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Juhani AA, Abdullah A, Alyaseen EM, Dobel AA, Albashri JS, Alalmaei OM, Salem Alanazi YM, Almutairi DR, Alqahtani LN, Alanazi SA. Interventions for great saphenous vein insufficiency: A systematic review and network meta-analysis. Vascular 2024:17085381241273098. [PMID: 39148483 DOI: 10.1177/17085381241273098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
BACKGROUND Great saphenous vein insufficiency (GSVI) adversely affects the quality of life of affected individuals. Minimally invasive endo-venous ablation techniques have emerged as effective and safe treatments, despite the longstanding use of surgical interventions. We aim in our study to evaluate all the available interventions in the literature, either endo-venous or conventional approaches for the treatment of GSVI. METHODS A thorough search was performed across four electronic databases to identify relevant studies. A frequentist network meta-analysis (NWM) was executed on the combined data to derive network estimates pertaining to the outcomes of concern. Risk ratios (RRs) were employed as the effect size metric for binary outcomes, while mean differences (MDs) were utilized for continuous outcomes, each reported with a 95% confidence interval. The qualitative review was conducted employing the Cochrane risk of bias assessment tool 1. RESULTS Our NWM included 75 studies encompassing 12,196 patients. Regarding technical success rate within the first 5 years after treatment, Endo-venous Laser Ablation (EVLA) with High Ligation and Stripping (HL/S), EVLA alone, Cyanoacrylate Adhesive Injection, cryostripping, HL/S and Radiofrequency Ablation (RFA) were significantly better than Ultrasound-Guided Foam Sclerotherapy and F-care. Also, invagination stripping was inferior to all interventions. Conservative Hemodynamic Cure for Venous Insufficiency and Varicose Veins (CHIVA) demonstrated a significantly lower recurrence rate with a RR of 0.35 [0.15; 0.79] compared to RFA, but RFA was more effective in recurrence prevention than HL/S and Mechanochemical Ablation (MOCA), with a RR of 0.63 [0.41; 0.97] and 0.18 [0.03; 0.95], respectively. Endo-venous Steam Ablation (EVSA) emerged as the most effective in reducing post-intervention pain, showing a MD of -2.73 [-3.72; -1.74] compared to HL/S. In Aberdeen Varicose Vein Questionnaire outcome, our analysis favored MOCA over most studied interventions, with an MD of -6.88 [-12.43; -1.32] compared to HL/S. Safety outcomes did not significantly differ among interventions. CONCLUSION Our findings revealed significant variations in the technical success rates, recurrence rates, and post-intervention pain levels among different interventions. CHIVA exhibited enhanced performance in terms of lower recurrence rates, while EVSA emerged as a promising choice for mitigating post-intervention pain. Additionally, our analysis underscored the significance of patient-reported outcomes, with MOCA consistently yielding favorable results in terms of enhancing quality of life and expediting the return to regular activities.
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Affiliation(s)
- Abdulkreem Aa Juhani
- Faculty of medicine and surgery,.King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Abdullah Abdullah
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Amnah A Dobel
- College of Medicine, Taif University, Taif, Saudi Arabia
| | | | - Osama M Alalmaei
- College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
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Pinto P, Fukaya E, Rodriguez LE, Obi A, Ting W, Aziz F, Nguyen K, Murphy EH, Ochoa Chaar CI. Variations and inconsistencies in venous ablation coverage policies between single-state and multistate carriers in the United States. J Vasc Surg Venous Lymphat Disord 2024; 12:101685. [PMID: 37703944 DOI: 10.1016/j.jvsv.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/02/2023] [Accepted: 07/05/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Vein ablation is a common and effective treatment for patients with chronic venous insufficiency. The overuse of vein ablation despite the existence of evidence-based guidelines has resulted in insurance companies developing restrictive policies for coverage that create barriers to appropriate care. This study compares the insurance coverage by single-state carriers (SSCs) and multistate carriers (MSCs), highlighting the variations and inconsistencies in the various policies. METHODS The American Venous Forum Venous Policy Navigator was reviewed for the various policies available in the United States. The policies were divided into SSCs and MSCs. The characteristics of the policies, including the anatomic and hemodynamic criteria for specific veins, duration of conservative treatment, disease severity, symptoms, and types of procedures covered, were compared between the two groups. SAS, version 9.4 (SAS Institute Inc) was used for statistical analysis. RESULTS A total of 122 policies were analyzed and divided between SSCs (n = 85; 69.7%) and MSCs (n = 37; 30.3%). A significant variation was found in the size requirement for great saphenous vein ablation. Although 48% of the policies did not specify a size criterion, the remaining policies indicated a minimal size, ranging from 3 to 5.5 mm. However, no significant differences were found between SSCs and MSCs. Similar findings were encountered for the small and anterior accessory saphenous veins. MSCs were more likely to define a saphenous reflux time >500 ms compared with SSCs (81.1% vs 58.8%; P = .04). A significant difference was found between the SSCs and MSCs in the criteria for perforator ablation in terms of size and reflux time. MSCs were significantly more likely to provide coverage for mechanochemical ablation than were SSCs (24.3% vs 8.2%; P = .03). SSCs were more likely to require ≥12 weeks of compression stocking therapy than were MSCs (76.5% vs 48.7%; P = .01). No significant differences were found in the clinical indications between the two groups; however, MSCs were more likely to mention major hemorrhage than were SSCs. CONCLUSIONS The results of this study highlight the variations in policies for venous ablation, in particular, the striking inconsistencies in size criteria. MSCs were more likely to cover mechanochemical ablation and require a shorter duration of conservative therapy before intervention compared with SSCs. Evidence-based guidance is needed to develop more coherent policies for venous ablation coverage.
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Affiliation(s)
- Paula Pinto
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, Yale University, New Haven, CT.
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | | | - Andrea Obi
- Division of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Windsor Ting
- Division of Vascular Surgery, The Mount Sinai Hospital, New York, NY
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA
| | - Khanh Nguyen
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR
| | - Erin H Murphy
- Division of Vascular Surgery, Sanger Heart & Vascular Institute, Charlotte, NC
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, Yale University, New Haven, CT
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Liu L, Wu ZH, Huang QM, Liu QG, Wang LN, Jin XH. Clinical observations in treatment of lower extremity varicose veins with trigger points acupuncture. Phlebology 2023; 38:675-682. [PMID: 37705487 DOI: 10.1177/02683555231198615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
OBJECTIVES To observe the effect of the acupuncture of myofascial trigger points (MTrPs) in the treatment of lower extremity varicose veins (LEVVs). METHODS Overall, 260 patients with LEVVs participated in this study. LEVVs were selected based on diagnostic criteria of Clinical, Etiology, Anatomy, and Pathophysiology levels 2-5 and classified into six types on the basis of their anatomical positions. The MTrPs in the lower extremities were localized in accordance with the classification of LEVVs and treated by MTrPs acupuncture combined with self-massage and self-stretching. The interval between each treatment was 2 weeks to 1 month, depending on needling pain tolerance of each patient. An in-house evaluation was used to estimate the proportion of varicose veins in the lower limbs and their accompanying symptoms. The treatment effect was evaluated before each treatment and at 1-year follow-up. RESULTS The mean evaluation score of LEVVs before the treatment course was 3.66 ± 1.19. After the course, this reduced to 1.18 ± 0.97, with the following response rates: 85% for excellent and good and 15% for medium. After 1-year follow-up, the mean evaluation score of all patients was 1.11 ± 0.92, with the following response rates: 87% for excellent and good, and 13% for medium. CONCLUSIONS In some patients, MTrP acupuncture could cure LEVVs and its accompanying symptoms. These LEVVs are probably caused by fascia tension as a pre-pathology induced by the MTrPs.
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Affiliation(s)
- Lin Liu
- School of Sport and Health, Nanjing Sport Institute, Nanjing, Jiangsu Province, China
- School of Sport Science, Shanghai University of Sport, Shanghai, Shanghai, China
| | - Zong-Hui Wu
- Southwest University Hospital, Chongqing, China
| | - Qiang-Min Huang
- School of Sport Science, Shanghai University of Sport, Shanghai, Shanghai, China
- Department of Pain Rehabilitation, Yiyang Traditional Chinese Medicine Clinic, Shanghai, China
| | - Qing-Guang Liu
- International College of Football, Tongji University, Shanghai, China
| | - Li-Na Wang
- Department of Anesthesiology and Pain Management, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xiao-Hong Jin
- Department of Anesthesiology and Pain Management, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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Kanber EM, Cetin HK. Comparison of Radiofrequency Ablation and Saphenous Vein Stripping for the Treatment of Recurrent Lower Extremity Venous Insufficiency. Vasc Endovascular Surg 2023; 57:726-731. [PMID: 37127282 DOI: 10.1177/15385744231173192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To compare the efficiency and safety of radiofrequency ablation (RFA) and saphenous vein stripping (SVS) for the treatment of recurrent lower extremity chronic superficial venous insufficiency (CSVI). METHODS Patients who underwent SVS and RFA for recurrent lower extremity CSVI following RFA and patients who had 2-year follow-up results were enrolled into the study. Total, 37 patients who underwent a second RFA session with 2-year follow-up results were available. Then 37 patients were selected from 88 patients who underwent SVS for recurrent lower extremity CSVI to achieve a 1:1 ratio for comparison. Groups were compared based on preoperative properties, operative parameters, postoperative outcomes, complications and follow-up results. RESULTS Duration of the procedure was 20.7 minutes in the RFA group and 30.7 minutes in the SVS group (P = .001). Postoperative pain at first hour, sixth hour and 24th hour were significantly lower in patients who underwent RF (P = .001 for each parameter). Moreover, hospitalization time (18.1 hours vs 24.6 hours, P = .001) and time to return to normal daily activities (1.6 days and 2.5 days, P = .001) were significantly shorter in the RFA group. Success of the procedure did not statistically significant at first year follow-up (P = .304). However, success was significantly higher for the SVS group at second year follow-up (73% for RFA group and 91.9% for SVS group, P = .032). CONCLUSION We achieved significantly shorter procedure time, less postoperative hospitalization time, and a shorter time to return to daily activities with RFA. In contrast, the success rate of SVS was significantly higher at the second year follow-up, but not the first year follow-up in comparison with RFA.
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Affiliation(s)
| | - Hakkı Kursat Cetin
- Department of Cardiovascular Surgery, SBU Sisli Hamidiye Etfal Training and Research Hospital, Turkey
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Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, Bush RL, Di Iorio M, Fish J, Fukaya E, Gloviczki ML, Hingorani A, Jayaraj A, Kolluri R, Murad MH, Obi AT, Ozsvath KJ, Singh MJ, Vayuvegula S, Welch HJ. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2023; 11:231-261.e6. [PMID: 36326210 DOI: 10.1016/j.jvsv.2022.09.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022]
Abstract
The Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society collaborated to update the 2011 Society for Vascular Surgery/American Venous Forum clinical practice guidelines and provide new evidence-based recommendations on critical issues affecting the care of patients with varicose veins. Each recommendation is based on a recent, independent systematic review and meta-analysis of the diagnostic tests and treatments options for patients with lower extremity varicose veins. Part I of the guidelines includes evidence-based recommendations for the evaluation of patients with CEAP (Clinical Class, Etiology, Anatomy, Pathology) class 2 varicose vein using duplex ultrasound scanning and other diagnostic tests, open surgical treatment (ligation and stripping) vs endovenous ablation techniques, thermal vs nonthermal ablation of the superficial truncal veins, and management of incompetent perforating veins in CEAP class 2 disease. We have also made recommendations on the concomitant vs staged treatment of varicose tributaries using phlebectomy or liquid or foam sclerotherapy (with physician-compounded foam or commercially prepared polidocanol endovenous microfoam) for patients undergoing ablation of incompetent superficial truncal veins.
