula resulting in right heart failure and a distal deep vein thrombosis. Deployment of a covered arterial stent graft resulted in resolution of the arteriovenous fistula and high-output cardiac state. Clinically significant arteriovenous fistulas resulting from inadvertent vessel injury during endovenous laser treatment appear to be amenable to percutaneous endovascular interventions. During these challenging endovascular cases, intravascular ultrasonography can be used to help delineate the morphology of the fistula tract and obtain vessel measurements to ensure accurate endoprosthesis sizing and placement.

Feasibility and short-term complication rate of mechanochemical ablation for epifascial tributaries of incompetent great saphenous veins

OBJECTIVE

The aim of the present study was to investigate the occurrence of skin complications after mechanochemical ablation with the ClariVein device (Merit Medical, South Jordan, Utah) for incompetent great saphenous veins (GSVs) and compare the results in terms of the target vein characteristics, especially in the presence of an epifascial GSV tributary.

METHODS

A single-center, retrospective study was performed. We reviewed 33 limbs of 32 patients with GSV insufficiency who had undergone mechanochemical ablation with the ClariVein device from December 2017 to February 2020. The 33 limbs were divided into two groups: the epifascial group, comprising 11 limbs of 11 patients, and the nonepifascial group, comprising 22 limbs of 21 patients. The patients underwent postoperative follow-up examinations at 1 week and 1, 3, 6, and 12 months. The skin complication counts and scores on a four-point scale were recorded.

RESULTS

Regarding the baseline characteristics, the epifascial group showed a significantly lower GSV depth in the distal thigh region compared with the nonepifascial group (2.64 ± 0.5 mm vs 7.05 ± 2.57 mm; P < .001). No statistically significant difference was found between the two groups in terms of the sclerosant (sodium tetradecyl sulfate) volume (5.45 ± 2.02 mL vs 6.59 ± 1.79 mL; P = .109) or ablation length (31.82 ± 3.92 cm vs 32.95 ± 4.05 cm; P = .449). All ClariVein procedures were technically successful (33 of 33 limbs; 100%), and no major complications were reported. The hyperpigmentation score was significantly greater in the epifascial group than in the nonepifascial group (score, 0.18 ± 0.4 vs 0 ± 0; P = .0401), although the hyperpigmentation count was not significantly different between the two groups (2 of 11 limbs [18.2%] vs 0 of 22 limbs [0.0%]; P = .1042). Although marginally higher counts and scores were observed in terms of phlebitis and bruising in the epifascial group, these differences were not statistically significant.

CONCLUSIONS

Endovenous treatment with the ClariVein device for incompetent GSVs can be performed safely. However, caution should be exercised when the epifascial GSV tributary is treated during the ClariVein procedure because of its predilection to result in hyperpigmentation.

Thromboprophylaxis practice after outpatient endovenous thermal ablation

OBJECTIVE

The use of endovenous thermal ablation (ETA) for the treatment of truncal varicose veins has been increasing worldwide; however, uncertainty remains regarding the need for thromboprophylaxis and follow-up of patients undergoing this minimally invasive procedure. A nationwide survey of among physicians performing ETA was conducted to assess the thromboprophylaxis practice and follow-up protocols after ETA in Switzerland.

METHODS

A questionnaire was sent to all ETA-certified physicians (n = 193) in Switzerland. The survey covered procedure type, thromboprophylaxis (including pharmacologic and compression therapy), duplex ultrasound follow-up examinations, and the management of endovenous heat-induced thrombosis (EHIT).

RESULTS

Overall, 121 responses were received, for a response rate of 62.7%. Of the 121 respondents, 71 were vascular medicine specialists (58.7%) and 46 were general or vascular surgeons (38.0%), representing the two largest groups of specialists, followed by 2 dermatologists (1.7%) and 2 interventional radiologists (1.7%). Pharmacologic thromboprophylaxis after ETA was always used by 86 physicians (71.1%), nearly always by 8 (6.6%), frequently used by 5 (4.1%), rarely used by 21 (17.4%), and never by 1 physician (0.8%). A direct oral anticoagulant drug was the preferred type of thromboprophylaxis used by 92 physicians (77.3%). The first dose of thromboprophylaxis was mostly administered immediately after intervention by 53 physicians (53.7%). The duration of postablation thromboprophylaxis ranged from 1 to 21 days, with 7 to 10 days used by 57 physicians. Compression therapy was used by all physicians, with large variation in duration ranging from 1 to 42 days after a single ETA session and after ETA with concomitant phlebectomy. Postablation duplex ultrasonography was performed routinely by 120 respondents (99.2%), and 84 respondents (69.4%) performed two to three duplex ultrasound scans. Management of EHIT depended on the EHIT class and differed widely among the physicians.

