Guidelines of the First International Consensus Conference on Endovenous Thermal Ablation for Varicose Vein Disease--ETAV Consensus Meeting 2012

Venous thrombosis following endovenous laser ablation with and without thromboprophylaxis

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Systematic Review and Meta-Analysis of Randomised Controlled Trials Comparing Thermal Versus Non-Thermal Endovenous Ablation in Superficial Venous Incompetence

OBJECTIVE

The objective was to compare technical success, complications, and quality of life after thermal vs. non-thermal endovenous ablation for the treatment of superficial venous incompetence.

DATA SOURCES

Electronic bibliographic sources (Google Scholar, Pubmed, Cochrane Database, Scopus, Web of Science, and Embase).

REVIEW METHODS

A systematic review and meta-analysis of randomised controlled trials was conducted using terms to identify relevant studies to be included. The primary outcome was vein occlusion rate at up to four weeks and one to two years from procedure. Secondary outcome measures included peri-procedural pain, nerve injury, endothermal heat induced thrombosis, and quality of life.

RESULTS

Eight randomised controlled trials met the selection criteria. These comprised a total of 1 956 patients, of whom 1 042 underwent endovenous thermal ablation and 915 underwent endovenous non-thermal ablation. There was no statistically significant difference in occlusion rate at all time points. Relative risk at four weeks and one to two years was 0.99 (95% CI 0.96 - 1.02) and 0.95 (95% CI 0.88 - 1.01), respectively. Non-thermal ablation was tolerated better and had less risk of nerve injury. There was no statistically significant difference in risk of endothermal heat induced thrombosis (EHIT). There was improvement in quality of life scores post-procedure but there was no statistically significant difference in thermal vs. non-thermal ablation. The quality of evidence assessed using GRADE methodology showed high quality for occlusion rate at four weeks and one to two years, moderate quality for nerve injury and peri-procedural pain, and low quality for EHIT.

CONCLUSION

Vein occlusion rates after thermal vs. non-thermal endovenous ablation are similar. In the early post-operative period, non-thermal endovenous ablation demonstrated the advantages of less pain and less risk of nerve injury. Improvement in quality of life after both thermal and non-thermal endovenous ablation is similar.

A randomized clinical trial to assess the impact of laser power with constant linear endovenous energy density on outcomes of endovenous laser ablation (SLEDGE trial)

OBJECTIVE

To date, conflicting evidence has been reported regarding the energy settings to use during endovenous laser ablation (EVLA). In the present study, we evaluated the outcomes of EVLA of the great saphenous veins (GSVs) using different power settings with the same linear endovenous energy density (LEED) of ∼70 J/cm.

METHODS

We performed a single-center, randomized, controlled noninferiority trial with a blinded outcome assessment of patients with varicose veins of the GSV who underwent EVLA with a wavelength of 1470 nm and a radial fiber. The patients were randomly assigned to three groups according to the energy setting: group 1, 5 W power and an automatic fiber traction speed of 0.7 mm/s (LEED, 71.4 J/cm); group 2, 7 W and 1.0 mm/s (LEED, 70 J/cm); and group 3, 10 W and 1.5 mm/s (LEED, 66.7 J/cm). The primary outcome was the rate of GSV occlusion at 6 months. The secondary outcomes were pain intensity along the target vein the next day and at 1 week and 2 months after EVLA, the necessity for analgesics, and the occurrence of significant complications.

RESULTS

From February 2017 to June 2020, 245 lower extremities of 203 patients were enrolled. Groups 1, 2, and 3 included 83, 79, and 83 limbs, respectively. At 6 months of follow-up, 214 lower extremities were examined with duplex ultrasound. GSV occlusion was observed in 72 of 72 limbs (100%; 95% confidence interval [CI], 100%-100%) in group 1 and 70 of 71 limbs (98.6%; 95% CI, 97%-100%) in groups 2 and 3 (P < .05 for noninferiority). No difference was found in the pain level, necessity for analgesics, or rate of any other complications.

CONCLUSIONS

The technical results, pain level, and complications of EVLA were not associated with the combination of energy power (5-10 W) and the speed of automatic fiber traction when a similar LEED of ∼70 J/cm was reached.

Case Report: Successful results of direct varicose vein ablation with EVLA in chronic venous insufficiency patient in Indonesia

Background: Varicose veins are considered a chronic venous disease. Delaying treatment might cause several late complications that contribute to a high burden on healthcare systems. It may be treated with endovenous laser ablation (EVLA) and stab avulsion as additional procedures. Varicose direct ablation has been promoted to replace stab avulsion in certain conditions. Here we report the case of a 71-year-old female who presented with chronic venous insufficiency managed by an endovascular therapeutic approach using direct varix ablation for the first time in National Cardiovascular Center - Harapan Kita, Jakarta, Indonesia. Case report: A 71-year-old female came to the outpatient clinic with a large bulging vein in her leg. Duplex ultrasound showed that the great saphenous vein (GSV) was incompetent with a varicose vein in the medial part of proximal GSV below the knee. The patient underwent EVLA with direct varicose ablation using Utoh's technique. Duplex sonography evaluation showed the right GSV was utterly obliterated, including the varicose vein. The patient was discharged two days after the procedure without significant complaints nor pain medication. Conclusions: Direct varicose ablation was proposed as a better alternative than stab avulsion. The varicose vein can be managed with EVLA without a scalpel, incision, avulsion, or phlebectomy. In this case presentation, the endovascular therapeutical approach with Utoh's ablation technique showed promising results, and no complication was found in the patient.

Risk factors for short and long-term great saphenous vein recanalization in patients treated with endovenous radiofrequency ablation

PURPOSE

The aim of this retrospective single-center study is to describe and analyze short-, mid-, and long-term risk factors for great saphenous vein (GSV) recanalization after endovenous radiofrequency ablation (RFA).