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Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Suman M Wasan
- Department of Medicine, University of North Carolina, Chapel Hill, and Rex Vascular Specialists, UNC Health, Raleigh, NC
| | | | - Jose Almeida
- Miller School of Medicine, University of Miami, Miami, FL
| | | | - Ruth L Bush
- Central Texas Veterans Affairs Healthcare System and Texas A&M University College of Medicine, Temple, TX
| | | | - John Fish
- Department of Medicine, Jobst Vascular Institute, University of Toledo, Toledo, OH
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University, Stanford, CA
| | | | | | - Arjun Jayaraj
- RANE Center for Venous and Lymphatic Diseases, Jackson, MS
| | - Raghu Kolluri
- Heart and Vascular Service, OhioHealth Riverside Methodist Hospital, Columbus, OH
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Andercou O, Stancu B, Coman HF, Cucuruz B, Noppeney T, Marian D. Radiofrequency Thermal Ablation for the Treatment of Chronic Insufficiency of the Saphenous Vein-A Comparative Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3308. [PMID: 36834003 PMCID: PMC9964993 DOI: 10.3390/ijerph20043308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/09/2023] [Accepted: 02/12/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES The broad spectrum of chronic venous disease encompasses varicose veins, edema, hyperpigmentation and venous ulcers. Radiofrequency thermal ablation is indicated for the treatment of superficial venous reflux of the lower limb. Our research is a comparative clinical study that aims to identify the most effective and safest therapeutic method in the management of chronic venous insufficiency of the lower limbs. MATERIALS AND METHODS Patients admitted to the Department of Surgery of the University of Medicine and Pharmacy in Cluj-Napoca, Romania, with the clinical diagnosis of varicose veins of the lower limbs, treated by thermal ablation with radiofrequency or by open surgical techniques during the year 2022, were included. RESULTS A percentage of 50.9% of the patients were treated by the radiofrequency thermal ablation procedure and 49.1% by surgical treatment. More than half of them were hospitalized for 2 days. The duration of hospitalization was significantly longer in patients who had postoperative complications (p < 0.001). The chance of being treated by open surgical treatment for a small saphenous vein is 10.11 times higher than by radiofrequency thermal ablation. CONCLUSION According to the applied tests, there is no statistical difference between the group treated by radiofrequency thermal ablation and the one surgically treated in terms of sex, age, origin, CEAP clinical stage at hospitalization, clinical diagnosis at hospitalization and affected lower limb.
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Affiliation(s)
- Octavian Andercou
- Department of Surgery, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400347 Cluj-Napoca, Romania
| | - Bogdan Stancu
- Department of Surgery, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400347 Cluj-Napoca, Romania
| | - Horațiu Flaviu Coman
- Department of Vascular Surgery, County Emergency Hospital, 400347 Cluj-Napoca, Romania
| | - Beatrix Cucuruz
- Department of Vascular Surgery, Martha Maria Hospital Nuremberg, 90491 Nuremberg, Germany
| | - Thomas Noppeney
- Department of Vascular and Endovascular Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Dorin Marian
- Department of Surgery, University of Medicine and Pharmacy “George Palade”, 540142 Targu Mures, Romania
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Hong KP. Mid-term results of radiofrequency ablation with multiple heat cycles for incompetent saphenous veins. J Vasc Surg Venous Lymphat Disord 2022; 11:483-487. [PMID: 36581000 DOI: 10.1016/j.jvsv.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/29/2022] [Accepted: 12/01/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Recent reports suggest that the number of radiofrequency ablation (RFA) cycles impacts the depth of vein wall damage. This study evaluates the mid-term occlusion rate after delivering increased energy during RFA of incompetent saphenous veins. METHODS Between 2016 and 2019, consecutive patients who underwent RFA with multiple heat cycles were enrolled in the study. The exclusion criterion was previous treatment history for chronic venous disease. Duplex ultrasound data and medical records were reviewed retrospectively. RESULTS This study enrolled 217 patients (345 veins). Follow-up examinations were performed for 65% of treated veins after 6 months, 31% after 12 months, and 26% after more than 24 months with a mean follow-up period of 23 ± 18.9 months. The numbers of great saphenous and small saphenous veins were 178 and 62, respectively. According to the Kaplan-Meier method, the occlusion rate of saphenous veins was 100% at 3 years and 95.4% at 5 years. Except for one case (0.3%) of endovenous heat-induced thrombosis class 2, no significant side effects were noted. CONCLUSIONS Routine use of RFA with multiple heat cycles for incompetent saphenous veins exhibits good clinical outcomes considering mid-term occlusion rate without an increase in side effects.
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Affiliation(s)
- Ki-Pyo Hong
- Department of Thoracic and Cardiovascular Surgery, National Health Insurance Service Ilsan Hospital, Goyang-si, Gyeonggi-do, Korea.
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Farah MH, Nayfeh T, Urtecho M, Hasan B, Amin M, Sen I, Wang Z, Prokop LJ, Lawrence PF, Gloviczki P, Murad MH. A systematic review supporting the Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society guidelines on the management of varicose veins. J Vasc Surg Venous Lymphat Disord 2021; 10:1155-1171. [PMID: 34450355 DOI: 10.1016/j.jvsv.2021.08.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/13/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Several diagnostic tests and treatment options for patients with lower extremity varicose veins have existed for decades. The purpose of this systematic review was to summarize the latest evidence to support the forthcoming updates of the clinical practice guidelines on the management of varicose veins for the Society for Vascular Surgery (SVS), the American Venous Forum (AVF) and the American Vein and Lymphatic Society. METHODS We searched multiple databases for studies that addressed four clinical questions identified by the AVF and the SVS guideline committee about evaluating and treating patients with varicose veins. Studies were selected and appraised by pairs of independent reviewers. A meta-analysis was conducted when feasible. RESULTS We included 73 original studies (45 were randomized controlled trials) and 1 systematic review from 12,915 candidate references. Moderate certainty of evidence supported the usefulness of duplex ultrasound (DUS) examination as the gold standard test for diagnosing saphenous vein incompetence in patients with varicose veins and chronic venous insufficiency (clinical, etiological, anatomic, pathophysiological classification [CEAP] class C2-C6). High ligation and stripping (HL/S) was associated with higher anatomic closure rates at 30 days and 5 years when compared with radiofrequency ablation and ultrasound-guided foam sclerotherapy (UGFS) (moderate certainty), while no significant difference was seen when compared with endovenous laser ablation (EVLA) at 5 years. UGFS was associated with an increased risk of recurrence compared with HL/S. EVLA was associated with lower anatomic closure rates at 30 days than cyanoacrylate closure (CAC) and higher rates at one and 5 years when compared with UGFS. Thermal interventions were associated with lower generic quality of life scores and an increased risk of adverse events when compared with CAC or n-butyl cyanoacrylate (low certainty). Thermal interventions were associated with a lower risk of recurrent incompetence when compared with UGFS and an increased risk of recurrent incompetence than CAC. The evidence for great saphenous vein ablation alone to manage perforator disease was inconclusive. CONCLUSIONS The current systematic review summarizes the evidence to develop and support forthcoming updated SVS/AVF/American Vein and Lymphatic Society clinical practice guideline recommendations. The evidence supports duplex scanning for evaluating patients with varicose veins and confirms that HL/S resulted in similar long-term saphenous vein closure rates as EVLA and in better rates than radiofrequency ablation and UGFS. Thermal interventions were associated with inferior generic quality of life scores than nonthermal interventions, but had a lower risk of recurrent incompetence than UGFS. The recommendations in the guidelines should consider this information as well as other factors such as patients' values and preferences, anatomic considerations of individual patients, and surgical expertise.
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Affiliation(s)
- Magdoleen H Farah
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Tarek Nayfeh
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Meritxell Urtecho
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Bashar Hasan
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Mustapha Amin
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | - Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Zhen Wang
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn
| | | | - Peter F Lawrence
- Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Calif
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn.
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Cost-effectiveness Analysis of Current Varicose Veins Treatments. J Vasc Surg Venous Lymphat Disord 2021; 10:504-513.e7. [PMID: 34450353 DOI: 10.1016/j.jvsv.2021.05.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/02/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To analyze the effectiveness and cost-effectiveness of technologies for treatment of varicose veins over 5 years - conservative care (CONS), surgery (HL/S), ultrasound guided foam sclerotherapy (UGFS), endovenous laser ablation (EVLA), and radiofrequency ablation (RFA), mechanochemical ablation (MOCA) and cyanoacrylate glue occlusion (CAE). METHODS A systematic review was updated and used to construct a Markov decision model. Outcomes were re-intervention on the truncal vein, re-treatment of residual varicosities and quality-adjusted life years (QALY) and costs over five years. RESULTS UGFS has a significantly greater re-intervention rate than other procedures, while there is no significant difference between the other procedures. The cost per QALY of EVLA versus UGFS in our base-case model is £16966 ($23700) per QALY, which is considered cost-effective in the UK. RFA, MOCA and CAE have greater procedure costs than EVLA with no evidence of greater benefit for patients. CONCLUSIONS EVLA is the most cost-effective therapeutic option, with RFA a close second, in adult patients requiring treatment in the upper leg for incompetence of the GSV. MOCA, UGFS, CAE, CONS and HL/S are not cost-effective at current prices in the UK National Health Service. MOCA and CAE appear promising but further evidence on effectiveness, re-interventions and health-related quality of life is needed, as well as how cost-effectiveness may vary across settings and reimbursement systems.