CONCLUSIONS

Our nationwide survey on thromboprophylaxis practices after ETA of truncal varicose veins in Switzerland showed that most physicians use pharmacologic thromboprophylaxis, with a direct oral anticoagulant drug the preferred agent. However, the timing of the first dose and the duration of thromboprophylaxis varied widely among the respondents, reflecting the uncertainty in this domain owing to the absence of high-quality evidence-based guidelines.

[Retrograde mechanochemical ablation of the great saphenous vein in treatment of stage III chronic venous insufficiency]

Presented herein is a clinical case report regarding successful treatment of a trophic ulcer of the right tibia by means of endovenous mechanochemical ablation of the great saphenous vein using the FlebogrifTM device. According to ultrasonography findings, the patient was found to have insufficiency of the saphenofemoral junction, axial truncal reflux, and the absence of incompetent perforator veins in the area of trophic disorders. Taking into account the clinical and ultrasound picture of the disease, the decision was made on the feasibility of performing crossectomy and retrograde mechanochemical ablation of the great saphenous vein. The chosen modality of the invasive intervention did not require tumescent anesthesia, allowed a catheter to be placed under the ulcer bed and, unlike thermal methods, excluded the risk of damage to the subcutaneous nerves and soft tissues. The operation made it possible to eliminate pathological truncal reflux along the entire length, which contributed to rapid healing of the trophic ulcer, relief of varicose disease symptoms, and significant improvement of the patient's quality of life. This clinical case report indicates the possibility of application of retrograde endovenous mechanochemical ablation in a patient with varicose disease, axial reflux and open venous ulcer (C6) and warrants further research in this direction.

Early results of mechanochemical ablation for small saphenous vein incompetency using 2% polidocanol

OBJECTIVE

The aim of the present study was to investigate the early results of mechanochemical ablation (MOCA) for the treatment of small saphenous vein (SSV) incompetence.

METHODS

We performed a single-center, retrospective analysis of a prospectively collected database of 60 patients treated with MOCA for single-axis SSV incompetence. All procedures were performed with the patient under local anesthesia using the ClariVein catheter (Merit Medical, South Jordan, Utah) combined with 2% polidocanol and, where appropriate, additional microphlebectomy. The primary study endpoint was to assess the SSV occlusion rate at the 1-, 6-, and 12-month follow-up examinations. The secondary endpoints included the Venous Clinical Severity Score, quality of life (QoL) assessment, periprocedural pain, and further complications after the intervention and during the follow-up period. Patient QoL was assessed using the Aberdeen Varicose Vein Questionnaire. Pain was measured using a 100-mm visual analog scale.

RESULTS

Technical success was achieved in 100% of the cases. The mean visual analog scale score on the first postoperative day was 15 mm. No major events were recorded. No neurological complications or deep vein thrombosis were observed. Minor complications included ecchymosis in 3.3% of cases (2 of 60), transient phlebitis of the SSV in 5% of cases (3 of 60), and itching in 3.3% of cases (2 of 60). At the 1-, 6-, and 12-month follow-up examinations, the occlusion rate was 100% (60 of 60), 98.3% (57 of 58), and 92.6% (50 of 54). The median Venous Clinical Severity Score had significantly decreased from 5 (interquartile range [IQR], 3-6) at baseline to 2 (IQR, 1-4) at the 1-month follow-up (P < .001), 1 (IQR, 1-2) at the 6-month follow-up (P < .001) and 1 (IQR, 0-1) at the 12-month follow-up (P < .001). The mean Aberdeen Varicose Vein Questionnaire score had improved from the baseline score of 25 ± 14.61 to 15.81 ± 13.76 at the 1-month follow-up (P < .001), to 9.81 ± 7.42 at the 6-month follow-up (P < .001) and 4.73 ± 3.32 at the 12-month follow-up (P < .001).

CONCLUSIONS

The results of our study have shown that MOCA is a feasible, safe, and painless procedure for the treatment of SSV incompetence with an occlusion rate of 92.6% at the 12-month examination. No sural nerve injuries or other major complications were observed. The procedure also provided good clinical results and positive effects on patient QoL.

Endovenous laser ablation: A comprehensive review

OBJECTIVE

To provide an evidence-based overview of endovenous laser ablation and describe its role as an effective and durable technique for the management of superficial venous insufficiency.

METHODS

The published literature on the treatment of varicose veins using endovenous laser ablation was reviewed. The literature search focused on the history of endovenous laser ablation, its safety and durability, known complications, and differences in outcomes based on the iterations of fiber type and laser wavelength.