MATERIALS AND METHODS

All consecutive patients with GSV incompetence and varicose veins underwent RFA were enrolled between 2009 and 2018. Data on demographic, pre- and postoperative color Doppler scan (CDUS) findings, perioperative complications, and follow-up were prospectively collected. Primary outcome was GSV recanalization rate at 1 week after RFA. Secondary outcomes were postoperative complication rate, as well as GSV recanalization rate at 1, 3, and 5 years after RFA. Risk factors for recanalization were also analyzed, for each follow-up assessment, identifying differences in recanalized (Rec) and non-recanalized (nRec) groups.

RESULTS

During the study period, 1297 patients were treated. Among these, 1265 had at least 1 week of follow-up. Mean follow-up time was 3.0 ± 1.9 years. Recanalization rate at 1 week, 1, 3, and 5 years was 2.4%, 4.3%, 9.3%, and 17.5%, respectively. After multivariate analysis for each follow-up evaluation, CEAP classes C4 and 5, as well as preoperative GSV diameter >6 mm and history of smoking were found to be independent predictors of recanalization. Furthermore, age >61 years and postoperative complications such as pigmentation, edema, and paresthesia were found to be dependent risk factors.

CONCLUSION

RFA remains a safe and durable technique to ablate incompetent GSV. Despite this, particular attention should be paid to patients with high CEAP classes to avoid short and long-term recanalization.

Correlation of Clinical Class with Duplex Ultrasound Findings in Lower Limb Chronic Venous Disease

Background

This study investigated the distribution of valve incompetence in patients with chronic venous disease (CVD) and its correlation with the clinical category of the clinical, etiological, anatomical, and pathophysiological (CEAP) classification.

Methods

In total, 1,386 limbs with clinically suspected CVD were categorized according to the CEAP classification and consecutively underwent duplex ultrasonography between April 2017 and December 2020.

Results

There were 362 limbs in male patients and 1,024 limbs in female patients. The limbs were classified as C0s–C1 (608 limbs, 43.8%), C2 (727 limbs, 52.5%), or C3–C6 (51 limbs, 3.7%). The prevalence of saphenous vein incompetence in CEAP C0s–C1 limbs was 43.6%. The saphenofemoral junction (SFJ) was competent in 37% of CEAP C2–C6 limbs. The CEAP C3–C6 category was not correlated with reflux patterns of the saphenous vein system (Cramer’s V=0.07), incompetent SFJ (Cramer’s V=0.07), deep vein reflux (Cramer’s V=0.03), or the distribution of incompetent segments in the great saphenous vein (GSV) (Cramer’s V=0.11).

Conclusion

Duplex ultrasonography is necessary to formulate a proper treatment plan for limbs categorized as CEAP C0s–C1. The SFJ was competent in more than one-third of CEAP C2–C6 limbs with GSV reflux; as such, flush ligation of the GSV may be unnecessary in these patients. The CEAP C3–C6 category showed no correlations with reflux patterns of the saphenous vein system, SFJ reflux, deep vein reflux, or the distribution of incompetent segments in the GSV.

Evaluation of a Physician Peer-Benchmarking Intervention for Practice Variability and Costs for Endovenous Thermal Ablation

IMPORTANCE

The frequency of use of endovenous thermal ablation (EVTA) to treat chronic venous insufficiency has increased rapidly in the US. Wide variability in EVTA use among physicians has been documented, and standard EVTA rates were defined in the 2017 Medicare database.

OBJECTIVE

To assess whether providing individualized physician performance reports is associated with reduced variability in EVTA use and cost savings.

DESIGN, SETTING, AND PARTICIPANTS

This prospective quality improvement study used data from all US Medicare patients aged 18 years or older who underwent at least 1 EVTA between January 1, 2017, and December 31, 2017, and between January 1, 2019, and December 31, 2019. All US physicians who performed at least 11 EVTAs yearly for Medicare patients in 2017 and 2019 were included in the assessment.

INTERVENTION

A performance report comprising individual physician EVTA use per patient with peer-benchmarking data was distributed to all physicians in November 2018.

MAIN OUTCOMES AND MEASURES

The mean number of EVTAs performed per patient was calculated for each physician. Physicians who performed 3.4 or more EVTA procedures per patient per year were considered outliers. The change in the number of procedures from 2017 to 2019 was analyzed overall and by inlier and outlier status. An economic analysis was also performed to estimate the cost savings associated with the intervention.

RESULTS

A total of 188 976 patients (102 222 in 2017 and 86 754 in 2019) who had an EVTA performed by 1558 physicians were included in the analysis. The median patient age was 72.2 years (IQR, 67.9-77.8 years); 67.3% of patients were female, and 84.9% were White. Among all physicians, the mean (SD) number of EVTAs per patient decreased from 2017 to 2019 (1.97 [0.85] vs 1.89 [0.77]; P < .001). There was a modest decrease in the mean number of EVTAs per patient among inlier physicians (1.83 [0.57] vs 1.78 [0.55]; P < .001) and a more substantial decrease among outlier physicians (4.40 [1.01] vs 3.67 [1.41] ; P < .001). Outliers in 2017 consisted of 90 physicians, of whom 71 (78.9%) reduced their EVTA use after the intervention. The number of EVTAs per patient decreased by a mean (SD) of 0.09 (0.46) procedures overall (median, 0.10 procedures [IQR, -0.10 to 0.30 procedures]; P < .001). The estimated cost savings associated with the decrease was $6.3 million in 2019.

CONCLUSIONS AND RELEVANCE

In this quality improvement study, substantial variability in the number of EVTAs performed per patient was observed across the US. When physicians were provided with a 1-time peer-benchmarked performance report card, the timing of the intervention was associated with a significant decrease in the number of EVTAs performed per patient, particularly among outlier physicians. This quality improvement initiative was associated with reduced variability in EVTA use in the US and a substantial savings for Medicare.