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Abstract
BACKGROUND Great saphenous vein (GSV) incompetence, causing varicose veins and venous insufficiency, makes up the majority of lower-limb superficial venous diseases. Treatment options for GSV incompetence include surgery (also known as high ligation and stripping), laser and radiofrequency ablation, and ultrasound-guided foam sclerotherapy. Newer treatments include cyanoacrylate glue, mechanochemical ablation, and endovenous steam ablation. These techniques avoid the need for a general anaesthetic, and may result in fewer complications and improved quality of life (QoL). These treatments should be compared to inform decisions on treatment for varicosities in the GSV. This is an update of a Cochrane Review first published in 2011. OBJECTIVES To assess the effects of endovenous laser ablation (EVLA), radiofrequency ablation (RFA), endovenous steam ablation (EVSA), ultrasound-guided foam sclerotherapy (UGFS), cyanoacrylate glue, mechanochemical ablation (MOCA) and high ligation and stripping (HL/S) for the treatment of varicosities of the great saphenous vein (GSV). SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 2 November 2020. We undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) treating participants for varicosities of the GSV using EVLA, RFA, EVSA, UGFS, cyanoacrylate glue, MOCA or HL/S. Key outcomes of interest are technical success, recurrence, complications and QoL. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, applied Cochrane's risk of bias tool, and extracted data. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) and assessed the certainty of evidence using GRADE. MAIN RESULTS We identified 11 new RCTs for this update. Therefore, we included 24 RCTs with 5135 participants. Duration of follow-up ranged from five weeks to eight years. Five comparisons included single trials. For comparisons with more than one trial, we could only pool data for 'technical success' and 'recurrence' due to heterogeneity in outcome definitions and time points reported. All trials had some risk of bias concerns. Here we report the clinically most relevant comparisons. EVLA versus RFA Technical success was comparable up to five years (OR 0.98, 95% CI 0.41 to 2.38; 5 studies, 780 participants; moderate-certainty evidence); over five years, there was no evidence of a difference (OR 0.85, 95% CI 0.30 to 2.41; 1 study, 291 participants; low-certainty evidence). One study reported recurrence, showing no clear difference at three years (OR 1.53, 95% CI 0.78 to 2.99; 291 participants; low-certainty evidence), but a benefit for RFA may be seen at five years (OR 2.77, 95% CI 1.52 to 5.06; 291 participants; low-certainty evidence). EVLA versus UGFS Technical success may be better in EVLA participants up to five years (OR 6.13, 95% CI 0.98 to 38.27; 3 studies, 588 participants; low-certainty evidence), and over five years (OR 6.47, 95% CI 2.60 to 16.10; 3 studies, 534 participants; low-certainty evidence). There was no clear difference in recurrence up to three years and at five years (OR 0.68, 95% CI 0.20 to 2.36; 2 studies, 443 participants; and OR 1.08, 95% CI 0.40 to 2.87; 2 studies, 418 participants; very low-certainty evidence, respectively). EVLA versus HL/S Technical success may be better in EVLA participants up to five years (OR 2.31, 95% CI 1.27 to 4.23; 6 studies, 1051 participants; low-certainty evidence). No clear difference in technical success was seen at five years and beyond (OR 0.93, 95% CI 0.57 to 1.50; 5 studies, 874 participants; low-certainty evidence). Recurrence was comparable within three years and at 5 years (OR 0.78, 95% CI 0.47 to 1.29; 7 studies, 1459 participants; and OR 1.09, 95% CI 0.68 to 1.76; 7 studies, 1267 participants; moderate-certainty evidence, respectively). RFA versus MOCA There was no clear difference in technical success (OR 1.76, 95% CI 0.06 to 54.15; 3 studies, 435 participants; low-certainty evidence), or recurrence (OR 1.00, 95% CI 0.21 to 4.81; 3 studies, 389 participants; low-certainty evidence). Long-term data are not available. RFA versus HL/S No clear difference in technical success was detected up to five years (OR 5.71, 95% CI 0.64 to 50.81; 2 studies, 318 participants; low-certainty evidence); over five years, there was no evidence of a difference (OR 0.88, 95% CI 0.29 to 2.69; 1 study, 289 participants; low-certainty evidence). No clear difference in recurrence was detected up to three years (OR 0.93, 95% CI 0.58 to 1.51; 4 studies, 546 participants; moderate-certainty evidence); but a possible long-term benefit for RFA was seen (OR 0.41, 95% CI 0.22 to 0.75; 1 study, 289 participants; low-certainty evidence). UGFS versus HL/S Meta-analysis showed a possible benefit for HL/S compared with UGFS in technical success up to five years (OR 0.32, 95% CI 0.11 to 0.94; 4 studies, 954 participants; low-certainty evidence), and over five years (OR 0.09, 95% CI 0.03 to 0.30; 3 studies, 525 participants; moderate-certainty evidence). No clear difference was detected in recurrence up to three years (OR 1.81, 95% CI 0.87 to 3.77; 3 studies, 822 participants; low-certainty evidence), and after five years (OR 1.24, 95% CI 0.57 to 2.71; 3 studies, 639 participants; low-certainty evidence). Complications were generally low for all interventions, but due to different definitions and time points, we were unable to draw conclusions (very-low certainty evidence). Similarly, most studies evaluated QoL but used different questionnaires at variable time points. Rates of QoL improvement were comparable between interventions at follow-up (moderate-certainty evidence). AUTHORS' CONCLUSIONS Our conclusions are limited due to the relatively small number of studies for each comparison and differences in outcome definitions and time points reported. Technical success was comparable between most modalities. EVLA may offer improved technical success compared to UGFS or HL/S. HL/S may have improved technical success compared to UGFS. No evidence of a difference was detected in recurrence, except for a possible long-term benefit for RFA compared to EVLA or HL/S. Studies which provide more evidence on the breadth of treatments are needed. Future trials should seek to standardise clinical terminology of outcome measures and the time points at which they are measured.
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Affiliation(s)
- Jade Whing
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Sandip Nandhra
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Craig Nesbitt
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
| | - Gerard Stansby
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
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Siribumrungwong B, Wilasrusmee C, Orrapin S, Srikuea K, Benyakorn T, McKay G, Attia J, Rerkasem K, Thakkinstian A. Interventions for great saphenous vein reflux: network meta-analysis of randomized clinical trials. Br J Surg 2021; 108:244-255. [PMID: 33793723 PMCID: PMC10364879 DOI: 10.1093/bjs/znaa101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/12/2020] [Accepted: 11/01/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND A variety of endovascular and open surgical interventions exist to treat great saphenous vein reflux. However, comparisons of treatment outcomes have been inconsistent. METHODS A systematic review and network meta-analysis of RCTs was performed to compare rates of incomplete stripping or non-occlusion of the great saphenous vein with or without reflux (anatomical failure) at early, mid- and long-term follow-up; and secondary outcomes (reintervention and clinical recurrence) among intervention groups. The surface under the cumulative ranking curve (SUCRA) method was used to estimate the probability of the intervention with the lowest anatomical failure rates. RESULTS Some 72 RCTs were included. Comparisons of endothermal techniques with open surgery were mostly not significantly different, except for endovenous laser ablation (EVLA), which had higher long-term anatomical failure rates (pooled risk ratio (RR) 1.87, 95 per cent c.i. 1.14 to 3.07). Mechanochemical ablation had higher anatomical failure rates than radiofrequency ablation (RFA) (pooled RR 2.77, 1.38 to 5.53), and cyanoacrylate closure (CAC) had a RR 0.56 (0.34 to 0.93) times lower than either RFA or EVLA at the early term. Ultrasound-guided foam sclerotherapy had a higher risk of anatomical failure and reintervention than open surgery, with the lowest SUCRA value, and CAC was ranked first, third and first for best intervention for anatomical failure at early, mid and long term respectively. However, clinical recurrence rates were not significantly different between all comparisons. CONCLUSION Mechanochemical ablation and ultrasound-guided foam sclerotherapy performed poorly, with higher anatomical failure rates in the long term. The other treatment modalities had similar rates of anatomical failure in the short and mid term.
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Affiliation(s)
- B Siribumrungwong
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand.,Centre of Excellence in Applied Epidemiology, Thammasat University Hospital, Thammasat University, Pathum Thani, Thailand
| | - C Wilasrusmee
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - S Orrapin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - K Srikuea
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - T Benyakorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
| | - G McKay
- Centre for Public Health, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - J Attia
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, and Hunter Medical Research Institute, NSW, Australia
| | - K Rerkasem
- Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine; Non-Communicable Disease Centre of Excellence, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - A Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Orhurhu V, Chu R, Xie K, Kamanyi GN, Salisu B, Salisu-Orhurhu M, Urits I, Kaye RJ, Hasoon J, Viswanath O, Kaye AJ, Karri J, Marshall Z, Kaye AD, Anahita D. Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review. Cardiol Ther 2021; 10:111-140. [PMID: 33704678 PMCID: PMC8126535 DOI: 10.1007/s40119-021-00213-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Indexed: 02/08/2023] Open
Abstract
PURPOSE OF REVIEW Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease. RECENT FINDINGS Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.
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Affiliation(s)
- Vwaire Orhurhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Robert Chu
- Johns Hopkins School of Medicine, Baltimore, MA, USA
| | | | | | | | - Mariam Salisu-Orhurhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rachel J Kaye
- Medical University of South Carolina, Charleston, SC, USA
| | - Jamal Hasoon
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Shreveport Shreveport, Shreveport, LA, USA
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Valley Anesthesiology and Pain Consultants-Envision Physician Services, Phoenix, AZ, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Aaron J Kaye
- Medical University of South Carolina, Charleston, SC, USA
| | - Jay Karri
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Zwade Marshall
- Regenerative Spine and Pain Specialist, Fayetteville, GA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport Shreveport, Shreveport, LA, USA
| | - Dua Anahita
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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13
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Outcomes of Saphenous Vein Intervention in the Management of Superficial Venous Incompetence: A Systematic Review and Network Meta-Analysis. Ann Surg 2021; 275:e324-e333. [PMID: 33843795 DOI: 10.1097/sla.0000000000004914] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the most effective modality of intervention to treat saphenous vein insufficiency. SUMMARY BACKGROUND DATA Endovenous therapies have instigated a paradigm shift in the management of superficial venous incompetence (SVI). When compared with open surgery, endovenous interventions (foam sclerotherapy (FS), radiofrequency ablation (RFA), endovenous laser ablation (EVLA), mechanochemical ablation (MOCA), and cyanoacrylate glue (CAE) closure) potentially offer reduced morbidity with similar procedural efficacy. METHODS A systematic review and series of network meta-analyses of randomized controlled trials (RCTs) were performed assessing risks of procedural failure (within 6-weeks) and recurrence (6-weeks to 5-years), defined by ultrasound, between the different SVI modalities. Treatment comparisons addressing risks of common adverse events, Venous Clinical Severity Score (VCSS) and pain were also performed. RESULTS A systematic search identified 51 articles, describing 36 RCTs, incorporating 7,576 limbs. Outcome data on ten modalities of intervention were analyzed up to five-year follow-up. CAE resulted in the lowest risk of procedural failure within six-weeks. Foam sclerotherapy had the highest risk of recurrence while high ligation with stripping (HLS) and CHIVA were ranked best to reduce long-term recurrence. No intervention increased risks of venous thromboembolism and there was minimal difference in morbidity between treatments. All interventions improved VCSS (Range -1.02 to -4.95), however RFA demonstrated the greatest improvement, followed by EVLA and HLS between two to five-years. EVLA was associated with the highest risk of pain, while MOCA offered the least. CONCLUSION While CAE offered the lowest risk of initial procedural failure, HLS resulted in lower rates of long-term recurrence without considerably increasing morbidity when compared with other endovenous options.
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14
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González Cañas E, Florit López S, Vilagut RV, Guevara-Noriega KA, Santos Espí M, Rios J, Soto SN, Giménez Gaibar A. A randomized controlled noninferiority trial comparing radiofrequency with stripping and conservative hemodynamic cure for venous insufficiency technique for insufficiency of the great saphenous vein. J Vasc Surg Venous Lymphat Disord 2020; 9:101-112. [PMID: 32353592 DOI: 10.1016/j.jvsv.2020.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 04/03/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The quality of available evidence regarding new minimally invasive techniques to abolish great saphenous vein reflux is moderate. The present study assessed whether radiofrequency ablation (RFA) was noninferior to high ligation and stripping (HLS) and conservative hemodynamic cure for venous insufficiency (CHIVA) for clinical and ultrasound recurrence at 2 years in patients with primary varicose veins (VVs) due to great saphenous vein (GSV) insufficiency. METHODS We performed a randomized, single-center, open-label, controlled, noninferiority trial to compare RFA and 2 surgical techniques for the treatment of primary VVs due to GSV insufficiency. The noninferiority margin was set at 15% for absolute differences. Patients aged >18 years with primary VVs and GSV incompetence, with or without clinical symptoms, C2 to C6 CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) clinical class, and GSV diameter >4 mm were randomized with a 1:1:1 ratio to RFA, HLS, or CHIVA. The rate of clinical recurrence at 24 months was the primary endpoint and was analyzed using a delta noninferiority margin of 15%. Ultrasound recurrence, safety, and quality of life were secondary endpoints. RESULTS From December 2012 to June 2015, 225 limbs had been randomized to RFA, HLS, or CHIVA (n = 74, n = 75, and n = 76). Clinical follow-up and Doppler ultrasound examinations were performed at 1 week and 1, 6, 12, and 24 months postoperatively. No differences in postoperative complications or pain were observed among the three groups. RFA was noninferior to HLS and CHIVA for clinical recurrence at 24 months, with an estimated difference in recurrence of 3% (95% confidence interval [CI], -4.8% to 10.7%; noninferiority P = .002) and -7% (95% CI, -17% to 3%; P < .001), respectively. For ultrasound recurrence, RFA was noninferior to CHIVA, with an estimated difference of -34% (95% CI, -47% to -20%; noninferiority P < .001) at 24 months. However, noninferiority could not be demonstrated compared with HLS (5.9%; 95% CI, -4.1 to 15.9; P = .073). No differences were found in quality of life among the three groups. CONCLUSIONS RFA was shown to be noninferior in terms of clinical recurrence to HLS and CHIVA in the treatment of VVs due to GSV insufficiency.