RESULTS

Treatment safety and efficacy of endovenous laser ablation appear to be based on the amount of energy administered over a defined distance, or the linear endovenous energy density. The ideal linear endovenous energy density varies with the laser wavelength and fiber-type. Post-operative pain and bruising may be reduced by the use of higher wavelength fibers or the use of radial or jacket-tip fibers as compared to bare-tip fibers. The incidence of endothermal heat-induced thrombosis remains low and has declined with increasing experience. Reports have demonstrated a greater than 90% technical success rate with saphenous endovenous laser ablation, long-term durability of ablation, and commensurate improvement in quality of life.

CONCLUSIONS

Endovenous laser ablation is a safe and durable treatment option for the management of incompetent superficial and perforator veins of the lower extremities. As an endothermal technology, it remains a key component of the standard of care for the treatment of chronic venous insufficiency.

Early results of an Asian prospective multicenter VenaSeal real-world postmarket evaluation to investigate the efficacy and safety of cyanoacrylate endovenous ablation for varicose veins

OBJECTIVE

The aim of A Singapore VenaSeal Real-World Post-Market Evaluation Study (ASVS) was to evaluate the performance of cyanoacrylate closure (CAC) for varicose veins in a prospective multiracial Singaporean Asian cohort. We report early clinical and patient satisfaction outcomes at 3 months after intervention.

METHODS

There were 100 patients (151 legs; 156 truncal veins) who underwent CAC between April and December 2018. Of the 151 legs, 49 (32.5%) were treated for great saphenous vein (GSV) incompetence, 96 (63.6%) for bilateral GSV incompetence, 1 (0.7%) for small saphenous vein (SSV) incompetence, and 5 (3.3%) for combined unilateral GSV and SSV reflux. At baseline, 68 legs (45.0%) had C4 to C6 disease, and 67 legs (44.4%) had concomitant multiple stab avulsions. Patients were reviewed at 2 and 12 weeks by duplex ultrasound to check for venous recanalization (defined as ≥5 cm in length), pain score, revised Venous Clinical Severity Score, EuroQol-5 Dimension questionnaire score, Aberdeen Varicose Vein Questionnaire score, 14-item Chronic Venous Insufficiency Questionnaire (CIVIQ-14) for quality of life measures, and patient satisfaction. Time to return to work and normal activities were also recorded.

RESULTS

There were 59 female patients, and mean age was 60.1 ± 12.7 years. There was 100% technical success. Patients tolerated the procedure well and reported low periprocedural pain (mean pain score, 2.9 [range, 0-9]). Patient surveys at the 3-month interval showed high satisfaction rates, with 72 of 91 (79.1%) being extremely or very satisfied. By day 10, of 100 patients, 93 (93%) resumed daily activities, whereas 36 (36%) had returned to work. At 2 weeks, GSV and SSV were completely occluded in 150 of 150 (100%) and 6 of 6 (100%) veins, respectively. At 3 months, GSV and SSV occlusion rates were 140 of 141 (99.3%) and 6 of 6 (100%), respectively. Transient superficial phlebitis was reported in 27 of 151 (18 %) legs, which was self-limited. At 3 months, revised Venous Clinical Severity Score improved from 5.00 (range, 1.00-18.00) to 1.00 (0.00-10.00; P < .001); EuroQol-5 Dimension score, from 0.686 (-0.382 to 1.00) to 1.00 (0.12-1.00; P < .001); Aberdeen Varicose Vein Questionnaire score, from 17.14 (1.29-61.15) to 4.83 (0.00-57.12; P < .001); and 14-item Chronic Venous Insufficiency Questionnaire, from 19.64 (1.79-73.21) to 7.14 (0.00-51.79; P < .001).

CONCLUSIONS

CAC has a high safety profile and is an effective way to block refluxing truncal veins in Asian patients at early follow-up. Patients are highly satisfied and report low postoperative pain. There is significant continued quality of life improvement at 3 months. Early results are encouraging, but we await further prospective long-term follow-up from the study.

Randomized clinical trial of mechanochemical and endovenous thermal ablation of great saphenous varicose veins

BACKGROUND

A variety of minimally invasive techniques are available for the treatment of varicose great saphenous vein (GSVs). Non-tumescent, non-thermal ablation methods have been developed. This study compared mechanochemical ablation (MOCA), a non-tumescent, non-thermal ablation technique, with two endovenous thermal ablation methods requiring tumescence in an RCT.

METHODS

Patients with GSV reflux were randomized to undergo MOCA, or thermal ablation with endovenous laser (EVLA) or radiofrequency (RFA). The primary outcome measure was the occlusion rate of the GSV at 1 year.