Effect of Compression Stockings after Endovenous Laser Ablation of the Great Saphenous Vein with a 1470 nm Diode Laser Device and a 2ring Fiber

The aim of this study was to demonstrate the effects of compression following the endovenous laser ablation (EVLA) of incompetent great saphenous veins (GSVs) using a 1470 nm diode laser (Ceralas E 1470 nm, biolitec) and a 2ring radial fiber (ELVeS Radial 2ring™, biolitec). In this single-center prospective study, 150 legs of 150 consecutive patients were randomly allocated to one of three groups (A, B, and C). Group A patients did not undergo postoperative compression. Group B patients wore a thigh-length graduated compression stocking (23–32 mmHg) for 7 days, whereas group C patients wore the same stocking for 28 days. No additional phlebectomies or sclerotherapies were performed. Investigations were performed prior to intervention, at the day of intervention (D0), at day 7 (D7), and at day 28 post intervention (D28). The primary endpoint was post-interventional pain measured on a 10-point scale. A significant but small pain decrease was observed in the first week of compression, by comparing group B’s mean pain scores to those of group A (p = 0.009). Wearing a compression stocking after EVLA reduced pain within the first week on a significant, but low level. Taking the very low differences in pain levels into account, the difference may not be clinically relevant and post-treatment compression may not be necessary if no additional phlebectomies or sclerotherapies are performed.

Rivaroxaban for the prevention of venous thromboembolism after radiofrequency ablation of saphenous veins concomitant with miniphlebectomy, sclerotherapy, or no treatment of varicose tributaries

OBJECTIVE

To assess the efficacy and safety of once-daily 10 mg rivaroxaban for venous thromboembolism prophylaxis after ClosureFast radiofrequency ablation (RFA) of saphenous veins.

METHOD

The medical records of patients, who had a Caprini score of ≥3, underwent RFA, received prophylactic rivaroxaban for five days, and completed follow up at one month were reviewed for efficacy (a combination of endovenous heat-induced thrombosis [EHIT] grade of 2-4, any symptomatic or asymptomatic deep vein thrombosis [DVT], and symptomatic pulmonary embolism [PE]) and safety (a combination of major and clinically relevant non-major [CRNM] bleeding) outcomes.

RESULTS

The results of RFA for 248 great saphenous and 24 small saphenous veins with the concomitant miniphlebectomy (63.8%) and sclerotherapy (16.5%) were analyzed. The primary efficacy outcome occurred in 5 of 218 (2.3%; 95%CI, 1.0-5.3%) patients: three EHITs and two symptomatic DVTs. The CRNM bleeding was reported in two patients (0.9%; 95% CI, 0.2-3.3%). No difference was observed in comparison with 79 similar patients who received 40 mg of subcutaneous enoxaparin during the same time period.

CONCLUSION

Once-daily 10 mg rivaroxaban is suitable for VTE prophylaxis after RFA of saphenous veins.

Current status of endothermal heat induced thrombosis

BACKGROUND

There remain many questions regarding the pathophysiology and risk factors for endothermal heat induced thrombosis formation. Moreover, there are a paucity of data on the timing of its occurrence, and there has been no consensus regarding for its treatment. The purpose of this review is to summarize the current knowledge on the pathophysiology, risk factors and treatment strategies for endothermal heat induced thrombosis.

METHODS

The PubMed database was searched from 2001 to present for endothermal heat induced thrombosis, EHIT, deep vein thrombosis, chronic venous insufficiency, varicose veins, endovenous laser and radiofrequency ablation (treatment). All relevant articles identified by the authors mentioning endothermal heat induced thrombosis were included in this review.

RESULTS

A multitude of risk factors, several pathophysiological hypotheses and different treatment strategies are described in the literature.

CONCLUSIONS

Endothermal heat induced thrombosis is marginally understood. There remains a theoretical risk for significant venous thromboembolic complications. With the new uniform classification of EHIT (American Venous Forum), healthcare providers should continue to investigate the nature of this event.

[Radiofrequency obliteration of varicose veins of lower extremity guided by combined venography and ultrasonography]

OBJECTIVE

To explore the technical details and short-term effects of radiofrequency obliteration of varicose veins of lower extremities guided by combined venography and ultrasound.

METHODS

Thirty-seven patients with varicose veins of lower extremities were treated with radiofrequency obliteration using Olympus Celon RFiTT^® under combined guidance of venography and ultrasound. The indications included varicose veins of lower extremities and reflux of the great saphenous vein confirmed by ultrasound. The contraindications included deep vein thrombosis, cardiac pacemaker, severe cardio- and cerebrovascular diseases or coagulation disorders. Under ultrasound guidance, the saphenous vein around knee level was punctured using a 21G needle, and a 7F sheath was introduced. Through the sheath a venography was made, and an Olympus Celon ProCurve radiofrequency catheter was inserted and advanced to the great saphenous vein under road map, and the catheter tip was positioned at the point 2 cm below the sapheno-femoral junction. The swelling anesthesia was made under ultrasound guidance. Then the radiofrequency obliteration was performed with pressing of the treatment section. The venography was repeated to ensure optimal outcomes. If necessary the radiofrequency obliteration could be repeated once to twice. After that the superficial varicose veins were stripping by small incisions under local anesthesia. After operation, medical decompression stocking was utilized immediately and sustained for three months. The clinical data, intraoperative radiation dose, exposure time and short-term effects were retrospectively analyzed.

RESULTS

After the operation, all the patients walked out of the operating room by themselves. The success rate of operation was 100%. The intraoperative radiation dose was 1.78-10.12 mGy (mean 6.56 mGy), and the exposure time was 61-448 s (mean 161 s). By 3 months follow-up, the symptoms were alleviated in all the 37 patients, and the occlusion rate was 100%. No complications such as skin burns, ecchymosis and deep venous thrombosis were found.

CONCLUSION

The short-term effects of radiofrequency obliteration using Olympus Celon RFiTT^® system in a manner of twice fixed point followed by once reciprocating radiofrequency were satisfactory. Radiofrequency obliteration of great saphenous veins guided by venography and ultrasound has not only the advantages of minimal trauma and rapid recovery, but also the advantages of accurate location, exact effect and avoidance of complications.