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Affiliation(s)
- Elena González Cañas
- Department of Vascular Surgery, Parc Taulí Hospital Universitari, Sabadell, Barcelona, Spain.
| | - Salvador Florit López
- Department of Vascular Surgery, Parc Taulí Hospital Universitari, Sabadell, Barcelona, Spain
| | - Roser Vives Vilagut
- Department of Pharmacology, Therapeutics, and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Marta Santos Espí
- Department of Vascular Surgery, Parc Taulí Hospital Universitari, Sabadell, Barcelona, Spain
| | - José Rios
- Biostatistics Unit, Universitat Autònoma de Barcelona, Barcelona, Spain; Medical Statistics Core Facility, Institut Investigacions Biomèdiques Audgust Pi I Sunyer (IDIBAPS) and Hospital Clinic, Barcelona, Spain
| | - Salvador Navarro Soto
- Department of General Surgery, Parc Taulí Hospital Universitari, Sabadell, Barcelona, Spain
| | - Antonio Giménez Gaibar
- Department of Vascular Surgery, Parc Taulí Hospital Universitari, Sabadell, Barcelona, Spain
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15
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[Pros and cons of classic crossectomy with stripping compared to endoluminal treatment : Competition or team play?]. Hautarzt 2020; 71:6-11. [PMID: 31807791 DOI: 10.1007/s00105-019-04515-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The chronic venous insufficiency (CVI) of the leg veins is one of the most common diseases in our society. Thus, it is important to know the clinical picture of CVI and the pros and cons of the different treatment options. Of the various treatments available for varicose veins (conservative therapy, operative procedures, endoluminal techniques, foam sclerotherapy), an evidence-based, treatment option should be individually chosen for each patient. In this article, the pros and cons of surgery are compared with endoluminal therapy in order to draw practical conclusions for the treatment decision.
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16
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Alwahbi A, Alamri A, Alotaibi W. Risk Factors of Saphenous Vein Insufficiency in Female Patients in Riyadh, Saudi Arabia. Cureus 2020; 12:e6643. [PMID: 31966948 PMCID: PMC6961556 DOI: 10.7759/cureus.6643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/13/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Venous reflux most frequently occurs in the great saphenous vein (GSV), which is the most commonly diseased vein and is associated with venous insufficiency and varicose veins. OBJECTIVE We aimed, in this study, to determine risk factors for saphenous vein insufficiency in female patients in Riyadh, Saudi Arabia. METHODS This was a retrospective cohort study. Data were collected from the medical records of adult female patients who developed saphenous vein insufficiency at King Abdulaziz Medical City, between 2015 and 2017. RESULTS A total of 97 subjects participated in the study, 53 patients had saphenous vein reflux while 44 patients did not have reflux. Leg swelling was the only symptom that showed a significant difference between the two groups (p<0.001); patients with reflux had significantly higher rates of endovenous laser therapy (p=0.021). While the same patient group showed significantly lower rates of sclerotherapy compared to patients without reflux (p=0.006). The proportion of hypertension patients without reflux (22.7%) was significantly larger than that of hypertension patients with reflux (1.9%) (p= 0.001). CONCLUSION More research is encouraged to provide better understanding and management of saphenous vein insufficiency in the Saudi population, especially in females who are at high risk.
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Affiliation(s)
- Abdullah Alwahbi
- Vascular Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Amal Alamri
- Vascular Surgery, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Wafa Alotaibi
- Vascular Surgery, King Saud Bin Abdulaziz University for Health Sciences (ksau-Hs), Riyadh, Saudi Arabia, Riyadh, SAU
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17
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Novak CJ, Khimani N, Kaye AD, Jason Yong R, Urman RD. Current Therapeutic Interventions in Lower Extremity Venous Insufficiency: a Comprehensive Review. Curr Pain Headache Rep 2019; 23:16. [PMID: 30830460 DOI: 10.1007/s11916-019-0759-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Chronic venous disease (CVD), although affecting up to 40% of the US population, is often underdiagnosed by healthcare professionals due to an incomplete understanding of the presenting symptoms. CVD is a common cause of lower extremity pain and discomfort, including aching, cramping, tingling, burning, swelling, heaviness, restlessness, and fatigue, and may lead to significant morbidity if left untreated. The negative impact of CVD on quality of life is well established and the optimization of management strategies is an important area of evolving research. RECENT FINDINGS Management of CVD has rapidly evolved over the last two decades with the development of minimally invasive endovenous ablative techniques, now the mainstay of treatment. We discuss the data supporting various methods of CVD treatment with an emphasis on the impact on patient comfort and quality of life. Both radiofrequency ablation (RFA) and endovenous laser therapy (EVLA) are excellent options for treatment of lower extremity venous disease, but RFA is associated with less post-procedure discomfort. Ultrasound-guided foam therapy is best reserved for the adjuvant setting or for patients ineligible for RFA or EVLA.
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Affiliation(s)
| | - Namrata Khimani
- Vein Institute and Pain Centers of America, New York, NY, USA.
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - R Jason Yong
- Vein Institute and Pain Centers of America, New York, NY, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Guo L, Huang R, Zhao D, Xu G, Liu H, Yang J, Guo T. Long-term efficacy of different procedures for treatment of varicose veins: A network meta-analysis. Medicine (Baltimore) 2019; 98:e14495. [PMID: 30762775 PMCID: PMC6408126 DOI: 10.1097/md.0000000000014495] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Various procedures for the treatment of varicose veins have been shown to have long-term effectiveness, but research has yet to identify the most effective procedure. The aim of this study was to investigate the long-term efficacy of different procedures based on Bayesian network meta-analysis and to rank therapeutic options for clinical decision-making. METHODS Globally recognized databases, namely, MEDLINE, Embase, and Cochrane Central, were searched for randomized controlled trials (RCTs). Quantitative pooled estimation of successful treatment rate (STR) and recurrence rate (RR) was performed to assess the long-term efficacy of each procedure with more than a 1-year follow-up. The surface under the cumulative ranking (SUCRA) probabilities of the P values regarding STR and RR were calculated to rank various procedures. Grades of Recommendations Assessment, Development and Evaluation (GRADE) criteria were utilized for the recommendation of evidence from pairwise direct comparisons. RESULTS A total of 39 RCTs encompassing a total of 6917 limbs were eligible and provided relative raw data. After quantitative analysis, the CHIVA procedure was determined to have the best long-term efficacy, as it had the highest STR (SUCRA, 0.37). Additionally, the results revealed that CHIVA possessed the highest probability of achieving the lowest long-term RR (SUCRA, 0.61). Moreover, the sensitivity analysis with inconsistency approach clarified the reliability of the main results, and the evidence of most direct comparisons was ranked as high or moderate. CONCLUSION CHIVA seemed to have superior clinical benefits on long-term efficacy for treating varicose veins. However, the conclusion still needs additional trials for supporting evidence.
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Affiliation(s)
- Liqin Guo
- School of Nursing, Huanggang Polytechnic College, Huanggang
| | - Rong Huang
- School of Nursing, Huanggang Polytechnic College, Huanggang
| | - Dunyong Zhao
- Institute of Digestive, Southwest Hospital, Third Military Medical University, Chongqing
| | - Guilian Xu
- School of Nursing, Huanggang Polytechnic College, Huanggang
| | - Hui Liu
- Department of Integrated Science, Huanggang Maternal and Child Health-Care Hospital, Huanggang
| | - Jian Yang
- School of Nursing, Huanggang Polytechnic College, Huanggang
| | - Tao Guo
- Department of Hepatobiliary and Pancreatic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
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Inderhaug E, Schelp CH, Glambek I, Kristiansen IS. Cost-effectiveness analysis of five procedures for great saphenous vein reflux in a Norwegian healthcare setting or societal setting. SAGE Open Med 2018; 6:2050312118801709. [PMID: 30263121 PMCID: PMC6153534 DOI: 10.1177/2050312118801709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/27/2018] [Indexed: 01/22/2023] Open
Abstract
Objective The aim of this work was to estimate cost-effectiveness of five common procedures for varicose vein surgery (high ligation and stripping, radiofrequency ablation, endovenous laser ablation, steam vein sclerosis and cyanoacrylate glue) in a Norwegian setting from both a societal and a healthcare payer perspective. Design Cost-effectiveness analysis using decision tree modelling. Methods A structured literature search was conducted to estimate the clinical effectiveness and the rate of complications in the five methods. Data on costs and health-related quality of life associated with varicose vein disease were also collected. With the aid of an expert panel, a structured decision tree was developed. A 1-year perspective was modelled, and a variety of common complications were included. Monte Carlo simulation was used for probabilistic sensitivity analyses. Results The laser ablation strategy was the most cost-effective option from a societal perspective, with an incremental cost-effectiveness ratio of €8448 compared to a no-treatment alternative, and had a 42% probability of being cost-effective using the Norwegian willingness-to-pay threshold of €59,880. From a healthcare payer perspective, however, the steam vein sclerosis strategy was the most cost-effective with an incremental cost-effectiveness ratio of €4072 compared to a no-treatment alternative, and this strategy had a 50% probability of being cost-effective. Conclusion Results from this study did depend upon the perspective chosen for analyses. Although recent endovenous surgical procedures (including laser ablation and steam vein sclerosis) provide clinically effective treatment for advanced, symptomatic varicose vein disease, availability of high-level data is currently limiting the cost-effectiveness analyses.
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Affiliation(s)
- Eivind Inderhaug
- Surgical Department, Haraldsplass Deaconess University Hospital, Bergen, Norway
| | | | - Inge Glambek
- Surgical Department, Haraldsplass Deaconess University Hospital, Bergen, Norway
| | - Ivar S Kristiansen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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Epstein D, Onida S, Bootun R, Ortega-Ortega M, Davies AH. Cost-Effectiveness of Current and Emerging Treatments of Varicose Veins. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:911-920. [PMID: 30098668 DOI: 10.1016/j.jval.2018.01.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/16/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To analyze the cost-effectiveness of current technologies (conservative care [CONS], high-ligation surgery [HL/S], ultrasound-guided foam sclerotherapy [UGFS], endovenous laser ablation [EVLA], and radiofrequency ablation [RFA]) and emerging technologies (mechanochemical ablation [MOCA] and cyanoacrylate glue occlusion [CAE]) for treatment of varicose veins over 5 years. METHODS A Markov decision model was constructed. Effectiveness was measured by re-intervention on the truncal vein, re-treatment of residual varicosities, and quality-adjusted life-years (QALYs) over 5 years. Model inputs were estimated from systematic review, the UK National Health Service unit costs, and manufacturers' list prices. Univariate and probabilistic sensitivity analyses were undertaken. RESULTS CONS has the lowest overall cost and quality of life per person over 5 years; HL/S, EVLA, RFA, and MOCA have on average similar costs and effectiveness; and CAE has the highest overall cost but is no more effective than other therapies. The incremental cost per QALY of RFA versus CONS was £5,148/QALY. Time to return to work or normal activities was significantly longer after HL/S than after other procedures. CONCLUSIONS At a threshold of £20,000/QALY, RFA was the treatment with highest median rank for net benefit, with MOCA second, EVLA third, HL/S fourth, CAE fifth, and CONS and UGFS sixth. Further evidence on effectiveness and health-related quality of life for MOCA and CAE is needed. At current prices, CAE is not a cost-effective option because it is costlier but has not been shown to be more effective than other options.
