Safety and efficiency of perilesional sclerotherapy in leg ulcer patients with postthrombotic syndrome and/or oral anticoagulation with phenprocoumon

Axial Ablation versus Terminal Interruption of the Reflux Source (AAVTIRS): A Randomised Controlled Trial

INTRODUCTION

Treatment of reflux has been shown to improve time to healing of Venous Leg Ulcers (VLU). Terminal Interruption of the Reflux Source (TIRS) treats reflux within the plexus of veins around an active VLU using foam sclerotherapy. The efficacy of TIRS in managing VLU has never been tested.

METHODS

We performed a pragmatic, single centre, assessor-blinded, randomised controlled trial comparing endovenous ablation of the axial superficial veins (Axial Ablation-AA) vs TIRS. Patients of any age with VLU of any duration were eligible.

RESULTS

98 Participants were randomised to AA or TIRS. 39/55, 70.9% (95%CI; 57.1-82.37) healed their VLU in the AA group, while 29/39, 74.36% (95%CI; 57.87-86.96) healed their VLU in the TIRS group, P = 0.45.4 were lost to follow-up. Median time to ulcer healing was 84 days (95%CI; 74.67-93.33) in the axial ablation group and 84 days (95%CI; 73.02-94.98) in the TIRS group. Hazard Ratio for ulcer healing with AA vs TIRS was 0.96 (95%CI 0.59-1.56). There were no significant quality of life differences.

CONCLUSION

The AAVTIRS trial did not show that axial ablation was superior to TIRS in the primary outcome of number of VLU healed in 6 months, or time to VLU healing. This trial is not powered to show non-inferiority. TIRS is a viable option for treatment of VLU. Further investigation is necessary before it can be recommended as an alternative to axial ablation.Trial registered at clinicaltrials.gov NCT04484168.

Factors associated with recanalization and reintervention following below knee polidocanol endovenous microfoam ablation for great saphenous and small saphenous veins

BACKGROUND

Polidocanol endovenous microfoam (PEM) has been used to treat lower extremity venous reflux for almost one decade with specific advantages for below knee (BK) truncal veins where thermal ablation poses a risk of injury to adjacent nerves. The current literature of the BK segment often examines short-term outcomes with modest sample sizes. We aim to identify factors associated with recanalization and reintervention in this subset of patients.

METHODS

We performed a retrospective study of a prospectively maintained database of patients from a single institution who underwent 1% PEM ablation for BK great saphenous vein (GSV) and small saphenous vein (SSV) reflux. Patients underwent duplex ultrasound (DU) within 7 days after injection, every 3 to 6 months for 1 year, and every 6 to 12 months thereafter. Patients with symptomatic recanalization underwent reintervention. The 26 patients lost to follow-up without DU after ablation were excluded. The factors associated with recanalization and reintervention were examined by multivariate and nonparametric analyses.

RESULTS

Between March 2018 and July 2023, 411 patients (166 male, 245 female) with 573 treated limbs (284 right, 289 left) met the study criteria. Of the 573 included limbs, 457 (79.8%) had undergone prior above knee saphenous ablations. A total of 554 BK GSV and 42 SSV ablations were performed. The most recent DU was performed at a mean of 231 ± 329 days. The overall recanalization rate was 10.6% (55 GSVs and 8 SSVs) at a mean follow-up of 104 ± 180 days. Comparing the closed and recanalized veins, we found no significant difference in age (P = .90), treated laterality (P = .14), patient body mass index (P = .59), preprocedural CEAP (clinical-etiology-anatomy-pathophysiology) score (P = .79), recanalization rate in GSVs vs SSVs (P = .06), or administered PEM volume (P = .24). The recanalized veins had significantly larger preprocedural diameters than the veins that remained closed (recanalized, 4.9 mm; closed, 4.3 mm; P = .001). Men had higher incidence of recanalization than women (men, 14.2%; women, 8%; P = .015). Anticoagulation use was associated with recanalization (odds ratio, 1.96; 95% confidence interval, 1.1-3.6; P = .03). Early recanalization at the first DU accounted for 31 failures (49.2%) and had a significantly lower administered PEM volume compared with later recanalization (early, 4 mL; late, 5 mL; P = .025). There were no significant differences between the 33 recanalized patients requiring reintervention (52.4%) and the 30 who did not. Twenty-four reinterventions were performed with PEM, 100% of which remained closed at a median of 160 days (interquartile range, 257 days).