Thromboprophylaxis practice after outpatient endovenous thermal ablation

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical outcomes of radiofrequency ablation for patients with varicose veins of the lower extremities combined with grade II iliac vein compression

BACKGROUND

Iliac vein compression (IVC) is a common condition in patients with varicose veins (VVs) of the legs. IVC has been classified into three grades in previous studies. Grade II IVC is defined by >50% stenosis without the development of collateral circulation. The purpose of the present study was to investigate the outcomes of radiofrequency ablation (RFA) for patients with VVs combined with grade II IVC.

METHODS

A retrospective analysis was conducted of 339 patients who had undergone RFA for VVs of the left leg from March 2017 to January 2019. Duplex ultrasonography, computed tomography venography, and venography were performed to evaluate for grade II IVC. All the patients were divided into two groups. Group 1 included patients with VVs only, and group 2, patients with VVs combined with grade II IVC. Propensity score matching was used to ensure an even distribution of confounding factors between groups. The venous clinical severity score (VCSS) and chronic venous insufficiency questionnaire (CIVIQ) score were recorded during the 12-month follow-up. Occlusion of the truncal veins was evaluated using duplex ultrasound scans.

RESULTS

Using 1:1 propensity score matching, 50 pairs of patients were enrolled in the present analysis. The average age of groups 1 and 2 was 58.7 ± 13.1 and 60.1 ± 7.1 years, respectively. The VCSS had decreased significantly from baseline to 12 months postoperatively (group 1, from 5 to 1; group 2, from 4 to 1; P < .01). A significant increase in the CIVIQ score was found between the baseline and 12-month evaluations for both groups (group 1, from 62.5 to 69; group 2, from 63 to 70; P < .01). The truncal occlusion rate was 98% in both groups at 12 months. No significant differences were found between the two groups in the VCSS, CIVIQ score, procedure complications, or occlusion rate during the 12-month follow-up.

CONCLUSIONS

RFA is effective for patients with VVs combined with grade II IVC.

Segmental saphenous ablation for chronic venous disease treatment

BACKGROUND

Endovenous thermal ablation for chronic venous disease treatment is recommended over traditional surgery. The present investigation compares endovenous laser ablation (EVLA) with radiofrequency (RF) for segmental endovenous sapheno-femoral junction ablation.

METHODS

This is a retrospective study in which 79 patients underwent a 6 cm great saphenous vein ablation by RF or by EVLA.Primary outcome was occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score, peri-procedural pain, aesthetic satisfaction.

RESULTS

At 12 ± 1 months recanalization of shrunk tract was recorded in 5/85 (5.8%) cases (2 RF, 3 EVLA) [OR: 1.6; 95%CI: 0.2-10.4; P = 0.6689]. Two cases (1/44 RF group and 1/38 EVLA group) also showed reflux recurrence [OR: 1.0; 95%CI: 0.06-17.8; P = 1.0000]. No significant differences between groups were found in AVVQ, VCSS, peri-procedural pain, or aesthetic satisfaction.

CONCLUSION

Saphenous sparing is feasible and effective by means of both EVLA and RF, representing a possible alternative to surgery.

[A device for endoluminal thermal obliteration of varicose veins]

Amongst the techniques of endoluminal thermal obliteration of varicose veins, the most commonly employed treatment modalities are endovasal radiofrequency ablation and endovasal laser obliteration, both using a generating source and a special device for carrying out thermal obliteration. It has been noted that each of the methods of thermal obliteration has a number of disadvantages, irrespective of using the energy of magnetic oscillations in a radiofrequency range or laser radiation, including high cost of expendable materials and equipment. The device we worked out for endoluminal thermal obliteration of varicose veins was based on the principle of high efficacy and safety, with a significant decrease in the cost of carrying out the manipulation. This was achieved by means of developing a new device wherein a thermal effect is exerted not via the direct impact of laser radiation on the venous wall but at the expense of using laser energy exceptionally for heating a metal tip located at the distal end of high-strength metallized fibre coated with a heat-resistant polymer. Analysing the initial short-term results of using the new technique of thermal obliteration in treating a total of 50 patients presenting with varicose veins made it possible to draw a conclusion on high efficacy of the method and its safety. The proposed device may repeatedly be used with any and simplest-in-design source of laser radiation regardless of the wavelength and power of radiation. Implementation of this technique into clinical practice will make it possible to decrease manifold the cost of the procedure of thermal obliteration of varicose veins, currently carried out with the use of the classic techniques - endovasal laser obliteration and endovasal radiofrequency ablation.

Update of the SFMV (French society of vascular medicine) guidelines on the conditions and safety measures necessary for thermal ablation of the saphenous veins and proposals for unresolved issues

Venous insufficiency is a very common disease affecting about 25% of the French population (if we combine all stages of its progression). It is a complex disease and its aetiology has not yet been fully elucidated. Some of its causes are well known, such as valvular dysfunction, vein wall defect, and the suctioning effect common to all varicose veins. These factors are generally associated and together lead to dysfunction of one or more of the saphenous veins. Saphenous vein dysfunction is revealed by ultrasound scan, a reflux lasting more than 0.5 seconds indicating venous incompetence. The potential consequences of saphenous vein dysfunction over time include: symptoms (heaviness, swellings, restlessness, cramps, itching of the lower limbs), acute complications (superficial venous thrombosis, varicose bleeding), chronic complications (changes in skin texture and colour, stasis dermatitis, eczema, vein atresia, leg ulcer), and appearance of unaesthetic varicose veins. It is not possible to repair an incompetent saphenous vein. The only therapeutic options at present are ultrasound-guided foam sclerotherapy, physical removal of the vein (saphenous stripping), or its thermal ablation (by laser or radiofrequency treatment), the latter strategy having now become the gold standard as recommended by international guidelines. Recommendations concerning thermal ablation of saphenous veins were published in 2014 by the Société française de médecine vasculaire. Our society has now decided to update these recommendations, taking this opportunity to discuss unresolved issues and issues not addressed in the original guidelines. Thermal ablation of an incompetent saphenous vein consists in destroying this by means of a heating element introduced via ultrasound-guided venous puncture. The heating element comprises either a laser fibre or a radiofrequency catheter. The practitioner must provide the patient with full information about the procedure and obtain his/her consent prior to its implementation. The checklist concerning the interventional procedure issued by the HAS should be validated for each patient (see the appended document).