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Affiliation(s)
- David Epstein
- Department of Applied Economics, School of Economics and Business Studies, University of Granada, Granada, Spain
| | - Sarah Onida
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK; Charing Cross Hospital, London, UK
| | - Roshan Bootun
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK; Charing Cross Hospital, London, UK
| | - Marta Ortega-Ortega
- Department of Applied Economics, Public Economics and Political Economy, School of Economics and Business, Complutense University of Madrid, Madrid, Spain.
| | - Alun H Davies
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, UK; Charing Cross Hospital, London, UK
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de Mik SM, Stubenrouch FE, Legemate DA, Balm R, Ubbink DT. Treatment of varicose veins, international consensus on which major complications to discuss with the patient: A Delphi study. Phlebology 2018; 34:201-207. [PMID: 30012048 PMCID: PMC6431782 DOI: 10.1177/0268355518785482] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective To reach consensus on which complications of varicose vein treatments
physicians consider major or minor, in order to standardize the informed
consent procedure and improve shared decision-making. Methods Using the e-Delphi method, expert physicians from 10 countries were asked to
rate complications as “major” or “minor” on a 5-point Likert scale.
Reference articles from a Cochrane review on varicose veins were used to
compose the list of complications. Results Participating experts reached consensus on 12 major complications: allergic
reaction, cellulitis requiring intravenous antibiotics/intensive care, wound
infection requiring debridement, hemorrhage requiring blood
transfusion/surgical intervention, pulmonary embolism, skin necrosis
requiring surgery, arteriovenous fistula requiring repair, deep venous
thrombosis, lymphocele, thermal injury, transient ischemic attack/stroke,
and permanent discoloration. Conclusion An international consensus was reached about what physicians consider to be
major complications of varicose vein treatments. This consensus may assist
in standardizing the information physicians discuss with patients prior to
varicose vein treatment.
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Affiliation(s)
- Sylvana Ml de Mik
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Dink A Legemate
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Ron Balm
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Dirk T Ubbink
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
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Gloviczki P, Dalsing MC, Henke P, Lal BK, O'Donnell TF, Shortell CK, Huang Y, Markovic J, Wakefield TW. Report of the Society for Vascular Surgery and the American Venous Forum on the July 20, 2016 meeting of the Medicare Evidence Development and Coverage Advisory Committee panel on lower extremity chronic venous disease. J Vasc Surg Venous Lymphat Disord 2018; 5:378-398. [PMID: 28411706 DOI: 10.1016/j.jvsv.2017.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/04/2017] [Indexed: 12/21/2022]
Abstract
On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel assessed the benefits and risks of currently used lower extremity chronic venous disease (CVD) treatments and their effects on health outcome of the American adult population. The main purpose of the meeting was to advise the Centers for Medicare & Medicaid Services on coverage determination for interventions used for treatment of CVD. A systematic review of the Agency for Healthcare Research and Quality was presented, followed by lectures of invited experts and a public hearing of representatives of professional societies and the industry. After discussing critical issues, the panel voted for key questions. This report summarizes the presented evidence to support recommendations of the Society for Vascular Surgery/American Venous Forum coalition and the presentations on selected discussion topics. These included important venous disease evidence gaps that have not been sufficiently addressed, venous disease treatment disparities and how they may affect the health outcomes of Medicare beneficiaries, and mechanisms that might be supported by the Centers for Medicare & Medicaid Services to improve the evidence base to optimize the care of patients with lower extremity CVD.
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Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Michael C Dalsing
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Peter Henke
- Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland, Baltimore, Md
| | | | - Cynthia K Shortell
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ying Huang
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Jovan Markovic
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Poder TG, Fisette JF, Bédard SK, Despatis MA. Is radiofrequency ablation of varicose veins a valuable option? A systematic review of the literature with a cost analysis. Can J Surg 2018; 61:128-138. [PMID: 29582749 PMCID: PMC5866149 DOI: 10.1503/cjs.010114] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Since the 1990s, new techniques for the treatment of varicose veins have emerged, including radiofrequency ablation (RFA) and laser treatment. We performed a study to compare the safety, efficacy and outcomes of RFA compared to those of open surgery and laser ablation for the treatment of varicose veins. We also carried out a cost analysis of RFA compared to open surgery to assess whether RFA could help free up operating room time by being performed in an outpatient context. METHODS We conducted a systematic literature review (publication date May 2010-September 2013 for articles in English, January 1991-September 2013 for those in French). We used several checklists to measure the quality of the studies. We also collected data on costing. RESULTS The literature search identified 924 publications, of which 38 were retained for analysis: 15 literature reviews, 1 good-practice guideline and 22 new primary studies. The overall level of evidence was low to moderate owing to the limited sample sizes, lack of information on patient characteristics and lack of standardization of the outcome measures. However, the results obtained are consistent from study to study. In the short and medium term, RFA is considered as effective as open surgery or laser treatment (moderate level of evidence) and presents fewer major and minor complications than open surgery (low level of evidence). Radiofrequency ablation can be performed on an outpatient basis. We calculated that RFA would be about $110-$220 more expensive per patient than open surgery. CONCLUSION Radiofrequency ablation is a valuable alternative to open surgery and would free up operating room time in a context of low accessibility.
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Affiliation(s)
- Thomas G Poder
- From the Unité d'évaluation des technologies et des modes d'intervention en santé (UETMIS) and the Centre de recherche du Centre hospitalier universitaire de Sherbrooke (CRCHUS), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Poder); the Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que. (Fisette); CRCHUS, CIUSSS de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Bédard); and the Vascular Surgery Unit, CIUSSS de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Despatis)
| | - Jean-François Fisette
- From the Unité d'évaluation des technologies et des modes d'intervention en santé (UETMIS) and the Centre de recherche du Centre hospitalier universitaire de Sherbrooke (CRCHUS), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Poder); the Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que. (Fisette); CRCHUS, CIUSSS de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Bédard); and the Vascular Surgery Unit, CIUSSS de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Despatis)
| | - Suzanne K Bédard
- From the Unité d'évaluation des technologies et des modes d'intervention en santé (UETMIS) and the Centre de recherche du Centre hospitalier universitaire de Sherbrooke (CRCHUS), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Poder); the Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que. (Fisette); CRCHUS, CIUSSS de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Bédard); and the Vascular Surgery Unit, CIUSSS de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Despatis)
| | - Marc-Antoine Despatis
- From the Unité d'évaluation des technologies et des modes d'intervention en santé (UETMIS) and the Centre de recherche du Centre hospitalier universitaire de Sherbrooke (CRCHUS), Centre intégré universitaire de santé et de services sociaux (CIUSSS) de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Poder); the Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que. (Fisette); CRCHUS, CIUSSS de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Bédard); and the Vascular Surgery Unit, CIUSSS de l'Estrie - Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Que. (Despatis)
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Radak D, Atanasijević I, Nešković M, Isenovic E. The Significance of Pain in Chronic Venous Disease and its Medical Treatment. Curr Vasc Pharmacol 2018; 17:291-297. [PMID: 29424318 DOI: 10.2174/1570161116666180209111826] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 01/23/2018] [Accepted: 01/23/2018] [Indexed: 11/22/2022]
Abstract
Chronic venous disease (CVeD) is a highly prevalent condition in the general population, and it has a significant impact on quality of life. While it is usually manifested by obvious signs, such as varicose veins and venous ulcers, other symptoms of the disease are less specific. Among the other symptoms, which include heaviness, swelling, muscle cramps and restless legs, pain is the symptom that most frequently compels CVeD patients to seek medical aid. However, there is a substantial discrepancy between pain severity and clinically detectable signs of CVeD, questioned by several opposing studies. Further evaluation is needed to clarify this subject, and to analyse whether pain development predicts objective CVeD progression. General management of CVeD starts with advising lifestyle changes, such as lowering body mass index and treating comorbidities. However, the mainstay of treatment is compression therapy, with the additional use of pharmacological substances. Venoactive drugs proved to be the drugs of choice for symptom alleviation and slowing the progression of CVeD, with micronized purified flavonoid fraction being the most effective one. Interventional therapy is reserved for advanced stages of the disease.
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Affiliation(s)
- Djordje Radak
- Department of Vascular Surgery, Dedinje Cardiovascular Institute, Belgrade University School of Medicine, 11040 Belgrade, Serbia
| | - Igor Atanasijević
- Department of Vascular Surgery, Dedinje Cardiovascular Institute, Belgrade University School of Medicine, 11040 Belgrade, Serbia
| | - Mihailo Nešković
- Department of Vascular Surgery, Dedinje Cardiovascular Institute, Belgrade University School of Medicine, 11040 Belgrade, Serbia
| | - Esma Isenovic
- Laboratory of Radiobiology and Molecular Genetics, Institute of Nuclear Sciences Vinca, University of Belgrade, Mike Petrovica Alasa 12-14, 11000 Belgrade, Serbia
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Vemulapalli S, Parikh K, Coeytaux R, Hasselblad V, McBroom A, Johnston A, Raitz G, Crowley MJ, Lallinger KR, Jones WS, Sanders GD. Systematic review and meta-analysis of endovascular and surgical revascularization for patients with chronic lower extremity venous insufficiency and varicose veins. Am Heart J 2018; 196:131-143. [PMID: 29421005 DOI: 10.1016/j.ahj.2017.09.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/26/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Chronic lower extremity venous disease (LECVD) is twice as prevalent as coronary heart disease, and invasive therapies to treat LECVD accounted for an estimated $290 million in Medicare expenditures in 2015. Despite increasing use of these invasive therapies, their comparative effectiveness is unknown. METHODS We conducted a systematic review and meta-analysis of treatments for patients (symptomatic and asymptomatic) with lower extremity varicosities and/or lower extremity chronic venous insufficiency/incompetence/reflux. We searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for relevant English-language studies published from January 2000 to July 2016. We included comparative randomized controlled trials (RCTs) with >20 patients and observational studies with >500 patients. Short-, intermediate-, and long-term outcomes of placebo, mechanical compression therapy, and invasive therapies (surgical and endovascular) were included. Quality ratings and evidence grading was performed. Random-effects models were used to compute summary estimates of effects. RESULTS We identified a total of 57 studies representing 105,878 enrolled patients, including 53 RCTs comprised of 10,034 patients. Among the RCTs, 16 were good quality, 28 were fair quality, and 9 were poor quality. Allocation concealment, double blinding, and reporting bias were inadequately addressed in 25 of 53 (47%), 46 of 53 (87%), and 15 of 53 (28.3%), respectively. Heterogeneity in therapies, populations, and/or outcomes prohibited meta-analysis of comparisons between different endovascular therapies and between endovascular intervention and placebo/compression. Meta-analysis evaluating venous stripping plus ligation (high ligation/stripping) compared with radiofrequency ablation revealed no difference in short-term bleeding (odds ratio [OR]=0.30, 95% CI -0.16 to 5.38, P=.43) or reflux recurrence at 1-2 years (OR=0.76, 95% CI 0.37-1.55, P=.44). Meta-analysis evaluating high ligation/stripping versus endovascular laser ablation revealed no difference in long-term symptom score (OR 0.02, 95% CI -0.19 to 0.23, P=.84) or quality of life at 2 years (OR 0.06, 95% CI -0.12 to 0.25, P=.50). CONCLUSIONS The paucity of high-quality comparative effectiveness and safety data in LECVD is concerning given the overall rise in endovascular procedures. More high-quality studies are needed to determine comparative effectiveness and guide policy and practice.