RESULTS

The study finally included 125 patients, of whom 117 (93·6 per cent) attended 1-year follow-up. At 1 year, the treated part of the GSV was fully occluded in all patients in the EVLA and RFA groups, and in 45 of 55 in the MOCA group (occlusion rates 100, 100 and 82 per cent respectively; P = 0·002). The preoperative GSV diameter was associated with the recanalization rate of the proximal GSV in the MOCA group. At 1 year after treatment, disease-specific life quality was similar in the three groups.

CONCLUSION

The GSV occlusion rate 1 year after treatment was significantly higher after EVLA and RFA than after MOCA. Quality of life was similar between interventions. Registration number: NCT03722134 (http://www.clinicaltrials.gov).

Commonly Used Endovenous Laser Ablation (EVLA) Parameters Do Not Influence Efficacy: Results of a Systematic Review and Meta-Analysis

OBJECTIVES

The objective of this systematic review and meta-analysis was to summarise available randomised controlled trials (RCTs) of EVLA efficacy, and to define the differences in success rate of variations in wavelength, administered energy, outcome definition, and follow up period.

METHODS

A literature search was conducted in Embase, Medline (Ovid-SP), Cochrane Central Database, and Web of Science from inception to November 2017. RCTs with follow up of more than three months were included. The studied outcome was the proportion of patients with EVLA treatment success, defined as absence of reflux or occlusion of the great saphenous vein (GSV). Pooled proportions of anatomical success were compared. Subgroup and meta-regression analysis included wavelengths (short [810, 940, and 980 nm], long [1470, 1500, and 1920 nm]), amount of energy (≤50 J/cm, > 50 J/cm), follow up (≤1 year, > 1 year), outcome definition (occlusion, no reflux), and quality of the studies (low risk of bias, unclear/high risk of bias).

RESULTS

Twenty-eight RCTs, with a total of 2829 GSVs were included. The overall success rate of EVLA was 92% (95% CI 90-94%, I² = 68%). In subgroup analysis, no statistically significant differences were found for long or short wavelengths (95% [95% CI 91-97%] vs. 92% [95% CI 89-94%], p = .15), high or low administered energy (93% [95% CI 89-95%] vs. 92% [95% CI 90-94%], p = .99), long or short follow up (89% [95% CI 84-93%] vs. 93% [95% CI 91-95%], p = .13) and outcome definition (occlusion group 94% [95% CI 91-96%] vs. absence of reflux group 91% [95% CI 87-94%], p = .26). Studies with low risk of bias reported a significantly higher success rate than high or unclear risk of bias (93% [95% CI 90-95%] vs. 89% [95% CI 83-93%], p = .04).

CONCLUSIONS

The overall success rate of EVLA is high (92%), even with increasing follow up. Commonly used parameters of EVLA (wavelength, administered energy, and outcome definition) have no influence on the treatment success rate.

Photoacoustic Imaging for Image-guided Endovenous Laser Ablation Procedures

Accurate fiber tip tracking is a critical clinical problem during endovenous laser ablation (EVLA) of small perforating veins. Currently, ultrasound (US) imaging is the gold-standard modality for visualizing and for accurately placing the ablation fiber within the diseased vein. However, US imaging has limitations such as angular dependency and comet tail artifacts. In addition, EVLA is often performed without any real-time temperature monitoring, which could lead to an insufficient thermal dose or overheating the surrounding tissue. We propose a new technique that combines US and photoacoustic (PA) imaging for concurrent ablation fiber tip tracking and real-time temperature monitoring during EVLA procedures. Our intended implementation of PA imaging for fiber tracking requires minimal modification of existing systems, which makes this technology easy to adopt. Combining US and PA imaging modalities allows for simultaneous visualization of background anatomical structures as well as high contrast, artifact-free, and angle-independent localization of the ablation fiber tip. Preliminary data demonstrates that changes in the amplitude of the PA signal can be used to monitor the localized temperature at the tip of the ablation fiber, which will be invaluable during EVLA procedures. These improvements can enhance the physician's accuracy in performing EVLA procedures and will have a significant impact on the treatment outcomes.

Evidence for varicose vein treatment: an overview of systematic reviews

BACKGROUND

Varicose veins affect nearly 30% of the world's population. This condition is a social problem and needs interventions to improve quality of life and reduce risks. Recently, new and less invasive methods for varicose vein treatment have emerged. There is a need to define the best treatment options and to reduce the risks and costs. Since there are cosmetic implications, treatments for which effectiveness remains unproven present risks to consumers and higher costs for stakeholders. These risks and costs justify conducting an overview of systematic reviews to summarize the evidence.

DESIGN AND SETTING

Overview of systematic reviews within the Discipline of Evidence-Based Health, at Universidade Federal de São Paulo (UNIFESP).