The 2020 appropriate use criteria for chronic lower extremity venous disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology

BACKGROUND

Stimulated by published reports of potentially inappropriate application of venous procedures, the American Venous Forum and its Ethics Task Force in collaboration with multiple other professional societies including the Society for Vascular Surgery (SVS), American Vein and Lymphatic Society (AVLS), and the Society of Interventional Radiology (SIR) developed the appropriate use criteria (AUC) for chronic lower extremity venous disease to provide clarity to the application of venous procedures, duplex ultrasound imaging, timing, and reimbursements.

METHODS

The AUC were developed using the RAND/UCLA Appropriateness Method, a validated method of developing appropriateness criteria in health care. By conducting a modified Delphi exercise and incorporating best available evidence and expert opinion, AUC were developed and scored.

RESULTS

There were 119 scenarios rated on a scale of 1 to 9 by an expert panel, with 1 being never appropriate and 9 being appropriate. The majority of scenarios consisted of symptomatic indications were deemed appropriate for venous intervention. For scenarios with anatomically short segments of reflux and/or no symptoms, the indications were rated less appropriate. For the indication of edema, a wide dispersion of ratings was observed especially for short segments of saphenous reflux or stenting for iliac/ inferior vena cava disease, noting that there are multifactorial causes of edema, some of which could coexist with venous disease and possibly impact effectiveness of treatment. Several scenarios were considered never appropriate, including treatment of saphenous veins with no reflux, iliac vein or inferior vena cava stenting for iliac vein compression as an incidental finding by imaging with minimal or no symptoms or signs, and incentivizing sonographers to find reflux.

CONCLUSIONS

The AUC statements are intended to serve as a guide to patient care, particularly in areas where high-quality evidence is lacking to aid clinicians in making day-to-day decisions for common venous interventions. This may also prove useful when applied on a population level, such as practice patterns, and not necessarily to dictate decision making for individual cases. As a product of a collaborative effort, it is hoped that this could be utilized by physicians and multiple stakeholders committed toward improving patient care and to identify and stimulate future research priorities.

[Pros and cons of classic crossectomy with stripping compared to endoluminal treatment : Competition or team play?]

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.

[Possibilities of endovenous laser obliteration of subcutaneous veins with tumescence by cold saline solution]

AIM

The purpose of the present study was to assess the possibility of carrying out endovenous laser obliteration (EVLO) with radial light guides on a laser device operating at a wavelength of 1470 nm, using for tumescence only cold normal saline solution without additional sedation or narcosis in patients with allergy to local anaesthetics.

PATIENTS AND METHODS

Our prospective non-comparative single-centre study consecutively included 37 patients who from November 2014 to June 2019 underwent a total of 41 isolated EVLO procedures without simultaneous miniphlebectomy or sclerotherapy of tributaries. Given the previous history of allergy to amide-group local anaesthetics and/or multiple allergic reactions to other agents, these patients received as anaesthesia and tumescence exclusively normal saline solution cooled to a temperature of +3-6ºC, without addition of local anaesthetics or any other therapeutic agents, with neither sedation nor narcosis.

RESULTS

The great saphenous vein was subjected to coagulation in 33 (80.5%) cases, the anterior accessory saphenous vein in 5 (12.2%), and the small saphenous vein in 3 (7.3%) cases. The median of the mean diameter of the veins at 3 cm from the saphenofemoral or saphenopopliteal junction amounted to 10 mm (1st quartile 8.2; 3rd quartile 11). The median of the mean length of the coagulated vein - 45 cm (1st quartile 22; 3rd quartile 51), the median of the average amount of the administered normal saline solution - 300 ml (1st quartile 200; 3rd quartile 450), the median of the average amount of normal saline per 1 centimetre of the venous length - 8.7 ml (1st quartile 7.5; 3rd quartile 10). All patients without exception tolerated the intervention. The process of laser obliteration was not discontinued due to pronounced perioperative pain syndrome in any case. All patients after the procedure answered the question 'Would you repeat a similar intervention if the need arises?' in the affirmative. All the 41 (100 %) veins subjected to coagulation were obliterated at early terms of follow up, with no ultrasonographic evidence of recanalization.

CONCLUSION

The obtained findings suggest a possibility of performing EVLO in patients with an allergy-burdened history in relation to local anaesthetics using for tumescence exclusively normal saline solution chilled to a temperature of +3-6ºC, with no additional sedation or narcosis. Such an approach makes it possible, on the one hand, not to change the organization of outpatient phlebological care and on the other hand to refuse from involving anaesthesiological support. Besides, it is absolutely safe in relation to the risk for the development of allergic reactions.

Post-procedural Compression vs. No Compression After Radiofrequency Ablation and Concomitant Foam Sclerotherapy of Varicose Veins: A Randomised Controlled Non-inferiority Trial

OBJECTIVE

To compare post-operative compression with no compression, after radiofrequency endothermal ablation (RFA) of a truncal varicose vein and concomitant foam sclerotherapy of the tributaries.

METHODS

This prospective randomised controlled, non-inferiority trial recruited patients from two centres in Northern Ostrobothnia, Finland. Patients with clinical class C2-C4 chronic venous disease were randomised to receive no compression after the operation, or to receive compression stockings continuously for two days, and then, during the daytime for five days. In follow up visits, additional foam sclerotherapy was performed for symptoms of distal incompetence. Patients were followed up for six months. The primary outcome was occlusion of the RFA treated truncal vein at six months. Secondary outcomes were return to full activity within 14 days, Aberdeen Varicose Vein Questionnaire (AVVQ) score, post-operative pain, need for painkillers, and postprocedural complications.