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Whiteley M, Shiangoli I, Dos Santos S, Dabbs E, Fernandez-Hart T, Holdstock J. Fifteen Year Results of Radiofrequency Ablation, Using VNUS Closure, for the Abolition of Truncal Venous Reflux in Patients with Varicose Veins. Eur J Vasc Endovasc Surg 2017; 54:357-362. [DOI: 10.1016/j.ejvs.2017.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 06/01/2017] [Indexed: 11/28/2022]
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de Almeida Mendes C, de Arruda Martins A, Fukuda JM, Parente JBHF, Munia MAS, Fioranelli A, Teivelis MP, Varella AYM, Caffaro RA, Kuzniec S, Wolosker N. Randomized trial of radiofrequency ablation versus conventional surgery for superficial venous insufficiency: if you don't tell, they won't know. Clinics (Sao Paulo) 2016; 71:650-656. [PMID: 27982166 PMCID: PMC5108164 DOI: 10.6061/clinics/2016(11)06] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 08/26/2016] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES: This study compared radiofrequency ablation versus conventional surgery in patients who had not undergone previous treatment for bilateral great saphenous vein insufficiency, with each patient serving as his own control. METHOD: This was a randomized controlled trial that included 18 patients and was carried out between November 2013 and May 2015. Each of the lower limbs of each patient was randomly assigned to undergo either radiofrequency ablation or conventional surgery. Clinical features (hyperpigmentation, hematoma, aesthetics, pain, skin burn, nerve injury, and thrombophlebitis) were evaluated at one week, one month, and six months postoperatively. Hemodynamic assessments (presence of resection or occlusion of the great saphenous vein and recurrent reflux in the sapheno-femoral junction and in the great saphenous vein) were performed at one month, six months, and 12 months postoperatively. The independent observer (a physician not involved in the original operation), patient, and duplex ultrasonographer were not made aware of the treatment done in each case. Clinicaltrials.gov: NCT02588911. RESULTS: Among the clinical variables analyzed, only the aesthetic evaluation by the physicians was significant, with radiofrequency ablation being considered better than conventional surgery (average, 0.91 points higher: standard deviation: 0.31; 95% confidence interval: -1.51, -0.30; p=0.003). However, in our study, we observed primary success rates of 80% for radiofrequency ablation and 100% for conventional surgery. CONCLUSIONS: If the physician is not required to inform the patient as to the technique being performed, the patient will not be able to identify the technique based on the signs and symptoms. Our study revealed that both techniques led to high levels of patient satisfaction, but our results favor the choice of conventional surgery over radiofrequency ablation, as patients who underwent conventional surgery had better hemodynamic assessments.
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Affiliation(s)
- Cynthia de Almeida Mendes
- Hospital Israelita Albert Einstein, Division of Vascular and Endovascular Surgery, São Paulo/SP, Brazil
- Hospital Municipal Dr. Moysés Deutsch – M’Boi Mirim, São Paulo/SP, Brazil
| | - Alexandre de Arruda Martins
- Hospital Israelita Albert Einstein, Division of Vascular and Endovascular Surgery, São Paulo/SP, Brazil
- Hospital Municipal Dr. Moysés Deutsch – M’Boi Mirim, São Paulo/SP, Brazil
| | - Juliana Maria Fukuda
- Hospital Israelita Albert Einstein, Division of Vascular and Endovascular Surgery, São Paulo/SP, Brazil
- E-mail:
| | | | | | - Alexandre Fioranelli
- Hospital Israelita Albert Einstein, Division of Vascular and Endovascular Surgery, São Paulo/SP, Brazil
- Irmandade da Santa Casa de Misericórdia de São Paulo, Division of Vascular and Endovascular Surgery, São Paulo/SP, Brazil
| | - Marcelo Passos Teivelis
- Hospital Israelita Albert Einstein, Division of Vascular and Endovascular Surgery, São Paulo/SP, Brazil
| | | | - Roberto Augusto Caffaro
- Irmandade da Santa Casa de Misericórdia de São Paulo, Division of Vascular and Endovascular Surgery, São Paulo/SP, Brazil
| | - Sergio Kuzniec
- Hospital Israelita Albert Einstein, Division of Vascular and Endovascular Surgery, São Paulo/SP, Brazil
| | - Nelson Wolosker
- Hospital Israelita Albert Einstein, Division of Vascular and Endovascular Surgery, São Paulo/SP, Brazil
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El-Sheikha J, Carradice D, Nandhra S, Leung C, Smith GE, Wallace T, Campbell B, Chetter IC. A systematic review of the compression regimes used in randomised clinical trials following endovenous ablation. Phlebology 2016; 32:256-271. [DOI: 10.1177/0268355516648497] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives There is insufficient evidence to inform guidelines on the optimal compression strategy following ablation for varicose veins. This study aimed to identify the practice of key opinion leaders performing randomised clinical trials involving endovenous ablation. Method A systematic review of MEDLINE/EMBASE/CENTRAL was performed identifying the compression strategies used in randomised clinical trials where at least one comparator arm underwent endovenous ablation. Results Thirty-four randomised clinical trials were identified. At least 14 different compression products were used, with at least 6 different pressures in 7 different regimes with durations from 2 to 84 days. There was no evidence of any convergence of practice over time. Conclusions A lack of evidence as to the optimal strategy for compression has resulted in a marked variation in clinical practice. There is no suggestion that this variation is becoming less over time indicating that experience is not helping to form a consensus and, therefore, further research is required.
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Affiliation(s)
- Joseph El-Sheikha
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - Daniel Carradice
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - Sandip Nandhra
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - Clement Leung
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - George E Smith
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - Tom Wallace
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
| | - Bruce Campbell
- Royal Devon and Exeter Hospital and University of Exeter Medical School, Exeter, UK
| | - Ian C Chetter
- Hull York Medical School, Academic Vascular Surgery Unit, Hull Royal Infirmary, UK
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Van der Velden SK, Lawaetz M, De Maeseneer MGR, Hollestein L, Nijsten T, van den Bos RR. Predictors of Recanalization of the Great Saphenous Vein in Randomized Controlled Trials 1 Year After Endovenous Thermal Ablation. Eur J Vasc Endovasc Surg 2016; 52:234-41. [PMID: 26994834 DOI: 10.1016/j.ejvs.2016.01.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 01/24/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE/BACKGROUND The objective was to identify predictors to develop and validate a prognostic model of recanalization of the great saphenous vein (GSV) in patients treated with endovenous thermal ablation (EVTA). METHODS The search strategy of Siribumrungwong was updated between August 2011 and August 2014 using MEDLINE, Embase, and the Cochrane register to identify randomized controlled trials (RCTs), in which patients presenting with GSV reflux were treated with radiofrequency or endovenous laser ablation. Leg level data (n = 1226) of 15/23 selected RCTs were pooled. The primary outcome was recanalization of the GSV; the secondary outcome was change in health related quality of life (HRQoL) measured by the Chronic Venous Insufficiency quality of life Questionnaire or Aberdeen Varicose Vein Questionnaire 1 year post-procedure. Candidate predictors were age, sex, body mass index, clinical class, GSV diameter, saphenofemoral junction reflux, type of device, energy, and length of treated vein. RESULTS At 1 year, 130 GSVs were recanalized (11%). Clinical class (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.4-3.3) and diameter (OR 1.8, 95% CI 1.2-2.7) of the GSV were the strongest predictors of recanalization. Other predictors included in the final model were sex, type of device, and length of treated vein. The performance of the recanalization model was moderate, with an area under the curve above 0.717. GSV diameter, type of device, and amount of energy delivered were the only predictors of the change of HRQoL. None of the candidate predictors were included in the final HRQoL model (R(2) = .027). CONCLUSION There are several important prognostic factors for GSV recanalization and change of HRQoL after EVTA. However, the performance of each model was unsatisfactory to allow use in clinical practice yet.
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Affiliation(s)
| | - M Lawaetz
- Danish Vein Centers, Åreknudeklinikken, and Surgical Center Roskilde, Naestved, Denmark
| | | | - L Hollestein
- Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands
| | - T Nijsten
- Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands
| | - R R van den Bos
- Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands
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Marsden G, Perry M, Bradbury A, Hickey N, Kelley K, Trender H, Wonderling D, Davies A. A Cost-effectiveness Analysis of Surgery, Endothermal Ablation, Ultrasound-guided Foam Sclerotherapy and Compression Stockings for Symptomatic Varicose Veins. Eur J Vasc Endovasc Surg 2015; 50:794-801. [DOI: 10.1016/j.ejvs.2015.07.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
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Spiliopoulos S, Theodosiadou V, Sotiriadi A, Karnabatidis D. Endovenous ablation of incompetent truncal veins and their perforators with a new radiofrequency system. Mid-term outcomes. Vascular 2015; 23:592-8. [PMID: 25501621 DOI: 10.1177/1708538114564462] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This is a prospective trial investigating endovenous radiofrequency ablation with the EVRF system for the treatment of symptomatic varicose veins. Primary endpoints include one-year anatomical and clinical success and procedure-related complications. Secondary endpoints include adjunctive procedures and recanalization rates, periprocedural pain assessment, and time return to normal activities. In 60 patients with 74 limbs, 58 great saphenous vein, 11 small saphenous vein, 2 anterior accessory saphenous vein, and 3 perforators were ablated. Additional ablations for further improvement were necessary in 28.4%. Clinical success was 94.6%. Anatomical success was 96.0% at one month and 89.2% at one year. Primary ablation success was 77%. Revascularization occurred in 12.1%. Clinically driven repeat ablation rate was 4.0%. Perforator ablation due to segmental revascularization was performed in 5.4%. Complications included one puncture-site infection, three scars, two cases of transient paresthesia, and one skin pigmentation. Periprocedural mean pain score was 2.4 ± 2.6. In 27.0% cases, the patients used analgesics and mean time return was 1.2 ± 0.5 days. The EVRF system yields satisfactory clinical and anatomical midterm outcomes with very low complication rates.
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Affiliation(s)
- Stavros Spiliopoulos
- Department of Diagnostic and Interventional Radiology, Patras University Hospital, Rio, Greece
| | - Vasiliki Theodosiadou
- Department of Diagnostic and Interventional Radiology, Patras University Hospital, Rio, Greece
| | - Athanasia Sotiriadi
- Department of Diagnostic and Interventional Radiology, Patras University Hospital, Rio, Greece
| | - Dimitrios Karnabatidis
- Department of Diagnostic and Interventional Radiology, Patras University Hospital, Rio, Greece
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Kosenkov AN, Vakhrat'yan PE, Avakyan AV. [Efficiency of minimally invasive methods in treatment of varicose veins]. Khirurgiia (Mosk) 2015:51-57. [PMID: 26271424 DOI: 10.17116/hirurgia2015651-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It was analyzed the results of studies comparing an efficiency of minimally invasive methods in treatment of varicose veins of lower extremities. Based on presented data similar efficiency of minimally invasive methods and conventional surgical treatment was proved. The graph reflecting remote results was made.
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Affiliation(s)
- A N Kosenkov
- Chair of Cardiovascular Surgery and Interventional Cardiology, I.M. Sechenov First Moscow State Medical University
| | - P E Vakhrat'yan
- Department of Vascular Surgery, acad. B.V. Petrovskiy Russian Scientific Center for Surgery of RAS, Moscow, Russia
| | - A V Avakyan
- Chair of Cardiovascular Surgery and Interventional Cardiology, I.M. Sechenov First Moscow State Medical University
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Lam YL, Toonder IM, Wittens CHA. Clarivein® mechano-chemical ablation an interim analysis of a randomized controlled trial dose-finding study. Phlebology 2015; 31:170-6. [DOI: 10.1177/0268355515599692] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The ClariVein® system is an endovenous technique that uses mechano-chemical ablation to treat incompetent truncal veins. This study was conducted to identify the ideal Polidocanol dosage and form for mechano-chemical ablation in order to occlude the great saphenous vein. When adhering to safe dosage levels, sclerosants with higher concentrations potentially limit the extent of treatment. It has been demonstrated that this problem may be overcome by using Polidocanol as a microfoam. This paper was established on findings of a preliminary analysis. Material and methods The initial study was a single-blinded multicenter randomized controlled trial where patients are allocated to three treatment arms. Group 1 consisted of mechano-chemical ablation +2% Polidocanol liquid, group 2: mechano-chemical ablation +3% Polidocanol liquid and group 3: mechano-chemical ablation +1% Polidocanol foam Results Eighty-seven, 34 males and 53 females (60.9%), mean age 55 years s.d. 16.0 (range 24–84), were enrolled in the study. Treatment length was 30 cm (range 10–30) for 95.2% of the patients. Mean operating time was 16 minutes (range 5–70). The mean saphenofemoral junction diameter (7.7 mm) was similar in all three groups. At 6 weeks post-treatment duplex ultrasound showed that 25 out of 25 = 100%, 27 out of 28 = 96.4% and 13 out of 23 = 56.5% were occluded in the mechano-chemical ablation + 2% Polidocanol liquid, mechano-chemical ablation + 3% Polidocanol liquid and mechano-chemical ablation + 1% Polidocanol microfoam respectively ( p < 0.001). However, stricter scrutiny showed that the anatomical success rate defined as occlusion of at least 85% of the treated length to be 88.0%, 85.7% and 30.4% respectively ( p < 0.001). Conclusion Mechano-chemical ablation using ClariVein® combined with 1% Polidocanol microfoam is significantly less effective and should not be considered as a treatment option of incompetent truncal veins. Further investigation to determine the ideal Polidocanol liquid dosage with mechano-chemical ablation is advocated and is being conducted accordingly.