METHODS

Systematic reviews on clinical or surgical treatments for varicose veins were included, with no restrictions on language or publication date.

RESULTS

51 reviews fulfilled the inclusion criteria. Outcomes and comparators were described, and a narrative review was conducted. Overall, there was no evidence that compression stockings should be recommended for patients as the initial treatment or after surgical interventions. There was low to moderate evidence that minimally invasive therapies (endovenous laser therapy, radiofrequency ablation or foam sclerotherapy) are as safe and effective as conventional surgery (ligation and stripping). Among these systematic reviews, only 18 were judged to present high quality.

CONCLUSIONS

There was evidence of low to moderate quality that minimally invasive treatments, including foam sclerotherapy, laser and radiofrequency therapy are comparable to conventional surgery, regarding effectiveness and safety for treatment of varicose veins.

Evaluation of pain during endovenous laser ablation of the great saphenous vein with ultrasound-guided femoral nerve block

Background

Endoluminal laser ablation is now considered the method of choice for treating greater saphenous vein insufficiency. General anesthesia and peripheral nerve blocks with sedation have the risk of post-procedural delay in discharge and prolonged immobilization with the risk of deep vein thrombosis. The main pain experienced by patients during the procedure is during the laser ablation and the multiple needle punctures given along and around the great saphenous vein. The aim of our study was to evaluate the safety and efficacy of blocking the femoral nerve only under ultrasound-guidance without sedation, to reduce or prevent pain during injectable tumescent anesthesia in endovenous laser ablation of the greater saphenous vein.

Methods

Sixty patients in two groups underwent endovenous laser ablation for the greater saphenous vein insufficiency at an outpatient clinic. All patients received tumescent anesthesia. However, one group received a femoral nerve block (FNB) under ultrasound guidance before the procedure. All patients were asked to record the pain or discomfort, using the visual analog score, from the start of the procedure until the end of the great saphenous vein laser ablation. The length of the great saphenous vein and duration of the procedure were also recorded. The results were analyzed using statistical methods.

Results

No complications from FNB were observed. The pain associated with application of tumescent anesthesia and laser ablation was more intense in the group without an FNB (P < 0.001). There was no significant difference between the two groups in the length of the great saphenous vein or procedure duration.

Conclusion

Ultrasound-guided FNB (without other peripheral nerve blocks) is a safe, adequate, and effective option to decrease and/or eliminate the intraoperative discomfort associated with tumescent anesthesia injections and laser ablation during endoluminal laser ablation of the greater saphenous vein.

Technique, Efficiency and Safety of Different Nerve Blocks for Analgesia in Laser Ablation and Sclerotherapy for Lower Limb Superficial Venous Insufficiency - A Multicentre Experience

INTRODUCTION

Laser ablation and sclerotherapy, as minimally invasive alternatives to surgery for varicose veins, have good efficacy, safety and cosmetic result. Some form of anaesthesia is generally used for pain control.

AIM

To describe the technique and evaluate the efficacy and safety of femoral, saphenous and sciatic nerve blocks in isolation or in combination for analgesia during laser ablation and sclerotherapy for lower limb varicose veins.

MATERIALS AND METHODS

In this prospective observational study, over a period of 33 months, in 856 limbs of 681 patients with varicose veins, ultrasound guided femoral, saphenous and sciatic nerve blocks for analgesia were performed in 769, 808 and 52 instances respectively; following which, endovenous laser ablation, sclerotherapy or combination of both were carried out using standard practice. After completion of the procedure, Visual Analogue Pain Scale (VAS) was used for pain assessment, and muscle weakness was assessed clinically.

RESULTS

Nerve blocks could be successfully performed in all patients. Observed pain scores were 0 or 1 in 591 (69%), 2 or 3 in 214 (25%) and 4 in 51 (9%) legs with no score more than 4. Higher grades of pain were noted in femoral blocks during early stages of our learning curve. Mild to moderate muscle weakness was observed in 163 (2%) and 7 (13%) patients who underwent femoral and sciatic block respectively, which persisted for an average of two and a half hours and none beyond four and a half hours; saphenous nerve being a pure sensory nerve, did not cause motor weakness.

CONCLUSION

For analgesia during laser ablation and/or sclerotherapy of varicose veins, ultrasound guided nerve blocks can be easily and quickly performed. They provide excellent pain relief and comfort to the patient and to the operator; and they do not cause any additional complication.

Endovenous laser ablation therapy in children: applications and outcomes

BACKGROUND

Endovenous laser ablation is well recognized as the first-line treatment for superficial venous reflux with varicose veins in adults. It is not widely reported and is not an established practice in pediatric patients.