RESULTS

Of 177 included patients, 90 were allocated to post-operative compression and 87 to no compression. At six months, both groups showed 100% occlusion rates in RFA treated truncal veins (95% confidence interval -0.043-0.042). Within 14 days of treatment, full physical activity was achieved by 87% of the compression group and 81% of the no compression group, (p = .29). At six months, the AVVQ scores were comparable and significantly improved in both groups, compared with baseline. Pain scores were comparable between groups, in day to day analyses, and they were significantly lower in both groups on day 10, compared with pre-operative pain caused by varicose veins. On average, post-operative pain medication was used for 2.3 days and for 2.8 days in the compression and no compression groups, respectively (p = .28). Complications throughout the six month follow up were comparable between groups, although skin rash/blisters occurred more often in the compression group (p = .01).

CONCLUSION

After treating C2-C4 varicose veins with RFA and concomitant foam sclerotherapy, no post-operative compression was non-inferior to post-operative compression, in terms of safety and efficacy. ClinicalTrials.gov Identifier: NCT02890563.

Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019

Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.

European College of Phlebology guideline for truncal ablation

Background

The purpose of the guideline was to achieve consensus in the care and treatment of patients with chronic venous disease, based on current evidence.

Method

A systematic literature search was performed in PubMed, Embase, Cinahl, and the Cochrane library up until 1 February 2019. Additional relevant literature were added through checking of references. Level of evidence was graded through the GRADE scale and recommendations were concluded.

Results

For the treatment of great and small saphenous vein reflux, endovenous ablation with laser or radiofrequency was recommended in preference to surgery or foam sclerotherapy. If tributaries are to be treated it should be done in the same procedure. Treatment with mecanicochemical ablation and glue can be used but we still need long term follow up results.

Conclusion

For the treatment of truncal varicosities, endovenous ablation with laser or radiofrequency combined with phlebectomies is recommended before surgery or foam.

The V-Block Occlusion Stent and Sclerotherapy Device for Varicose Vein Treatment: A Retrospective Analysis

BACKGROUND

The procedure aims to show our results with a novel nontumescent, nonthermal technique to treat varicose veins. The V-block occlusion stent is a minimally invasive device for treating reflux of the great saphenous vein (GSV). It is an office-based procedure that does not require tumescence anesthesia. The V-block stent is a self-expandable device that functions as a vein occluder and blood clot trap. Once the V-block is in place, further treatment of the saphenous vein such as ultrasound-guided sclerotherapy can be performed. The V-block device is intended to eliminate the possibility of forwarding passage of clot and sclerosant (embolization) to the deep and pulmonary circulations.

METHODS

Patients were treated in an outpatient setting with the V-block occluding device. Follow-up was performed using duplex ultrasound to assess occlusion of the saphenous vein as well as the Aberdeen Varicose Vein Questionnaire and Venous Severity Scoring to determine changes in quality of life after the procedure. Patients were followed up at 1 week, 1 month, and 3 months after V-block placement. Duplex scanning was performed to confirm GSV occlusion at all follow-up visits. After deployment of the occlusion stent, a maximum of 2% polidocanol foam was injected with a double barrel syringe which simultaneously evacuated blood from the greater saphenous vein. Follow-up assessment for safety included evaluation of potential complications, device migration, and potential injury at the deployment site.

RESULTS

Fifty-one symptomatic subjects with documented GSV reflux were enrolled in the study. Complete occlusion of the GSV was achieved in 98% of the patients during the 7-day postprocedural visit. There was no injury at the deployment site. No migration of the V-block device was observed. No deep vein thrombosis or any other complication was recorded. One patient of the 50 patients and 51 procedures experienced an adverse event, phlebitis that resolved under conservative therapy within 4 days with no residual effect. There was a significant improvement in the Aberdeen Vein quality of life measurements and the pain scores. After 3 years, 18 patients were willing to undergo a duplex follow-up examination. The occlusion rate after 3 years was 77.8. There were no device-related complications after this period.

CONCLUSIONS

The study demonstrated a good safety and performance profile without any major adverse events. The primary end point of vein occlusion and obliteration was met.

Endovenous Celon radiofrequency-induced thermal therapy of great saphenous vein: A retrospective study with a 3-year follow-up

Objective:

Our main objective was to evaluate the short- and long-term efficacy of Celon radiofrequency-induced thermal therapy for endovenous treatment of incompetent great saphenous vein. The secondary objectives were to report on possible short-term side effects and complications.

Methods:

This was a retrospective study of 112 consecutive patients included between 2013 and June 2015. These patients were treated (146 great saphenous vein, C2–C6) either at the hemodynamic room using local anesthesia or at the operating theater under general anesthesia with or without phlebectomy. All patients received radiofrequency-induced thermal therapy at 18 W power, 1 s/cm pullback rate and 5–7 pullbacks per segment of 10 cm (i.e. maximum 10 pullbacks). A clinical follow-up via ultrasound monitoring was done at 1 week, 1 month, 6 months, 1 year, 2 years and 3 years.

Results:

The 3-year survival occlusion rate was 96.71% and 98% for overall and radiofrequency-induced thermal therapy patients, respectively. No major side effects were observed. A case of endovenous heat-induced thrombosis was reported. Slight neurological disorders were reported (0.88%).

Conclusion:

Our unit’s endovenous Celon radiofrequency-induced thermal therapy of incompetent great saphenous vein was efficient, well tolerated, without major side effects. Moreover, in order to reduce possible neurological disorders, we advise multiple pullbacks at 1 s/cm and using tumescence anesthesia.

Double prepuncture as a valuable adjunctive technique for complex endovenous ablation

OBJECTIVE

The objective of this study was to characterize the technique and to report the results of double prepuncture used during complex radiofrequency ablation (RFA) in cases of treating multiple incompetent veins or encountering focal obstruction to catheter advancement.

METHODS

A double prepuncture technique was applied in patients requiring endovascular ablation of multiple veins and patients with great saphenous vein cannulation failure. We treated 13 limbs in 12 patients during a 24-month period with RFA in which the double prepuncture technique was used. Clinical history, operative reports, outcomes, and follow-up were reviewed.