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Affiliation(s)
- YL Lam
- Department of Vascular Surgery, Maastricht University Medical Centre, The Netherlands
- Department of Dermatology, Maastricht University Medical Centre, The Netherlands
| | - Irwin M Toonder
- Department of Vascular Surgery, Maastricht University Medical Centre, The Netherlands
| | - Cees HA Wittens
- Department of Vascular Surgery, Maastricht University Medical Centre, The Netherlands
- Department of Vascular Surgery, Universitätsklinikum Aachen, Germany
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Schuller-Petrović S, Pavlović M, Schuller-Lukić B, Schuller S. Retrospective analysis of routine use of a double heat cycle (DHC) during radiofrequency segmental ablation (ClosureFAST™
) of saphenous veins. J Eur Acad Dermatol Venereol 2015; 30:1009-12. [DOI: 10.1111/jdv.13178] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/07/2015] [Indexed: 11/25/2022]
Affiliation(s)
- S. Schuller-Petrović
- VENEX - Vein and Dermatology Centre; Vienna Austria
- DCP-VENEX Center & Dermatology Centre Parmova; Ljubljana Slovenia
| | - M.D. Pavlović
- DCP-VENEX Center & Dermatology Centre Parmova; Ljubljana Slovenia
| | - B. Schuller-Lukić
- VENEX - Vein and Dermatology Centre; Vienna Austria
- Department of Dermatology; Rudolfstiftung; Vienna Austria
| | - S. Schuller
- VENEX - Vein and Dermatology Centre; Vienna Austria
- Department of Dermatology; SMZ Ost; Vienna Austria
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Wittens C, Davies AH, Bækgaard N, Broholm R, Cavezzi A, Chastanet S, de Wolf M, Eggen C, Giannoukas A, Gohel M, Kakkos S, Lawson J, Noppeney T, Onida S, Pittaluga P, Thomis S, Toonder I, Vuylsteke M, Kolh P, de Borst GJ, Chakfé N, Debus S, Hinchliffe R, Koncar I, Lindholt J, de Ceniga MV, Vermassen F, Verzini F, De Maeseneer MG, Blomgren L, Hartung O, Kalodiki E, Korten E, Lugli M, Naylor R, Nicolini P, Rosales A. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015; 49:678-737. [PMID: 25920631 DOI: 10.1016/j.ejvs.2015.02.007] [Citation(s) in RCA: 505] [Impact Index Per Article: 56.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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O'Donnell TF, Balk EM, Dermody M, Tangney E, Iafrati MD. Recurrence of varicose veins after endovenous ablation of the great saphenous vein in randomized trials. J Vasc Surg Venous Lymphat Disord 2015; 4:97-105. [PMID: 26946904 DOI: 10.1016/j.jvsv.2014.11.004] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 11/12/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recurrence of varicose veins after surgery (REVAS) for saphenous incompetence has been well described after ligation and stripping (L&S) but not after the now most frequently performed method of saphenous ablation, endovenous ablation (EVA). The purpose of this study was to define the overall incidence of REVAS as well as both the sites of reflux and the causes of REVAS through a systematic review and meta-analysis of randomized controlled trials (RCTs) for EVA. These studies have the advantage of prospectively collected data and a uniform duplex follow-up. METHODS We searched databases (January 1, 2000 through July 1, 2014) for published RCTs evaluating EVA treatment of great saphenous vein (GSV) incompetence that employed endovenous laser ablation or radiofrequency ablation. RCTs were eliminated that (1) did not have follow-up of at least 2 years, (2) did not obtain postoperative duplex scans, (3) did not clearly report the incidence of recurrent varicosities after GSV ablation, and (4) treated the small saphenous or anterior accessory saphenous veins. RESULTS Of the 68 studies screened, 20 RCTs that employed EVA of the GSV were identified. Eight had a follow-up of at least 2 years, but one was eliminated because of lack of information on both the site and cause of REVAS. The resultant seven RCTs provided eight comparisons (one study compared both types of EVA to a comparator arm): three used radiofrequency ablation, and five employed endovenous laser ablation. Overall recurrent varicose veins developed in 125 limbs after EVA (22%), with no difference in the incidence vs the L&S group (22%) based on the number of limbs available at the time of the development of recurrence for both groups, but this incidence is dependent on the length of follow-up after the initial treatment. The two studies with serial follow-up showed an approximate doubling of REVAS over time for both EVA and L&S. By contrast, the cause of REVAS was different between the two methods. Neovascularization occurred in only two limbs (2%) after EVA vs 18 (18%) in the L&S group. Recanalization was the most common cause of REVAS for EVA (32%; 40 of 125 limbs), followed by the development of anterior accessory saphenous vein incompetence (19%; 23 of 125 limbs). In contrast to other reports, incompetent calf perforating veins were an infrequent cause of REVAS (7%; eight of 125). CONCLUSIONS There is no difference in the incidence of REVAS for EVA vs L&S, but the causes of REVAS are different with L&S, which has important implications for treatment.
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Affiliation(s)
| | - Ethan M Balk
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Mass
| | - Meghan Dermody
- CardioVascular Center, Tufts Medical Center, Boston, Mass
| | - Erica Tangney
- CardioVascular Center, Tufts Medical Center, Boston, Mass
| | - Mark D Iafrati
- CardioVascular Center, Tufts Medical Center, Boston, Mass
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Abstract
Venous leg ulceration (VLU) is one of the most predominate medical disorders worldwide and in the western hemisphere it affects around 1.5% of the general population and up to 5% of the elderly population. Unfortunately, this trend will only increase given the growth of an aging population worldwide. Understanding its pathophysiology that begins with venous hemodynamic abnormalities and leads to inflammatory alterations with microcirculatory changes is critical to delivering effective curative therapy. As such, the main component to treatment is reversing the underlying venous hypertension and pro-inflammatory milieu using compression treatment along with various adjuvant therapies. Given its impact, a comprehensive multi-pronged approach to care, treatment and prevention is required to reverse the increasing trend that is observed worldwide.
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Affiliation(s)
- Yung-Wei Chi
- Department of Internal Medicine, Section of Cardiovascular Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Joseph D Raffetto
- Vascular Surgery Division, VA Boston Healthcare System, West Roxbury, MA, USA
- Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Nesbitt C, Bedenis R, Bhattacharya V, Stansby G. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev 2014:CD005624. [PMID: 25075589 DOI: 10.1002/14651858.cd005624.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Minimally invasive techniques to treat great saphenous varicose veins include ultrasound-guided foam sclerotherapy (UGFS), radiofrequency ablation (RFA) and endovenous laser therapy (EVLT). Compared with flush saphenofemoral ligation with stripping, also referred to as open surgery or high ligation and stripping (HL/S), proposed benefits include fewer complications, quicker return to work, improved quality of life (QoL) scores, reduced need for general anaesthesia and equivalent recurrence rates. This is an update of a review first published in 2011. OBJECTIVES To determine whether endovenous ablation (radiofrequency and laser) and foam sclerotherapy have any advantages or disadvantages in comparison with open surgical saphenofemoral ligation and stripping of great saphenous vein varices. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2014) and CENTRAL (2013, Issue 12). Clinical trials databases were also searched for details of ongoing or unpublished studies. SELECTION CRITERIA All randomised controlled trials (RCTs) of UGFS, EVLT, RFA and HL/S were considered for inclusion. Primary outcomes were recurrent varicosities, recanalisation, neovascularisation, technical procedure failure, patient QoL scores and associated complications. DATA COLLECTION AND ANALYSIS CN and RB independently reviewed, assessed and selected trials which met the inclusion criteria. CN and RB extracted data and used the Cochrane Collaboration's tool for assessing risk of bias. CN and RB contacted trial authors to clarify details as needed. MAIN RESULTS For this update, eight additional studies were included making a total of 13 included studies with a combined total of 3081 randomised patients. Three studies compared UGFS with surgery, eight compared EVLT with surgery and five compared RFA with surgery (two studies had two or more comparisons with surgery). Study quality, evaluated through the six domains of risk of bias, was generally moderate for all included studies, however no study blinded participants, researchers and clinicians or outcome assessors. Also, nearly all included studies had other sources of bias. The overall quality of the evidence was moderate due to the variations in the reporting of results, which limited meaningful meta-analyses for the majority of proposed outcome measures. For the comparison UGFS versus surgery, the findings may have indicated no difference in the rate of recurrences in the surgical group when measured by clinicians, and no difference between the groups for symptomatic recurrence (odds ratio (OR) 1.74, 95% confidence interval (CI) 0.97 to 3.12; P = 0.06 and OR 1.28, 95% CI 0.66 to 2.49, respectively). Recanalisation and neovascularisation were only evaluated in a single study. Recanalisation at < 4 months had an OR of 0.66 (95% CI 0.20 to 2.12), recanalisation > 4 months an OR of 5.05 (95% CI 1.67 to 15.28) and for neovascularisation an OR of 0.05 (95% CI 0.00 to 0.94). There was no difference in the rate of technical failure between the two groups (OR 0.44, 95% CI 0.12 to 1.57). For EVLT versus surgery, there were no differences between the treatment groups for either clinician noted or symptomatic recurrence (OR 0.72, 95% CI 0.43 to 1.22; P = 0.22 and OR 0.87, 95% CI 0.47 to 1.62; P = 0.67, respectively). Both early and late recanalisation were no different between the two treatment groups (OR 1.05, 95% CI 0.09 to 12.77; P = 0.97 and OR 4.14, 95% CI 0.76 to 22.65; P = 0.10). Neovascularisation and technical failure were both statistically reduced in the laser treatment group (OR 0.05, 95% CI 0.01 to 0.22; P < 0.0001 and OR 0.29, 95% CI 0.14 to 0.60; P = 0.0009, respectively). Long-term (five-year) outcomes were evaluated in one study so no association could be derived,but it appeared that EVLT and surgery maintained similar findings. Comparing RFA versus surgery, there were no differences in clinician noted recurrence (OR 0.82, 95% CI 0.49 to 1.39; P = 0.47); symptomatic noted recurrence was only evaluated in a single study. There were also no differences between the treatment groups for recanalisation (early or late) (OR 0.68, 95% CI 0.01 to 81.18; P = 0.87 and OR 1.09, 95% CI 0.39 to 3.04; P = 0.87, respectively), neovascularisation (OR 0.31, 95% CI 0.06 to 1.65; P = 0.17) or technical failure (OR 0.82, 95% CI 0.07 to 10.10; P = 0.88).QoL scores, operative complications and pain were not amenable to meta-analysis, however quality of life generally increased similarly in all treatment groups and complications were generally low, especially major complications. Pain reporting varied greatly between the studies but in general pain was similar between the treatment groups. AUTHORS' CONCLUSIONS Currently available clinical trial evidence suggests that UGFS, EVLT and RFA are at least as effective as surgery in the treatment of great saphenous varicose veins. Due to large incompatibilities between trials and different time point measurements for outcomes, the evidence is lacking in robustness. Further randomised trials are needed, which should aim to report and analyse results in a congruent manner to facilitate future meta-analysis.