CONCLUSIONS

PEM is successful for the treatment of BK GSV and SSV reflux with a closure rate of 89% at a mean of 231 days and shows promise as salvage therapy. Most cases of recanalization were noted in the early postprocedure period and were associated with a lower PEM volume. A larger vein diameter, male sex, and anticoagulation use are associated with higher rates of recanalization.

Axial ablation versus terminal interruption of the reflux source (AAVTIRS): a randomised controlled trial

BACKGROUND

Treatment of superficial venous reflux has been shown to improve ulcer healing time and reduce the risk of ulcer recurrence. Terminal ablation of the reflux source (TIRS) is an alternative to formal endovenous ablation or surgery which can be performed by injecting sclerosant foam into the peri-ulcer plexus of the veins. TIRS has been shown to be successful and in our experience is the option preferred by many patients, when offered as an alternative to axial ablation (AA).

AIM

To determine if the proportion of ulcers healed within 6 months of endovenous treatment differs between patients undergoing AA of varicose veins or TIRS by peri-ulcer foam sclerotherapy.

METHODS

AAVTIRS is an assessor-blinded randomised controlled trial. Patients will be recruited from a dedicated ulcer clinic in Roscommon University Hospital and from the vascular surgical clinics in University Hospital Galway. All patients attending the ulcer clinic will be screened for eligibility.

RANDOMISATION

Random computer-generated sequence is stratified by ulcer size. Allocation will be concealed using sealed opaque envelopes.

BLINDING

Assessors reviewing wounds at follow -p visits will be blinded to patient allocation.

PRIMARY ENDPOINT

The proportion of ulcers healed within 6 months of enrolment.

DISCUSSION

This will be the first time that TIRS has been evaluated with a properly powered randomised trial in the setting of venous ulcer management. Streamlining the management of venous ulcers has broad health economic benefits. If it is found that TIRS is superior or non-inferior to AA, then a less expensive, less invasive injection can be offered as an alternative to AA in an attempt to encourage the healing of venous ulcers. If AA is found to be superior to TIRS, then this would suggest that all patients undergoing ablation in the management of venous ulcers should have their superficial reflux fully treated, building on the evidence of the EVRA trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04484168. Registered on 23 July 2020.

[Venous ulcus cruris-Surgical treatment]

Venous ulcus cruris is usually a chronic disease and an extreme burden for patients and their families. An analysis based on a random statutory health insurance sample of the AOK Hessen/KV Hessen estimated the number of affected people to be 400,000 in Germany. A venous ulcus cruris is always caused by an underlying chronic venous insufficiency (CVI). A spontaneous healing of this chronic disease without treatment is not to be expected. The conservative treatment includes an adequate compression treatment and exudate management. Surgical treatment is based on three pillars: an open surgical or endovenous approach to resolve the pathological venous reflux, uIcer surgery and in rare cases the various procedures of fascia surgery as well as defect coverage by a combination of negative pressure wound therapy and skin transplantation.

[Specific indications for foam sclerotherapy]

BACKGROUND

Foam sclerotherapy is well established in the treatment of varicose veins of different sizes.

METHODS

A literature review was performed to determine which specific indications for foam sclerotherapy exist.

RESULTS

Treatment of venous leg ulcers, varices that might rupture, varicose veins in geriatric patients, pudendal veins and seroma could be determined as specific indications for foam sclerotherapy.

CONCLUSION

In some indications, foam sclerotherapy is the treatment option of first choice. It is an effective and safe treatment option.

[Practical Aspects of Sclerotherapy]

Sclerotherapy is an important part of the treatment of varicose veins. It may also be performed in patients with contraindications for operative procedures. By adjusting the mode of application (liquid or foam) and the concentration it can be used for the treatment of all vein types. In comparison to other treatment options it is especially well suited for the treatment of spider veins and reticular veins, pudendal varicosity and so called "feeding" varicose veins in the proximity of venous leg ulcers. A current European guideline, which was approved by 23 European phlebologic societies, supports the good international standardization of this treatment technique.