RESULTS

RFA was performed with the double puncture technique on, collectively, 10 great saphenous veins, 5 small saphenous veins, and 5 anterior accessory saphenous veins. Mean preoperative Clinical, Etiology, Anatomy, and Pathophysiology score was 4.38 ± 1.6. Three limbs required prepuncture because of difficulty in advancing the catheter cephalad through tortuosity and focal obstruction after failure with techniques such as a guidewire, a guide catheter, and manual compression with ultrasound guidance. Ten limbs received planned double prepuncture for multiple adjacent incompetent veins, for which venipuncture and cannulation of the second target vein would be difficult after tumescent application to the first vein. Postoperative ultrasound demonstrated successful closure of all target veins in which the double prepuncture technique was used. One patient had a deep venous thrombosis (7.7%) that resolved without complications.

CONCLUSIONS

Double prepuncture is a useful technical adjunct both for simultaneous endovenous ablation of multiple adjacent incompetent veins and when catheter passage is impeded. This technique aids in efficient and successful application of endovenous ablation to complex venous anatomy.

Side effects and occlusion rate after tumescentless treatment of the great saphenous vein with EVLA

We have performed a retrospective analysis of side-effect profile of endovenous laser ablation (EVLA) of great saphenous veins in patients operated on in general sedation or general/regional anesthesia with or without tumescence solution injection. The results confirmed our initial assumptions that omitting tumescence (and in addition, avoiding any external compression and cooling) may actually significantly reduce the incidence of moderate/severe postoperative pain and brusing without compromising closure rates. As these are probably caused by vessel wall perforations they seem to be more common in the tumescence cohort. The results are in line with recent basic research which showed that fiber tip centering may reduce perforations (easier to perform in vessels filled with blood), that blood itself does not either reduce or enhance laser‘s effect, and that various lasers over a wide range of wavelengths (from hemoglobin-absorbing to water-absorbing) have comparable clinical efficacy. Hence, omitting tumescence and external compression probably reduces the incidence of postoperative pain and brusing in patients treated with EVLA.

A Defined Protocol to Resolving Cannulation Failure during Endovenous Ablation Procedures

During endovenous ablation for the treatment of insufficient veins, failure to cannulate the entirety of the refluxing vein with the treatment catheter prevents technically successful ablation. In this technique report, we describe a defined protocol to overcome cannulation failure of axial veins for endovenous ablation. This protocol utilizes commonly available adjunctive techniques including ultrasound-guided digital compression, the use of a guidewire, the use of a guide catheter, and placement of a second puncture site in a step-wise fashion to overcome varying degrees of tortuosity or obstruction. The sequential application of these techniques as described in this report allows endovenous ablation to be applied to patients with challenging venous anatomy.

Resultados de médio e longo prazo do tratamento endovenoso de varizes com laser de diodo em 1940 nm: análise crítica e considerações técnicas

Contexto

Desde a introdução do laser endovenoso para tratamento das varizes, há uma busca pelo comprimento de onda ideal, capaz de produzir o maior dano seletivo possível com maior segurança e menor incidência de efeitos adversos.

Objetivos

Avaliar os resultados de médio e longo prazo do laser de diodo de 1940 nm no tratamento de varizes, correlacionando os parâmetros utilizados com a durabilidade do desfecho anatômico.

Métodos

Revisão retrospectiva de pacientes diagnosticados com insuficiência venosa crônica em estágio clínico baseado em clínica, etiologia, anatomia e patofisiologia (CEAP) C2 a C6, submetidos ao tratamento termoablativo endovenoso de varizes tronculares, com laser com comprimento de onda em 1940 nm com fibra óptica de emissão radial, no período de abril de 2012 a julho de 2015. Uma revisão sistemática dos registros médicos eletrônicos foi realizada para obter dados demográficos e dados clínicos, incluindo dados de ultrassom dúplex, durante o período de seguimento pós-operatório.

Resultados

A média de idade dos pacientes foi de 53,3 anos; 37 eram mulheres (90,2%). O tempo médio de seguimento foi de 803 dias. O calibre médio das veias tratadas foi de 7,8 mm. A taxa de sucesso imediato foi de 100%, com densidade de energia endovenosa linear (linear endovenous energy density, LEED) média de 45,3 J/cm. A taxa de sucesso tardio foi de 95,1%, com duas recanalizações por volta de 12 meses pós-ablação. Não houve nenhuma recanalização nas veias tratadas com LEED superior a 30 J/cm.

Conclusões

O laser 1940 nm mostrou-se seguro e efetivo, em médio e longo prazo, para os parâmetros propostos, em segmentos venosos com até 10 mm de diâmetro.

Utility of Adjunctive Digital Subtraction Venography for the Treatment of Saphenous Vein Insufficiency

PURPOSE

To report the use of adjunctive venography for the treatment of superficial venous reflux.

METHODS

Two hundred consecutive patients (mean age 60.9 years, range 33-86; 128 women) with chronic venous disease underwent saphenous or perforator vein ablation in 268 limbs (305 venous trunks) guided by adjunctive venography and fluoroscopy in addition to ultrasound between October 2010 and May 2016. Intraprocedural venograms were independently evaluated by 2 vascular specialists to identify the presence of venous anomalies and the need for fluoroscopy-guided maneuvers to successfully complete venous ablation. Intraprocedural venography results were compared with preoperative venous duplex scan reports to ascertain if the duplex study could be of value in identifying preoperatively any anatomical variants that may pose a technical challenge to the operator.

RESULTS

In this cohort, 542 venograms (2.0/limb) were performed with a mean duration of 4.9±9.1 minutes (range 1-48). Two thirds of patients (132, 66%) had anomalies or abnormalities within the target vein; more than a third (88, 44%) required an endovascular maneuver to successfully complete the ablation and 17% (34) of cases were impossible to complete without adjunctive fluoroscopic guidance. Per-patient comparison of intraprocedural venography with preoperative venous duplex reports identified 21 (11%) patients with abnormalities detected on ultrasound (23 anomalies) compared with 123 (64%) on venography (193 anomalies). This gave ultrasound a 17.1% sensitivity, 100% specificity and positive predictive value, and 40.7% negative predictive value.