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Affiliation(s)
- Craig Nesbitt
- Sunderland Royal Hospital, Kayll Road, Sunderland, UK
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O'Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, Lurie F, Henke PK, Gloviczki ML, Eklöf BG, Stoughton J, Raju S, Shortell CK, Raffetto JD, Partsch H, Pounds LC, Cummings ME, Gillespie DL, McLafferty RB, Murad MH, Wakefield TW, Gloviczki P. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014; 60:3S-59S. [PMID: 24974070 DOI: 10.1016/j.jvs.2014.04.049] [Citation(s) in RCA: 387] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Carroll C, Hummel S, Leaviss J, Ren S, Stevens JW, Cantrell A, Michaels J. Systematic review, network meta-analysis and exploratory cost-effectiveness model of randomized trials of minimally invasive techniques versus surgery for varicose veins. Br J Surg 2014; 101:1040-52. [PMID: 24964976 DOI: 10.1002/bjs.9566] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 02/27/2014] [Accepted: 04/17/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND A Health Technology Assessment was conducted to evaluate the relative clinical effectiveness and cost-effectiveness of minimally invasive techniques (foam sclerotherapy (FS), endovenous laser ablation (EVLA) and radiofrequency ablation (RFA)) for managing varicose veins, in comparison with traditional surgery. METHODS A systematic review of randomized clinical trials (RCTs) was undertaken to assess the effectiveness of minimally invasive techniques compared with other treatments, principally surgical stripping, in terms of recurrence of varicose veins, Venous Clinical Severity Score (VCSS), pain and quality of life. Network meta-analysis and exploratory cost-effectiveness modelling were performed. RESULTS The literature search conducted in July 2011 identified 1453 unique citations: 31 RCTs (51 papers) satisfied the criteria for effectiveness review. Differences between treatments were negligible in terms of clinical outcomes, so the treatment with the lowest cost appears to be most cost-effective. Total FS costs were estimated to be lowest, and FS was marginally more effective than surgery. However, relative effectiveness was sensitive to the model time horizon. Threshold analysis indicated that EVLA and RFA might be considered cost-effective if their costs were similar to those for surgery. These findings are subject to various uncertainties, including the risk of bias present in the evidence base and variation in reported costs. CONCLUSION This assessment of currently available evidence suggests there is little to choose between surgery and the minimally invasive techniques in terms of efficacy or safety, so the relative cost of the treatments becomes one of the deciding factors. High-quality RCT evidence is needed to verify and further inform these findings.
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Affiliation(s)
- C Carroll
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Hardman RL, Rochon PJ. Role of interventional radiologists in the management of lower extremity venous insufficiency. Semin Intervent Radiol 2014; 30:388-93. [PMID: 24436566 DOI: 10.1055/s-0033-1359733] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Lower extremity venous insufficiency affects over half of all women. Interventional radiologists should be aware of the clinical evaluation of women with venous insufficiency and classification of disease. Endovascular therapies available for treatment of lower extremity venous insufficiency include: endovenous laser ablation, radiofrequency endovascular ablation, and sclerotherapy. The interventional radiologist should be versed on which therapy to select in each clinical presentation and the procedural techniques. The authors review the role of the interventional radiologist in managing this lower extremity venous disorder.
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Affiliation(s)
- Rulon L Hardman
- Department of Radiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Paul J Rochon
- Department of Radiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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Hamel-Desnos C, Desnos P, Allaert FA, Kern P. Thermal ablation of saphenous veins is feasible and safe in patients older than 75 years: A prospective study (EVTA study). Phlebology 2014; 30:525-32. [PMID: 24942061 DOI: 10.1177/0268355514540882] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To investigate the tolerance and safety of thermal ablation (TA), consisting of radiofrequency or endovenous laser (EVLA) of saphenous veins (SV) in elderly (group 1 ≥75 years), compared with a control group (group 2 <75 years). METHOD An Observational multicenter-prospective study was conducted, under the aegis of the French and Swiss Societies of Phlebology (18 centers). Ninety patients were included in group 1, 617 in group 2 (mean age 80 years and 53 years; 69% women in both groups), representing 863 SV. Mean trunk diameters were similar in both groups (small SV: 6 mm; great SV: 7 mm). In group 1, comorbidities were more frequent, particularly cardiac insufficiency, diabetes, history of thrombosis, and CEAP clinical class was significantly higher. RESULTS EVLA was used in 86% of cases. Settings used were similar in both groups for each technique. Only 6% of TA was performed in an operating room for group 1 (14% group 2). Tumescent local anaesthesia (TLA) alone was used in 91% of cases in group 1 (85% group 2). The mean pain score was only 1.6 for the procedure itself (VASP 0-10; 10 max.) and 1.4 for the 10 days following the procedure. Side effects were few, but rate of paraesthesia was higher when general anaesthesia was used (11.8%) compared with TLA alone (2.2%). At three months, 100% of SV was occluded in group 1 (99.5% group 2), with high satisfaction score (9.3/10). CONCLUSION TA is safe and effective in elderly; it should be performed strictly under TLA to minimize side effects.
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Affiliation(s)
| | - P Desnos
- French Society of Phlebology, Paris, France
| | - F-A Allaert
- Medical Evaluation Chair and Cenbiotech, Dijon, France
| | - P Kern
- Private Office of Vascular Medicine and Service of Angiology, University Hospital Lausanne, Vevey, Switzerland
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van Eekeren RR, Boersma D, de Vries JPP, Zeebregts CJ, Reijnen MM. Update of endovenous treatment modalities for insufficient saphenous veins—A review of literature. Semin Vasc Surg 2014; 27:118-36. [DOI: 10.1053/j.semvascsurg.2015.02.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Eklöf B, Perrin M. Review of randomized controlled trials comparing endovenous thermal and chemical ablation. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.rvm.2013.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Dermody M, O'Donnell TF, Balk EM. Complications of endovenous ablation in randomized controlled trials. J Vasc Surg Venous Lymphat Disord 2013; 1:427-436.e1. [DOI: 10.1016/j.jvsv.2013.04.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 04/19/2013] [Accepted: 04/30/2013] [Indexed: 11/16/2022]
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Kuhlmann A, Prenzler A, Hacker J, Graf von der Schulenburg JM. Impact of radiofrequency ablation for patients with varicose veins on the budget of the German statutory health insurance system. HEALTH ECONOMICS REVIEW 2013; 3:9. [PMID: 23551943 PMCID: PMC3637434 DOI: 10.1186/2191-1991-3-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 03/19/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES In contrast to other countries, surgery still represents the common invasive treatment for varicose veins in Germany. However, radiofrequency ablation, e.g. ClosureFast, becomes more and more popular in other countries due to potential better results and reduced side effects. This treatment option may cause less follow-up costs and is a more convenient procedure for patients, which could justify an introduction in the statutory benefits catalogue. Therefore, we aim at calculating the budget impact of a general reimbursement of ClosureFast in Germany. METHODS To assess the budget impact of including ClosureFast in the German statutory benefits catalogue, we developed a multi-cohort Markov model and compared the costs of a "World with ClosureFast" with a "World without ClosureFast" over a time horizon of five years. To address the uncertainty of input parameters, we conducted three different types of sensitivity analysis (one-way, scenario, probabilistic). RESULTS In the Base Case scenario, the introduction of the ClosureFast system for the treatment of varicose veins saves costs of about 19.1 Mio. € over a time horizon of five years in Germany. However, the results scatter in the sensitivity analyses due to limited evidence of some key input parameters. CONCLUSIONS Results of the budget impact analysis indicate that a general reimbursement of ClosureFast has the potential to be cost-saving in the German Statutory Health Insurance.
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Affiliation(s)
- Alexander Kuhlmann
- Leibniz Universität Hannover, Center for Health Economics, Hannover, Germany
| | - Anne Prenzler
- Leibniz Universität Hannover, Center for Health Economics, Hannover, Germany
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Choi JH, Park HC, Joh JH. The occlusion rate and patterns of saphenous vein after radiofrequency ablation. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 84:107-13. [PMID: 23397027 PMCID: PMC3566468 DOI: 10.4174/jkss.2013.84.2.107] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 11/12/2012] [Accepted: 11/17/2012] [Indexed: 11/30/2022]
Abstract
Purpose Radiofrequency ablation (RFA) is a widely accepted to treat the varicose vein. However, outcome studies for occlusion rate and patterns of the saphenous vein after RFA are scarce. The purpose of our study is to report the results of RFA in patients with varicose vein. Methods We retrospectively reviewed the clinical outcomes after RFA using ClosureFAST (Covidien) catheter. We evaluated the occlusion rate and patterns with duplex scanning after RFA. Results A total of 200 limbs (148 patients) underwent RFA. The truncal veins were ablated in 163 great saphenous veins (GSV) and 41 small saphenous veins (SSVs). The mean age was 52.1 ± 11.9 years and female to male ratio was 125 : 87. At the mean follow-up of 13.9 months, the CEAP score, VCSS, and QoL score were significantly improved 2.33 ± 0.78 to 1.29 ± 0.96 (P < 0.0001), 3.48 ± 0.98 to 0.63 ± 1.16 (P < 0.0001), and 6.91 ± 6.69 to 3.38 ± 4.74 (P < 0.0001), respectively. The occlusion rate was 94.6% (53/56) in GSV and 94.5% (17/18) in SSV. The most common occlusion pattern in GSV was total occlusion of main trunk with patent superficial inferior epigastric vein in 41.1%. And, the most common pattern in SSV was the total occlusion of SSV with stump in 66.7%. Conclusion RFA is an effective modality in the treatment of varicose vein. At the mean follow-up of 13.9 months, the occlusion rate was 94.6%in GSV and 94.5% in SSV. There are several patterns of saphenous occlusion after RFA.
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Affiliation(s)
- Jung Hyun Choi
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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Great saphenous vein diameter does not correlate with worsening quality of life scores in patients with great saphenous vein incompetence. J Vasc Surg 2012; 56:1634-41. [DOI: 10.1016/j.jvs.2012.02.065] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 02/22/2012] [Accepted: 02/28/2012] [Indexed: 11/20/2022]
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Braithwaite B, Hnatek L, Zierau U, Camci M, Akkersdijk G, Nio D, Sarlija M, Ajduk M, Santoro P, Roche E. Radiofrequency-induced thermal therapy: results of a European multicentre study of resistive ablation of incompetent truncal varicose veins. Phlebology 2012; 28:38-46. [PMID: 22865420 DOI: 10.1258/phleb.2012.012013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To investigate the effectiveness of bipolar radiofrequency-induced thermal therapy (RFITT) in a multicentre non-randomized study. METHODS Some 672 incompetent saphenous veins (85% great saphenous varicose vein, 15% short saphenous vein) in 462 patients (56.5% CEAP [clinical, aetiological, anatomical and pathological elements] class 3 or worse) were treated in eight European centres. Patients were assessed between 180 and 360 days postoperatively. Occlusion rates were determined by duplex ultrasound and compared with the power used for treatment, pull back rate and experience of the operating surgeon. RESULTS Complete occlusion rates of 98.4% were achieved when treatments were performed by an experienced operator (more than 20 cases), when the maximum power setting on the RFITT generator was between 18 and 20 W and the applicator was withdrawn at a rate slower than 1.5 second/cm CONCLUSIONS RFITT is efficacious, well tolerated by patients and has a low incidence of procedure-related post-operative complications.
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Affiliation(s)
- B Braithwaite
- Queens Medical Centre - Vascular Surgery, Nottingham, UK.
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