Indications, contraindications and performance: European Guidelines for Sclerotherapy in Chronic Venous Disorders

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7th – 10th May 2012 in Mainz. The conference was organized by the German Society of Phlebology.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, Polidocanol (POL) and Sodium tetradecyl sulphate (STS). Other sclerosants are not discussed in detail. In this paper the recommendations concerning indications, contraindications, concentrations, volumes and technique of liquid and foam sclerotherapy of varicose veins and venous malformations are reviewed.

Results from RCTs in Sclerotherapy: European Guidelines for Sclerotherapy in Chronic Venous Disorders*

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7th–10th May 2012 in Mainz. The conference was organized by the German Society of Phlebology.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, Polidocanol (POL) and Sodium tetradecyl sulphate (STS). Other sclerosants are not discussed in detail. In this paper the results from recent RCTs in sclerotherapy are reviewed.

Sclerotherapy of varicose veins in dermatology

Venous disorders rank among the most frequent diseases in the German population. Early diagnostic investigation and treatment can prevent their progression and may reduce the risk for secondary diseases. The therapeutic spectrum for varicose veins includes conservative as well as interventional and surgical methods. Because it is minimally invasive and well-tolerated, sclerotherapy represents an important treatment method for venous insufficiency, recurrent varicosis and venous malformations. We review the role of sclerotherapy as a treatment option of chronic venous insufficiency in dermatology.

European guidelines for sclerotherapy in chronic venous disorders

Aim

Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy.

Methods

This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7–10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines.

Results

This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

[Therapy of venous leg ulcers. New and established approaches]

Venous leg ulcers are the most severe complication of chronic venous insufficiency. Based on the pathogenesis and the clinical evidence, the first step in treating a venous leg ulcer should be the treatment of the venous insufficiency. According to the guidelines of the German Society of Phlebology, several methods are available: the surgical or interventional therapy of varicosities, the stenting of stenotic pelvic veins in a post-thrombotic syndrome, direct surgical intervention at the ulcer as excision, debridement or fasciotomy. In the case of an arthrogenic venous stasis syndrome, physical therapy can be helpful. Additionally wound dressings, medicinal therapy and reduction of pain are relevant.There is a good level of evidence only for sufficient compression therapy and elimination of varicosities by surgery or sclerotherapy.

Differential diagnosis and therapy of leg ulcers

A leg ulcer is a symptom and the treating physician needs to find out its origin by differential diagnostic approaches and procedures. The correct diagnosis leads to a specific therapy that ideally accelerates the healing of the ulceration. Identifying the pathogenesis of a leg ulcer is the first and main step towards healing. Although vascular diseases are the major causes of leg ulcers, one needs to consider, in addition to venous and arterial disorders, autoimmune, infectious, metabolic and neoplastic causes. The simple truth that one can only make a diagnosis that was considered holds particularly true in leg ulcers. The differential diagnostic considerations presented here appear in the daily routine of a dermatologist and the article provides help in diagnostic approaches and therapeutic decisions.

Evidence-based treatment of chronic leg ulcers

BACKGROUND

Chronic leg ulcers are defined as those that show no tendency to heal after 3 months of appropriate treatment or are still not fully healed at 12 months. In this article, we present an approach to the challenging problem of chronic leg ulcers that is based on the principles of evidence-based medicine, i.e., the explicit use of the best available scientific evidence as a guide to treatment.

METHODS

Selective review of the relevant literature, including current guidelines and meta-analyses, concerning diagnostic and therapeutic strategies for chronic leg ulcers.

RESULTS

The main types of causally directed treatment are: vein surgery to eliminate pathological reflux, interventions to improve the circulation in arterial occlusive disease, and treatment of underlying diseases, such as diabetes mellitus.

CONCLUSION

Physicians providing modern evidence-based management of chronic leg ulcers should make use of their own clinical experience in combination with the best current scientific evidence. It seems clear that the many available treatment options should be evaluated critically in an interdisciplinary setting. In particular, causally directed treatment must be provided in addition to symptomatic, stage-based local wound treatment.