CONCLUSION

Venography is a valuable addition to ultrasound to facilitate complete ablation of insufficient saphenous veins in selected patients with complex anatomy.

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

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

A multicenter, randomized, placebo-controlled trial of endovenous thermal ablation with or without polidocanol endovenous microfoam treatment in patients with great saphenous vein incompetence and visible varicosities

Objectives

*

Varithena 017 Investigator Group: Michael Vasquez, MD, Venous Institute of Buffalo, Amherst, NY; Antonios Gasparis, MD, Stony Brook University Medical Center, Stony Brook, NY; Kathleen Gibson, MD, Lake Washington Vascular, Bellevue, WA; James Theodore King, MD, Vein Clinics of America, Oakbrook Terrace, IL; Nick Morrison, MD, Morrison Vein Institute, Scottsdale, AZ; Girish Munavalli, MD, Dermatology, Laser & Vein Specialists of the Carolinas, Charlotte, NC; Eulogio J. Sanchez, MD, Batey Cardiovascular Center, Bradenton, FL. Varithena® is a trademark of Provensis Ltd, a BTG International group company.

To determine the efficacy and safety of polidocanol endovenous microfoam (PEM 0.5%, 1.0%) and placebo each administered with endovenous thermal ablation.

Methods

A multicenter, randomized, placebo-controlled, blinded study was conducted in patients with great saphenous vein incompetence and symptomatic and visible superficial venous disease. Co-primary endpoints were physician-assessed and patient-assessed appearance change from Baseline to Week 8.

Results

A total of 117 patients received treatment (38 placebo, 39 PEM 0.5%, 40 PEM 1%). Physician-rated vein appearance at Week 8 was significantly better with PEM (p = 0.001 vs. placebo); patient-assessed appearance trended similarly. Polidocanol endovenous microfoam provided improvements in clinically meaningful change in patient-assessed and physician-assessed appearance (p < 0.05), need for additional treatment (p < 0.05), saphenofemoral junction reflux elimination, symptoms, and QOL. In PEM recipients, the most frequent adverse event was superficial thrombophlebitis (35.4%)

Conclusions

Endovenous thermal ablation + PEM significantly improved physician-assessed appearance at Week 8, increased the proportion of patients with a clinically meaningful change in appearance, and reduced need for additional treatment. www.clinicaltrials.gov (NCT01197833)

Successful lysis in a stroke following endovenous laser ablation and extensive miniphlebectomy of varicose veins

Stroke is a very rare but potential fatal complication of endovenous thermal treatment in patients with a right-to-left shunt. To our best knowledge, there are only two reports in the literature of stroke after endovenous thermal ablation of varicose veins, one after endovenous laser ablation and one after radiofrequency ablation and phlebectomy, both treated conservatively. This report describes a successful lysis in a patient with an ischemic stroke associated with bilateral endovenous heat-induced thrombosis class I after endovenous laser ablation of both great saphenous vein and extensive miniphlebectomy in a patient with an unknown patent foramen ovale.

Comparison of 1470 nm Laser and Radial 2ring Fiber with 980 nm Laser and Bare-Tip Fiber in Endovenous Laser Ablation of Saphenous Varicose Veins: A Multicenter, Prospective, Randomized, Non-Blind Study

OBJECTIVE

The aim of this study is to compare the clinical efficacy and safety of two laser wavelengths and fiber types in endovenous laser ablation (EVLA) of saphenous varicose veins of the lower limb.

DESIGN

Multi-center prospective randomized non-blind clinical trial.

PATIENTS AND METHODS

From January 2007 to December 2011, 113 patients (113 limbs) with primary varicose veins were randomized into two groups. They were treated with radial 2ring fiber and 1470 nm laser in Group I (57 limbs) and bare-tip fiber and 980 nm laser in Group E (56 limbs) in order to ablate the saphenous vein. Vein occlusion rates at 12 weeks and pain in treated region were recorded as primary endpoint. Visual analogue scale (VAS) for assessment of pain, rates of bruising, complications and equipment failure were recorded as secondary endpoint of safety.

RESULTS

Occlusion rates at 12 weeks were 100% in both groups. Rates of pain (0% vs. 25.0%) and bruising (7.0% vs. 57.1%) were significantly lower in Group I (p <0.0001). VAS of pain was significantly lower on postoperative day 1, day 5 and 2nd week in Group I.

CONCLUSION

Treatment of saphenous varicose veins by EVLA using a 1470 nm laser and a radial 2ring fiber resulted in comparable occlusion rates at 12 weeks and less postoperative pain and bruising than EVLA with a 980 nm laser and a bare-tip fiber. (This article is a translation of Jpn J Vasc Surg 2014; 23: 964-971.).

Treatment of endovenous heat-induced thrombosis (EHIT) with rivaroxaban (Xarelto®)

Introduction: Endovenous heat-induced thrombosis (EHIT) is a known complication after endovenous ablation of the superficial varicose veins (incidence rate 0–6 % (varies by definition and diagnostic algorithm). However, only expert suggestions for indication, duration and dosing of treatment drugs exist. The most common recommendation is low-molecular weight heparin in half-therapeutic dosage for EHIT class 2 and therapeutic dosage for patients with EHIT class 3 or 4. Rivaroxaban is an attractive option in the treatment of venous thromboembolic diseases due to the simplification of treatment.

Case report: After successful ablation of the great saphenous vein (GSV) in a patient with complete insufficiency (Hach III) combined with sclerotherapy of superificial varicose veins of the calf the patient got a prophylactic anticoagulation with low-molecular weight heparin (LMWH) and compressions stockings grade II. Nevertheless we saw in the control-compression ultrasound after 7 days an asymptomatic EHIT class 1. Due the progression to EHIT class 3 after another seven days under watchful waiting we treated the patient with Rivaroxaban for 14 days. After the treatment we saw a complete resolution of the clot. Anticoagulant treatment and compression stockings (for three weeks after EVLT) were discontinued.