OBJECTIVE

To illustrate a variety of pediatric venous conditions in which endovenous laser ablation can be utilized and to demonstrate its feasibility and safety in children.

MATERIALS AND METHODS

We conducted a retrospective review of endovenous laser ablation procedures performed between January 2007 and July 2014 at two large pediatric institutions.

RESULTS

We included 35 patients (17 males) who underwent endovenous laser ablation to 43 veins. Median age at first treatment was 14 years (range: 3-18 years). Median weight was 56 kg (range: 19-97 kg). Underlying diagnoses were common venous malformation (15), Klippel-Trenaunay syndrome (8), superficial venous reflux with varicose veins (5), verrucous hemangioma-related phlebectasia (4), venous varix (2) and arteriovenous fistula (1). The most common aim of treatment was to facilitate sclerotherapy. Thirty-four patients had treatment in the lower limbs and one patient in an upper limb. Ten of the veins treated with endovenous laser ablation had an additional procedure performed to close the vein. Complications attributable to endovenous laser ablation occurred in two patients (6%). One patient experienced post-procedural pain and one patient developed a temporary sensory nerve injury. Median clinical follow-up was 13 months (range: 28 days-5.7 years). The aim of the treatment was achieved in 29 of the 35 (83%) patients.

CONCLUSION

Endovenous laser ablation is technically feasible and safe in children. It can be used in the management of a range of pediatric venous diseases with good outcomes.

Morphological Comparison of Blood Vessels that were Heated with a Radiofrequency Device or a 1470-nm Laser and a Radial 2Ring Fiber

Introduction: Radio waves and lasers can be used as heat sources during endovenous thermal ablation (EVTA) for saphenous vein insufficiency. A morphological comparison of veins that had been treated with EVTA was performed between those treated with an endovenous closure system (a radiofrequency [RF] system) and those treated with a Radial 2Ring fiber connected to a 1470-nm laser generator (2R). Methods: The experiment was conducted in a system that reproduces the physiological conditions found in the saphenous veins during EVTA. The 2R experiment was performed at two different power levels, 60 J/cm (2R-60) and 90 J/cm (2R-90). The heated vessels were morphologically examined in detail, and the detected morphological changes were classified into three groups: low-temperature changes (LTC), mid-temperature changes (MTC), and high-temperature changes (HTC). The thickness of the layers exhibiting each type of change was measured. Results: In the 2R groups, HTC, MTC, and LTC were observed from the superficial to deep layers. In the 2R-60 group, the layers exhibiting LTC, MTC, and HTC were 17 ± 3.2, 42 ± 10.5, and 190 ± 14.6 µm thick, respectively. In the 2R-90 group, these layers were 14 ± 4.0, 105 ± 64.2, and 363 ± 71.3 µm thick, respectively. In the RF group, only LTC were observed (thickness: 251 ± 72.6 µm). Conclusions: The RF device was able to heat the target vessels more efficiently than the laser device. (This article is a translation of Jpn J Phlebol 2015; 26: 23-8.).

Fatal pulmonary embolism following ultrasound-guided foam sclerotherapy combined with multiple microphlebectomies

Ambulatory ultrasound-guided foam sclerotherapy (UGFS) for refluxing saphenous veins is considered a safe therapy. Venous thromboembolic complications after UGFS as well as after all other ambulatory ablative venous interventions are rarely reported. This paper reports a fatal pulmonary embolism (PE) following UGFS in combination with an extended phlebectomy, and questions what measures should be taken to minimize the risk for thromboembolic complications after these procedures. In the reported case (unsuspected), extensive non-occluding atherosclerosis as well as obesity in combination with use of an oral contraceptive might have contributed to the development of the PE while the use of a β-blocker might have increased its fatal course considerably. Routine measurement of the ankle-brachial pressure index reduces the risk for undetected atherosclerosis. It appears that ‘in the real world’ of ambulatory phlebological treatments thromboembolic complications are more common (2.4–4.7%) and appear accompanied by post-procedural mortality. It is concluded therefore that pharmacological thromboprophylaxis appears warranted in selected cases, perhaps even routine application could be considered. Attention is drawn to the highly thrombogenic but not uncommon combination of overweight and use of oral contraceptive. Apart from applying some form of pharmacological thromboprophylaxis, technical adaptations that might prevent or reduce spill over of foam into the deep venous system should be considered. Firstly, next to adherence to the generally accepted maximum of 10 mL of foam per session, it seems prudent to maximize the injected volume of foam per site. Secondly, it seems best to inject the foam in an elevated leg without groin compression. The concentration of the sclerosant does not appear decisive in this respect, although higher concentrations appear more effective and therefore might be injected in lower volumes without compromising efficacy.