Review of published information on foam sclerotherapy

BACKGROUND

New data on foam sclerotherapy of varicose veins has been recently published.

OBJECTIVE

To identify the current treatment modalities and their effectiveness in use of foam sclerotherapy.

MATERIALS AND METHODS

Review of the recent literature regarding clinical treatment of varicose veins using foam sclerotherapy, with emphasis on safety and efficacy. RESULTS Foam sclerotherapy of the great saphenous vein is more effective than liquid. Higher sclerosant concentrations tend to induce higher occlusion. Catheter-assisted sclerotherapy may further improve occlusion rates. To achieve adequate occlusion, vein diameter and volume of foam must be matched. If a critical foam volume is exceeded, the risk of deep venous thrombosis increases. Foam sclerotherapy offers the possibility of using lower sclerosant concentrations than with liquids. Foam sclerotherapy can also be used in venous malformations and periulcerous tributaries. Side effects are hyperpigmentation, skin necrosis, scotoma, and thromboembolic events. Thromboembolism prophylaxis is necessary only in patients with special risk factors.

CONCLUSION

Foam sclerotherapy has significantly better efficacy than liquid. It is essential to select the correct concentration and the correct foam volume. In the hands of an experienced physician, foam sclerotherapy is a safe and effective option for treating varicose veins.

What do we know of post-thrombotic syndrome? Current status of post-thrombotic syndrome in adults

The post-thrombotic syndrome (PTS) is a common but not completely understood and rarely studied sequela of an acute deep vein thrombosis. The influence of several risk factors on the incidence or severity of PTS is controversial. The therapeutic options for PTS are still limited. Appropriate medical compression stockings can reduce the incidence (-50 %) as well as the severity of PTS. In the case of severe, symptomatic PTS, they should be worn lifelong. As PTS is a chronic and often progressive disease, patients need regular clinical follow-up and encouragement to continuously wear their compression therapy. New strategies for treating PTS are needed.

Integration of patient safety technologies into sclerotherapy for varicose veins

The American College of Surgeons, the Joint Commission, the Needlestick Safety and Prevention Act, and the Occupational Safety and Health Administration all direct surgical departments, including vascular surgeons who supply sclerotherapy services, to develop formal mechanisms to improve the safety of the patient and health care worker (HCW), including integration of new safety technologies. The purpose of the present study was to identify and evaluate new safety technologies for outpatient sclerotherapy for chronic venous disease. Using national resources for patient safety and literature review, the following safety technologies were identified: (1) a safety needle to reduce inadvertent needlesticks to workers, and (2) the reciprocating procedure device (RPD) to reduce iatrogenic injuries to patients. Both devices were evaluated in the clinic, and physician responses were determined. Although the safety sheath of the needle was somewhat bulky and could interfere with the ultrasound transducer, sclerotherapy could be performed with it. The RPD safety device required instruction to show how the RPD functioned ("push-push" to aspirate-inject with the RPD rather than the usual "push-pull" with the conventional syringe), but the RPD permitted better needle control and more precise injections. The RPD was well accepted by physicians who found it to be convenient, safer, and less painful. Subsequently, the involved services successfully integrated these safety technologies into their routine clinical practices. As recommended by the Joint Commission, safety technologies can be successfully evaluated and introduced into the clinic to improve patient and HCW safety during physician-performed syringe and needle procedures, including sclerotherapy.

Foam sclerotherapy — A possible option in therapy of varicose veins

The therapy of varicose veins is multimodal and depends on the individual clinical findings. In addition to compression therapy, invasive approaches for elimination of reflux for the treatment of varicose veins are available, such as surgical and interventional methods and sclerotherapy. The administration of a sclerosing agent into a varicose vein results in an occlusion of the treated vein. Recently the use of foam sclerotherapy had a renaissance. Several studies have documented the efficacy of foam sclerotherapy in selected patients. The possibility of treating patients in an outpatient setting, with low costs and rapidly, makes foam sclerotherapy very attractive compared to invasive and minimally invasive methods. However long-term follow-ups in properly controlled randomized trials are needed before foam sclerotherapy can be recommended as a routine procedure. This paper introduces the method and the treatment possibilities with foam sclerotherapy in chronic venous insufficiency.