ClariVein® - Early results from a large single-centre series of mechanochemical endovenous ablation for varicose veins

Objectives

This study assessed the effectiveness and patient experience of the ClariVein® endovenous occlusion catheter for varicose veins from a large single-centre series in the UK.

Methods

A total of 300 patients (371 legs) underwent ClariVein® treatment for their varicose veins; 184 for great saphenous vein (GSV) incompetence, 62 bilateral GSV, 23 short saphenous vein (SSV), 6 bilateral SSV and 25 combined unilateral great saphenous vein and SSV. Patients were reviewed at an interval of two months post procedure and underwent Duplex ultrasound assessment. Postoperative complications were recorded along with patient satisfaction.

Results

All 393 procedures were completed successfully under local anaesthetic. Complete occlusion of the treated vein was initially achieved in all the patients, but at eight weeks’ follow-up, there was only partial obliteration in 13/393 (3.3%) veins. These were all successfully treated with ultrasound-guided foam sclerotherapy. Procedures were well tolerated with a mean pain score of 0.8 (0–10). No significant complications were reported.

Conclusions

ClariVein® can be used to ablate long and short saphenous varicose veins on a walk-in–walk-out basis. Bilateral procedures can be successfully performed, and these are well tolerated as can multiple veins in the same leg. Early results are promising but further evaluation and longer term follow-up are required.

The Efficacy of Femoral Block and Unilateral Spinal Anaesthesia on Analgesia, Haemodynamics and Mobilization in Patients undergoing Endovenous Ablation in the Lower Extremity

OBJECTIVE

This study aimed to investigate the efficacy of femoral block and unilateral spinal anaesthesia on analgesia, haemodynamics and mobilization during endovenous ablation in patients with lower extremity venous insufficiency.

METHODS

Forty patients of ASA physical status I and II, with ages ranging between 30 and 45 years, and who were scheduled for endovenous laser ablation for varicose veins were prospectively enrolled in this study. Patients were randomized into a unilateral spinal anaesthesia group (group HS, n=20) or a femoral block group (group F, n=20). Group HS received 7.5-10 mg of heavy bupivacaine for unilateral spinal anaesthesia, while group F received 100 mg prilocaine for femoral block with ultrasound guidance. The level of motor blockage (Bromage score), visual pain score, mean heart rate and mean arterial pressures were recorded at postoperative 0, 1, 2, 3d and 6 h, respectively.

RESULTS

Perioperative visual pain score values in both groups were <4. None of the groups required an additional analgesic agent. Bromage scores were significantly lower in group F than in group HS during the postoperative period (p<0.01). Motor function returned to normal in all patients at 3 h in group F and at 6 h in group HS. Postoperative mean heart rate and arterial pressure did not differ between the groups (p>0.05).

CONCLUSION

In patients with lower extremity venous insufficiency who were undergoing endovenous laser ablation, an ultrasound-guided femoral block provided similar analgesia with that of unilateral spinal anaesthesia. In group F, the duration of anaesthesia and mobilization time was shorter.

Obesity and lower limb venous disease - The epidemic of phlebesity

Introduction Lower limb venous disease affects up to one half, and obesity up to one quarter, of the adult population. Many people are therefore affected by, and present to health services for the treatment of both conditions. This article reviews the available evidence of pathophysiological and clinical relationship between obesity and varicose veins, chronic venous insufficiency and ulceration and deep vein thrombosis. Methods A literature search of PubMed and Cochrane libraries was performed in accordance with PRISMA statement from 1946 to 2015, with further article identification from following cited references for articles examining the relationship between obesity and venous disease. Search terms included obesity, overweight, thrombosis, varicose veins, CEAP, chronic venous insufficiency, treatment, endovenous, endothermal, sclerotherapy, bariatric surgery and deep vein thrombosis. Results The proportion of the population suffering from lower limb venous disease and obesity is increasing. Obesity is an important risk factor for all types of lower limb venous disease, and obese patients with lower limb venous disease are more likely to be symptomatic as a result of their lower limb venous disease. The clinical diagnosis, investigation, imaging and treatment of lower limb venous disease in obese people present a number of challenges. The evidence base underpinning medical, surgical and endovenous management of lower limb venous disease in obese people is limited and such treatment may be associated with worse outcomes and increased risks when compared to patients with a normal body mass index. Conclusion Lower limb venous disease and obesity are both increasingly common. As such, phlebologists will be treating ever greater numbers of obese patients with lower limb venous disease, and clinicians in many other specialties are going to be treating a wide range of obesity-related health problems in people with or at risk of lower limb venous disease. Unfortunately, obese people have been specifically excluded from many, if not most, of the pivotal studies. As such, many basic questions remain unanswered and there is an urgent need for research in this challenging and increasingly prevalent patient group.

ClariVein® - Early results from a large single-centre series of mechanochemical endovenous ablation for varicose veins

Objectives This study assessed the effectiveness and patient experience of the ClariVein® endovenous occlusion catheter for varicose veins from a large single-centre series in the UK. Methods A total of 300 patients (371 legs) underwent ClariVein® treatment for their varicose veins; 184 for great saphenous vein (GSV) incompetence, 62 bilateral GSV, 23 short saphenous vein (SSV), 6 bilateral SSV and 25 combined unilateral great saphenous vein and SSV. Patients were reviewed at an interval of two months post procedure and underwent Duplex ultrasound assessment. Postoperative complications were recorded along with patient satisfaction. Results All 393 procedures were completed successfully under local anaesthetic. Complete occlusion of the treated vein was initially achieved in all the patients, but at eight weeks' follow-up, there was only partial obliteration in 13/393 (3.3%) veins. These were all successfully treated with ultrasound-guided foam sclerotherapy. Procedures were well tolerated with a mean pain score of 0.8 (0-10). No significant complications were reported. Conclusions ClariVein® can be used to ablate long and short saphenous varicose veins on a walk-in-walk-out basis. Bilateral procedures can be successfully performed, and these are well tolerated as can multiple veins in the same leg. Early results are promising but further evaluation and longer term follow-up are required.

Clinical results of endovenous LASER ablation (EVLA) using low linear endovenous energy density (LEED) combined with high ligation for great saphenous varicose veins

PURPOSE

This study was designed to analyze the efficacy and complications in endovenous LASER ablation (EVLA) with 1470 nm diode lasers using low linear endovenous energy density (LEED) combined with high ligation for varicose veins of the great saphenous vein (GSV).

METHODS

One hundred and sixteen limbs of 102 patients were analyzed using 6 W with 2 mm/s constant pullback speed delivered by 30 J/cm LEED. The SFJ was ligated with a small inguinal incision. The complications and status of the GSV were checked at 1 and 6 months postoperatively.

RESULTS

The occlusion rates for the GSV were 98 (84.5 %) at 1 month and 116 (100 %) at 6 months, postoperatively. The rate of partial occlusion was higher in males than in females (p = 0.004). There were 2 DVT, 27 feelings of the cord (23.3 %), and 36 numbness at the knee area (31.0 %) at 1 month, and 3 feelings of the cord (3.4 %) and 6 numbness of the knee (8.6 %) at 6 months postoperatively. The diameter and depth of the GSV did not affect the rates of feeling of the cord or numbness (p = 0.728, 0.208, 0.247, 0.884, respectively).

CONCLUSION

EVLA with a 1470-nm diode laser using low LEED combined with high ligation for the GSV has lower complication rates and higher occlusion rates of GSV.

Randomized clinical trial of 940- versus 1470-nm endovenous laser ablation for great saphenous vein incompetence

Background

The independent effect of wavelength used for endovenous laser ablation (EVLA) on patient-reported outcomes, health-related quality of life (HRQoL), treatment success and complications has not yet been established in a randomized clinical trial. The aim was to compare two different wavelengths, with identical energy level and laser fibres, in patients undergoing EVLA.

Methods

Patients with great saphenous vein incompetence were randomized to receive 940- or 1470-nm EVLA. The primary outcome was pain at 1 week. Secondary outcomes were: patient satisfaction, duration of analgesia use and time without normal activities assessed at 1 week; HRQoL after 12 weeks; treatment success after 12 and 52 weeks; change in Venous Clinical Severity Score (VCSS) after 12 weeks; and adverse events at 1 and 12 weeks.

Results

A total of 142 legs were randomized (940-nm EVLA, 70; 1470-nm EVLA, 72). Patients in the 1470-nm laser group reported significantly less pain on a visual analogue scale than those in the 940-nm laser group: median (i.q.r.) score 3 (2–7) versus 6 (3–8) (P = 0·004). Duration of analgesia use was significantly shorter after 1470-nm EVLA: median (i.q.r.) 1 (0–3) versus 2 (0–5) days (P = 0·037). HRQoL and VCSS improved equally in both groups. There was no difference in treatment success rates. Complications were comparable in both groups, except for more superficial vein thrombosis 1 week after 1470-nm EVLA.

Conclusion

EVLA using a 1470-nm wavelength fibre was associated with improved postoperative pain and a reduction in analgesia use in the first week after surgery compared with use of a 940-nm fibre. Treatment success and adverse event rates were similar. Registration number: NCT01637181 (http://www.clinicaltrials.gov).